The use of virtual reality (VR) in the mediation of acute pain in adults has shown real benefit to patients for the past 20 years. This review of the literature provides a descriptive synthesis of the types of VR technology, the mechanisms by which VR mediates pain, and a history of early research in the area. A review of the use of VR to mediate chronic pain in adults, and both acute and chronic pain in pediatric populations follows. The studies reviewed provide mixed results and it is noted that many studies have small sample sizes, are case studies, and do not control for extraneous variables such as the dosage and type of VR technology used. Although VR is an exciting area of inquiry that promises to yield multiple applications, there is a necessity to conduct larger random controlled trials to better understand the use cases for which VR is most effective. The control and treatment of pain remains a topic of great interest and importance. While the use of pharmacology is undoubtedly the most effective and efficient way to treat pain, there is growing concern about the side effects of traditional pain medications, such as opioids, and the development of tolerance to pain medications. In addition, pain is a subjective experience that is influenced by a plethora of factors that are not physical in nature. Social and cultural factors, as well as gender and personal parameters, impact the experience of pain . There iAdjunctive non-pharmacologic techniques, such as hypnosis, cognitive behavioral therapy and music have been used to complement the pharmacological treatment of procedural pain, but the magnitude of these benefits has only been partially embraced by mainstream science –4. PhysiWithout significant clinical research on efficacy, VR and especially Head Mounted Device (HMD) VR, may not be considered a cost-effective complementary pain intervention. Research on both the experience of pain and the associated negative emotions of being exposed to a painful medical procedure are necessary to support the value of VR. If the use of VR is proven to be effective, the benefits could extend beyond pain reduction. The use of VR to complement and enhance pain relief could lead to reduced use of pharmaceutical analgesia and therefore exposure to its side effects and risks .A number of systematic reviews and meta-analyses on specific aspects of the use of VR and pain have been conducted. For example, Chan, Foster, Sambell and Leong conducted a review of the use of VR in acute procedural pain management ; and DinThe objectives of the review are to provide an introduction and overview of research related to the use of VR to manage pain, providing greater breadth to reviews previously undertaken. The focus on breadth, as opposed to depth in one specific setting, aims to stimulate interest and research in the field by exposing readers to the numerous applications and settings in which VR can be used to manage pain.Google Scholar was used to search for relevant studies. Searches were performed between 22 September 2021 and 30 January 2022 using a combination of medical subject headings and free-text terms. After preliminary searches, the following combined terms were used: “Virtual reality AND distraction,” “Virtual reality AND pain,” “Virtual reality AND analgesia.” The terms “acute,” “chronic,” “pediatric,” and “immersive” were then added. A hand search of reference lists of included studies and previously published systematic reviews was also conducted.A meta-analysis could not be conducted due to differences in study designs and types of controls. A descriptive synthesis is presented.Virtual reality is not a standard intervention and there are numerous ways in which the technology itself can be applied. It can be used to create a fully or partially virtual world . MazurekA further distinction in VR technology is whether the experience is immersive or non-immersive. VR is considered immersive when a head-mounted display (HMD) is used. When the virtual environment is presented on a flat screen  the experience is considered non-immersive . When usSome studies have found Immersive VR to be more effective in promoting analgesia than non-immersive VR systems –17. AustOthers have found that the success of VR is not dependent on having an HMD . Mott etWithin immersive VR systems, it is now possible to create interactive experiences. Portable and affordable motion tracking systems allow for movements of a virtual body, called an avatar, to be controlled by movements of the user's real body . Even moInteractive VR was used in a randomized controlled trial of 48 healthy volunteers to investigate the intensity or level of distractibility of the VR technology used. Two VR conditions were compared – interactive VR using eye-tracking integrated into the helmet and passive/no eye-tracking VR. Each participant received two nociceptive thermal stimuli – one during the active VR condition and one during the passive VR condition (order randomized). Active VR decreased the ratings of pain unpleasantness and pain severity. The subjects also reported higher levels of feeling “present” and greater immersion, supporting the theory of attention distraction in pain relief .Pain is a complex and dynamic phenomenon. From the nociceptive stimulation to the perception of pain, several endogenous mechanisms can increase or decrease the signal, changing the pain experience. The final experience of pain implies a sensory activation to identify location, intensity or duration of the nociceptive activity. This sensory component of pain is generally related to activities in brain structures such as the somatosensory cortices S1 and S2 . But theCognitive and affective components can have a positive effect in the treatment of pain. Bushnell et al. assert that life-style choices or mind-body techniques, such as the practice of meditation or yoga, can reduce pain perception . MeditatAhmadpour et al. explain the construct of distraction in relation to VR . They deMelzack's Neuromatrix Theory of Pain supports the theory of distraction, asserting that inputs such as cognition, sensation and affect can alter pain output. Not only is this mechanism linked to the perception of pain, it differs from the mechanism used by many analgesics that disrupt pathways that transmit nociceptive signals to the central nervous system , 33. BecVirtual reality adds the dimension of immersion and heightened distraction by appealing to many senses and gaining more of the patients' attention. Virtual environments use head tracking systems, tactile feedback and highly stimulating visual and auditory sensations. In this way, the individual becomes immersed in the virtual world, taking attention away from the perception of pain . MechaniGold et al.  explore Recent studies suggest that VR pain reduction is at least partially triggered by descending pain inhibitory mechanisms originally known as Diffuse Noxious Inhibitory Mechanisms from the Le Bars animal studies , 36 and Studies comparing CPM and distraction in the same subjects suggest different mechanisms and possible additive effects . Moreovevia the fibers descending from the periaqueductal gray (PAG) area of the midbrain, analgesia was achieved. “The discovery that the PAG receives inputs from a variety of areas of the brain, notably cortical regions involved in attention and emotion, suggests that modulation of the descending pain-control system may underlie the profound effects of attention and emotion”  is another region of the brain that is important in understanding the way in which VR may mediate pain perception. Bantick et al. assert that the perigenual ACC mediates attentional processes and emotional reactions to pain . This fiGold et al.  hypothesResearch has also found specific autonomic responses when comparing VR and a 2D distraction video of the same scene. The authors showed that autonomic responses recorded by heart rate variability and galvanic skin responses had significantly higher parasympathetic activity during the VR session, suggesting a release of the tonic sympathetic activity normally recorded during thermal stimuli as used in this project . InteresFinally, recent studies with chronic pain patients suggest that there may be an additive effect of the repetitive use of VR . The aboHunter Hoffman and David Patterson are recognized as pain specialists and VR pioneers. They are both researchers at the University of Washington and have worked for over 20 years to demonstrate VR's unique ability to alleviate acute pain. Their seminal work was conducted with burn patients. They developed a VR game called SnowWorld where patients use wide-view goggles, an audio headphone, and a simple hand controller to interact with snowmen, igloos, penguins, wooly mammoths, and flying fish by throwing snowballs , 52. ImmHoffman et al.  then conThe majority of early studies on VR and pain targeted burn patients as participants due to the levels of pain, discomfort and anxiety experienced , 20. TheNot all early research found a positive relationship between the use of VR and the mediation of pain. Mahrer and Gold provide a review of early research into VR and pain analgesia, finding differing results across studies . Some deBy far the majority of research on pain and VR has been in the area of acute pain or pain associated with procedures. Additional research is needed to understand the role of VR in managing chronic pain. The small number of studies completed indicate positive potential. Sarig-Bahat et al. used VR to promote range of movement in people with neck pain and found a significantly reduced level of pain .A study of 30 patients with chronic pain from many conditions (and therefore not controlling for pain type or location) was conducted where participants were provided with a fantasy world immersive VR session of 5 min. There was a statistically significant effect of pain reduction in the VR conditions. Pain was reported to be reduced by 60% between the pre-VR vs. during the VR session. The pain decreased by 33% between the pre-VR condition and the post-VR condition, demonstrating the lasting impact of the effect .A systematic review and meta-analysis of VR as an analgesic for acute and chronic pain in adults by Mallari et al. suggests that the results of studies exploring the use