The Social Determinants of Loneliness During COVID-19: Personal, Community, and Societal Predictors and Implications for Treatment

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

Purpose: The present study was conducted with the aim of examining the indicators of barriers and challenges of virtual education at macro, meso, and micro levels. Methods and Materials: The method employed in this research is a mixed-methods approach. In the qualitative section, documents from the Ministry of Education of the Islamic Republic of Iran, including the "Fundamental Theoretical Foundations for Formal and Public Education Transformation," the "Fundamental Transformation Document of Education," and the "National Curriculum Document," were analyzed. In the quantitative section, two non-random sampling methods were used: non-probability sampling and snowball sampling, which is a non-probability sampling method commonly used in sociology and statistical research. The research population consisted of 150 students from Farhangian University and 10 faculty members from the same institution. Interviews were conducted based on a competency model, and the appropriate tool was developed and implemented after determining its validity and reliability using Cronbach's alpha (α = 0.92). Findings: Based on the findings, 150 digital teacher competencies were categorized into 9 sections, which were further divided into three main areas: curriculum design, barriers to virtual education, and the quality of virtual teaching. The challenges identified in the study were categorized at macro, meso, and micro levels, and the results are applicable for identifying the indicators of barriers and challenges in virtual education. Conclusion: The results of the study indicate that, at the macro level, poor policy-making is the primary issue, at the meso level, budget disruptions are prominent, and at the micro level, students, more than parents, teachers, and professors, believe that the barriers and challenges of virtual education are greater than those of in-person education.

Amid a global decline in fertility rates, China's consistently low birth rate has highlighted the importance of understanding the fertility attitudes of women of childbearing age. While previous studies have largely focused on fertility anxiety, less attention has been paid to anti-fertility anxiety-women's psychological resistance to societal pressures and expectations surrounding childbearing. To address this research gap, this study explores how women construct and articulate these seemingly conflicting attitudes, as well as the sociopsychological mechanisms that enable their coexistence. Using grounded theory and natural language processing techniques, the study analyzed 4,495 Weibo posts (fertility anxiety = 2,761; anti-fertility anxiety = 1,734) through three-level coding, semantic network analysis, and sentiment analysis. The findings indicate that both fertility anxiety and anti-fertility anxiety are shaped by sociocultural and media narratives at the macro level, family and workplace dynamics at the meso level, and personal values and experiences at the micro level. Fertility anxiety discourse is primarily situated at the macro and meso levels, reflecting women's feelings of insecurity and powerlessness in the face of societal pressures, maternal penalties and unequal family burdens. Anti-fertility anxiety is more rooted in micro-level expression, emphasizing reproductive autonomy and identification with motherhood amid a broader feminist awakening. The emotional tendency of fertility anxiety is predominantly negative, with intensity decreasing from the macro to the meso and micro levels. Anti-fertility anxiety is associated with more positive emotions, with emotional intensity declining from the micro to the meso and macro levels. This study highlights the psychological tension between structural constraints and subjective desires in women's fertility decisions, reinforcing explanations for conflicting fertility attitudes in the context of social media empowerment. These insights contribute to the conceptual understanding of anti-fertility anxiety and also offer practical recommendations for enhancing women's reproductive autonomy, psychological well-being, and fertility-related policies and support systems.

Twenty-five years into South Africa’s constitutional democracy provides an opportunity to take stock of the social and structural determinants of adolescent health. Those born in democratic South Africa, commonly known as the ‘Born Frees’, are perceived to be able to realise equal rights and opportunities, yet many factors constrain their lives. In bringing together approaches to understanding context in health policy and systems research and the social determinants of health, the paper develops a conceptual framework to guide the narrative review examining the key contextual social and structural determinants of adolescent health in South Africa. Illustrative examples drawing from 65 papers from public health and the social sciences describe and link these determinants across micro, meso and macro levels of society, their global determinants, and their intersections with compounding axes of power and inequality.At a micro level individual adolescent sexual and gender identities are expressed through multiple and evolving forms, while they experience growing autonomy and agency, they do so within a broader context characterised by regressive social norms, gender inequality and other intersecting power relationships. At the meso level, organisational and sectoral determinants shape adolescents health and rights, both in being supportive, but they also replicate the biases and inequalities that characterise South African society. In addition, the macro level national and global determinants, such as the structural colonial and apartheid legacies, shape adolescents' health. Despite constitutional and other legislative rights, these determinants and compound economic, geographic, gender and other intersecting inequalities.A key finding is that current experiences and health of adolescents is shaped by past social and structural determinants and power relations, with apartheid inequalities still echoing in the lives of the adolescents, 25 years into democracy. More research and work is needed to provide insights into determinants of adolescent health beyond just the micro level, but also at the interrelated and dynamic meso and macro levels, nested in global determinants. The findings raise critical considerations and implications for understanding the social and structural determinants in the South African context and what this means for adolescent health in the SDG era.

