Nonprofit organizations (NPOs) promote citizens’ participation in community life through several different kinds of organizations: some more informal (such as associations and volunteering groups), others more formal or public (such as charities and foundations). This heterogeneity, as well as the well-known peculiarities of NPOs when compared to profit and public ones, poses new challenges to their management. In the constant need to find balance between financial constraints and social value, a main resource for NPOs is the management of intangible assets, such as knowledge, positive relationships within the organization and with users, external image, loyalty and commitment, and so on. From the literature on for-profit organizations, it is well known that proper management of intangible assets improves an organization’s sustainable competitive advantage, not only by enhancing its members’ affiliation and commitment but even by enhancing their productivity. This is particularly relevant when taking into account the main role of volunteers in the third sector. Volunteers, indeed, show different job attitudes and organizational behaviors than paid employees, as their membership and accountability are less formalized and they frequently lack a proper teamwork, due to the high volunteer turnover. At the same time, from the managers point of view, managing volunteers and paid workers require higher skills and competencies than managing human resources in for-profit organizations. Developing these reflections and considerations, we aim to conduct a systematic literature review on the association between intangible assets and performance in NPOs. The literature will be conducted following the indications from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. It provides an evidence-based minimum set of items to be included in the review, as well as a workflow to properly manage and choose the papers to be included. The authors conducted the research using EBSCO, ProQuest, and Scopus databases. The literature on the management of for-profit organizations has proven a connection between intangible assets, performance, and innovation potential in these organizations . IntangiSeveral studies have shown that the Intellectual Capital (IC) framework is the primary theoretical approach for the study of intangible assets in organizations. IC allows researchers and practitioners to identify, organize, and break down intangible assets into meaningful dimensions . This clMore recently, intangible assets and IC have emerged as relevant also for nonprofit organizations (NPOs). NPOs are private, independent, self-governed organizations, based on voluntary participation, whose profit is not distributed to individuals or owners, but reinvested in the organizational mission, that represents a contribution to the public good or the general welfare . NPOs, iMany studies have shown that NPOs would benefit from proper IC management. Previous literature on the subject has analyzed the impact of IC and knowledge management system in NPOs and provides some hints about the potential impact of these intangible dimensions on NPOs’ performance. At the same time, current literature still needs a systematic analysis of whether and how volunteer groups, foundations, charities, and associations deal with this management, and what are the results of this process, in terms of their performance and overall impact on society. Effective management of IC requires the assessment of both individual and organizational performance.In the managerial literature, organizational performance is determined by the results of an organization when compared to its goals and objectives . OrganizAs far as the NPOs are concerned, the operationalization and measurement of performance within the third sector pose a further challenge for scholars and practitioners. A first issue regards the absence of a financial bottom line that could act as an evaluation criterion . AnotherBuilding on these considerations, the authors of this study aim to conduct a systematic literature review on the association between intangible assets and performance in NPOs. Preliminary searches were done to determine that there is no published review addressing this question in the last 10 years.The literature review has been conducted following the guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement . The eliDue to the small number of studies dealing with this subject, no further criteria for exclusion are used. Even though this choice does not allow for further quality checks , given the decision to include only peer-reviewed papers, it seems reasonable to not exclude other works.The following databases and search engines were employed for the search: EBSCOhost, ProQuest, and Web of Science. Several terms were used to implement the search strategy. Each database required a different detailed strategy. At the same time, the following generic strategy covers the focus of our research: AND (nonprofit or nonprofit or “not for profit” or voluntary or “third sector” or NPO or NPOs) AND (performance or outcome or effectiveness or achievement or productivity)Considering the overlap between theoretical considerations on intangible assets and the IC framework, in the second round of search, on the same databases and in the same time range, the authors chose to add keywords that would allow the identification of papers addressing intangible assets, with an IC framework approach. For this reason, the authors’ final search strategy was the following: AND (nonprofit or nonprofit or “not for profit” or voluntary or “third sector” or NPO or NPOs) AND (performance or outcome or effectiveness or achievement or productivity)According to the needs, the keywords were searched in the publication title or abstract.All references were gathered in a Mendeley database, and duplicate references were removed. Two authors independently reviewed the chosen references, deciding to exclude further papers eventually. Papers were analyzed with respect to their content, and papers with content that were not fully within the scope of this review, due to knowledge transfer processes or best practices in NPOs and not within empirical research, were eliminated. In the reference scrutinization phase, the authors looked for papers written in the English language that contain keywords of interest in the title, and then scrutinized the papers’ abstract to check the inclusion criteria.Of the sixteen full-text articles assessed for eligibility, seven papers did not address this review regarding the association between IC and performance in NPOs. The remaining nine papers were determined as eligible and were included for review see .The included works revealed themes that could be reorganized as expressions of the IC framework, despite showing peculiarities in their application . Three oThe performance of NPOs was measured and reported using several measures across the studies. While four studies used a scale on organizational performance or effectiveness, measuring how it was perceived by the NPOs’ members by means of validated or ad hoc Likert scales  or strucWith regard to the types of NPOs involved, participants in most studies (five out of nine) were gathered independently from the kind of NPOs they belonged to . Two stuOverall, the selected studies showed that IC dimensions are related or have an impact on NPOs’ performance. Studies addressing two or all the dimensions of IC in the same model showed differentiated effects on performance. Within these models, human capital and relational capital are strongly related with NPOs performance, above all in terms of internal and external effectiveness , perceivOverall, the authors found few studies about the association between intangible assets and organizational performance in NPOs. As All the studies selected in the literature review showed an effect of one or more dimensions of IC on NPOs’ performance. While the previous section described the results of the studies according to the number of dimensions tackled in the study and the type of study conducted, the following section will reorganize and comment on the results considering the three dimensions of IC. According to the organization detailed in With regard to human capital, the knowledge shared by the employees and volunteers in terms of education, training, and procedures, as well as their motivation, sense of efficacy, and perceived support emerge as the most important elements for NPOs to succeed. Interestingly, this association is confirmed in all the studies, independently from the performance measure used. This point is consistent with the idea that in NPOs, “people are the most decisive factor” ; p. 21. Regarding relational capital, one of its most studied dimensions is NPO-organization cooperation . DescribStructural/organizational capital seems to be less studied and has less implicated dimensions when considering the association between intangible assets and NPOs’ performance. It is interesting to note that the role of structural/organizational capital strongly emerges in the qualitative study included in the review , and in First of all, the literature review was built on a small number of papers, despite representing all the works in the field addressing our research question. At the same time, the authors believe that the low number of works is not due to the low importance of this topic for NPOs’ performance, but to the general tendency to consider NPOs as informal organizations . SecondlThis review showed that the literature on intangible assets and performance is mainly related to the IC framework, highlighting that, despite the different impacts and implications, all of the IC dimensions have a role in influencing performance. The low attention given to the structural dimension of IC reflects the lack of attention of NPOs toward formal strategic planning. Despite this, our results suggest that a more IC focused planning and management process would lead to higher quality and effectiveness in NPOs’ performance. Hopefully, the first definition of the impact of IC on NPOs’ performance would inform and encourage researchers and practitioners in tackling more of these topics when addressing and intervening in the third sector. At the same time, the authors’ results appear to be the first in the literature to indicate the importance of further analyzing the role of IC on NPOs due to the emergence of several indicators of IC as potential predictors for organizational performance. Further research could shed new light on the role of those factors on the quality of work in NPOs, by verifying whether patterns of influence already found in for-profits could be confirmed in NPOs. Finally, the fragmentation in the measurement methods and tools, above all when addressing organizational performance, calls for a better classification of performance measures in NPOs.All authors, IB, PB, BB, and MC developed the research project and reviewed the literature. IB carried out the data analysis.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.