of VR in mediating chronic pain are not consistent. They speculate that VR may effectively reduce chronic pain intensity during and possibly immediately after the VR exposure. However, they do not believe there is likely to be a lasting analgesic effect in patients with chronic pain conditions with the treatment protocols tested to date . They prRecent studies using a home-based VR treatment over a period of 8 weeks found a significant effect for VR compared to a sham VR . These rWhen considering the use of VR for chronic pain, the question of whether one can become habituated to VR has been raised, but research does not support this. Rutter et al. found that over eight sessions of VR the significant decrease in pain intensity, anxiety and thoughts of pain remained across the administrations of a cold pressor . And earThe impact of VR on pain tolerance and pain threshold has been further investigated in healthy populations, demonstrating a significant effect in increasing the threshold and tolerance levels . In thesAnother study in a healthy population was conducted by Loreto-Quijada et al.  in orderHoffman et al.  investigResearch in healthy populations allows for the control of numerous variables, but whether this research can be extrapolated to patients who are suffering from clinical pain that is beyond their control, is unclear.The question of whether VR can be successfully used to mediate pain in pediatric populations has been posed by many researchers. A large random controlled trial (RCT) by Sharar et al.  found siAminabadi et al.  found a In 2018 Gold and Mahrer undertook a randomized control study of 143 patients having blood drawn. The age range was between 10 and 21 years, and findings demonstrated lowered levels of pain for the VR condition and lowered levels of anxiety, with the effect of lower anxiety most prominent in those with reported high anxiety . DahlquiAdditional randomized studies have demonstrated the effectiveness of VR in pain management in a variety of medical circumstances, including adolescents with cancer undergoing lumbar puncture , pediatrIannicelli et al.  publisheA recent (2020) review of 17 RCTs investigating VR distraction for acute pain in children included 1,008 participants aged 4–18 years, undergoing various procedures in healthcare settings . Again nResearch results are thus mixed and while use of VR for mediating acute pain in pediatric settings has yielded some positive findings, it is clear that future well-designed, large, high-quality research studies are required to validate these findings. This research will likely need to isolate cases where VR is successful based on age cohorts, the type of procedure, and the type and dosage of VR used. In addition, the distinction between state anxiety and pain perception must be clarified and the interconnectedness of the two states investigated as part of the research, along with other emotional states. The content of the VR application also makes a difference on efficacy, for example, game-based VR was more effective in managing pain in children, while adults preferred relaxing environments . ContentOverall, VR has been found to be effective as a complementary form of pain management. The significant findings discussed in this review illustrate the benefits of VR to manage pain. VR is indicated for use in severe clinical cases and also in less severe instances if the cost-benefit is demonstrated . The extWhile the majority of results have been positive, it is noted that many studies have small sample sizes, are case studies and do not control for extraneous variables such as the interrelationship between pain and anxiety, and the dosage and type of VR technology used. There are also mixed results for the use of VR to treat chronic pain, and to treat both acute and chronic pain in pediatric populations. There is a necessity to conduct larger RCTs to better understand the use cases for which VR is most effective. Mallari  recommenThe cost of VR has resulted in the majority of studies being conducted in clinical settings. As the price of technology decreases and as VR becomes more ubiquitous, the potential to include the technology in home-based care in the longer term should be investigated , 32. VR The number of studies on VR and pain illustrates the interest, efficacy and potential of this area of development for pain management and treatment . The effAs our understanding of VR as a complementary form of pain management improves, the use of VR is likely to proliferate. This is an exciting area of inquiry and promises to yield multiple applications.Both authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This report describes the essential steps in the development, implementation, evaluation and quality assurance of the written part of the Swiss Federal Licensing Examination for Human Medicine (FLE) and the insights gained since its introduction in 2011.Based on existing scientific evidence, international expertise, and experience gained from previous examinations, the FLE is developed by experts from all five medical faculties in Switzerland with the support of the Institute for Medical Education and is held simultaneously at five locations. The exam organisers document and review every examination held and continuously optimise the processes; they have summarised the results in this report. The essential steps comprise the development, revision and translation of questions; construction of the exam and production of materials; candidate preparation; implementation and analysis. The quality assurance measures consist of guideline coherence in the development of the questions and implementation of the exam, revision processes, construction of the exam based on the national blueprint, multiphase review of the translations and exam material, and statistical analysis of the exam and the comments from candidates. The intensive collaboration, especially on the part of representatives from all the participating faculties and a central coordination unit, which provides methodological support throughout and oversees the analysis of the exam, has proven successful. Successfully completed examinations and reliable results in the eleven examinations so far implemented represent the outcomes of the quality assurance measures. Significant insights in recent years are the importance of appreciating the work of those involved and the central organisation of exam development, thus ensuring the long-term success of the process.Common guidelines and workshops, quality assurance measures accompanied by the continuous improvement of all processes, and appreciation of everyone involved, are essential to carrying out such an examination at a high-quality level in the long term. Swiss Catalogue of Learning Objectives for Undergraduate Medical Training (SCLO) [Principal Relevant Objectives and Framework for Integrative Learning and Education in Switzerland (PROFILES) [http://www.profilesmed.ch/]). On successful completion, the candidates may practise their medical profession under supervision and commence their further medical training. The examination consists of two parts , , ). There n Canada , 10] or orcommitn Canada , 12] or orcommitn Canada  tests inOverall, there are only few publications on how to develop a high-quality written exam designed specifically as a national licensing examination. Considering the additional aspect of bilingual implementation, even fewer reports can be found. This report follows up on previous publications concerning the Swiss FLE , 3]. It. It3]. IThe MC exam is an examination with two parts, each of which consists of 150 MC questions to be completed in 4.5 hours. It is closely coordinated and takes place simultaneously at all five medical faculties. For general information on this examination, please refer to the previously published overview article . In addiThis project report is based on the experience gained from the eleven written federal examinations held since 2011. After each examination season, the recent exam along with quality assurance and quality indices are reviewed and documented to ensure continuation of what has proven effective and to identify potential areas for improvement. The essential development, implementation, evaluation and quality assurance steps, along with the insights, are collated by the exam organisers in an iterative process. The examination process is explained in detail below. Figure 1 https://www.iml.unibe.ch/themen/uebersichten/projekte].Around 60 experts nominated by the faculties write draft questions that are discussed and, if necessary, revised in author groups (peer review) during the first day of a two-day workshop. On the second day of the workshop, the new questions are reviewed for a second time and finalised in editorial groups consisting of at least one representative from each faculty and representatives from different medical disciplines. Any old questions that were created five years previously or were conspicuous in the most recent examination due to statistical deviations or candidate comments are reviewed for their relevance and revised by the same editorial groups. Following a centralised formal and linguistic review of the new questions by methodology experts at the IML, the questions are examined by a national review board  to verify their suitability (level of difficulty) and clinical relevance before they are approved in the database for construction of the next exam. The questions are managed using software developed at the IML . The current blueprint consists of three main dimensions: A total of 300 questions are selected from the question database for each examination in line with the nationally applicable blueprint . Type of condition  and setting  are further dimensions of the blueprint.Dimension 3: To prevent the strategic omission of individual fields of knowledge during study, the percentage target values are not published and thus are not specified in the table. At least 20% of the questions that have proven effective in previous examinations are used. The compatibility of learning objectives and exam questions is guaranteed by the clear definitions provided in the examination regulations, and content-wise by the blueprint and the criteria for the types of questions selected. The representative