To analyze Taiwanese ecotourism with international standards, this research employed the social learning theory (SLT) to identify the determinants of Taiwanese community ecotourism with the international standards. This basic theory of social psychology comprehensively assays the interplays and interconnections among the three analytical perspectives , the four essential issues  of the Global Sustainable Tourism Council, the six assessed dimensions of ecotourism resolution from the WCC, and the twenty-nine assessed indexes of the KES ecotourism evaluations. It was then possible to comprehensively explore the sustainable determinants of Taiwanese ecotourism with the international standards through the FA of quantitative and qualitative analyses in combination with the highest research validity, reliability, representativeness, and accuracy. After analyzing the evaluated measurements, the empirical and valuable conclusions and findings are (1) these analytical perspectives, appraised attitudes, evaluated criteria, and sub-criteria positively advance Taiwanese ecotourism with the international standards (PITEEICIS); (2) the sustainable determinants of Taiwanese ecotourism with the international standards include the Support for Capacity Building of the Local Community (SCBLC), Cooperation with the Local Community (CLC), Supports for the Local Enterprises (SLE), Local Participation and Benefits Sharing Duties (LPBSD), Tourist Management (TM), and Responsible Tourist Behaviors Inducement (RTBI). Importantly, the majority of ecotourism industrialists and experts still focus on the economic benefits, such as supporting the local community and enterprises, rather than tourist behavior inducement to stimulate ecotourism participation in order to promote and advance the Taiwanese ecotourism to the international standards; (3) in order to promote Taiwanese ecotourism to the international conventions, the Taiwanese government and organizations in ecotourism should contribute toward the local welfare and create and design various training programs and courses to enhance local community’s awareness and capability of ecotourism development in order to establish a complete system that stimulates the ongoing planning and decision making of local community participation and regularly monitors, records, and reflects their opinions, based on the area’s history, culture, and natural attributes, to develop and sell sustainable local products by creating fair trade principles and valuable products. With the rapid increase in global Gross Domestic Product (GDP) and swift development of transportation technology, domestic and international tours have increasingly become entertainment for contemporary people. The majority of people would like to discover novel news, information, and life experiences through a series of tours. In addition, many local regions, areas, and communities also utilize tourism to expose their news, information, and culture to the public in order to attract more people to visit, which then develops the regional economy and reputation. In the wake of the booming tourism development, each ecological environment has confronted a bulk of unpreceded and irreversible destruction and hyper-pollutions . In ordeThrough the higher transmission speed of wireless technology, the sources used to surf and download local information, such as local news, local real-time video, local transportation information, local on-time announcements, local festival schedules, etc., can also be used by local organizations to expose the local news, messages, and statements in real-time without time and space restrictions. Furthermore, people now would like to easily visit anywhere in the world, which depends on the swift development of transportation technology and convenient infrastructure . TherefoTourism, ecotourism, and protected areas, by the International Union for Conservation of Nature (IUCN) International Union for Conservation of Nature (IUCN), ecotourism is defined as “the environmentally responsible travel and visitation to relatively undisturbed natural areas, in order to enjoy and appreciate nature  that promotes conservation, has low visitor impact, and provides for beneficially active socio-economic involvement of local populations” [In the book, lations” . “As thelations” .For this reason, the WCC of IUCU has unanimously passed a resolution on the international standards for sustainable ecotourism in association with the 17 Sustainable Development Goals (SDGs) of the 2030 agenda for the sustainable development of the United Nations (UN) Department of Economic and Social Affairs. As for the Eco-friendly Development (ED) in ecotourism resolution from the WCC, the eleventh (sustainable cities and communities with decent work and economic growth), twelfth (responsible consumption and production), and fourteenth (life below water) SDGs are the measures recommended for sustainable economic growth, consumption, and production practices and the conserved and sustainable use of nature and natural heritage. In detail, the eleventh SDG aims to expedite, maintain, contain, and increase economic sustainability in order to advance the establishment of safe residential sections with disaster prevention for each individual. The twelfth SDG was created to ensure sustainably consumed and productive models and the fourteenth SDG was promoted for the sustainable development of ocean and water natural resources. In regards to the Responsible Management (RM) ecotourism resolution from the WCC, the fifth , eighth (decent work and economic growth), ninth , and seventeenth  SDGs are effective approaches for ecotourism organizations. The ecotourism organizations are supposed to have the responsibility of advancing gender equality in each employee to facilitate the efficient production of sustainable economic growth in order to expand the sustainable global collaboration relationship. Importantly, organizations in ecotourism should further establish safe, tolerant, innovative industrialization with disaster prevention [In terms of the Environmental Conservation (EC) in ecotourism resolution from the WCC, the thirteenth (climate action) and fifteenth (life on land) SDGs are effective goals for ecotourism organizations. Ecotourism organizations have to take aggressive actions to confront and diminish the impact of global climate change through a series of actions such as sustainable terrestrial ecosystem utilization and the sustainable management of forests as well as the avoidance of desertification, soil degeneration, and loss of biodiversity. With respect to the Genuine Ecotourism Experiences Provision (GEEP) in ecotourism resolution from the WCC, the fourth  and sixteenth  SDGs establish the effective magnanimity of ecotourism organizations. Ecotourism organizations have to provide empirical experiences and provisional tour activities and programs to advance inclusive and equal quality education to establish the environmental conservation lifelong learning mechanism in order to strengthen an inclusive, equal, and sustainable society . In regaEcotourism organizations are necessary to conduct the tourists in such a way as to maintain and protect the natural water, resources, energies, and sanitation structure throughout tourism activities. Ultimately, in reference to the Local Participation and Benefits Sharing (LPBS) ecotourism resolution from the WCC, the first (no poverty), second (zero hunger), third , and tenth  SDGs indicate effective structures for ecotourism organizations. Ecotourism organizations have to plan for the diminishment of poverty through the accomplishment of food security and improvement of nutritional status in order to achieve good public health and well-being. Hence, ecotourism not only focuses on the expedition of environmental protection but also emphasizes cultural conservation as well as benefits the local economy by the presence of tourists to continuously achieve the sustainable triple-bottom balance between the earth’s environment, social humanities, and economic benefits .Therefore, the World Tourism Organization (UNWTO) and United Nations Statistics Division (UNSD) have started to collect exhaustive ecotourism data to understand the complete performance and development of global ecotourism to construct the evaluated international standards and evaluated indicators of development of the suitability of global tourism from the economic, environmental, and social dimensions of the sustainable tourism information diagram in 2017, the year of international sustainable ecotourism . SubsequSubsequently, the WCC has officially announced the One Program to request the director general, commissions, and members to support an initiative for the international standards in ecotourism at its session in Hawai‘i, United States of America, 1–10 September 2016 that (1) practically expands the sustainable tourism guidelines to cover the best ecotourism practices, including an updated IUCN definition of ecotourism, relevant standards and indicators for culturally sensitive community engagement and welfare, environmental learning, and appropriate infrastructure and tourist behaviors, to seek the prevention of a negative anthropogenic influence on species and ecosystems, (2) empirically implements, in existing national, regional, and international certification schemes, standards and guidelines focused on ecotourism in order to improve and promote conservation outcomes by encouraging the uptake of the best practices and adherence to and strengthening of globally accepted international standards, and (3) systemically designing, creating, and delivering a series of training opportunities for ecotourism governance, auditing, and certification as well as the implementation of the best practices for ecotourism development and management.In regard to the development of Taiwanese ecotourism, the Tourism Bureau of the Executive Yuan officially established the Taiwan Ecotourism Association (TEA) in 2001 by organizing the government, civil powers, and resources to facilitate the ecotourism development in Taiwan with the aim of promoting the sustainable and wise use of Taiwan’s natural, cultural, and ecological resources in ecotourism. Based on the fundamental goals of the TEA, there are five main purposes: (1) conducting training courses and workshops covering multiple aspects of ecotourism; (2) promoting ecotourism by partnering with industries; (3) setting up a platform to consolidate efforts from all parties for ecotourism development, (4) establishing an evaluation and certification program to enhance the quality of ecotourism, and (5) reinforcing international cooperation and coordinating demands from international markets. In order to empirically elaborate on tourism operations, community development, biodiversity, geodiversity, geological heritage, places of geological interest, wildlife, and the natural environment, Taiwanese ecotourism must explore its sustainable determinants with the international standards.However, the driving business contents and organization framework, the critical demand for contemporary Taiwanese ecotourism, and the evaluation indicators and certificates with international standards are the current severe shortages in the TEA. Therefore, after making a comprehensive survey of the research on ecotourism development in Taiwan, there was no one official study able to focus on detecting the sustainable determinants of Taiwanese ecotourism with international standards. In order to realistically provide the research evaluations and assessments of the sustainable determinants of Taiwanese ecotourism with the international standards of the Taiwanese government, parastatal ecotourism organizations and associations and ecotourism researchers, developers, and tourism industry professionals, as well as the national, regional, and international certification schemes, standards, and guidelines on this research topic were used to concentrate on ecotourism to encourage the adoption of international standards and norms with the updated IUCN definition and guidelines to be analyzed in-depth and discussed.For this reason, these sustainable determinants are able to promote and seek auditing and certification for Taiwanese ecotourism in landscapes and seascapes of conservation value, according to international standards. In order to empirically explore the sustainable determinants of ecotourism with the international standards, the ecotourism destinations, accommodations, and tours have been defined as the analytical perspectives because the tours focus on the individual’s feeling, accommodations depend on the organizations in ecotourism, and the destinations assemble the local natural and cultural resources and assets. Then, the four creditable dimensions  of the GSTC were classified as the