Critical Health Situation Research Articles

Intention to use telemedicine services during a health crisis: A motivation‐opportunity‐ability theory approach

AbstractTelemedicine, despite its longstanding presence, has emerged as a valuable resource amidst health crises. Yet, research on individuals' willingness to embrace telemedicine in such circumstances remains scarce. This article employs the Motivation–Opportunity–Ability theory to construct a novel framework for investigating how motivational, opportunity‐related, and ability‐related factors influence individuals' intention to use telemedicine during a health crisis. A sample of 468 respondents from Indonesia participated in an online survey. The data were analyzed using covariance‐based structural equation modeling and the Hayes PROCESS macro. The findings revealed that contamination avoidance, telemedicine usability, and privacy concerns significantly influence the intention to use telemedicine services. Moreover, the findings also confirmed the moderated moderating effect of e‐health literacy and technology optimism on the relationship between contamination avoidance and intention to use telemedicine services. By deepening our understanding of the factors shaping individuals' intention to use telemedicine services, this study makes valuable academic contributions to the field of telemedicine adoption literature. Additionally, it provides practical insights for telemedicine providers aiming to enhance individuals' intention to use telemedicine services during critical health situations.

The Effect of Boko Haram Insurgency on Health and Nutrition among the Residents of Bolori 2 of Maiduguri Metropolitan Council of Borno State, Nigeria.

The Effect of Boko Haram Insurgency on Health and Nutrition among the Residents of Bolori 2 of Maiduguri Metropolitan Council of Borno State, Nigeria.

Prevalence and Factors Associated with Puerperal Sepsis among Women Attending the Postnatal Ward at Fort Portal Regional Referral Hospital

Puerperal sepsis is a widespread issue globally, causing maternal health complications across hospital maternity wards. Typically, around 4-6% of hospital-admitted patients within maternity wards contract clinical infections, including sepsis. The overarching aim of this study was to identify the contributing factors to puerperal sepsis among postnatal mothers in the maternity ward at Fort Portal Regional Referral Hospital. Conducted as a cross-sectional investigation, questionnaires were distributed to mothers in the maternity ward for selfcompletion. All postnatal mothers who delivered at Fort Portal Regional Referral Hospital and developed puerperal sepsis were included in the study. Quantitative data was manually analyzed using Microsoft Excel, summarized through averages and percentages, and presented via tables, graphs, and pie charts. The study uncovered that the prevalence of puerperal sepsis at Fort Portal Regional Referral Hospital stands at 22.4%. Key findings include that the majority of respondents were multiparous (80.6%), with 49.4% delivering at the hospital, 41.7% at home, and 8.8% with the assistance of a traditional birth attendant. Furthermore, 64.7% had spontaneous vaginal deliveries, while 35.3% underwent cesarean sections. Additionally, 58.8% were assisted by doctors, and 41.2% were assisted by midwives/nurses. Of note, 57.6% experienced normal labor duration, while 42.4% endured prolonged labor, and 12.9% encountered antepartum hemorrhage. The prevalence of puerperal sepsis was strongly associated with factors such as parity, mode of delivery, place of delivery, duration of labor, and concurrent medical conditions like diabetes, hypertension, and HIV infection. Recommendations stemming from these findings emphasize collaborative efforts between the government (particularly the Ministry of Health) and hospitals to alleviate costs for mothers during critical health situations. Moreover, aseptic techniques during delivery assistance should be rigorously practiced to mitigate the incidence of puerperal sepsis. Keywords: Puerperal sepsis, Clinical infection, Patients, Postnatal mothers, Caesarean section, Vaginal delivery.

Impact of COVID-19 on cancer care pathways in a comprehensive cancer center in northern Italy.