The main purpose of this study is to propose a research model to explore the key factors affecting consumers’ willingness to use online banking. There are two stages in this research. Firstly, the decision making trial and evaluation laboratory (DEMATEL) and analytic network process (ANP) were used to explore the key factors of companies in operation of online banking. Secondly, the structural equation modeling (SEM) was used to explore the key factors of consumers’ actual use of online banking. The results showed differences in the factors that companies and consumers adopted. Based on the findings, companies can adjust their business strategies and improve the consumers’ willingness of online banking usage. The primary factor valued by both companies and consumers is trust. Hence, in the business of internet banking, the companies must strengthen areas such as liquidity monitoring, information security, and compliance with financial regulations, in order to reduce risks and gain customers’ trust. With technological innovation and changes in life styles, business interactions between consumers and banks are gradually changing from the handling of business by customers in person in physical banks to having access to the financial services they need directly via technologies such as Internet banking or mobile banking , 2. 3]  3] stateIn recent years, financial technology has set off a huge wave all over the world and such disruptive innovation that combines technology with financial services has posed a threat to the business model of the traditional financial sector . Amid thInternet banking is a financial service that has been developed by banking operators for many years, and which provides real-time, fast and convenient services. Consumers can have access to various banking services such as online transfers, payment of bills, currency exchange services, enquiries of account data, and financial investments after applying for a set of accounts and passwords of their own , 10. ThaWith the development of Internet banking, consumers have already gotten used to the services it provides. In addition, Internet banking provides a greater security due to highly protected account privacy in the system and well-developed dispute settlement mechanisms, claim laws and regulations, as compared with early forms of Fintech. However, in the wave of Fintech, the inherent system defects of Internet banking will hinder its development, such as restricted amounts of online remittance and incompatibility with the system of the device used by users. Based on the above, this study aimed to identify the key factors influencing the use of Internet banking. Discussions were conducted from the aspect of business operator and consumer use, respectively. The degree of recognition of such factors by experts and consumers was integrated through expert questionnaires and consumer questionnaires, and the differences and similarities between the two were also analyzed. The research results could be used as a basis for banking operators to develop strategies for improving Internet banking, as well as a reference indicator for consumers in using Internet banking.Nowadays, consumers can effortlessly search and compare the websites of banks in terms of the quality and content of the services provided. Compared with physical bank branches, the rapid growth of Internet banking could bring banking industry operators great benefits, as well as fierce horizontal competition. For banking industry operators, it is of great importance to know expert business strategies for Internet banking and the basis for consumers to use Internet banking. Accordingly, this study aimed to address the following research problems:In operating Internet banking, banking industry operators should give priority to the influence factors that will improve consumer’s intention to use Internet banking.In using Internet banking, which influence factor will be prioritized by consumers to decide whether or not to continue to use the Internet banking?What are the differences in the influence factors considered by banking industry operators and consumers?This study engaged in an in-depth discussion on five factors that influence consumer use of Internet banking services, namely, perceived usefulness, perceived ease of use, perceived risk, trust, and satisfaction, through expert questionnaires and consumer questionnaires. Accordingly, research purposes of this study were as follows:To discuss the factors influencing the business strategy for Internet banking through expert questionnaires based on ANP.To discuss the factors influencing consumer use of Internet banking through consumer questionnaires based on SEM.To discuss the differences in the influence factors considered by banking operators and consumers by integrating the results of the expert questionnaires and consumer questionnaires.Electronic banking started to rise in 1960 and was mainly represented by Automated Teller Machines (ATM) as an extension of over-the-counter service, followed by the new financial services derived from the development of computer technology. For the main purpose of electronic banking, consumers could conduct business interactions with banks via communication devices and could have access to services without going to bank branches. The operation of electronic banking been focused on banking services until the 1990s. Except for certain services that could be completed via an ATM, consumers were still required to go to bank branches to handle most business. Over recent years, the well-developed Internet technology has brought the rise of a brand-new type of financial service system, namely, Internet banking. The first security first network bank (SFNB) in the world started to operate online in 1995.Internet banking enables customers to have access to remote financial services, such as enquiries of account data, payment of bills, financial payments, and online transfers, not in bank branches, but through the Internet via information devices such as PCs, Notebook PCs, and mobile devices . With InConsumers can use Internet banking without purchasing any software device and they do not need to store or backup data, as all transaction information is stored at the bank terminal. However, such transaction information also includes the private information of consumers. In case of malicious attacks on Internet banking or bank staff misconduct, damages will be caused to the rights and interests of the consumers, and consumer use of Internet banking will be further affected. Therefore, how to operate Internet banking to provide consumers with a safe and convenient environment and how to improve consumer trust and satisfaction with Internet banking are topics that banking operators must consider. proposedIn most prior studies discussing Internet banking, perceived usefulness and perceived ease of use were included as factors to influencing consumer use of Internet banking.  believedIn TAM, perceived usefulness and perceived ease of use can not only influence consumer use intention but also influence other factors . 19] fo fo19] foAccording to the above literature review, perceived usefulness and perceived ease of use were included in the research dimensions of this study, and perceived usefulness was defined as the degree to which a consumer believes that in using a new system, the information provided by such system will improve transaction efficiency, which indicates that a consumer expects to improve his/her transaction efficiency in using Internet banking. Meanwhile, perceived ease of use was defined as the degree to which a consumer believes that using new technology would be effortless, which indicates that consumers will effortlessly complete banking business in learning or operating a system interface.For quite some time, researchers have considered perceived risk as an important factor influencing consumer behavior in transactions and have verified its influence on consumer consumption decisions. Research has found that consumers will choose not to conduct a certain transaction if they have a higher perceived risk for the transaction , 23, 24.Consumers need to provide their private information before getting access to the online services provided by a company when they conduct transactions via telephone or the Internet; therefore, data security issues will be incurred. Data security issues, in turn, will increase consumers’ perceived risk for transactions via telephone or Network, which will further influence consumer use of online transactions , 28, 29.In prior studies discussing Internet banking, perceived risk was included in the factors influencing consumer use of Internet banking. Those studies found that consumers will choose not to use Internet banking in the case of a higher perceived risk , 33, 34.Prior scholars believed that the e-commerce environment involves more uncertainties and risks. As a result, in the development of e-commerce, trust is a critical factor , 37, 24.The nature of transactions conducted via Internet banking is different from those conducted via a physical bank. Users must deliver important files or private information via the Internet, and damage will be caused to the rights and interests of users in the case of security flaws. As a result, users will not trust Internet banking and even refuse to use Internet banking services , 41, 42.In most prior studies discussing Internet banking, trust was included in the factors influencing consumer use of Internet banking.  believedTrust will not only influence consumer intention to use Internet banking services but also influence other factors. Consumers will have higher perceived usefulness and satisfaction with Internet banking if they have higher trust in Internet banking .According to the above literature review, trust was regarded as one of the research dimensions of this study and was defined as consumers trusting the reliability and integrity of Internet banking , 51, 52.In recent years, satisfaction has been widely discussed in studies in the field of information systems and e-commerce and is considered as the key factor influencing customer retention and consumer loyalty . proposedIn prior studies discussing Internet banking, satisfaction was included in the factors influencing consumer use of Internet banking, and such studies found that consumers will be more willing to use Internet banking services if they are more satisfied with Internet banking , 20. AccIn this research, the questionnaire survey was conducted in two stages. DEMATEL questionnaire was used in the first stage, and ANP questionnaire was used in the second stage with the respondents same as the experts in the first stage. This research explored the keys factors of online banking usage, and its influence factors were multi-criteria, with feedback and interaction among all criteria. Hence, this research used ANP, which could solve the above problems . ANP wasThe research hypothesis was established based on the analysis results of DEMATEL, and SEM was used for further analysis. In this part, a questionnaire survey was conducted on consumers with a 5-point , and disThe DEMATEL technique was proposed by the Battelle Memorial Institute in Geneva in 1973  and was In recent years, DEMATEL has been applied in more studies analyzing the casual relationship and degree of influence between factors. As a result, in this study, before the application of this technique, the relationship between factors influencing the use of Internet banking was tested; then, results were imported into ANP and SEM, and ultimately the priority of such factors was identified.1. Define factors and identify scales. In this step, definitions of the factors were listed through a literature review and brainstorming, etc. The questionnaires were then designed. Finally, the degree of influence between two factors was judged according to an expert subjunctive mental model. In this study, five scales were used for representing the degree of influence between factors, in which 0 = no influence, 1 = low influence, 2 = medium influence, 3 = high influence and 4 = very high influence.2. Find the direct-relation matrix. The number of criteria was n. Based on the experts’ opinions obtained through questionnaires, pairwise comparisons of the criteria in respect of the influence relationship and degree of influence were conducted, and an n × n matrix was obtained. H illustrates the direct-relation matrix, as shown in 3. Normalize the direct-relation matrix. Define β; X illustrates