Search Results (179)

Transitioning to a circular economy (CE) is now a strategic priority for countries to decouple economic growth from environmental degradation. However, in developing contexts, the readiness of environmental resource sectors to adopt CE principles is unknown due to a lack of data and uneven institutional capacity. This study presents the first regional baseline assessment of circularity readiness in Vietnam’s environmental resource sectors, focusing on land, mining, water and waste. A five-dimensional readiness framework (policy, resource management, innovation, business, awareness) was developed and applied across Vietnam’s six ecological–economic regions. A Delphi process with 12 experts was conducted in three rounds to capture and refine expert judgments, supplemented by triangulated proxy indicators (e.g., plastic recycling rates, wastewater treatment coverage). Readiness scores were aggregated at dimension and regional levels and analyzed using radar charts, heatmaps and hierarchical clustering. Results showed significant regional disparities. The Southeast (SE) and Red River Delta (RRD) have high readiness due to clearer policy frameworks, stronger institutions and more dynamic business ecosystems. The Northern Midlands and Mountains (NMM) and Central Highlands (CH) have low readiness due to infrastructural gaps, weak innovation and limited public engagement. The Mekong Delta (MD) and North Central Coast (NCC) have medium readiness, reflecting partial progress but uneven implementation. The study made three contributions: (1) a new context-specific framework for CE readiness in environmental resource sectors; (2) the value of expert-based, proxy-informed methods in data-scarce contexts; and (3) a policy roadmap for different regional readiness levels. Findings suggest that the CE should be integrated into resource planning, regional observatories should be established and CE-related research and development (R&D) should receive investment. Future research should move towards standardized quantitative indicators and predictive models to track how readiness changes under policy interventions. Full article

The evolution of TMJ-replacements has been driven by advancements in personalization, materials and digital planning technologies. However, there is little data on how surgeons perceive the prosthetic systems and their limitations in practice. The perspective from surgeons is critical to identifying the gap between current technology and clinical need. Using an international, structured survey based on a modified Delphi methodology, including expert validation, pilot testing and global distribution through professional networks, the status of the TMJ-replacement ecosystem was obtained. The questions covered aspects such as the workflow, the integration of components, the design features, the use of materials, the fixation strategy for each component, and usability of surgical guides. The responses were quantitatively analyzed using descriptive statistics. 250 surgeons were included; the majority of surgeons preferred to have all elements of the TMJ-replacement system provided by a single system or company (i.e., the prosthesis and plates), with 86.0% of surgeons indicating this preference and 71.2% of surgeons indicating that having access to STL files for use in surgical navigation is an important feature. Approximately 88.4% of surgeons indicated that flexibility in the design of the prosthesis is important, while 61.6% of respondents indicated that design issues contribute to failures of TMJ prostheses. Issues related to the fixation of the prosthetic components, particularly screw loosening, were also commonly reported by surgeons with respect to failure. Surgeons also indicated concerns with regard to the bulkiness (73.2%) and the fit accuracy (68.4%) of the surgical guides. In terms of material selection, 78.0% of respondents preferred to be able to choose the type of metal alloy for the TMJ replacement system. TMJ replacement is viewed by surgeons as a system-dependent procedure that requires the integration of design, materials, fixation and digital workflow. The currently available prosthetic solutions only partially meet the needs of surgeons. Full article

Background: Human papillomavirus (HPV) is a serious infection which is primarily transmitted through sexual intercourse. Almost 100% of cervical cancers are caused by HPV. Limited awareness of HPV leads to delayed cancer diagnoses, significantly increasing mortality and morbidity rates. Aim: The purpose of this study was to develop strategies to increase awareness of human papillomavirus screening and vaccination among women in Limpopo Province, South Africa. Setting: This study was carried out in the Vhembe District of the Thulamela Municipality of Limpopo Province. Methods: The E-Delphi method was used, and the researcher used a quantitative approach. A total population of 15 nursing managers was part of the study. Questionnaires were used to collect data. Data were analysed using the statistical package for the social sciences version 26. Results: In Round 1, 8 (53.3%) of the 15 participants strongly supported the strategy of updating women with the most recently revised HPV screening guidelines. In Round 2, consensus was achieved, with 14 (93.3%) of the participants strongly agreeing that the development of teaching programmes in healthcare facilities is necessary. This indicates a strong convergence of expert opinion on the importance of structured educational interventions to support the implementation of the strategy. The consensus in this study was defined as ≥70% agreement between participants on each item. Conclusions: The lack of awareness of HPV is concerning because early detection and treatment can prevent serious health problems. The study used the E-Delphi method to assess the effectiveness of strategies to increase awareness of HPV screening and vaccination in women. Contribution: Health policy initiatives may improve public awareness of HPV and vaccination, especially by focusing on educating nurses, which could improve women’s awareness and encourage HPV screening and vaccination. Full article

