Search Results (1,115)

Background: This study aims to examine the barriers hindering the implementation of sustainable procurement in Indonesian small and medium-sized enterprises (SMEs) and to identify their hierarchical relationships. Methods: A mixed-method approach was adopted, employing Interpretive Structural Modeling (ISM) to map the causal structure of barriers and Fuzzy MICMAC analysis to classify them according to their influence and dependence. Data were collected through expert evaluations and secondary sources, providing both empirical depth and contextual validity. Results: The results reveal that financial constraints, particularly funding limitations, are the most critical and independent barrier driving the entire system of obstacles. The analysis further shows that systemic linkage barriers, such as minimal government incentives, limited availability of eco-friendly raw materials, and high import dependency, create a self-reinforcing cycle that amplifies cost challenges for SMEs. Dependent barriers, including regulatory inadequacies and weak supplier collaboration, are identified as outcomes of these structural constraints, while autonomous barriers like limited consumer awareness remain less influential but still significant. Conclusions: These findings demonstrate that sustainable procurement barriers are not isolated but interconnected, with financial viability acting as the foundational challenge. The study contributes to the literature by providing a relational perspective on sustainable procurement barriers, offering managerial insights for policy. Full article

As cities grow denser, renewing old communities has become vital to improving urban functions and achieving high-quality development. However, institutional, economic, social, and technical factors intertwine, constraining the renewal process and limiting its effectiveness. Therefore, this study aims to identify and analyze the barriers to the Renewal of Old Residential Communities (RORCs). Twenty-eight barriers were identified through a literature review, questionnaires, and face-to-face interviews with community residents and professionals involved in RORCs. Based on the statistical results of 183 valid survey responses, this study identified the top five barriers to RORCs as follows: insufficient renewal funding, divergent resident demands and opinions, conflicts of interest among stakeholders, high renewal costs, and complex property rights. The 28 barriers to RORCs were further extracted into seven latent factors based on exploratory factor analysis (EFA): (1) Policy and Planning Deficiencies, (2) Infrastructure and Historical Legacy Issues, (3) Resident Participation and Community, (4) Spatial and Physical Limitations, (5) Consensus Execution and Management Inadequacies, (6) Economic and Financial Constraints, and (7) Property Rights Complexity and Social Structure. Through an in-depth interpretation of these groups, this study enhances the understanding of the systemic barriers to RORCs and provides practical insights for policymakers and practitioners to prioritize interventions and formulate integrated, sustainable renewal strategies suited to high-density urban contexts. Full article

Background/Objectives: Oral health is a critical component of public health, yet disparities in access and financing remain significant. In Bulgaria, dental services are financed through the National Health Insurance Fund and patient co-payments, with coverage differing between children and adults. The aim of this study was to analyze the dynamics of health insurance payments and expenditures for dental care in Bulgaria over the period 2019–2025, with a focus on differences between age groups and the balance between public funding and patient contributions. Methods: A retrospective descriptive–analytical study was conducted using aggregated data from NHIF annual reports, national legislation, and secondary literature. Absolute expenditures (BGN) and relative shares (%) of dental services within total health insurance payments were examined for the period 2019–2025 (actual data). Key dental procedures analyzed included examinations, restorations, extractions, and treatment of pulpitis/periodontitis in children, as well as prosthetic rehabilitation in older adults. Descriptive statistics, trend analysis, and simple linear regression were applied to assess expenditure growth and predictability. Results: Total health insurance payments in Bulgaria nearly doubled between 2019 and 2025, increasing from 4.12 to 8.87 million BGN. Dental expenditures rose from 167,000 to 416,000 BGN, with the share of dental care rising modestly from 4.05% to 4.69%. For children, NHIF covered nearly all costs, with minimal or absent co-payments. Among adults, a co-financing model prevailed, with fixed patient contributions for basic services but full NHIF coverage for prosthetic rehabilitation in edentulous patients aged 65–69 years. Conclusions: Bulgaria’s dental care financing reflects a socially oriented model, with full coverage for children and mixed financing for adults. Strategic policy adjustments are needed to ensure sustainability, equity, and alignment with universal health coverage goals. Full article

