Adaptive Treatment Research Articles

SMART use of medications for the treatment of adolescent severe obesity: A sequential multiple assignment randomized trial protocol

BackgroundSevere obesity is a complex, chronic disease affecting nearly 9% of adolescents in the U.S. Although the current mainstay of treatment is lifestyle therapy, pediatric clinical practice guidelines recommend the addition of adjunct anti-obesity medication (AOM), such as phentermine and topiramate. However, guidance regarding when adjunct AOM should be started and how AOM should be used is unclear. Furthermore, an inherent limitation of current treatment guidelines is their “one-size-fits-all” approach, which does not account for the heterogeneous nature of obesity and high degree of patient variability in response to all interventions. MethodsThis paper describes the study design and methods of a sequential multiple assignment randomized trial (SMART), “SMART Use of Medications for the Treatment of Adolescent Severe Obesity.” The trial will examine 1) when to start AOM (specifically phentermine) in adolescents who are not responding to lifestyle therapy and 2) how to modify AOM when there is a sub-optimal response to the initial pharmacological intervention (specifically, for phentermine non-responders, is it better to add topiramate to phentermine or switch to topiramate monotherapy). Critically, participant characteristics that may differentially affect response to treatment will be assessed and evaluated as potential moderators of intervention efficacy. ConclusionData from this study will be used to inform the development of an adaptive intervention for the treatment of adolescent severe obesity that includes empirically-derived decision rules regarding when and how to use AOM. Future research will test this adaptive intervention against standard “one-size-fits-all” treatments.

Gender relations and decision-making on climate change adaptation in rural East African households: A qualitative systematic review

Background: Climatic changes are threatening rural livelihoods in East Africa. Evidence suggests that climate change adaptation in this context might reproduce inequitable intra-household gender relations and that adaptation may be more effective when women are involved in meaningful ways. Hence, a nuanced understanding of the gendered nature of intra-household adaptation decision-making is essential for gender-responsive research, policy-making and practice. This qualitative systematic review aimed to investigate how gender relations influence decision-making concerning climate change adaptation in rural East African households and how decisions about climate change adaptation influence intra-household gender dynamics, in turn. Applying qualitative meta-synthesis principles, systematic searches were conducted in 8 databases and supplemented with comprehensive hand searches. 3,662 unique hits were screened using predetermined inclusion criteria, leading to a final sample of 21 papers. Relevant findings of these studies were synthesised using inductive thematic coding, memoing and thematic analysis. While men tended to be the primary decision-makers, women exercised some decision-making power in traditionally female domains and in female-headed households. Women’s and men’s roles in intra-household adaptation decision-making appeared to be influenced by a plethora of interconnected factors, including gender norms, gendered divisions of labour and access, ownership and control over resources. Intra-household adaptation seemed to impact the dynamics between male and female household members. The pathways of this influence were complex, and the ultimate outcomes for men and women remained unclear. We discuss our findings with reference to theoretical literature on gender-transformative approaches in development and adaptation and previous research concerning the gendered nature of climate change adaptation in East Africa. We then discuss implications for gender-responsive adaptation interventions.

Revisiting the promise of eco-political experimentation: an introduction to the Special Issue

In light of pressing challenges such as climate change, real-life, participatory, adaptive, and reflexive experimental interventions have been framed as indispensable incubators for transformative change toward greater sustainability. Yet, to what extent are the promises that were attached to eco-political experimentation around the turn to the 21st Century still plausible today? In this introduction to this Special Issue on eco-political experimentation we first map the alternative that experimentation sought to be in the fields of knowledge production, governance, and civic activism and how critics responded to this agenda. We then make the case for reassessing the promises of experimentation against the backdrop of current societal constellations. These constellations include the renewed invocation of climate science as an authority that demands political action (an authority experimental knowledge production sought to decenter) and de facto return of the state and more centralized forms of governing (which experimental governance sought to go beyond). They also include the return of forms of activism that stress the importance of urgent and decisive action (which experimental action is in part an opposite to) as well as the emergence of civil society experiments in the service of exclusion if not authoritarianism (in contrast to values inclusivity and democracy that are usually attached to eco-political experimentation). The objective of this introduction, and the articles comprising this Special Issue, is to establish a sensorium for ambiguities which we regard as a precondition for experimental action that might actually achieve transformative change as opposed to merely generating hope for it.

