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Purpose – To assess the claim of moral hazard proponents that individuals insulated from paying for the health care they use tend to demand more, often unnecessary, services, or engage in unhealthier behaviors than they otherwise would, collectively driving up demand and increasing health care spending (HCS).

Methodology/Approach – To test the hypothesis that moral hazard increases rather than decreases HCS, I apply a multivariate analysis to examine data from 21 OECD countries over a 20-year period, using out-of-pocket spending (OPS) as a proxy for moral hazard and as the key variable predicting HCS, controlling for other potential drivers of spending.

Findings – OPS is independently associated with HCS, yet in the direction opposite to what moral hazard theory predicts – about $13 higher HCS per additional $10 OPS (p = 0.000).

Research limitations – As with other cross-national studies, limitations include (1) inability to assess differences in health care delivery and quality within and across countries; (2) differences in the measurement and availability of variables across countries; (3) lack of access to data of potential significance, and (4) hard to evaluate cross-national political and cultural differences with implications for health policy.

Policy implications – At least in the United States, unless a fully publicly financed system to cover medically necessary services is implemented, the policy goals of extending adequate health insurance to a national population and controlling HCS nationally will not be met.

Originality/Value of Paper – Most research on moral hazard in US health care has drawn from comparisons within rather than among national health systems. Therefore, the originality and value of this cross-national study lies in its ability to identify variables that could not be included in single nation studies and which have the ability to inform policy and political action.

Brain tumor segmentation and classification is the interesting area for differentiating the tumorous and the non-tumorous cells in the brain and classifies the tumorous cells for identifying its level. The methods developed so far lack the automatic classification, consuming considerable time for the classification. In this work, a novel brain tumor classification approach, namely, harmony cuckoo search-based deep belief network (HCS-DBN) has been proposed. Here, the images present in the database are segmented based on the newly developed hybrid active contour (HAC) segmentation model, which is the integration of the Bayesian fuzzy clustering (BFC) and the active contour model. The proposed HCS-DBN algorithm is trained with the features obtained from the segmented images. Finally, the classifier provides the information about the tumor class in each slice available in the database. Experimentation of the proposed HAC and the HCS-DBN algorithm is done using the MRI image available in the BRATS database, and results are observed. The simulation results prove that the proposed HAC and the HCS-DBN algorithm have an overall better performance with the values of 0.945, 0.9695 and 0.99348 for accuracy, sensitivity and specificity, respectively.

The proposed HAC segmentation approach integrates the properties of the AC model and BFC. Initially, the brain image with different modalities is subjected to segmentation with the BFC and AC models. Then, the Laplacian correction is applied to fuse the segmented outputs from each model. Finally, the proposed HAC segmentation provides the error-free segments of the brain tumor regions prevailing in the MRI image. The next step is to extract the useful features, based on scattering transform, wavelet transform and local Gabor binary pattern, from the segmented brain image. Finally, the extracted features from each segment are provided to the DBN for the training, and the HCS algorithm chooses the optimal weights for DBN training.

The experimentation of the proposed HAC with the HCS-DBN algorithm is analyzed with the standard BRATS database, and its performance is evaluated based on metrics such as accuracy, sensitivity and specificity. The simulation results of the proposed HAC with the HCS-DBN algorithm are compared against existing works such as k-NN, NN, multi-SVM and multi-SVNN. The results achieved by the proposed HAC with the HCS-DBN algorithm are eventually higher than the existing works with the values of 0.945, 0.9695 and 0.99348 for accuracy, sensitivity and specificity, respectively.

This work presents the brain tumor segmentation and the classification scheme by introducing the HAC-based segmentation model. The proposed HAC model combines the BFC and the active contour model through a fusion process, using the Laplacian correction probability for segmenting the slices in the database.

The purpose of this paper is to propose a holistic cyber security implementation framework (HCS-IF) that lays out the ground for a conceptual, coherent, systematic, overarching and consolidated approach to implement cyber security strategies (CSSs).