the normalized direct-relation matrix, as shown in 4. Calculate the total-relation matrix. Define limk→∞Xk = 0, the total-relation matrix T is as shown in I illustrates a unit matrix:5. Produce a causal diagram. Define T = [tij]n×n, as all elements in T, and define D and R as the vector of n × 1 and represent the sum of the columns and sum of the rows in relation matrix T, as shown in Eqs Di demonstrates the total influence of element i as the cause on other elements, and Rj demonstrates the total influence of other elements on element j as the effect. The value of (D+R) demonstrates the total degree of influence of and on the element, by which the prominence of the element in the problem group is obtained. (D-R) demonstrates relation; a positive value represents that the element is a dominant element while a negative value represents that the element is an influence element. (D+R) and (D-R) represent the horizontal axis and vertical axis of the causal diagram, respectively. As independence among factors is considered in the DEMATEL technique, it is more suitable for research on problems in the real world, as compared with traditional research method. By calculating and applying the DEMATEL technique, the degree of correlation among factors and the dependence and feedback of factors in the network architecture could be identified [entified , 71. Theentified , 73. In In recent years, the Analytic Network Process (ANP) has been widely applied in decision problems under uncertainties and multiple criteria. It is mainly used to divide a decision problem into a vertical hierarchy architecture. It only considers the influence between upper and lower hierarchies, and it assumes that elements in the hierarchies are independent of each other. However, in measuring various decision problems in real life, not only the elements in the same hierarchy will influence each other, but also elements in different hierarchies will influence each other, illustrating not only a linear hierarchy-upon-hierarchy relationship but a network-like relationship. Therefore,  proposedIn practice, the ANP technique provides decision makers with a set of evaluation scales, which includes five items, namely, 1 = equal importance, 3 = weak importance, 5 = considerable importance, 7 = great importance and 9 = absolute importance, and four items between these five scales: 2, 4, 6, and 8 . DecisioIn prior studies, the ANP process was divided into six steps , 59, 75,H is calculated in In this step, ANP questionnaires are converted into a matrix and the pairwise comparison matrix As there are several decision makers and each respondent may have different cognition of questions, pairwise comparison values may vary. As a result, in this study, pairwise comparison values of all experts were integrated into a pairwise comparison matrix by the geometric mean.Wij is obtained in λmax represents the maximum eigenvalue in matrix H:Upon completion of integration of the pairwise comparison matrix, eigenvector λmax is obtained by following the above steps and the consistency index (CI) is calculated, as shown in Upon completion of establishing the pairwise comparison matrix, a consistency test must be conducted, in order to confirm the consistency among the judgment of the respondents. Then, a random index is calculated according to the order of the pairwise comparison matrix and its values are as listed in CR ≤ 0.1 demonstrates that the degree of difference in judgment on the weights of factors among decision makers is within an acceptable range, i.e., there is consistency; CR>0.1 requires a review of the questions and modifying the judgment on pairwise comparisons. stated tw represents the relationship between two elements. Finally, the elements in all criteria are listed on the left and top of the matrix, respectively, to form a complete integrated matrix called a supermatrix.In order to evaluate the dependence between criteria, a supermatrix is established. Each evaluation scale in the matrix represents the influence of the elements within a criterion on the elements in other criterion  as well as the influence on the elements within the same criterion (interdependence); however, not all elements will influence other elements. In such a case, W. If the performance indicators depend on each other, a fixed convergence extreme will be obtained by multiplying matrix W several times, and the extreme will remain unchanged.Eigenvectors of the performance indicators of all criteria are integrated into a large matrix which is called an unweighted supermatrix. The unweighted supermatrix is multiplied by the eigenvectors obtained by the pairwise comparison matrix of the evaluation criteria to form the weighted supermatrix, which is represented by SEM is a regression-based multi-variable technique that integrates two statistical approaches, namely, factor analysis and path analysis. It is a kind of data analysis method for confirmatory empirical study and can be used to discuss the relationship between multiple sets of variables for the purpose of analyzing the casual relationship among multiple variables to verify theory . In appl proposedGenerally, SEM is used to establish a theoretical basis through a literature review. In this study, however, discussion was conducted in view of practice. Casual relationships among variables were identified through DEMATEL questionnaires. As SEM has the apriority of theory, integrates statistical approaches, can measure and analyze problems at the same time, and puts emphasis on multiple indicators, it is applicable to processing the relationships among multiple variables. SEM currently is widely applied in researches on business strategy, consumer use intention, and other problems , 79.In this study, the casual relationships among five dimensions, including perceived usefulness, perceived ease of use, perceived risk, trust and satisfaction, were discussed by applying the linear structure relationship (LISREL), and the goodness of fit, reliability, and validity of the model were tested to verify the model. Related measurement indexes were as listed in Analytic Hierarchy Process (AHP) is proposed by . The maiThe research model flow established in this research is shown in Three types of statistical software, including Super Decision, SPSS 22.0, and LISREL 8.80, were applied in this study for analysis, and suggestions were proposed based on the research results.In this study, correlations among five dimensions, namely, perceived usefulness, perceived ease of use, perceived risk, trust and satisfaction, were measured by the DEMATEL technique to obtain the structural relation diagram of such dimensions. The diagram was used as a reference basis for designing ANP and SEM questionnaires. Upon recovery of the questionnaires in Stage 1, the total-relation matrix was calculated in As shown in In this study, the arithmetic average (0.470) was calculated according to the values listed in The influence relationships among dimensions identified by the DEMATEL technique are shown in The analysis results found by the Super Decision software are listed in In this study, based on the correlations among dimensions identified through the results of the DEMATEL questionnaires completed by experts, the architecture diagram from the aspect of consumer use was further designed, as shown in H1: Consumer perceived ease of use for Internet banking will influence the perceived usefulness.H2: Consumer perceived ease of use for Internet banking will influence trust.H3: Consumer perceived ease of use for Internet banking will influence satisfaction.H4: Consumer perceived risk for Internet banking will influence trust.H5: Consumer perceived risk for Internet banking will influence satisfaction.H6: Consumer perceived usefulness for Internet banking will influence trust.H7: Consumer perceived usefulness for Internet banking will influence satisfaction.H8: Consumer trust in Internet banking will influence perceived usefulness.H9: Consumer satisfaction with Internet banking will influence trust.In order to identify the degree of recognition of each dimension by consumers, an online questionnaire survey was implemented in this study. A total of 398 questionnaires were recovered, including 373 valid questionnaires after removing 25 invalid questionnaires. The results of the descriptive statistics based on all valid questionnaires are listed in 1. Reliability. Upon removing the invalid samples, it was necessary to confirm whether there was a change in the factor structure during the process of data deletion. Accordingly, prior to SEM verification, the reliability and validity were tested in this study to measure the goodness of fit of the model. The analysis results in respect of reliability are listed in 2. Validity. [alidity.  believedIn this study, the goodness of fit of the model was further evaluated, as shown in Upon completion of verification of the reliability, validity, and goodness of fit of the model, nine research hypotheses for the model were verified in this study. A significant positive influence relationship was observed among all hypotheses except for H6 (significantly negative) and H9 (insignificant). The empirical results are shown in Upon completion of the verification of hypotheses, in this study, the degree of recognition of the five dimensions by consumers was further analyzed by analyzing the scales of the questionnaires completed by consumers, as shown in A comparison table of the degree of recognition of the five dimensions by experts and consumers was prepared based on Tables Through comparisons of the degree of recognition of the five dimensions by experts and consumers, the business strategies for Internet banking of banking directors and the actual use by consumers were identified. Banking industry operators may make a reference to the opinions of both experts and consumers and make a cross analysis in developing business decisions on Internet banking in the future, in order to obtain the best business decision. Consumers may also select the optimal Internet banking based on the research results in using Internet banking.Internet banking is a financial service that has been developed by banking operators for many years, and consumers have already gotten used to the services provided by Internet banking. With the rise of financial technology, however, consumers have access to financial services from more diversified channels other than traditional institutions. Therefore, Internet banking is faced with increasingly fierce competition. Most prior studies discussing Internet banking did not analyze or compare aspects of the business operator and consumer use at the same time. In view of the above, the business strategies for Internet banking of banking directors and the actual use by consumers were identified through expert and consumer questionnaires, respectively, and DEMATEL, ANP and SEM techniques were applied to analyze the degree of recognition of the factors influencing the use of Internet banking by experts and consumers. The research findings were as follows:In this study, the five factors influencing the use of Internet banking were identified through a literature review. First, the architecture in the aspect of the operator established in this study was evaluated by the DEMATEL technique. The empirical results showed influence and certain correlations among the five factors, as shown in The empirical results showed that banking directors consider the factor of trust as the most important influence factor, which demonstrated that the experts’ business strategies for Internet banking focus on data maintenance and system security. Accordingly, this study believed that banking industry operators should develop optimized security protection mechanisms and simulate and develop a set of standard operating procedures for potential malicious attack incidents in the future, so as to improve banks’ crisis management abilities and reduce consumer concerns about the security of Internet banking.Correlations among the five influence factors were discussed by the DEMATEL technique in this study, after which research hypotheses were proposed and the architecture in the aspect of consumer use was developed and verified by SEM. The degree of recognition of the five factors by consumers was identified by a questionnaire survey, as shown in As shown in The empirical results showed that the factor of trust is considered as the most important influence factor by both banking operators and consumers, while the degree of