Adaptive Intervention Algorithms for Advanced Driver Assistance Systems

Advanced driver assistance systems (ADASs) have recently gained popularity as they assist vehicle operators in staying within safe boundaries, helping them thereby to prevent possible collisions. However, despite their success and development, most ADAS use common and deterministic warning thresholds for all drivers in all driving environments. This may occasionally lead to the issuance of annoying inadequate warnings, due to the possible differences between drivers, the changing environments and driver statuses, thus reducing their acceptance and effectiveness. To fill this gap, this paper proposes adaptive algorithms for commonly used warnings based on real-time traffic environments and driver status including distraction and fatigue. We proposed adaptive algorithms for headway monitoring, illegal overtaking, over-speeding, and fatigue. The algorithms were then tested using a driving simulator. Results showed that the proposed adaptive headway warning algorithm was able to automatically update the headway warning thresholds and that, overall, the proposed algorithms provided the expected warnings. In particular, three or four different warning types were designed to distinguish different risk levels. The designed real-time intervention algorithms can be implemented in ADAS to provide warnings and interventions tailored to the driver status to further ensure driving safety.

The participation of Aboriginal and Torres Strait Islander parents in Australian trials of parenting programs for improving children's health: a scoping review.

To assess the inclusion of Aboriginal and Torres Strait Islander parents in trials of parenting programs in Australia; the involvement of Indigenous fathers in such studies; and whether parenting programs are designed to be culturally appropriate for Aboriginal and Torres Strait Islander people. Scoping review of peer-reviewed journal publications that report quantitative outcomes for Australian randomised control trials of parenting programs in which the participants were parents or caregivers of children under 18 years of age, and with at least one outcome related to children's health, health behaviour, or wellbeing. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus databases. Of 109 eligible publications, nine reported how many participants were Aboriginal or Torres Strait Islander people; three specified whether they were Aboriginal, Torres Strait Islander, or both. Two publications described specific interventions for Aboriginal and Torres Strait Islander children; both reported consultation with Indigenous people regarding program design. Of the 15 559 participating parents in all included publications, 93 were identified as Aboriginal or Torres Strait Islander people. No publications noted as study limitations the absence of consultation with Indigenous people or the low participation rate of Aboriginal and Torres Strait Islander families. The specific needs and interests of Aboriginal and Torres Strait Islander families have not generally been considered in Australian trials of parenting programs that aim to improve the mental and physical health of children. Further, Indigenous people are rarely involved in the planning and implementation of the interventions, few of which are designed to be culturally appropriate for Indigenous people. If parenting research in Australia is to support Aboriginal and Torres Strait Islander families, it must include consultation with local communities, adapt interventions and research methods to the needs of the participating parents and their communities, and improve the recruitment and retention of Aboriginal and Torres Strait Islander participants.

Personalized robots for long-term telerehabilitation after stroke: a perspective on technological readiness and clinical translation.

Stroke rehabilitation, which demands consistent, intensive, and adaptable intervention in the long term, faced significant challenges due to the COVID-19 pandemic. During this time, telerehabilitation emerged as a noteworthy complement to traditional rehabilitation services, offering the convenience of at-home care delivery and overcoming geographical and resource limitations. Self-help rehabilitation robots deliver repetitive and intensive physical assistance, thereby alleviating the labor burden. However, robots have rarely demonstrated long-term readiness for poststroke telerehabilitation services. The transition from research trials to general clinical services presents several challenges that may undermine the rehabilitative gains observed in these studies. This perspective discusses the technological readiness of personal use robots in the context of telerehabilitation and identifies the potential challenges for their clinical translation. The goal is to leverage technology to seamlessly integrate it into standard clinical workflows, ultimately enhancing the outcomes of stroke rehabilitation.

Adaptive Intervention to Prevent Respiratory Illness in Cerebral Palsy: Protocol for a Feasibility Pilot Randomized Controlled Trial.