appraised attitudes. Lastly, the six assessed dimensions of ecotourism resolution from the WCC, in association with the seventeen SDGs of the 2030 agenda for sustainable development and the twenty-nine assessed indexes of the KES ecotourism evaluations in connection with the six assessed dimensions of the ecotourism resolution from the WCC, were extensively discussed and considered as the evaluated criteria and sub-criteria in this research. Therefore, this research has innovatively employed the social learning theory (SLT)  to form The core reason the SLT was created was to extensively discuss the dependences and influences among individual behaviors, organizational operation, and performance as well as social development and tendency ,15. The In statistical measurements, the Factor Analysis (FA) of quantitative analysis  was applCurrently, over two hundred green certificates and certifications in the world have been created to offer to the various tourism-related industries and companies to apply based on each of their specific demands which have instituted their ecological certificate recognition and mechanism. These green and ecological certificate recognitions are able to assist tourism-related industries to concretely strengthen their comparison and sustainability in regard to their operational costs and corporate images in order to contribute to environmental protection and cultural preservation. Focusing on the evaluated indicators and certificate and ecotourism development, the Korea Tourism Organization (KTO) of the Korean Ministry of Culture and Tourism (KMCT) has instituted the Korean Ecotourism Standards (KES) since 2010 furthermore, the KES has been proofed and recognized by the global ecotourism certificate system of the Global Sustainable Tourism Council (GSTC), which means any tourism organizations can obtain the accreditations of the KES and CSTC if they can respect regulations and pass the KES ecotourism evaluations. In detail, the destinations , accommodations (organizationism), and tours  have been identified as the three core perspectives from the KES ecotourism evaluations . FurtherFirst of all, there are two assessed sub-criteria in the EFD evaluated criteria  which inSecondly, there are eleven sub-criteria in the RM evaluated criteria and which are 1. Compliance with Laws (CL): the tourism organizations have to respect national and international laws associated with ecotourism development, management, and regulations covering public health, safety, labor, cultural, and environmental aspects. 2. Financial Insurance (FI): the tourism organizations have to plan and implement insurance contracts to protect tourist destinations, residents, facilities, and visitors. 3. Sustainable Management Strategies (SMS): the tourism organizations have to establish and administer multi-year (destination) management strategies. These strategies cover environmental, economic, social, cultural, quality, health, safety, and aesthetic issues in order to publicly develop and increase public participation and the appropriate financial funds and subsidies. 4. Management Units (MU): the tourism organizations must have effective staff and individual social responsibility for a coordinated approach to reach sustainable ecotourism. The effective staff is supposed to be appropriate for the ecological conservation scope and deal with environmental, economic, social, cultural, quality, health, and safety issues .They establish an efficient system for equal employment, equal training, fair wages, fair evaluation, and periodic guidance and training (including advanced levels) regarding staff roles and responsibilities for sustainable ecotourism in collaboration with the stakeholders in the ecotourism system. 5. Monitoring (M): the ecotourism organizations have to establish a periodically reviewed, improved, and monitored proclamation system to monitor, publicly report, and respond to environmental, economic, social, cultural, tourism, and human rights issues, including both direct and indirect ecotourism impacts annually, at least . 6. StraThirdly, there are nine sub-criteria in the EC evaluated criteria which are 1. Active Environmental Management (AEM): the ecotourism organizations have to possess a regular system to comprehensively review, evaluate, and improve the practices, with stakeholders’ involvement, in order to administer to the total numbers of tourists and tour activities based on the environmental, economic, socio-cultural, and managerial carrying capacity of the local natural resources . In addiFourthly, there are three sub-criteria in the GEEP evaluated criteria which are 1. Nature and Cultural Experiences (NCE): the ecotourism organizations are supposed to supply tourist activities with consideration to the individual enjoying, experiencing, and understanding the nature and culture of the destination. 2. Interpretation Services (IS): the ecotourism organizations have to offer accurate interpretive information at natural and cultural sites. The local information is comprehensive, culturally appropriate, developed with community collaboration, and communicated in languages pertinent to tourists. 3. Interpretation Planning and execution (IPE): the ecotourism organizations have to design a series of plans and manuals for interpretation service and review and regularly improve these plans and manuals .Fifthly, there is one core sub-criteria in the RTBI evaluated criteria which is the Tourist Management (TM): the ecotourism organizations have to plan and design a strong tourism system, developed with the consent of and in collaboration with the affected community, to strictly protect natural and cultural assets and sites and take into account the cumulative impacts of interactions with wildlife, regarding the sale, trade, display, or gifting of local assets and in consideration of historical and archaeological artifacts.Sixthly, there are four sub-criteria in the LPBS evaluated criteria which are 1. Local Participation and Benefits Sharing Duties (LPBSD): the ecotourism organizations should contribute to the local welfare of the ecotourism stakeholders. 2. Support for Capacity Building of the Local Community (SCBLC): the ecotourism organizations have to create and design various training programs and courses to enhance the local community’s awareness and capability of ecotourism development. 3. Cooperation with Local Community (CLC): the ecotourism organizations have to establish a complete system that stimulates planning and decision-making on an ongoing basis of local community participation and regularly monitors, records, and reflects their opinions. The local community access to natural and cultural sites is also monitored, protected, and, if necessary, rehabilitated or restored. 4. Supports for the Local Enterprises (SLE): the ecotourism organizations have to construct a cultural preservation system, based on the area’s history, culture, and natural attributes, to develop and sell sustainable and valuable local products through fair trade principles .In order to comprehensively evaluate the interplays and interconnections among the three analytical perspectives , the four essential issues  of the GSTC, the six assessed dimensions of ecotourism resolution from the WCC, and the twenty-nine assessed indexes of the KES ecotourism evaluations must be analyzed. To comprehensively explore the sustainable determinants of Taiwanese ecotourism with international standards, the SIT behavioral theory was applied to estimate the interactive dependencies and relationships among individuals, organizations, and society. The reason is the SIT was able to be selected to comprehensively assess the in-group favoritism and out-group discrimination as well as the intergroup conflict appearance due to direct group competition from people who have recently become part of the group.Ref.  used theIn the current social science research, the FA of quantitative analysis has been the mainstream quantitative methodology for administering large-scale questionnaires by detecting the interplays and dependencies among each evaluated criterion. It is able to comprehensively assay a bulk of complicated research questions and issues, according to its theoretical concept, analytical design and structure, and statistical method. For this reason, this research employed the FA of quantitative analysis to handle the assessments of 247 valid large-scale questionnaires. The entire commonalities among the three analytical perspectives , the four essential issues  of the GSTC, the six assessed dimensions of ecotourism resolution from the WCC, and the twenty-nine assessed indexes of the KES ecotourism evaluations were explored in-depth by the FA of quantitative analysis . AccordiSuch that, 1: K numbers of common potential factors were defined from the L numbers of general influenced factors.2: the M numbers are more than the K numbers.W .If maximization: , In order to enforce the research reliability and exactness, the ANP of qualitative analysis was further applied for dealing with the expert questionnaires to construct an analytical hierarchy in order to systematically analyze the entire cause and effect among each appraised attitude, evaluated assessed criterion and sub-criterion, and candidate. In view of the theoretical inducement of ANP of qualitative analysis,  mentioneIn the interactive pairwise compared matrix, the measured weights were defined as W (W = [w (eigenvector) were able to be measured through a succession of assessments of the vector quantities method (AW = nW) by calculating the inductive principle .Importantly, the consistency index (C.I.) was able to be calculated in each interactive pairwise compared matric and then, the consistency ratio (C.R.) was further able to be estimated through the numbers of C.I. and random index (R.I) computed from the estimated table of random index figure in Equation (4)In terms of the verification of ANP of qualitative analysis, the numbers of the C.R. in each pairwise compared matric need to be lower than 0.1 in the evaluated measurements of each pairwise compared matric.The initial concept-concertizing research step: Originally agglomerating the behavior perspectives of SIT theory and marketing elements of holistic marketing to comprehensively solve the research question in order to achieve the research topic and goal.The second theory-organizing research step: Concretely integrating the behavior perspectives of SIT theory and marketing elements of holistic marketing , middle region , southern region , and eastern region . The descriptive statistic of the FA of quantitative analysis is expressed in With reference to Equation (1) of the FA approach of quantitative analysis, The entire commonalities of each appraised criterion of FA of quantitative analysis are shown in After administering the FA of quantitative analysis, the evaluated model was established to identify the sustainable determinants of Taiwanese ecotourism with the international standards by verifying the interconnections among the appraised perspectives and attitudes, evaluated criteria and sub-criteria, and the following candidates: Negative Impact on the Taiwanese Ecotourism with the International Standards (NGITEIS), No Impact on the Taiwanese Ecotourism with the International Standards (NITEIS), and Positive Impact on the Taiwanese Ecotourism with the International Standards (PITEIS), as shown in In association with As a result, (1)The three analytical perspectives , the four essential issues  of the GSTC, the six assessed dimensions of ecotourism resolution from the WCC, and the twenty-nine assessed indexes of the KES ecotourism evaluations positively advance Taiwanese ecotourism with the international standards (PITEEICIS), empirically closing the research gap in the current related Taiwanese ecotourism research fields and effectively providing the political recommendations for the sustainable ecotourism development for the Taiwanese government.(2)The top five synthetically comparative weights in the PITEEICIS are the sustainable determinants of Taiwanese ecotourism with the international standards and these are the Support for Capacity Building of the Local Community (SCBLC), Cooperation with the Local Community (CLC), Supports for the Local Enterprises (SLE), Local Participation and Benefits Sharing Duties (LPBSD), and the Local Participation and Benefits Sharing (LPBS) as well as Tourist Management and Responsible Tourist Behaviors Inducement (RTBI). Importantly, the majority of ecotourism industrialists and experts still focus on sharing the economic benefits, such as supporting the local community and enterprises, rather than inducing tourist behaviors to stimulate ecotourism participation in order to promote and advance Taiwanese ecotourism with the international standards.