recognition of other influence factors varies. Accordingly, the views of both parties were integrated and the following suggestions were proposed:Banking operators should improve the security mechanism of Internet banking and develop several backup systems to ensure safe use. In addition, banking operators should consider the interests and needs of consumers to provide the products and services they need, in order to improve consumer’s trust with Internet banking.Banking operators should cultivate the expertise and quality of customer service personnel of Internet banking, in order to ensure that consumer concerns will be addressed in real time, and further increase consumer satisfaction with Internet banking.Banking operators should design an easy-to-operate interface according to the actual use by consumers, in order to enable consumers to address difficulties through self-learning in terms of operation and make them have faith in completing banking business via Internet banking.Banking operators should inform consumers of the latest services and preferential measures regularly, in order to make them believe that using Internet banking will bring the benefits and improve the execution efficiency of financial transactions.The limitation of this research mainly lies in the data collection. Expert interviews were conducted for data collection and analysis in the first stage of this research. Although the interviews aimed for objectivity, but biases might still occur due to the subjective consciousness of the respondents. In this regard, it is suggested that the number of respondents may be increased in the future research to make their judgment closer to the actual situations. In addition, the research hypothesis was established based on the results of DEMATEL, which was completely different from the traditional models. After the establishment of the hypothesis, it was necessary to discuss its rationality with the respondents of the first stage, making the entire process time-consuming. With more researches on online banking in the future, researchers may confirm the hypothesis rationality of this study.With the advancement of the technology of big data analysis, online banking can recommend commodities more accurately after the user behavior analysis, and facilitate online trades, gradually leading to an increase in online business revenue. Banks may establish event-based marketing mechanisms to identify the users’ needs based on the changes in their behaviors, and then actively embed proper advertisements. For example, if the customers are found to have never purchased any fund in the past but to frequently browse the fund-related information in recent weeks, this indicates that the customers might be interested in fund investments, so the preferential activities of the current funds and selected fund information may be actively offered. For another example, customers often spend one to two months finding their next investment target, during the meantime, the bank may also actively recommend products suitable to the customer according to their risk attributes. Nowadays, banks not just unilaterally recommend products but emphasize interaction on websites and customer feedback, which indicates that website operation transforms from function orientation to customer demand orientation. From the perspective of overall benefits, establishing online banking can reduce service costs and increase commission incomes, as well as enhance brand images and increase customer loyalty.Online banking is an essential and important service in the development of banking industry. From the perspective of bankers, transaction with online banking can provide customers with more diversified financial services, and reduce the internal labor costs, so as to reduce operating costs and improve service efficiencies. From the perspective of customers, online banking not only provides 24-hour transaction services, but also enables customers to easily access the previous transaction data. In recent years, the integrated management services of personal financial commodities have been developed. Customers can benefit from reduced or waived online banking fees, such as transfer and foreign exchange. Hence, the operation of online banking can create a win-win situation for both banks and customers. In recent years, the ratio of electronic transaction has risen and e-commerce platforms have become one of the representative images of financial institutions. Customers attach great importance to the stability of online banking systems, the ease of use of operating interfaces, the security of transaction data, and the speed of information transmission, so the improvement of service quality and system quality is also an issue that online banking service providers must pay attention to.In the future, financial institutions should focus on developing online banking systems that are personalized, convenient to use, and consistent with the consumption trend. On the other hand, online banking systems with high stability, efficiency, and security are easier to be developed and maintained, and have flexibility, which can save the future development and maintenance costs. Practically, financial and marketing functions are added in cooperation with business planning to develop innovative banking business, to further integrate financial services with personal and corporate needs, and to make all kinds of financial commodity information more popular in a faster and timelier manner. Financial institutions no longer only consider establishing more branches to expand their business, but re-examine the cost structures and operating expenses, as well as effectively use information technology, so as to change their traditional business models and the previous competition patterns of banks. Online banking is not only about the transactions between banks and customers, but also provides platforms for bankers to understand the information and services needed by customers, so as to make financial services better meeting customers’ needs.


Telemedicine refers to the delivery of medical care and provision of general health services from a distance. Telemedicine has been practiced for decades with increasing evidence proving its potential for enhanced quality of care for patients, reduction in hospital readmissions, and increase in savings for both patients and providers. The COVID-19 pandemic has resulted in a significant increase in the reliance on telemedicine and telehealth for provision of health care services. Developments in telemedicine should be structured as complements to current health care procedures, not with the goal of completely digitizing the entire health care system, but rather to use the power of technology to enhance areas that may not be working at their full potential. At the same time, it is also clear that further research is needed on the effectiveness of telemedicine in terms of both financial and patient benefits. We discuss the current and rapidly increasing knowledge about the use of telemedicine in the United States, and identify the gaps in knowledge and opportunities for further research. Beginning with telemedicine’s origins in the United States to its widespread use during the COVID-19 pandemic, we highlight recent developments in legislation, accessibility, and acceptance of telemedicine. The World Health Organization (WHO) defines digital health as the use of digital technologies for health purposes, a category that encompasses the increasing use of technologies for health services . RelatedIn the United States, 76% of hospitals connect with patients using some form of telemedicine . Kane anHere we provide a background of the increasing use of telemedicine in the United States and emphasize its relevance for medical students and residents. Beginning with telemedicine’s origins in the United States to its widespread use during the COVID-19 pandemic, we highlight developments in legislation, accessibility, and acceptance of telemedicine. Omitted from this review are comprehensive descriptions of the technical aspects of telemedicine, as well as newer developments in technology such as artificial intelligence. This review is meant to be a starting point for students, and thus we omit more technical information for the sake of brevity and focus.In the United States, one of the early uses of telemedicine was established by the National Aeronautics and Space Association (NASA) in 1960, for monitoring astronauts in flight by physicians and medical teams during their mission Project Mercury . NASA deIn the United States there are several successful and active models of telemedicine and telehealth, demonstrating their potential. In 2013, there were approximately 4 neurologists per 100,000 people in the country, caring for over 700,000 strokes per year . To dealTelemedicine has also been particularly useful in radiology, since nearly all radiology examinations produce digital content, known as teleradiology. In 2014, teleradiology was reported to account for more than half of all telemedicine services performed in the United States . Images Even fields that traditionally have depended on face-to-face communications, such as psychiatry, have been able to provide care of comparable quality using telemedicine. As of 2016, a mere 43.1% of the 44.7 million Americans with any sort of mental illness had used mental health services in the United States . Being aThe implementation of certain at-home monitoring telemedicine and telehealth systems has also been successful. For example, Columbia University in New York, NY, USA created a home telemedicine unit through its Informatics for Diabetes Education and Telemedicine initiative . This hoAt-home telehealth monitoring, especially for patients with chronic diseases, has proven to be beneficial for not only patients but also hospitals. The Patient Protection and Affordable Care Act requires the US Centers for Medicare & Medicaid Services to penalize readmissions to hospitals that occur within 30 days after discharge . This prSimilar results were seen in the implementation of a home health program for veterans, which used telemonitoring to help manage veterans with chronic illnesses, such as diabetes and depression. The Care Coordination/Home Telehealth program yielded high satisfaction from patients and produced a 19% reduction in the number of hospital visits as compared with their usual care . The proAs COVID-19 continues to spread, many hospitals and physician practices have transitioned to telemedicine to conduct nonessential appointments . A studyThe increasing use of telemedicine has led to increasing interest among payors to cover such services. Several insurance companies, and certain government-funded programs, have expanded their policies adjusting for telemedicine services. In 2018, Medicaid in several states broadened the scope of telehealth and telemedicine services for which they reimburse, thus reducing barriers for their use. For example, California approved reimbursement for substance use disorder services delivered through telehealth; Kentucky prohibited the requirement that a physician must be present with the recipient of health care for reimbursement; and Colorado expanded reimbursement to teledentistry .In light of the current opioid epidemic in the United States, telemedicine can provide a newer and quicker avenue for crisis intervention, which is being recognized by payor groups. For example, Connecticut had previously prohibited prescription of controlled substances through telemedicine, but as of 2018 the state has made an exception for the prescription of drugs that treat opioid use disorder or substance use disorder . AdditioA survey conducted by the American Telemedicine Association in 2014 found that hospitals were not billing for telemedicine services because government payers would not pay for them, and neither would major private payers . FurtherState governments have the power to decide whether they will cover telemedicine practices; and states are not required to submit an amendment to Medicaid if they decide to reimburse for telemedicine (in the same way as they do for in-person services). As of 2015, Medicaid reimbursed for telemedicine services in 46 of the 50 states . As of JIn response to COVID-19, Medicare has temporarily expanded its services to cover telemedicine services outside of the prior designated sites and platforms through which one could qualify for reimbursement. As of March 6, 2020, Congress waived the Medicare requirements that