Digital health apps are among the most visible facets of the ongoing digital transition in health care, with mental health–focused apps as one of the main therapeutic areas. However, concerns regarding their scientific robustness drove regulators to establish evaluation procedures, with Germany’s Digitale Gesundheitsanwendungen program pioneering in app prescription with costs covered by statutory health insurance. Portugal gathers a set of conditions and requirements that position it as an excellent test bed for digital health apps. Its daunting mental health landscape reinforces the potential interest in new interventions. To understand if they would be acceptable, we need to understand the supply side’s attitudes and perceptions toward them, that is, those of psychiatrists and psychologists.This study aims to understand the attitudes and expectations of psychiatrists and psychologists toward digital mental health apps (DMHAs) in the Portuguese context, as well as perceived benefits, barriers, and actions to support their adoption.We conducted a 2-stage sequential mixed methods study. Stage 1 consisted of a cross-sectional web survey adapted to the Portuguese context that was delivered to mental health professionals and psychologists. Stage 2 complemented the insights of the web survey results with a key opinion leader analysis.A total of 160 complete survey responses were recorded, most of which were from psychologists. This is the most extensive study on mental health professionals’ attitudes and perceptions of DMHAs in Portugal. A total of 87.2% (136/156) of the respondents supported the opportunity to prescribe DMHAs. Increased health literacy , wider adherence to treatment , and proper disease management  were the most frequently agreed upon benefits of DMHAs. However, only less than half  of the respondents planned to prescribe or recommend DMHAs, with psychologists being more favorable than psychiatrists. Professionals faced substantial barriers, such as a lack of information on DMHAs , the level of initial training effort , and the need for adjustments of clinical processes and records . Professionals reported that having more information on the available apps and their suitability for health objectives , more scientific evidence of the validity of the apps as a health intervention , and established recommendations of apps by specific clinical guidelines or professional societies  would be essential to foster adoption.More information about DMHAs regarding their clinical validity and how they work is necessary so that such an intervention can be adopted in Portugal. Recommendations from professional and scientific societies, as well as from governmental bodies, are strongly encouraged. Although the benefits of and the barriers to using these apps are consensual, more evidence, along with further promotion of mental health professionals’ digital literacy, is needed.RR2-10.2196/41040 Digital health apps substantiate, perhaps more tangibly than most solutions developed so far, the opportunities the digital age may bring for human health -3. ChiefThe same report  highlighThe realization that most tools in the field needed to be more mature to match formulated expectations prompted specialists to increasingly voice concerns that most apps need to meet more clinical and technical validation standards, often lacking any empirical support for their adoption -11. A grGermany took the lead by implementing a regulatory framework specific to digital health apps and their market access and reimbursement. Its Digitale Gesundheitsanwendungen (DiGA) program  was inauPolicy for Device Software Functions and Mobile Medical Applications [Digital Health Policy Navigator for developers [Belgium ranks second in implementation; although mHealthBelgium  was launications  and its ications , divulgeications , and lauvelopers .Mental disorders are one of the areas where the penetration of digital health apps is most prevalent ,20. ReasPortugal is often cited as a country where mental disorders, particularly anxiety and depression, are above average; the prevalence of mental health disorders in 2019 was estimated at 8.27% of disability-adjusted life years and 19.27% of disease cases. The statistics for anxiety and depressive disorders were expected to be 2.58% and 3.16% of the total disability-adjusted life years and 9.08% and 5.88% of the disease prevalence, respectively . A summaConversely, there is limited access to psychological and psychiatric care, with waiting times ranging from 13 to 237 days for a psychiatry consultation in the Portuguese National Health Service from July to September 2022 . The timIn a country burdened by out-of-pocket payments about double the EU average ,48, the One of the key promises of digital health apps is increased access. However, no innovative intervention in health—be it a drug, medical device, or any other—achieves critical mass without the endorsement of health professionals -51. TherTo our knowledge, only one study has been performed on the Portuguese landscape of web-based interventions for psychologists . No studThis paper aimed to understand mental health professionals’ attitudes (defined as psychologists and psychiatrists in this study) toward DMHAs in the Portuguese context. Mental health professionals will be questioned regarding perceived benefits, barriers to adoption, and potential ways of supporting the adoption of DMHAs. These apps were the focus of this study. The authors aimed to achieve this by directly inquiring mental health professionals regarding their specific clinical practices, perceived needs, and expectations.The research team used a mixed methods methodology. Stage 1 consisted of a cross-sectional web-based survey adapted to the Portuguese context and delivered to mental health professionals and psychologists. It used a web-based quantitative data–focused survey, adapted to the Portuguese context, which served as a primary data source. Stage 2 used the answers collected from the survey to help conduct a qualitative key opinion leader (KOL) analysis.As per the research protocol , the metNotably, this study did not include a literature review of technology adoption, relevant case studies, or subsequent interviews with mental health professionals and psychologists on their views and perceptions toward DMHAs. This was deemed appropriate, as such processes had the objective of building up the questionnaire, and we intended to apply a translated version of the survey to the Portuguese context. Following the original publication, we conducted a web-based survey on a pretest group of health care professionals.In Portugal, psychiatrists and psychologists are expected to prescribe or otherwise interact with DMHAs and act upon the patients’ mental health. To maximize the targeting of these professionals, we restricted our approach to these 2 groups of health care workers. Moreover, to complement our interpretation of the survey results and help us understand the meaning and generalizability to the national context, we conducted a KOL analysis with a select set of professionals belonging to 1 of the 2 surveyed groups, with roles in clinical practice, academia, industry, or a combination of these.Furthermore, given that no prescription processes are established in Portugal for DMHAs, it is not possible to rigorously define who would be authorized to recommend or prescribe DMHAs. Therefore, we asked clinicians to answer questions that report to recommendation or prescription according to their own cases, as psychiatrists are allowed to prescribe medication in Portugal, whereas psychologists are not. Our results should be interpreted accordingly.Moreover, in our survey, we did not ask about health insurance coverage status, as it proves more relevant, in the Portuguese context, to understand whether they work for the National Health Service, in private practice, or both. As previously stated, we targeted only psychiatrists and psychologists for this survey, with the latter comprising most of the respondents . Although no data regarding the number of psychologists are available at the time of this study’s conclusion, it is our perception and that of the KOLs that the largest share of mental health professionals would be attributable to this group of practitioners.In addition, we chose to represent survey data differently, intending to highlight the distribution of the categorical  answers and define their centrality without recurring to arithmetic operations.The first part of the study comprised a cross-sectional, web-based survey. We used the final survey questionnaire available in the This translation was delivered to 10 mental health professionals—5 from each professional group, psychologists and psychiatrists—to gather their input. Mental health professionals’ feedback was focused on calibrating the survey to (1) reflect essential questions to ask regarding the use of digital health tools by mental health professionals and (2) adapt to a Portuguese mental health care context. This allowed us to focus solely on mental health and DMHAs. The survey used by Dahlhausen et al  depictedBefore broad diffusion, the survey questionnaire was pretested by 5 different colleagues to determine the completion time and identify shortcomings. As a result, an introductory page on digital health apps and developments in their regulatory landscape was included to provide initial baseline information before the start of the survey. The completion time was estimated to be between 4 and 7 minutes. To establish a basis for comparison with a reimbursable app system, mental health professionals were asked to consider a scenario in which these apps fulfilled regulatory requirements and addressed safety, quality, and efficacy concerns. Accordingly, mental health professionals’ responses are to be interpreted under this assumption and not necessarily to these apps’ current form as available in Portugal. Nonetheless, it could be argued that because both Portugal and Germany belong to the EU and its internal market, an app developer would want to maximize comparability between apps, tweaking them for populational specificities.Several web-based channels and methods were used to distribute the questionnaire to health care professionals. The survey’s link was circulated in the newsletter of the Portuguese Order of Psychologists and through the social media of several members of the Psychiatry Specialty College of the Portuguese Order of Medical Doctors. The professionals who engaged in the questionnaire’s adaptation were invited to perform snowball recruiting by sharing the survey link through their social media accounts and with professional contacts and forums where they were involved.In addition, Knok healthcare , a fullyThe platform used was Inqueritos@UP, the University of Porto’s internal survey manager by LimeSurvey. The survey adhered to and was reported following the Checklist for Reporting Results of Internet E-Survey (CHERRIES) guidelines. The period for answer collection ran from September 26, 2022, to November 6, 2022, the same 6-week period applied in the study by Dahlhausen et al .Ethics Approval, Informed Consent, and Participation section, comprises all relevant information on these aspects. To maximize responses, the only inclusion criterion was to be registered with the mental health professional’s respective professional order. No exclusion criteria were introduced, and no financial incentives