Search Results (1,929)

China’s rural public open spaces (POS) are largely governed as common-pool resources through self-organized collective arrangements, often regarded as a viable pathway to sustainable commons management. Yet, in practice, these systems remain prone to overuse and under-maintenance, reflecting collective action failures associated with the tragedy of the commons. The governance of rural POS therefore constitutes a complex social–ecological problem shaped by the interplay of institutional rules, biophysical conditions, and user–stakeholder interactions. Taking Taigu District in Shanxi Province—characterized by heterogeneous social–ecological contexts and collective action dilemmas—as the empirical case, this study develops a meso-level baseline model to identify the key conditions (design principles) for sustainable rural POS governance. Adopting an expert-based epistemological approach, 24 specialists in rural governance (scholars, planners, and local administrators) were engaged. Grounded in commons and collective action theories within the Social–Ecological Systems (SES) framework and informed by Transaction Cost Economics (TCE), the study operationalizes a Delphic Hierarchy Process (DHP), combining three rounds of Delphi to establish consensus on governance conditions with the Analytic Hierarchy Process (AHP) to derive their relative weights. The model specifies 14 governance conditions across four interrelated dimensions: ecological (e.g., clearly defined resource boundaries and congruence between resource characteristics and user needs), institutional (e.g., simple and enforceable rules, accessible conflict-resolution mechanisms, accountable monitoring, and calibrated external support), social (e.g., social capital, leadership capacity, clearly defined user boundaries, and group interdependence), and interactional (e.g., resource dependence, equity in benefit distribution, and supply–demand alignment). It further clarifies their relative importance and systemic interdependencies. By operationalizing commons design principles within a meso-level analytical framework, the study advances their empirical application in rural planning and offers five targeted managerial implications to strengthen institutional robustness and the long-term sustainability of self-governed rural POS. Full article

In this study, a hybrid multi-criteria decision-making (MCDM) model was developed for analyzing consumer adoption decisions regarding generative artificial intelligence (Gen AI). By extending the technology acceptance model (TAM) into a structured decision system, the proposed framework integrates ethical and risk-related criteria, including perceived cost, perceived risk, transparency, accountability, intellectual property concerns, and data privacy, into a formal causal and evaluative structure. First, a Delphi-based consensus process is employed to identify and refine key adoption criteria. Subsequently, the decision-making trial and evaluation laboratory (DEMATEL) method is applied to quantify causal relationships among these criteria and to construct an influence network revealing prominence and directional effects. In total, 251 questionnaires were distributed in Taiwan, and 231 valid responses were collected. The results indicated the decision-making factors that underlie the adoption of Gen AI by consumers. The results highlighted transparency as a dominant causal factor that significantly influences multiple ethical and functional dimensions of Gen AI adoption. To address uncertainty and vagueness in human judgment, fuzzy importance–performance analysis was also incorporated. Best non-fuzzy performance values were obtained through defuzzification, enabling the classification and prioritization of critical adoption factors within a four-quadrant decision matrix. The proposed framework provides a mathematically grounded decision-support model for elucidating the structural interdependencies among adoption criteria and to facilitate strategic decision making for Gen AI system design and governance. This study contributes to the MCDM and operations research literature by transforming a behavioral acceptance model into a formal decision-analytic framework, thereby enhancing the analytical rigor and applicability of TAM-based adoption studies in complex socio-technical systems. Full article

Acne is a prevalent dermatological condition occurring globally and influenced by a variety of endogenous and exogenous factors. The microbiome and its contribution to skin disease have been increasingly explored, along with the influence of the exposome and host immune responses on this complex microbial system. Nine experts from different countries in Africa, America, Asia, and Europe gathered to harmonise definitions, identify key pathogenic and protective microbial strains, and prioritise the factors that most significantly impact the skin’s microbiome in the context of acne. Opportunity areas on the role of the microbiome in the prevention, treatment, recurrence, and sequelae avoidance in acne were identified. The relationships between current treatments and the diversity of the microbiome were described. Current microbiome-targeted strategies were assessed, including practical considerations of innovative future perspectives. The panel discussions emphasise the urgent need for universally adaptable guidelines encompassing alternatives to oral antibiotic therapies, in light of increasing antimicrobial resistance and the significant burden of treatment-related adverse events. Full article

