Perspectives on public Trust in Nonprofit Organizations.
\r\n\t- BMD measurement technology
\r\n\t- Osteoporosis and fracture risk
\r\n\t- Bone growth and remodeling
\r\n\t
\r\n\tThe submission is also open to any other original study related to these research topics.
Hepatic fibrosis, nodular rigeneration, distortion of hepatic architecture are the histopathological characters of liver cirrhosis. The main outcome of this pathological condition is the portal hypertension (PH) by the disruption of the hepatic blood flow, beside the damage of liver metabolic functions. Moreover the alteration of the splanchnic blood flow and the block of portal flow can be localized also in the prehepatic and posthepatic site. The prehepatic causes of PH are portal vein thrombosis, splenic vein thrombosis, arteriovenous fistula, blood overflow in the splanchnic district; the posthepatic causes are the Budd-Chiari syndrome, inferior vena cava obstruction, right-sided heart failure [1]. The liver cirrhosis is a remarkable medical problem in the world. Cirrhosis and hepatic chronic diseases are an important cause of morbidity and mortality worldwide, but with many differences in the geographic distribution. The global mortality rate ranges from 2% to 4% of total deaths in 2017, with decrease from the rate variance 1%–9%, evaluated in 1990 [2]. The more evident clinical evolutions of liver cirrhosis are PH, damage of coagulation, digestive hemorrhage, ascites, hepatic encephalopathy, hepatocarcinoma.
The PH leads to some pathological conditions in the esophageal and gastroduodenal tract, that can cause digestive hemorrhage. Esophageal varices are the lesion currently developed in the patients with PH by liver cirrhosis or other pre and posthepatic obstacles to splanchnic blood flow. Consequently in these patients all gastrointestinal bleedings are usually ascribed to esophageal varices. Instead others gastroduodenal lesions, potentially hemorrhagic, can be associated with PH. In this group of lesions there are the portal hypertensive gastropathy (PHG), gastric antral vascular ectasia (GAVE), gastric and duodenal ulcer, isolated gastric varices. The aim of this presentation is to evaluate the development, the clinical prominence and therapeutic needs of these lesions, which are associated but also conditioned by PH.
Varices are activated collateral vessels and they develop following the obstruction of portal flow. The role of activation of collateral vessel is to allow the retourn of digestive portal blood flow into the systemic circulation. PHG has similarly its cause in the obstruction in portal flow. All PHG occur in patients with PH, but not all patients with PH can develop PHG. The PHG was previously called as hemorrhagic gastritis within the large group which includes many bleeding gastric pathologies; later it was correctly framed and defined in the context of complications of PH. The clinical observation shows that the patients with severe PH and longer liver disease duration with esophageal varices, expecially if treated with endoscopic procedures, have more frequently PHG. In the gastric mucosa there are congestion and dilated capillaries [3]. The hemodynamic changes of the PH, caused by some mechanical and functional obstacles to portal circulation, as hepatic cirrhosis, pre or posthepatic block, portal hyper-inflow, are the pathophysiological basis of PHG. The congestion of the gastric mucosa is the first phenomenon of the obstruction of the portal flow. The most important question is whether and in which way can occur the change in hematic perfusion of the stomach during PH. The etiology of PHG is not completely known. In the PH there is an important hemodinamic characteristic, that is a hyperdynamic circulation based on the increased hematic flow in the mesenteric, splenic and total gastric sections. The hyperdynamic circulation is one factor which induces the PHG, based on the changes in blood flow of gastric mucosa [4]. The hyperdynamic characteristcs in the PH lead to some important hemodynamic changes in the patients. In the hyperdynamic circulation of PH intrahepatic vascular resistence greaten, whereas mean arterial pressure and systemic vascular resistence reduce and there is wide vasodilatation in the splanchnic sector. Finally the gastric blood flow is globally increased, but the particular gastric mucosal flow should be reduced [5]. The gastric mucosal blood flow, in the patients with PHG, is now discussed. Some studies report decreased gastric mucosal blood flow [6], but these data can be modified, as increase of mucosal blood flow, after correction of PH, for example by TIPS [7]. There are other studies that underline, on the contrary, the increase of gastric mucosal blood flow [8]. Clinical observation in PHG shows major tendency to actions of gastrotoxic substances and decreased wound healing. Consequently the more obvious clinical appearance of PHG is the gastrointestinal bleeding, usualy of mild or moderate entity and diffuse from the gastric wall. Ultimately the hemodynamic changes cause the impairments of gastric mucosal defense competence with major sensitivity to injuries and alteration of growth factors, with minor possibility of mucosal healing [9]. Synthetically the weak gastric mucosa more easily can bleed and reduced mucosal blood perfusion, with altered gastric microcirculation leads to increased sensitivity to hypoxia and noxions agent, with erosion, ulcers and bleeding. PHG is related to severity of liver cirrhosis and in particular is connected with the increase degree of hepatic vein pressure gradient (HVPG). PHG is a dinamic condition because in its evaluation can occur some reversible gastric mucosal changes [10]. PHG incidence raises with increasing of hypertension in the portal area and is associated with esophageal and gastric varices; it’s a strong predictor of gastroesophageal varices bleeding [11]. In fact PHG occur frequently in patients with liver cirrhosis and its major incidence is based on the severity of PH. This lesion can modify its degree from midl to severe and can disappear. Bleeding can occur but is not frequent and often of not serious entity. The role of sclerotherapy of esophageal varices on the natural history of PHG is not unanimously defined. Following some experience, the treatment of esophageal varices does not seem to influence the evolution of PHG, but there are others observations opposite to this hipothesis in the literature [12]. PH develops direct action on gastric mucosa. The PHG encompasses a large types of gastric mucosal lesions in the cirrhotic patients. These lesions should be distinguished from others lesions as GAVE, which is an independent pathology. These following modifications shape the PHG. About gastric mucosal hemodinamic changes, it’s not clear if gastric mucosal hyperhemia is by active or passive hemodynamic congestion. In the pathogenesis of PHG there are together the action of increase of the portal pressure and of gastric blood flow (hyperdynamic splanchnic circulation) which causes its development. Moreover in PHG there is the damage of gastric mucosal defense factors, with the occurrence of bleeding, that is its unique clinical manifestation [13]. In the pathogenesis of PHG can be identified some steps. The hemodynamic changes in the splanchnic district and in particular in the stomach are