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Tourism consumption as a typical representative of service consumption, has strong comprehensiveness and driving force, continuously expanding new consumption upgrade space. In the context of the digital economy, the development of the mobile internet has opened up new opportunities for the tourism industry acting as an important factor influencing the consumer behaviour of the residents. Based on 9007 resident survey data from the China General Social Survey (CGSS) in 2017, this paper explores the relationship between Internet use, access to information and residents' travel consumption behavior by means of probit model and mediating effect model. First, according to the findings, Internet use has a positive impact on residents' travel consumption behavior, increasing residents' tourism expenditure. Second, the mechanism suggests that access to information plays a partially mediating role between Internet use and travel consumption behavior. Third, further analysis revealed that, for the retired population, the more frequently they use the Internet, the more likely they are to spend on travel. Compared to those with lower incomes, those with higher incomes will spend less on travel after retirement. With this in mind, in order to promote residents' tourism consumption, speed and fee reduction should be continuously promoted, urban and rural information infrastructure should be strengthened, and accessibility of tourism information for residents should be improved. At the same time, there is a need to innovate the way tourism products are promoted, improve the types of tourism products and launch diversified tourism products., Competing Interests: NO authors have competing interests Enter: The authors have declared that no competing interests exist., (Copyright: © 2024 Lei, Yang. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Car-sharing is a travel mode that can serve as an alternative to private cars, helping to reduce urban pollution. However, currently, there is a low willingness among travelers to use car-sharing, which is reflected in both low market penetration and user frequency. Therefore, it is essential for the government to encourage the use of car-sharing by providing subsidies. To better encourage the usage of car-sharing, this paper applies a two-fold evolutionary game model involving travelers and the government to explore the impact of subsidies on travelers' choices, and the factors that could affect the subsidies' efficiency. A simulation, using data from Beijing, was conducted to determine the implications of subsidy policies. The results show that a mileage-based subsidy and a fixed subsidy are applicable to travel of high and low mileages respectively, and under both subsidy modes, subsidies for trips with short duration or short pick-up and return time are more effective. Furthermore, we find that the efficiency of subsidies increases as the scale of car-sharing users, demand elasticity, or total number of travelers increases. Additionally, the subsidy levels should be lower than the environmental benefits of car-sharing but higher than the difference in travel costs between private cars and car-sharing. Future work will involve other game players such as car-sharing operators in order to draw deeper conclusions, and will involve the collection of data from more countries and cities to develop the robustness of the conclusions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The study examined the determinants that affect tourism receipts in Thailand. To this end, quarterly data from eight main provinces of Thailand from the period 2015-2019 were used and constituted a repeated measures design. Accordingly, a generalized linear mixed model was applied for developing two different random intercept models by treating 1) province, and 2) a combination of province and calendar quarter as cluster-specific effects. It was found that determinants that increased tourism receipts were the number of visitors, the average cost per day, the length of stay of visitors, the presence of low-cost airlines, and a relatively low offence rate. Moreover, an increase in the number of visitors in the fourth quarter produced a higher amount of additional receipts as compared to a similar increase in the first quarter. Specifically, for Thailand attracting high-spending tourists and extending tourist visas for more than 30 days is recommended. Beyond Thailand, uncovering interaction effects as described above may help tourism agencies to focus their limited resources on the determinants that matter., Competing Interests: The authors declare that they have no conflict of interest., (Copyright: © 2024 Khemthong et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

To stimulate the regional tourism economy, local governments often seek to increase the number of 5A-rated tourist attractions. However, there have been few analyses examining the economic benefits and influence mechanisms of 5A-rated attraction selection. Using the quality signaling theory and data from 282 prefecture-level cities spanning 2002 to 2019, this study examines the impact of 5A-rated attraction selection on the local tourism economy with the difference-in-differences method. This study's results demonstrate that the selection of 5A-rated attractions significantly contributes to the growth of the local tourism economy. The robustness test results confirm the validity of this conclusion. A mechanism analysis reveals that 5A-rated attractions positively impact the tourism economy via investments in infrastructure, popularization of informatization, and increased external openness. Furthermore, the study suggests that the effect of 5A-rated attractions is more pronounced in economically underdeveloped regions and low-level cities. The results of this study contribute to the sustainable development of China's tourism economy and may provide guidance for the establishment of tourism evaluation systems in other international locations in order to foster economic growth., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Community-based mask wearing has been shown to reduce the transmission of SARS-CoV-2. However, few studies have conducted an economic evaluation of mask mandates, specifically in public transportation settings. This study evaluated the cost-effectiveness of implementing mask mandates for subway passengers in the United States by evaluating its potential to reduce COVID-19 transmission during subway travel., Materials and Methods: We assessed the health impacts and costs of subway mask mandates compared to mask recommendations based on the number of infections that would occur during subway travel in the U.S. Using a combined box and Wells-Riley infection model, we estimated monthly infections, hospitalizations, and deaths averted under a mask mandate scenario as compared to a mask recommendation scenario. The analysis included costs of implementing mask mandates and COVID-19 treatment from a limited societal perspective. The cost-effectiveness (net cost per averted death) of mandates was estimated for three different periods based on dominant SARS-CoV-2 variants: Alpha, Beta, and Gamma (November 2020 to February 2021); Delta (July to October 2021); and early Omicron (January to March 2022)., Results: Compared with mask recommendations only, mask mandates were cost-effective across all periods, with costs per averted death less than a threshold of $11.4 million (ranging from cost-saving to $3 million per averted death). Additionally, mask mandates were more cost-effective during the early Omicron period than the other two periods and were cost saving in January 2022. Our findings showed that mandates remained cost-effective when accounting for uncertainties in input parameters (e.g., even if mandates only resulted in small increases in mask usage by subway ridership)., Conclusions: The findings highlight the economic value of mask mandates on subways, particularly during high virus transmissibility periods, during the COVID-19 pandemic. This study may inform stakeholders on mask mandate decisions during future outbreaks of novel viral respiratory diseases., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