distribution of the content is ensured by the blueprint and by the candidate survey following the exam using a questionnaire with open-ended and closed-ended questions. By tagging the questions in the question database, compliance with the blueprint is supported.Analysis of the questionnaire revealed that it is important to many candidates to cover the studied subjects as comprehensively as possible (comments on open-ended questions in the questionnaire) and to have questions that in terms of content reflect the learning objectives  to 5 (completely agree), closed-ended question in the questionnaire). Compliance with the blueprint and broad coverage is only possible thanks to detailed tagging of the questions.The templates for the exam booklets are generated from the question database and printed before being sent to the faculties. The subjects covered by the questions are divided equally between the two exam booklets; the length of the text in each booklet is identical.The quality of the exam booklets is assured by means of multiphase review involving verification of the content and formal aspects (form and language) by experts.Despite the preceding revision process during question development and translation, anomalies are still occasionally detected when reviewing the print proofs. These are checked and corrected by physicians during a content review phase.https://www.iml.unibe.ch/angebote/assessment/pruefungsdienstleistungen/self-assessment]. Candidates can obtain information from the website of the Federal Office of Public Health and faculty informational events concerning the examination procedure  and receThe preparatory information is reviewed every year and adapted, as necessary. Feedback from the candidates in the questionnaire and argumentation in objections to the exam result have shown that not all candidates actively study the information provided prior to the exam. Hence, this information is also sent directly to each candidate in advance.The exam takes place on two days at the same time (4.5 hours each) at five faculties. The exam is taken not only by successful graduates of master’s programmes in Switzerland but also by candidates holding unrecognised foreign medical qualifications issued outside of the EU/EFTA.Common guidelines on exam implementation regulate the conditions of the examination premises, aids permitted, and instructions to be read out during the exam, for example. Some candidates find it difficult to absorb information or instructions on the day of the exam. Hence, they additionally receive all the information in advance. Suggestions entered in the questionnaire by the candidates help to continually improve the procedure.An item analysis is performed for every exam question set (assessment of item measurement properties). Difficulty and discrimination are primarily assessed; these remain visible in the question pool. If a question is reused, it can thus be compared across different exam years. The aim is to achieve a minimum of 0.2 as the item discrimination index (r), and 50-90% for P as the degree of difficulty. The multiple true/false questions of the Kprim type are analysed using the half-point method developed at the IML .The exam results and candidate comments on questions that appear to be flawed are initially analysed by methodology experts. Conspicuous questions are discussed with several clinical experts and excluded from the analysis if formal or content-related deficiencies are detected: for example, if a question that is too difficult is found to be of “specialist” level, or a previously overlooked formal error is identified when the r value is too low. The passing score is based on two internationally recognised standard-setting methods  and an The final decision concerning the passing score is made by the national board of examiners. Formal or content-related deficiencies in exam questions discovered during the analysis are reported to the authors and the review board so that the next round of question development can be optimised accordingly. Questions with poor difficulty and discrimination scores and content-related deficiencies are not reused. All important analysis steps are carried out under the four-eyes principle: prior to publication, the most important results are reviewed by a second individual based on a checklist. For example: Was the passing score ultimately agreed by the board of examiners and recorded in the meeting minutes actually applied in the results lists, the charts in the analysis report, and in the letters to the candidates? Are the answers on the answer sheets of candidates who have failed actually consistent with the electronically recorded answers considered in the results calculation? The analyses represent an essential final step in assuring the quality of the entire examination process; further details are provided in Chapter 4 of . Continuously optimised quality assurance measures throughout the examination process, including reporting of deficiencies discovered in the exam questions to the authors and the review board, mean that the number of questions having to be excluded from the analysis due to formal or content-related deficiencies has continually decreased over the years (approx. 40 from the first (13.3%) and about 15 (5%) from the most recent examination). The results from the eleven examinations implemented to date revealed thoroughly reliable exam results . Figure 2 Important quality assurance measures entail, among others, the common guidelines on the development of questions and implementation of the examination, the preparation of questions in national workshops, the multiphase revision process involving all faculties, construction of the examination based on the national blueprint, and multiphase review of the translations and the exam material. Analysis of the examination, including analysis of candidate comments, is a final, significant quality assurance step in the entire examination process. Though Edwards et al.  also desThe correlation between the written exam results and the results of the practical exam  suggests that the questions offer a degree of practical relevance given that the tasks set in the OSCE are practice orientated. We believe that, in the future, it would be desirable to verify that those graduates passing this entire exam  are also providing their patients with appropriate care as competent doctors. This association is evident from similarly standardised, quality-assured examinations abroad , 22], , , 24]..24].It is important to note that this article addresses the multiple-choice part only, which becomes a complete examination  when suphttp://www.profilesmed.ch/] such that candidates from Switzerland are better prepared for the examination. Another explanation may be that most candidates with unrecognised foreign medical qualifications have pursued their further training in one discipline and are no longer so familiar with the general exam content. Appreciation for the work of those involved and the central organisation of exam development are two of the major insights gained in recent years that are essential to the long-term success of the process. The appreciation of those involved in medical teaching is a key aspect, as the clinical and scientific activities are frequently given a higher weighting when they are more conducive to individual careers. It can therefore prove difficult to find suitable individuals for teaching positions and assessment tasks, in particular. This appears to be a common challenge, as (inter)national surveys have shown . A. Ahttp:/ve shown . The strengths of this report lie in the fact that it is based on the many years of practical experience gained by the various participants in the development, implementation and evaluation of this national examination, which is currently held in two national languages at five locations. The exam results have proved thoroughly reliable in the last eleven years, which is very much due of course also to the large number of exam questions.One weakness is that this report is based on experience that has not been subjected specifically to scientific study. However, the insights discussed are based on a continuous optimisation process that is thoroughly documented, traceable, and comprehensible, and has been summarised by the authors for this report. http://www.profilesmed.ch/]. The blueprint is now based on this framework, accordingly. The structure of the blueprint, in particular, has therefore been simplified. There are fewer dimensions, for instance, as the previous dimensions of “age” and “gender” and part of the old “medical action” dimension are already considered under the “situations as starting points” of PROFILES, and could be deleted or shortened accordingly. On the other hand, the differentiation under “setting”  is now greater than in the SCLO , as the precise setting of the described case is often critical to eliciting the correct answer. Furthermore, the previous dimension of “problems as starting points” has become “situations as starting points” in PROFILES, with physiological situations also listed , and disciplines such as “emergency” and “palliative care” occupying a more prominent position. It has also been decided that, as of 2022, the written examination will be implemented digitally at all sites using tablet computers. Consequently, new question types can be used in the future that will permit in large part the automated analysis of free texts based on long menus [Looking ahead, it can be said that the development of this examination will steadily continue. Since 2021, the examination has been subject to the new “PROFILES” set of learning objectives [ng menus ; videos Common guidelines, joint workshops, quality assurance measures with ongoing optimisation of all processes, and appreciation for all involved, are essential to carrying out such an examination at a high-quality level in the long term. A national examination can only be achieved with the support of countless dedicated individuals. Our special thanks go to the participants of the workshops and review boards, and those responsible at the sites. We also thank the board of examiners and the Federal Office of Public Health for their valuable input and support.The authors declare that they have no competing interests.