Digital transformation has become a central strategic priority as organizations increasingly rely on digital technologies to redesign business processes, governance structures, and value creation mechanisms in digitally evolving environments. However, existing approaches to digital transformation readiness often rely on additive maturity models or capability inventories that assume transformation capacity increases through cumulative capability development. Such approaches overlook how strategic emphasis must be distributed across transformation domains under governance and resource constraints. This study addresses this limitation by conceptualizing digital transformation readiness as a problem of strategic prioritization rather than cumulative capability accumulation. To operationalize this perspective, the study develops the Strategic Focus Index (SFI), a governance-aligned diagnostic instrument that evaluates how organizations distribute strategic attention across interdependent transformation domains. The index is constructed through a two-round Delphi study involving 53 experts from industry, academia, and the public sector, followed by statistical validation and an illustrative diagnostic application. The findings demonstrate how domain-level prioritization patterns can be systematically interpreted to identify potential imbalances in transformation efforts. By reframing readiness assessment as a prioritization-based diagnostic rather than a linear maturity measure, this study contributes a structured approach for evaluating digital transformation in digital business and platform-based environments. Full article

Culturally unsafe mental health services contribute to persistent inequities for Aboriginal and Torres Strait Islander peoples, yet existing cultural safety frameworks lack clear, prioritised, community-endorsed implementation guidance. This study aimed to establish Aboriginal consensus on cultural safety principles, implementation priorities and practical actions for culturally safe mental health services. A three-round modified Delphi study was conducted with 37 Aboriginal participants from Western Australia with expertise in mental health, social and emotional wellbeing and lived experience. In Round 1, participants completed an online survey rating the importance of cultural safety principles and identifying those requiring urgent action. In Rounds 2 and 3, facilitated yarning sessions reviewed findings, refined principles, grouped them into implementation domains, and identified priority actions. Aboriginal Participatory Action Research ensured Aboriginal leadership and governance throughout. All principles achieved strong consensus for importance. The most urgent priorities were trustworthiness, Aboriginal governance, trauma-informed care, addressing racism and strengthening the Aboriginal workforce. Participants organised the refined principles into six implementation domains, with Leadership and Governance identified as foundational to reform. Trustworthiness was reframed as an aspirational outcome requiring structural change. This study provides a community-endorsed, prioritised framework for translating cultural safety principles into mental health service practice and policy. Full article

Background/Objectives: The multiple benefits of physical activity and exercise (PAE) for non-communicable diseases (NCDs) and, thus, for public health underscore the importance of their multidisciplinary implementation in clinical practice. However, there is a lack of validated instruments that comprehensively assess physicians’ knowledge, attitudes, intentions, abilities, and behaviour (KAIAB) regarding PAE promotion in NCD management. Methods: This study aimed to develop and validate a new questionnaire to assess physicians’ KAIAB towards PAE and to evaluate their KAIAB levels. A two-stage design, including an e-Delphi method and a cross-sectional study, was conducted in Greece from January 2022 to May 2022. Results: In the first stage, after achieving consensus and stability within a purposive sample of 16 physician–experts (response rate 100%), the questionnaire was effectively developed and validated (Content Validity Ratio: 0.5–1) using a two-round e-Delphi method. In the second stage, a cross-sectional study was conducted in two physician populations from 12 medical specialities (response rate: 18.2%) and demonstrated that the new questionnaire had sufficient face validity and high reliability (Cronbach’s alpha: 0.805– 0.931). The three original Bloom levels’ cut-off points were also used to classify physicians’ KAIAB levels in the second stage. KAIAB levels were assessed using median and interquartile range (Mdn/IQR) and were found to be low (13/6), moderate (128/79), high (35/9), moderate (21/8), and moderate (33/8), respectively. Conclusions: The new questionnaire is reliable and valid. It is recommended that the questionnaire be applied in larger studies to further verify its validity and applicability. Additionally, it was found that although physicians reported high intentions and moderately positive attitudes toward PAE promotion, their knowledge in these domains and their exercise prescription practices remained limited. This underscores the need to enhance policies and initiatives in medical education and the healthcare system. Full article