were offered. The study’s Data Protection and Privacy Policy, made available in the The gathered data were analyzed according to the methods used in the study by Dahlhausen et al  to allowOnly data excluded because of different health system organizations and their consequences for mental health professionals  or of reasonable suggestion during the feedback period were treated differently and according to the nature of each variable.The correspondence map between the initial questionnaire  and thetidyverse, data.table, png, gt, gtExtras, gtsummary, Hmisc, likert, grid, forcats, scales, reshape2, and rcompanion.Furthermore, data were analyzed to find associations among variables, especially between health care professionals’ demographic and professional characteristics, attitudes toward DMHAs, and the likelihood of prescription. These were conducted on RStudio  using chi-square tests or, when conditions for using chi-square tests were not met, Fisher exact tests with Monte Carlo approximation and 2000 replicates ,59. R paThe KOL analysis  served tThe KOL analysis followed a 2-step approach. The first step consisted of semistructured individual web-based interviews, followed by a second round of confirmation of the gathered consensus. The method used for the KOL analysis could be defined as a compromise between the Nominal Group Technique and the Delphi Technique .In the first part of this interview, each KOL was asked what were, in their opinion, the top 3 benefits, barriers to adoption, and measures that could support the adoption of DMHAs in the Portuguese context. In the second part of the interview, the interviewers showed KOLs the results of the conducted web survey and asked them to comment on the results. The requested comments were focused on whether these results agreed with their perception of most Portuguese psychiatrists and psychologists, asking them to justify their opinions and statements.The second stage of the KOL analysis consisted of circulating the main elements gathered during performed interviews and asking for their comments in free text, namely, whether they agreed with the established consensus and whether something important was missing. This analysis was divided into benefits, barriers to adoption, and support measures to ensure methodological consistency.A total of 25 KOLs were identified and selected to participate in this research . Invitations to participate were made via email through the identification of publicly available professional email addresses. Snowball recruiting was used to find more participants; every contacted KOL was asked to suggest other KOLs that could be reached for this study. KOLs were given a 7-day period to answer whether they wanted to participate and, if so, to point to 3 dates and times for the interview. Those who did not respond to the initial invitation received a follow-up email after 3 days to increase the response rate. Interviews ran from November 25 to December 23, 2022, lasting between 35 and 70 minutes.Overall, 4 of the KOLs were psychiatrists and 2 were psychologists. This is an important feature to remember, as the number of psychiatrists who answered the survey was much smaller than that of the psychologists. This allowed us to expand the interpretation power of the answers provided by psychiatrists. Notably, every KOL contributes regularly to the public discourse on mental health and the use of technology to tackle problems around mental ill health, for example, in written media. Moreover, half of the KOLs  have already developed DMHAs or more comprehensive digital health tools, and 5 (83%) out of 6 KOLs work in academia and private or public sector.The Ethics Committee of the Faculty of Medicine of the University of Porto pronounced itself favorable to the research project on June 30, 2022 (Opinion 52/CEFMUP/2022).Ethical considerations and safeguards for the study and its supporting documents (including the web-based survey) were encoded in the study’s Data Protection and Privacy Policy, which received approval from the Data Protection Officer of the University of Porto and is transcribed as follows:To preserve participants’ privacy, they will not be asked to provide any personally identifiable information. In addition, participants will not be tracked for having started or completed the survey, increasing privacy but limiting the possibility of reminders.Informed consent and consenting capacity: all potential participants  will be given web-based written information on the study and its objectives and will be asked to provide consent (click to agree) that they are willing to participate, do so freely and voluntarily. Nonparticipation will not compromise their current roles. Participation in the study will be voluntary, and no inducements or incentives to participate will be offered.Confidentiality: Any data or personal details that could potentially reveal the identity of individuals will be removed. Only anonymized, deidentified information will leave the place of origin. A database with responses will be maintained on a password-protected database. All research data will be stored on a password-protected desktop computer at the host organization. Study participants will be invited, through a link provided on the last page of the survey, to provide their name and electronic address to allow the research team to facilitate their receipt of a synopsis of the study findings on publication. This list will be kept separately on a password-protected database and a password-protected desktop computer at the host organization. All data will be stored securely at the host institution and destroyed 3 years after the PhD defense date. It is estimated that the PhD will be defended between October 2023 and December 2023.General Data Protection Regulation compliance will be adhered to in terms of the following:Data privacy rights: participants will have the right to request information about their data throughout the research process.Transfer of data: participants will be informed about the circumstances under which their data may be transferred and safety measures that will be taken to protect the data .Retention of data: Participants will be informed of the duration for which their data will be stored.Using Inquéritos@UP, survey data were stored at the university’s servers and thus not shared with external entities, constituting another layer of privacy protection. Furthermore, the survey’s first page briefly explained the required data and the rationale behind it.A total of 160 health care professionals completed the questionnaire, with only some nonresponses to specific questions. Although the overall survey response rate could not be determined, given its means of distribution and the adopted privacy-ensuring settings, 400 people opened the survey. This translates into a completion rate of 40%, making this study the most extensive on mental health care professionals’ attitudes and expectations toward DMHAs in Portugal.Many practitioners worked in >1 type of practice, most commonly at clinics  and hospitals , with only 10.6% (17/160) working at the primary care level. A considerable portion of professionals were involved with private consultation services, either individually  or in a group . However, in the study by Dahlhausen et al , most clPotential benefits to the patient from DMHAs, namely, improved ability to make informed choices, proper disease management, improved treatment adherence, improved access to health care, and increased health literacy were perceived very positively by responding health professionals. This was demonstrated by the overall positive perceptions toward using DMHA services; in no case did the general agreement have <65% of the responses. A higher general agreement proportion of the answers  was found concerning the gains in health literacy  and treatment adherence .With regard to general disagreement ratios , the most unfavorable perceptions  were demonstrated toward the capacitation of informed choices by the patients. This question  and another regarding improved access to health care  represented the highest proportions of neutral answers (including “Don’t Know” and “Neither Agree nor Disagree”).In parallel, the same evaluation process was used to assess the practitioners’ attitudes and perceived potential benefits of these apps for health care professionals. The domains covered were satisfaction of higher DMHA-based demand from new patients, improved patient satisfaction, time savings owing to efficiency gains, better quality of care for patients, greater treatment success, and additional treatment options.Overall, the distribution of the answers represented a reasonably positive impression of practitioner-specific potential benefits, although with a slightly inferior portion of general agreement answers owing to conditioning by higher neutral and general disagreement responses.The highest general agreement proportion of the answers was attributed to better time management owing to efficiency gains , closely followed by the benefit of having an additional treatment option . The lowest general agreement ratio was regarding the expectation of greater treatment success , which also demonstrated the highest neutral and second highest general disagreement shares.For the general disagreement ratios, the highest proportion was described concerning the possibility of improving the quality of patient assistance , closely followed by the previously mentioned improved treatment success. The share of neutral answers ranged from 21.3%  to 46.3% .Our adapted survey did not assess the perceptions on additional new patients, or additional income for this group of benefits, having added others regarding the satisfaction of higher DMHA-based demand and the DMHA as an additional treatment option at the suggestion of our survey reviewers.Of the 160 participants, 68 health care professionals  declared to have an increased likelihood (“Likely” or “Very Likely”) to prescribe DMHAs in the coming 12 months, representing 42.5% of all the answers.There were some differences in the prescription intentions between the 2 professional groups analyzed. For this variable, psychologists revealed a 48% share of increased likelihood answers, whereas psychiatrists only had 22% of their responses corresponding to these.Concerning professionals’ attitudes, 136 mental health care professionals  declared to have a generally positive (“Positive” or “Very Positive”) attitude toward the possibility of mental health professionals and psychologists being able to prescribe, recommend, or use clinically and technically validated DMHAs, representing 85% of all the answers. A much smaller difference was found in comparison with their intentions to prescribe. Psychologists and psychiatrists responded with 88% and 81%, respectively, generally positive attitude answers.Introduction section. This leads us to conclude that what we observe in this sample are the aprioristic perceptions and attitudes toward DMHAs.It is important to note while describing prescription intentions that practically no respondents to the survey have prescribed DMHAs to their patients. Simultaneously, there is no legally established prescription and reimbursement process in Portugal, as described in the χ21=3.9; P=.048; Cramer V=0.19) and those who worked in a clinic (Fisher exact P=.03) reported a higher intention of prescription. Male respondents also reported a higher likelihood of assuming more