The COVID-19 pandemic burdened health care systems worldwide. Health services were reorganized with the dual purpose of ensuring the most adequate continuity of care and, simultaneously, the safety of patients and health professionals. The provision of care to patients within cancer care pathways (cCPs) was not touched by such reorganization. We investigated whether the quality of care provided by a local comprehensive cancer center has been maintained using cCP indicators. A retrospective single-cancer center study was conducted on eleven cCPs from 2019 to 2021 by comparing three timeliness indicators, five care indicators and three outcome indicators yearly calculated on incident cases. Comparisons of indicators between 2019 and 2020, and 2019 and 2021, were performed to assess the performance of cCP function during the pandemic. Indicators displayed heterogeneous significant changes attributed to all cCPs over the study period, affecting eight (72%), seven (63%) and ten (91%) out of eleven cCPs in the comparison between 2019 and 2020, 2020 and 2021, and 2019 and 2021, respectively. The most relevant changes were attributed to a negative increase in time-to-treatment surgery-related indicators and to a positive increase in the number of cases discussed by cCP team members. No variations were found attributed to outcome indicators. Significant changes did not account for clinical relevance once discussed by cCP managers and team members. Our experience demonstrated that the CP model constitutes an appropriate tool for providing high levels of quality care, even in the most critical health situations.

Role of a Qualified Physician and Health Behavior in Effective Treatment of Cervical Spondylotic Myelopathy.

Objectives: This research investigated the impact of having a qualified physician on improving disease awareness and effective treatment for cervical spondylotic myelopathy. Previous studies have observed that patients with cervical spondylotic myelopathy are less satisfied with their treatment and medical facilities. This study hence aimed to investigate the role of a qualified physician and the moderating influence of health behavior between disease awareness and effective treatment for cervical spondylotic myelopathy. Methods: The primary data was collected from 144 cervical spondylotic myelopathy patients admitted in Meram Medical Faculty Hospital. A questionnaire on 5-point Likert scale was developed, whose items were checked for validity and reliability. The study adopted a cross- sectional approach, by conducting a normality test, correlation measurement of all variables like disease awareness, qualified physician and health behavior, and a regression analysis to explore the impact of independent variables on the dependent variable, and to test the hypotheses of the study. Results: The results of this research revealed that patients of cervical spondylotic myelopathy would get effective treatment when their health behavior is positive and when they have an awareness of the critical health situation. Conclusion: This research contributed a framework significantly to the research gap. It demonstrated the extraordinary practical and theoretical implications related to cervical spondylotic myelopathy. Future directions are also recommended by highlighting the limitations of this research, in order to continue to contribute to the effective treatment of cervical spondylotic myelopathy patients.

Concerted Model of Healthcare for Awá Indigenous of Nariño, Colombia.

Indigenous communities in Colombia are facing a critical health situation; alternative health care models based on the vision of the communities themselves are needed. The objective of this research was to create a health care model that decreases health inequities for the Indigenous Awá population of Nariño, Colombia. This study was guided by the paradigm of community-based participatory action research; the process was carried out in 2015 and 2016. The proposed Intercultural Health Care Model is essentially based on health promotion, disease prevention, community empowerment, social participation in health, decentralized health care and coordination between the two medicines (traditional and allopathic). Strategies such as those reported herein, with concerted efforts rather than imposition, maintain human rights and respect for the sovereignty and autonomy of Indigenous people.

Autonomous Tool for Monitoring Multi-Morbidity Health Conditions in UAE and India.

Multi-morbidity is the presence of two or more long-term health conditions, including defined physical or mental health conditions, such as diabetes or schizophrenia. One of the regular and critical health cases is an elderly person with a multi-morbid health condition and special complications who lives alone. These patients are typically not familiar with advanced Information and Communications Technology (ICT), but they are comfortable using smart devices such as wearable watches and mobile phones. The use of ICT improves medical quality, promotes patient security and data security, lowers operational and administrative costs, and gives the people in charge to make informed decisions. Additionally, the use of ICT in healthcare practices greatly reduces human errors, enhances clinical outcomes, ramps up care coordination, boosts practice efficiencies, and helps in collecting data over time. The proposed research concept provides a natural technique to implement preventive health care innovative solutions since several health sensors are embedded in devices that autonomously monitor the patients' health conditions in real-time. This enhances the elder's limited ability to predict and respond to critical health situations. Autonomous monitoring can alert doctors and patients themselves of unexpected health conditions. Real-time monitoring, modeling, and predicting health conditions can trigger swift responses by doctors and health officials in case of emergencies. This study will use data science to stimulate discoveries and breakthroughs in the United Arab Emirates (UAE) and India, which will then be reproduced in other world areas to create major gains in health for people, communities, and populations.