limited provision of telehealth care to rural areas . These sIn the United States, there is not one standardized license a physician receives that is valid throughout the country, but rather a physician’s medical license is issued only for their state of practice. This poses an issue for interstate telemedicine practices, but in 2014 the Federation of State Medical Boards passed the Interstate Medical Licensure Compact to help facilitate interstate practice [Concerns about the quality and security of medical records have previously hampered the adoption of telemedicine. In a study conducted by Resneck et al in 2016, medical residents posed as patients and submitted internet pictures to direct-to-consumer telemedicine websites and apps treating skin diseases. In terms of security concerns, they found that none of the websites asked for the patients’ ID to prove the photographs were not false . Often cImportant aspects of telemedicine and telehealth adoption are the ease of use and lack of technical prerequisites on the part of both patients and health care facilities, as well as reliability of new technologies. If telephone calls are not adequate as a means of making telemedicine visits, access to videoconferencing poses an accessibility barrier both for patients and for health care providers. On the patient side, access to the internet, video cameras, and software poses an issue; and for health care systems, installation of certain videoconferencing software may breach privacy governance policies . In dealFinally, despite significant improvement in the reliability and ease of use of technology, there remain a few of limitations, such as some loss of nonverbal communication between physician and patient. This includes, for example, a reassuring touch from a physician or a physician’s ability to smell alcohol on a patient’s breath and address alcohol consumption during the visit. These limitations could compromise the quality of health care in some cases from both the patient’s and physician’s point of view .For telemedicine to ultimately be successful, it must be accepted by both patients and physicians. In 2016, a survey conducted in Austria asked patients and health professionals to rank what they perceived as the highest- and lowest-ranked benefit of and barrier to eHealth and telemedicine. With a demographic of 43.2% working in health professions and 56.8% in non–health professions, the overall highest-ranked benefit of eHealth was location-independent access to health care services, and the lowest-ranked benefit was better financing of health care. The highest-ranked barrier to eHealth was data security, and the lowest-ranked barrier was increase of administrative burden . The higThis study also showed that acceptance of telemedicine may vary depending on socioeconomic factors. Participants were categorized by education level, gender, health profession or non–health profession, and digital age group. Digital age group was defined as 2 groups: digital natives, those who grew up in a digital world (defined by age ≤35 years); and digital immigrants, those who did not grow up in a digital world, but adopted the culture . ParticiFor telemedicine and telehealth to be implemented successfully, patients must be educated about and comfortable with their use. Systems of informed consent are an essential part of this process, allowing patients to change their consent as they learn more about the technology being used and implemented—especially those with unintended but potential consequences. For example, a study implementing a voice-response telephone counseling system affected some participants in an unanticipated manner. Participants in this study were asked to call a telephone line daily and report their diet and exercise behavior, and most participants spent around 5 minutes per week speaking with the system . Over thTelemedicine and telehealth can play a large role in care for those with chronic diseases, if approved by both patient and provider. A study conducted in an amyotrophic lateral sclerosis (ALS) clinic held appointments with patients over live videoconferences in place of their regular visit and measured satisfaction surveys from both the patients and care providers. Patients had an overall high level of satisfaction with videoconferencing checkups. They commented that such specialized-care videoconferencing eliminated the need to drive long distances and allowed appointments to be conducted that would have ordinarily been missed or canceled due to bad weather . A symptFor elderly patients, doctor’s appointments often provide an outing; the videoconferencing appointment kept these patients at home, depriving them of an opportunity to mobilize . SuggestGeronimo et al  also surAcceptance depends not only on physicians and patients, but also on the other health care providers interacting with these systems, such as nurses. Health care providers working through various e-ICU systems were surveyed for their general attitudes toward its efficacy and sustainability. The survey found that providers who used the e-ICU more frequently had positive reactions, whereas those who used it less were more likely to have a negative view and to suggest that it imposes a greater burden on nurses . Nurses—Public policy must be compatible with increased eHealth implementation for telemedicine to be practiced regularly. Despite the exceptions to Medicare’s telehealth reimbursement policy, the current regulations prevent widespread adoption and use of eHealth and set a precedence for other large private insurers. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) Act was introduced to the US Senate in 2017, but has yet to make progress. This act proposes the removal of the geographical restrictions under Medicaid and, if passed, would expand coverage of telemedicine services . As a reState legislation is one of the largest determining factors in telemedicine adoption, and it has been shown that, in states that require private insurers to reimburse for telemedicine, adoption rates have increased . For telWe have reviewed the definitions, challenges, and potential future directions for telemedicine in the United States. It is no longer a question of whether eHealth has a role to play in health care delivery, rather it is a matter of making it happen. As we are learning during this COVID-19 pandemic, telemedicine and telehealth are critical to ensuring public health and are poised to become reliable and acceptable methods of seeking care for many conditions.


The implementation of policies promoting the adoption of an open science (OS) culture must be accompanied by indicators that allow monitoring the uptake of such policies and their potential effects on research publishing and sharing practices. This study presents indicators of open access (OA) at the institutional level for universities worldwide. By combining data from Web of Science, Unpaywall and the Leiden Ranking disambiguation of institutions, we track OA coverage of universities’ output for 963 institutions. This paper presents the methodological challenges, conceptual discrepancies and limitations and discusses further steps needed to move forward the discussion on fostering OA and OS practices and policies. The implementation of policies promoting the adoption of an open science (OS) culture must be accompanied by indicators that allow monitoring the penetration of such policies and their potential effects on research publishing and sharing practices. In this paper we present open access (OA) indicators for universities worldwide. We analyse the presence of OA by type of access, field differences and comparisons with scientific impact and international collaboration. We explore discrepancies between the operationalization of OA indicators and the different definitions of OA provided in the literature.https://ec.europa.eu/info/research-and-innovation/strategy/goals-research-and-innovation-policy/open-science/open-science-monitor_en) exemplify such efforts and the prioritization of OA for these agencies, the latter being the tool the European Commission is using to monitor its uptake. However, more granular levels of analysis are needed to better understand how OA is expanding, which OA models are being implemented and what the potential side-effects of such models are. Universities have been supporting OA for many years now. The most common strategy has been to build and maintain institutional repositories, and introduce mandates that oblige their researchers to deposit pre- or postprints of their publications , which tracks OA versions of published research with a document identifier , including e-prints self-archived in repositories, recently becoming the most standard mechanism to identify OA.Until recently, there were no more than estimates as to the amount of OA publications. However, the development of platforms like CrossRef, DOAJ or even Google Scholar, along with computational advancements on web scrapping, have led to a plethora of large-scale analyses to empirically identify OA literature . OverallIn this article we present a first attempt at analyzing OA at the institutional level. The main goal of the study is to provide methodological insights that can ease the analytical use and interpretation of OA indicators while providing a general overview of institutional OA uptake. Hence, the article is in nature descriptive, not aiming at responding specific research questions on OA uptake, but to set the basis so that more specific research questions can be developed in the future in an informed way. In order to achieve the proposed goal, we structure our findings in the following way. First, we inform on how OA is being achieved in different institutions and countries, describe national trends, and pathways by which OA is being expanded. Second, we deepen the analysis into green and gold OA types to understand potential discrepancies between the common understanding of these two types OA and how it is actually operationalized in Unpaywall. The results of this study have been recently incorporated to the 2019 edition of the Leiden Ranking released in May 2019  and a ficitable) indexed in the Science Citation Index Expanded, Social Sciences Citation Index and Arts & Humanities Citation Index for the 2014–2017 period. We link publications to the 963 universities identified in the Leiden Ranking database via their disambiguated list of institutional names, also hosted at CWTS , here we report indicators for letters, articles and reviews .For each publication, we identify if they are openly accessible and the type of OA by querying the Unpaywall information. A dump version of the Unpaywall database retrieved in April, 2019. Unpaywall relies on Digital Object Identifiers (DOI), which means that we will only include records which have a DOI assigned to them. Furthermore, the Unpaywall API does not label types of OA but records different pieces of evidence of OA availability of each publication. More information on the Unpaywall approach to OA is available at their User Guide offered for researchers . •Hybrid OA. Toll access (non-OA) journals make specific publications openly accessible usually after the author pays a fee, claiming an alleged need to account for potential losses derived from subscription fees. •Bronze OA. This OA type was first suggested by The labelling of OA types is described in Overall, a total of 4,621,721 distinct publications records are examined. 