caused by increased portal pressure. The most evident modification is the congestion in the gastric wall, with the tissue impairment. Consequently there is the activation of cytokines and growth factors (TNF alfa) and subsequent activation of endothelial constitutive nitric oxide (NO) synthase in the gastric mucosa. The increased presence of NO synthase produces excess of NO which leads to hyperdinamic circulation and overproduction of peroxinitrite, that induces, with endothelin, the major susceptibility of gastric mucosa to injuries [14]. There are controversial data in the literature on the kind of changes of gastric mucosa blood flow: in some studies there is the increase but in others there is decrease of blood flow. In summary remain unclear if hemodynamic changes in PHG are active or passive congestion [15, 16]. Others observations suggest that cirrhotics with PHG have increased gastric perfusion but without congestion. The magnitude of changes in gastric perfusion and the endoscopic severity of PHG had no relationship with the degree of PH [17]. In the patiens with liver cirrhosis can occur both gastric lesions, PHG and GAVE. These pathologies have different pathophysiology and management. They have the same clinical manifestations as gastric bleeding, usually chronic but in some cases the gastric hemorrhage can be acute and with high entity. The endoscopic diagnosis for differentiation can be difficult and the histology can be useful [18]. The endoscopic appearance of the PHG is characteristic: flushed and edematous mucosa that suggest mosaic pattern, dilated mucosal and submucosal vessels without inflammation. Further evolutions of these lesions are friable mucosa which bleeds easily on contact and there are hemorrhagic spots. The site of these pathological mucosal lesions can occur frequently in the proximal stomach, but the same lesions by mesenteric hypertension can be observed in others sections of the gastrointestinal tract [3]. Histological features of PHG are dilated, congested capillaries, edema, extravasated red blood cells (RBCs), smooth muscle hyperplasia [19]. Further special problem is the connection of PHG with infection of Helicobacter pylori (H.pylori). Some data from the literature report that infection prevalence of H.pylori in cirrhotic patients with PHG is lower than general population [20]. The diminution of H.pylori infection in cirrhotic patients should be related to the gastric vascular congestion characteristic of PHG [21]. Mucosal gastric changes in PH are characterized by the alteration of mucus protection, that become slimmer, riduction of gastric acidity based on minor acid secretion, decrease of Prostaglandin with lowered gastric blood flow and impaired gastric barrier. The alteration of gastric mucosal barrier is worsened by severe impairment of gastric wall microcirculation, with the result of vascular congestion, followed by mucosal hypoxia and reduction of oxigen released in gastric mucosa. In summary the debility of gastric mucosal barrier of PHG could make easy mucosal lesions and infectious invasion, e.g. by H.pylori. However the vascular congestion, impaired microcirculation and mucosal hypoxia in PHG allow the increase of intestinal metaplasia of gastric mucosa, which is an opposed element to H.pylory infection [22]. In summary, based on these data of the literature, a current evaluation suggest that the minor H.pylori infection rate in cirrhotic patients with PHG can be connected to intestinal metaplasia of gastric mucosa [23]. Clinical presentation of PHG is the gastrointestinal bleeding. The hemorrhage can present as acute or chronic complication. The frequence of acute bleeding shows a wide range from 2% to more than 40% in various reports [12, 24, 25]. The great variance of frequency can be due to vast time frame of references and to difficulties and imprecisions of endoscopic examination during acute bleeding in congiunction with others potential source hemorrhage as esophageal varices. In summary the endoscopic diagnosis can be sure only if the bleeding point is identified [26]. The acute bleeding in PHG usually, almost 90% of cases, can occur in the patients with advanced cirrhosis, longer duration and major extension and severity of gastropathy. The extent of bleeding in the PHG is usually mild or moderate [27, 28]. Very difficult is the evaluation of the incidence of chronic bleeding from PHG, that frequently can be mild. Some references of the literature report the frequence variation that oscillates between 3%–26% [29]. In fact there are many uncertainties in the definition of chronic bleeding as which level of hemoglobin reduction, but, most important, the coexistent clinical condition of anemia in cirrhotic patients, also without gastrointestinal bleeding. The diagnosis of PHG is only endoscopic. Some endoscopic features have been identified as diagnostic: snake skin, stripped appearance, mild reddening mosaic in the mild appearance of gastropathy; flat red spots, fine red speckling mosaic characterize the endoscopic appearance of moderate disease; finally the more severe condition of gastropathy can be identified in the diffuse hemorrhagic lesions, red spots, point bleeding mosaic. This summary of some classifications proposal of endoscopic features of PHG shows the discordance among various experience reported in the literature, about shared definitions and identifications for each endoscopic lesion of PHG [13, 25, 30]. Most frequently the detection of asymptomatic PHG occur during endoscopic control of esophageal varices in the patients with chronic liver disease. In these patients there is not appearance of gastrointestinal bleeding and you can say that PHG developed spontaneusly. In the evolution of PHG should be evaluated the role of the treatment of esophageal varices by sclerotherapy or ligation. Some data of the literature refer an increased occurrence of PHG following endoscopic therapy of esophageal varices. In this perspective should be proposed prophylactic pharmacotherapy with nonselective betablockers as propranolol. In summary for asymptomatic PHG is usually not required treatment [28, 31]. If the PHG is recognized as the cause of anemia due to chronic bleeding, drug therapy can be started with iron replacement, in some cases blood transfusion and drugs that can lower the pressure in the portal district as betablocker propranolol. In the cases of acute bleeding the first procedures are for the resuscitation of the patient with blood transfusion, vasoconstrictors as somatostatin or analogues and antibiotics. It’s suddenly mandatory the endoscopic control of esophageal varices and possible their treatment if bleeding. When there is the endoscopic certainty of PHG as source of acute hemorrhage, should be possible the use of endoscopic therapy also for PHG and the current pharmacotherapy by betablocker propranolol, somatostatin or analogues, vasopressin. In the rare cases of acute hemorrhage not responded to medical therapy can be requested emergency therapy with TIPS [18]. Endoscopic therapy of PHG has been proposed with the use of the laser, but the results are uncertain and consequently it has been little used. All the drugs employed in the management of PHG, connected with hypertensive condition in the portal district are based on the reduction of gastric blood flow and gastric perfusion [3].