In the post-epidemic era, the restart of China's inbound tourism is imminent. However, there are gaps in our current understanding of how distance perception dynamically affects inbound tourism in China. In order to understand the past patterns of inbound tourism in China, we mapped the data of 61 countries of origin from 2004 to 2018 into a dynamic expanding gravity model to understand the effects of cultural distance, institutional distance, geographical distance, and economic distance on inbound tourism in China and revealed the dynamic interaction mechanism of non-economic distance perception on inbound tourism in China. Our research results show that cultural distance has a positive impact on China's inbound tourism, while institutional distance has a negative impact. The significant finding is that the dynamic interaction of the above two kinds of perceived distance can still have a positive impact on China's inbound tourism. Its practical significance is that it can counteract the influence of institutional distance by strengthening the cultural distance. Generally speaking, geographical distance and institutional distance restrict China's inbound tourism flow, while cultural distance, economic distance, and interactive perceptual distance promote China's inbound tourism flow., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

An in-depth study of the mechanisms governing the generation, evolution, and regulation of differences in tourism economics holds significant value for the rational utilization of tourism resources and the promotion of synergistic tourism economic development. This study utilizes mathematical statistical analysis and GIS spatial analysis to construct a single indicator measure and a comprehensive indicator measure to analyze tourism-related data in the research area from 2004 to 2019. The main factors influencing the spatial and temporal differences in the tourism economy are analyzed using two methods, namely, multiple linear regression and geodetector. The temporal evolution, overall differences and differences within each city group fluctuate downwards, while the differences between groups fluctuate upwards. Domestic tourism economic differences contribute to over 90% of the overall tourism economic differences. Spatial divergence, the proportion of the tourism economy accounted for by spatial differences is obvious, the comprehensive level of the tourism economy can be divided into five levels. The dominant factors in the formation of the pattern of spatial and temporal differences in the tourism economy are the conditions of tourism resources based on class-A tourist attractions and the level of tourism industry and services based on star hotels and travel agencies. This study addresses the regional imbalance of tourism economic development in city clusters and with the intent of promoting balanced and high-quality development of regional tourism economies., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Telemedicine, a method of healthcare service delivery bridging geographic distances between patients and providers, has gained prominence. This modality is particularly advantageous for outpatient consultations, addressing inherent barriers of travel time and cost., Objective: We aim to describe economical outcomes towards the implementation of a multidisciplinary telemedicine service in a high-complexity hospital in Latin America, from the perspective of patients., Design: A cross-sectional study was conducted, analysing the institutional data obtained over a period of 9 months, between April 2020 and December 2020., Setting: A high-complexity teaching hospital located in Cali, Colombia., Participants: Individuals who received care via telemedicine. The population was categorised into three groups based on their place of residence: Cali, Valle del Cauca excluding Cali and Outside of Valle del Cauca., Outcome Measures: Travel distance, time, fuel and public round-trip cost savings, and potential loss of productivity were estimated from the patient's perspective., Results: A total of 62 258 teleconsultations were analysed. Telemedicine led to a total distance savings of 4 514 903 km, and 132 886 hours. The estimated cost savings were US$680 822 for private transportation and US$1 087 821 for public transportation. Patients in the Outside of Valle del Cauca group experienced an estimated average time savings of 21.2 hours, translating to an average fuel savings of US$149.02 or an average savings of US$156.62 in public transportation costs. Areas with exclusive air access achieved a mean cost savings of US$362.9 per teleconsultation, specifically related to transportation costs., Conclusion: Telemedicine emerges as a powerful tool for achieving substantial travel savings for patients, especially in regions confronting geographical and socioeconomic obstacles. These findings underscore the potential of telemedicine to bridge healthcare accessibility gaps in low-income and middle-income countries, calling for further investment and expansion of telemedicine services in such areas., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Improving travel time prediction for public transit effectively enhances service reliability, optimizes travel structure, and alleviates traffic problems. Its greater time-variance and uncertainty make predictions for short travel times (≤35min) more subject to be influenced by random factors. It requires higher precision and is more complicated than long-term predictions. Effectively extracting and mining real-time, accurate, reliable, and low-cost multi-source data such as GPS, AFC, and IC can provide data support for travel time prediction. Kalman filter model has high accuracy in one-step prediction and can be used to calculate a large amount of data. This paper adopts the Kalman filter as a travel time prediction model for a single bus based on single-line detection: including the travel time prediction model of route (RTM) and the stop dwell time prediction model (DTM); the evaluation criteria and indexes of the models are given. The error analysis of the prediction results is carried out based on AVL data by case study. Results show that under the precondition of multi-source data, the public transportation prediction model can meet the accuracy requirement for travel time prediction and the prediction effect of the whole route is superior to that of the route segment between stops., Competing Interests: The authors have declared that no competing interests exist.

As a typical representative of tourism resources, the spatial distribution of A-level scenic spots has a profound impact on the layout of tourism industry. Scenic spot accessibility is also important for the development of tourism. However, the relationship of regional accessibility and spatial distribution of A-level scenic spots are understudied. The study used quantitative geography and geographic information system spatial analysis methods and analyzed the evolution of spatial distribution and regional accessibility of A-level scenic spots in Guangdong Province from 2001 to 2020. The results present the following: 1. Agglomeration distribution is the main distribution type of A-level scenic spots in Guangdong Province, and the spatial distribution is unbalanced. 2. From 2001 to 2020, the spatial distribution of A-level scenic spots in 21 prefecture-level cities of Guangdong Province has gradually developed from "wide gap" to "relatively reasonable." 3. Distribution density of A-level scenic spots in Guangdong Province has evolved into the main core area of high density. 4. Center of the gravity of A-level scenic spots in Guangdong Province developed from east to west during 2002-2007 and moved to the east after 2007. 5. Accessibility between A-level scenic spots and tourist source areas in Guangdong Province is good, with an evident aggregation phenomenon. This study reveals the spatial distribution evolution law and regional accessibility of A-level scenic spots, which is conducive to healthy, sustainable, and stable development of tourism in Guangdong Province., Competing Interests: The authors have declared that no competing interests exist.