Cities 2021 Preface

CITIES International Conference is an annual international conference continually held by the Urban and Planning Regional Department of Institut Teknologi Sepuluh Nopember (ITS Surabaya). With its debut conference in 2005, CITIES was and has been designated as a vessel for researchers, academics, and practitioners to present, disseminate, and discuss research results and scientific analyses in urban and regional research areas. Through the dedicated endeavours of every party, CITIES, which was once national-scoped in its early years, has transformed into an international-scoped conference since 2013. Thus, the diversity of speakers and participants has expanded to worldwide audience, be it from the Asian, European, Australian, or American Continent. CITIES International Conference 2021 will bring the theme “Post-COVID Cities: A Paradigm Shift?”. This theme was chosen due to the fact that urban areas become the most susceptible towards the transmission of SARS-CoV-2. The COVID-19 pandemic has brought forth both various impacts to urban development which are classified into four major themes: environmental quality, socio-economic structure, governance, and urban transportation & design. Such rapid and huge shifts also encourage researchers in the planning field to reflect and simultaneously question fundamental points, such as the efficacy of planning approaches, roles, functions, and models so long adopted to respond and manage critical health situations due to the COVID-19 pandemic. The urban medium no longer facilitates planning and management within the constraints of business as usual. There is an emergence of necessity that cities be smarter, more inclusive, resilient, and sustainable. With said necessity, CITIES International Conference 2021 is designated to become a meeting place for stakeholders, be it academia, researchers, practitioners, and bureaucrats within and beyond national boundaries, to disseminate research results, practical experiences in local, national, and global levels, as wells as share insights and recommendations regarding post-COVID-19 pandemic plans and management. CITIES International Conference 2021 was held virtually using the zoom meeting platform due to COVID-19 outbreaks and travel restriction due to the high contamination number. CITIES International Conference 2021 was held on two days, on 20th October 2021, comprising keynote speeches and plenary sessions, and 21st October 2021, comprising panel discussion sessions. List of Sponsor Funding Acknowledgements, List Of Committees, Conference Photographs are available in this pdf.

SARS-COV-2 – the pandemic of the XXI century, clinical manifestations – neurological implications

In December 2019, in Wuhan, China, the first cases of infection with SARS-CoV 2 responsible for COVID-19 disease were identified. SARS-CoV 2 was declared a pandemic on March 11, 2020, and since then has attracted the medical world's attention. The threat to humans' health that this emerging pandemic could leave raises awareness on the importance of understanding the mechanisms that underlie the developing conditions. The epidemiology, clinical picture, and pathogenesis of COVID-19 show that this virus presents new strategies to overcome the past defensive medicine. While all the current data has focused on the pulmonary and cardiovascular manifestations, little has been written about the neurological implications of the disease. This review updates new clinical aspects that SARS-CoV 2 expresses in humans by focusing primarily on neurological manifestations. The damage to the nervous system became more apparent - anosmia, ageusia, polyneuritis, meningitis, meningoencephalitis, stroke, acute necrotizing encephalopathy. Oxygen therapy is vital for those in critical health situations. Finally, prevention is the most important element in breaking the epidemiological chain.

Multi-Model Medical Image Segmentation Using Multi-Stage Generative Adversarial Networks

Image segmentation is a challenging problem in medical applications. Medical imaging has become an integral part of machine learning research, as it enables inspecting interior human body with no surgical intervention. Much research has been conducted to study brain segmentation. However, prior studies usually employ one-stage models to segment brain tissues, which could lead to a significant information loss. In this paper, we propose a multi-stage Generative Adversarial Network (<inline-formula> <tex-math notation="LaTeX">$GAN$ </tex-math></inline-formula>) model to resolve existing issues of one-stage models. To do this, we apply a <i>coarse-to-fine</i> method to improve brain segmentation using a multi-stage <inline-formula> <tex-math notation="LaTeX">$GAN$ </tex-math></inline-formula>. In the first stage, our model generates a <i>coarse</i> outline for both the background and brain tissues. Then, in the second stage, the model generates a <i>refine</i> outline for the white matter (<inline-formula> <tex-math notation="LaTeX">$WM$ </tex-math></inline-formula>), gray matter (<inline-formula> <tex-math notation="LaTeX">$GM$ </tex-math></inline-formula>), and cerebrospinal fluid (<inline-formula> <tex-math notation="LaTeX">$CSF$ </tex-math></inline-formula>). We perform a fusion of the <i>coarse</i> and <i>refine</i> outlines to achieve high results. Despite using very limited data, we obtain an improved Dice Coefficient (DC) accuracy of up to 5&#x0025; compared to one-stage models. We conclude that our model is more efficient and accurate in practice for brain segmentation of both infants and adults. In addition, we observe that our multi-stage model is 2.69&#x2013;13.93 minutes faster than prior models. Moreover, our multi-stage model achieves higher performance with only a few-shot learning, in which only limited labeled data is available. Therefore, for medical images, our solution is applicable to a wide range of image segmentation applications for which convolution neural networks and one-stage methods have failed. This helps to advance the process of analyzing brain images, thus providing many advantages to the healthcare system, especially in critical health situations where urgent intervention is needed.