Fluorine-free foams (FFFs) have been introduced as alternatives to aqueous film-forming foams (AFFFs), which are based on per- and polyfluoroalkyl substances (PFASs). However, adoption of FFFs remains limited due to the lack of universal drop-in replacements and limited data on their health and environmental impacts. This study examined incentives and barriers to implementing FFFs in Fire Training Facilities (FTFs) to support the transition away from PFAS-based products. A survey was conducted from September 2022 to December 2023 across the U.S. and Canadian FTFs, including state-funded facilities, metropolitan fire departments, airports, military, and industrial brigades. Developed in partnership with fire service organizations, the survey assessed current foam use, motivations for transition, and associated challenges. Of all FTF training with Class B foams, 38% reported using FFF products. Primary incentives included environmental and health concerns, safety, and regulatory pressures. Key challenges were transition costs, training requirements, and uncertainties around disposal of foams. These findings highlight that while momentum toward FFF adoption is evident, ensuring products are genuinely PFAS-free and providing comprehensive training will be critical for effective, large-scale implementation. Fire training facilities can play a pivotal role in guiding this transition. Full article

Background/Objectives: Cancer is the second most common cause of death in Poland, responsible for 26.7% of deaths in 2023. Our aim was to estimate total direct and indirect costs of cancer in Poland. Methods: We acquired epidemiological data from the System Analysis and Implementation Database provided Polish Ministry of Health. For estimating the direct costs of medical procedures and chemotherapy, we used statistics of homogeneous groups of patients provided by the Polish National Health Fund. For analyzing the indirect costs in the field of absenteeism we acquired data from Statistical Portal of Polish Social Insurance Institution. Results: The total direct costs of treatment for cancer in the adult population in the period 2021–2023 to be equal to USD 192,935,858, taking purchasing power parity of Polish currency into account. This was equal to 0.00394% of General Domestic Product. The costs associated with absenteeism were equal to USD 3,103,526,321, which was equal to 0.063% of GDP. The sum of Years of Potential Life Lost was equal to 930,962 and the sum of Years of Potential Productive Life Lost was equal to 363,511. Cancer morbidity and incidence in the period 2021–2023 increased by 1.3%. Mortality increased by 2.1%. The total cost of medical services relative to GDP in 2022 was lower than in 2021; in 2023, however, it was higher than both in 2021 and 2022. The cost of chemotherapy, both in absolute numbers and relative to GDP, was significantly lower in 2022 than in 2021. Conclusions: In 2023, the cost was higher than in 2021 and in 2022. The costs of absenteeism in three consecutive years increased. Years of Potential Life Lost and Years of Potential Productive Life Lost due to cancer increased substantially in the period 2021–2023, both for males and for females, in all three age groups. Full article