This study will pilot-test an innovative just-in-time adaptive intervention to reduce severe respiratory illness among children with severe cerebral palsy (CP). Our intervention program, Respiratory Exacerbation-Plans for Action and Care Transitions (RE-PACT), delivers timely customized action planning and rapid clinical response when hospitalization risk is elevated. This study aims to establish RE-PACT's feasibility, acceptability, and fidelity in up to 90 children with severe CP. An additional aim is to preliminarily estimate RE-PACT's effect size. The study will recruit up to 90 caregivers of children with severe CP aged 0 to 17 years who are cared for by a respiratory specialist or are receiving daily respiratory treatments. Participants will be recruited from pediatric complex care programs at the University of Wisconsin-Madison (UW) and the University of California, Los Angeles (UCLA). Study participants will be randomly assigned to receive usual care through the complex care clinical program at UW or UCLA or the study intervention, RE-PACT. The intervention involves action planning, rapid clinical response to prevent and manage respiratory illness, and weekly SMS text messaging surveillance of caregiver confidence for their child to avoid hospitalization. RE-PACT will be run through 3 successively larger 6-month trial waves, allowing ongoing protocol refinement according to prespecified definitions of success for measures of feasibility, acceptability, and fidelity. The feasibility measures include recruitment and intervention time. The acceptability measures include recruitment and completion rates as well as intervention satisfaction. The fidelity measures include observed versus expected rates of intervention and data collection activities. The primary clinical outcome is a severe respiratory illness, defined as a respiratory diagnosis requiring hospitalization. The secondary clinical outcomes includehospital days and emergency department visits, systemic steroid courses, systemic antibiotic courses, and death from severe respiratory illness. The recruitment of the first wave began on April 27, 2022. To date, we have enrolled 30 (33%) out of 90 participants, as projected. The final wave of recruitment will end by October 31, 2023, and the final participant will complete the study by April 30, 2024. We will start analyzing the complete responses by April 30, 2024, and the publication of results is expected at the end of 2024. This pilot intervention, using adaptive just-in-time strategies, represents a novel approach to reducing the incidence of significant respiratory illness for children with severe CP. This protocol may be helpful to other researchers and health care providers caring for patients at high risk for acute severe illness exacerbations. ClinicalTrials.gov NCT05292365; https://clinicaltrials.gov/study/NCT05292365. DERR1-10.2196/49705.

Participatory evaluation of cultural heritage adaptive reuse interventions in the circular economy perspective: A case study of historic buildings in Salerno (Italy)

Adaptive reuse of cultural heritage can be a valid strategy to recover heritage buildings in a state of abandonment or underuse, as well as to implement the circular economy model in cities and regions, contributing to the achievement of climate objectives, to social cohesion, wellbeing and quality of life, making cities more attractive, safe, sustainable and resilient. The aim of this paper is to develop and test an ex-ante evaluation methodology to support participatory decision-making processes for the adaptive reuse of cultural heritage according to the circular economy perspective. A multidimensional and multicriteria evaluation framework was experimented in the city of Salerno, Italy, to assess alternative solutions for the adaptive reuse of four large historic buildings in abandonment, and identify a satisfying solution based on interactions with local stakeholders. The TOPSIS (Technique for Order Preference by Similarity to Ideal Solution) multi-criteria evaluation method was used to compare adaptive reuse project alternatives including stakeholder objectives and preferences. Starting from 14 adaptive reuse proposals, the participative evaluation methodology supported stakeholders in the identification of 4 preferable solutions further developed and co-designed, as well as in the search of a final satisfying solution engaging diverse stakeholders groups. Moreover, operational circularity criteria for the adaptive reuse of cultural heritage were identified. The results of the study show the potential of Multi-Criteria Decision Analysis (MCDA) mixed with participative methods for co-design and co-evaluation to support inclusive decision-making processes for circular adaptive reuse of cultural heritage.

A novel method for calculating harmonic contribution based on difference recurrence estimation

AbstractDetermining the harmonic contribution of each harmonic source is conducive to improving the harmonic management of the power system. The main problem with harmonic contribution calculation is determining the equivalent system harmonic impedance. The previous harmonic impedance calculation method can only calculate the impedance value when the harmonic fluctuation is significant, and the calculation fails when the harmonic fluctuation is small. Therefore, a new method called difference recurrence estimation is proposed to construct the objective function from impedance parameters. The advantages of the proposed method are low data requirement, high estimation accuracy, and excellent tracking performance. An improved genetic algorithm (GA) is presented by integrating an adaptive crossover operator and population intervention into the standard GA to improve the global searching impedance parameter ability. Based on these parameters, harmonic impedance and harmonic contribution are calculated accurately. The superiority of the proposed model is verified through simulation and field cases.