The Effect of Nursing Students' Self-Efficacy on Patient-Centered Communication During the COVID-19 Pandemic: The Mediating Effect of Learning Burnout.

Background: The 2019 coronavirus disease (COVID-19) outbreak has put the global health system under the spotlight. As part of the medical workforce, nurses play an important role in interacting with and caring for patients; hence, patient-centered communication (PCC) has been emphasized in nursing education. Thus, it is worth investigating how future nurses perceive PCC and PCC-related factors under the special circumstances of COVID-19. For this purpose, the present study analyzed the mechanisms underlying the association between self-efficacy and nurse–patient communication tendency through learning burnout among nursing students during the COVID-19 pandemic.Methods: The general self-efficacy questionnaire, college students' learning burnout scale, and doctor–patient communication tendency scale were used to survey 2,231 nursing students in higher vocational medical colleges at the onset of the COVID-19 pandemic.Results: General self-efficacy can directly negatively correlate with the degree of nursing students' overall nurse–patient communication, including caring, sharing, and health promotion. Dejection from learning burnout partially mediated the relationships between self-efficacy and caring and between self-efficacy and sharing; it fully mediated the relationship between self-efficacy and health promotion. Reduced personal accomplishment partially mediated between self-efficacy and caring, while it fully mediated between self-efficacy and health promotion; however, it did not play a role in the sharing model.Conclusion: Self-efficacy influences nurse–patient communication through learning burnout. Specifically, dejection and reduced personal accomplishment—two aspects of learning burnout—may compromise nursing students' willingness to engage in PCC. Thus, the importance of PCC, especially during critical health situations such as pandemics, should be emphasized further in future nursing education.

Design of a secured telehealth system based on multiple biosignals diagnosis and classification for IoT application

AbstractThe aim of this article is to design a new telehealth system with secured wireless transmission and classification of multiple biosignals using e‐Health sensors platform and Xbee modules with Arduino Uno and Raspberry Pi as acquisition and processing units, respectively. The collected data, such as temperature, airflow, position, Galvanic skin response and oxygen in the blood can be evaluated in order to monitor patient health state using threshold detection. The prediction of the cardiac state based on automatic identification of arrhythmias is validated by the classification of ElectroCardioGram (ECG) signals using Artificial Intelligence (AI) by exploiting TensorFlow and Keras tools. Different AI algorithms and a combination with different Machine Learning (ML) basing to transfer learning approach are tested. These algorithms include Artificial Neural Network (ANN), Convolutional Neural Network (CNN), Support Vector Machine (SVM), K‐Nearest Neighbour (KNN) and Random Forest (RF). At first, ANN and CNN are used to classify ECG‐scalogram images using softmax, then the used CNN model (VGG16) is employed to extract features and pass them to other traditional classifiers (SVM, KNN and RF) allowing to evaluate and select the best classifier, such that the ECG signal can be classified into four categories namely Normal Sinus Rhythm (NSR), Atrial Fibrillation (AF), Congestive Heart Failure (CHF) and other cardiac arrhythmia (ARR). The proposed method has been evaluated using real recorded signals and four PhysioNet databases. A Graphical User Interface (GUI) has been designed with C# under Visual Studio IDE allowing to display the results using personal computer (PC) or a network linked phone, which makes it possible to transfer the diagnosis with the prediction results to a remote clinic control room as Internet of Things (IoT) system application. The best classification accuracy of 99.56% is attained, confirming that the designed system allows a good trade‐off between low cost and performances in addition, it is easy to use with quick access to multiple biosignals. It has improved vital characteristics monitoring and diagnosis services quality under a robust secured wireless transmission using lightweight chaos‐based algorithm, thus preventing loss of life during critical health situations.