Food safety issues are inextricably linked to people's lives and, in extreme cases, endanger public safety and social stability. People are becoming increasingly concerned about food safety issues in a modern society with high-quality economic development. People's incomes are increasing day by day as the economy continues to grow, and the tourism industry has grown by leaps and bounds. However, many problems arose, such as the issue of food safety in tourism. Tourism food safety issues affect not only the development of the food industry but also the development of tourism. Food safety oversight of tourist attractions has always been a relatively concerning issue in the country, and it is also something that the general public is concerned about. It can be said that food safety supervision of tourist attractions is the most important thing in food safety supervision. In this context, it becomes an important task to evaluate the safety of tourist food. This work proposes a multiscale convolutional neural network (AMCNN) combined with neural networks and attention layers to realize the safety and quality evaluation of tourist food. The algorithm uses the lightweight Xception network as a basic model and utilizes multiscale depth-separable convolution modules of different sizes for feature extraction and fusion to extract richer food safety feature information. Furthermore, the convolutional attention module (CBAM) is embedded on the basis of the multiscale convolutional neural network, which makes the network model focus more on discriminative features. Tourism has become an important part of people's daily lives, and holiday travel has become a very important way of consumption for people to meet their daily needs. China not only has a large population but also is very rich in tourism resources. Tourism includes play, food, accommodation, shopping, and many other aspects and plays an important role in promoting the development of the national economy. Food in tourist attractions is an important part of tourism, and food has always played an important role as an element in the process of tourism. Particularly, now, a lot of tourism activities are themselves food-centric. For example, various food festivals and beer festivals are often held all over the country, and the purpose of tourism is to consume various foods, so the importance of food safety in tourism is obvious. Food safety is a priority for most people. Food safety in tourist attractions not only is related to the health of every tourist but also highlights the image of a region as well as the economic development and social stability of the region. In the tourism income of domestic tourists, the proportion of the main tourism of the six elements of food, accommodation, travel, shopping, and entertainment is not large, and the scenic spot ticket income only accounts for 2.37% of the total tourism income. However, the income from eating, accommodation, transportation, shopping, entertainment, and so on generated by its drive accounted for 97.63%, and food consumption accounted for a large proportion –5.Tourism food safety mainly covers the following points: first, the catering services that tourists receive in restaurants, tourist attractions, and the means of transportation they take; second, buying special food products in tourist attractions and on the way; third, the catering services, food shopping, and picking activities that tourists receive during the travel process that may have food safety problems. Particularly in some tourism products centered on food, such as some food festival tourism and snack square tourism, it is more likely to become the source of food safety problems. First of all, the country has a large population and a large tourist population base. Once a tourist food safety problem occurs, its control and investigation are extremely difficult. Second, consumers are highly mobile, and some specific travel groups may even travel across multiple provinces or even countries or regions along the travel agency's established routes. As a result, food safety incidents can be far away from where they occur and where they are discovered. Then, there is a big difference in the number of tourists in the peak and low seasons of tourism. This results in the neglect of food safety issues due to the increase in the number of receptions during the peak tourist season, thereby increasing the chance of food safety issues. Finally, the economic base of tourist destinations varies widely. Some tourist destinations with poor economic foundations have relatively weak food safety awareness and food safety supervision. At the same time, limited by the local equipment and sanitary conditions, it is difficult to provide a scientific and effective food safety guarantee for tourists –10.Studying the evaluation of food safety and quality extensively.Designing a deep learning-based method for evaluating food safety and quality using the AMCNN method.Performing detailed experimentation to support the effectiveness and efficiency of the proposed system compared with existing algorithms.The main reasons for the safety and quality of tourism food are as follows. First, the potential food safety crisis in the tourism food industry chain is a complex system, and the links included in the industry chain vary with the type of tourism food. Generally speaking, the main components of the tourism industry chain include six major links: planting (breeding), processing, storage, transportation, sales, and consumption. Any problem in any link will have a negative impact on the health and food safety experience of tourists. Since the tourism food industry chain is long, problems in each link will have an impact on the safety of the final tourism products, further increasing the probability of tourism food safety problems. At the same time, it also increases the difficulty for the regulatory authorities to investigate and supervise food safety incidents. Second is the information asymmetry in the tourism food industry chain. Particularly between tourists and tourist food producers and operators, there is a high degree of information asymmetry. Tourists have little knowledge of local tourist food information after entering a specific tourist area. However, travel agencies and tourist food operators often transmit information on the quality and safety of tourist food through selective filtering from the perspective of their own interests, which misleads tourists' consumption choices to a certain extent. Third, the scale of the tourism food industry chain is not large. Due to the remote location of most tourist attractions and weak food supervision capabilities, small workshops and self-employed individuals are the main forces in the production and operation of tourist food. These practitioners lack safety and hygiene awareness and have not received relevant food safety training. In the market competition, the strategy of sacrificing quality to reduce prices is often chosen, which brings serious hidden dangers to the food safety of tourist attractions –15. ThesThe remainder of the paper is structured as follows. Tirado et al.  studied Havelaar et al.  establisNguyen-Viet et al.  conducteBelluco et al.  systematThis work combines the safety and quality of tourism food with neural networks and proposes an AMCNN to realize the safety and quality evaluation of tourism food.The convolutional neural network is developed from the multilayer perceptron, which overcomes the defect that the multilayer perceptron network is difficult to extract high-dimensional feature information from. The CNN method is widely adopted in several applications, such as hand-gesture recognition  and signThe convolutional layer uses the local connection to extract local information, which is the basic unit. Each convolution layer is composed of a certain number of convolution kernels and bias items of the same size, and local perception and feature extraction are performed on image features through multiple convolution kernels. The initial part of the convolutional layer mainly extracts local information such as edges and textures, while the second half of the convolutional layer can iteratively abstract and integrate local features so as to extract global features with better discrimination. During network training, the BP is utilized to continuously adjust the parameters of the convolution unit to obtain the best extraction effect. And by changing the number, size, stride, and other convolution parameters of the convolution kernel of the convolution layer, one can get different feature maps. The convolution operation is as follows:The pooling layer is mainly located between the two convolutional layers, and its function is to reduce the dimension of features while preserving useful information as much as possible. It can extract main features, remove irrelevant information, and reduce the parameters of the model. The pooling process is invariant to rotation, translation, scaling, and so on and reduces the size of the originally large feature map. This greatly reduces the parameters in the next layer, reduces the amount of parameter calculation, and avoids the occurrence of overfitting. Commonly used pooling layers include an average pooling layer and a maximum pooling layer. Average pooling is to select all elements in a specified rectangular area and take the average value as a new feature value. Maximum pooling is to select all elements in the specified rectangular area and take the maximum value as the new feature value. The pooling operation is as follows:The FC layer, as the name indicates, links two neurons with weights, and the fully connected layer is often located at the end of the convolutional neural network. To extract features from the data, a convolution and pooling process are used. After that, all of the newly acquired feature information is transferred to the sample space via the completely linked layer, allowing the samples to be fully feature classified. The FC operation is as follows:The activation function is generally used after the convolution and pooling operations, and the basic convolution modules composed of the same convolution layer and pooling layer are continuously stacked to complete the feature extraction. Among them, the convolution operation extracts features, the pooling operation completes data dimensionality reduction, and the activation function introduces nonlinear mapping. All the three are progressive. This enables the convolutional neural network to approximate any nonlinear function curve, extract complex and diverse nonlinear features, and solve complex practical problems.The Sigmoid function maps the input value to a fixed interval and performs well in multiclassification problems, but the function has obvious shortcomings. First, if the input is far to the left or right of the origin, the gradient value passed will be wirelessly close to 0. This results in slow parameter updates, long network training times, and, worse, gradient explosion and gradient vanishing problems. Secondly, the function contains exponential exponentiation, which requires a large amount of computation and slow training. Finally, its mean is not 0, and the resulting gradient is always positive or negative. The center point of the Tanh function image is 0, and the output value ranges from −1 to 1. This function is very similar to the Sigmoid function, but it has a wider