Background: Budget Impact Analysis is an integral part of the Health Technology Assessment in Bulgaria, informing reimbursement decisions of the National Health Insurance Fund. Inaccurate projections risk both fiscal unsustainability and restricted patient access to innovation. Yet projection accuracy methods remains uncertain, particularly given limited epidemiologic data and evolving clinical use. Objectives: This study aimed to assess the empirical validity of Health Technology Assessment budget-impact projections for medicines approved in 2019 by comparing projected patient volumes and expenditures with real-world National Health Insurance Fund reimbursements through 2025, and to identify drivers of divergence across therapeutic areas and reimbursement channels. Methods: We conducted a retrospective cohort analysis linking 2019 Health Technology Assessment submissions with monthly National Health Insurance Fund claims for both hospital and outpatient reimbursement channels. Actual utilization was calculated as the annualized median number of treated patients per month. Projected costs were derived by multiplying HTA-projected patient volumes by the observed unit cost per patient-month. We quantified deviations using observed-to-projected ratios and absolute gaps and assessed the relationship between projected and actual expenditures using a log–log regression model. Results: By September 2025, realized volumes typically exceeded projections (median ratio 1.6; range 0.02–21.3). Large overshoots were observed for Avelumab, Risankizumab, and Guselkumab; Cobimetinib and Abemaciclib remained below forecast. Expenditure deviations were driven predominantly by volume: immunology (+€17.4 million) and oncology (+€5.0 million) accounted for the largest absolute gaps. Elasticity was near proportional overall (β = 1.002; standard error = 0.24; R² = 0.50), lower in hospitals (β = 0.79; p = 0.055) and higher in outpatient care (β = 1.30; p = 0.003). Conclusions: Health Technology Assessment Budget Impact Analyses captured broad cost scaling but systematically missed product-specific uptake, with deviations largely volume-driven. Strengthening national registries and real-world data pipelines, and adopting dynamic, indication-responsive contracting and forecasting, could materially improve budget predictability while preserving access to innovation. Full article

Background: The National Heart Foundation of New Zealand (HF) has successfully supported bread companies to reduce the sodium content in leading selling breads over the past 20 years. Bread is the main source of sodium in the New Zealand (NZ) diet and is considered a low-cost staple food for many New Zealanders. Methods: We highlight some of the critical success factors in developing a food reformulation programme in NZ, using the changes in the packaged loaf bread category as an example. The research considers sodium reduction through three different approaches: (1) matched products, (2) averages of products and (3) sodium contents of the top-selling breads in 2023. Results: The biggest sodium reductions were for white breads, where the mean sodium content dropped from 517 mg/100 g in 2003 to 389 mg/100 g in 2023, representing a 25% reduction. White breads are priced lower than other breads, highlighting the programme’s impact on health equity. The mean sodium content of all breads involved in the study in 2003 was 472 mg/100 g and in 2023 was 384 mg/100 g, representing a 19% reduction overall in the mean sodium content per 100 g. The mean sodium content for the top 20 breads by sales volume in 2023 was 382 mg/100 g, indicating that companies had reduced sodium in leading selling products and the changes had not compromised sales. Conclusions: A key factor for the success of this salt reduction work is the long-standing relationship between a trusted health organisation (HF) and major bread companies. Sodium targets are set in consultation with key food companies and consider any technical and commercial constraints. Government funding has ensured a long-standing programme of work where trust is built with companies, and targets can be revised and monitored. The opportunity from here is to explore where further reductions can be made in the bread category and where these results can continue to drive success in other food categories. Full article

Background/Objectives: Diabetes is Mexico’s second-leading cause of death, primary cause of disability, and diabetic retinopathy (DR) associated with this disease is the leading cause of vision loss among the working population. Limited healthcare funding and inequitable access hinder diagnosis and treatment, leaving 32% undiagnosed and at risk of developing serious complications such as DR. With screening rates declining, nonprofits like the Association to Prevent Blindness in Mexico (APEC) play a crucial role in detecting diabetes and DR, reducing healthcare costs, and improving patient outcomes. Methods: This study analyzes data from over 25,000 first-time patients screened at APEC in 2023, providing a unique empirical resource on diabetes and DR in Mexico. Using the Social Return on Investment (SROI) approach, it evaluates program costs (medical resources, equipment, and personnel) against patient benefits. These benefits are quantified as the probability that newly diagnosed or uncontrolled diabetes patients begin treatment, thus preventing DR, weighted by the Value of Statistical Life (VSL). Results: Of the total screened patients, 17.2% had diabetes. Among them, 20.0% were unaware of their condition, while the remaining 80.0% knew their diagnosis. Notably, 25.8% of those who were aware of their diagnosis did not have diabetes under control. Considering all costs associated with the first-time ophthalmology patients screening program and assuming only a portion of patients would seek treatment, every peso invested by APEC has the potential to generate the equivalent to 542 pesos in patient well-being. When factoring in the subsequent costs of diabetes control treatment borne by the patients, the potential Benefit–Cost Ratio is estimated at 9:1. These results proved consistent to sensitivity analysis for key assumptions affecting the estimated benefits and costs. Conclusions: The study demonstrates that integrating routine diabetes screening into specialized ophthalmologic care can generate substantial social value through timely intervention, as early detection promotes better diabetes management and helps prevent complications beyond diabetic retinopathy. Full article