Triple-negative breast cancer (TNBC) has been associated with a poorer prognosis than other subtypes, due to its more aggressive behaviour. Since 2020, significant advances in locoregional and systemic therapy have improved outcomes for patients with TNBC, but the implementation of these treatments remains inconsistent across Canada. There is, therefore, a critical need for evidence-informed, consensus-driven guidance to support the integration of new therapies into practice. Research Excellence, Active Leadership Canadian Breast Cancer Alliance (REAL Alliance), a pan-Canadian group of breast cancer specialists and Breast Cancer Canada, a patient advocacy organization, convened to develop national clinical consensus recommendations for the management of breast cancer. Through a selective literature review and modified Delphi process of national experts in the fields of medical oncology, radiation oncology, surgical oncology and pharmacy, REAL Alliance developed national consensus recommendations for the management of TNBC. The result is a set of 23 recommendations: four overall general recommendations, 11 in early-stage TNBC, and eight in metastatic TNBC. These recommendations are intended for oncology healthcare professionals, and are intended to guide evidence-informed, consistent care across Canada. Full article

Compared with other construction operations, high-altitude operations are more dangerous. Falling from a height is the main type of accident in construction. It is important to study the human risk of falling from height to reduce falling accidents. Based on the Human Factors Analysis and Classification System (HFACS) model, a preliminary evaluation index system for fall risk in building construction was established. Through the Delphi method and sensitivity analysis, the initial indicators were screened, the index factors that did not meet the requirements were removed, and the final human risk index evaluation system was determined. The system includes five first-level indicators and 17 s-level indicators of organizational influence, unsafe supervision, preconditions for unsafe behavior, and unsafe behavior. Subsequently, the analytic network process–entropy weight method (ANP-EWM) is used to subjectively and objectively weight the evaluation indicators, and the combined weight is obtained through game theory. The matter–element extension model is constructed to evaluate the human risk of falling from height in construction. Finally, an empirical analysis is carried out with the Y project as a case study. The novelty of this study lies in integrating human-factor analysis with the matter–element extension model for fall risk assessment in construction, while combining ANP, the entropy weight method, and game theory to balance subjective and objective weighting. The proposed model provides a practical tool for evaluating and controlling human risk in high-altitude construction operations. The results show that the correlation degree calculated according to the matter–element extension model is K₄ = 3.5, and the human risk of falling from height in the construction of Y project has generally reached an excellent level. However, the evaluation level of some evaluation indexes is still low, which is consistent with the actual situation of construction enterprises in Y project. This model provides a direction for the study of human risk assessment of falling from different construction heights. Full article

Background: Mild and moderate pain represent a large proportion of emergency department (ED) presentations but are frequently underestimated and inconsistently managed, particularly in vulnerable populations such as children and older adults. Standardised and evidence-based approaches are needed to ensure timely, safe, and effective pain control across the entire emergency care pathway. Methods: A national multidisciplinary Delphi consensus was conducted under the auspices of the Italian Society of Emergency Medicine (SIMEU). A Scientific Steering Committee performed a systematic literature review and developed 26 statements comprising 92 items across four thematic areas: analgesia at triage, risk factors and analgesia at discharge, analgesia in children, and analgesia in elderly patients. Thirty-three experts from across Italy participated in three Delphi rounds, rating each item using a five-point Likert scale. Consensus was defined as ≥66% agreement (scores 4–5). Results: Consensus was achieved for 78 out of 92 items. Key recommendations include early pain assessment at triage using validated scales, paracetamol as first-line therapy for mild and moderate pain across all age groups, and the use of multimodal analgesia for moderate pain. Fixed-dose combinations of paracetamol and ibuprofen were strongly endorsed for their efficacy, safety, and opioid-sparing effect in adults, children, and elderly patients. Clear guidance was also provided for analgesic selection at discharge, duration of therapy, patient education, and management of special populations. Conclusions: This multidisciplinary Delphi consensus provides practical, evidence-based recommendations to harmonize the management of mild and moderate pain in ED. Implementation of these recommendations may improve pain control, patient safety, and quality of care in non-urgent emergency settings. Full article

As urbanization continues to reshape societies, the concept of child-friendly cities (CFCs) has emerged as a rights-based approach to support the well-being of children in urban environments, particularly as increasing numbers of children grow up in rapidly expanding cities. While international frameworks provide general guidance, effective implementation requires contextual adaptation. Despite Jordan’s commitment to the Convention on the Rights of the Child, limited research has examined how CFC principles translate into urban policy and practice. This study explores the conceptualization of CFCs in the Jordanian context by identifying and prioritizing key stakeholders, urban features, barriers, and evaluation indicators. A structured Delphi methodology consisting of iterative rounds was used to gather cross-sectoral expert perspectives and establish areas of consensus. The findings reveal disparities in resources and efforts across governorates and cities while highlighting the recognized role of municipalities and local governments alongside a limited acknowledgement of non-traditional actors such as media. Prioritized features emphasize clean and climate-responsive environments, while funding limitations were identified as a major constraint and child safety as the most critical indicator. This study provides a consensus-based reference for understanding the key dimensions of CFCs in Jordan and contributes to the discussion on localizing CFC frameworks. Full article