(3)In order to promote Taiwanese ecotourism to the international conventions, the Taiwanese government and organizations in ecotourism should contribute to local welfare and create and design various training programs and courses to enhance the local community’s awareness and capability of ecotourism development in order to establish a complete system that stimulates the ongoing planning and decision making of local community participation and regularly monitors, records, and reflects their opinions, based on the area’s history, culture, and natural attributes, to develop and sell valuable and sustainable local products through the fair trade principles.(4)In particular, taking the Taiwanese government in line with international practices, the Taiwanese government and organizations in ecotourism need to plan and design a strong tourism system, developed with the consent of and in collaboration with the affected community, to strictly protect natural and cultural assets and sites and take into account the cumulative impacts of interactions with wildlife regarding the sale, trade, display, or gifting of local assets in consideration of historical and archaeological artifacts.This research employed the SLT in the basic theory of social psychology to comprehensively assay the interplays and interconnections among the three analytical perspectives , the four essential issues  of the GSTC, the six assessed dimensions of ecotourism resolution from the WCC, and the twenty-nine assessed indexes of the KES ecotourism evaluations. It was able to comprehensively explore the sustainable determinants of Taiwanese ecotourism with the international standards through the FA of quantitative and qualitative analyses in connection with the highest research validity, reliability, representativeness, and accuracy. After administering a succession of the evaluated measurements, the empirical and valuable conclusions and findings are:With reference to the sustainable development of ecotourism in Taiwan, the internationalization of ecotourism has been imperative. Hence, Taiwan has to develop and establish a comprehensive sustainable ecotourism institution and system with the international standards. However, to the best of our knowledge, there is not any available research that comprehensively analyzes and develops a complete model to detect the sustainable determinants of Taiwanese ecotourism with international standards. To academically fill this gap, this research employed the SLT and was able to discover the correlations among the four essential issues  of the GSTC, the six assessed dimensions of ecotourism resolution from the WCC, and the twenty-nine assessed indexes of the KES ecotourism evaluations in the main analytical hierarchy and concept.In terms of future directions, evaluated results, and measured consequences, this research was able to explore the sustainable determinants of Taiwanese ecotourism with the international standards in order to create an evaluation mechanism which adopts the international practices and accreditations of the WCC and CSTC.Specifically, with respect to the research limitations, this research may be restricted to Taiwan; however, this research originally focused on the sustainable determinants of Taiwanese ecotourism with the international standards. In addition, although this research employed the SLT of the basic theory of social psychology to fill the current research gap in the sustainable determinants of Taiwanese ecotourism with the international standards with quantitative and qualitative analyses, there are still multiple decision-making methods and theories to be used in order to detect more key sustainable determinants for completing the Taiwanese ecotourism development and certifications with the international standards.


Background: In addition to searching for effective methods of treatment, interventions are sought to support well-being, quality of life, mental health, and recovery. Sailing has its specific features, including task orientation, challenges, contact with people, and nature. This specificity may be treated as a potential therapeutic factor, but it is also likely that people with certain psychological characteristics are involved in it. Therefore, the study aimed to assess some psychological features of women with cancer experience who decided to take part in the Onco-Cruise (Polish: Onko-Rejs). Methods: Participants were 56 women . We used NEO-FFI, the Zimbardo Time Perspective Inventory, and The Multidimensional Health Locus of Control Scale. Results: Onco-Cruises participants were characterized by a high level of extraversion , openness , low neuroticism , predominance of present hedonistic  and future time perspective , and the internal health locus of control . Conclusion: Group sailing can be favorable for broadly understood health and cancer recovery, but people who choose this activity have certain psychological predispositions, especially indicating high needs for stimulation. Permanent features should be taken into account when proposing various interventions for oncology patients to best suit them to their natural possibilities and preferences and, thus, make them most effective. According to reports by the World Health Organization, in 2020, one in six people in the world died of cancer, which was a total of 10 million people . Depending on the characteristics of the cancer and its stage, specific therapeutic methods are used, including cytoreductive surgery, radiation treatment, targeted endocrine/molecular therapy, and chemotherapy . AggressOne of the commonly used methods of actively coping with stress is physical activity . ScientiRegarding sailing, our information shows that there is currently one pilot study available for cancer patients, involving 19 breast cancer women. The results show a reduction in the level of anxiety and distress and an improvement in the quality of life in the study group. As part of the intervention, in addition to sailing theory and practice, the patients had sessions with a psychologist and a physical exercise specialist . In PolaSailing, apart from sports and the recreational aspect, is closely related to nature. It helps build a sense of security, relieves anxiety related to diagnosis and treatment, and promotes self-reflection, including understanding life changes . In addiAccording to the Big Five Theory, the universal structure of personality consists of the following features : extravePublished studies on the health benefits of sailing interventions focus on the clinical aspects of participants ,25,26,36Women who qualified to participate in a week-long sailing cruise on the Mediterranean, organized by the Onco-Cruise Foundation-I Choose Life, were invited to participate in the study. The inclusion criteria were: consent to participate in the study, age from 18 years, female gender, diagnosis of oncological disease (current or in the past), oncological treatment (current or in the past), and qualification for participation in an Onco-Cruise. The exclusion criteria were: withdrawal of consent to participate in the study. Initial consent to participate in the study was expressed by 102 persons, to whom research questionnaires were sent. A total of 56 sets of questionnaires were received in return, all of which could be included into the analysis.The study was carried out by the method of a diagnostic survey, with the use of four questionnaires. Three of them were standardized tools:NEO-FFI. The Personality Inventory by Paul T. Costa Jr. and Robert R. McCrae in the Polish adaptation of Zawadzki et al.  was usedThe Polish Short Version of Zimbardo Time Perspective Inventory, PS-ZTPI , was useMultidimensional Health Locus of Control Scale (MHLC) by Kenneth A. Wellston, Mitchell J. Stein, and Craig A. Smith  in PolisWe also used our own questionnaire, consisting of 28 questions divided into three parts. The first part included questions about age, education, occupation and current professional activity, place of residence, relationship, and attitude to faith/religion. The next one contains questions about the health status: year of cancer diagnosis, type of cancer(s), number of cancer diseases diagnosed so far, type of cancer treatment , chronic diseases, mental disorders, medications taken on a regular basis, and assessment of the frequency and satisfaction with social relations. In the third part, there were questions related to sailing and concerned: past sailing experiences, including participation in previous editions of Onco-Cruises, sailing certification, reasons for the decision to participate in an Onco-Cruise, and expected results.The data were collected in two periods, before the Onco-Cruise in 2019 and 2021. The declared Onco-Cruise participants were invited and informed about the possibility of taking part in the study through the Onco-Cruise-I Choose Life Foundation. People who gave their informed consent to participate in the study received a complete set of questionnaires. Anonymous questionnaires were filled in by themselves, with unlimited response time, and then returned via the Foundation. The respondents’ answers were placed in a database and then analyzed using STATISTICA 14.0 software. At this stage, we did not have a control group, but we wanted to capture not only the average intensity of the studied features, but above all, their most common prevalence and the overall specificity of the mental functioning of the surveyed women. In such a situation, we believed that a useful approach would be to compare the results to the sten scores in the case of research tools with Polish standardization (NEO-FFI) and the results of Polish adaptations , and, in the case of ZTPI, to compare the profile with a Balanced Time Perspective (BTP), i.e., optimal distribution of the intensity of individual traits .The study group consisted of 56 women aged 25 to 72 years . The vast majority lived in the city (82.14%), had higher education (76.78%), was currently professionally active (71.42%), and was in a relationship (71.42%). Details are presented in The diagnosis of breast cancer dominated (62.50%) in the study group. Most of the respondents have so far been treated with several methods, most often surgical (89.28%) and chemotherapy (69.64%). Almost half of the respondents did not currently have any therapeutic recommendations, and only control examinations (48.21%). This procedure was also recommended for the majority in the near future (62.50%). Some of the respondents declared the presence of a chronic disease other than cancer. Arterial hypertension (25%) and depressive disorders (23.21%) were the most frequently mentioned. The respondents also declared taking medications on a permanent basis, most often Tamoxifen (23.21%) and Levothyroxine (21.42%). Details of the clinical characteristics are presented in The descriptive statistics of the analyzed psychological variables are presented in Dividing of person’s scores obtained in each scale by 3 ,42 made In our study, we focused on describing the relatively constant psychological characteristics such as personality, temporal orientation, and the health locus of control. We assumed that the respondents would be dominated by people with a high level of extraversion, agreeableness, conscientiousness, and openness to experience, but not neuroticism.The results of our study showed that the level of extraversion of the surveyed women is high, which means they tend to focus their energy, orientation, and attention on the outside world, including social contacts, having fun, and seeking stimulation ,43. ReseAnother result obtained in our study indicates an average, and most often, low level of neuroticism in the respondents. Previous studies have shown that high levels of neuroticism are associated with negative health behaviors , also leAgreeableness is most associated with positive interpersonal behavior . InteresWhen we were designing the study, we assumed that the participants would have both a strong future orientation and a present hedonistic and would be convinced of the possibility of influencing their health and well-being. Indeed, in terms of temporal orientation, the participants of our study obtained the highest results in the present hedonistic and future. However, due to the low reliability of the scale of the present hedonistic, we treat the results with great caution. It is imperative to check them in future research. The combination of a strong present hedonistic and future perspective may seem surprising. Most often, these two features are presented as two poles of involvement in each area of time: involvement in the present steals the layers of attention directed toward the future . HoweverThe last feature analyzed in the study was the health locus of control. We assumed that the respondents would be convinced of