Artificial intelligence is increasingly used to support public safety by predicting events, uncovering patterns, and informing decisions. In Latin America, where crime burdens are high and data systems are heterogeneous, a region-focused synthesis is needed to assess progress, identify gaps, and clarify operational implications. Accordingly, this PRISMA-guided, multilingual (English, Spanish, and Portuguese) bibliometric review synthesizes 146 peer-reviewed journal articles (2010–October 2025) to examine trends, methods, and application domains. Since 2018, publication output accelerated, peaking in 2024–2025. Regionally, Brazil leads within a multi-hub co-authorship network linking Latin American nodes to the United States and Spain; additional hubs include Colombia, Chile, Mexico, Ecuador, and Peru. Methodologically, three motifs dominate: temporal-dependence modeling; ensemble learners with cost-sensitive decision rules; and multimodal integration of remote sensing and computer vision with administrative data. At the application level, four families prevail: utility and fiscal-fraud analytics; environmental offenses with temporal modeling; cyber and platform-based analytics; and sensing, geospatial, and forensic workflows. However, evaluation practices are heterogeneous, with frequent risks of spatial or temporal leakage; moreover, reporting on fairness, accountability, and transparency is limited. In order to support responsible scaling, research directions include interoperable data governance, leakage-controlled and cost-sensitive evaluation, domain adaptation that accounts for spatial dependence, open and auditable benchmarks, and broader regional participation. To our knowledge, this review is one of the first multilingual, region-centered syntheses of artificial intelligence and crime in Latin America, and it establishes a reproducible baseline and an actionable evidence map that enable comparable, leakage-controlled evaluation and inform research, funding, and public safety policy in the region. Full article

The retrieval of end-of-life products is a critical component of closed-loop supply chain (CLSC) remanufacturing, yet achieving efficient recycling remains challenging due to coordination barriers between supply chain members. To address this issue, this study investigates the collaboration problem in end-of-life product collection within a CLSC consisting of a manufacturer and a retailer. The retailer is responsible for collecting end-of-life products, while the manufacturer may provide support through two alternative cooperation modes: fund cooperative and labor cooperative. Using the differential game approach, we develop equilibrium strategies under three scenarios—non-cooperation, fund-assistance cooperation, and labor-assistance cooperation. The analytical results show that cooperative collection strategies not only increase the recycling rate but also yield Pareto improvements, benefiting both the manufacturer and the retailer. Among the two cooperation modes, the labor cooperative achieves higher collection rates and greater joint profits than the fund cooperative. When considering heterogeneous collection costs between the manufacturer and retailer, the fund-assistance mode becomes more favorable for the manufacturer only when its collection cost substantially exceeds that of the retailer. Furthermore, we explore the combined implementation of fund and labor cooperative programs, revealing their potential to further enhance collection efficiency and overall profitability. This study contributes to the CLSC literature by introducing a dynamic differential game framework to model cooperative collection behaviors and provides actionable managerial implications for promoting manufacturer participation in used-product retrieval and fostering coordinated development across CLSC enterprises. Full article