Exploring the spatial pattern of tourism resources and tourism economy is vital to improve the utilization efficiency of tourism resources and promote sustainable tourism development. This research investigated the quantity and types of tourism resources and analyzed the spatial patterns of tourism resources on Hainan Island from the perspectives of spatial variation and spatial association. The spatial and temporal pattern of the number of tourists and tourism revenue during 2010-2019 were further analyzed. The influencing factors of tourism development were explored based on the geographic detector. The results showed that 10425 tourism resources exist on Hainan Island, and the type of buildings and facilities had the largest number of tourism resources. The geological landscape, astronomical phenomena and meteorological landscapes, buildings and facilities, ruins and remains, tourism commodities, and human activities showed significant spatial agglomeration. Domestic tourism was far more developed than inbound tourism in terms of the number of tourists and tourism revenue. However, the spatial difference of tourism resources and tourism economy was apparent on Hainan Island. Factor analysis showed that the quantity of hotels, the proportion of tertiary industry in the GDP, and the regional population were the most influential factors for the distribution of tourism resources, while the density of the road network, the quantity of hotels, the per capita GDP, the proportion of tertiary industry in GDP, the regional population, and the quantity of tourism resources showed obvious influences on the tourism economy of Hainan Island. Interactions of the factors mainly fell into three types: synergistic increases, single factor weakening, and nonlinear weakening. It is suggested that the local government should fully exploit diversity types of tourism resources on Hainan Island to attract more tourists and improve the tourism revenue; improving the inbound tourism, and to strengthen the construction of road network on Hainan Island., Competing Interests: The authors have declared that no competing interests exist.

While there has been much speculation on how the pandemic has affected work location patterns and home location choices, there is sparse evidence regarding the impacts that COVID-19 has had on amenity visits in American cities, which typically constitute over half of all urban trips. Using aggregate app-based GPS positioning data from smartphone users, this study traces the changes in amenity visits in Somerville, MA from January 2019 to December 2020, describing how visits to particular types of amenities have changed as a result of business closures during the public health emergency. Has the pandemic fundamentally shifted amenity-oriented travel behavior or is consumer behavior returning to pre-pandemic trends? To address this question, we calibrate discrete choice models that are suited to Census block-group level analysis for each of the 24 months in a two-year period, and use them to analyze how visitors' behavioral responses to various attributes of amenity clusters have shifted during different phases of the pandemic. Our findings suggest that in the first few months of the pandemic, amenity-visiting preferences significantly diverged from expected patterns. Even though overall trip volumes remained far below normal levels throughout the remainder of the year, preferences towards specific cluster attributes mostly returned to expected levels by September 2020. We also construct two scenarios to explore the implications of another shutdown and a full reopening, based on November 2020 consumer behavior. While government restrictions have played an important role in reducing visits to amenity clusters, our results imply that cautionary consumer behavior has played an important role as well, suggesting a likely long and slow path to economic recovery. By drawing on mobile phone location data and behavioral modeling, this paper offers timely insights to help decision-makers understand how this unprecedented health emergency is affecting amenity-related trips and where the greatest needs for intervention and support may exist., Competing Interests: The authors have declared that no competing interests exist.

This study aims to explore various barriers in accessing outpatient care among the participants from different age groups and to identify determinants associated with physician visits. The study had adopted Andersen's Behavioral Model (ABM) of Health Services Use. A cross-sectional study design was adopted to collect data from 417 participants through a questionnaire survey. Poisson regression models were used to explore determinants for explaining the differences in outpatient care use. The regression results revealed that divergent relationships existed among age groups. Children and elderly participants tended to decrease the probability of seeking care. Elderly participants confronted more difficulties in access and were dependent on family members. Despite free care provisions, participants visited and spent their out-of-pocket expenditure mostly at non-universal health coverage (non-UHC) facilities. Convenience and the availability of specialist physicians led the higher-income parents to seek care of their children at non-UHC facilities. Highly educated people of working age preferred more self-care or institutionalized care to save time. Children up to the primary level of education were more likely to visit a doctor. We concluded that investments in education or well-informed health services provision would improve health care utilization. Findings of Andersen's Behavioral Model variables suggested that improvements in the quality of services, medical professional skills, and efficient resource allocation may induce seeking care at UHC facilities. Consequently, it will reduce the number of referred cases, caseloads at tertiary care units, and visits to non-UHC facilities at longer distances.

Aims: Heart failure with reduced ejection fraction (HFrEF) is associated with poor outcomes. While several medications are beneficial, achieving optimal guideline-directed medical therapy (GDMT) is challenging. COVID-19 created a need to explore new ways to deliver care., Methods: Fifty consecutive patients were taught to identify fluid congestion and monitor their vital signs using BP monitors and electronic scales with NP-led telephone support. Quantitative data were collected and a patient experience interview was performed., Results: The majority (76%) of the cohort (male, 76%; Māori/Pacific, 58%) had a new diagnosis of HFrEF, with 90% having severe left ventricular (LV) dysfunction. There were 216 contacts (129 (60%) by telephone), which eliminated travelling, (time saved, 2.12 hours per patient), petrol costs ($58.17 per patient), traffic pollution (607 Kg of CO2) and time off work. Most (75%) received contact within two weeks and 75% were optimally titrated within two months. Improvements in systolic BP (SBP) (124mmHg to 116mmHg), pulse (78 bpm to 70 bpm) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (292 to 65) were identified. Of the 43 patients who had a follow-up transthoracic echocardiogram (TTE), 33 (77%) showed important improvement in left ventricular ejection fraction (LVEF)., Conclusions: Patients found the process acceptable and experienced rapid titration with less need for clinic review with titration rates comparable with most real-world reports., Competing Interests: Dr Lund reports other from Amgen inc and personal fees from Novartis outside the submitted work.