The HCS-IF is conceptually proposed to address the actual needs that are extracted from literature review. The HCS-IF uses and integrates a set of high-level conceptual security controls, solutions, processes, entities, tools, techniques or mechanisms that are already known in the domains of information security management, software engineering and project management to address the identified needs.

The HCS-IF components and controls collectively interact and cooperate to implement CSSs. The proposed framework is compared with other related frameworks, and the results show that the HCS-IF outperforms other frameworks on most of the suggested comparison criteria.

From a practical standpoint, governments and practitioners alike stand to gain from the findings of this research. Governments who want to implement CSSs on a national level will find the proposed framework useful in overseeing cyber security implementation. Practitioners will be prepared to address the anticipated cyber security implementation challenges and the required controls needed to facilitate cyber-security implementation in a holistic overarching manner.

This paper aims to explore hospital consultants' social identification, in terms of perceptions of their position in society, the salient targets for their social identification and how this appears to influence their perceptions of management activities and change.

A purposeful sample of 15 hospital consultants from a wide range of specialities and work locations in Ireland were recruited. Semi‐structured, in‐depth interviews were undertaken and thematic analysis was used to interpret the interview data.

The paper finds that all interviewees perceived public attitudes towards hospital consultants, as a group, to be negative. Twelve interviewees derived most sense of belonging from group membership within their immediate work area. These groups seemed to represent sources of validation and esteem and enabled consultants to exercise control over their work. Many consultants, however, described a sense of detachment from their employing health boards. Management, as a salient target for social group identification, was perceived as associated with powerlessness and lack of respect. Interviewees generally viewed involvement in management with little enthusiasm and considerable caution.

This paper shows that management approaches to hospital consultants could benefit from awareness that their social identity may already be under threat. Assaults on core professional values in the communication surrounding change are likely to provoke resistance. Existing work groups, with which consultants identify, could serve as a less threatening means to engage them with issues of cost and quality than externally imposed structures.

This paper informs ways in which hospital consultants could be more successfully involved in health service management.

This paper aims to examine the specific role that partnerships play in the relationship between adaptation strategy, international experience, and export performance of handicraft firms in an emerging country setting. The authors' purpose is to identify the key factors that may contribute to the success of export activities of small handicraft companies in international markets.

Drawing on a non-probability sampling technique, the authors collected survey data from 410 handicraft companies located in Morocco. The authors' conceptual model, which draws on the network theory, was tested using covariance-based Structural Equation Modeling by means of AMOS 24 Software.

The results indicate that adaptation marketing strategy and partnerships impact positively the export performance of handicraft firms. Partnerships also play an intermediary role by partially (fully) mediating the relationship between adaptation strategy (international experience) and export performance.

This study may assist marketers and entrepreneurs in handicraft companies to better understand the causal relationship between adaptation strategy, marketing experience and export performance of entrepreneurs' firms. Managers in these companies should be aware of the importance that partnerships play in boosting the export performance through marketing practices and experience.

The authors' paper contributes to the scant literature on the adaptation marketing strategy and export performance and the intermediary role of partnerships in the specific context of handicraft businesses operating in North African emerging markets, namely Morocco.

The purpose of this paper is to propose a novel maturity model for health-care cloud security (M²HCS), which focuses on assessing cyber security in cloud-based health-care environments by incorporating the sub-domains of health-care cyber security practices and introducing health-care-specific cyber security metrics. This study aims to expand the domain of health-care cyber security maturity model by including cloud-specific aspects than is usually seen in the literature.

The intended use of the proposed model was demonstrated using the evaluation method – “construct validity test” as the paper’s aim was to assess the final model and the output of the valuation. The study involved a literature-based case study of a national health-care foundation trust with an overall view because the model is assessed for the entire organisation. The data were complemented by examination of hospitals’ cyber security internal processes through web-accessible documents, and identified relevant literature.

The paper provides awareness about how organisational-related challenges have been identified as a main inhibiting factor for the adoption of cloud computing in health care. Regardless of the remunerations of cloud computing, its security maturity and levels of adoption varies, especially in health care. Maturity models provide a structure towards improving an organisation’s capabilities. It suggests that although several cyber security maturity models and standards resolving specific threats exist, there is a lack of maturity models for cloud-based health-care security.