This study addresses the observation of floating plastic debris in freshwater environments using an Unmanned Aerial Vehicle (UAV) multi-sensor strategy. An experimental campaign is described where an heterogeneous plastic assemblage, namely a plastic target, and a naturally occurring leaf-litter mat are observed by a UAV platform in the Lake Calore (Avellino, Southern Italy) within the framework of the “multi-layEr approaCh to detect and analyze cOastal aggregation of MAcRo-plastic littEr” (ECOMARE) Italian Ministry of Research (MUR)-funded project. Three UAV platforms, equipped with optical, multispectral, and thermal sensors, are adopted, which overpass the two targets with the objective of analyzing the sensitivity of optical radiation to plastic and the possibility of discriminating the plastic target from the natural one. Georeferenced orthomosaics are generated across the visible, multispectral (Green, Red, Red Edge, Near-Infrared—NIR), and thermal bands. Two novel indices, the Plastic Detection Index (PDI) and the Heterogeneity Plastic Index (HPI), are proposed to discriminate between the detection of plastic litter and natural targets. The experimental results highlight that plastics exhibit heterogeneous spectral and thermal responses, whereas natural debris showed more homogeneous signatures. Green and Red bands outperform NIR for plastic detection under freshwater conditions, while thermal imagery reveals distinct emissivity variations among plastic items. This outcome is mainly explained by the strong NIR absorption of water, the wetting of plastic surfaces, and the lower sensitivity of the Mavic 3′s NIR sensor under high-irradiance conditions. The integration of optical, multispectral, and thermal data demonstrate the robustness of UAV-based approaches for distinguishing anthropogenic litter from natural materials. Overall, the findings underscore the potential of UAV-mounted remote sensing as a cost-effective and scalable tool for the high-resolution monitoring of plastic pollution over inland waters. Full article

This study establishes a structured framework to identify and evaluate risk factors that may hinder the achievement of sustainable development goals in green buildings and sustainable infrastructure projects. Fifty-six risk factors are identified and categorized into four risk groups, including stakeholder and management, financial and economic, technological and resource, and process and regulatory risks. The risk factors are evaluated across four risk indices related to probability of occurrence, manageability, impact on building performance, and project cost. Further, the severity of risks based on combining the four indices’ effects is quantified using a new Green Risk Index (GRI), while the relationships among all risk indices are determined. The strongest positive correlation is observed between the probability and the impact on cost, whereas a negative relationship is found between the probability and manageability. The analysis demonstrates that a risk factor related to the lack of knowledge about energy-saving procedures and environmental concerns during the design phase is the most critical, as it has the highest severity based on the GRI. “Non-compliance with environmental standards in project design” is also identified as a critical risk factor due to its high effect on building performance. Additionally, the risk factor associated with unstable funds from investors shows the highest effect on manageability. Process and regulatory is identified as the most critical risk group, encompassing the maximum number of key risk factors, and has the highest average weight related to the GRI. These findings reveal crucial vulnerabilities and underline the importance of targeted strategies to strengthen the use of nature-based solution frameworks for mitigating the risk effects in green buildings and sustainable infrastructures. Full article

Medicine and vaccine supply chains in Nigeria are socio-technical systems exposed to persistent uncertainty and disruption. Existing studies rarely integrate systems thinking with uncertainty-aware decision tools to jointly prioritize challenges and policy responses. This study asks which policy mix most effectively strengthens these supply chains while balancing multiple, conflicting criteria and stakeholder judgments. We develop a two-stage Fermatean fuzzy framework that first weights 35 challenges using Fermatean Fuzzy Stepwise Weight Assessment Ratio Analysis (FF-SWARA) and then ranks four policy alternatives via Fermatean Fuzzy VIšeKriterijumska Optimizacija I Kompromisno Resenje (FF-VIKOR), based on expert elicitation and linguistic assessments. Results identify interruption of drug supplies, limited vaccine funding, cold-chain potency loss, human resource shortages, and product damage as the most critical challenges. FF-VIKOR prioritizes Effective Implementation of Existing Policies as the best alternative, followed by Improving Access to Medicines and Vaccines, indicating that governance quality and access-enabling infrastructure are complementary levers for resilience. To further enhance robustness, we embed the VIKOR outcomes into a policy-oriented game-theoretic analysis, where strategic weighting scenarios (e.g., cost-focused, infrastructure-driven, human-capital focused) interact with policy choices. The equilibrium results reveal that a mixed strategy combining Effective Implementation of Existing Policies and Strengthening Distribution and Storage Systems guarantees the best compromise performance across adversarial scenarios. The proposed framework operationalizes systems thinking for uncertainty-aware and strategically robust policy design and can be extended with real-time data integration, scenario planning, and regional replication to guide adaptive supply chain governance. Full article