positive attitudes toward DMHAs (Fisher exact P=.046). The demographic or work-related characteristics of other health care professionals were not significantly associated with either DMHA attitudes or prescription intentions.Respondents who reported more positive attitudes toward DMHAs (P=.01). This was not the case for the association between the digital affinity and the mental health professionals’ attitudes (Fisher exact P=.67). Our results lead us to believe that Portuguese professionals expect to prescribe DMHAs shortly (the next 12 months); however, they are not currently very optimistic about these tools. This may suggest that they are open to changing their views.We found a statistically significant association between the digital affinity score and prescription intention , the lack of information about digital apps gathered the most support from the respondents, including the highest percentage of “Totally Agree” answers. In addition, important issues such as the initial effort for health professionals , the need to adjust and adapt clinical records and practices , and ethical and legal questions  were very commonly identified as obstacles.Respondents were found to disagree more frequently with the idea that uncertainty around informed consent  and data privacy and safety  would be substantial obstacles to DMHA adoption. At the same time, the most neutral answers (“Don’t Know” or “Neither Agree nor Disagree”) were registered regarding the lack of support from the manufacturer for technical issues , considerably superior to the next highest value .In total, 10 different measures were presented to increase the adoption of DMHAs. For all cases, respondents expressed a favorable agreement with the utility of their adoption, ranging from 52% to 94% of the answers.The highest share of agreement was reached concerning the need for more information about available DMHAs . Closely behind, most professionals considered that the existence of scientific evidence about the validity of the apps , the recommendation by professional and scientific societies , and the definition of the prescription process  along with the sharing and reporting of positive experiences by peers  were relevant measures to foster adoption.The highest levels of disagreement were registered for the need to integrate DMHAs in health insurance plans , followed by changes to the legal framework  and manufacturer helplines for health care professionals . The most relevant share of neutral answers was registered regarding the integration of DMHAs in health insurance plans , which also reported the lowest level of agreement .Methods section. The interviews started with an overview of the study by the coauthors. They proceeded to ask the KOLs what were, in their opinion, the 3 main benefits of, barriers to, and measures to support the adoption of DMHAs in the Portuguese context in descending order. An initial briefing was shared with the invitation to participate.Of the 25 contacted KOLs, 11 (44%) replied to our invitation to participate in the interviews, 7 (64%) of whom gave positive replies. One KOL did not show up for the scheduled interview, and the remaining 6 were interviewed during the period mentioned in the The 3 main benefits identified by the interviewed KOLs and that gathered consensus were the following:Improved access and accessibility to health care at the personal and population levels, including geographically more remote areas and preventive services.Improved efficiency in providing care, both from the point of view of direct cost (payment per treatment) and allocation of available human resources.Proximity to the user .The 3 main perceived barriers to DMHA adoption identified by interviewed KOLs and that gathered consensus were the following:Lack of knowledge and literacy of professionals at the digital skills level about existing DMHAs and related evidence-based information.Absence of training programs on DMHAs, especially those that positively position them and do not constitute them as a threat to professionals .The health system is not designed to consider digital tools .The 3 main measures to support DMHA adoption identified by interviewed KOLs and that gathered consensus were the following:Creation of appropriate regulation, especially for clinical practice and reimbursement, and adequate health policies to boost the digital component safely.Promotion of literacy on mental health and training in digital apps , building awareness, and competency in digital tools in a constructive and collaborative perspective.Production of directives by the Ministry of Health and Professional Orders, such as an executive document with a selection of apps that could be useful and easy to implement while demonstrating good screening test characteristics.Results section for the web-based survey, ie, Demographics, Perceived Potential Benefits From DMHAs and Attitudes Toward DMHAs, Prescription Intentions of DMHAs, Perceived Barriers to DMHA Prescription, Measures to Support Adoption of DMHAs) to the KOLs and asking them whether they believed the obtained results to be aligned with their perception of most Portuguese psychiatrists and psychologists, justifying why.The second part of the interview consisted of the presentation of the results of the survey , low payment fees to professionals, or matters related to stigma.Finally, regarding the measures to support the adoption of DMHAs, the KOLs aligned with the adoption support measures identified in the survey and the distribution of responses. The action “integration of applications in health insurance” generated the most comments. KOLs considered that it could reflect ≥1 of the following 3 issues: In addition, KOLs pointed out several peculiarities of the Portuguese context that they believed were important for any stakeholder  who wishes to develop a likely successful DMHA to address mental health professionals’ needs. These were as follows:Health system financing and the incentives it produces must be considered, as health systems with budgeting practices based on production estimates instead of outcomes will experience severe difficulties in monetizing DMHAs and validating them as productive or cost-effective investments.Even if they are not inferior to other interventions, DMHAs may allocate resources more effectively and deliver savings by shifting individuals with lower mental health care needs to DMHAs and allowing mental health professionals to focus more of their time and attention on more complex cases.Professionals’ resistance to novelty and workflow change, as well as negativity bias and feelings of being replaced by apps, must be addressed to ensure a successful embracement of DMHAs. KOLs considered this to be particularly true for psychiatrists, supported by the number of people who answered that they had the expectation of increased initial effort for health professionals (72% of the survey’s respondents), need to adjust and adapt clinical records (71%), and additional workload (56%).DMHAs must be adapted for use in a clinical setting, namely for severe mental issues (such as schizophrenia), where DMHAs are currently unfit to deal with acute severe episodes. Furthermore, DMHAs must be balanced to prevent a user’s perception of pseudoautonomy that leads to the early abandonment of therapeutic interventions. Further research and development are required in these areas.Stigma plays a key role. This is not exclusive to one type of actor and ranges from the perceptions that professionals have of users and patients to insurance companies’ pricing policies and offers. Information sharing with third parties other than professionals and users must be selective and scrutinized to prevent distrust in these tools and to avoid discrimination toward people who use them.Any DMHA must bear in mind cybersecurity risks and their impact on the user. Mental health issues are usually intimate matters, and that places a higher emphasis on information security.Research and development on DMHAs must be ongoing, both from a clinical and a technical standpoint. Evidence generation, treatment, and analysis are expected to be performed on a rolling basis owing to their digital nature.Regarding the perceived benefits of DMHAs for patients, our findings were generally aligned with those of the study by Dahlhausen et al  despite The respondents were less enthusiastic about the perceived benefits of DMHAs for professionals, namely, regarding the expectation of improved treatment success and the possibility of improving the quality of patient care. They did recognize the benefits of better time management owing to efficiency gains and the benefit of having additional treatment options.We found a wider gap between the practitioners’ attitudes toward DMHAs and their intentions to prescribe them in comparison with German professionals. This may be because of the effects of social desirability bias on provided answers -66 and tConcerning the barriers to DMHA adoption, our respondents agreed more with the importance of the lack of information about digital apps and the initial effort for health professionals, as well as the need to adjust and adapt clinical records and practices, alongside ethical and legal questions. They demonstrated general neutrality toward the importance of the lack of support from the manufacturer for technical issues and reimbursement schemes, and KOLs have attributed this neutrality to a lack of knowledge about these tools or concerns with patient data privacy.By contrast, these mental health professionals agreed that more information about DMHAs, increased scientific evidence about their validity, recommendations by professional and scientific societies, and the definition of a prescription process along with the sharing and reporting of positive experiences by peers were all relevant measures to foster adoption.To leverage DMHA adoption, both Portuguese and German professionals recognized the importance of the first 2 points and concurred on classifying direct exchange with developers as one of the least important issues. They disagreed, however, on the necessity of integrating apps into health insurers’ commercial packages.In the German study, health care professionals with higher digital affinity were considerably more positive toward attitudes and prescription intentions; however, the strength of the associations was weak. While DiGA is already at work, DMHAs do not currently have a clear path for partaking in Portugal’s clinical process and care provision.Although a direct comparison between the professional groups of this study and the ones in the replicated paper is not immediate, the strictest association occurs in practitioners in psychiatric specialties (“child and adolescent psychiatry and psychotherapy” and “psychiatry and psychotherapy”), corresponding to the Portuguese psychiatrists, and the remaining specialties , corresponding to psychologists in the Portuguese case.The first group’s differences between attitude and intention toward recommendation or prescription ranged from 38.5% to 45.9%, whereas the second group’s differences ranged from 35.2% to 36.6%. In our study, for psychiatrists, we found a difference of 59% between the reported positive attitudes toward DMHAs and their intention to prescribe them . For psychologists, the same difference was 40% .Although Portuguese psychologists’ answers are more favorable than their German counterparts, the differences between attitudes