sensitive area and is easier to train. The function still has the problem of saturation and exponentiation, so the disappearance of the gradient is also an inevitable disadvantage of a large amount of calculation.The ReLU function is only derivable in the positive interval, and the derivative is always 1, which effectively solves the problem of vanishing gradients in backpropagation calculations. And the function structure is very simple; the positive and negative intervals are linear functions, the calculation amount is extremely small, and the calculation speed and convergence speed are very fast. The output of the negative interval of the function is always 0, and the neurons in it will not be trained. This makes neurons more sparse, reduces the interference of irrelevant information, and helps to better extract relevant features. The disadvantage of the ReLU function is that the gradient of some neurons may always be 0, which makes the neurons inactivated, and some parameters cannot be learned.On the basis of Inception V3, the Xception network model integrates depthwise-separable convolution into the network model. As part of the Inception network, the convolution calculation procedure is broken up into numerous distinct processes in order to fully decouple spatial correlation and cross-channel correlation. For the Inception module, cross-channel and spatial correlations are initially addressed. The standard Xception structure is shown in The higher the channel blocks, the more plausible the assumption of complete decoupling of spatial and cross-channel correlations. With the above analysis, Xception is proposed. It first maps the cross-channel correlation through a 1 × 1 convolution and then maps the spatial correlation in a separate space on the output channel of the convolution. Xception can realize that each channel corresponds to one block, making the convolution separable. In Xception, a connection structure similar to ResNet's residual structure is used, which greatly speeds up the convergence speed while using depthwise-separable convolution to increase the network width. Xception is demonstrated in In the evaluation of tourism food safety quality, Xception not only reduces the number of network model parameters but also improves representation for the network and improves performance for tourism food safety quality evaluation.From a mathematical point of view, the attention mechanism is essentially a weighted operation and the distribution of weights. For the critical and effective part of the feature information, a relatively large weight will be assigned to the part. For the feature information that is not useful, a relatively small weight is assigned. The purpose is to strengthen effective information and suppress useless information.All CNNs may use CBAM, which is an efficient and straightforward module. The module is gradually merged into an attention map in spatial and channel dimensions in the intermediate feature map. A multiplier is used to increase the number of optimal features based on the input feature map and attention map.The connection between feature channels is used by the channel attention module to produce a channel attention map. Each channel for the feature map is a detector, so spatial dimension is reduced to further increase computational efficiency. The most common method for aggregating spatial data is to use average pooling. More precise channel attention may be obtained using maximum pooling, which primarily extracts another unique object characteristic clue. As a result, the employment of both max and average pooling layers can greatly boost the network model's capacity to represent data. It is typically not recommended to utilize two pooling layers alone.The spatial attention module forms a spatial attention map based on spatial relationships. The difference from channel attention is that spatial attention focuses on location. When computing spatial attention, average pooling and max pooling are used first. These two functions are combined to form feature descriptors, and pooling operations are applied along the channel axis to make the information regions more prominent.CBAM mainly consists of two steps. First, in terms of channel dimension, two channel descriptors are pooled using max pooling and average pooling, and the two channel descriptors are merged by channel dimension at the same time. Second, the information is compressed into one channel descriptor using global average pooling and global max pooling in the spatial dimension of the merged channel descriptors. The weight matrix aggregated in the compression operation is calibrated, and the dependencies between pixels are modeled on the basis of the above operations. The feature map is then convolved with a hidden layer containing a single convolution kernel to generate the final weight calibration.This research develops the Xception network model for the quality of tourism food safety by widening the receptive field and extracting crucial and richer information to improve the evaluation performance. Depth-separable convolution is the foundation of the Multiscale Convolutional Unit (MCU). The MCU replaces the original single convolution kernel with 3 × 3, 5 × 5, and 7 × 7 convolution kernels, respectively. They can extract different features, and the fusion of their features can generate richer feature information, improve representation for network models, and thus improve the performance.The network structure of the attention-based multiscale lightweight network (AMCNN) designed in this paper is illustrated in First, the data is input into two 3 × 3 convolutions with 8 channels for shallow feature extraction. Then, the features of tourism food safety and quality data are extracted by MCU. The number of channels is 16, and the step size is 2. A total of 48 output channels may be generated from the fusion of characteristics derived from separate receptive fields. This is followed by four depthwise-separable convolution modules, which extract features from the fused data and build up a multiscale Xception model. As a final step, the attention module is implanted into the final network model, which selects the most important aspects from the data and eliminates all other nonessential ones. Then, global average pooling is performed and sent to softmax for tourism food safety and quality assessment.Machine learning and deep learning-based methods are widely used in food safety review, food processing monitoring, foreign object recognition, and other domains. These approaches offer researchers and businesses faster and more efficient working systems and make it possible for customers to acquire safer food. The systems' processing capacity can be enhanced to a large extent, especially when using machine learning or deep learning methods.This work uses a self-made dataset for related experiments, which contains a total of 29,038 training samples and 12,031 test samples. The input feature of each sample is an 8-dimensional feature, and the specific information is shown in Firstly, the extremely important training process in the neural network is analyzed, and the change in the training error of the network is illustrated in In the beginning, as the amount of training increases, the loss decreases rapidly. After reaching a certain number of iterations, the loss no longer decreases significantly, indicating that the convergence state has been reached.To verify the effectiveness and advancement of the AMCNN method in this work, it is compared with other methods. The experimental results are illustrated in AMCNN can achieve 93.7% accuracy and 91.1% recall, corresponding to the best performance in the table. Compared with the CNN method, 1.6% accuracy improvement and 1.5% recall improvement can be obtained.To verify the effectiveness of using the Xception structure in this work, we compared it with the performance when using Inception. The rest of the parameters of the network remain the same, and the experimental results are illustrated in Compared with using the traditional Inception structure, using Xception can achieve 1.8% accuracy and a 1.4% recall improvement. This verifies the validity of using the latter in this work.To verify the effectiveness of this work using the CBAM attention mechanism, we compared it with the performance without CBAM. The rest of the experimental parameters remain unchanged, and the experimental results are illustrated in Compared with not using the CBAM attention module, we can get a 2.3% accuracy improvement and a 1.8% recall improvement after using this module. This proves that CBAM can guide the network to learn more discriminative features, thereby improving model performance.To verify that the multiscale features extracted by the MCU module can promote model optimization, the performance without MCU is compared with the evaluation performance after using MCU. The experimental results are illustrated in Compared with not using the MCU attention module, we can get a 2.6% accuracy improvement and a 2.4% recall improvement after using this module. This shows that multiscale features can effectively improve network performance.This work compares the effects of different activation functions on network performance, and the compared methods are Sigmoid, Tanh, and ReLU. The rest of the experimental parameters are set unchanged, and the experimental results are illustrated in Compared with the Sigmoid and Tanh activation functions, the ReLU activation function can achieve the best performance improvement. Therefore, in this work, ReLU is uniformly used for nonlinear processing of features. The proposed model can be enhanced by devising distributed neural networks, which works in a decentralized structure , 35. TheTourism food safety refers to various safety problems that may be caused by the food consumed by tourists in the process of tourism. It includes the main aspects of tourists eating in vehicles or scenic spots during the travel process, purchasing various local specialty foods, or picking their own food during the travel process. Due to the rapid increase of the current national income level, tourism has become the main consumption mode of people in modern society and an important part of the national economy, and the food safety associated with tourism has also attracted attention. Therefore, it becomes an important task to evaluate the safety of tourist food. This work combines it with neural networks and proposes an AMCNN to realize the safety and quality evaluation of tourist food. First, this work selects Xception as the base network. Secondly, in order to extract more abundant features of information about tourism food safety and quality, the depthwise-separable convolution in the network has improved. It uses depth-separable modules with different convolution kernels to extract data features at multiple scales and, at the same time, fuse the extracted multiscale feature information. Finally, the convolutional attention module is introduced on this basis to strengthen the effective feature information in channel and space and suppress the useless feature information. Extensive experiments verify the feasibility of the AMCNN method for food safety and quality evaluation. The proposed model can be enhanced by devising distributed neural networks, which works in a decentralized structure. The accuracy of the model can be further improved by utilizing optimization methods.