Gastric antral vascular ectasia (GAVE) occurs roughly in the 30% of the patients with cirrhosis [32]. Two types of GAVE syndrome, with different natural history and clinical features, can be identified. The non- cirrhotic GAVE syndrome in particurar is associated to autoimmune diseases, more frequently in aged women, with Rainaud’s syndrome, sclerodactyly, atrofic gastritis [33]. Beside association with various autoimmune diseases, there are, in non-cirrhotic GAVE syndrome, the pathological association with sclerodermia, chronic renal failure, etc. [34]. The etiology of GAVE syndrome is now yet undefined and the pathogenesis of vascular characteristic alterations as ectasia should by contracted by mechanical actions on the gastric mucosa. This hypothesis is based on some histological characteristics, in particular the fibromuscolar hyperplasia, as results of mechanical actions [35]. The histologic features of GAVE can be summarized with the following data: prevalent presence of the lesions in the antrum, vascular ectasia, submucosal fibrohyalinosis, spindle cells (smooth muscle cell – myofibroblast hyperplasia) proliferation, fibrin thrombi in mucosal vessells [36, 37]. The GAVE syndrome shows the characteristic endoscopic appearance of watermelon stomach, gastric dilation, linear lesions localized in the antrum, vasodilation and tendency to the bleeding. Endoscopic features of GAVE are represented by conglomerates of red spots which are organized in a linear pattern in the gastric antrum, taking shape of watermelon stomach. Following the pathogenetical proposal of Lowes J R, can be evaluated the role of neuroendocrine cells proliferations in GAVE and effect of its vasoactive intestinal peptide on vessels wall with vascular ectasia [38]. The occurrence of GAVE in the patients with liver cirrhosis should be due to the obstacle of the portal flow, consequent PH, spontaneous shunting of mesenteric flow through collateral vessells, as esophageal varices, and impaired hepatic catabolism of some vasoactive substances [35]. The management of GAVE syndrome is not well established in all clinical manifestations. The central aim of the therapeutic procedures is the control of the bleeding, that occurs more frequently in GAVE than in PHG, usually as chronic gastrointestinal hemorrhage, in cirrhotic patients with clinical appearance of chronic anemia. The chronic anemia is a clinical condition that belongs to liver cirrhosis and can be also caused by PHG; for this reason the differential diagnosis of the causes of anemia is necessary to prepare specific therapies [18]. Some procedures have been employed: medical therapies with estrogen and progesterone, tranexamic acid (antifibrinolitic substance), octreotide, propranolol. All these medical treatments showed partial therapeutic effectiveness, therefore, if the ineffective medical therapies, can be accessed to invasive surgical therapies for control of hypertensive condition in mesenteric district, as TIPS or to direct treatment of hemorrhagic source with antrectomy. Unfortunately the surgical procedures in cirrhotic patients can be connected with not negligeable risk of morbidity and mortality [35, 39, 40, 41]. In the treatment of GAVE have been employed endoscopic procedures based on thermoablative techniques. In particular argon plasma coagulation and Nd:Yag laser coagulation. For these procedures usually should be repeated some sessions. Cryotherapy has been used with rapid expansion in the stomach of compressed nitroux oxide and following freezing of the mucosa, allowing therapeutic effect on diffuse lesions [42, 43, 44]. In the final evaluation we can conclude that endoscopic approach with thermoablative procedures as argon plasma coagulation, Nd:Yag laser coagulation and cryotherapy have advantagious therapeutic effects on decrease of bleeding and needs of blood transusion in complicated hemorrhagic GAVE [18]. In summary PHG and GAVE are potential hemorrhagic mucosal lesions of the stomach that can develop in the patients with PH by liver cirrhosis. Both pathologies can cause more frequently chronic or sometime acute gastrointestinal bleeding. Therefore these conditions have some pathological and clinical differences. The PHG occur only in cirrhotics with PH, the hemorrhagic lesions are located mostly in the gastric fundus and the pharmacological therapies are frequently effective. The GAVE can be also present in the patients without liver cirrhosis and PH (60%–70% of the cases), the gastric site of the lesions is antrum almost always, there is the histological characteristic of fibrin thrombi in the mucosal vessells and signs of mucosal inflammation, finally the therapeutic procedures are endoscopic (argon, laser, cryotherapy).
Another lesions, possible source of upper gastrointestinal bleeding in cirrhotic patients are the peptic ulcers, located in duodenum and stomach. The frequency of bleeding from gastroduodenal ulcers in cirrhotics, rather than from esophageal varices ranges from 5% to 15% [45, 46]. Gastroduodenal peptic ulcer disease maintains a not negligeable prevalence in the general population that reaches 14% [47]. The etiology and natural history of peptic ulcer pathology is connected and conditioned by certain well known factors: mainly environmental, behavioral and infectious, as the infection of H.pylori, curative use of NAIDS, etc. However the role of associated pathologies cannot be left out. In fact liver cirrhosis carries an enlarged risk of occurrence of peptic ulcer disease with the incidence that varies widely from 10% to 49% [48]. The pathophysiological connections among peptic ulcer disease, liver cirrhosis with metabolic changes related and infection of H.pylori are object of numerous studies. Especially the prevalence of H.pylori infection in cirrhotic patients is reported in the various researches with great variability and this does not allow to define if the H.pylori infection has a specific role in the pathogenesis of ulcerative disease in cirrhotics. For example in some studies the high incidence of peptic ulcer in the patients with liver cirrhosis is associated also to great presence of H.pylori infection until 60% of cases [49]. On the other hand there are many studies which refer the prevalence rates of H.pylori infection in cirrhotics not dissimilar compared to the values of non cirrhotic patients [50]. Ultimately the data on the role of H.pylori about the occurrence and development of peptic ulcer during chronic liver disease are debatable and in conclusion uncertain; in any case it’s not evident a significant action of H.pylori infection in the pathophysiology of peptic ulcer disease in the cirrhotic patients. Therefore in summary we can believe that there are no significant differences in the prevalence of H.pylori infection between general population and patients with chronic liver disease [50]. Neverthless this observation, it can be accepted that peptic ulcers develop more frequently in the cirrhotic patients. The clinical appearances of peptic ulcers in cirrhotic patients are characterized by negative features of ulcer disease evolution as greater frequence of bleeding and recurrence of the disease and retarded recovery. The reason of greater occurrence of peptic ulcers is based on the modification of gastric-acid secretion, changed gastric mucosal blood flow and, mostly, on damaged mucosal defense mechanisms. In fact there is not evidence of increase of gastric-acid secretion in cirrhotic patients with PH and, on the contrary, the possible variations are almost always as hypocloridric changes