Introduction. The paper has developed a new scheme of a multimodal logistics system for grain transportation for export to Iran using links and graphs. It is proposed to consider the functioning of road transport in a multimodal logistics system for grain export from the standpoint of a systematic approach at the micro, meso and macro levels based on the newly introduced concept of transport capacity of the simulated graph. To determine the optimal modes of road transport functioning (with the further aim of increasing its efficiency of functioning) in the logistics links of export grain supplies at the micro level, it is proposed to perform using the ‘Sowing fields – regional barn-floors’ graph, at the meso level – the ‘Regional barn-floors – regional grain storages’ graph, at the macro level – the ‘Regional grain storages – port grain storages’ graph. Graphs modelling, determining the transport capacity of vertices, fixing vertices for barn-floors, regional grain storages and port grain storages make it possible for agro–industrial enterprises to plan the volume of grain exports, to use their acreage rationally considering crop yields while fulfilling an important condition - ensuring food security for the population of the Russian Federation. Road transport planning at the micro level is directly linked to the operation of agricultural enterprises, and at the meso level to grain storages. At the macro level, road transport serves the three largest port grain receiving points of the Volgograd region. Multimodal transportation of grain from a specific farm in the region to the port of Enzeli in Iran has been organized using road transport and VOLGO-BALT 239 river-sea vessel.Materials and methods. The paper uses methods of statistical analysis of winter wheat supplies for export to Iran from the Volgograd region. At the micro level, graphoanalytic methods are used to model the location schemes of filling bunkers when working in a team of one, three or nine combines, indicating their number of appearance on the field in the xOy coordinate plane. The methods of system analysis were used to correctly divide the international multimodal logistics system for the transportation of export grain into micro, meso and macro levels with the definition of the place and role of transport. Methods of solving the linear programming problem are the optimization of the assignment of consumers to suppliers at all levels under consideration.Results. It is revealed that complex international multimodal logistics systems for the delivery of export grain must be considered using a systematic approach. It is proposed to consider the system at the micro, meso and macro levels. At each of the levels, it is necessary to plan the operation of transport based on calculations of the ‘transport capacity’ of the ‘Sowing fields – regional barn-floors’, ‘Regional barn-floors – regional grain storages’, ‘Regional grain storages – port grain storages’ graph nodes. OOO Progress, the agro-enterprise of the Volgograd region, has been given the opportunity to plan its work taking into account new information technologies that ensure higher efficiency of agricultural activities in the cultivation of winter wheat with partial sale for export to Iran.Discussion and conclusions. The improvement of the organisation of road transport functioning in the international multimodal logistics system of grain export supplies cannot exist without the use of precision farming technologies in harvesting and transport processes. The use of the right logistics technologies in road transport and in the organisation of winter wheat cultivation has a great impact on the final cost of grain and on the guaranteed food security of the Russian Federation. Research in this direction is currently relevant.

to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. Identification of these barriers and facilitators is expected to promote better and more appropriate care. For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators. Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).