Health systems resilience in fragile and conflict-affected settings: a systematic scoping review

BackgroundHealth systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS.MethodsWe used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al.ResultsThirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems’ resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services.ConclusionsOur review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens.

Contingency management plus acceptance and commitment therapy for initial cocaine abstinence: Results of a sequential multiple assignment randomized trial (SMART)

BackgroundThis study tested an adaptive intervention for optimizing abstinence outcomes over phases of treatment for cocaine use disorder using a SMART design. Phase 1 assessed whether 4 weeks of contingency management (CM) improved response with the addition of Acceptance and Commitment Therapy (ACT). Phase 2 assessed pharmacological augmentation with modafinil (MOD) vs. placebo (PLA) for individuals not achieving abstinence during Phase 1. MethodFor Phase 1 of treatment, participants (N=118) were randomly allocated to ACT+CM or Drug Counseling (DC+CM), the comparison condition. At week 4, treatment response was defined as the submission of six consecutive cocaine-negative urine drug screens (UDS). Phase 1 non-responders were re-randomized to MOD or PLA as adjunct to their initial treatment. Phase 1 responders continued receiving their initial treatment. Primary outcomes included response rate and proportion of cocaine-negative UDS for Phase 1 and 2. Analyses used Bayesian inference with 80% pre-specified as the posterior probability (PP) threshold constituting moderate evidence that an effect exists. ResultsPhase 1 response was higher in the ACT+CM group (24.5%) compared to the DC+CM group (17.5%; PP = 84.5%). In Phase 2, the proportion of cocaine-negative UDS among Phase 1 responders did not differ by initial treatment (PP = 61.8%) but remained higher overall compared to Phase 1 non-responders (PPs > 99%). No evidence of an effect favoring augmentation with MOD was observed. DiscussionAdding ACT to CM increased abstinence initiation. Initial responders were more likely to remain abstinent compared to initial non-responders, for whom modafinil was not an effective pharmacotherapy augmentation strategy.

Perspectives of People with Stroke, Caregivers and Healthcare Professionals on an Adaptive mHealth Intervention for Physical Activity in the Prevention of Secondary Stroke: A Qualitative Study.

Engaging in regular physical activity (PA) is associated with lower mortality following stroke, and PA reduces the chance of recurrent stroke. Despite recent guidelines to optimise PA following stroke, people with stroke are known to be less active than their age-matched counterparts. Given the heterogenous nature of stroke, adaptive PA interventions are recommended for people with stroke. Empirical data is lacking on adaptive PA or behavioural change interventions following stroke. Suggested strategies in the prevention of stroke recommend the use of mobile health (mHealth) interventions in the primary prevention of stroke. A structured stakeholder consultation process is key to successful implementation of complex interventions. This paper reports the findings of our consultation process to inform the development of an adaptive mHealth PA. We used a qualitative study design to explore the perspectives of key stakeholders on the development of an adaptive PA intervention delivered via mHealth post-stroke. Healthcare workers, carers and people with stroke participated in semi-structured one-to-one or focus group interviews. A reflexive thematic analysis was undertaken on transcribed interviews; key themes and sub-themes were developed using coding and summarised by two researchers, then reviewed by the full research team. Twenty-eight stakeholders were interviewed and three main themes were identified; Key feature of a mHealth intervention, delivering a mHealth intervention, Challenges to development and use. There was widespread agreement across stakeholder groups that an adaptive mHealth PA intervention following stroke would be beneficial to people with stroke, following discharge from acute care. Our consultation supports the development of an adaptive PA programme that addresses specific impairments that can hinder exercise participation after stroke.

Sequential multiple assignment randomised trial to develop an adaptive mobile health intervention to increase physical activity in people poststroke in the community setting in Ireland: TAPAS trial protocol

IntroductionStroke is the second-leading cause of death and disability globally. Participation in physical activity (PA) is a cornerstone of secondary prevention in stroke care. Given the heterogeneous nature of stroke,...