4,620,666 include a DOI, out of which 1,881,193 records were identified as OA. The results are reported at different levels. First analyses investigate the share of OA on the overall output of each university, differences by country, continent and field. We then look specifically into the two main OA types: green and gold. We focus specifically on these two types as they represent the largest groups of OA publications. In the case of green OA publications, we focus on two aspects. First, the relation between green OA documents produced by an institution and share of which are stored in their institutional repository. Second, potential distortions on how OA types are operationalized and how they are commonly defined, specifically looking into the role played by PubMed Central (PMC). In the case of gold OA, we introduce different national models of gold OA publishing. We characterize gold OA publishing based on three variables: share of papers published in national journals, share of papers published in English language and share of papers published in journals following including APCs. Language of documents and journal’s country are identified using data from Web of Science. In the case of the latter, we identify the country of the journal by querying the field Publisher Address (PA). This approach is not exempt of limitations, as some publishers have an international outlook, while others may shape their geographic focus based on the location of their editors. Hence, the results of this analysis should be interpreted with caution and as a first attempt for developing taxonomies of gold OA publishing.n = 11, 601) than DOAJ , and for which we have no information on APCs. Therefore, the numbers on gold OA journals with/out APCs provided represent a lower bound of all the gold OA journals for which APC information is available via DOAJ. A total of 768 APC journals were identified. After some inspection, we found some inconsistencies in the way APC is defined according to DOAJ. That is, not in all cases, APC refers to an author pays model, but in some cases, journals offer an optional subscription fee for those interested on accessing to printed versions of the journal. This is the case for many journals stored in the SciELO platform which are free of costs for both readers and authors, but which offers the option to pay a subscription fee for printed versions of the journal.In the case of APCs, we queried the Directory of Open Access Journals (DOAJ). Here we must note that this is not a comprehensive list of OA journals. Unpaywall identifies a larger number of gold OA journals , two of the three universities showcased are South African, while the third one is Egyptian. In the case of Cairo University, no OA type in any field reaches a quarter of the total output of the university. In the other two cases, the profiles are quite similar, with the University of Cape Town exhibiting higher shares of green OA than the University of Witwatersrand. For South America, three Brazilian universities outstand as the largest ones; Universidade de São Paulo, Universidade Estadual Paulista and Universidade Estadual de Campinas. The gold OA preponderance previously observed at an aggregate level both for the continent and Brazil, is also noted at the institutional level in all three universities. However, we do observe that such preponderance is coming mainly from the Life and Earth Sciences and the Social Sciences and Humanities. Finally, for Asia (last row), we profile three Chinese universities for which green and gold OA shares go hand in hand in all three cases, with the exception of the field of Biomedical and Health Sciences, where green OA reaches higher shares of the total output.We will now delve into green OA, to better comprehend the indicators shown displayed on this typology. Green OA was originally defined as self-archiving of preprint or post print versions of published manuscripts. That means that green OA is achieved as the result of a proactive attitude of the authors or an institutional colleague, like librarians, towards OA. In their seminal paper, First, the assignment of OA output to each university is given based on the affiliation of authors and not the contents of institutional repositories. This means that universities with large proportions of their output in green OA may not be succeeding on storing their output in their institutional repositories themselves. https://www.ncbi.nlm.nih.gov/pmc/). This source alone represents 60.8% of the green OA literature identified. However, some of its contents are retrieved from elsewhere, including OA journals such as Plos ONE. 86.5% of the 881,834 documents in PMC are simultaneously also gold, bronze or hybrid OA. The remaining 13.5% is accessible via another repository as well as PMC. As it is indeed a repository, in this study it is considered as a green OA source, but the effect of such decision in OA shares at the institutional level is highly significant. Second, low coverages of green OA output in institutional repositories can be due to inter-institutional collaboration  or self-archiving in thematic  or supranational repositories . However, there is a third phenomenon which drifts further away the original definition of green OA from the actual numbers that are reported based on the general labelling obtained via Unpaywall. That is, the effect of repositories which store OA documents without authors’ intervention. Previously, we referred to this as different perspectives of green OA based on “the degree of engagement” of the authors . We distIn As previously observed, Gold OA is the second largest type of OA of the four analysed here , but witThis pattern is followed by most countries, but some differences can be observed. For instance, United States and United Kingdom represent countries with high level of APC publishing, high shares in national language and almost exclusively in English language. Switzerland also fits into this pattern despite being a non-English speaking country. Another differing pattern is observed for countries like Spain or Portugal, where the share of English language publications is much lower although the share of national publications is still below 25% (23% and 21% respectively). In the case of Poland, although 98% of Gold OA publications are in English language, 45% come from national journals, with APC publications in the lower bound of the 50%–75% interval (52%). A similar pattern is followed by South Africa. Finally, we highlight the case of Brazil, where national gold OA publications represent 63% of the total of gold OA publications.The purpose of this study is to present a global view of the state of OA uptake at the institutional level. For this, we have included all universities appearing in the 2019th edition of the Leiden Ranking and retrieved all their publications from Web of Science. These have been crossed with Unpaywall, a database which identifies evidences of OA for publications under the requirement that they have a DOI assigned to them. An important limitation of this tool is that it is dependent on DOIs, which means that we underestimate OA penetration overall, and especially in the Arts and Humanities fields . Based oStill, we find great differences between countries. For instance, Brazilian universities show a higher median share of Gold OA than Green OA, being the only case where this happen. This is a paradigmatic case, arguably the result of a long-standing OA policy commitment promoting national OA journals via the SciELO programme . FurtherA closer look into green OA reveals some counterintuitive findings. First, the presence of repositories such as PubMed Central (PMC) which, although laudable, distort to some extent our perception of what is green OA and what it is not, particularly at the institutional level. This repository (and there might be others), indexes automatically OA literature, meaning that it includes self-archived publications as well as those from OA journals and OA publications from toll journals (Hybrid OA). Depending on how restrictive we are on our definition of green OA , we might disregard this source and hence reduce the overall presence of this type of OA. This along with the inclusion of bronze OA, evidence some discrepancies between the conceptual definition of OA and how it is operationalized in practice, leading the way to alternative conceptual framings of OA which might be closer to actual evidence of OA e.g., . Here, wIn the case of gold OA, where the definition is much clearer, the intrusion of an author pays model (or APC model), along with the emergence of predatory journals , has ledWhile it is out of the scope of this study to analyse or compare the quality of OA journals, we do attempt to characterize such journals. For this, we expand on the modelling proposed by While the study is descriptive in nature, it opens the opportunity for institutions, funding agencies and national science policy officers to better understand the expansion of OA in their country and better design and model effectives mandates of OA. Furthermore, new indicators can be designed which may fit into indicator frameworks of OS , moving 10.7717/peerj.9410/supp-1Supplemental Information 1Data has been aggregated at different levels of analysis and cannot be reported at the publication level due to proprietary rights from Clarivate.Click here for additional data file.


Water safety and quality can be compromised by the proliferation of toxin-producing phytoplankton species, requiring continuous monitoring of water sources. This analysis involves the identification and counting of these species which requires broad experience and knowledge. The automatization of these tasks is highly desirable as it would release the experts from tedious work, eliminate subjective factors, and improve repeatability. Thus, in this preliminary work, we propose to advance towards an automatic methodology for phytoplankton analysis in digital images of water samples acquired using regular microscopes. In particular, we propose a novel and fully automatic method to detect and segment the existent phytoplankton specimens in these images using classical computer vision algorithms. The proposed method is able to correctly detect sparse colonies as single phytoplankton candidates, thanks to a novel fusion algorithm, and is able to differentiate phytoplankton specimens from other image objects in the microscope samples  using a machine learning based approach that exploits texture and colour features. Our preliminary experiments demonstrate that the proposed method provides satisfactory and accurate results. In order to asses water safety and quality, it is necessary to perform toxic phytoplankton analysis and quantification. This procedure is usually performed by expert taxonomists by manual counting on the microscope. Expert assessment usually achieves low recall rates (75%) in water samples with high debris concentration , and meaThe state of the art automatic procedures are focused on several stages of the process: (1) the sample gathering, (2) the automatic detection and segmentation of the specimens, and (3) the identification and counting of species. This work is focused on providing a novel solution to the automatic detection and segmentation of phytoplankton specimens is conventional microscope images, aiming at the application of automatic identification and quantification techniques using readily available equipment in the laboratories.Data gathering in state-of-the-art solutions usually relies on robotic contraptions that can capture images of plankton specimens in the water without human intervention. Some notable examples are Shadowed Image Particle Profiling and Evaluation Recorder (SIPPER) , Video POn the other hand, the automatic detection and segmentation of phytoplankton specimens is approached in a different way depending on the kind of images acquired from each device. In this regard, some of the previous devices, like VPR ,7 or KRIFinally, the taxonomic identification and counting of the phytoplankton species is usually approached using machine learning approaches applied to single-specimen images ,20,21,22The taxonomic identification from single-specimen images has experimented a remarkable research interest in many recent works, and achieved satisfactory results on several identification targets. In this sense, some works have focused on the phytoplankton identification at the genus level ,24, whilIn these works, several machine learning approaches have been explored, ranging from classical approaches to deep learning. For example, in regards to classical machine learning methods, several works have explored SVMs ,25 as weThus, the access to most of the recent advances in automatic phytoplankton analysis is tied to ability to automatically obtain single-specimen images of phytoplankton. However, the state of the art is dominated by the use of automatic imaging devices which are not readily available in most of laboratories worldwide. Instead, the most prevalent phytoplankton analysis method is to manually gather and process the water samples and manually inspect them using regular light microscopes. In this sense, as regular microscopes equipped with digital cameras are widely available, it is relatively affordable to obtain digital images of water samples from the routine work of laboratory technicians. Thus, it would be desirable to provide automatic analysis solutions that can take advantage of these conventional microscope images, so that an automatic analysis solution, aiming at releasing the expert taxonomists from tedious