SARS-CoV-2 outbreak in Iran: The dynamics of the epidemic and evidence on two independent introductions.

The SARS‐CoV‐2 virus has been rapidly spreading globally since December 2019, triggering a pandemic, soon after its emergence. While Iran was among the first countries confronted with rapid spread of virus in February 2020, no real‐time SARS‐CoV‐2 whole‐genome tracking in early phase of outbreak was performed in the country. To address this issue, we provided 50 whole‐genome sequences of viral isolates ascertained from different geographical locations in Iran during March–July 2020. The corresponding analysis on origins, transmission dynamics and genetic diversity of SARS‐CoV‐2 virus, represented at least two introductions of the virus into the country, constructing two major clusters defined as B.4 and B.1*. The first entry of the virus might have occurred around very late 2019/early 2020, as suggested by the time to the most recent common ancestor, followed by a rapid community transmission that led to dominancy of B.4 lineage in early epidemic till the end of June. Gradually, reduction in dominancy of B.4 occurred possibly as a result of other entries of the virus, followed by surge of B.1* lineages, as of mid‐May. Remarkably, variation tracking of the virus indicated the increase in frequency of D614G mutation, along with B.1* lineages, which showed continuity till October 2020. The increase in frequency of D614G mutation and B.1* lineages from mid‐May onwards predicts a rapid viral transmission that may push the country into a critical health situation followed by a considerable change in composition of viral lineages circulating in the country.

The belief in health in the adoption of COVID-19 prevention and control measures.

Reflect, in the light of the Health Belief Model, on the adoption of behavioral measures in the context of COVID-19. Theoretical-reflective essay, based on the Health Belief Model, to reflect on adherence to preventive behaviors in the pandemic of COVID-19. Adherence to preventive behaviors is strongly influenced by socioeconomic, territorial, political and individual factors in the face of critical health situations. In addition, the spread of false news modulates the thinking and execution of behavioral actions in the population. It is necessary to understand the importance of health communication processes and the use of tools aimed at responsible human behavior and engaged in the adoption of a preventive posture.

Wireless Body Area Networks Routing Protocols: A Review

Wireless Body Area Networks (WBANs) are designed for monitoring the patient’s conditions and assist them in critical health situation. Tiny size wireless sensors sense the data related to patient health. Further, the sensed data sends to base station for further process. The base station sends the data to the nearest sink node or to the nearest medical center or hospital. In order to complete this entire process, wireless sensors need efficient routing without any error or delay. The routing protocols have been suffered with various challenges and issues which are related to the routing and energy issues. This paper provides a comprehensive survey of important existing routing protocols for WBANs. Paper also discusses the protocols strengths, limitations with their critical analysis.

Decisions in complex clinical situations: Prevalence and factors associated in general public

Many studies have focused on advanced directives. However, the type of treatment that citizens would choose in critical health situations and whether their decision varies with their sociodemographic characteristics and their experiences of life both within and outside the family context, are unknown. This study analyzes the factors associated with choosing or refusing life support treatment in hypothetical situations of differing clinical complexity. This transversal descriptive study was carried out by questionnaires given to 1051 participants from primary care centres. The Life Support Preferences Questionnaire (LSPQ) used to assess preferences of life-sustaining treatment, describes six scenarios with different prognoses. Analysis of the sociodemographic characteristics and life experiences of the subjects led to the following findings. In situations of very severe prognosis, treatment is mostly rejected. When there is chance of recovery, treatment is mostly accepted, especially in the least aggressive cases and when deciding for another person. A greater propensity to reject treatment was observed among subjects over 55 years, those in poor health and those who had observed a terminal illness in a family member. Practising Catholics are more likely to accept treatment in all medical situations described. Preferences for life support treatment are linked to sociodemographic characteristics and life experiences of patients. Physicians should bear in mind these characteristics when confronted with critical clinical situations, involving difficult decisions.

Dying in the intensive care unit

Modern intensive care is responsible both for curative interventions in critical health situations and palliative terminal care for the dying ICU patient. By applying an integrated ethics approach, this article examines organizational and cultural factors shaping good terminal care in the ICU. Starting with a reflection on what it means to be human, ethical goals for care of the dying are formulated. Among them, the article focuses on practices ensuring a dignified dying process, on the structured engagement of patients' families, on respecting cultural and spiritual values, and on a clinical pathway for terminal care as an institutional framework. In conclusion, it becomes evident that good terminal care in the ICU not only depends on ethically sound decisions on withholding or withdrawing medical interventions but also on organizational and cultural aspects which must be acknowledged and shaped.