and intentions have a similar magnitude. However, more Portuguese psychiatrists presented positive attitudes, while slightly fewer reported prescription intentions, thus yielding a larger difference than the one found in German psychiatrists.First, it is important to highlight that in a country with no payment or reimbursement tracks or clinical or technical validation standards specific to digital health apps, these findings are based on the individual KOL’s experience and perception of the national landscape.Second, the interviewed KOLs mainly considered that the survey’s results, despite the sample size and a possible bias in favor of digital tools, were representative of the study’s intended population. This increased our confidence in the obtained results and, consequently, in the conclusions they can draw toward DMHA promotion.Third, the fact that KOLs were unanimous regarding several issues—such as access to care, patient centricity, or (need for) mental health professionals’ digital literacy draws attention to the fact that the Portuguese health system needs profound transformation. Alerts have been abundant since Europe’s health systems suffered from the COVID-19 pandemic and its clinical backlog , which hThe reported results from the survey and the KOL analysis revealed a general immaturity in implementing DMHAs  in Portugal.The survey shows an explicit generalized agreement with the perceptions listed concerning potential benefits, barriers, or measures to foster adoption. These results seem polarized to one of the extremes, as disagreement answers were never >21% for the specific questions.Moreover, the topics generating the most neutral answers require some practical implementation of these tools—specifically, on the improvement of patient satisfaction, treatment success, and capability to make informed choices; on the lack of support from the manufacturer for technical issues; and on reimbursement of medical prescription, as well as integration of DMHAs in health insurance coverage. We hypothesize that this neutrality confirms a lack of practical experience with these tools. Otherwise, professionals would have more positive or negative perceptions because of their experience and less ambiguity or one-way polarization.Our theory is compatible with other findings from the survey; although Portuguese professionals are at least as positive in their attitudes toward DMHAs as German professionals, the former group has only a smaller share of those who do intend to prescribe them, thus generating a wider gap between attitudes and prescription intentions for Portuguese mental health professionals than that found for German counterparts in the study by Dahlhausen et al . If theiThis theory is also compatible with the Portuguese health system paradigm concerning mental health as described by the KOLs, who repeatedly reported the professionals’ resistance to change and novelty, as well as the intrinsic fear of being replaced by DMHAs, as barriers to DMHA adoption. This barrier should be taken seriously so as not to create a negative reinforcement loop that further restrains professionals from adopting and applying such tools.This is all the truer as the Portuguese National Health Plan  ranks “aPortugal faces important challenges despite being a relatively small country (approximately 10.5 million inhabitants), namely, a rapidly growing aging population , decliniThe study elicits preferences and issues that are clearly important to understand the demand side, as it is visible, for example, through the high degree of agreement in survey answers and KOL responses. Furthermore, the mixed methods methodology allows us to combine the perspective of those closest to potential users with a helicopter view with in-depth knowledge, making the derived conclusions more robust.All biases inherent to sampling and KOL selection are potential limitations of this study, with the social desirability of the provided answers and the role of expectation in the survey’s answer process , as well as self-selection, being among the most relevant. Their impact on provided answers is mitigated by the fact that in a postpandemic reality, telehealth   has provThe sample number may constitute a further limitation, as 160 answers only partially characterize a population of 1528 psychiatrists and an undetermined number of psychologists. However, the level of agreement between the elements gathered in the survey and the KOLs’ assessment, both before and after seeing the survey results, leads us to believe that the underlying uncertainty in the provided answers might not be as considerable as expected. Furthermore, the proportion between psychologists and psychiatrists in our study and the study by Dahlhausen et al  is approFinally, the comparability between studies is limited by their different scopes and stages of regulatory development: the study by Dahlhausen et al  was prodFrom a general perspective of digital health apps, it would be useful to fully replicate this study to understand which points are common to all apps and which are solely applicable to DMHAs. Deloitte’s report for Health Cluster Portugal  is the oMoreover, as this is a portrait of the landscape as far as DMHA are concerned and one of the main difficulties that we felt was survey engagement (despite extensive dissemination efforts), it would be essential to perform this extended work with further engagement from professional orders, professional societies, and market-based stakeholders . OutreaGiven that this necessarily entails regulation, it would be interesting to expand further on the regulatory science angle and the opportunity for either regulatory tracks at the EU level  or reguFinally, it is widely agreed that digital interventions have appreciable potential to deliver more and better health care. However, if these—or any other health interventions—are to succeed, they need rigorous planning by diagnosing the status, defining targets and priorities, establishing objectives and desirable results, and outlining the best evidence-based strategies and plans to achieve them . MonitorPortuguese mental health professionals’ perceptions of digital health apps present clear aprioristic expectations regarding the benefits of DMHAs for users, especially concerning improved therapeutic adherence and health literacy. Although professionals generally recognize the benefits for patients, they are less optimistic about the expected advantages for themselves and their peers. Although the usefulness of DMHAs for professionals needs to be clarified, benefits such as efficiency gains and having an additional treatment option are among the most valued benefits from the onset.Chief among the main perceived barriers are the need for more information about digital health apps, preconceptions of initial use efforts for health professionals, and the need to adjust and adapt clinical records. The main enablers of DMHA use identified include more information about these apps, both regarding how they work and scientific evidence about the validity of such apps, as well as recommendations by professional and scientific societies. Governmental or regulatory guidelines are strongly recommended.Portuguese mental health professionals, compared with German mental health professionals, were similar in most of the reported answers. Some notable differences were fewer positive perceptions concerning treatment success and quality of patient assistance, a wider gap between attitudes and prescription intentions for Portuguese mental health professionals, and the need for considerable workflow adjustments as limitations for adoption.Concerning how digitally literate mental health professionals perceive themselves and their patients to be, the scores of digital literacy–related issues in terms of barriers and measures to support adoption in the survey, along with the conclusion by the KOLs that this is one of the main issues faced by mental health professionals in Portugal, lead us to posit that mental health professionals perceive themselves to have high degrees of digital illiteracy. They also perceived a strong need for patients to be educated should DMHAs or other digital tools be implemented to deliver mental health care.Mental health professionals believe that their role in digitalizing health care provision consists mainly of promoting literacy among peers, namely, to and by younger age groups, thus forming communities able to capacitate a growing number of professionals. Their participation in professional and scientific societies is another avenue for further engagement. Finally, mental health professionals believe that the Portuguese government sector should play a crucial role in shaping the health system and enabling the proper organizational and financial means and incentives to catalyze transformation.


The purpose of this paper is to contribute to the existing literature by investigating the determinants of the profitability of Islamic and conventional banks in the Middle East region and revealing the most important factors for these two types of banks. Few papers have studied the performance of Islamic banks and compared their performance with conventional banks. The results from these limited research papers are also various, mainly because the sample sizes are small, or they have analysed data only from one country. Our research used a fixed effect panel data analysis on a sample of 270 banks  from 12 Middle East countries. We used an unbalanced annual panel of data covering the period 2012–2020. The results show that bank size, equity to assets, annual GDP growth, and annual average oil price have a significant positive effect on Islamic banks’ profitability, while non-performing loans to total gross loans and cost of running operations to operating income have a significant negative effect on both bank types. The results also show that non-performing loans to total gross loans and annual GDP growth contribute more to conventional banks profitability, while oil price contributes only to Islamic banks performance. Inflation and net loans to total assets have no effect on bank profitability for either Islamic or conventional banks. Furthermore, we also found that the Islamic banking industry had a more competitive structure. Our findings have important implications for managers, policy makers, investors and other stakeholders. They can help them to make decisions regarding investments, plans, budgeting, evaluation and the management of business operations. A well-functioning banking system is vital for any economy. By attracting money from depositors and directing it towards investors, banks boost the economy’s overall wealth. Profitable banks contribute to better resource allocation and economic growth. They promote it by providing finance for worthwhile projects . TrujillThe financial world has established conventional banking as a standard practice that is primarily motivated by the profit maximisation concept . HoweverGiven the fact that Islamic banks need to comply with the sharia principles, the question arises whether they can achieve the same profitability as conventional banks and whether their profitability is driven by the same factors. Thus, the main purpose of this paper is to contribute to the existing literature by investigating the determinants of the performance of Islamic and conventional banks and revealing the most important factors for these two types of banks.This