identification and counting works, can be made available at low cost. However, to the best of our knowledge, these images have not been the target of automated analyses, with the exception of some few related works ,27,28.Some of these related works propose to use fluorescence imaging and the integration of images with multiple focal points ,27, or eIn this work, we propose a novel fully automatic computational approach to detect and separate the individual phytoplankton specimens that are present on multi-specimen microscope images. The proposed solution aims to be a preliminary approach that aims being able to systematically apply the most recent advances in automatic phytoplankton identification using conventional microscopy. Detecting separate specimens in microscope water samples is a challenging task due to the high variability of the phytoplankton species, specially in fresh water samples, and the presence of diverse types of debris.The proposed preliminary approach consists in a fully automatic pipeline based on classical algorithms for segmentation and novel methods for the fusion of specimens. This method also makes use of machine learning approaches capable of differentiating phytoplankton from the many spurious objects present in the images like zooplankton, garbage or minerals by exploiting texture and colour information. This preliminary approach is a baseline for further research that intends to continue advancing in this area.The proposed fully automatic methodology for phytoplankton specimen detection, represented in C. The Gaussian window spread is set to σ = 75 μm which is large enough to ensure that the window is larger than the target cells. The offset is empirically set to The first step separates any existing foreground from the water background for the posterior analysis. For this purpose, we consider that the foreground includes a variety of objects apart from phytoplankton like zooplankton, garbage, sand particles, etc. Due to the capture process, the images also have other kind of imperfections, such as shadows or uneven illumination which complicate this step. The proposed foreground-background separation consists in thresholding each of the RGB channels independently, and then combining the results. An adaptive Gaussian threshold  is used The output of this step, illustrated in the example of To separate the different existing specimens, a blob detection process is performed using the Suzuki and Abe’s algorithm . This al2 are discarded as being considered not representative and possibly misleading for the analysis. The exclusion of solitary cells < 5 μm is not a general consideration but a criterion that we have adopted due to a limitation of image resolution. Solitary cells with a major axis less than 5 μm are too inconspicuous to establish correct taxonomic identification, even at Once each preliminary candidate has been detected, they are analysed and candidates with areas below 5 μm account ,32,33. TThe previous step is able to correctly segment most of the specimens of the analysed images. However, for sparse specimens as well as phytoplankton colonies, which are very common, the phytoplankton specimens are detected as several candidates. The reason for this sparse detection as several candidates is that the physical bonds between the individual cells of the specimens are not visible in the microscope images. However, the joint detection of these candidate as a single specimen is required in order to correctly identify the species in subsequent taxonomic classification processes.For that reason, we designed an extra merging stage with a new, robust and precise method to obtain adequate unique identifications of phytoplankton colonies and sparse specimens. Representative examples of this are presented in Volvox aureus, Eudorina elegans and Microcystis flos-aquae. These specimens are not equally oversegmented in the first step and, therefore, present different challenges for the fusion algorithm.The new proposed method is based on the fusion of nearby candidates that share similar visual features. In order to perform this analysis, we first create a graph containing every detection in an image using a Delaunay triangulation ,35 of thThis final step aims at classifying candidate specimens into phytoplankton specimens and other objects that are present in the image, like organic garbage, minerals or zooplankton, among others. To carry out this objective, the previous detections are used to train a classifier that differentiates both classes, filtering therefore undesirable detections from the target ones.This step uses the previously detected specimens with their bounding box grown a 10% more in each direction to include a better context with some background information.To classify this data, we have explored the use of several alternative classifiers using colour and/or texture features. In particular, the tested classifiers are Random Forest (RF) , SupportThe BoVW model allows to represent an image region through histograms of visual patterns (words). The visual words consist in local patterns characterised by specific combinations of base visual features. The specific combinations defining the visual words are learned using a clustering algorithm and stored into a dictionary posteriorly used as reference to compute the histograms. In this work, K-means clustering  is used k-means. A specific number of k-means cluster centres The colour features are obtained using the RGB values for each image position as base visual features of the BoVW model. All the bounding boxes detected using the previous stages in the training set are used to compute the colour dictionary. The RGB values inside the bounding boxes are gathered and clustered using In this case, the set of complex responses to a Gabor filter bank act as base features for each image position in the BoVW model. Thus, the visual words represent local shape patterns, and the histograms of these patterns along the whole regions represent texture.j denotes the imaginary part and B denotes the filters bandwidth in octaves.The used filter bank consists of Gabor filters of a single scale  and bandwidth, and a varying number of orientations. The complex Gabor filter for each orientation The bank of filters is composed of B, the number of orientations k-means clusters The central frequency The filter bank responses are processed in a similar way to colour features, by considering all the pixels within the bounding boxes. However, in this case, the filter bank responses are computed over the whole image, prior to splitting it into bounding boxes, to minimize the aliasing effects due to the image boundaries. Also, the input image is converted to grayscale for the texture description procedure.v/v) glutaraldehyde, because it is efficient at preserving both cellular structures and pigment [A 2 L water sample was collected at a depth of 3 m using a van Dorn bottle in the coastal freshwater lake of Doniños   on 16 November 2017. The phytoplankton sample was concentrated by filtering volume of  pigment ,46,47,48Botryococcus braunii Kützing, Volvox aureus Ehrenberg, Dictyosphaerium pulchellum H.C. Wood), Cyanobacteria 24.95% (i.a. Woronichinia naegeliana (Unger) Elenkin, Microcystis flos-aquae (Wittrock) Kirchner, Anabaena spiroides Klebahn) and Bacillariophyceae (diatoms) 15.29% (i.a. Aulacoseira granulata var. armata (Ehrenberg) Simonsen, Fragilaria crotonensis Kitton).The phytoplankton sample was homogenised for 2 min prior to microscopic examination. In addition, the sample was subjected to vacuum for one minute to break the vacuoles of some cyanobacterial taxa and prevent them from floating. The data on the taxonomic composition and abundances of the different taxa in the water sample, characterised by quantitative analysis in a Ütermohl sedimentation chamber  using a Aliquots of the phytoplankton sample with a total volume of 1 mL were examined under light microscopy using a Nikon Eclipse E600 equipped with an E-Plan However, taking images at this magnification complicates the systematic application of an automatic approach due to several reasons. First, because there is size heterogeneity and diversity of taxa inherent to phytoplankton samples, which prevents the observation of whole organisms of some species at The resulting digital image dataset is comprised of 211 digital microscopy images obtained from the described water sample. The 12 Mpx at A random subset of 50 images was used for training while the rest were reserved for testing. The ground truth consists of bounding boxes enclosing the phytoplankton specimens, which were marked by an expert.The experimentation consisted in the evaluation of the initial candidate detection, quality of segmentation and the final phytoplankton detection.The candidate detection stage is evaluated in terms of false negative rates (FNR). Detections are counted as positive when their bounding box overlaps at least 50% of the true specimen. The parameters of the foreground-background separation and the initial candidate detection stage are empirically optimised to minimize the FNR by only observing the training set.The quality of the segmentation is evaluated by the production of over and undersegmentations. Oversegmentation occurs when two or more boxes cover a specimen that should only be detected by one. Undersegmentation is the opposite, two or more specimens are enclosed in the same bounding box. This evaluation also serves to measure the impact of the novel colony merging stage. To that end, the parameters of the colony merging are selected to provide a satisfactory under/over-segmentation balance in the training set.The final phytoplankton detection is evaluated using precision at high levels of recall, namely 90% and 95%. This is due to the intention of preserving most of the phytoplankton specimens in an imbalanced dataset. Additionally, precision-recall (PR) curves are used to illustrate the performance of the optimised systems. PR curves are also used instead of Receiver Operating Characteristic (ROC) curves due to the imbalanced nature of the problem.For the phytoplankton detection stage, we tested RF, SVM, kNN, BT and GMM classifiers with the described colour and texture feature sets alone or both. For each of these classifiers, using either colour or texture features . The results of these The comparison with other methods in the state of the art was not considered in this work due to the novelty of this approach and the relative lack of works treating this issue. This is especially notable when looking at the modality of images we employ since, as far as we know, no other work neither automatic nor semiautomatic makes use of regular microscopy images despite them being common and relatively affordable to obtain. Moreover, the BoVW model allows to integrate feature extraction into the machine learning pipeline, using base features of diverse information sources, as colour or texture. The exhaustive comparison with competing alternative methodologies to represent colour and texture is out of the scope of this preliminary work.The specimen candidate detection step results in a FNR of 0.4% using the test set, which is equivalent to 4 missed specimens among the total of 994 that are present in the test set. The low FNR is motivated by the fact this initial stage aims at identifying as much phytoplankton specimens as possible. Consequently, 851 incorrect detections were also provided, detections that are posteriorly filtered in the corresponding stage. These false positives are zooplankton and inert organic matter that present similar appearances to our phytoplankton. They are visually difficult to classify due to the intra-class heterogeneity of phytoplankton species. In spite of that, phytoplankton shows some distinctive features when compared to the spurious objects in these images. This is why a learning-based approach was used for the candidate refinement stage.Sparse specimen and colony merging is evaluated by the comparison of the over and undersegmentation metrics before and after the application of this step. In particular, before the colony merging step, we obtained ratios of 20.36% and 8.86% for over and undersegmentation, respectively. Thanks to the application of the merging process, oversegmentation was reduced to a 3.43% while undersegmentation increased to a 12.53%. Thus, the fusion algorithm presents a positive impact given it improves oversegmentation ratio approximately a 17% while only increasing the undersegmentation approximately a 4%. These