likely related to worsening of liver disease [51]. The damaged protective function of gastric mucosal barrier seems to have a greater role in the pathophysiology of peptic ulcers in cirrhotics, based on the occurrence of chronic atrophyc gastritis in liver cirrhosis, the reduced strength of gastric mucosa due to parietal venous congestion and protein and vitamin deficiencies [52]. Others metabolic and functional modifications should integrate the pathogenetic framework of peptic ulcer in cirrhotic patients: raised level of gastrin and histamine, increase of duodenogastric reflux, impaired gastric empting, reduced prostaglandin level in gastric mucosa and decrease of mucosal oxigen saturation [53, 54]. Most recent studies confirm this proposal evaluation referring that the severity degree of liver pathological involvement plays an important role in the development of peptic ulcer disease. Decompensated cirrhosis, the action of PH, more effective if more serious, on gastric mucosal blood flow, on efficiency of mucosal defense barrier and on epithelial resumption, can support ulcer development, the retard of mucosal recovery and possible recurrence of peptic disease [50, 55]. In summary in the pathophysiology of peptic ulcer in cirrhotics, the H.pylori infection and NSAID therapeutic use are risk factors with effects no different than in the general population. However in the patients with cirrhosis and PH, in which peptic ulcer disease occur with notable percentage, the liver pathology operates a significant pathogenetic role [56]. The prevalence of peptic ulcer in cirrhotics is more high compared with general population, both in symptomatic patients with bleeding and in asymptomatic patients [57]. There is a greater prevalence of peptic ulcer disease in cirrhotic patients and these patients have major risk of bleeding from peptic ulcer related to general population; moreover each occurrence of peptic ulcer bleeding is followed by the decompensation of hepatic cirrhosis with increase of severity of clinical conditions [58, 59]. In the patients with liver cirrhosis upper gastrointestinal bleeding is currently reported to esophageal varices, but in the 30% -40% of cases the source of bleeding is not esophageal varices but gastroduodenal ulcers, with subsequent remarkable morbidity and mortality [60]. Upper gastrointestinal bleeding is the common and expected complication of liver cirrhosis with PH. The first therapeutic purpose is to control the hypovolemic alterations of various degrees of severity due to amount of hemorrhage and to steady the hemodynamic conditions. The subsequent step requires by diagnostic approach to differentiate the bleeding from esophageal varices or from others gastroduodenal pathologies connected to hepatic cirrhosis, as peptic ulcers. The hemodynamic instability requires resuscitation, that can be restrictive or aggressive, by infusion of cristalloids (Ringer lactate, normal saline, etc.) or also, in some cases, of colloids (albumin, plasma, dextrane, etc.). If the indication is found can be useful the use of blood transfusion. In the first therapeutic approach the evaluation of bleeding severity encompasses also the assessment of level of the risk of rebleeding in order to graduate the subsequent phases of treatment using Glasgow Blatchford score [61]. The severe gastrointestinal hemorrhage from ulcer lesions in cirrhotic patients adversely affects the prognosis through worsening of already impaired liver functions. In the patients with upper gastrointestinal bleeding from peptic ulcers the therapeutic perspective is based on the pharmacologic treatment that includes the use of proton pump inhibitors, somatostatin and octreotide, and on the endoscopic diagnostic definition and management. The endoscopic therapies, with hemostatic purpose, include various procedures as epinephrine injection, thermocoagulation, sclerosant injection, use of the clips, TC-325 Hemospray. The global management of non variceal upper gastrointestinal bleeding has been recently defined by international guideline [62]. Finally in case of failure of pharmacologic and endoscopic management of peptic ulcers in cirrhotics and serious unmanageable clinical conditions, could be proposed direct surgical gastroduodenal procedures as rescue therapy.
Gastric varices are usually connected with esophageal varices, but can be also isolated along the gastric wall. Gastric varices are classified by endoscopy with topographical criterion as gastroesophageal varices type I (lesser gastric curvature), gastroesophageal varices type II (greater gastric curvature); isolated gastric varices type I (gastric fundus), isolated gastric varices type II (any stomach location, except fundus) [63]. The pathogenesis of isolated gastric varices could be ascribed to portal or splenic vein thrombosis. The occurrence of bleeding from isolated gastric varices in the patients with PH shows the percentage incidence from 5% to 10% [64]. The diagnosis of gastric varices is endoscopic. The first general therapeutic approach in the case of bleeding from gastroesophageal or isolated gastric varices is included within the current management of gastrointestinal hemorrhage in the PH, by pharmacological and endoscopic procedures, or portosystemic derivation procedures as TIPS. The specific treatment of isolated gastric varices bleedind is endoscopic usually by injection with cyanoacrylate [65].
In the clinical scenario of gastroduodenal lesions associated with PH and liver cirrhosis, both are important actors, but the PH and hepatic chronic disease remain the protagonist of the clinical state. In fact the degree of functional hepatic impairment and of hypertensive status in the splanchnic district affect much the patients general conditions. Moreover the upper gastrointestinal bleeding is the more frequent complication of this complex pathological condition. Esophageal varices currently develop in the cirrhotics with PH and this is the characteristic source of gastrointestinal bleeding. However upper digestive hemorrhage in cirrhotic patients alwais requires the diagnostic definition of bleeding source, which may also be due to pathologies related to PH. In fact, albeit less frequently, others gastroduodenal lesions, with pathogenetic association to liver cirrhosis and PH, may present intestinal hemorrhage. The PHG is in several cases neglected complication of liver cirrhosis and PH. PHG is connected with the degree of PH and can have a role as prognostic index of liver cirrhosis. The management of PHG is based on pharmacological, endoscopic or, in some few cases, on emergency therapy with TIPS. GAVE can affect one third of cirrhotics. PHG and GAVE may both occur in patients with liver cirrhosis. However these pathologies have different pathophysiology and management. The central diagnostic aim is to distinguish GAVE from PHG because the therapeutic procedures that allow decrease of portal pressure, effective for PHG, are not efficacious therapy for GAVE, usually treated by endoscopic approach. Gastric and duodenal ulcer are more frequent in cirrhotics and may worsen prognosis. Early diagnosis and treatment of peptic ulcer in cirrhotic patients are significant to avoid complications. Gastric varices, usually connected with esophageal varices, can be, in some cases, isolated; their therapeutic approach in case of bleeding is enclosed within the effective management of gastrointestinal hemorrhage in the PH. In conclusion the complete diagnosis that identifies with certainty, the bleeding source is decisive for the therapeutic choices.