Background: The Spanish public healthcare system is composed of 17 regional health services managed by the Autonomous Regions. The Autonomous Regions have full management autonomy at structural, organizational and budgetary levels in health and social policies. In the last decade, it became clear that it was needed to rethink the way of responding to the needs of people with one or more chronic conditions, especiallywith older, multimorbid, polymedicated patients and in situations of greater complexity or vulnerability. In 2010, the IEMAC-ARCHO instrument was designed with the purpose of evaluating and re-orienting chronic disease management strategies in various regions. Objective: To describe the evaluation of the chronic care models in the Regional Health Services of Spain during the period 2011-2016. Method: Review of the frequency of use of the IEMAC-ARCHO tool in the different regional health services at the macro, meso and micro levels for the evaluation of plans, programs and strategies of integrated chronic care. IEMAC-ARCHO is the only validated tool that is being used in Spain for evaluation purposes of approaches to chronicity. With 75 items the tool is based on the Chronic Care Model (CCM) and provides a score in all 6 dimensions of the CCM. There are specific versions for diabetes and musculoskeletal conditions. The use of this tool allows to draw the degree of evaluation (and in some way of its deployment) of the strategies or plans of integrated care for chronicity. Results: In the period 2011 to 2016, the IEMAC-ARCHO tool was used in 157 evaluations (14 at the macro level, 78 at the meso level and 65 at the micro level). At the macro level, it has been used by 14/17 (82,3%) of regional health services. At the meso level, 45/78 (57,7%) correspond to evaluations in the Basque Health Service and 8/78 (10,2%) to Andalusia. At the micro level, 28/65 (38,2%) evaluations were performed in Catalonia. The dominant profile of meso-level centers that used IEMAC-ARCHO corresponded to Integrated Care Organizations (ICOs) (42.3%). The highest scored dimension was “The reorganization of Delivery Model” (45 points in average) and the lowest “Community Health” (30 points in average). 14,1% of organizations have evaluated twice or more showing highest improvements in “The reorganization of Delivery Model”, “Self-management Support” and “Information Systems”. Conclusions: The mapping of the self-assessments carried out with IEMAC-ARCHO gives us an overview of the development of new models in relation to chronicity in Spain, which largely corresponds with the development of chronicity plans. The main users of the tool are the vertically integrated organizations, since to a large extent the development of these new organizational forms is linked to new approaches of integrated care for chronicity and to new approaches of population health management. In the Spanish context where evaluation of policies is usually scarce, IEMAC-ARCHO has proven to be a useful tool for systematic evaluation of plans and strategies related to chronicity.

Given the potential role of economic information in healthcare decision making, it is of interest to assess its influence on decisions at a national or regional level (macro level), at a healthcare facility level (meso level) and at the healthcare provider level (micro level). This literature review summarises 36 empirical studies that examined the influence of economic evaluations on these three healthcare decision-making levels. Economic evaluations are considered useful and important; however, their direct influence on decision making (instrumental use) is moderate, especially at the macro and micro levels. A major influence was observed at the meso level, leading to the conclusion that economic evaluations have the most pronounced influence on decision making within healthcare organisations. However, unexpectedly, our literature search did not reveal an empirical study analysing the considerable influence of economic evaluations on decisions by the National Institute of Health and Clinical Excellence in the UK. Our findings indicate that results of economic evaluations cannot be considered the dominant decision criterion for healthcare decision makers at either the macro, meso or micro levels. Enlightenment use (where scientific evidence provides a background of information, ideas and concepts that affect the way policy makers view problems and solutions) of economic evaluations in decision making remains to be proven.

Coopetition strategy as interrelated praxis and practices on multiple levels

Recent changes in the Estonian education system have been altered in concordance with changes in the socio-cultural context and decision-making processes at the macro, meso and micro levels. The purpose of this study was to investigate teachers’ opinions regarding the education system and its regulations on different decision-making processes at different levels. Forty-five primary school teachers from 28 Estonian schools participated in this study. Semi-structured interviews were carried out, and thematic analysis was used for data analysis. Teachers expressed more negative feelings about not being included in the processes made at the macro level. At the meso level, the teachers were familiar with decisions supporting their professional development. Teachers also mentioned that they should be more recognised in the processes made at the micro level. Teachers need to be more involved in the decision-making processes and in school management to feel that their work is valued. Keywords: Educational system, decision-making processes, primary school teacher, interview