Background: Cerebral palsy (CP) is the leading cause of permanent physical disability in children. Although hip surveillance is a global standard, spinal surveillance remains inconsistent, often leading to reactive rather than proactive management of neuromuscular scoliosis. This study aims to establish an international consensus on a risk-based spinal surveillance protocol. Methods: A three-round modified Delphi process was conducted in 2024 with 15 international pediatric spine surgeons, identified through purposive sampling. The process adhered to CREDES standards and focused on establishing standards for timing, frequency, and radiographic surveillance. Consensus thresholds were defined a priori as excellent (≥80%) and good (≥73%) agreement. Results: The panel reached excellent consensus (93%) on a “Traffic Light” system based on the Gross Motor Function Classification System (GMFCS) levels. Green Group (Walkers, GMFCS I–II): Clinical surveillance. Amber Group (Poor Walkers, GMFCS III, and asymmetric hemiplegic GMFCS I–II): Annual radiographs starting at ages 3–8. Red Group (Non-Walkers, GMFCS IV–V): Six-monthly radiographs starting at ages 3–5. There was 100% consensus on the mandatory use of sitting radiographs for non-ambulatory patients to prevent masking true pelvic decompensation. Critical referral triggers were identified as a Cobb angle >20°, pelvic obliquity ≥5°, or a progression rate ≥1° per month. Conclusions: The “Traffic Light” protocol helps identify the “window of opportunity” for intervention before reaching the 90° “point of no return,” where surgical risks increase nonlinearly. This proactive approach aims to reduce surgical complications and systemic delays in specialized care. Full article

Pressure injuries remain highly prevalent in hospital and home settings, particularly among elderly patients, intensive care unit patients, and individuals with impaired mobility, generating significant healthcare and economic impacts. Although low-level laser therapy has been explored as an adjunctive therapy to accelerate healing, few validated protocols exist to guide its systematic application in clinical nursing practice. This methodological study aimed to develop and validate a nursing care protocol for low-level laser therapy in stage 1 pressure injuries, conducted in three stages: integrative literature review, protocol development, and content validation using the Delphi technique with specialist nurses selected via the Lattes Platform. Judges evaluated the protocol using a five-point Likert scale, and validity was assessed by the Content Validity Index (CVI) and Cronbach’s alpha, both with minimum acceptable values of 0.80. The integrative review identified four studies supporting low-level laser therapy efficacy, informing the protocol’s technical parameters. Thirty-one specialists participated in the first Delphi round and 25 in the second, achieving a Global CVI of 0.915 and Cronbach’s alpha of 0.91, with all items reaching consensus. The validated protocol demonstrated satisfactory content validity and internal consistency, supporting its clinical applicability and potential to standardize nursing practice and reinforce patient safety. Although the protocol demonstrated satisfactory methodological validity, further clinical studies are needed to assess feasibility, implementation, and effectiveness in routine nursing care. Full article

Designing sustainable pedestrian infrastructure in hyper-arid cultural landscapes requires balancing visitor experience, heritage protection, and environmental constraints. This study develops a statistically grounded model for planning sustainable walking trails in Al-Ula, Saudi Arabia, using multi-spectral remote sensing data integrated with expert-based evaluation. A GIS-based Multi-Criteria Decision-Making (MCDM) framework was applied to assess topographic slope, vegetation cover (NDVI), built-up density (NDBI), Land Surface Temperature (LST), and solar exposure. Indicator weights were validated through a three-round Delphi survey involving fifteen experts. The results indicate strong consensus among experts, identifying LST (21%) and slope (20%) as the most influential determinants of trail suitability in desert environments. These findings highlight the critical role of thermal stress in shaping safe and sustainable pedestrian mobility in hot climates. The optimized 44.5 km trail network, classified into three difficulty levels, improves energetic efficiency by reducing caloric expenditure by 24% compared to conventional routing. In addition, the proposed network has the potential to reduce carbon emissions associated with heritage-related travel by approximately 75% through modal shift from vehicles to walking. The framework provides a practical decision-support tool for planners seeking to develop low-carbon, climate-responsive tourism infrastructure aligned with the objectives of Saudi Arabia’s Vision 2030. Full article