“Despite the diversity among NPOs, there is one thing that they have in common–
Moreover, most studies conceptualize the public’s trust in nonprofit organizations primarily according to a “narrow” relationship management perspective. This perspective equates the general public with nonprofit stakeholders such as donors, volunteers, or public authorities that are directly related to the organization through actual experiences and transactions, and stronger relationships respectively. Bryce [2], for example, argues that “[t]he public’s positive or negative experiences in core transactions with an organization may be the principal bases for the impairment or improvement of the public trust”. To restore and improve public trust in nonprofit organizations, he accordingly suggests the use of relationship marketing concepts. Similarly, Sargeant and Lee [7] put public’s trust at the core of a relational fundraising approach, even though the authors find empirical evidence that “trust may operate at two levels distinguishing donors from non-donors”. However, the very same approaches to address both donor and public trust may not be reasonable.
This chapter calls into question former relationship-focused conceptualizations of public trust. The aim of this chapter is hence to move beyond the narrow trust perspective to conceptualize and operationalize public’s trust in nonprofit organizations in accordance with a broader perspective. That is, the larger public had no or few actual transactions with the organization yet, and rather vague assumptions or interests based on initial points of contact such as through the media, word-of-mouth, or the organization’s fundraising activities. In the case of a series of positive contact points, a stronger relationship might evolve subsequently at a later stage [8]. The nature of public’s trust in nonprofit organizations hence depends upon few contact points between the public and the organization, which are embedded in a comparatively loose connection between those involved. To directly address these contact points, the current chapter suggests that nonprofit organizations can send signals through the implementation of branding and accountability strategies, rather than through relationship management approaches. These strategies arise from the broad trust perspective, and from recent trends in nonprofit trust literature that turned out to be most promising, also as strategies for restoring public’s trust in the case of a scandal as we have seen them repetitively in the nonprofit domain over the past years. As such, they have ability to directly influence the mechanisms that are related to public’s trust in nonprofit organizations.
To fully evolve, this chapter claims public trust to be associated with five mechanisms, including 1) promise of mission and values, 2) organizational reputation, 3) transparency and accountability, 4) performance and social impact, and 5) use of contributions. It follows that public trust depends on how well the organization performs relating to each of these fields that act as mechanisms for strengthening trust. In contrary, if the nonprofit organization blocks one or more of these mechanisms, it impairs this trust; and at its worst, a corresponding scandal is likely to be provoked. Both for the improvement and impairment of public’s trust in nonprofit organizations, this chapter provides nonprofit scholars and managers with insights into the mechanisms behind it, and provides strategies to successfully build, maintain, and restore public trust.
The nonprofit organizations’ very existence is assumed to be based on their greater trustworthiness. Nonprofit organizations are prohibited by law from distributing profits to private parties, and unlike their commercial counterparts, they do not have legal owners with residual claims [5, 9]. The nonprofit character accordingly provides signals of trust that help the public and other nonprofit stakeholders to overcome uncertainty caused by agency problems regarding the organizations’ behavior and quality [4, 5, 10]. In view of some of the most recent nonprofit scandals (e.g. SOS-Children Villages or Oxfam’s scandals of misconduct), scholars yet question the effectiveness of Hansmann’s [9] nondistribution constraint alone to mitigate these scandals’ effects [10]. Where the nonprofit character by itself cannot offer assurance regarding the organizations’ good intentions, and the public has difficulties assessing the organizations trustworthiness, additional trust signals are vital [2, 11, 12].
According to the narrow perspective, these signals primarily refer to relationship-based management, marketing, and fundraising measures that are suitable to target stakeholders such as donors, or volunteers within a stronger relationship. Bryce [2] suggests sending a series of relationship messages, for example, with the purpose of affirming the ability to make discretionary decisions regarding the use of contributions, or communicating realizable future performances. As such, the narrow perspective assumes a stronger transactional relationship between the public and the organization, expecting the public to be susceptible to these messages. Although someone who has already donated to an organization is expected to value messages on how his or her donation is used, this chapter questions the larger public to be susceptible to corresponding messages. According to the broad perspective, the larger public rather relies on general cues or signals that may be derived from an organization’s self-assessments, statements relating to the organizational mission and values as well as fundraising activities, annual reports, or websites. Third-party organizations such as watchdogs and funding agencies, or even word-of-mouth, and the media can provide additional signals to inform the public’s assessments of the organization’s trustworthiness [13, 14]. It follows that nonprofit organizations, in turn, must be able to identify and communicate trust building signals to stakeholders and the larger public to cultivate trust within their network of relationships [12]. See Table 1 for a comparison of both perspectives on public’s trust in nonprofit organizations.
Perspectives on public Trust in Nonprofit Organizations.
Within this context, scholars have defined public’s trust in nonprofit organizations mainly in accordance with a rather narrow trust perspective, and relating to strong stakeholder relationships (e.g., [1, 2, 7]). They accordingly refer to trust as a two-dimensional construct. The first dimension refers to generally positive trust-related expectations, or specific characteristics of the trustee (the nonprofit organization), such as its ability, benevolence, and integrity. Considering the special features of organizations from the nonprofit sector, the benevolence dimension is particularly dominant in this domain [16, 17]. The second dimension refers to the (nonprofit) stakeholder’s willingness to accept vulnerability, which comes with an element of risk [18]. According to the broad perspective, public trust, however, evolves in the context of weak relationships between organizations and the larger public, based on initial points of contact. Such contact points may sufficiently inform the public’s assessments of the organization’s general trustworthiness, yet, do not contain major elements of risk. For example, if an individual from the larger public derives information from an organization’s website, this may shape the individual’s first opinion on the organization’s trustworthiness but he or she does rather face no or a weak risk at this point of (weak) relational involvement with the organization. Therefore, this chapter draws on a definition highlighted by Becker et al. [15], that builds on Morgan and Hunt’s conceptualization ([19]: 23) to explicitly focus on the first dimension, and conceptualize public trust as “existing when one party has confidence in an exchange partner’s reliability and integrity”. Public trust is hence considered an aggregate of each interaction between an individual and the organization, which further reflects the overall public attitude towards an organization [15, 20].