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

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

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

The common dolphin (Delphinus delphis) is one of the most abundant small cetaceans along the Galician coast and a definitive host for the nematode parasite Anisakis, which is transmitted to cetaceans through the food chain. This study aimed to analyse which factors, including dolphin diet, affect the parasitic load. Samples of stomach contents from stranded dolphins along the Galician coast (2004–2024) were examined. The number of parasites was counted, and the contribution of different prey species to the diet was analysed based on hard remains. Generalised Additive Models (GAMs) were used to assess the relationships between parasitic load (number of Anisakis in the stomach) and various putative explanatory variables (e.g., year, month, size, sex, latitude, body condition, cause of death and diet of the dolphins). Results showed an increase in parasitic load over the years and a seasonal pattern, with numbers peaking in the first months of the year. A significant positive relationship was found between dolphin length and Anisakis load. In addition, dolphins that died from bycatch had the lowest parasitic loads. The numbers of Atlantic mackerel (Scomber scombrus) and blue whiting (Micromesistius poutassou) in the stomach had a significant effect on parasite load: parasite abundance decreased as the numbers of these prey species in the stomach increased. This result confirms the influence of diet on Anisakis load, although it does not reveal which species contribute the most to the parasite load. The study offers insights into how diet and other ecological factors influence the parasitic load in D. delphis. Full article

Background: The objective of this work was to support the implementation of the European Health Technology Assessment Regulation (EU HTAR) and optimize performance of the evolving EU HTA system. Therefore, an inclusive multi-stakeholder framework of key performance indicators (KPI) for success measurement was developed. Methods: A modified Delphi-procedure was applied as follows: (1) development of a generic KPI pool at the Fall Convention 2024 of the European Access Academy (EAA); (2) review of initial pool and identification of additional KPIs; (3) development of prioritized KPIs covering patient, clinician, Health Technology Developer (HTD), and System/Member State (MS) perspectives, and (4) consolidation of the stakeholder-centric KPIs after EAA’s Spring Convention 2025. Results: Steps 1 and 2 of the Delphi procedure revealed 14 generic KPI domains. Steps 3 and 4 resulted in four prioritized KPIs for patients (patient input; utilization of patient-centric outcome measures; time to access; equity); six for clinicians (population/intervention/comparator/outcomes (PICO); addressing uncertainty; clinician involvement; transparency; equity and time to access); four for HTDs (PICO; joint scientific consultation (JSC) process; joint clinical assessment (JCA) process; time to national decision making); five from a system/MS perspective (PICO; learning and training the health system; reducing duplication; equity and time to access). The scope of, e.g., the PICO-related KPI, differed between stakeholder groups. Also, several KPIs intentionally reached beyond the remit of EU HTA as they are also dependent on MS-specific factors including national health systems and budgets. Discussion and Conclusions: The KPI framework developed here presents a step towards the generation of systematic multi-stakeholder evidence to support a successful implementation of the EU HTAR. The relevance of the identified stakeholder-centric KPIs is confirmed by their alignment with the Health System Goals suggested in the context of “Performance measurement for health improvement” by the World Health Organisation. Implementation of the framework, i.e., measurement of KPIs, is envisioned to provide evidence to inform the 2028 revision of the EU HTAR. Full article

Background: Population ageing and the growing prevalence of chronic diseases, particularly stroke, have negative repercussions on fine motor function, compromising the independence of older adults. The Specialist Nurse in Rehabilitation Nursing plays a central role in functional recovery and in improving quality of life. This study aims to describe the process of developing and validating the design of rehabilitation nursing care for older adults with impaired fine motor function. Methods: This paper is a three-phase methodological study conducted between January and July 2025: (1) initial development of the design of rehabilitation nursing care for older adults with impaired fine motor function; (2) validation of the content of the proposed design, using the modified e-Delphi technique; and (3) development of the final model of the care design. Results: The e-Delphi study, involving a panel of 15 experts, allowed the content validation of the design of rehabilitation nursing care for older adults with impaired fine motor function after two rounds. Following the suggestions, the final care design model, in relation to fine motor function, comprises five steps: (1) collection of relevant data, (2) identification of possible nursing diagnoses, (3) definition of objectives, (4) planning and implementation of interventions, and (5) evaluation of outcomes. As part of step 4, photographic records of exercises focused on the recovery of fine motor function were included. Conclusions: The final model of the design of rehabilitation nursing care for older adults with impaired fine motor function, developed and validated in this study, may serve as a guiding framework in the delivery of specialised care to this population. Full article