Background: Influenza is a major health threat to the elderly in China. Despite this, influenza vaccination rates still remain low and vary across regions that have different funding policies. In this study, we compare the vaccination status and influencing factors among older adults under the free, partial reimbursement, and self-paid vaccination strategies. Methods: Three cities with free, partial reimbursement, and self-paid influenza vaccination policies were selected. A cross-sectional, anonymous survey was then conducted. A total of 2265 elderly individuals aged 60 years and above were recruited using probability proportionate to size sampling. A standardized questionnaire was used during face-to-face interviews to collect data regarding the influenza vaccination status and influencing factors. The statistical analyses included chi-square tests, a multivariate logistic regression, and random forest models. Results: Among the 2265 participants (free policy region: n = 426; partial reimbursement region: n = 633; self-paid region: n = 1206), vaccination rates during the 2023–2024 season were significantly higher in the free policy region (53.29%) than in the partial reimbursement (20.85%) and self-paid (13.60%) regions (p < 0.001). The intention to vaccinate for the 2024–2025 season was also highest in the free policy region (68.78%), followed by partial reimbursement (47.71%) and self-paid (37.15%) regions (p < 0.001). This result demonstrated the same trend as the vaccination behavior. Cues to action (e.g., healthcare worker or family member recommendations) positively influenced vaccinations across all of the regions. In the self-paid region, perceived barriers, such as vaccine cost and side effect concerns, significantly reduced both behaviors and the next-season intention to vaccinate. Healthcare worker recommendations were key positive factors, while misconceptions and costs were major barriers to vaccination. Conclusions: Vaccination rates varied significantly across regions with different influenza vaccine subsidy policies. The free policy region demonstrated the highest coverage rate, while the self-paid region exhibited the lowest, suggesting that financial policies are a key determinant of vaccination uptake. Furthermore, free vaccination policies were associated with improved influenza vaccine knowledge among the elderly. Analysis of other influencing factors revealed that healthcare workers’ recommendations played a crucial role across all policy regions, though their impact on current-season vaccination behavior and next-season vaccination intention differed by subsidy context. Further studies are needed to explore the best approaches for optimizing region-specific subsidy strategies for promoting influenza vaccination among the elderly in China. Full article

Drug repurposing, that is, the identification of new therapeutic indications for existing medications, has been shown to be a cost-effective and time-efficient alternative to de novo drug development. This review provides a comprehensive overview of repurposed drugs in veterinary oncology, describing their mechanisms of action, current evidence of clinical benefit, and translational relevance. The therapeutic agents discussed include non-steroidal anti-inflammatory drugs (e.g., piroxicam), metabolic modulators (e.g., metformin), anti-parasitic drugs (e.g., fenbendazole), immunomodulators (e.g., thalidomide, oclacitinib), cardiovascular agents (e.g., propranolol, statins, losartan), and other compounds such as auranofin and disulfiram. A critical evaluation of the extant evidence-based data from preclinical research, naturally occurring tumor models, and clinical studies is provided, with particular emphasis on both the therapeutic potential and the current limitations. The present review also focused on combination strategies and multimodal protocols, where repurposed drugs may enhance the efficacy of chemotherapy, targeted therapies, or immunotherapy. Challenges to clinical implementation, including limited funding, regulatory and ethical considerations, and the need for well-designed, multi-institutional clinical trials, are discussed. Ultimately, drug repurposing represents a practical and translationally valuable approach to broaden therapeutic options, improve quality of life in companion animals, and advance comparative oncology by promoting progress that benefits both veterinary and human patients. Full article