the possibility of influencing their health and well-being, despite the fact that their treatment was largely based on the medical intervention. The examined women obtained the highest result in the internal health locus of control. Previous studies have confirmed that the sense of control over their own health in cancer patients is associated with better mental adjustment , as wellSummarizing the results of our study on relatively constant psychological features, such as personality structure, time perspective orientation, and the locus of health control, it can be assumed that they are significant for making a decision about participation in an Onco-Cruise. It can be concluded that in the studied group, many psychological features have pro-health values and may constitute an important element of planning secondary health prophylaxis. Onco-Cruises most likely fulfill their pro-health role as declared by the participants and the Foundation, but it is naturally selected for this type of activity—it is chosen by people with specific psychological characteristics. Most likely, the key may be an individual need for stimulation, manifested inter alia by a high level of extraversion and openness and low neuroticism. However, considering the potential invariability of these features, future research should also take into account more factors that build motivation to participate in such endeavors as the Onco-Cruise. Undoubtedly, the combination of fixed features with factors influencing motivation could allow for more effective psychological help, which is needed in the face of cancer.There are some limitations to this study. First, it was a pilot study without a control group. Our main goal was the initial understanding of the characteristics of psychological traits, but also the collection of demographic and clinical data, in order to be able to adequately select the control group in the next stages of the project.A serious limitation is the low reliability of the ZTPI present hedonistic scale obtained in the present study. Similarly, in the Polish adaptation of the tool, this scale obtained the lowest reliability rates α = 0.45 . In our Due to the lack of standardized norms for MHLC without a control group, it is difficult to interpret the results based solely on measures of central tendency.Women experiencing oncological disease who participated in Onco-Cruises were characterized by a high level of extraversion, agreeableness, openness, and conscientiousness, and low level of neuroticism, predominance of a present hedonistic and future perspective over time, and an internal health locus of control. The pilot study had several goals. The essential element was the initial recognition of the constant psychological characteristics of women participating in Onco-Cruises. We also wanted to obtain information on the demographic and clinical characteristics of participants. This will enable us to better plan further studies on the impact of participation in Onco-Cruises on the mental and emotional state . Due to the wide scope and length of future surveys, we wanted to distinguish such constant features that are particularly expressive and can potentially be associated with the reception of the cruise experience in order to control them at a later stage of the research. In the pilot study, we chose well-known and popular psychological tools, which makes it possible to compare our results to other research. We wanted to check if they would be appropriate in the context of the specificity of the group and the nature of the further study. Therefore, taking into account the intensity of individual features, their potential importance for further research in relation to other already available results and the research economy in relation to the psychometric values of the tools, we decided to control time perspective and personality traits in the Big Five concept at a later stage. However, due to the planned extensive scope of the study and individual comments on the length of the current survey, we considered the study with a shorter Big Five measuring tool, e.g., the Polish version of the Ten Item Personality Inventory . We deciThe study also allowed us to use current experiences and results for further research in the field of relatively constant psychological traits associated with different forms of activities undertaken by patients with chronic diseases that differ in intensity, duration, and nature. This, in turn, can be used to learn about the preferences of patients and to create various adequate forms of activity proposals, tailored to personal characteristics. Regarding this option, we suggest that it is worth staying with the tools used in the pilot study.


I) and total joint faulting cumulated per km (TFAULT) were the highest for the IRI of JPCP.The international roughness index (IRI) can be employed to evaluate the smoothness of pavement. The previously proposed mechanical-empirical pavement design guide (MEPDG), which is used to model the IRI of joint plain concrete pavement (JPCP), has been modified in this study considering its disadvantage of low prediction accuracy. To improve the reliability of the prediction effect of the IRI for JPCP, this study compares the prediction accuracy of the IRI of JPCP by using the machine-learning methods of support vector machine (SVM), decision tree (DT), and random forest (RF), optimized by the hyperparameter of the beetle antennae search (BAS) algorithm. The results from the machine-learning process show that the BAS algorithm can effectively improve the effectiveness of hyperparameter tuning, and then improve the speed and accuracy of optimization. The RF model proved to be the one with the highest prediction accuracy among the above three models. Finally, this study analyzes the importance score of input variables to the IRI, and the results show that the IRI was proportional to all the input variables in this study, and the importance score of initial smoothness (IRI Joint plain concrete pavement (JPCP), using shrinkage to control the cracks, is a common form of concrete pavement without any reinforcement . It is wLong-term Pavement Performance (LTPP) is the most comprehensive study of pavement performance data collection, covering about 900 roads in the United States, Canada, and other countries with various influencing factors, including general information, climate data, material test data, traffic data, and pavement inspection data . It is oI is initial smoothness measured as IRI, m/km, TC is the percentage of slabs with transverse cracking , SPALL is the percentage of joints spalled, PATCH is the pavement surface area with flexible and rigid patching  as a percentage, TFAULT is the total joint faulting cumulated per km, mm, SF is the site factor, and AGE is the pavement age in years, FI is the freezing index, days, and The Mechanical-Empirical Pavement Design Guide (MEPDG) is a common method for predicting the smoothness of pavement ,27. The It is clear from the figure that the predicted value of the IRI of JPCP by the MEPDG differs greatly from the actual value, that is, the fitting effect is poor. Therefore, it is of great practical significance to propose a more accurate and efficient model to predict the IRI of JPCP. Gulfam-E-Jannat et al. conducted a regression analysis to evaluate IRI models by comparing the predicted distress to observed distress . SoulimaWith the development of machine learning, the application of machine-learning models to predict the performance of pavement has become a research hotspot for architectural engineering researchers ,45,46,47I), pavement age in years (AGE), percentage of slabs with transverse cracking  (TC), percentage of joints spalled (SPALL), pavement surface area with flexible and rigid patching  (PATCH), total joint faulting cumulated per km (TFAULT), freezing index (FI), percentage of subgrade material passing the 0.075-mm sieve Extraction of the sub-training set. By the Bootstrap method, N samples are randomly extracted from data set D, put back to form K sub-training data sets, and K decision trees are established.(2)Construction of decision tree. The construction of subclassifies mainly uses a classification regression tree. Firstly, K features are randomly selected from M features at each node of the decision tree as the segmentation feature set of corresponding nodes. The optimal segmentation feature and segmentation node are determined according to relevant criteria. The segmentation node is divided into two nodes, and the corresponding data is also divided into two nodes. The above process is repeated until the stop condition is met.(3)Construction of random forest. Step (2) is repeated, and stops when K decision trees are generated, and then these are combines into a random forest (4)K decision trees in the random forest are used to classify the test data set DT, and K prediction results ((5)The mode in the prediction result of the decision tree is selected as the final prediction result of each sample in the prediction data set.Tuning the hyperparameters of the model before the model training is beneficial in improving the prediction effect of the model. In this study, BAS was selected to optimize the hyperparameters of SVM, DT, and RF. The relationship between the RMSE values of the three models and the number of iterations is shown in This study evaluated the prediction effect of the above three models on the IRI of JPCP by comparing and analyzing the fitting effect of the predicted value and the actual value of SVM, DT, and RF tuned by BAS. The comparative analysis of the predicted value and actual value of the training set and test set of the three models is shown in I, TFAULT, FI, AGE, TC, SPALL, and PATCH were 2.2460, 1.4710, 1.1685, 0.5864, 0.5385, 0.3458, 0.2626, and 0.2416, respectively. That is, the IRI of JPCP was proportional to IRII, TFAULT, FI, AGE, TC, SPALL, and PATCH, and the importance of variables on the IRI of JPCP decreased according to the above order. IRII and TFAULT were the most important variables on the IRI of JPCP. It should be noted that IRII is an objective parameter that cannot be artificially designed during road maintenance. Therefore, road engineers should pay attention to TFAULT when designing JPCP, as it is of great significance in improving the IRI of JPCP. The effect of SPALL and PATCH on maintaining road surface smoothness was weak, indicated by the low important scores.To further analyze the importance of the input variables selected in this study on the IRI of JPCP, the importance scores of eight input variables were analyzed, as shown in To address the issue of the reliability of the IRI prediction for JPCP being low, this study proposed the idea of using a hybrid machine-learning model to predict the IRI of JPCP. Firstly, this study used BAS to tune the hyperparameters of SVM, DT, and RF. Then, by comparing the prediction effect of SVM, DT, and RF optimized by BAS on the IRI of JPCP, the machine-learning model with the highest accuracy prediction was selected. Through the study of the above analysis, the following conclusions are drawn. (1)I, TFAULT, FI, AGE, ρ200, TC, SPALL, PATCH) in the database had a reasonable distribution, wide coverage, and low correlation. Therefore, using this database to predict the effects of the models, the prediction effect of the IRI of JPCP will not be affected by unreasonable data distribution and a high correlation between variables.The data of the input variables (IRI(2)IRI of JPCP in general among the three machine-learning models. In addition, the RF model had no fitting phenomenon due to the introduction of two randomness variables; DT had a poor-fitting effect on the predicted value of the IRI of JPCP.BAS had a good hyperparameter tuning effect on SVM, DT, and RF, indicated by the fact that RMSE values could quickly converge in the process of machine learning. By comparing and analyzing the predicted value and actual value of the IRI of JPCP from the three models in the training set and test set, it was found that RF had the best prediction effect  on the (3)I and TFAULT were the two most important parameters for maintaining the roughness of the road surface. Considering that IRII is an objective parameter of road surface, road engineers should pay more attention to the influence of TFAULT on road surface smoothness in the design process. The effect of SPALL and PATCH on maintaining road surface smoothness was weak, indicated by the low important scores.IRIRegarding future development, it is possible to consider using the present hybrid machine-learning model to predict the IRI of both JPCP and jointed reinforced concrete pavement (JRCP). In addition, the results obtained can be applied to the mixture design of cement concrete pavement by considering the IRI development of the pavement.