metrics show that the dataset presents a non-negligible amount of overlapping between specimens, responsible for the original measurement of undersegmentation. The metrics also demonstrate the abundance of sparse specimens and colonies characterised by their transparency and lack a visual connectivity, making them hard to detect as a whole object in the previously stage. These results are satisfactory as some undersegmentation increase is bound to happen when merging specimens, however, it is much lower, than the decrease in oversegmentation. Therefore, we can conclude that the algorithm satisfactorily balances the merging of the oversegmented specimens without resulting in too many false fusions.Regarding the phytoplankton detection, As it can be observed in the tables and figures, the performance of several combinations of classifiers and feature sets are similar, therefore validating the suitability of our proposed pipeline. We consider these results satisfactory given the high complexity, the heterogeneous classes and the high variability of the specimens that the system is trying to identify . Furthermore, as demonstrated by the exhaustive experiments, the system is capable of extracting different features that provide reasonable results across a wide variety of representative classifiers.The best classifier considering precision at 90% of recall is the RF classifier using texture features. In particular, this model obtained a precision of 77.2%. The empirically selected parameters are: number of bins The most important difference among the studied classifiers occurs when switching between the input features. Texture features demonstrate the best performances regardless of the classifier. It should be noted that the difference between using only texture or using only colour features is not very relevant for the RF and BT classifiers, which can be quantified as less than a 2% decrease in performance. On the other hand, the rest of the methods present a much higher reduction in performance, when comparing texture with colour features.Remarkably, the GMM approach loses 13% precision at 90% recall when switching from texture to colour features.In terms of the descriptor size, kNN, BT and RF are favoured using larger configurations  maintained acceptable ratios due to the preference for larger descriptors. SVM and GMM, which favour the opposite, decreased in precision. Nevertheless, the fusion of features has proved useful for slightly improving the RF precision at 95% recall.Representative examples of final results of the proposed method are depicted in By analysing the phytoplankton detection results of the best performing system in the test set, we consider that the proposed approach is satisfactory in differentiating phytoplankton from debris and other objects in the water sample. Specifically, it is remarkable that the number of detected phytoplankton specimens is approximately only half of the detected candidates. Thus, we can conclude that the classification system is robust to the presence of heterogeneous non-target objects in the image. However, these results do not allow to evaluate how robust is the proposed candidate detection mechanism to a very high density of debris and spurious elements in the images. Nevertheless, it should be noticed that the sample concentration can be easily controlled during the water sample preparation through dilution (and the quantitative results corrected consequently) to avoid the exceptionally corrupted samples representing these situations.One possible limitation of the presented experiments is that the system was tested with images obtained from a single water sample. This implies that the quantity and diversity of non-target objects, as well as the distribution of phytoplankton species and stage of development is biased towards some specific conditions. Nevertheless, we consider that the number of different images is high enough, as well as there is a high number and diversity of both phytoplankton species and non-target objects in the sample to be representative of a realistic scenario. The obtained results, although preliminary, allows us to validate the suitability of the proposed methods, which are to be refined by future research in the same line of work.Moreover, the present study does not include taxonomic classification and quantification of individual species. Thus, it is not a complete system for phytoplankton analysis. However, such taxonomic classification has been already extensively explored, and successfully approached, in the literature, using the single-specimen images obtained with flow cytometry imaging approaches. The present work allows to obtain single-specimen images from conventional microscopy images that should be readily usable for species classification approaches.Finally, we have not included a comparison with previous approaches in this work. The reason is that the most related works ,27,28 doIn this work, we present an innovative way of detecting and separating phytoplankton specimens in multi-specimen microscope images from water samples. The designed preliminary fully automatic methodology is based on an initial detection of candidates based on a foreground-background segmentation and a completely novel colony merging algorithm. Finally, given the complexity of this issue, the detections are refined using a learning-based strategy that aims at detecting true phytoplankton specimens. Several classifiers and a wide variety of feature sets were tested, providing in all the cases satisfactory identifications that validate and corroborate the suitability of the proposed automatic computational pipeline.The results are satisfactory as baseline for further improvement, given the high complexity of the problem and the domain as well as the lack of comparable methods in the state of the art. While the proposed methods need to be tested over more diverse water samples, they can serve as a stable base for future research. In this sense, these are important initial steps towards automating potability testing and plankton studies using conventional microscopes, which are widely available on laboratories worldwide. Overall, the main advantage of this work when compared to other works in this field is its cost and availability. While flow cytometry imaging approaches are suitable methods for obtaining single-specimen phytoplankton images, they are not often found in laboratories. Meanwhile, the proposed methods in this work can be used with a regular microscopes as long as they are equipped with a digital camera. Moreover, and unlike some previous works, since we have managed to use fixed parameters for both magnification and focal point in the imaging protocol, it is not required that an expert taxonomist supervises the image acquisition process. Finally, although species classification and quantification is not approached in this work, state of the art approaches for single-specimen phytoplankton images classification should be easily adapted to work on top of the proposed analysis pipeline.Future lines of work include testing the method with more phytoplankton samples to verify its performance with a wider amount of species and images. We intend on creating a new classification step to separate relevant species, with a special focus on those that produce toxins. This is the ultimate goal of this project as toxic phytoplankton monitoring has to be done regularly to ensure water safety. We plan on creating a classifier following the same methodology used in this work to classify the toxic species. Finally, other working lines include the exploration of alternative features or deep learning methods.


Introduction: COVID-19 is a global public health threat that Africa faces including the country Malawi. With an already burdened health system and an economically challenged population due to the poverty level, Malawi is suddenly faced by a pandemic that will test the country’s healthcare systems. Its government has already instituted an array of initiatives and plans and funding efforts toward the effective containment of the pandemic. Some of these efforts include reorientation and training for health workers, securing funding to procure and distribute needed personal protective equipment, medicine supply, health promotion, surveillance and case management. These efforts are being done in the context of an already heavy burden of diseases such as HIV/AIDS, malnutrition and poor health literacy. Whether efforts of the government and other stakeholders are enough, these remain to be seen in containing the virus and its aftermath. Until an effective treatment or vaccine is available, Malawi has to remain vigilant and needs to continue all its efforts to address its COVID-19 epidemic. COVID-19 presents major challenges to Africa as the virus finds its way to the inroads of the continent  includinWhile the rest of the world was battling their own epidemics before the first cases were reported in Malawi, the government already made the pronouncements that the pandemic is a national threat. Early measures were put in place including the banning of public gatherings of more than a hundred people in places such as churches, mosques, meetings, rallies, conferences, weddings and funerals. When the situation necessitated implementing a lockdown strategy, the government suddenly faced a major impediment when a legal action was undertaken by the Human Rights Defenders Coalition in the High Court of Malawi which resulted in an injunction that blocked government´s attempts to execute the measure . This isThe government launched a masterplan, the National COVID-19 Preparedness and Response Plan, which came into effect in March and to finish in June 2020 to help guide in the protection of its citizens by reducing the risk of exposure to the virus. It also kept on working with the Africa Centre for Disease Control and WHO African Region. This plan includes: reorientation and training of personnel who work in highly infectious environments, securing funding to procure and distribute needed personal protective equipment, medicine supply, investigation, and case management. Screening and surveillance at borders and all points of entry, enforcing quarantine or recommending self-quarantine (due to insufficient quarantine facilities) for 14 days for all people coming from COVID-19 high-risk countries were also intensified as part of this plan . Health The need to fund the COVID-19 fight was recognized by the government by providing a budget of $213 million to the National COVID-19 Preparedness and Response Plan. In preparation of augmenting this budget, discussions have already been initiated with the International Monetary Fund for a budget of $150 million. A National Relief Fund to accept contributions from donors, private companies and individuals was also set up. The response plan involves $20 million spending on health care efforts and hiring 2000 extra health personnel. Efforts have been implemented to shield vulnerable populations from socio-economic impacts of the pandemic through the provision of $40 monthly payments that is equivalent to the country’s minimum wage. This benefits one million people and small business personnel [These efforts of the country to curb the spread of COVID-19 and mitigate its impact may be commendable, however the challenges remain colossal. The country´s health system is already burdened with HIV/AIDS with a prevalence among adults at 9.2%, of which only 69% are virally suppressed . This wiIt is believed that many countries in Africa including Malawi are yet to feel the full impact of the pandemic. The current actions of the government are hinged on this premise thus the various programs and initiatives that it mounted. These preparations, if indeed enough, remain to be seen as its health system has already been facing many challenges prior to the pandemic. On the bright side, the country may capitalize on the seeming resilience of its health system which survived the ravages of historical diseases amongst its population. COVID-19 provides an extra jolt for the country to revisit its investment in health. There is no doubt that the health sector needs to be revitalized by creating a robust health environment for better health outcomes. Until an effective treatment or vaccine is available, the government of Malawi and other stakeholders need to continually strengthen its efforts to curb its COVID-19 epidemic. Who knows, there is a good spillover after this battle.The authors declare no competing interests.