Objective: To investigate the association between participation in government subsidies for domestic travel (subsidise up to 50% of all travel expenses) introduced nationally in Japan on 22 July 2020 and the incidence of symptoms indicative of COVID-19 infections., Design: Cross-sectional analysis of nationally representative survey data., Setting: Internet survey conducted between 25 August and 30 September 2020 in Japan. Sampling weights were used to calculate national estimates., Participants: 25 482 survey respondents (50.3% (12 809) women; mean (SD) age, 48.8 (17.4) years)., Main Outcome Measures: Incidence rate of five symptoms indicative of the COVID-19 infection (high fever, sore throat, cough, headache, and smell and taste disorder) within the past month of the survey, after adjustment for characteristics of individuals and prefecture fixed effects (effectively comparing individuals living in the same prefecture)., Results: At the time of the survey, 3289 (12.9%) participated in the subsidy programme. After adjusting for potential confounders, we found that participants in the subsidy programme exhibited higher incidence of high fever (adjusted rate, 4.7% for participants vs 3.7% for non-participants; adjusted OR (aOR) 1.83; 95% CI 1.34 to 2.48; p<0.001), sore throat (19.8% vs 11.3%; aOR 2.09; 95% CI 1.37 to 3.19; p=0.002), cough (19.0% vs 11.3%; aOR 1.96; 95% CI 1.26 to 3.01; p=0.008), headache (29.2% vs 25.5%; aOR 1.24; 95% CI 1.08 to 1.44; p=0.006) and smell and taste disorder (2.6% vs 1.8%; aOR 1.98; 95% CI 1.15 to 3.40; p=0.01) compared with non-participants. These findings remained qualitatively unaffected by additional adjustment for the use of 17 preventative measures (eg, social distancing, wearing masks and handwashing) and fear against the COVID-19 infection., Conclusions: The participation of the government subsidy programme for domestic travel was associated with a higher probability of exhibiting symptoms indicative of the COVID-19 infection., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Based on the data of 812 small towns in Chongqing, China, this paper attempts to conduct an empirical analysis on whether tourist towns with excellent natural environment, policy advantage, and market preference are more ecologically livable than ordinary small towns. It is found that as a whole, tourist towns are indeed more ecologically livable than ordinary small towns. Also, from the perspective of grading, both the national and provincial tourist towns have the advantage of ecological livability, but the advantage of national ones is more prominent. Furthermore, the ecological livability of tourist towns is affected by location advantage and policy inclination. The implications of the results are discussed following the outcomes of the coronavirus disease 2019 outbreak. The suggestions beyond the coronavirus disease 2019 are also provided., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Su and Zhou.)

The emergence and development of car-sharing has not only satisfied people's diverse travel needs, but also brought new solutions for improving urban traffic conditions and achieving low-carbon and green sustainable development. In recent years, car-sharing has had competition with other ways of getting around, as the acceptance of car-sharing has grown, notably taxis. Therefore, it is particularly important to explore car-sharing travel costs advantages from the perspective of consumers and discover the competitive and complementary spaces between car-sharing and other modes. Therefore, taking Beijing as an example, this paper uses GPS trajectory data based on car-sharing orders to design a travel cost framework of car-sharing and taxis. We calculate and compare the travel cost difference between these two modes under different travel characteristics. The results indicate that car-sharing is a more economical way for consumers to travel for short or medium lengths of time, while people are more inclined to take taxis for distances of long duration. Compared with on workdays, at the weekend, the cost advantage of car-sharing is greater for long-distance trips. Moreover, the cost advantage of car-sharing increases gradually with the increase in travel distance. In addition, the travel costs of car-sharing and taxis are also affected by peak and off-peak traffic periods. Compared with off-peak periods, it is more cost-effective for travelers to take taxis during peak traffic periods for various travel distances. From the perspective of the travel cost, it is of great theoretical significance to discuss the substitution (market competition) and complementary relationship (market cooperation) between car-sharing and taxis in a detailed and systematic way. It provides methods and ideas for the comparative cost calculation of car-sharing and other travel modes. This paper also provides enlightenment and guidance for the development of car-sharing. Enterprises should implement differentiated pricing, designing different charging methods for different traffic periods, travel miles, and rental times, and set up additional stations in the surrounding areas of the city. Relevant government departments should also strictly manage the market access of car-sharing, and add or open car-sharing parking lots in centralized areas and for specific periods.

Gahar Lake is located within Oshtorankooh Protected Area (east of Lorestan Province in Iran), which has extensive potentials for the development of the tourism industry. The aim of the present research was to determine the economic value of the Gohar Lake resort using the zonal travel cost method. Therefore, at first, 380 questionnaires were distributed among the tourists by the simple random sampling method based on appropriate spatiotemporal distribution during the visiting seasons. The questionnaire items were categorized as economic, social, and miscellaneous parts. The calculation results revealed a value of USD 84.538 per visitor and a value of USD 1,986,657.163 per year, indicating the high value and importance of the region. The analysis showed that socio-economic variables have a significant role in the use or non-use of the resort. The obtained R2 coefficient was 0.82, indicating that around 82% of the changes in the number of visitors can be justified by the variables introduced in the model. The results also revealed the need to pay more attention to this region and formulate a tourism development plan., Competing Interests: The authors have declared that no competing interests exist.