study focuses on the countries of the Middle East. In this region of the world both Islamic and conventional banks operate, which allows us to examine and compare the determinants of profitability for the two types of banking. Moreover, the Middle East is the region of the world with the most developed Islamic banking. Thus, it may indicate that Islamic banks are competitive with their conventional counterparts.Both Islamic and conventional banks are profit-maximising organisations that are essential for the effective use of resources and, as a result, lessen information asymmetries, assist in lowering transaction costs, and facilitate diversification for small investors and savers. As financial intermediaries, they provide services such as: asset transformation, a payment system, custodial services, and risk management. In theory, these two types of banks differ significantly. While conventional banks’ intermediation is primarily debt-based and permits risk transfer, Islamic banks’ intermediation is asset-based and focuses on risk sharing . The IslThere might be fundamental differences between the Islamic and conventional banking in theory; in practice, however, they are relatively small. Principally, Islamic banks should rely on the participation model, where profits and losses are shared between the contracted parties. However, the competition has forced them to rely mainly on fixed return products , where tIt is difficult to predict whether the performance of Islamic banks is affected by the same determinants as the conventional institutions. On the one hand, due to the specific Islamic activity, the profitability of Islamic banks would not be determined by the same factors that have an impact on conventional banks. Looking at the issue on the other hand, the similarity of Islamic banking practice to the conventional banking model may result in the observation that there is no difference between the profitability determinants for Islamic and conventional banks. Our research will give an answer to this issue.Our paper seeks to make the following contributions to the literature on the determinants of banks’ performance. First, to the best of our knowledge, this study, along with those by Mateev et al. ,17, reprSecond, we contribute to the existing empirical studies on the determinants of profitability of both conventional and Islamic banks, which have yielded ambigous findings. Thus, our study gives information whether the same determinants impact the performance of the two types of banking. This issue is especially important for bank managers, investors and policy makers, who should receive the answer for the question whether Islamic banks should have the same regulations to abide by as the conventional institutions.Third, we used static and dynamic models which suggest that in the case of the conventional banks there is a much stronger ROAA persistence. So we found that the Islamic banking industry had a more competitive structure. In addition, we included in the static approach the estimation of fixed effect models and random effect models as well as subsample analysis and alternative independent variables to ensure the robustness of the results.Our study provides detailed evidence of the impact on both bank-specific and macroeconomic determinants on banks’ profitability. The results of our research show that such bank specific determinants as the bank size and equity to assets have a significant positive effect on Islamic banks’ profitability, while non-performing loans to total gross loans and cost of running operations to operating income have a significant negative effect on both bank types. The results also show that non-performing loans to total gross loans have the greater impact on the profitability of conventional banks. Net loans to total assets do not affect the bank profitability for either Islamic or conventional banks. Taking into consideration macroeconomic determinants, we found that annual GDP growth and annual average oil price have a significant positive effect on Islamic banks’ profitability. GDP growth shows also a positive impact on the profitability of conventional banks. There was no link between the annual consumer price index in the bank’s country and the profitability of the Islamic and conventional banks.The remainder of this paper is organised as follows: Section 2 presents the background of Islamic banks’ development. Section 3 reviews the existing literature of theories on profit. Section 4 reviews the existing empirical literature on the determinants of bank profitability and hypothesis development. Section 5 presents the data and methodology applied. Section 6 is devoted to results and discussion. Section 7 presents the robustness checks. Section 8 summarises the study and suggests a direction for further studies.st and 2nd place, respectively , return on equity (ROE), or net interest margins (NIM), have been extensively examined since the 1990s. Some of the earliest studies were conducted by Short , Bourke As Al-Homaidi et al.  noted, pBased on the existing literature, this paper attempts to find the macroeconomic and bank-specific determinants which affect Islamic and conventional banks’ profitability, reflected in return on average assets (ROAA) and return on average equity (ROAE) ratios in the region of the Middle East.The macroeconomic determinants are those factors that are beyond the control of a bank but reflect the economic environment that affects the performance of banks. The factors which belong to this group include GDP growth, inflation rate, and oil price.The GDP growth can be defined as the annual change of the GDP. It is the most general and most direct measure of macroeconomic development , which iH1: GDP growth positively affects the profitability of conventional and Islamic banks.The relationship between inflation and banks profitability has been profoundly discussed in the literature. Inflation also reflects aspects of the business cycle . It is aAccordingly, our second hypothesis is as follows:H2: There is a positive relationship between the inflation rate and banks profitability for conventional banks and a negative relationship for Islamic banks.Oil is a significant source of revenue for Middle Eastern countries and the main reason for the emergence and growth of Islamic banking in this region of the world. However, the oil price is not a variable that is usually taken into account in the studies of bank performance. A study that examined the relationship between oil price and bank profitability in the Gulf Cooperation Council (GCC) region was conducted by Esmaeil et al. . Their aSince the growth of Islamic banks has been funded by export of oil, our third hypothesis is as follows:H3: Oil price increase positively affects only the profitability of Islamic banks.Bank-specific factors are determinants that are predominantly influenced by the decisions of a bank’s management and its policy objectives. Such factors are the size of the bank, level of liquidity, capital adequacy, asset quality, and efficiency.Bank size is measured in terms of the total assets of the bank. Empirical studies on the influence of bank size show inconclusive results. On the one hand, the higher the value of a bank’s assets, the lower its operating costs due to the economies of scale; therefore, higher profitability can be expected as the bank’s assets increase. On the other hand, extremely large banks may achieve lower profitability, e.g., due to bureaucratic procedures. As far as conventional banks are concerned, the positive and significant influence of bank size on its profitability has been demonstrated, inter alia, by Demirgüç-Kunt and Huizinga , KhrawisWe follow the literature that found a positive relation between bank size and the bank’s profitability and, therefore, our fourth hypothesis is as follows:H4: Bank size positively affects the profitability of conventional and Islamic banks.Bank liquidity can be measured by net loans to total assets ratio, a factor that is expected to have a positive impact on bank performance. Financing provided by banks is the main source of a bank’s income, therefore, the higher its level, the higher the bank’s profitability. But, on the other hand, a high level of this ratio may contribute to a decrease in the bank’s liquidity and an increase in the number of outstanding loans. In such a situation, the bank’s profitability may decline. A positive and significant impact of the net loan to assets ratio was found in the studies by Trujillo-Ponce  as well Accordingly, our fifth hypothesis is as follows:H5: Bank liquidity positively affects the profitability of conventional and Islamic banks.Capital adequacy is usually measured by the equity to assets ratio, which can be interpreted as the bank’s capital strength or insolvency risk . A high We follow the literature that found a positive relation between capital adequacy and the bank’s profitability and, therefore, our sixth hypothesis is as follows:H6: Capital adequacy positively affects the profitability of conventional and Islamic banks.Another variable that should be included in the study of the determinants of bank profitability is the asset quality ratio, which can be defined as an estimation of the quality of a bank’s assets and is normally based on the loans and leases. The asset quality ratio is used in evaluating the credit risk associated with assets. Generally, the lower the ratio, the better the asset quality of the bank . As proxAccordingly, our seventh hypothesis is as follows:H7: There is a negative relationship between share of non-performing loans in the total gross loans and the profitability of conventional and Islamic banks.Efficiency ratios are used to analyse how well the bank is managing and controlling its assets . StandarWe follow the literature that found a negative relationship between the cost of running operations divided by operating income and the bank’s profitability and, therefore, our eighth hypothesis is as follows:H8: There is a negative relationship between the cost of running operations divided by operating income and the profitability of conventional and Islamic banksIn the first stage, a goal was formulated to which the scope of the study was subordinated. Due to the need to obtain detailed information, it was decided to use the Orbis database, which allowed for high-quality data to be obtained from banks financial statements. Factor analysis was then carried out after processing the collected data, and applied to rule out potential collinearity and reduce dimensions, bearing in mind we started with 358 banks from 12 countries, 18 explanatory variables, and 2 dependent variables–ROAA and ROAE. As a next step, descriptive statistics were calculated and panel models were constructed to verify the effect of the independent variables on the ROAA and ROAE for both Islamic and conventional banks .Our research was initiated by the discovery of a gap in the literature focusing on the differences between Islamic and conventional banks, especially related to the ambiguous determinants of profitability amongst Middle East banks. We noticed that many studies have not come to the same conclusion because surveys were conducted in different countries, in different periods, and taking into consideration different econometric methods. Differences in the business models between conventional and Islamic banks can lead not only to profitability differences, but also to cost-effectiveness