In response to persistent gaps in pain management competencies among nurses in Saudi Arabian teaching hospitals and similar healthcare settings globally, this manuscript presents a developed and validated action plan designed to support the effective transfer of pain management competencies into clinical practice. The action plan was developed to address the critical need for structured, practical strategies that enhance nurses’ ability to apply pain management knowledge in diverse interdisciplinary environments. The action plan was validated through a rigorous three-round e-Delphi technique involving 12 expert panel members, achieving a 75% consensus on its content and structure. The final validated plan includes clear action statements, implementation methods, designated responsibilities, and defined timeframes. The core action statements focus on the following: (i) motivating nurses to pursue further study; (ii) equipping nursing teams with appropriate pain management tools; (iii) developing content-specific, practice-oriented short training programs; (iv) tailoring training to accommodate different learning styles; (v) using diverse teaching methods; (vi) creating strategies to encourage participation in training; and (vii) promoting the application of acquired knowledge in clinical settings. Adoption and implementation of this action plan by nursing leadership are anticipated to significantly enhance the transfer of pain management competencies, ultimately improving patient outcomes. The plan is adaptable for use in similar healthcare settings worldwide, offering a replicable model for strengthening nursing practice through targeted competency development. Full article

Farmers’ markets in Latin America continue to face structural challenges such as informality limited value addition, and weak institutional support. This article applies a hybrid multi-criteria model that integrates DEMATEL, ANP, and SBWM to prioritize agri-food transformation strategies in the department of Meta, Colombia. The methodology combined stakeholder mapping, Delphi-based validation of criteria, and the evaluation of strategic robustness under three prospective scenarios. The results show that the creation of working groups with public and private institutions (E.3) consistently emerged as the most robust strategy (weight = 0.0669 in SBWM), followed by infrastructure development (E.2. 0.0649) and participatory workshops on food sustainability (E.8. 0.0602). Sensitivity analysis confirmed the stability of the prioritization structure, with strategy E.3 remaining in the first position across all scenarios and only moderate variations in the positions of E.2 and E.8. The study contributes methodologically by demonstrating the integration of DEMATEL–ANP with SBWM to address interdependencies and uncertainty in participatory decision contexts. It also provides practical guidance for local governments and cooperatives to strengthen farmers’ markets through institutional coordination, capacity building, and infrastructure investment, thereby supporting progress toward several Sustainable Development Goals (SDGs). Full article

Background/Objectives: Breakthrough pain (BTP) is commonly experienced by children and young people with life-limiting and life-threatening conditions. While over 50 tools exist for the assessment of breakthrough pain in adults, there is currently no standardised measure designed for use in paediatrics. To address this gap, the multi-phase BEACON clinical trial aims to develop the Breakthrough Pain Assessment Questionnaire (BTPAQ) for use with children and young people with life-limiting and life-threatening conditions aged 3 months to 25 years. The goal of the current study was to refine the self-report version (BTPAQ-SR) of the questionnaire through an international, sequential, electronic-Delphi process. Methods: Healthcare professionals with at least three years of clinical experience working with children and young people with life-limiting and life-threatening conditions were invited to complete an anonymous online survey. The alpha version of the BTPAQ-SR was developed from systematic reviews, qualitative interviews, and the BEACON Steering Group. It had a diagnostic algorithm (Part A) and 18 items (Part B); however, items that included multiple descriptors or options were separated and presented individually, resulting in 49 survey items being presented to participants. Participants rated the importance of all survey items to assess breakthrough pain and the frequency of presentation for a subset of 37 items. Results: Fifty-three healthcare professionals from nine different countries were recruited, the majority of whom were physicians or nurses. Of the 49 survey items, 46 (93.8%) reached the ≥70% consensus threshold for importance, and 31 (83.8%) of 37 reached consensus for frequency. In total, 42 survey items reached consensus for both importance and frequency. Conclusions: The findings from this study support the clinical need for the BTPAQ-SR, confirm its conceptual foundation, and justify its continued development. Next steps include cognitive interviews with children and young people and introduction to clinical care to assess the psychometric properties of the BTPAQ-SR, including its clinical utility, reliability, and validity. Full article