The paper explores the travelling behaviour of migrant groups using Facebook audience estimates. Reduced geographical mobility is associated with increased risk of social exclusion and reduced socio-economic and psychological well-being. Facebook audience estimates are timely, openly available and cover most of the countries in the world. Facebook classifies its users based on multiple attributes such as the country of their previous residence, and whether they are frequent travellers. Using these data, we modelled the travelling behaviour of Facebook users grouped by countries of previous and current residence, gender and age. We found strong indications that the frequency of travelling is lower for Facebook users migrating from low-income countries and for women migrating from or living in countries with high gender inequality. Such mobility inequalities impede the smooth integration of migrants from low-income countries to new destinations and their well-being. Moreover, the reduced mobility of women who have lived or currently live in countries with conservative gender norms capture another aspect of the integration which is referring to socio-cultural norms and gender inequality. However, to provide more solid evidence on whether our findings are also valid for the general population, collaboration with Facebook is required to better understand how the data is being produced and pre-processed., Competing Interests: The authors have declared that no competing interests exist.

In response to the coronavirus disease 2019 (COVID-19) pandemic, several national governments have applied lockdown restrictions to reduce the infection rate. Here we perform a massive analysis on near-real-time Italian mobility data provided by Facebook to investigate how lockdown strategies affect economic conditions of individuals and local governments. We model the change in mobility as an exogenous shock similar to a natural disaster. We identify two ways through which mobility restrictions affect Italian citizens. First, we find that the impact of lockdown is stronger in municipalities with higher fiscal capacity. Second, we find evidence of a segregation effect, since mobility contraction is stronger in municipalities in which inequality is higher and for those where individuals have lower income per capita. Our results highlight both the social costs of lockdown and a challenge of unprecedented intensity: On the one hand, the crisis is inducing a sharp reduction of fiscal revenues for both national and local governments; on the other hand, a significant fiscal effort is needed to sustain the most fragile individuals and to mitigate the increase in poverty and inequality induced by the lockdown., Competing Interests: The authors declare no competing interest., (Copyright © 2020 the Author(s). Published by PNAS.)

The issue of tourism impacts is one that has plagued the tourism industry. This study develops a quantitative approach using hierarchical variance analysis, which deals with the exploration of the relevant factors and the confirmation of their significant contribution to analyze the residents' perception of tourism impacts. Hierarchical variance analysis includes three mathematical procedures: Cronbach's alpha tests, the exploration of relevant factors, and a hierarchical factor confirmation. Data are collected using a structured questionnaire completed by 452 surveyed residents living in Ly Son Island, Vietnam. The significant effects of socio-demographic variables on the overall impact assessment are observed. The bilateral and simultaneous relationships are analyzed using a one-factor ANOVA. A two-factor ANOVA shows the significant contribution of each socio-demographic variable on the economic, socio-cultural, and environmental impacts. Interaction between factors such as "Education level", "Type of work", etc. are hierarchically confirmed. The findings allow a better understanding of the residents' perception of the effects of tourism on society, the economy, and the environment. This provides a scientific basis to help define problems and promote legal regulations for community participation in tourism planning in a small island destination.

Background: Children's habitual physical activity, including active travel and catching public transit (walking and cycling to and from destinations), and independent mobility (mobility without an adult) have decreased. Public transit trips are physically active and can provide access to hobbies independent of parents, but there is no device-measured data about children's total physical activity time following the introduction of free public transit. Our aim is to compare physical activity and independent mobility between children living in two Finnish towns, one with a recently introduced free public transit system, and the other without free public transit., Methods: The city of Mikkeli has provided free public transit for all comprehensive school children since 2017. Various districts from Mikkeli, and the reference town of Kouvola (towns from South-Eastern Finland with a comparative population size and geographical structure), are selected based on their accessibility and the availability of public transit services. Samples of 10-12-year-old children will be recruited through primary schools. We will compare moderate-to-vigorous physical activity time, sitting time (a thigh-worn Fibion® device) and independent mobility (a participatory mapping method, PPGIS) of children: 1) who live in towns with and without free public transit, 2) who live and go to school in districts with high vs. low perceived and objective access to free public transit, and 3) who report using vs. not using free public transit. In addition, ethnography will be used to get insights on the social and cultural effects of the free public transit on children's and parent's everyday life., Discussion: There is a need for scalable solutions that can increase children's physical activity independent of their socioeconomic background or place of residence. This project will give information on how a political action to provide free public transit for children is associated with their total physical activity time and independent mobility patterns, therefore providing highly relevant information for political decision-making and for promoting independent physical activity in children.

After the recession in Japan in the 1990s, Japanese art exhibitions began to appear. The purpose of these exhibitions was to revitalize these areas through the presentation of art (attracting visitors and tourists). Correspondingly, this study explores the significance of exhibition-driven tourism in Japan. The Echigo-Tsumari Art Triennial (ETAT) was used as a case to study how exhibition-driven tourism has impacted sustainable tourism, economics, and the population. The current paper collected panel data from 1900 to 2018. These panel data were analyzed by descriptive statistics and a correlation analysis (a one-way ANOVA and a Pearson correlation analysis in SPSS26). The empirical analysis showed that the Echigo-Tsumari Art Triennial (exhibition-driven tourism) had positive impacts on sustainable tourism, economics, and the population; its correlations with Niigata were also clear. This study generated results that are valuable from both academic and industry perspectives (exhibition-driven tourism), as this field has not been extensively researched. The current paper also presents the theoretical and practical implications of the statistical results.