Effects of changing veterinary handling techniques on canine behaviour and physiology Part 2: Behavioural measurements

Abstract Signs of distress in dogs during veterinary visits are often normalised rather than viewed as welfare concerns. Interventions designed to reduce fear during veterinary visits were evaluated to see if they affected dogs’ behaviours compared to dogs without interventions. Twenty-eight dogs were examined at four visits across eight weeks. Dogs were randomised into intervention (distress reduction/adaptive care) and control groups (standard care) and evaluated via the Working Dog Questionnaire – Pet Dog Version (WDQ-Pet). At visit 1 (baseline) all dogs received the control protocol. Homework was assigned following visit 1 to practice collaborative examination (intervention) or to pet the dog (control) for the same allotted time. At each visit, behaviours were scored (clinical stress score) via video and in-person observations when dogs entered the hospital, stepped onto a scale to be weighed, entered the exam room, at the beginning and end of examination, and after venipuncture. There were no differences between groups at visit 1, or across visits entering the hospital or exam room. At visit 4, intervention scores either decreased or remained low when weighed, and at the beginning and end of the physical exam. Control scores were significantly higher than the intervention scores during these periods. Reduced clinical stress scores indicate intervention dogs had improved care experience compared to the control. The study results highlight the value of applying simple and adaptable interventions, ultimately leading to improved animal care and welfare.

Inherently spatial: data and analytical insights for the identification of forest socio-ecological hotspots

We draw insights regarding intricacies with spatially explicit data and analyses when studying the vulnerability of forest socio-ecological systems to disruptive abiotic and biotic factors. Common issues associated with data include location precision, spatial delimitation, methodological comparability, and measurement consistency. Spatial data analyses are challenged by issues of interpolation and extrapolation, inferences using data at different spatial scales, and assessment of disruption impacts at detectable spatial scales. The inextricable empirical nature of spatial data and analyses requires carefully conducting and disclosing the sensitivity of findings, and including robustness tests to openly inform decision-makers on issues of uncertainty associated with possible interventions. These considerations might be central to identifying forest socio-ecological hotspots as forest-dominated geographic areas encompassing social and ecological systems vulnerable to disruptions caused by abiotic and biotic factors, but where risks to human wellbeing may be considerably reduced through adaptive interventions.

System Identification of User Engagement in mHealth Behavioral Interventions

Digital behavior change interventions (DBCIs) such as “just-in-time” adaptive interventions (JITAIs) have demonstrated efficacy for increasing physical activity behavior. However, the effectiveness of these interventions is heavily dependent upon user engagement. Despite the inherent dynamic nature of engagement, as it varies over time based on an individual’s changing environment, context, and psychological state, the current understanding of engagement primarily comes from static snapshots of the behavior. The availability of intensive longitudinal data from JITAIs provides a unique opportunity to build and test dynamic models of behavior change from a process systems lens, relying on prediction-error methods from system identification. However, data missingness is a significant practical consideration in this process. Therefore, in this work we address missingness using a Bayesian imputation approach, which we evaluate using data from the HeartSteps II JITAI. Ultimately, the methods presented support the discovery of key factors that impact engagement behavior over time and can play an important role in the development of large-scale personalized interventions.

Emotion-Semantic-Aware Dual Contrastive Learning for Epistemic Emotion Identification of Learner-Generated Reviews in MOOCs.

Identifying the epistemic emotions of learner-generated reviews in massive open online courses (MOOCs) can help instructors provide adaptive guidance and interventions for learners. The epistemic emotion identification task is a fine-grained identification task that contains multiple categories of emotions arising during the learning process. Previous studies only consider emotional or semantic information within the review texts alone, which leads to insufficient feature representation. In addition, some categories of epistemic emotions are ambiguously distributed in feature space, making them hard to be distinguished. In this article, we present an emotion-semantic-aware dual contrastive learning (ES-DCL) approach to tackle these issues. In order to learn sufficient feature representation, implicit semantic features and human-interpretable emotional features are, respectively, extracted from two different views to form complementary emotional-semantic features. On this basis, by leveraging the experience of domain experts and the input emotional-semantic features, two types of contrastive losses (label contrastive loss and feature contrastive loss) are formulated. They are designed to train the discriminative distribution of emotional-semantic features in the sample space and to solve the anisotropy problem between different categories of epistemic emotions. The proposed ES-DCL is compared with 11 other baseline models on four different disciplinary MOOCs review datasets. Extensive experimental results show that our approach improves the performance of epistemic emotion identification, and significantly outperforms state-of-the-art deep learning-based methods in learning more discriminative sentence representations.