Nature Communications 10.1038/s41467-020-14367-0, published online 05 February 2020Correction to: In the published version of this paper, the members of the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium were listed in the Supplementary Information; however, these members should have been included in the main paper. The original Article has been corrected to include the members and affiliations of the PCAWG Consortium in the main paper; the corrections have been made to the HTML version of the Article but not the PDF version. In the PCAWG Drivers and Functional Interpretation Group, the affiliation for Erik Larsson has also been changed from ‘Computational Biology Center, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA’ to ‘Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden’. Additional corrections to affiliations have been made to the PDF and HTML versions of the original Article for consistency of information between the PCAWG list and the main paper.


Physical ergonomics has established itself as a valid strategy for monitoring potential disorders related, for example, to working activities. Recently, in the field of physical ergonomics, several studies have also shown potential for improvement in experimental methods of ergonomic analysis, through the combined use of artificial intelligence, and wearable sensors. In this regard, this review intends to provide a first account of the investigations carried out using these combined methods, considering the period up to 2021. The method that combines the information obtained on the worker through physical sensors  or biopotential sensors , with the analysis through artificial intelligence systems (machine learning or deep learning), offers interesting perspectives from both diagnostic, prognostic, and preventive points of view. In particular, the signals, obtained from wearable sensors for the recognition and categorization of the postural and biomechanical load of the worker, can be processed to formulate interesting algorithms for applications in the preventive field , and with high statistical power. For Ergonomics, but also for Occupational Medicine, these applications improve the knowledge of the limits of the human organism, helping in the definition of sustainability thresholds, and in the ergonomic design of environments, tools, and work organization. The growth prospects for this research area are the refinement of the procedures for the detection and processing of signals; the expansion of the study to assisted working methods , and to categories of workers suffering from pathologies or disabilities; as well as the development of risk assessment systems that exceed those currently used in ergonomics in precision and agility. Ergonomics deals with the design of work environments so that they are suitable for humans, and aims at the objectives of health and safety, and productivity at work . ErgonomPhysical ergonomics is concerned with human anatomical, anthropometric, physiological and biomechanical characteristics as they relate to physical activity. Relevant topics include working postures, materials handling, repetitive movements, work-related musculoskeletal disorders (WMSDs), workplace layout, physical safety, and health . High exTechnological innovation, and in particular wearable devices ,12, offeworker-activity-environment]. Ideally, the combination of wearable sensors and AI could help ergonomics in identifying the factors that promote occupational well-being, directing the targeted use of economic resources to implement ergonomic design that contributes to the primary prevention of health issues in the workers. Secondly, the use of wearable sensors and AI could help to verify the long-term tolerability conditions of work, through an accurate recognition of the exposure conditions, integrating the strain aspects developed by the worker, and comparing them with the work requirements.In current and foreseen employment contexts, characterized by the complexity of the work organization, the absence of exactly decodable tasks—as well as the aging of the workforce, and the emergence of situations with exposure to multiple risk factors —it is ofInnovations in AI  have been shown to increase productivity, and could potentially improve the safety and health of workers in the workplace . TherefoPhysical ergonomics related to physical activity concerning human anatomical characteristics;Cognitive ergonomics related to mental processes;Organizational ergonomics related to optimization of socio-technical systems.As reported by Karwowski , the conTo the best of the authors’ knowledge, no systematic reviews consider the potential combined use of wearable devices and AI algorithms in physical ergonomics applications. Some reviews have focused on the potential use of wearable devices in ergonomics ,23,24,25The systematic review is a method of selecting, evaluating, and summarizing studies based on a specific topic . Our sysThe literature search was conducted on Scopus and PubMed databases, and it was limited to English documents. Each database was queried using the following keyword structure: (“wearable” OR “sensors”) AND  AND (“AI” OR “ML”).Conference reviews, reviews, book chapters and erratum;Papers not available;Papers duplicated.In order to simplify our research, the exclusion criteria were:Papers proposing human-machine interface solutions without wearable devices, and not explicitly related to occupational medicine ;Papers proposing wearable devices for cognitive ergonomics ;Papers proposing only a wearable device solution without AI ;Papers proposing wearable devices for other purposes .Concerning the screening by title, abstract, and full text, the following exclusion criteria were defined:Documents were screened evaluating, firstly, title and abstract contents and, in case the documents did not meet the inclusion criteria, secondly the full text. The systematic review includes 25 papers divided into journal articles (16 out of 25), and conference papers (9 out of 25).Most of the papers were published between 2018 and 2021, peaking in 2020 as shown in The papers were analyzed according to several categories: aim of the study; people involved, and task performed by the subjects; type of wearable device and its positioning on the human body; signal acquired by the sensor and features extracted; principles, methods, standards and/or guidelines underlying the ergonomic assessment; AI strategy (ML and/or DL); results of the studies. Wearable devices have developed exponentially through novel sensors and technologies, and the long-term monitoring of vital signs and other principles, as described in . The verOf these studies, 3 out of 25 articles tested a prototype device on healthy volunteer subjects. Akanmu et al.  developeOther prototypes were tested on healthy worker subjects. Specifically, Aiello et al.  developeSome authors tested commercial devices on healthy volunteer subjects. A potential approach is described in ; the autThe Equivital EQ02 Life Monitor system consists of a multi-parameter body worn sensor . Other eFinally, Fridolfsson et al.  used a cThe majority of the studies (18 out of 25) used inertial wearable sensors. Inertial sensors refer to accelerometers, gyroscopes and magnetometers that measure linear acceleration, angular velocity and magnetic fields. Typically, three orthogonal gyroscopes, three orthogonal accelerometers, and three orthogonal magnetometers are contained in an IMU . Eight sIn particular, Matijevich et al.  found thOne of the applications of inertial sensors is the recognition of human postures in several environments, i.e., during activities in the workplace . PostureThe diagram in Furthermore, a substantial minority of articles used only biopotential sensors, namely devices that convert a biological response in an electrical signal. In the current study, examples of biopotential wearable sensors were used by Mudiyanselage et al.  and UmerFinally, other studies ,52,56,57Manual material handling is an important risk factor for the development of WMSDs in construction workers. Ergonomic criteria allow the quantification of risk levels during manual handling activities , such asOne of the ergonomic criteria quoted in the systematic literature review is the Revised NIOSH Lifting Equation (RNLE). The RNLE is a manual material handling risk assessment method associated with lifting and lowering tasks in the workplace ,72. MudiTwo papers ,42 classAnother ergonomic criterion found in the review, and which was used to prevent ergonomic risk factors, is the Occupational Safety and Health Administration (OSHA) . On one A total of 9 out of 25 studies used different principles, methods, standards, and/or guidelines for ergonomic risk, in particular: International Organization for Standardization (ISO) 5349 and 11226 ,53, Job Finally, 10 out of 25 articles did not mention a specific ergonomic criterion. For instance, Estrada and Vea  classifiML and DL are two branches of AI that can help to prevent WMSDs, as studied in . In the Ensemble classifiers combine a set of several ML algorithms, named base learners, to obtain a single classifier that outperforms the others . In the In terms of accuracy, several classifiers showed high values. Among the ensemble classifiers, RF was the best algorithm showing accuracy values above 90%. Antwi-Afari et al.  achievedFeature extraction is a useful process of dimensionality reduction and/or redundant data reduction that avoids the loss of important information. The extracted features refer to the signals acquired from sensors placed on a specific body part . These fTwo studies ,41 out oSensor features could be analyzed to identify an ideal wearable system . MatijevIn some articles ,54,80,82Differently from the above-mentioned articles, Mudiyanselage et al.  extracteThe ergonomic analysis technique that makes use of sensors and AI is mainly aimed at the prevention of WMSDs, and particularly affects the body sectors of the upper limbs and back, widely treated in ergonomics. Through this approach, aspects related to the posture of the whole body have also been partly explored, addressed in ergonomics only recently, and for which, in the literature, there are still no clear thresholds of sustainability or indications of optimal levels of variability over time. The application of this approach provides useful information on the needs of ergonomics to improve the conditions of safety at work, and the comfort of the worker; to design suitable work environments and equipment; or to set up work organizations that avoid the onset of phenomena of accumulation of fatigue or overload. Above all, this approach can be advantageous for the analysis of complex or difficult to observe work situations.As the diffusion of this approach progresses, the wealth of knowledge could help improve the prevention of WMSDs, both associated with acute and cumulative load. This could provide useful information for setting up working methods that are well tolerated, even during the entire working life—an important aspect especially for professions with high biomechanical wear, such as for construction operators or healthcare professionals.This approach assists not only in the study of the characteristics of force, repetitiveness, and posture , but also in the kinematic traits of the worker’s behavior. Specific kinematic traits could be useful as indicators to control and predict the appearance of any alterations capable of endangering the integrity of the worker, but also to monitor the critical phases during the return to work for people with dysfunctions, disabilities or previous pathologies.Furthermore, the data detectable through sensors can enrich the value of the ergonomic intervention of evaluation and design, attracting interest also on aspects properly investigated by other disciplines, such as engineering, psychological, organizational, medical, but also economic ones. The technological approach can be all the more innovative