Based on an extensive literature review as well as former trust conceptualizations (e.g., [2]), this chapter presents five mechanisms that are associated with public’s trust in nonprofit organizations. The mechanisms relate to fundamental principles and special features of nonprofit organizations, and corresponding processes in the sector. Following all five mechanisms are explained in detail. That is, the mechanisms’ bases for the development of public trust as well as managerial actions that potentially impair public trust are presented. Table 2 illustrates the mechanisms in an overview.
Mechanism | Basis for public trust | Managerial action impairing public trust | Strategies to build, maintain, and restore public trust | |
---|---|---|---|---|
Nonprofit branding | Voluntary nonprofit accountability | |||
1. Promise of mission and values | Adherence to act according to organizational mission and values |
| Ability to signal the organization’s mission and core values | Ability to signal adherence to the organization’s mission and core values |
2. Organizational reputation | High organizational reputation (competence and likeability) |
| Ability to enhance organizational reputation through shaping single brand images | Ability to contribute to the organizational reputation through joining high-reputational initiatives |
3. Transparency and accountability | Compliance with transparency and accountability standards |
| Ability to signal integrity and accountability | Ability to strengthen compliance with transparency and accountability standards |
4. Performance and social impact | Financial, stakeholder, market, and mission performance, mission impact |
| Ability to signal quality regarding performance and impact | Ability to signal quality regarding performance and impact (e.g., performance and impact seals) |
5. Use of contributions | Mission-based use, discretion, preservation |
| Ability to signal the adequate use of contributions | Ability to (externally) certify the adequate use of contributions |
Five Mechanisms that are Associated with Public Trust in Nonprofit Organizations.
Promise of mission and values is the first mechanism that is associated with public’s trust in nonprofit organizations. An organization’s mission refers to the organization’s long-term objective and determines its strategic direction [21], and is thus also relevant to public trust [2, 7, 22]. Values further range from ethical responsibilities to competitive values, and specify how an organization conducts its activities and strategies [23]. In the nonprofit sector values such as altruism, humanity, equality, helpfulness, but also trustworthiness and honesty are prominent [23, 24], having distinct impacts of public’s trust. Both missions and values can vary considerably across organizations, with substantially different meanings and relevance for the larger public as well as other stakeholders [14, 25]. For example, Oxfam states its organizational mission, as follows “We fight inequality to end poverty and injustice.”, and “commit[s] to living [their] values [in particular, equality, empowerment, solidarity, inclusiveness, accountability, courage] so that [they] can be known for [their] integrity. This means transforming [their] governance, management, and operational structures, and nurturing a culture of continuous learning and reflection” [26]. The principal basis for public trust relates to the organization’s adherence to act according to its organizational mission and values. If organizations, however, violate or misrepresent these, public trust is impaired [2]. Also, a lack of clarity in expressions of mission statements and values may impair public trust such that the public perceive nonprofit managers as insincere about their true goals, and therefore assess the organization’s trustworthiness as significantly lower [27].
The organizational reputation constitutes the second mechanism that is associated with public’s trust in nonprofit organizations. Organizational reputation, namely the collectively held mental image of the organization [28, 29], is considered a highly important intangible asset in nonprofit organizations [30]. It consists of different mental images across various stakeholder groups that can vary highly depending on which assessments are gathered. In view of recent nonprofit scandals, the reputation of nonprofit organizations has been tremendously threatened because it is influenced through monitoring problems. According to Prakash and Gugerty [10], “[i]t is not an exaggeration to say that the negative reputational effects of a few ‘bad apples’ are beginning to undermine the reputation of the sector as a whole”, and the organizational reputation has distinct impacts on public trust [31]. In the nonprofit sector, reputation is conceptualized primarily with respect to the organization’s competences and its likeability that accordingly acts as a basis for public trust [29]. If an organization, in turn, cannot maintain its images as sufficiently competent and likeable across a variety of people, public trust is impaired.
Transparency and accountability represent the third mechanism that is related to public trust. Its importance is based on the fact that in the nonprofit domain organizations are – dependent on the home countries’ varying regulations – are more or less not obliged to comprehensively report financial and non-financial information publicly. However, we know about the importance of transparency and accountability standards in the sector that is vital to improve public trust [32, 33, 34]. That is, nonprofit stakeholders and the larger public face uncertainty because they cannot easily observe the organization’s project and operational expenses, and so its behavior and the quality of services [10]. It follows that high transparency and compliance with transparency and accountability standards build an essential basis for public trust [10, 34, 35]. This basis is threatened through organizations that lack transparency, or (at its worst) do not comply with legal accountability standards and requirements.
The organization’s performance and social impact represent the fourth mechanism that improves public trust. Nonprofit organizations often provide services that are highly intangible and of which the quality is difficult to observe [16]. The organization’s performance in the form of financial, stakeholder, market, and mission performance is hence difficult to verify both for contributors and beneficiaries, and even more so, for the larger public [14]. Achieving and measuring actual impacts has been found to be increasingly important for organizations and their contributors; yet, social impact measurement is still in its infancy, and few organizations have capacities for accordant evaluations [36]. Despite agency problems regarding the organizations’ performances and social impacts, they form the basis to ultimately further the mission. It follows that organizational performance (and to a growing extent, also social impact) are particularly relevant for public’s trust. Impairments of public trust accordingly include organizational mal-performance [2], and no social impact.
The use of contributions is the fifth mechanism that is associated to public’s trust in nonprofit organizations. That is, the majority of nonprofit organizations rely on external funding (for example, from private and corporate donors, or public authorities and foundations) to finance the organization’s project and operating expenses, to ultimately ensure the organization’s continuation. The principal basis for improving public trust according to this mechanism is the mission-based use as well as discretion in the handling of contributions, and its preservation. On the other hand, trust is impaired through managerial actions such as misuse, misrepresentation, negligence, and imprudence in the handling of donations and other contributions [2, 37]. In the past, the unreasonable use of contributions have been particular serious in some cases, and subsequently resulted in a nonprofit scandal that affected not only involved organizations, but questioned the legitimacy also of other organizations in the nonprofit sector. For example, in 2014, Greenpeace International’s use of contributions created a scandal because an employee of the organization used large amounts of donated funds for foreign exchange trading [38]. In contrary, it is assumed that nonprofits clearly stating their use of contributions exhibit higher levels of trustworthiness. Some organizations recently started to develop new marketing and fundraising models around this topic. For example, the nonprofit organization
Pursuant to conceptualizations of the narrow relationship management perspective, scholars rarely distinguish between the larger public and other external stakeholder groups in their operationalizations of public trust. In their study on public’s trust in nonprofit organizations, Sargeant and Lee [7] yet found empirical evidence indicating that donors place significantly more trust in charitable organizations than non-donors. Because only few operationalizations and measurement approaches explicitly focus on public trust, this chapter involves also those focusing on donor trust. Table 3 shows the prevailing trust measurement scales in the nonprofit sector.