or capital stability differences. We based our study on the experience and limitations of previous studies performed by the researchers in the past .It is worth emphasising that despite the fact that some researchers have proved the existence of certain differences between Islamic and conventional banks, the differences they have indicated between the two types of banking do not translate into their financial states and generally the same profitability factors could be observed being measured by ROAA and ROAE. Based on the research carried out by Farah , it may The bank-level data of the Islamic and conventional banks’ accounting statements were retrieved from Orbis. The dataset covers 12 countries located in the Middle East, namely Bahrain, Iran, Iraq, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, the Syrian Arab Republic, the United Arab Emirates, and Yemen. The total value of Islamic bank assets in these countries in the sample is US$ 1,344,009,577 in 2019 . The market is characterised by a relatively high-income level and competition that is intensifying with a high percentage of customers whose primary concern is product purity. The region has an overall high level of economic development, but its countries range from being very poor, such as Yemen, to being extremely wealthy, such as Qatar, the United Arab Emirates, and Kuwait. It is highly reliant on oil and four of the countries were among the top ten oil exporters in 2020; Saudi Arabia, Iran, the United Arab Emirates, and Kuwait. Jordan and Lebanon are the only net oil importers among the region in the sample. The largest oil reserves are to be found in Saudi Arabia, with 20 per cent of the world’s known oil reserves [The empirical literature on bank performance focuses primarily on assessing the relationship between bank performance measures such as ROE and ROA and several predictors of bank performance based on fundamental data such as size of bank, share of non-performing loans, level of operational costs, etc., as well as general macroeconomic factors such as GDP growth, inflation, interest rates. In order to measure the profitability of banks, we use two measures that are commonly used in the literature, namely return on average assets (ROAA) and return on average equity (ROAE). While ROAA is measured as net income to total assets, ROAE is measured as net income to shareholders’ equity. These two profitability measures reflect how banking management uses the bank’s actual investment resources (assets or equity) to generate profits. The evolution of these profitability measures is shown in Figs ROAA is determined by dividing net profit after taxes by total assets. This measurement of the company’s operating efficiency is based on the profits generated by the company from its total assets. The ratio can be calculated by applying the following formula: Net profit after taxes/average assets.Based on our sample, conventional banks are more profitable than Islamic banks; through the entire period, ROAA for conventional banks was higher than for Islamic banks. This could be driven by high assets and larger market size .It is worth noting that only for Islamic banks was ROAA negative in 2019 . In the ROAE is calculated by dividing net profit after tax by total shareholder equity. This ratio determines the rate of return on a company’s investment for its shareholders. To calculate this indicator, the following formula is applied : Net proFrom 2012 to 2015, ROAE for both Islamic and conventional banks was similar, on a positive level. It can be seen that in 2016, ROAE for Islamic banks was negative. A negative ROAE is clearly interpreted as an unfavourable financial situation for the company, but in the case of Islamic banks it must be remembered that some of the banks are relatively new, so they could show losses and at the same time be supplied with capital from the investor-founder. This is evidenced by the fact that since 2017, a continuous increase in the indicator can be observed, and only in 2016 was negative ROAE seen within the analysed period. A similar situation was observed for conventional banks, where, in 2019, negative ROAE was observed .To summarise, ROAE is affected by ROAA as well as by the bank’s degree of financial leverage. As returns on assets, in general, tend to be lower for financial institutions, most banks often use financial leverage to increase the return on equity to a competitive level and this is a trend we have observed for both the Islamic and the conventional banks.It would seem that the situation should be less complex as soon as Islamic banks are engaged in banking and financial activities in the country, because the Islamic bank then applies sharia rules. However, in a financial system where we see the coexistence of conventional and Islamic banks, the task is not so simple for an Islamic bank, which has to compete with the conventional banks. Therefore, even if we compare two Islamic banks with the same activities, selling the same products and following the same rules, but operating in two different countries, their financial results and operational goals may differ significantly . This isOrbis database enabled the acquisition of data for the period 2012–2020, however, the obtained panel dataset was unbalanced. This meant that for some banks, data on selected ratios or selected years were unavailable. Missing data caused some cases to be removed from the dataset during the final model estimation.As already mentioned above, our research sample ultimately consisted of 111 Islamic banks and 159 conventional banks. For both groups, the In our study, we included two measures of bank financial performance which we used as dependent variables in the model see . The firBased on the literature review, we included a set of independent variables in the model, which we have divided into bank-specific factors and macroeconomic factors . The defsize of a bank (variable LogTA) is usually measured as the logarithm of total assets. The natural logarithm of total assets is taken as a proxy of bank size, which is frequently used in empirical literature [The terature ,45,74. HEquity divided by total assets (variable ETA) represents the group of capital structure indicators. It should be noted that a high share of equity in the bank’s assets increases the security of both the bank itself and its customers who have entrusted the bank with their money. In addition, equity is a source of coverage for potential losses. The greater the share of equity, the lower the bank’s need for external capital. However, too high a level of equity capital may reduce the bank’s ability to increase its profitability. Dermirgüç-Kunt and Huizinga [ETA on conventional and Islamic banks profitability.Huizinga , in theiHuizinga  found evnet loans divided by total assets (variable NLTA), should have a positive effect on profitability for both types of banks. Bank loans are the main source of a bank’s income, therefore, the higher the level of financing provided by banks, the higher the bank’s profitability should be.The next indicator, Cost of running operations divided by operating income (variable CI) is expected to be negatively related to profitability of both conventional and Islamic banks, as it increases the expenses of each type of the bank. Efficient banks should be able to reduce their operating costs successfully which ultimately increases their profitability.Non-performing loans divided by total gross loans (variable NPL) is expected to be negatively correlated with the profitability of both conventional and Islamic banks. Usually, the loan is perceived as non-performing when the borrowers fail to return principal and/or interest within a specified period, which is normally 3 months or 90 days. Scholars also denote non-performing loans as problematic or bad loans. In this study, the ratio of non-performing loans to total gross loans has been used [een used .Change in GDP in the bank’s country compared to the previous year (variable GDP) is used as a proxy of the economic cycle. It is expected that the profitability of both Islamic and conventional banks will rise in good economic times and decrease in recessions. These effects are expected as credit quality will decrease in recessions and, therefore, as the risk of default will rise, the bank returns are expected to be lowered. In addition, higher rates of GDP growth can stimulate higher demand for financing offered by banks.Annual consumer price index in the bank’s country (variable CPI) is expected to positively affect profitability of conventional banks. Inflation affects banks pricing behaviour, and hence, if banks expect general inflation to be higher in the future, they may believe that they can increase their prices without experiencing a decline in demand for their output. However, it is also expected see the negative link between annual consumer price index in the bank’s country and profitability of Islamic banks.annual average oil price (variable OP), a positive impact on Islamic banks profitability is expected as the Middle East countries are mainly oil exporters.Concerning In order to investigate the relationship between dependent and independent variables, we used both static and dynamic panel modelling. The static modelling of panel data makes it possible to distinguish individual effects from effects caused by external factors. It becomes possible to control the influence of the individual, internal differentiation of entities. In the case of panel data, fixed effects (FE) and random effects (RE) models are most often used. Both have their strengths and weaknesses. FE models constitute an appropriate specification if the research process is focused on a selected group of entities. They are most often used for the so-called long panels with a small number of entities and a long test period. RE models are appropriate if the panel is a sample from which conclusions are drawn for the entire population. RE models assume that the error term can vary randomly . In our Yi,t represents the dependent variable for the bank i in the time t,β0 represents the constant term,Xk,it is the k-th independent bank-specific variable for the bank i in the period t,Xl,it is the l-th independent macroeconomic variable in the country of the bank i in the period t,βk represents the parameter for k-th independent bank-specific variable,βl represents the parameter for l-th independent macroeconomic variable,αi is an individual-specific effect for the bank i that does not vary across time,εi,t is the error term which assumes different values for each bank at each point in time.In turn, dynamic panel models assume that there is a persistence of banks’ financial performance. The persistence of bank profits reflects impediments to market competition, informational inefficiency, and/or sensitivity to macroeconomic shocks . The dynYi,t-1 represents the one-period lagged dependent variable for the bank I,δ represents the speed of adjustment to equilibrium.