the more it uses prototypes , often made with open-source resources, and not pre-deterministically channeled towards a single aspect of interest. Considering some variables detectable through sensors, the design of optimal work situations can be addressed to specific categories of workers, such as the elderly, in order to be able to implement targeted adaptations of the workplace that guarantee the expected levels of productivity and safety.In addition to the purposes of monitoring, evaluation, and design, the combined technique that uses sensors and AI opens up new scenarios for ergonomic interventions of an educational and participatory prevention type; this provides a contribution for workers to explore new ways of carrying out work, possibly also with the adoption of technological aids and devices, such as exoskeletons. The illustrated approach also opens the way to analysis and consideration of multiple conditions of exposure to physical, chemical, environmental, organizational factors at work, for which neither consolidated methodologies for risk assessment are currently available nor is evidence of association available, with the motor, physiological or biomechanical functions of the human operator.Further studies may make improvements to the illustrated technique, specifying the optimal positioning of the sensors, defining the best AI system, but also proposing the elaboration and development of other methods of ergonomic analysis, different from those already used and accepted by classical ergonomics. An interesting aspect of the study related to the topic presented here, and mainly focused on WMSDs, concerns the interpretation of worker well-being as an integrated construct that includes physical, psychosocial, and organizational aspects . As it has, in fact, been demonstrated by various studies, these aspects act with reciprocal influence on the conditions of the human operator, and the intervention on one of the risk factors could have repercussions on the other dimensions. This broadening of perspective also affects the long-term benefits that can be prepared for, and guaranteed by, short-term investments in improving occupational safety and health. Furthermore, given the multifactorial nature of the underlying causes of WMSDs, a future study perspective could concern the assessment of exposure associated with prolonged low-intensity static work, typical of teleworkers and the increasing digitalization of work.This article presented a systematic review of the combined use of wearable devices and AI for ergonomic purposes, selecting 25 relevant studies from the scientific literature. The analysis highlighted a deep interest, which has grown in recent years, for the use of wearable sensors coupled with AI algorithms (both ML and DL) to monitor the biomechanical risk to which workers are exposed to during their activities. The review provides the researcher with an overview of the latest uses of AI and wearable sensors in the context of physical ergonomics. Additionally, this review could be useful to support professionals in selecting the most suitable wearable technology and AI strategy for ergonomic assessments and improvements in industrial and non-industrial settings.


While there have been increased calls for strengthening community health systems (CHSs), key priorities for this field have not been fully articulated. This paper seeks to fill this gap, presenting a collaboratively defined research agenda, accompanied by a ‘manifesto’ on strengthening research and practice in the CHS. The CHS research agenda domains were developed through a modified concept mapping process with a team of 33 experts on the CHS including policy-makers, implementers and researchers from institutions in six countries: Uganda, Guatemala, South Africa, Sweden, Tanzania and Zambia. The process began remotely with brainstorming research priorities and concluded in a one-week workshop that was held in Zambia where priorities for strengthening CHS were discussed, grouped into domains, interpreted, and drafted into a collective declaration. Eight domains of research priorities for CHSs were identified: clarifying the purpose and values of the CHS, ensure inclusivity; design, implementation and monitoring of strategies to strengthen the CHS; social, political and historical contexts of CHS; community health workers (CHWs); social accountability; the interface between the CHS and the broader health system; governance and stewardship; and finally, the ethical methodologies for researching the CHS. By harnessing a set of diverse and rich experiences and perspectives on CHS through a structured process, a multifaceted research agenda and manifesto that transcend context, disciplines and time were developed. We posit this as an entry into greater debate and diversity in the field as we continue to find ways to strengthen research and practice in the CHS. As a relatively new and contested area of research, there is great potential to engage this growing interest and develop the field through initial research agenda setting. This is critical in generating dialogue and debate that can inform both inform both practice and further research.Community health systems (CHSs) are the subject of growing interest based on their potential to leverage different community resources and advance population well-being. However, CHSs are understood in quite varied ways across the health systems’ research fraternity. These variations range from a restricted view of community health workforce endeavours or other local community volunteer programmes aimed at social accountability, to more generally understood concepts that encompass all of society’s efforts aimed at improving population well-being. Research agenda setting is approached in several ways including: the commissioning of small research activities; literature reviews; and convening of conferences, among others. Generally speaking, input from subject experts, engagement of a wide scope of stakeholders, building consensus and sharing of the research agenda to foster further debate are typical steps or processes in this endeavour. While some of these agenda-defining processes are aimed at to arriving at more inclusive research agendas, some are more focused on specific interests, often short-lived and limited in scope by disciplines and geographical reach. The latter often result in specific research questions that can easily be answered within a specific period of time and with resources that are usually readily available. For example, a recent literature and consultative review on global research agenda for CHSs largely focused only on community health worker (CHW) programmes. While this agenda is important, it does not adequately represent the scope of the field of CHSs, given that CHWs are just one of the components. Inclusive research agendas are more dynamic and create a stimulus upon which more long-term or enduring human interests are sustained is the kind of vision that our CHS research agenda setting is based on.Policy agendas such as the Millennium Development Goals and Sustainable Development Goals are implemented through research agendas among other ways. Research agendas are therefore essential in directing resources and coordinating efforts towards achieving set policy goals by creating logical frameworks through which channel scarce resources and actions can be used. In this paper, we aim to share a collaboratively defined agenda of CHS research priorities, crowned by a manifesto statement that emerged from the process. The participants in the agenda-defining process consisted of researchers from seven institutions, as well as front-line workers, managers and senior policy-makers from the Zambian Ministry of Health. Over the course of a one-week workshop, this collective leveraged their diversity  to undertake a multidisciplinary exploration and mapping of research priorities for the CHS. This is envisioned to spiral into a more enduring and dynamic debate of shaping and reshaping CHSs that are responsive and accountable.In this section we present the process by which we developed the priorities that formed the basis for defining domains of the CHS agenda and the manifesto. A group of public health and health system players engaged in thinking, researching, policy-making and advocacy on CHSs met for a week (10–14 June 2019) at the Chaminuka Lodge in Lusaka, Zambia to collate our collective understandings of the CHS and generate a research agenda. The group of 33 participants included junior and senior health systems researchers from institutions in Zambia (8), South Africa (8), Sweden (4), Uganda (1), Tanzania (1), and Guatemala (1), as well as stakeholders from the Zambian Ministry of Health (4), community health workforce (3), and international partner organizations (3) see . Our implementation of the method was guided by the steps outlined by Trochim and Kane with some adjustments in an effort to ensure that the process was inclusive and representative of the group’s collective ideas. Below are the steps we undertook  to gain an integrated view of how participants saw the statements fitting together in overarching themes. The idea statements were plotted on a point map (or distance matrix), where the statement points’ proximity to each other was based on the frequency with which they were grouped together. The point map was then partitioned into clusters of statements using hierarchical cluster analysis, and the team of facilitators examined how the points were grouped together into 6 to 15 clusters of ideas. At each level of clustering, the team assessed the coherency of the ideas that composed the clusters and whether the successive splitting of clusters added a valuable distinction for making sense of the themes represented in the ideas. They found that a 10-cluster solution was a good base for presenting the general domains and the ideas they contained to the broader group of participants . On the third day, the participants were engaged in reviewing the concept map of the 10-cluster solution. Interpretation took place in small group discussions and a designated notetaker in each group recorded participants’ suggestions on how to make sense of the thematic domains that the clusters represented, and if they might be combined or divided to better capture important conceptual domains in CHSs research. The facilitator team reviewed the small groups’ interpretations of the clusters and found general consensus about the domains that were judged to be coherent and adequately capturing an important theme, and also significant overlap in the suggestions for modifying domains. Integration of the small-groups’ interpretations led to the identification of eight thematic domains organizing the statements. On the fourth day, participants were engaged in further interpretation of the integrated list of thematic domains that emerged from the previous day’s discussions. In this step, the groups were charged with refining the definitions of the domains, developing a visual representation of how the domains fit together in a model or ‘landscape’ of CHSs, and a written declaration of how to strengthen CHS, drawing on their interpretation of the domains. Each of the four groups shared its visual model of the CHS domains and its declaration during a world cafe session later in the day. The lead workshop organizers later met with a small group of participants to synthesize the definitions of the priority research domains, reflect on the visual models and declarations coming out of the process, and draft an overall manifesto on research and practice for strengthening the CHS. The domains and the manifesto statement were then circulated to workshop participants for feedback.The initial concept map in  Further conceptual interpretation of these domains in small groups was based on the same eight thematic domains, but participants employed different visual and metaphorical devices to depict their interrelationships. One model depicted