An Adaptive Pacing Intervention for Adults Living With Long COVID: A Narrative Study of Patient Experiences of Using the PaceMe app.

Adaptive pacing (AP) is a self-management technique which seeks to balance energy and rest in individuals with chronic health conditions. Adaptive pacing can help people with myalgic encephalomyelitis/chronic fatigue syndrome learn how to manage their energy expenditure thereby reducing their risk of post-exertional malaise (PEM) and other symptoms. Given some symptom similarity, AP also has rehabilitation potential for people experiencing disability from long COVID. The purpose of this study was to explore patient experiences of an AP intervention (the "PaceMe" app) to determine its value for individuals experiencing long COVID. Twenty-five participants each took part in two narrative interviews (at intervention start point and at 3-6 months). Data were analyzed using narrative thematic analysis. Our analysis identified 4 themes relating to key benefits of the PaceMe app: (1) PEM management, (2) Support, (3) Validation, and (4) Control and Agency. By illuminating the critical facts and centring patient voices, these findings contribute a better understanding of the experiences and needs of those with long COVID and highlight the value of a digital health intervention as a vital component of rehabilitation.

Risk and Sustainable tourism resilience in the Post Economic Crisis and COVID-19 pandemic period

The study aims to explore the resilience and adaptation of the tourism sector during economic and health crises, with a focus on specific events and their impact. The main objective is to contribute with valuable insights to the ongoing discourse on crisis management and sustainable practices within the tourism industry. Thus, it presents the dynamics of the tourism sector's resilience and adaptability amidst challenges, spotlighting the repercussions of the 2008–2012 economic crisis and the unprecedented COVID-19 pandemic. Through a theoretical analysis of tourism risk, the research asserts the industry's susceptibility to exogenous hazards, emphasizing the multi-level risks spanning from individual businesses to the broader tourism landscape. The study shows the distinct characteristics that differentiate the 2008–2012 economic-financial crisis, highlighting globalization's intricate interdependencies, and the consequential impact on public finances. Amidst these challenges, the tourism sector faced a notable reduction in tourist numbers, nights spent in accommodations, and a fluctuating percentage of international tourists. However, a detailed examination reveals the industry's resilience strategies during the economic crisis, as tourists, while adjusting behaviour, continued to engage in travel with altered preferences, prompting the sector to adapt and survive. Shifting focus to the COVID-19 pandemic, the study unfolds a sector witnessing unprecedented challenges ranging from business closures and mass unemployment to financial losses. The global decrease in tourist arrivals echoes the profound impact of travel restrictions and the obligatory vaccination certificate. Analyzing the resilience of the tourism sector during the pandemic, the study explores the aftermath of decreased visitor numbers, a substantial hit to the sector's economic contribution, and the liquidation of numerous small and medium-sized enterprises. The article also sheds light on anti-crisis measures and strategies adopted during the pandemic, including EU funding initiatives and policy recommendations. Throughout, the study implicitly underlines the importance of adaptive strategies and policy interventions for sustained resilience in the tourism sector, providing valuable insights for policymakers, industry practitioners, and researchers dealing with challenges imposed by economic and health crises.

Urban Acupuncture as Recovery Approach to Improving the Liveability of Neighbourhoods Affected by Beirut Port Explosion

Abstract Following the port explosion in 2020, Beirut witnessed an unprecedented crisis, revealing the incompetence of its development plans and promoting the emergence of new approaches to improve liveability in damaged areas. Currently, urban planning has shifted from the traditional focus on large-scale interventions to the focus on flexible and adaptive small-scale interventions, especially in financially weak areas. Inspired by traditional Chinese medicine, urban acupuncture (UA) exemplifies this shift through localized interventions aimed at revitalizing cities by simulating their energy. This paper aims to investigate the potential of implementing UA as a recovery approach in Rmeil neighbourhood, heavily impacted by the explosion, to improve its liveability. By analysing and comparing two international examples, the paper highlights the interventions used to activate the urban context. It finally proposes six strategic interventions and ten key actions tailored to achieve social, economic, and environmental results in Rmeil with less effort. This paper represents the foundation for implementing urban acupuncture on a broader level in Beirut and other spots in Lebanon.