δ means that there is a persistence of financial performance. A value close to 0 means that the industry is fairly competitive (a high speed of adjustment), while a value of δ close to 1 implies a less competitive structure (very slow adjustment) [A statistically significant value of the parameter ustment) . In thisTo assess the validity of estimating separate models for Islamic and conventional banks, we conducted the Chow test  for the In this section, we analyse bank-specific and macroeconomic factors affecting the ROAA and ROAE of Islamic and conventional banks. Descriptive statistics for all variables are presented in To begin with, we performed a correlation and multicollinearity analysis see  Tables. We initially estimated static and dynamic models for both Islamic and conventional banks. We used the two-step system generalised method of moments estimator in the dynamic approach . In this2(8)>33.79 in the case of ROAA models, χ2(8)>18.26 in the case of ROAE models). Due to the presence of heteroscedasticity, we used robust standard errors in the estimation. However, due to the fact that most of the estimated dynamic models did not meet the assumptions, we based our further analysis on the static approach. The Hausman test shows that the FE model is suitable for both Islamic and conventional banks in this case (χETA) positively influenced Islamic banks and did not have an impact on conventional banks. Our findings offer partial empirical support for H6, which suggests that capital adequacy positively affects profitability but only in the case of Islamic banks.We also observed a difference in the impact of bank capital adequacy on ROAA. Higher capital adequacy  ratio on both Islamic and conventional banks. Hence, we accept H8.However, we did observe a strong negative impact of the cost to income  as a measure of liquidity, non-interest expense divided by average assets (NIEAA) as a measure of efficiency, and loan loss reserve to gross loans (LLRGL) as a measure of asset quality. The results obtained were presented in To further test the robustness of the results, we replaced some of the independent variables in the estimated models with alternative indicators. We used net loans divided by the sum of deposits and short-term funding  countries, while the second subsample consisted of countries which are not members of the GCC. The applied division is significant because GCC member states, being the leading oil producers amongst the Middle Eastern countries, strive to create similar or identical regulations in various areas, including economic, financial, trade, customs, and communication regulations, as well as in the educational and cultural spheres. The estimation results of the models for ROAA were presented in The results obtained in the subsamples generally confirm the previous conclusions. However, there are some differences in the results for both subsamples. For example, the bank size had a stronger impact on the ROAA of banks in non-GCC countries because banks in this subsample were on average smaller and showed greater diversity, resulting in a clearer impact of size on profitability. The influence of oil prices was significant on the ROAA of Islamic banks in the GCC region. On the other hand, the impact of the GDP variable on ROAA and ROAE was significant only for conventional banks in the subsamples.The empirical analysis allows us to shed some light on the relationship between bank-specific factors as well as macroeconomic indicators and the profitability of Islamic and conventional banks in the Middle East. Using a fixed effect panel data analysis on a sample of 270 banks  from 12 countries over the period 2012–2020, we confirmed some of the findings from earlier studies: for instance, a positive relationship between GDP growth and banks profitability, a negative relationship between cost-income ratio and profitability, and a negative relationship between non-performance loans to gross loans ratio and performance of banks. We also found that three factors impact only the profitability of Islamic banks. These are capital adequacy, the size of the bank and oil price. All three variables are positively related to the performace of Islamic banks.The results of our study are invaluable for bank managers, regulators, investors and customers. While managers need to assess the results of prior management decisions, bank regulators are concerned about the safety and soundness of the banking system. They monitor the performance of banks in order to identify those banks that may be experiencing serious problems. Without regular performance monitoring, important issues might be missed and result in financial failure. Policymakers and regulators should formulate policies that ensure the resilience of banks against crises, such as the Covid-19 pandemic. When comparing conventional and Islamic banks, several noticeable differences in financial indicators and their impact on profitability become evident. Therefore, regulators should not treat the two types of banks identically when creating and implementing banking regulations. For instance, they should apply different incentives for consolidation processes. In the case of conventional banks, further consolidation processes may have negative consequences for customers, competition, and systemic risk. In contrast, the situation is different for Islamic banks, where there are many very small entities and consolidation processes could have a positive impact on their profitability, without having severe negative consequences for customers. Another issue for regulators and bank managers is to lower operational costs. Digital transformation can enhance efficiency, flexibility, and resilience in banking operations for both conventional and Islamic banks. The push towards electronic banking was further propelled by the COVID-19 pandemic. It is also recommended that regulators and policymakers, when making decisions that affect the economy, take into account that some of the macroeconomic factors i.e. GDP growth, affect the profitability of banks.According to our estimations, oil prices affect only the profitability of Islamic banks. When the price of oil is high, Islamic banks could consider extending financing to oil-related businesses in order to increase profitability. However, since the price of oil is volatile, they are advised to provide mainly short-term financing. They also need to find tools to mitigate any unfavourable influence of oil price shocks.The empirical findings of our study suggests that both conventional and Islamic banks should focus on improving the process of monitoring non-performing loans, as the negative impact of non-performing loans on profitability has been observed. Banking managers may also undertake measures to reduce exposure to unfavorable sectors and direct attention to more promising industries. Islamic banks still need to find ways to boost non-interest income, while commercial banks should note that a more conservative philosophy towards banking as exemplified by Islamic principles may serve them to avoid losses.Our study also has some limitations. The main one is some gaps in data on non-performing loans of Islamic banks. However, the available data was numerous enough to determine the impact of bad loans on the performance of both Islamic and conventional banks. Thanks to the large sample size, we consider our research sound and very reliable. Furthermore, in our study we used two variables which measure the profitability of the banking sector ROAA and ROAE. There are other variables which are commonly used to measure profitability. Future work could include i.e. the Net Interest Margin (NIM) and Net Profit Margin (NPM) as a dependent variable for conventional and Islamic banks respectively.It is recommended that the results of this paper are confirmed against another sample from different regions. Further, it is also recommended that a comparison of Islamic and conventional bank performance does not just consider profitability. This research could be extended by adding new independent variables and by comparing profitability factors between regions. This could also be combined with the approach of Islamic bank stability during the next years of the COVID-19 crisis, including an increase of oil price since it is frequently argued that the resistance towards crisis is due to the distinctive Islamic bank investment policies.S1 Table(TIF)Click here for additional data file.S2 Table(TIF)Click here for additional data file.S3 Table(TIF)Click here for additional data file.S4 Table(TIF)Click here for additional data file.S5 Table(TIF)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.


Our study aimed to compare the biomechanical behaviour of mandibles with or without titanium miniplates when subjected to an impact after bone healing using a finite element model (FEM) of the human mandible. We simulated mandibular trauma on an FEM of a human mandible carrying or not two parasymphyseal miniplates and applying a concentrated force of 2000 N to four different areas, including the insertion area, the area straddling the edge of the miniplates and the adjacent bone, at a distance from the miniplates on the symphysis, and on the basilar border of the mandible below the miniplates. Then, we compared the Von Mises stress distributions between the two models. In the case of an impact on the miniplates, the maximum Von Mises stress occurred in two specific areas, on the cortical bone at the posterior border of the two miniplates at a distance from the impact, while in the model without miniplates, the Von Mises stresses were homogenously distributed in the impact area. The presence of titanium miniplates in the case of trauma affects the biomechanical behaviour of the mandible and could cause more complex fractures. We recommend informing patients of this potential risk. The use of titanium miniplates is the gold standard in the treatment of mandibular fractures and mandibular osteotomies . NeverthNumerical modelling may help us understand the stress distribution on the bone tissue and the bone implant surface while enabling us to simulate different types of trauma and osteosynthesis , in contFurthermore, using finite element analysis (FEA), which is recognized as a valid and non-invasive method of predicting the biomechanical behaviour of the mandible in terms of stress, strain, and deformation  under phThis study aimed at comparing the biomechanical behaviour of a mandible (with or without miniplates) subjected to an impact, according to the Von Mises stress distribution, using an FEA of a human mandible.