them as elements of a self-sustaining ecosystem, another as systems within systems, while another arranged them as components of a building with a foundation of values and purpose and an overarching roof of governance. In another model, the domains were organized into micro-, meso- and macro-levels. Variations across the small-groups’ interpretations reflected varying mental models of the function of CHS and complex ideas surfaced about how domains of research priorities should fit together to strengthen them.The CHS Chaminuka Manifesto, named after the venue of the workshop in Zambia , represe We believe that communities are complex social systems with long histories, imbued with power relations that play out between people, families, neighbourhoods, committees and health workers. We understand CHSs as embedded in these community social systems and in broader health systems, with porous boundaries between them. The CHSs represent a significant health system asset or resource comprising both hardware elements, such as human resources, drugs and technologies, as well as software elements such as values, relationships and trust. Health systems typically engage the CHS through CHW programmes. CHWs are mandated to provide primary and preventive health services, but both their mandate and their capacity to carry it out effectively are impacted by factors such as motivation, training, degree of embeddedness in communities they serve, and the disjuncture between their role as described on paper, and what is expected in practice. It is therefore vital that the research takes seriously the lived realities of CHWs, and seeks to establish effective strategies for identification, selection and recruitment of CHWs and best practice for training and continuous development of CHWs, enhance their agency, motivation and job satisfaction, and remove barriers to effective retention of CHWs in, and relationships with, the health system. We believe that the CHS is also a site for the empowerment and participation of communities within broader health systems, allowing communities to hold government to account. This is to be achieved by strengthening community participation mechanisms that shift power relations, ensuring responsiveness of health systems to community needs, and actively pursuing strategies for collective action. This entails:Building capacity for collaborative governance and accountability, understood to include oversight, direction and stewardship to enable and strengthen the CHS, promote intersectoral collaboration, overcome fragmentation, ensure allocation of resources and build trust; Strengthening the interface and relationships between CHSs and their broader health systems, as well as between the community and health services; Recognizing the importance of addressing imbalances in power and building trust in relationships between stakeholders in strengthening the CHS.  We also believe that it is the responsibility of governments to support and strengthen the CHS, which includes:Working to overcome health system fragmentation Ensuring equitable resource allocation to CHSs Coordinating partnerships between actors within CHSs, and monitoring the impact of external partner actions on CHSs Ensuring balance of power between formal sector health workers and volunteer CHWs Recognizing the importance of boundary spanners, which mediate relations between CHSs and broader health systems Building trust between the formal health-care system and the CHS Strengthening the capacity of communities to hold government to account for maintaining their responsibility to the CHS.  We are explicit in positioning the values and principles underpinning our understanding and conceptualization of CHSs, and therefore our research in, on and for the CHS. Core to our values is the need to foreground marginal and vulnerable populations, and to fight to make those who are invisible, visible. The values and principles we believe should be taken into account when designing, implementing, monitoring and evaluating the CHS are:A focus on reducing inequalities by acknowledging and striving to meet the intersectional needs of individuals as members of complex communities A concern with the health and well-being , rather than a disease-focused approach A commitment to locally driven solutions A whole-of-society perspective that seeks to harness the social determinants of health to promote well-being.  As such, we believe that research on, in, for and with CHSs should:Be inclusive Be locally driven and embedded in communities and societies Generate new knowledge through co-production Centre around community engagement through non-hierarchical participatory methodologies that foreground trust, balance of power, and strong and sustained interpersonal relationships Acknowledge the complexity and context-sensitive nature of CHSs, through a whole-of-society perspective Always be conducted with the intention of contributing to real-world social change Shift the centre of knowledge generation on the CHS to countries themselves, and in ongoing dialogue with policy-makers and practitioners.  In conducting this research, it is crucial to take account of, and research, the history, political-economy, and social and gendered contexts of the CHS, from global to local, including local knowledge beliefs and cultural practices. We understand this complex context not only as the context in which CHSs are embedded, but also as the context in which researchers conduct their work. In doing so, we recognize that global imbalances in knowledge generation may allow for certain ideas, interests and discourses on the CHS to dominate in ways that silence others. The participants of the Chaminuka workshop resolve to continue building collaborations, research partnerships and community engagement platforms to strengthen CHSs. We further commit to conducting ethical, emancipatory research for and with all stakeholders towards inclusive empowered communities, while acknowledging the importance of histories, power and relationships, and using critical perspectives to understand the impact of these contextual factors on our daily work and relationships. Abbreviations: CHS, community health system; CHWs, community health worker. This paper presents priority research domains and a manifesto declaration produced through a collaborative process to articulate an agenda for strengthening CHS. The process was enhanced by participants’ varied positionalities, which encouraged us to consider more carefully our starting points and assumptions on the CHS. For example, some of us were senior, others junior, others have focused on the role of CHWs in health systems, others on citizen mobilization and advocacy; some of us on health systems and their management, others on multisectoral development; some on macro-level policy and design, others on front-line action; some of us are researchers, other practitioners, and policy-makers. However, in terms of country level representation, the participants were largely from low- and middle-income countries and only country was represented from the high-income category of countries. While this posed a potential limitation to the priority and agenda setting process, the whole process was never made context specific, participants generally reflected on all their experiences in either context. A significant number of the participants had experiences with CHSs in high income countries through collaborations and lived experiences. In this application, the software-generated map of the thematic cluster solution served as a jumping-off point for further engaging participants in dialogue and interpretation, thereby raising contestation and generating an opportunity to find coherence and resolution through collective sense-making. By explicitly raising and harnessing different perspectives, we were able to stimulate rich thinking and a variety of representations of the CHS . Such an approach nonetheless is limited by the wealth of experience, depth and critical nature of the participants and dialogues undertaken.The process was facilitated by a modified concept mapping approach, which provided a structured and participatory tool for integrating our collective ideas about what is important for CHSs. During the workshop, we challenged the idea of a single narrative on the CHS and emphasized the development of a multifaceted research agenda that could accommodate multiple perspectives and starting points cutting across generations, disciplines and context. We consider that the process was rich and robust enough to stimulate richer discussions around the development of the CHS field of research and practice, an iterative end that we welcome all to engage in as we build more responsive health systems around the world. We acknowledge the funders of this study. In addition, we are grateful to all the workshop participants who freely shared their knowledge and CHSs experiences that enabled us to write this paper. All participants of the brainstorming and workshop sessions consented to participating the process and having their views shared through this publication. Authors declare that they have no competing interests. MT led the drafting of the manuscript, AKH, HS, FJ, and AH supported MT in the drafting of the manuscript. In addition, AH provided overall technical oversight to the manuscript writing process. FJ, EW, and AH were a part of the lead team in the concept mapping process that was used to develop the content of the manuscript. JZ reviewed and provided technical guidance to the drafting of the manuscript. The Chaminuka collective actively participated in the priority setting process and their views are well captured in the manuscript. All authors reviewed and approved the manuscript for submission.1School of Pharmacy, University of Waterloo, Waterloo, ON, Canada. 2Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden. 3Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda. 4School of Public Health & Family Medicine (SPHFM), University of Cape Town, Cape Town, South Africa. 5School of Public Health, University of the Western Cape, Cape Town, South Africa. 6South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa. 7Centre for the Study of Equity and Governance in Health Systems, Guatemala City, Guatemala. The Chaminuka Collective consists of the following members, displayed with their affiliations:Isabel Goicolea; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden. Charles Michelo; School of Public Health, University of Zambia, Lusaka, Zambia. Paul MalizganiChavula; School of Public Health, University of Zambia, Lusaka, Zambia. Adam Silumbwe; School of Public Health, University of Zambia, Lusaka, Zambia. KasapoChibwe; School of Public Health, University of Zambia, Lusaka, Zambia. Doreen Sitali; School of Public Health, University of Zambia, Lusaka, Zambia. Chama Mulumbwa; School of Public Health, University of Zambia, Lusaka, Zambia. MargarateMunakampe; School of Public Health, University of Zambia, Lusaka, Zambia. Wanga Zulu; School of Public Health, University of Zambia, Lusaka, Zambia. Miguel San Sebastian; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden. Uta Lehmann; School of Public Health, University of the Western Cape, Cape Town, South Africa. Tumelo Assegaai; School of Public Health, University of the Western Cape, Cape Town, South Africa. Leanne Brady; School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa. Lance Louskieter; School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa. Jill Olivier; School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa. Marsha Orgill; School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa. SiriliNathaneal; School of Public Health and Social Sciences, Muhimbili University, Dar es Salaam, Tanzania.Supplementary file 1. The Workshop Participants List.Click here for additional data file.Supplementary file 2. List of 98 Statements of Research Priorities Needed to Strengthen CHS.Click here for additional data file.