Differences between Italian and immigrant female citizens’ hospitalizations related to obstetrical and gynecological diseases in the province of Ferrara, Italy

Introduction In the recent years, the province of Ferrara, in the Italian Northeast has been characterized by the phenomenon of massive immigration. The aim was to study hospital admissions related to the immigrant female population and its implications. Materials and Methods The Local Healthcare Unit of the National Health Service provided data related to hospital admissions between 01/01/2006 to 31/12/2006. Results and Conclusions On 53699 admissions of female subjects, 2656 were related to immigrants. A total of 1509 admissions were obstetrical or gynecological hospitalizations. The high number of DRGs representative of spontaneous abortions and voluntary interruptions of pregnancy may be an expression of social problem of some sections of the immigrant people community. The dissemination of information on the existence of social assistance programs is important. This can prevent the occurrence of critical health situations, especially during pregnancy and childbirth. BACKGROUND AND AIM OF THE WORK The territory of the province of Ferrara, in north-eastern Italy has been in recent years characterized by the phenomenon of mass migration of people from countries especially outside the European Union [1]. This led to differing health needs compared to the Italian population one. This could be a result from the differences in demographic characteristics of the two populations, such as the lower mean age of the immigrant population. The present work is aimed to identify areas of possible interventions allowing optimization of resources in the light of possible changes over time. MATERIALS AND METHODS The Local Healthcare Unit (LHU) of Ferrara provided data related to the hospital admissions from 01/01/2006 to 31/12/2006 granted to immigrant and Italian citizens. The database included nationality, date of birth, residence. The gender was inferred from the tax code. From a health-related point of view, the database showed data related to the type of access, the type of admission (ordinary or day hospital (DH)), the days of hospitalization, the hospital facility, the DRG (Version 19). The facilities included those directly controlled by LHU, the University Hospital, private structures, and extra-provincial structures. GynecologicalDRG included those from 353 to 369 included and obstetrical-DRG included those from 370 to 384. Access 2003 [2] and Excel 2003 [3] were used to manage and analyse data.

Preferencias de tratamiento de soporte vital en condiciones críticas de salud

ObjectiveTo explore citizens' treatment preferences in critical health situations. MethodWe performed a cross-sectional study through a questionnaire administered to 306 participants, randomly selected from nursing consultations, cultural centers, nursing homes and the university. Treatment preferences in critical health situations were measured through the Life Support Preferences Questionnaire (LSPQ). A descriptive bivariate and multivariate analysis was performed. ResultsThe mean age of participants was 39.28 years (SD: 24.52), 37% had primary school or no education, and 29.1% were male. Age was inversely correlated with accepting treatments; thus acceptance of life support measures was lower among participants older than 55 years than among the youngest participants and was also lower among those with a lower educational level than those with a higher educational level. No differences were found between men and women. In serious diseases with no possibility of recovery, all age groups rejected treatment. When there was the potential for recovery or for non-invasive treatments, participants aged 21 years old or older would prefer to be treated. ConclusionThere is wide variability among the population when accepting or rejecting life support treatment. The view that treatment should be accepted at all costs is inappropriate. Disseminating knowledge of advance directives and the use of these documents is recommended as the most effective way to respect patients' wishes when they are unable to express themselves.

Institutional Deficiencies and the Rationing of Access to Health Services in Developing Countries: Markers and Challenges (Carences institutionnelles et rationnement de l'acces a la sante dans les pays en developpement: Reperes et enjeux)

The economic analysis of the links between institutions and development is crucial with regard to the socio-economic and human challenges linked to the health situation and the conditions of the access to health services in developing countries. This paper tries to put emphasis on the major role of institutional deficiencies in explaining the persistence of the critical health situation of populations in disadvantaged countries. First, we analyze the causes and features of internal deficiencies within the developing countries themselves as well as those characterizing donator countries and multilateral organizations. We then examine the challenges implied by the remedy of these deficiencies, and draw some possible paths for the emergence and the sustainability of the institutional changes that could be envisaged.