Background/Objectives: Intranasal carboxymethyl-β-glucan (CMBG)-resveratrol represents an innovative therapeutic approach for upper airway diseases, combining antimicrobial, anti-inflammatory, antioxidant, immunomodulatory, and antiallergic properties. Despite growing preclinical and clinical evidence, consensus on its clinical applications remains poorly defined. To establish evidence-based recommendations for the clinical use of intranasal CMBG-resveratrol through a multidisciplinary Delphi Consensus process. Methods: A two-round Delphi Consensus was conducted. In the first round, an expert board prepared, reviewed, and validated 22 statements based on current scientific evidence from preclinical and clinical studies. In the second round, 38 multidisciplinary experts evaluated each statement using a 5-point Likert scale (from 5 = strongly agree to 1 = strongly disagree). Consensus was defined as ≥80% agreement (scores 4 + 5). Results: All 22 statements achieved consensus (range: 83–100%). Strong agreement (≥90%) was reached for statements regarding the pathophysiological rationale (infection-inflammation-oxidative stress cycle), resveratrol’s pleiotropic mechanisms of action, the role of CMBG in enhancing stability and bioavailability, and clinical efficacy in respiratory infections and allergic rhinitis. The mean scores ranged from 4.2 to 4.9, indicating high expert agreement across all domains. Conclusions: This multidisciplinary Delphi Consensus provides evidence-based recommendations for the use of intranasal CMBG-resveratrol to manage upper airway diseases, particularly respiratory infections and allergic rhinitis. The formulation’s multitarget approach addresses the complex pathophysiology of these conditions through simultaneous antimicrobial (mainly antiviral), anti-inflammatory, and immunomodulatory effects. Full article

Objective: This study compared fetal adrenal gland ultrasound parameters between pregnancies complicated by fetal growth restriction (FGR) diagnosed according to Delphi consensus criteria and gestational-age-matched normally grown controls, and interpreted their apparent discriminatory performance cautiously. Methods: This prospective single-center case–control study with a cross-sectional ultrasound assessment enrolled 60 singleton pregnancies (30 FGR, 30 controls) between 24 and 41 weeks’ gestation. Controls were recruited contemporaneously from the same unit and had normal fetal biometry and Doppler findings. All examinations were performed using a Voluson E8 system by a single experienced operator; operator blinding to group status was not feasible in routine clinical practice. Standard fetal biometry and Doppler indices (umbilical artery [UA] PI, middle cerebral artery [MCA] PI, uterine artery [UtA] PI) were recorded and the cerebroplacental ratio (CPR) was calculated. Fetal adrenal assessment included the total adrenal gland volume, fetal zone (FZ) width, and middle adrenal artery (MAA) Doppler PI. Results: Maternal age, body mass index, and gestational age at scan were similar between groups (p > 0.05). Compared with controls, the FGR group had higher UA PI and UtA PI and lower MCA PI and CPR (all p < 0.001). Absolute adrenal gland volume was lower in FGR (0.46 ± 0.03 vs. 0.68 ± 0.04 cm³; mean difference −0.22 cm³, 95% CI −0.24 to −0.20; p < 0.001), and FZ width was smaller (median 4.70 vs. 6.55 mm; Hodges–Lehmann shift −1.80 mm, 95% CI −2.00 to −1.70; p < 0.001). MAA PI was higher in FGR (2.44 ± 0.14 vs. 1.79 ± 0.12; mean difference 0.65, 95% CI 0.58–0.72; p < 0.001). In this selected case–control dataset, adrenal volume, FZ width, and MAA PI each showed apparent complete separation (empirical AUC = 1.00); however, these findings should be interpreted cautiously because absolute adrenal measures were not adjusted for fetal size and such performance may reflect spectrum effects in a relatively small sample. Conclusions: In pregnancies with Delphi-defined FGR, absolute fetal adrenal volume and fetal zone width were lower, and MAA PI was higher than in controls. These findings should be considered hypothesis-generating and require external validation in larger multicenter cohorts using standardized and size-adjusted measurement approaches before clinical implementation. Full article