The Asia-Pacific region is known as a favorite destination for global medical travelers due to its medical expertise, innovative technology, safety, attractive tourism destination and cost advantage in the recent decade. This study contributes to propose an approach which effectively assesses performance of medical tourism industry based on considering the economic impact factors as well as provides a conceptual framework for the industry analysis. Grey system theory is utilized as a major analyzing approach. According to that, factors impact on the sustainable development of medical tourism in Asia-Pacific region could be identified. The performance of each destination in this region was simultaneously revealed. The results presented an overall perspective of the medical tourism industry in the scope of the Asia-Pacific region, and in Taiwan particularly. Data was collected on six major destinations including Singapore, Thailand, India, South Korea, Malaysia and Taiwan. The results proved that tourism sources and healthcare medical infrastructures play a crucial role in promoting the healthcare travel industry, while cost advantage and marketing effectiveness were less considered. In addition, performance analyse indicated that Thailand has a good performance and stands in the top ranking, followed by Malaysia, India, Singapore, South Korea and Taiwan, respectively. The revenue of Taiwan has increased slowly in the last six years, with a market worth approximately NT$20.5 billion, and the number of medical travelers is expected to increase to 777,523 by 2025. The findings of this study are expected to provide useful information for the medical tourism industry and related key players in strategic planning., Competing Interests: The authors declare no conflicts of interest.

Living organ donors face direct costs when donating an organ, including transportation, lodging, meals, and lost wages. For those most in need, the National Living Donor Assistance Center (NLDAC) provides reimbursement to defray travel and subsistence costs associated with living donor evaluation, surgery, and follow-up. While this program currently supports 9% of all US living donors, there is tremendous variability in its utilization across US transplant centers, which may limit patient access to living donor transplantation. Based on feedback from the transplant community, NLDAC convened a Best Practices Workshop on August 2, 2018, in Arlington, VA, to identify strategies to optimize transplant program utilization of this valuable resource. Attendees included team members from transplant centers that are high NLDAC users; the NLDAC program team; and Advisory Group members. After a robust review of NLDAC data and engagement in group discussions, the workgroup identified concrete best practices for administrative and transplant center leadership involvement; for individuals filing NLDAC applications at transplant centers; and to improve patient education about potential financial barriers to living organ donation. Multiple opportunities were identified for intervention to increase transplant programs' NLDAC utilization and reduce financial burdens inhibiting expansion of living donor transplantation in the United States., (© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Based on the theory of social construction and self-consistency, this study aims to investigate the mechanism of relational leadership's role in employees' unethical pro-organizational behavior (UPB) from the perspective of moral identity and ethical climate. We found that relational leadership negatively correlates with the instrumental ethical climate, positively correlates with caring ethical climate, and exerts no significant impact on the rule ethical climate. Instrumental ethical climate and caring ethical climate mediate the relationship between relational leadership and employees' unethical pro-organizational behavior. In addition, moral identity negatively moderates the relationship between instrumental ethical climate and employees' unethical pro-organizational behavior, and between caring ethical climate and employees' unethical pro-organizational behavior. Furthermore, moral identity positively moderates the relationship between a rule ethical climate and employees' unethical, pro-organizational behavior., Competing Interests: The authors have declared that no competing interests exist.

Background: Anticoagulation therapy is used for atrial fibrillation (AF) patients for reducing the risk of cardioembolic complications such as stroke. The previously recommended anticoagulant, warfarin, has a narrow therapeutic window, and it requires regular laboratory monitoring, unlike direct oral anticoagulants (DOAC). From a societal perspective, it is important to measure time and travel costs associated with warfarin monitoring to better compare the total therapy costs of these two alternative forms of anticoagulation management. In this study we design a georeferenced cost model to investigate societal savings achievable with the shift from warfarin to DOACs in the study region of North Karelia in Eastern Finland., Methods: Individual-level patient data of 6519 AF patients was obtained from the regional patient database. Patients' geocoded home addresses and other GIS data were used to perform a network analysis for the optimal routes for warfarin monitoring visits. These measures of revealed accessibility were then used in the cost model to measure monetary time and travel costs in addition to direct healthcare costs of anticoagulation management., Results: The share of time and travel costs in warfarin monitoring is 26.6% of the total therapy costs in our study region. With current drug retail prices in Finland, the societal expense of anticoagulation management is only 2.6% higher with DOACs than in the baseline with warfarin. However, when 25% lower distributor's prices are used, the total societal cost decreases by 13.6% with DOACs., Conclusions: Our results indicate that patients' time and travel costs critically increase the societal cost of warfarin therapy; and despite the higher price of DOACs, they are already cost-efficient alternatives to warfarin in anticoagulation management. In the future, the cost of AF complications should be included in the cost comparison between warfarin and DOACs. Our modeling approach applies to different geographical regions and to different healthcare processes requiring patient monitoring.

Background: Migrants often face barriers to accessing healthcare. We examined disparities in access to and use of HIV-related health services between migrant and non-migrant people recently diagnosed with HIV living in the Netherlands, taken into account sexual orientation. Also, we examined differences in experiences in living with HIV between these groups., Methods: We used a questionnaire and clinical data collected between July 2013 and June 2015 among migrant and non-migrant participants of the European cross-sectional aMASE (Advancing Migrant Access to health Services in Europe) study in the Netherlands. Using univariable logistic regression analyses, we compared outcomes on between migrants and non-migrants, stratified by sexual orientation (with non-migrant men having sex with men [MSM] as the reference group)., Results: We included 77 migrant MSM, 115 non-migrant MSM, 21 migrant heterosexual men, 14 non-migrant heterosexual men and 20 migrant women. In univariable analyses, all heterosexual groups were less likely to ever have had an HIV-negative test before their diagnosis and were more likely to be diagnosed late than non-migrant MSM. All migrant groups were more likely to have experienced difficulties accessing general healthcare in the Netherlands and were less likely to have heard of post-exposure prophylaxis than non-migrant MSM. Migrants frequently reported uncertainty about their rights to healthcare and language barriers. Most (93%) participants visited a healthcare facility in the 2 years before HIV diagnosis but only in 41% an HIV test was discussed during that visit (no statistical difference between groups). Migrant heterosexuals were more likely to have missed appointments at their HIV clinic due to the travel costs than non-migrant MSM. Migrant MSM and women were more likely to have experienced HIV discrimination in the Netherlands than non-migrant MSM., Conclusion: Disparities in access to and use of HIV-related health services and experiences exist by migrant status but also by sexual orientation. Our data suggests heterosexual men and women may particularly benefit from improved access to HIV testing (e.g., through provider-initiated testing), while migrant MSM may benefit from improved access to HIV prevention interventions (e.g., pre-exposure prophylaxis).