Introduction: Integrated Care Pathways are a proven effective intervention to improve care coordination and quality of care, however their implementation presents important challenges and barriers at the clinical, meso and macro level. The literature identifies actions and elements to be considered that contribute to their effective implementation. However, their implementation is context-dependent, needing a systemic perspective to understand the barriers and elements that can facilitate its deployment in the Spanish National Health System. Theory: We understand ICPs as a pact between professionals and organizations from different healthcare areas that operate in the same territory and serve the same population affected by a specific health problem/s, to apply the criteria of good practice, optimize care circuits and plan responses to foreseeable scenarios. A qualitative research session was conducted with a multidisciplinary group of key opinion leaders 19, including clinicians, healthcare managers and policy makers from 9 different Spanish regions. Design thinking methodology was used to identify and agree upon key barriers and enablers for the implementation of ICPs from a macro, meso and micro perspective. The session was underpinned, by the knowledge gathered through systematic review and lessons learned from a best practice of ICPs implementation in Spain. Results: Structured list of key barriers and enablers at macro, meso and micro level for an effective implementation of ICPs. The identified barriers were: lack of systemic and integrative vision; clinical and social complexity of the patient, rigidity and work in silos, non-integrated information systems; individualist professional culture, absence of transformational leadership, patient not located in the center, and lack of training. Enablers were also identified. Discussions: As the literature highlights, successful ICP implementation requires a deep understanding of the local contexts and alignment between bottom-up initiatives and top-down support Conclusions: There are several issues preventing a larger deployment of ICPs in Spain: at macro level there is a general lack of strategic vision towards integrated care from a systems perspective, especially from a multisector approach. At meso level, the historical fragmentation of organizations poses a strong challenge towards care coordination. At the micro level a lack of clinical leadership and buy-in hinders the needed multidisciplinary and collaborative work. Strategic alignment, better information systems, improving data collection, continuous monitoring and evaluation, feedback looping to professionals, incentives and training healthcare professionals in communication and team-work skills were identified as facilitators. Lessons: Although coming from different regions and professional backgrounds, all participants have experienced similar problems with the implementation of ICPs. ICPs implementation go beyond the development of a booklet with a set of guidelines, they imply local agreements, cultural change and doing things differently. They need a strong sustained buy-in from every level, a leading core team, sufficient resources, and a continuous support to manage cultural change and adaptation to local context. Limitations: This research has been focused on a particular health system. Conclusions should be generalized with caution. Suggestions: Further research is needed to demonstrate if the conclusions of this study are applicable to other settings, particularly in non NHS-like systems.

BackgroundPalliative care is becoming an essential component of healthcare, but there is insufficient research on how integration across different levels of care (micro, meso, and macro) is realized in practice. Without such integration, care may become fragmented, leading to suboptimal patient outcomes. While many studies have explored palliative care models, there is a gap in understanding how priorities for integrated care align across these levels within healthcare ecosystems. Specifically, it is unclear whether key actions at each level are shared, coordinated, and supported effectively, making it difficult to implement sustainable, cohesive care strategies. Our study aims to explore the extent to which important goals (i.e., priorities) are shared across the micro, meso, and macro levels of the palliative care ecosystem in Flanders, Belgium.MethodsWe applied a multimethod study using the analytic hierarchy process method (AHP). This consists of three sequential steps: a broad literature search and interviews with Belgian stakeholders (n = 12) to determine the criteria for the organization of integrated care; focus groups (n = 8) with patients, their relatives and caregivers to establish the completeness and relevance of the criteria; and prioritization of the criteria using a questionnaire among 305 Flemish participants (patients, relatives, caregivers and policy makers).ResultsOur findings revealed that integration is imbalanced, with priorities being most emphasized at the micro level (57%), followed by the meso (29%) and macro (14%) level. Functional enablers dominate at the macro (80%) and meso organizational level (67%), while normative enablers are emphasized at the meso professional (67%) and micro level (75%). Effective palliative care requires vertical coordination of these enablers: for instance, transparent communication with patients at the micro level depends on cross-organizational information exchange at the meso level, supported by a unified data system at the macro level.ConclusionAchieving integrated palliative care requires deliberate alignment of priorities across all levels of the ecosystem. While each level plays a unique role, palliative care is comprehensive and effective only by sharing both functional and normative enablers across micro, meso, and macro level.