New developments on biomaterials are important in surgery. The behavior of a new membrane produced from sugarcane will be evaluated in the middle ear of rats.Aim: This study analyzed the results from the interaction of the sugarcane-base biopolymer membrane in the middle ear of a rat.Materials and Methods: We ran an experimental, prospective, paired study with 24 Wistar rats. The sugarcane-base polymer membrane was inoculated in the right ear; and an autologous fascia in the left ear. The rats were divided in 3 groups of 8, and slaughtered at 4, 8 and 12 weeks after surgery. Histological analyses were performed on the rats' middle ear mucosa and their tympanic membranes.Results: There was an inflammatory reaction on the experimental group and middle ear subacute exudate in 50%of the cases; 30% chronic exudate; and 20% was normal. In the control group there was only one case of exudate. The inflammation was initially described as intense, but it decreased over time. Myringosclerosis was observed in both groups. The sugarcane biopolymer membrane was absorbed later when compared with fascia.Conclusion: The sugarcane biopolymer membrane induced an inflammatory reaction in the middle ear which decreased over time, and mild fibrosis. Future studies can indicate its use in otolaryngology. The materials used in surgery can be classified into biological and synthetic, according to their origin (either organic or not)The autologous materials used for grafting are fat tissue, perichondrium, cartilage, dura mater, periosteum from the temporal bone and fasciaThus, other types of materials are being considered to be used as graft, such as support material or as healing adjuvants for the surgical wound in middle ear surgery. The biocompatible materials used to replace human tissue or to help heal wounds cause some degree of inflammation. Such inflammation, however, must not be very intensive, but enough to cause tissue repair.® and the Epifilm® are membranes made up from an ester of hyaluronic acid, however with poor results when used as graft material in tympanoplastyEpidiscWithin this concept of new biomaterials we have the biopolymer. A biopolymer is a macromolecule made up of numerous monomers. The polymers which derive from vegetal oils, such as latex, are already being tested in human beings. In ear surgery, one latex membrane from the rubber tree was used to coat the surgical neocavity of the canal-wall-down tympanomastoidectomy and caused early wound healingZoogloea sp., when this bacteria is within a medium rich in sugar cane syrupThe sugar cane biopolymer is made up of numerous exopolysaccharides, 87.6% is glucose. The polysaccharides are synthetized and excreted by the in natura, with residual sugars, was used as dressing in the treatment of accidental injuries in dogs. The dressings caused: increased in granulation tissue, infection control, and shorter healing timeThe biopolymer Brazil is the largest sugar cane producer in the world. The possibility of developing a new biocompatible material, which can be used in ear surgery, produced from a raw material which is abundant in our country has encouraged us to run the present study.Rattus norvegicus albinus), weighing 335 to 440g (mean weight of 392g), with about four months of age. The study design was: experimental, prospective and paired. As exclusion criterion we considered any middle ear change or TM change (perforation or tympanosclerosis).We used twenty-four albino, male Wistar rats , the autologous abdominal fascia was introduced with the same dimensions of the polymer membrane, in the same shape as per described for the experimental group.In the ears of the experimental group (right side), the TM was perforated in its The rats were randomly broken down into two groups of eight animals in each: group t1 (slaughtered after 4 weeks of surgery), group t2 (slaughtered after 8 weeks) and group t3 (slaughtered after 12 weeks). After slaughtering, the tympanic bullas were submitted to histochemical processing with decalcification and inclusion in paraffin. The slides were dyed with hematoxylin and eosin (HE). In some slides we used the Picrosirius Red (PSR) besides the HE.Histocompatibility was assessed by an experienced pathologist, and had the following criteria: the inflammatory reaction intensity caused by the presence of fibrosis in the tissue in contact with the material. We observed signs of inflammation and fibrosis in the mucosa and the TM. We also investigated the likelihood of the sugar cane polymer membrane be absorbed in the middle ear of the rats.The type of inflammation was divided into acute, subacute and chronic. The acute histological pattern is characterized by the exudation of liquid and plasmatic proteins (edema) and the migration of leucocytes, especially neutrophils. The chronic pattern is characterized by the presence of lymphocytes, macrophages, blood vessel proliferation, fibrosis and tissue necrosis. The subacute type is defined by the inflammatory reaction with components of the acute and chronic patterns occurring simultaneously.Some semi-quantitative criteria were adopted. The intensity of the inflammatory process was described based on the finding of cellularity in the exudate, on the extension of the process through the tympanic bulla and by the presence of cell necrosis. The inflammatory activity intensity was classified as follows: nil - no signs of inflammation, mild exudate with little cell infiltrate, reaction involving up to 1/3 of the bulla lumen, no necrosis; moderate - exudate with moderate cell infiltrate, reaction involving between 1/3 and 2/3 of the bulla lumen, a little necrosis; intense - exudate with large cell infiltrate, reaction involving more than 2/3 of the bulla lumen, intense cell necrosis.Fibrosis is characterized by the presence of fibroblasts and collagen deposits on the extracellular matrix. In order to confirm the presence of fibrosis in some slides selected by the pathologist, besides HE dyeing, we also used PSR dyeing. Subepithelial bulla fibrosis was classified as mild, moderate and intense.In assessing the degree of absorption of the tympanic bulla material: nil - material without signs of absorption; mild absorption - peripheral fragmentation with cellular infiltration in the material; moderate absorption - central fragmentation with a cell infiltrate; intense absorption - total fragmentation of the material; complete absorption - no material.The present study was approved by the Ethics Committee in Animal Experimentation of the Center of Biology Sciences, where the experiment was registered under protocol # 23076.019069/2008-11.The mucosal ciliated epithelium was preserved or with mild edema in 18 cases. Nonetheless, in two ears of group t1 and in four from group t2 there was subepithelial edema, with unspecific inflammatory reaction. We did not notice fibrosis.The TM was histologically normal in most of the ears studied, or with mild thickening in the intermediate layer. Signs of tympanosclerosis were seen in six ears.In the lumen of the tympanic bulla we found one case with exudate during t1 time, considered moderate. The fascia was found in only four ears, two in t1 and one in each of the other times .Figure 1There were inflammation signs in the tympanic bulla, with characteristics of subacute and chronic reaction. We did not find changes which would indicate an exclusively acute inflammatory process. There was a subacute exudate in approximately 50% of the cases, 30% chronic exudate and in 20% of the cases we did not find any reaction whatsoever  and 3.FiThe subacute inflammatory process was seen in 11 ears . There wChronic inflammation was found in six ears . The presence of giant cells characterized this reaction as foreign body type . The chrThe ciliated columnar epithelium was preserved or it had mild edema in 16 ears from the experimental group. Mucosal changes were localized and did not extend to the entire air space of the tympanic bulla; nonetheless, the point of direct contact with the material had the most reactivity .Figure 5The TM remained normal or with mild thickening in 13 ears. The histological changes seen pointed towards tympanosclerosis of varied degrees.As far as the fibroblastic activity goes most of the cases were histologically classified as mild fibrosis. There was a greater thickening on the mucosa, with collagen deposits seen upon PSR dye, in two ears only, one in t1 and another in t2.On The material absorption analysis can be seen on On The sugar cane biopolymer membrane was initially used in ear surgery as a free lateral graft in chinchillas. In this situation, there was a TM perforation closure similar to what was found in the control groupThe rat's tympanic bulla is anatomically and histologically similar to the human middle earWe know that this mucosa reacts with an intense inflammatory response to most aggressor agents. One study was carried out injecting inert substances, pathogenic and non-pathogenic substances in the middle ear of rats. The authors did not find important differences as far as the inflammatory response intensiveness goes in relation to each substance, except when there was a live bacteriaThe exudate seen around the sugar cane biopolymer membrane matches the one observed in other semisynthetic materials. Papers comparing the biopolymer membrane with e-PTFE and polypropylene have shown the inflammatory reaction in a similar intensityThe TM's inner layer is contiguous with the middle ear mucosa and reacts to the same stimuli. Tympanosclerosis was present in both groups. It is likely that the TM thickening was secondary to its perforation. One can insert material in the tympanic bulla through the retroauricular access, with later bone trephination, nonetheless, we chose a pathway with less tissue trauma and one that is technically faster. Should there be a third group submitted only to perforation, but without material inoculation, we could better identify whether TM changes could result from contact with the material or the surgical manipulation.®®Inflammation reduced over time see . At the One study on a new material for the pubovaginal sling compared the sugar cane biopolymer with polypropylene and divided the animals in two groups of 30 and 90 daysOn The sugar cane biopolymer membrane is an inert material, and was kept intact in most of the cases. Nonetheless, it degraded as of t2 time, with its absorption in the three cases in time t3. The capacity of being absorbed or replaced in the open bed was observed when the biopolymer membrane was used to replace the dura mater of rats. In this situation, there was a propensity to absorption, with signs of disorders in the original architecture and its replacement by fibrosisOne important characteristic of biomaterials is its capacity to integrate with live tissue. The polylisin latex membrane, a type of biopolymer, was experimentally used in dogs to correct esophageal defects. The biomembrane caused tissue scarring, with spontaneous shedding from the open bed as soon as there was complete neoformation on the extension covered by itThe sugar cane biopolymer membrane caused an inflammatory reaction in the rats' middle ear, with greater intensity that that of the autologous fascia. Other studies need to be carried out in order to check the possibility of its use in ear surgery, as graft material in tympanoplasty, support material or even to make prosthesis for ossicular reconstruction.The sugar cane biopolymer membrane caused an inflammatory reaction in the middle ear of rats with remission in the later time of the experiment. The likelihood of its future use in ear surgery still requires further studies.