In the global economy, tourism is one of the most noticeable and growing sectors. Thissector plays an important role in boosting a nation's economy. An increase in tourism flow canbring positive economic outcomes to the nations, especially in gross domestic product (GDP) andemployment opportunities. In South Asian countries, the tourism industry is an engine ofeconomic development and GDP growth. This study investigates the impact of tourism onPakistan's economic growth and employment. The period under study was from 1990 to 2015. Tocheck whether the variables under study were stationary, augmented Dickey-Fuller andPhillips-Perron unit root tests were applied. A regression technique and Johansen cointegrationapproach were employed for the analysis of data. The key finding of this study shows that there isa positive and significant impact of tourism on Pakistan's economic growth as well as employmentsector and there is also a long-run relationship among the variables under study. This studysuggests that legislators should focus on the policies with special emphasis on the promotion oftourism due to its great potential throughout the country. Policy implications of this recent studyand future research suggestions are also mentioned.

Background: The financial burden experienced by patients with cancer represents a barrier to clinical trial participation, and interventions targeting patients' financial concerns are needed. We sought to assess the impact of an equity intervention on clinical trial patients' financial burden., Materials and Methods: We developed an equity intervention to reimburse nonclinical expenses related to trials (e.g., travel and lodging). From July 2015 to July 2017, we surveyed intervention and comparison patients matched by age, sex, cancer type, specific trial, and trial phase. We longitudinally assessed financial burden (e.g., trial-related travel and lodging cost concerns, financial wellbeing [FWB] with the COmprehensive Score for financial Toxicity [COST] measure) at baseline, day 45, and day 90. We used longitudinal models to assess intervention effects over time., Results: Among 260 participants, intervention patients were more likely than comparison patients to have incomes under $60,000 (52% vs. 24%, p < .001) and to report travel-related (41.0% vs. 6.8%, p < 0.001) and lodging-related (32.5% vs. 2.0%, p < .001) cost concerns at baseline. Intervention patients were more likely to report travel to appointments as their most significant financial concern (24.0% vs. 7.0%, p = .001), and they had worse FWB than comparison patients (COST score: 15.32 vs. 23.88, p < .001). Over time, intervention patients experienced greater improvements in their travel-related (-10.0% vs. +1.2%, p = .010) and lodging-related (-3.9% vs. +4.0%, p = .003) cost concerns. Improvements in patients reporting travel to appointments as their most significant financial concern and COST scores were not statistically significant., Conclusion: Cancer clinical trial participants may experience substantial financial issues, and this equity intervention demonstrates encouraging results for addressing these patients' longitudinal financial burden., Implications for Practice: Clinical trials are critical for developing novel therapies for patients with cancer, yet financial barriers may discourage some patients from participating in cancer clinical trials. This study found that patients who received financial assistance from an equity intervention experienced significant improvements over time in their concerns about the cost of travel and lodging associated with clinical trials compared with comparison patients who did not receive financial assistance from the equity intervention. Among cancer clinical trial participants, an equity intervention shows potential for addressing patients' concerns regarding clinical trial-related travel and lodging expenses., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2019.)

Objective: To systematically review the literature on women's experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services., Background: Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women's experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic., Methods: A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women's experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists., Results: We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women's reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases., Conclusions: Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women's lives., Competing Interests: The authors have declared that no competing interests exist.

Background: Active travel for utilitarian purposes contributes to total physical activity and may help counter the obesity epidemic. However, the evidence linking active travel and individual-level body weight is equivocal. Statistical modeling that accounts for spatial autocorrelation and unmeasured spatial predictors has not yet used to explore whether the health benefits of active travel are shared equally across socioeconomic groups., Methods: Bayesian hierarchical models with spatial random effects were developed using travel survey data from Saskatoon, Canada (N = 4625). Differences in log-transformed body mass index (BMI) were estimated for levels of active travel use (vehicular travel only, mixed vehicular/active travel, and active travel only), household income, and neighbourhood deprivation after controlling for sociodemographic and physical activity variables. The modifying effect of household income on the association between active travel and BMI was also evaluated., Results: Significant and meaningful decreases in BMI were observed for mixed (β = - 0.02, CrI - 0.036 to - 0.004) and active only (β = - 0.043, CrI - 0.06 to - 0.025) compared to vehicular only travelers. BMI was significantly associated with levels of household income and neighbourhood deprivation. Accounting for the interaction between travel mode and household income, decreases in BMI were observed for active only compared to vehicular only travellers in the highest income category (β = - 0.061, CrI - 0.115 to - 0.007)., Conclusion: Strategies to increase active travel use can support healthy weight loss and maintenance, but the opportunity to benefit from active travel use may be limited by low income. Considerations should be given to how interventions to increase active transportation might exacerbate social inequalities in BMI. Spatial statistical models are needed to account for unmeasured but spatially structured neighbourhood factors.

Christianity emerged as a small and marginal movement in the first century Palestine and throughout the following three centuries it became highly visible in the whole Mediterranean. Little is known about the mechanisms of spreading innovative ideas in past societies. Here we investigate how well the spread of Christianity can be explained as a diffusive process constrained by physical travel in the Roman Empire. First, we combine a previously established model of the transportation network with city population estimates and evaluate to which extent the spatio-temporal pattern of the spread of Christianity can be explained by static factors. Second, we apply a network-theoretical approach to analyze the spreading process utilizing effective distance. We show that the spread of Christianity in the first two centuries closely follows a gravity-guided diffusion, and is substantially accelerated in the third century. Using the effective distance measure, we are able to suggest the probable path of the spread. Our work demonstrates how the spatio-temporal patterns we observe in the data can be explained using only spatial constraints and urbanization structure of the empire. Our findings also provide a methodological framework to be reused for studying other cultural spreading phenomena., Competing Interests: The authors have declared that no competing interests exist.