The multidimensional impact of hearing loss on the various demands of life in children using cochlear implants is represented by variables that can influence the hearing, language and quality of life outcomes of this population.To evaluate the factors influencing the quality of life of children with cochlear implantation, considering age, hearing age, age at evaluation, hearing skills, spoken language, family degree of receptiveness, schooling and socioeconomic status of the parents.Participated 30 children using cochlear implants, aged 6 to 12 years and their respective parents. The children were evaluated by the categories auditory performance, by language category, and by the children with cochlear implants: perspectives parents questionnaire. Parents were assessed by the family involvement scale.The cochlear implant impacted the quality of life of the children, with more significant results on the increase of the social relations domain and the decrease of the family support domain. Overall, the increase of the age in the evaluation, better hearing and language skills, the mother's level of schooling and the family receptiveness correlated with the quality of life of children with cochlear implants.The influencing factors that correlated with the quality of life of the implanted children were the child's older age at the evaluation, the better hearing and language skills, the mother's level of schooling and the family receptiveness. The benefits of a Cochlear Implant (CI) in children are well known. The success related to spoken language recognition and comprehension skills are well-established in both national and international literature.12The use of specific tools to assess the quality of life of children with CI allows the assessment of the impact of hearing loss and the device use in everyday situations, beyond the evaluation of the hearing and spoken language skills provided by the formal clinical measures. The information acquired through the opinion of the parents, or in some situations, by the patients themselves, has the potential value of guiding conducts during the intervention process.14Thus, greater investments in the investigation of these other life demands of the child with a CI are necessary and may result in greater benefit, in addition to guiding the speech therapy, family counseling and guidance during the therapeutic process with a more individualized approach for each child.Therefore, the aim of this study was to evaluate the factors influencing the quality of life of children with cochlear implants, considering the age at surgery, hearing age, age at evaluation, hearing skills, spoken language, degree of family receptiveness, the parents’ level of schooling and socioeconomic level.This was a cross-sectional, descriptive, quantitative study, approved by the Research Ethics Committee of Hospital de Reabilitação de Anomalias Craniofaciais of Universidade de São Paulo (HRAC/USP), Retirar under CAAE no. 61753416.0.0000.5441.Thirty children of both genders, aged between 6 years and 12 years, who were CI users enrolled in the Cochlear Implant Section (SIC) of HRAC/USP, and their respective parents participated in the study. The participants signed the Free and Informed Consent Form (FICF) and Assent Form. The sample consisted of a convenience sample, with parents and children attending the CI follow-up routine between March and August 2017.The inclusion criteria of this study were: having a minimum of six complete years of age (72 months) to 12 incomplete years (144 months), having severe and/or profound bilateral sensorineural hearing loss, having undergone CI surgery according to the multifactorial criteria for cochlear implant surgery indication proposed by the interdisciplinary team of the Cochlear Implant Section (SIC-HRAC/USP), with total electrode insertion and during the sensitive period of auditory neural plasticity, up to three years and six months of age,The children's auditory performance was determined based on the Categories of Auditory Performance (CAP) scaleThe Family Involvement Rating scale,http://resource.isvr.soton.ac.uk/audiology/Software/ParQ120.htm.The children's quality of life assessment was measured using the Children with Cochlear Implants: Parent's Perspectives (CCIPP) questionnaire,The more positive the answer, the greater the association between quality of life and the CI use from the parents’ perspective.st quartile, median and 3rd quartile values were used for the representation of variables: age at surgery, hearing age, age at evaluation, auditory skills, spoken language skills, degree of family receptiveness, level of schooling, and socioeconomic level of the parents. The inferential correlation analysis between the influencing variables and quality of life was performed using the non-parametric statistical dependence test between two variables, Spearman's rho Correlation Test. The level of significance was set at p ≤ 0.05%.The statistical analyses were carried out using the software SPSS, version 18. Percentages, mean, standard deviation, minimum, maximum, 1Quality of life assessment involves several factors, such as physical and emotional well-being, self-esteem, family, friends, school, satisfaction with the CI, social aspects, mobility, self-care, pain, telephone use, speech comprehension, environmental sound perception, communication, self-sufficiency, use of electronic devices, other peoples’ attitudes, self-confidence, preferences, interests and ethical and moral values.8In this sense, measuring the quality of life in the pediatric population requires the use of sensitive measures to assess these aspects. The use of specific evaluation tools is highly advantageous, because it allows the assessment of parents’ perceptions and provides information about auditory and speech language development and expresses significant changes in the perception of the family regarding the CI user's satisfaction. These data help professionals in the intervention process.24In the last 10 years, four studies31The results of the present study are in agreement with previous findings. From the parents’ perspective, the CI improved the quality of life in all domains related to the child and in one of the domains related to the family. The subscale of social relations showed a more significant impact, followed by communication, functionality, autonomy, education, well-being and happiness, of the effects of CI on the family, and of the support and assistance given to the child .The fact32Among the evaluated domains, the subscale support and assistance to the child recorded the lowest indexes of quality of life scores in relation to the other scales. The same was observed in other studies14In the analysis of the CCIPP subscales , autonomEven with overall good quality of life results, the minimum and maximum response values and the standard deviation between the subscales showed the variability of results, distancing some children from the group's mean values, due to the different perspectives shown by some parents . Researc36For children who did not reach the highest percentages of quality of life after the CI use , the impConsidering the multidimensionality and multifactorial aspects of the implantation and development process of children with cochlear implants that occur at different temporal scales, it is natural that in some studies, certain variables have a strong effect on one group of children but not on others, explaining the variability of results found in this and other studies.Because of this, variables related to the family nucleus such as the socioeconomic level, parental level schooling and family receptiveness in speech therapy are also receiving attention from the literature due to the fact that small children usually spend most of their time interacting with their parents and depend on them for the full rehabilitation process. In this study, the mother's level of schooling was positively correlated with the domain of communication and social domain, and more receptive parents had an impact on the child's communication and education. No statistically significant correlations were found between quality of life and socioeconomic aspects . In the Overall, the quality of life was influenced by five of the investigated variables. When analyzed individually, family receptiveness appeared as one of the most significant variables, acting as a strong predictive marker of development and better quality of life in these children. Considering the different variables that involve the development of children with CI, it is evident the complexity that includes the control of all influencing factors involved in the CI indication, adaptation and monitoring of this population. The desirable balance between the investigated variables alone does not guarantee the full performance of auditory skills, language skills and quality of life.The influencing factors that correlated with the quality of life of the children with CI were the older age at the evaluation, the better hearing and language skills, the mother's level of schooling and the family's receptiveness.This knowledge can guide the speech therapist in charge of the rehabilitation to promote improvements in the planning of specialized speech therapy, consistent with the individuality of the child and his/her family, contemplating personalized guidelines aimed at different socioeconomic and instructional realities, guaranteeing to the families the same possibilities of access to information and opportunities for development. Moreover, this evidence can help the interdisciplinary teams at the stage of cochlear implant indication and when evaluating the progress of the results, guiding the postoperative follow-up based on the specific characteristics of each child and family regarding these factors.The authors declare no conflicts of interest.


Successfully launching a sustainable EHDS requires a clear understanding of the current situation in Member States, taking into account the existing diversity. With this in mind, country visits are being carried out in a group of 12 countries: Denmark, Belgium, Hungary, Netherlands, Estonia, Ireland, Portugal, Finland, Czech Republic, Slovenia, Sweden, Germany. The aim of the country visits is to map the state-of-play of health data management in different countries and explore their preparedness to join the EHDS. The topics explored include: the health data sources available, the health data infrastructure , data quality assurance mechanisms, data governance, as well as resource and training needs and opportunities. Another aim of the country visits is to explore needs and expectations at national level, and how the EHDS can respond to them. This presentation will include an overview of the health data management systems of the 12 countries mapped, providing a snapshot of the situation across Europe. It will then present the findings on their preparedness to join the EHDS. Preparedness takes into account a variety of factors, including political will, as well as legal and technical factors. The presentation will further share the lessons learnt and best practices highlighted from the country visits. Finally, based on these findings, the presentation will close with an overarching view on the preparedness across Europe to deploy the EHDS for the secondary use of health data, EHDS2, as well as planned actions that would facilitate the implementation of the EHDS2 in different member states.