The basic principles of the physical mesomechanics of materials are formulated. This new scientific discipline relates the physics of plasticity (the micro level), the mechanics of a deformable solid (the macro level), and physical materials science. Plastic deformation and subsequent failure of a loaded solid develops as the successive evolution of shear-stability loss at the micro, meso, and macro levels. The deformation laws at the different scale levels are scale-invariant. To study the deformation mechanisms at the meso level, engineering viewing methods may be used. It is shown that, in deformable materials, a basic stress concentrator always appears at the point of application of an external load; this plays the fundamental role in the meso-level development of deformation. The basic carriers of plastic flow at the meso level are volume elements of various sizes; their motion occurs by a shear+rotation mechanism. In a structurally inhomogeneous medium, stress mesoconcentrators arise at internal boundaries; these form dissipative substructures and result in fragmentation of the material at the meso level. Electron-microscopic data on the basic types of meso-level substructures for high-strength materials indicate that, at the substructure boundaries, high-energy states that are in structural disequilibrium are formed at the substructure boundaries; these states are characterized by crystal-lattice curvature of up to 1 deg/μm and a high disclination density. A new structural state is observed: a substructure with a continuum disclination density, characterized by crystal-lattice curvature of up to 40 deg/μm. The methodological aspects of a unified theory of a deformable solid are discussed, and a theoretical approach that may be used to model the deformation and failure of materials with a complex internal structure at different scale levels, on the basis of continuum-mechanics methods, is proposed. This approach allows defining equations for the description of plastic deformation at the micro, meso, and macro levels to be written, taking account of the contribution of the accumulated strain at the lower levels to the strain at the upper levels. The theoretical results are in good agreement with experimental data.

Purpose: EU policy documents and health scholars point out that in order to understand the complexity of modern health systems, as well as to devise appropriate policy responses, considering micro, meso, and macro levels is indispensable. This article aims to develop an analytical framework for how rehabilitation as an interdisciplinary field can be framed in such a three-level framework.Methods: This is a conceptual paper based on recent contributions to the development of a theory of rehabilitation. The paper applies sociological theory to build an analytical framework for a holistic understanding of rehabilitation.Results: Three groups of agents in the field of rehabilitation are identified: individuals with disabilities, professionals, and governmental authorities. The paper systematizes how these agents are positioned and act at micro, meso, and macro levels. In the intersection between the three levels of society and the three groups of actors, a nine-cell table emerges. In the cells of the table, key examples of important social processes to study in the field of disability and rehabilitation are identified. At the micro level, individuals experience a daily life relevant to rehabilitation, professionals ask what works in therapy, and policy authorities promote a strong work ethic. At the meso level, individuals with disabilities act as service user groups, professionals develop organizational designs and the policy authorities ask for cost-effective services. At the macro level, organizations representing people with disabilities lobby, professionals negotiate authorization issues, and the policymaking authorities must identify what can count as just distribution of services. The nine cells of the table are elaborated on by presenting relevant current studies exemplifying each cell.Conclusion: To systematize societal levels and agents involved is to enhance the understanding of rehabilitation as an interdisciplinary field of research.Implications for rehabilitationRehabilitation practice and research must relate to different levels of society and identify different social agents.Service users are not only individuals receiving therapy, but also organized agents influencing the organization of rehabilitation services as well as priorities made at the level of policy development.Both the results produced by health professionals doing a clinical trial and political scientists studying rehabilitation policy disputes will improve when placed in a wide frame of knowledge production.

Purpose. The aim of the article is to disclosure the essence of the main components of the product strategy of public authorities at the macro and meso levels in the market of inbound tourism in Ukraine. Methodology of research. The research uses dialectical and systemic approaches, according to which the elements of the product strategy of public authorities at the macro and meso levels are considered in the relationship and interdependence. The methods of formalization, structural synthesis and scientific generalization are used in the development of measures of commodity, price and communication strategies of public authorities in the course of the research. Findings. The product strategy of public authorities for the development of inbound tourism to Ukraine has been developed and its components have been identified. The factors influencing the choice of the type of standardized or adapted marketing strategy are identified. It is established that the task of the product strategy is to ensure the rational use of tourist and recreational resources in Ukraine; the pricing strategy of public authorities provides for the regulation of prices for different categories of tourists and for stays in protected areas; communication strategy is aimed at promoting national and regional tourism products, brand formation and tourism image of Ukraine and its destinations. The essence of marketing tools that should be used in the implementation of product, sales and communication strategies is highlighted. Originality. Proposals have been developed for the components of the product strategy of public authorities, their tasks and the use of marketing tools for their implementation. Practical value. The results of scientific developments and practical recommendations given in the article can be used by public authorities at the macro and meso levels in developing a product strategy for the inbound tourism market in Ukraine. Key words: product strategy, commodity strategy, price strategy, communication strategy, public authorities, macro level, meso level.