End-stage renal disease patients regularly need haemodialysis three times a week. Their poor access to haemodialysis facilities is significantly associated with a high mortality rate. The present cross-sectional study aimed to measure the potential spatial access to dialysis services at a small area level (census tract level) in North Khorasan Province, Iran. The patients were interviewed to obtain their travel information. The two-step floating catchment area (2SFCA) method was used to measure the spatial accessibility of patients to the dialysis centres. The capacity of the dialysis centre was defined as the number of active dialysis facilities in each centre and the haemodialysis patients in each area were considered as the users of dialysis services. The travel cost from each patient's residence to the haemodialysis facilities was visualized by the Kriging interpolation algorithm in the study area. Spatial accessibility to the dialysis centre was poor in the northern part of the study area. Fortunately, there were not many haemodialysis patients in that area. Patients' travel costs were high in the northern areas compared to the rest of study area. We observed a statistically significant reverse correlation between the self-reported travel time and computed spatial accessibility (-0.570, P value <0.01, two-tailed spearman test). This study supports the notion that the 2SFCA method could be associated with revealed access time to dialysis facilities, especially in low traffic and in flat areas such as northern Khorasan. The mapping of patients' distribution and interpolated travel cost to the haemodialysis facilities could help policymakers to allocate health resources to the areas where the need is greater.

Tourist satisfaction has always been a crucial research issue in the tourism economy. This paper utilizes the Spatial Durbin Model (SDM) to analyze the impact of urban tourism satisfaction on urban macroeconomics from a macro perspective, using quarterly data on tourist satisfaction in 35 large and medium-sized cities along with major urban macroeconomic variables. This study is quite distinct from previous research that focused on constructing a tourist satisfaction index and analyzing the influence factors of tourism satisfaction from the perspective of the micro-level internal composition of tourism. The empirical results show: Firstly, in respect of the impact of urban tourists' satisfaction on the GDP income of cities, the SDM and the SDM with a lagged first-order dependent variable (SDM&#95;dlag) show that the short-term and long-term indirect effects of log-tourist satisfaction are significantly positive, indicating that city satisfaction has a significant positive spatial spillover effect on GDP growth in other cities; Secondly, in respect of the influence of urban tourist satisfaction on the cost of urban life in the SDM, the long-term direct and indirect effects of logarithmic satisfaction are significantly positive, implying, in the long run, that tourist satisfaction has a positive intraregional spillover effect and spatial spillover effect on urban living costs; Finally, the SDM&#95;dlag for the regression of urban tourist satisfaction on the cost of urban daily life shows that the short-run direct and indirect effects of city tourist satisfaction are significantly negative, indicating that tourist satisfaction has intra-regional and spatial spillover effects, and its rise will reduce the cost of living expenses in local and other cities in the short term. Overall, we have further elucidated the role of different levels of urban tourist satisfaction in city macroeconomics from the spatial dimension, thereby enriching the existing research on tourist satisfaction to some certain extent., Competing Interests: The authors have declared that no competing interests exist.

Despite proposed conceptual frameworks of eating behaviors, little is known about environmental factors contributing to changes in food habits. Few studies have reported the external influence of tourism on the inhabitants' eating patterns. The present study aimed to investigate whether tourism pressure affects Canary Islands inhabitants' adherence to the Mediterranean diet pattern. Data were obtained from a health and lifestyle population-based survey conducted in 2009 and 2015. From the reported intake frequency, a Mediterranean diet score was defined (0 to 11 points). Tourist overnight stays, which were stratified by nationality and area of destination, were used as a proxy variable to measure tourism pressure. A multilevel linear regression analysis by restricted maximum likelihood estimation was performed to examine the relationship between tourism pressure and the Mediterranean diet score. A significant negative association between the Mediterranean diet score and British tourism pressure was observed ( β = -0.0064, p = 0.010), whereas German tourism pressure increased inhabitants' adherence ( β = 0.0092, p = 0.042). The socioeconomic level of tourists seems to play a role in differences in the tourism pressure effect by nationality. Further investigation of other highly touristic destinations is needed to confirm these findings that could contribute to a shift in tourism and public health nutrition policies.

Ecotourism as a strategy for achieving biodiversity conservation often results in limited conservation impact relative to its investment and revenue return. In cases where an ecotourism strategy has been used, projects are frequently criticized for not providing sufficient evidence on how the strategy has reduced threats or improved the status of the biodiversity it purports to protect. In Lao PDR, revenue from ecotourism has not been directly linked to or dependent on improvements in biodiversity and there is no evidence that ecotourism enterprises have contributed to conservation. In other developing countries, direct payments through explicit contracts in return for ecosystem services have been proposed as a more cost-effective means for achieving conservation, although further research is needed to evaluate the impact of this approach. To address this need, a new model was tested in the Nam Et-Phou Louey National Protected Area (NPA) in Lao PDR using a direct payments approach to create ecotourism incentives for villagers to increase wildlife populations. Over a four-year period, we monitored along a theory of change to evaluate assumptions about the linkages between intermediate results and biological outcomes. Preliminary results show a negative correlation between ecotourism benefits and hunting infractions in target villages; no increase in hunting sign in the ecotourism sector of the NPA relative to a three-fold increase in hunting sign across the NPA's non-tourism sectors; and an overall increase in wildlife sightings. This case provides key lessons on the design of a direct payments approach for an ecotourism strategy, including how to combine threat monitoring and data on wildlife sightings to evaluate strategy effectiveness, on setting rates for wildlife sightings and village fees, and the utility of the approach for protecting very rare species.