Most studies on immigrant health focus on immigrant groups coming from extra-European and/or low-income countries. Little attention is given to self-rated health (SRH) in the context EU/EEA migration. To know more about health among European immigrants can provide new insights related to social determinants of health in the migration context. Using the case of Italian immigrants in Norway, the aim of this study was to (i) examine the levels of SRH among Italian immigrants in Norway as compared with the Norwegian and the Italian population, (ii) examine the extent to which the Italian immigrant perceived that moving to Norway had a positive or negative impact on their SRH; and (iii) identify the most important factors predicting SRH among Italian immigrants in Norway.n = 321). To enhance the sample's representativeness, the original dataset was oversampled to match the proportion of key sociodemographic characteristics of the reference population using the ADASYN method (oversampled n = 531). A one-sample Chi-squared was performed to compare the Italian immigrants' SRH with figures on the Norwegian and Italian populations according to Eurostat statistics. A machine-learning approach was used to identify the most important predictors of SRH among Italian immigrants.A cross-sectional survey was conducted among adult Italian immigrants in Norway (Most of the respondents (69%) rated their SRH as “good” or “very good”. This figure was not significantly different with the Norwegian population, nor to the Italians living in Italy. A slight majority (55%) perceived that their health would have been the same if they continued living in Italy, while 23% perceived a negative impact. The machine-learning model selected 17 variables as relevant in predicting SRH. Among these, Age, Food habits, and Years of permanence in Norway were the variables with the highest level of importance, followed by Trust in people, Educational level, and Health literacy.Italian immigrants in Norway can be considered as part of a “new mobility” of high educated people. SHR is shaped by several interconnected factors. Although this study relates specifically to Italian immigrants, the findings may be extended to other immigrant populations in similar contexts. Health is a broad concept that embodies a wide range of meanings. The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” . SeveralMigration is a life event that can impact the health and well-being of individuals –21 and iTo understand the nexus between migration and health, a growing number of studies suggest the importance of looking at the whole migration process, including where immigrants come from, why they move, how they moved, and their living conditions in the country of resettlement , 49. ComThe existing studies on the health challenges among immigrant populations in European countries mostly rely on studies conducted among immigrants from outside Europe , 25 and There are no data attesting the sanitary or health conditions of Italian emigrants in Norway at that time, but sources are documenting where and how they lived. From this information, it is possible to hypothesize that their living conditions were not ideal, as Italian immigrants often had to share their living space with 20–30 people in extremely cramped spaces in a perennial state of overcrowding , 59. In After the Second World War, Norway, like many other European countries, including Italy, experienced an economic phase of full expansion which increased the need for labor in the country, stimulating the arrival of new groups of foreigners . During Compared to the modest figures that have characterized the immigration of Italians to Norway in the past, since 2008 the number of those who moved to this country has experienced an unprecedented surge . This waAs studies of migrants' health in the context of intra-European migration are few, investigating this phenomenon can provide new knowledge on the specific contribution of migration as a determinant of health: what happens to the health of a group of immigrants with relatively high resources when they move? This topic will be addressed in this study by investigating the case of Italian immigrants in Norway, a group that remains largely under-researched despite its growth. More specifically, the aim of this study was three-fold: (i) examine the levels of SRH among Italian immigrants in Norway as compared with the Norwegian population and the Italian population in Italy; (ii) examine the extent to which the Italian immigrant perceived that moving to Norway had a positive or negative impact on their SRH; and (iii) identify the most important factors predicting SRH among Italian immigrants in Norway.Mens sana in corpore sano,” conducted in collaboration with the Oslo's Committee of Italians living abroad (Comites) and the Italian Embassy in Norway (n = 531). More details about the oversampling procedures, including a comparisons of key socio-demographic characteristics of the reference population compared to the original sample and the resampled dataset, are described in The study is part of a research project on the health among Italians living in Norway “n Norway . A crossn Norway . Since an Norway . More spMens Sana in Corpore Sano study  was developed to allow comparisons with existing surveys in Norway and Europe. More specifically, the items were taken from or closely inspired by items used in Survey on living conditions . For the analyses, the item was dichotomized into two levels in agreement with the approach used by Statistics Norway . EurostaA variable assessing the Italians' perceived impact of migration to Norway on their SRH was used as an indication of the extent to which, all in all, the respondents perceived that their health was influenced by the migration process. This was measured with a single item inquiring the following: “Imagine that you did not move to Norway and, instead, continued to live in Italy. What of the following statements would better reflect your health in such a hypothetical circumstance?” The response options were: 1 = “My health would have been better in Italy than now in Norway”, 2 = “My health would have been more or less the same in Italy as it is now in Norway”, 3 = “My health would have been worse in Italy than it is now in Norway”, and 4 = “I don't know.” The item was presented immediately after the SRH instrument, to prompt respondents to refer to the same understanding of “health” as in the SRH measurement.Mens Sana in Corpore Sano survey included a large number of items relative to the Italian immigrants' life in Norway , Median and inter-quartile range (Q1-Q3), or means (M) and standard deviations (SD).A Chi-squared analysis was performed to compare the Italian immigrants' SRH with figures about the Norwegian population according to aggregated data retrieved from Eurostat's SRH statistics, which is part of the Health in the European Union survey . For thiMachine learning is an application of artificial intelligence that automatically detects multidimensional and non-linear patterns within a high-volume dataset to make predictions based on these patterns . Since tIn this study, a framework of data analytics was used to identify the most important correlates of SRH among Italian immigrants. Five machine-learning models Decision Tree Classifier (DTC); Random Forest Classifier (RFC); Logistic Regression Classifier (LR); eXtreme Gradient Boosting classifier (XGB); Adaptive Boosting classifier (ADA) were trained to predict both SRH by evaluating 35 independent variables (see section Instruments). A 10-folds cross-validation approach was used to test the accuracy of these machine-learning models . MoreoveDescriptive statistics for SRH, the perceived impact of moving, and all variables included in the predictive model are presented in 2 = 0.65, p = 0.42), nor compared to the Italians living in Italy . Most of the respondents (69.11%) reported “better” SHR levels  while 30.89% reported worse SHR levels . These proportions were not significantly different compared with figures for the Norwegian population  perceived that their health would have been more or less the same if they continued living in Italy, with 16.06% perceiving their health was better in Norway compared to how it would have been if they continued living in Italy. The prevalence of Italian immigrants perceiving that their health was worse in Norway compared to what would have been if they continued living in Italy was 22.76%. The remaining 6.10% selected the response option “I don't know”.This study aimed to investigate (i) SRH among Italian immigrants living in Norway as compared with the Norwegian and Italian general population, (ii) the extent to which they perceived that their SRH was influenced positively or negatively as a result of moving, and (iii) the factors predicting better or worse SRH among the Italian immigrants in Norway. A large majority reported experiencing good or very good health. The study found no statistically significant difference in SHR ratings among the Italian immigrants as compared with the Norwegian and Italian general population. Most of the Italian immigrants perceived that their SRH was more or less the same in Norway as it would have been if they continued living in Italy, though a relatively large group perceived a negative impact on their health. Several factors contribute to explaining ‘worse' or ‘better' SRH levels. Sociodemographic characteristics such as age and education were among the variables that most influenced SRH. Gender, somehow surprisingly, did not emerge as a relevant factor predicting SRH. Health-related behaviors (primarily food habits) were also relevant predictors of SRH. Indicators of acculturation , and