First category: Second-order construct operationalizations | ||||
---|---|---|---|---|
Donor trust | ||||
First-order dimensions and measurement items (7-point scale; anchored at | ||||
1. Relationship investment 2. Mutual influence 3. Forbearance from opportunism 4. Communication acceptance | 1. I read all the materials (this NPO) sends to me. 2. Supporting (this NPO) is very important to me. 3. I would not encourage others to support (this NPO). 1. I share the views espoused by (this NPO). 2. (This NPO) does not reflect my views. 3. I feel I can influence policy in (this NPO). 4. I find myself influenced by (this NPO). 1. I am very loyal to (this NPO). 2. (This NPO) is one of my favorite charities to support. 3. My giving to (this NPO) is not very important to me. 4. My giving to (this NPO) is high on my list of priorities. 1. I look forward to receiving communications from (this NPO). 2. I do not enjoy the content of communications from (this NPO). 3. Communications from (this NPO) are always informative. | |||
Second category: Scale measurement approaches | ||||
Donor trust | ||||
(7-point scale; anchored at | ||||
1. The NPO are very unpredictable. I never know how they are going to act from one day to the next. 2. I can never be sure what the NPO are going to surprise us with next. 3. I am confident that the NPO will be thoroughly dependable, especially when it comes to things that are important to my organization. 4. In my opinion, the NPO will be reliable in the future. 5. The NPO would not let us down, even if they found themselves in an unforeseen situation (e.g., competition from other funders, changes in government policy). | ||||
(5-point scale; anchored at | ||||
Ability Willingness | 1. In my opinion, the NPO is competent. 2. I have the feeling that the NPO knows its business. 3. I believe that the NPO is able to achieve the goals, which it commits itself to. 4. I am convinced that the NPO is able to keep its promises. 5. In my opinion, the NPO has the skills and the qualification to act reliably. 1. In my opinion, the NPO is trustworthy. 2. I think that the NPO is honest to its donors. 3. I can rely on the NPO. 4. I am convinced of the NPO’s willingness to keep its promises. 5. The NPO acts altruistically. | |||
Public and donor trust | ||||
(7-point scale; anchored at | ||||
1. I would trust this NPO to always act in the best interest of the cause. 2. I would trust this NPO to conduct their operations ethically. 3. I would trust this NPO to use donated funds appropriately. 4. I would trust this NPO not to exploit their donors. 5. I would trust this NPO to use fundraising techniques that are appropriate and sensitive. | ||||
(7-point scale; anchored at | ||||
1. To always act in the best interests of the cause. 2. To conduct their operations ethically. 3. To use donated funds appropriately. 4. Not to exploit their donors. 5. To use fundraising techniques that are appropriate and sensitive. | ||||
(7-point scale; anchored at | ||||
1. I trust this NPO to always act in the best interests of the cause. 2. I trust this NPO to conduct its operations ethically. 3. I trust this NPO to use donated funds appropriately. |
Operationalizations and measurement approaches of public Trust in Nonprofit Organizations.
Note. α = Cronbach’s alpha; AVE = average variance extracted; n.r. = values not reported.
The existing operationalizations and measurement approaches relating to (public) trust in nonprofit organizations can be divided into two categories. The first category refers to second-order trust operationalizations, and few scholars operationalize trust in the nonprofit sector by means of second-order-constructs (e.g., [40, 41]). Corresponding operationalizations come from the narrow relationship management perspective such that they focus on trust emerging from stronger relationships between donors and nonprofit organizations. For example, Sargeant and Lee [40, 41] operationalize donor trust with respect to four components: 1) relationship investment, 2) mutual influence, 3) forbearance from opportunism, and 4) communication acceptance. The authors claim this operationalization of trust only to be relevant “in the context of a donor’s relationship with a specific organization” ([40]: 618) as the dimensions are based on an existing donor-organization-relationship. The respective first-order dimensions show sufficient high values of Cronbach’s alpha, and average variance extracted, exceeding the respective thresholds of .70, and of .50 respectively [44, 45]. It is important to note that the four dimensions do not include any of the two trust dimensions (trustworthiness of NPO and risk for donors), given that the authors rather identified “key behaviors indicative of the presence [of trust]” ([7]: 616).
The second category relates to scale measurement approaches of trust in the nonprofit sector that directly address the trust concept as outlined in this chapter. Most studies fall into this category, and either measure trust according to a narrow or a broad perspective (e.g., [8, 17, 42, 46]). That is, most measurement scales seek to measure donor trust, whereas one prevailing measurement scale is used both in the context of donor and public trust. All scales exhibit sufficient psychometric properties. The measures explicitly focusing on donor trust emerge from the narrow perspective, such that they include the first dimension of trust, measuring the organization’s trustworthiness; to a lesser extent, they also include the risk dimension [17, 42]. The measures to operationalize both donor and public trust have been used in two ways: They include either the measurement items (1)–(3) [46], or all items (1)–(5), which specify additional donor and fundraising aspects [7, 8]. The latter rather emerges from a narrow perspective, and more strongly focuses on trust in the context of donor and fundraising issues. As such, the measure also refers to the potential risk of donors [7, 8]. In contrast, Sargeant and Woodliffe’s [46] scale includes the measurement items (1)–(3). The scale explicitly focuses on the first trust dimension, such that corresponding items target the nonprofit organization’s trustworthiness, and relate to weaker relationships between organizations and the public. Against this background, and in accordance with the broader perspective, this chapter suggests that Sargeant and Woodliffe’s scale is particularly suitable for operationalizing public trust. However, these items still do not address all mechanisms that are associated with public’s trust, and the accordant measurement scale is therefore capable of improvement (see future research ideas).