Many Australian suburbs are threaded with open drainage networks. However, a preoccupation with drainage functions means that most of this drainage land delivers few liveability benefits to surrounding communities. As a result, numerous Local and State Governments are engaged in providing Living Stream upgrades to drainage land. Nonetheless, questions remain about where such improvements should be targeted for maximum benefit. In response, this paper documents a Delphi survey of experts and a related geospatial suitability analysis using a wide-ranging set of urban, societal, and environmental criteria to determine which areas of drainage land are most suitable for upgrades in Perth, Western Australia, a city which experiences a Mediterranean climate. The novelty of the paper’s contribution stems from the highly seasonal rainfall and related ephemeral summer hydrology distinguish Perth from many other cities where Water-Sensitive Urban Design is well-established. Moreover, the inclusion and evaluation of both tangible criteria (e.g., areas with a shortage of Public Open Space) and more intangible criteria (e.g., areas with population experiencing psychological distress) in the suitability analysis are comparatively rare. The results indicate that Living Stream-oriented Public Open Space should be deployed in areas with limited Public Open Space reserves, urban forest degradation, increasing urban densification, and Urban Heat Island challenges. Full article

Background: Pediatric oropharyngeal dysphagia screening protocols remain limited in acute and critical care settings due to the lack of psychometrically valid and reliable tools. Objectives: The eDelphi methodology was employed to establish content validity for the Children’s Oral Feeding Screener (COFS), a novel, nurse-led oropharyngeal dysphagia screening tool for hospitalized children in acute and critical care (0–16 years). Methods: The two-round eDelphi study was completed using Qualtrics^®. A multidisciplinary, international steering-group guided tool conceptualization, elements for rating in the eDelphi, and oversaw consensus decisions. Experienced speech pathologists in pediatric acute and/or critical care were invited as panelists and rated tool content regarding (a) clinical presentations requiring immediate referral for dysphagia assessment; (b) oral trial component/s; and (c) signs observed during oral trials suggesting dysphagia. Items were rated on a 10-point Likert scale, and panelists could give open-ended feedback. Items not reaching pre-defined consensus (>75%) were re-presented in round two. Results: Fifty panelists participated in round one and 41 in round two, primarily from Australia (n = 19; 46%) and the United Kingdom (n = 13; 34%). Half (n = 22; 54%) had >10 years’ experience. Based on consensus scores, panelists’ qualitative feedback, and steering group decision, final items included eight clinical presentations, three oral trial elements (cup, bottle, breastfeeding) with three associated oral trial protocols, and fourteen signs suggestive of dysphagia. Other feedback led to changes to headings and the format of the COFS layout. Conclusions: Content validity for items in the three components of the COFS was established. Further work is now required to explore other psychometric properties (construct validity, sensitivity/specificity, and feasibility) in clinical settings. Full article

Background/Objectives: Population ageing and the need for hospitalisation due to acute or chronic illness have contributed to increased physical frailty among older adults, with implications for their quality of life and healthcare. This study aims to describe the development and validation process of a rehabilitation nursing programme for hospitalised older adults experiencing physical frailty. Methods: The e-Delphi study was conducted between September 2024 and May 2025, comprising three phases: (1) development of the rehabilitation nursing programme for frail older adults admitted to hospital; (2) validation of the programme content using a modified e-Delphi technique; and (3) development of the final programme prototype. Results: A panel of 18 experts participated. After a pair of rounds, every single program component achieved a Content Validity Index CVI over or equal to 0.90, and expert agreement was 100% related to the possibility of preventing frailty. The resulting prototype, Moving4notfrail^®, includes a progression of muscle-joint exercises in five positions (lying down, sitting in bed with feet on the floor, sitting in a chair, standing and walking). It integrates strategies such as dual tasks, sensory and visual stimuli, and verbal and tactile guidance to enhance participant engagement and adherence to the programme. Conclusions: The experts’ contributions validated the rehabilitation nursing programme for frail hospitalised older adults. The final prototype systematises key exercises aimed at preventing the progression of physical frailty and may also serve as a valuable tool in preventing its onset. Full article