health-related factors  also emerged as important predictors. Variable related to trust, such as trust in people and trust in the health system were also of high relevance.Our study indicates that most of Italian immigrants in Norway generally perceive having good health, and similar SRH compared to the Norwegian population. This is an important finding as other studies among Italian immigrants living in other countries than Norway suggest that the SRH of immigrants is generally worse than the host population's , 38, 40.As education is a strong predictor of health and health-related behaviors, when considering our findings it is important to bear in mind that the Italians participating in the study had a particularly high educational level, with more than 40% having a University degree and almost one-fourth a Ph.D. By way of comparison, in 2019, the rate of Italians aged 25–64 with a university degree was 19.6% , while iThe absence of a significant impact of gender in SRH is also an interesting finding. Several studies show the presence of a gender gap in SRH, with women generally perceiving worse health than men , 79. FigAge emerges as the strongest (negative) predictor of SRH. This is not surprising, and it is in accordance with previous studies showing that SRH tends to worsen with age , 80. ThiYears of permanence, together with language proficiency , are commonly used as indicators for measuring acculturation, defined as taking on values and practices of the host country . Higher “Trust in people” is an indicator of social capital and cohesion . SeveralTogether with trust in people, also trust in the health care system has been regarded as important for SHR. Trust in the health system plays a role in explaining one's access to and utilization of medical care, adherence to medications, continuity of care, and -thus- SRH . Norway Social relations are an important determinant of health , 97. AlsHealth literacy together with empowerment relative to health behaviors emerged as highly relevant predictors of SRH. Other health-related behaviors such as food habits and weekly physical activity were also identified as factors supporting better SRH. Altogether, these findings are consistent with other studies documenting the relevance of health literacy and health-related behaviors for SRH , 100.Health literacy has been defined as people's knowledge, motivation, and competencies to access, understand, appraise and apply health information to make judgments and take decisions in everyday life concerning health and utilization of professional health services . PrelimiThe only finding that was in contrast with current scientific literature was the negative association of SRH with the Italian immigrants' frequency of nature experiences. In the past decade, a large body of evidence has demonstrated that contact with nature provides a wide range of health benefits. WHO, for instance, has reviewed the evidence on the health benefits of urban nature , concluding that these spaces significantly contribute to reducing morbidity and mortality among urban residents by eliciting stress reduction, stimulating social cohesion, providing opportunities for physical activity, and buffering the effects of air pollution . SpendinTo the best of the authors' knowledge, this is one of the few studies investigating health and, specifically, SRH in the context of intra-EEA immigration. The findings of this study provide new knowledge about Italian immigrants in contemporary time, a largely under-researched group. The study reflects the conditions of the Italians living in Norway and cannot be generalized to Italian migration to other countries as the socio-demographic and migration-related characteristics of Italians migrating to Norway may be different from Italians migrating elsewhere . The ItaThe study has several limitations. One of the limitations of the study is that we could not have direct access to a complete and updated contact list of Italian residents in Norway, which hindered us from performing a randomized or stratified sampling. However, the resampled dataset used in this study, which balanced the original dataset with respect to the profile of key socio-demographic characteristics of the target population , allowedBy using a machine learning approach, we were able to produce a predictive model of SRH that showed relatively high precision. Such an approach allows to detect complex linear and non-linear patterns within the data, with a complete overview of the relationship between the dependent variable (SRH) and the independent variables. This approach presents, however, some limitations. Firstly the findings could be difficult to be interpreted by readers. In the attempt to address this issue, we provided a thorough explanation of the analytical process throughout the text. Another limitation of this approach may reside in its largely inductive nature, which may result in outcomes difficult to explain or apprise in light of existing health theories. On the other hand, this inductive nature can help detect relevant variables not commonly used in studies with deductive analytical approaches. Finally, due to the relatively small sample size, the machine learning models, which are usually adopted in the context of big-data analysis, may have failed in detecting all the possible patterns in the dataset.By focusing on SRH as an indicator of health, an instrument commonly used in national and international surveys (such as the Eurostat), we could compare the ratings of SRH among Italian immigrants in Norway with the Norwegian and the Italian general populations. SRH is largely used in population studies, showing high reliability  and valiMobility across Europe is increasingly becoming part of the life of the European population. Most studies on immigrants' health have focused on groups coming from non-EEA countries. Therefore, knowledge of migration health in the context of intra-EEA is needed. The Italians living in Norway can to a large extent be considered as part of a “new mobility” characterized by high educated people, navigating in a globalized world of work and study opportunities. Our study shows that Italian immigrants in Norway tend to have similar SHR compared with the Norwegian general population, with the majority of the immigrants perceiving that the migration process did not have a relevant impact on their health. This finding is in contrast with previous studies indicating deterioration of health after migration and suggests the need of gathering evidence of the impact of migration on health among diverse populations groups. Still, given the high education of the Italians in our study, we could have expected higher SRH levels compared to both the Norwegian and the Italian general populations. The fact that SRH of the Italian immigrants is the same as the overall population both in Italy and in Norway can indicate that Italians living in Norway may have lost the advantage given by a high educational level in the migration process. This is corroborated by the consistent group of Italian immigrants perceiving that their health would have been better had they continued living in Italy. Altogether, this suggests the presence of health challenges also in this group of highly educated immigrants. Trust in people and in the health sector, the acculturation process, alongside with socio-demographic characteristics and health-related behaviors, are important in shaping the health of this population group. Although this study relates specifically to Italian immigrants, the findings may be extended to other immigrant populations in similar contexts. More research on SRH in the context of intra-EEA immigration is recommended.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by University of Fortaleza Ethics Committee. The patients/participants provided their written informed consent to participate in this study.LT was the overall project coordinator for the Mens Sana in Corpore Sano project, contributed substantially to the design of the study, drafted the introduction, discussion, conclusion, and led the team of authors. AR performed the resampling, statistical analysis, and drafter the relative parts in the methods. MM provide substantial intellectual contribution in the wiring of the introduction section, especially with respect to the historical perspective, and drafted the section on the Italians migration in Norway. GC was together with LT initiator of the project Mens Sana in Corpore Sano, and contributed substantially to the design of the study, statistical analysis, drafting of the results section, and revision of the manuscript. All authors contributed to the article and approved the submitted version.www.sobigdata.eu, accessed on 2 November 2021, SoBigData++: European Integrated Infrastructure for Social Mining and Big Data Analytics. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.This study was part of a larger project Mens Sana in Corpore Sano, as part of the activities of the project Scienze senza confini (Science without borders) and financed by the Italian Ministry of Foreign Affairs through COMITES Oslo. In particular, this study received some minor funding for administrative expenses and to arrange dissemination seminars. None of the authors is employed or an elected member of COMITES Oslo or the Italian Ministry of Foreign Affairs, nor has received direct funding to conduct this research. The authors' participation in the research activity was entirely funded by their respective institutions. This work is supported by the European Community's H2020 Program under the funding scheme H2020-INFRAIA-2019-1 Research Infrastructures grant agreement 871042, The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.