To build and maintain public’s trust in nonprofit organizations, this chapter claims strategies from the field of nonprofit branding as well as nonprofit accountability to be of great significance. They are also suitable for restoring public trust, if managerial action has led to its impairment. Of particular importance are these strategies in the case of nonprofit scandals. One the one hand, they can help involved nonprofit organizations to recover from scandals. On the other hand, they have great ability to protect other nonprofit organizations from negative spillover effects in the sector. The underlying rationale of the functioning of these strategies is that external stakeholders face uncertainty regarding the organization’s trustworthiness [10], and they “seek assurances beyond those provided by public regulations that organizations are behaving responsibly, following societal expectations and norms of behavior” ([13]: 1). This is where strategies of nonprofit branding and nonprofit accountability provide assurance for the public, attesting the organization’s trustworthiness [47, 48].
The first strategy of improving public’s trust in nonprofit organizations refers to the field of nonprofit branding. Precisely, the nonprofit brand equals a “shortcut” that provides the general public with valuable information about the nonprofit organization ([49]: 22). In particular, the brand’s signaling function enables organizations to spread signals relating to the organization’s mission and core values [49, 50]. It thus has the ability to clearly inform the public’s assessments of the organization’s trustworthiness with respect to its mission and values as well as its performance. Moreover, branding strategies can effectively target the various mental images of nonprofit stakeholders, to successfully build up a high organizational reputation. A strong brand ultimately has the potential to act as an additional safeguard and reinforcement to the public along with the nondistribution constraint, which may represent a seal of trust [51]. For Sargeant [8], nonprofit brands “are in essence a promise to the public that an organization possesses certain features or will behave in certain ways”. In this line, Laidler-Kylander and Stenzel [49] “believe that the brand is the vehicle for building this trust”. A strong nonprofit brand can accordingly protect the respective organization against negative spillover effects caused by other nonprofit organizations, and they are less susceptible to risk [51]. In their prominent article “The Role of Brand in the Nonprofit Sector”, Kylander and Stone [52] share their results evaluating the brand of one of the biggest nonprofit organizations worldwide, the World Wildlife Fund (WWF), citing Marsh, COO of the WWF, as follows “Our brand is the single greatest asset that our network has, and it’s what keeps everyone together” ([52], p. 5).
The second strategy of improving public’s trust in nonprofit organizations arises from the field of nonprofit accountability. Nonprofit accountability and governance programs and initiatives aim to develop common standards across nonprofit organizations to support good governance in nonprofit sectors worldwide. In particular, voluntary nonprofit accountability in the form of various codes of conduct, self-regulation mechanisms, and certification and accreditation schemes has great potential to improve and restore public’s trust in nonprofit organizations [10, 32, 35, 48, 53]. Slatten et al. [48] argue that “the adoption of standards for ethical and accountable behavior may provide the solution [to the climate of shaken public trust in the non-profit sector]”. First empirical evidence shows that voluntary accountability, and externally certified accountability (including accreditation systems), can enhance public trust in nonprofit organizations [32, 53]. It follows that organizations increasingly devote efforts to demonstrating their trustworthiness with various seals and certifications [2, 34, 51]. Precisely, voluntary nonprofit accountability strategies address the trust-driving mechanisms by their ability to signal adherence to the organization’s mission and core values, and regarding the quality of organizational performance [32]. These strategies further contribute to the organizational reputation by joining high-reputational initiatives [13], and they particularly strengthen compliance with certain transparency and accountability standards, also through (external) certifications that attest the organization’s adequate use of contributions [37, 53].
This chapter also suggests directions for further research regarding public trust in nonprofit organizations. First, although a number of scholars agree that public’s trust in (charitable) nonprofit organizations is under increasing pressure (mainly caused by public scandals and commercialization issues) [54, 55], other scholars find no empirical evidence for decreased public trust and confidence in the nonprofit sector (e.g., [56]). When related to the important component of giving behavior, a recent meta-analysis by Chapman et al. [6] showed that even though trust is often assumed to affect giving, the body of evidence available for their analysis was rather small. Against this background, a first research idea relates to investigations of public trust among different nonprofit organizations based on, for example, the ICNPO categories, organizational mission categories, or other classifications. Precisely, public trust may be high relating to cultural organizations, but lower in the health sector, and thus vary among the different organizations. Evidence also confirms the link between people’s trust and the organizations’ mission category. Considering the organizational diversity in the nonprofit sector, scholars, such as Kearns [1] and O’Neill [56], propose a more differentiated perspective to distinguish between several nonprofit industries. Further research should take the organizational diversity in the nonprofit sector into account.
Second, few operationalizations and measurement approaches focus explicitly on the public’s trust in nonprofit organizations. Given the high importance of the public’s trust for nonprofits and corresponding ways to measure it, the second future research idea relates to scale development processes for public trust. These processes should accordingly be based on the broader trust perspective, such that they relate to weaker relationships between organizations and the general public. On the one hand, scholars could build on Sargeant and Woodliffe’s [46] measurement scale, and include additional items that address the five trust driving mechanisms. On the other hand, scholars could operationalize public trust as a second-order construct. The five mechanisms accordingly provide the basis for first-order dimensions, and corresponding measurement items respectively.
Third, nonprofit branding and nonprofit accountability strategies are first attempts to improve and restore public’s trust in nonprofit organizations. However, conceptual and empirical research on the link between public trust and accordant research fields and strategies still is limited. Yet, both nonprofit branding and nonprofit accountability have gained increasing importance over the past few years, and scholars have found them to be very promising, in particular in the context of trust research [8, 10, 32, 48, 49]. Another future research idea accordingly refers to this topic, to further investigate the link between these research fields and public’s trust. Findings could be used to provide nonprofit managers with more specific recommendations to further improve public’s trust in nonprofit organizations. This chapter thus points to the overall need to further the public trust discussion.
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\\n\\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
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\n\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\n\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\n\nPublishing of a Retraction Notice will adhere to the following guidelines:
\n\n1.2. REMOVALS AND CANCELLATIONS
\n\n2. STATEMENTS OF CONCERN
\n\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\n\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\n\n3. CORRECTIONS
\n\nA Correction will be issued by the Academic Editor when:
\n\n3.1. ERRATUM
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\n\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n3.2. CORRIGENDUM
\n\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n4. FINAL REMARKS
\n\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\n\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\n\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\n\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
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This will ensure that we discover ways to live in our world that allows us and other beings to flourish. We can no longer rely on medicalized approaches to health that wait for people to become ill before attempting to treat them. We need to live in harmony with nature and rediscover the beauty and balance in our everyday lives and surroundings, which contribute to our well-being and that of all other creatures on the planet. This topic will provide insights and knowledge into how to achieve this change in health care that is based on ecologically sustainable practices.
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