®  in order to recreate the skull’s geometry. The meshing was created using Hypermesh® software . The component properties were assigned using Hypercrash® , and the simulations were conducted using Radioss® . The skull base, facial bones’ geometry, and mesh patterns, including the glenoid fossae of both temporomandibular joints and the maxillary teeth and their alveolar surfaces, were reused from our initial model. We also retained the mandible’s geometry, but the meshing was refined thanks to a specific 3 mm thick cortical tetrahedral 3D meshing and a 3D tetrahedral meshing for the mandibular cancellous bone. Since the structure is complex, it was not possible to apply hexamesh; therefore, the tetrahedral mesh was used with an element of 1 mm. The meshes of the mandibular teeth and their alveolar surfaces were adapted. To ensure that the size of the mesh elements had no impact on the stress distribution, we compared the mesh used with 1 mm elements with a mesh using 0.5 mm elements.We used a 3D finite element model (FEM) which had been previously developed and validated by our team . DICOM d® . Five millimetre screws were designed with the same software. The meshing was continued with nodes placed between the miniplates, screws, and the maxillary bone and distributed in such a way so as to simulate the osseointegration of the implants.Two 4-hole 1.0 mm thick 2.0 miniplates  were placed on the right parasymphysis, simulating the previous treatment of a vertical simple parasymphysis fracture. We considered that the patient had a healed fracture of the right parasymphysis of the mandible, corresponding to a fully consolidated bone after callus remodelling following fracture that resulted in “restitutio ad integrum”. The geometry of the miniplates was extracted from the STL files furnished by their manufacturer and meshed using HypermeshThe model was previously validated  accordinThe mesh was continued between the teeth and bone, cancellous and cortical bone, cortical bone and miniplate, and cancellous bone and screws. Penalty contacts were applied between mandibular and maxillary teeth and between the mandible and facial bone to avoid penetration of one part by another.The skull base, including the glenoid fossae, the maxillary bone, and the maxillary teeth, was restrained in all directions. Condyle translation was blocked in all three directions and rotation was restrained except in the sagittal plane in order to facilitate the creation of FEM simulations of mouth opening and closure .Jaw elevator muscle forces were simulated by creating a concentrated force applied to the mandibular insertions of the masseter (388.5 N), the temporal (333 N), and medial pterygoid muscles (432 N) using force vectors following the axis of contraction of each muscle in order to simulate muscle contraction as described in the literature .Our material data on the compact and cancellous bones, teeth, and titanium were extracted from the analyses conducted in previous studies ,32,33,34Blunt trauma numerical simulations on modelled mandibles with and without miniplates were run on Altair Radioss  using a concentrated force of 2000 N, which has been frequently used in the literature ,35,36,37The FEA results shown in our figures represent the color-coded Von Mises stress (MPa) distribution in the mandible with and without miniplates subjected to the corresponding impact loading.The Von Mises stress distribution was relatively consistent between the tetrahedral mesh with 1 mm elements and the tetrahedral mesh with 0.5 mm elements . In partRange stress histograms  showed tOur study stands out as the first FEA study evaluating the biomechanical behaviour of osseointegrated mandibular miniplates in the case of trauma occurring after bone healing. We have established that miniplates changed the biomechanical behaviour of the mandible in our numerical model in the case of trauma involving the miniplate area.Our finite element analysis showed that in the case of an impact in the miniplate area, the stresses were mostly absorbed by the miniplates, which tended to protect the underlying bone. However, these stresses were transmitted through the miniplates to the bone close to the edges of the miniplates, creating several areas of high-level stresses. These areas are exposed to an increased risk of fracture, which could result in complex fracture lines and in multi-fragmentary fractures located at the edge of the miniplates. From a biomechanical perspective, titanium is more rigid than bone, thereby allowing the miniplates to absorb stresses instead of the underlying bone. However, this rigidity does not allow dispersing stresses, which are transmitted through the miniplates to the bone on their edges, creating high levels of stress areas on this bone. In fact, in the case of an impact at a distance from the miniplates, stresses are absorbed by the miniplate, more rigid, and weakly transmitted to the bone. This could explain the shift towards low stress values in the stress range histograms of the bone in the case of an impact at a distance from the miniplates. In the case of an impact on the miniplates, the stress histogram showed no difference in term of stress-level distribution. However, the Von Mises distribution was different depending on the presence of miniplates, with less stresses on the bone under the miniplates and more stresses on the bone at the border at the miniplates. In this case of a direct impact on the miniplates, stresses were transmitted to the bone close to the edges of the miniplates.Our findings are in accordance with our clinical observations of fractures occurring at the edges of miniplates on mandibles bearing miniplates  6]..6].In this multicentre case series, we identified 13 patients presenting a fracture on a mandible bearing miniplates for at least 6 months. The indication of the former osteosynthesis was a fracture due to assault in nine cases, a horse hoof kick in one case, and a bilateral sagittal split osteotomy for the correction of dental class II in three cases. The mechanism of the second trauma was assault in 10 cases, including the 9 cases who initially presented with a fracture due to an assault, a subsequent hoof kick for the patient who had been kicked initially, and a traffic accident for 2 patients treated with bilateral sagittal split osteotomy. The fractures were located close to the former miniplates on the posterior or the anterior border in four cases. The new fracture occurred under the miniplate in only two cases. In these cases, there was only a single miniplate located on the external oblique line following Champy’s technique. This particular technique is recognized to protect the angle from tension force due to mastication , but notComminuted fractures occurring at the edges of the miniplates require more complex surgical procedures. Indeed, the presence of the former miniplates could affect the positioning of the new osteosynthesis miniplate; therefore, their removal may be required. However, removing an osseointegrated miniplate could be complex, and bone drilling may be necessary if the miniplate is covered by bone. Bone drilling might affect the new osteosynthesis miniplate’s positioning as well, and a longer miniplate might be required. Removing miniplates or using a longer miniplate may necessitate a longer incision and a larger subperiostal dissection. Furthermore, in the case of comminuted fracture or bone loss due to the former miniplates’ removal, load-bearing osteosynthesis miniplates should be used (rather than load-sharing miniplates). These considerations could account for the higher rate of postoperative complications such as malocclusion, postoperative infection, osteomyelitis, and malunion associated with recurrent mandibular fractures .Our findings add further arguments in favour of the removal of miniplates in a specific sample of patients: those with a high risk of facial trauma. This population has been described in the literature ,10,12,39Our study has further limitations. First, the temporomandibular joint’s anatomy was simplified, and the boundary conditions imposed on the condyles also resulted in a simplification of the temporomandibular joint’s movements. Consequently, the Von Mises stress distribution in the area of the condyles could not be described. These boundary conditions applied to the condyle can also influence the stress distribution, as certain loading scenarios, depending on their relative direction, can result in higher stress concentrations on the impact area.Shared nodes between the screws and the bone simulated the osseointegration but may also facilitate the transmission of the forces through the screws to the bone compared with in vivo screwing.The size of the mesh elements was constrained, in particular by the thinness of the miniplates. The maximal size possible was 1 mm. Thus, it was complicated to carry out a convergence analysis with a sufficient number of meshes with different element sizes without requiring the use of extremely small elements for a model of this size, leading to computational difficulties. Then, we decided to compare our model with a mesh including 1 mm elements to a smaller one with 0.5 mm elements. We did not find any major difference between the stress distribution and the maximal stress value.Bones’ mechanical properties were simplified, retaining only a differentiation between the cortical bone and the cancellous bone and no correlation between these bones’ properties and Hounsfield units. Moreover, the thickness of the cortical bone was uniformly distributed (3 mm), which remained an approximation of the in vivo variable cortical thickness. Nevertheless, our two modelled mandibles shared the same bone mechanical properties. Our study focused on the fully consolidated bone after callus remodelling following fracture that resulted in “restitutio ad integrum” ,41. In tOur finite element models simulate trauma on a fully dentate mandible with no third molars. Our results cannot be applied to other cases. In edentulous patients, the reduction in mechanical forces secondary to tooth loss results in changes in mandibular shape following bone resorption in less stimulated areas . MoreoveAge may also have an impact on the biomechanical behaviour of the mandible, bones’ mechanical properties, and mandibular shape. Indeed, the presence of an impacted third molar, depending on its position or angulation, alters the stress concentration in the mandibular angle , reducinFurthermore, the soft tissues that could dampen or transmit impact forces were represented in none of our models. Therefore, the results of our comparison between the two models still remain valid. Moreover, despite these limitations which are usually encountered in FEAs, our results are in accordance with our clinical observations of mandibular fractures occurring on mandibles bearing miniplates  and withFinally, there are only a few studies about the biomechanical impact of mandibular titanium miniplates after bone healing in the case of facial trauma recurrence in the literature, and those were mainly conducted by our research team. More clinical and experimental data are required to support our conclusion.As suspected in further studies, our numerical simulation tends to confirm that the presence of miniplates on the mandible may cause more complex fractures in the case of trauma. Consequently, we recommend highlighting this risk in the information delivered to patients about the interest of removing miniplates after bone consolidation in patients with previous assault injuries, patients suffering from addictions , patients practicing fighting or contact sports, or those involved in military activities.In the future, our model will be improved to study the strains of the whole mandible, including the condyles. In this way, we need to free the mandible from the boundary conditions applied to the condyles. To achieve this, we will incorporate in the model the temporomandibular joint soft tissues  and possibly the soft tissues of the face. Moreover, the biomechanical properties of bone will be correlated to the Hounsfield units to be more precise. Eventually, to validate our proposal for the removal of titanium osteosynthesis in patients with a high risk of mandibular fracture, a prospective, randomized clinical study comparing a group of patients at risk of trauma retaining miniplates and a group of patients at risk not retaining miniplates should be conducted. This would enable us to assess the incidence of mandibular fracture recurrences and the complications of a systematic osteosynthesis removal versus the complexity of the osteosynthesis of a new fracture at the edge of a miniplate, along with the socio-economic impact and the impact on the healthcare system.