Due to the selected research method, the research results may lack generalizability. Therefore, future research studies can investigate the propositions further. Another is that the current thresholds were determined empirically, although it worked for the case study assessment. However, to establish more realistic threshold levels, there is a need for more validation of the model using more case studies.

The paper includes maturity model for the assessment management and improvement of the security posture of a health-care organisation actively using cloud. For executives, it provides a detailed security assessment of the eHealth cloud to aid in decision making. For security experts, its quantitative metrics support proactive and reactive processes.

The paper fulfils a recognised requirement for security maturity model focussed on health-care cloud. It could be extended to resolve evolving cyber settings.

The purpose of this paper is to investigate where students in a Swedish compulsory school acquire their knowledge of food safety and how trustworthy they deem them to be.

A survey of students’ self-reported sources of and trust in food safety knowledge was performed. A student response system was used for data collection, and the students were asked to answer questions presented on a PowerPoint presentation using a small wireless handheld device: a clicker. A questionnaire with 24 questions was used, and the responses were collected at 18 different schools with a total of 529 participants attending school Year 9.

Mothers were reported as being the most important source of food safety knowledge (38 per cent), especially among girls, and were also given high credibility (36 per cent). Boys reported trusting home and consumer studies (HCS), fathers and media to a higher extent. Girls reported cooking at home more often but, for all students, it was more common to rarely or never cook at home, which is why HCS teaching can be seen as valuable for many students. HCS teaching needs to be improved in order to raise its credibility. About half of the students (51 per cent) reported to have the highest trust for their source of knowledge.

The students could only choose one source of knowledge and trust, although it is usual to learn from many different sources.

HCS teaching needs to get higher credibility among students as a counterweight against other sources.

Educated consumers could influence their health.

Limited research has been performed on food safety knowledge among adolescents.

The purpose of this paper is to evaluate the impact of delivering healthy eating messages through an interactive health corner (HC) on improving healthy dietary habits in participants.

Self-administered questionnaires were administered to participants after the education session. In total, 5,292 valid questionnaires were obtained, yielding a response rate of 93.3 per cent. In the last three months of the pilot study, a random sample of 305 from 1,493 participants was chosen and followed up six months later. Bivariate analysis was used to study the association of knowledge gained and attitude. Behavioural change was measured in terms of whether participants had reported an increase in their consumption of healthier food.

Majority (>98 per cent) of participants reported that the HC corner was useful, and had helped increase their awareness and knowledge of creating healthier meals and making healthier food choices. 95.7 per cent were willing to make changes after visiting the HC. At six months follow-up, 84 per cent of the participants reported positive changes in their dietary habits. Those who made positive changes were younger (mean age: 58.0 years) compared with those who did not (mean age 61.0 years, p=0.035).

Incorporating cooking demonstrations as part of nutrition education is effective in inculcating healthy eating practices and changing self-reported eating habits in the short term. Further research is needed to verify actual change in eating habits and to determine if this change is sustainable in the long run.

Currently, no similar initiative has been implemented and studied to evaluate the effectiveness of this mode of health promotion in a primary care setting. This study will help the authors to evaluate if the intervention was effective in changing attitudes and behaviours after an education session at the HC.

Domestic refrigerator manufacturers have had to cease their use of CFCs following the implementation of the Montreal Protocol. Two primary substitute refrigerants have been adopted; one being HFC‐134a and the other being hydrocarbons. Given the availability of hydrocarbons and pressure from both the green movement and the Framework Convention on Climate Change, there has been a marked increase in their use. The purpose of the paper is to examine the role of financial investment appraisal methods in the decision processes of refrigerator manufacturers in their responses to the phasing out of CFCs. The contribution made by financial decision tools to their decision‐making processes arising from the CFC phase‐out has not been reported. The decision choices of refrigerator manufacturers is of importance to the issue of whether their responses to the Protocol reflect a strategy designed to enhance long‐term competitiveness, or whether they were in response to immediate pressures to satisfy regulatory, cost and other short‐term interests. To address these issues, field study data were collected from refrigeration and refrigerant companies operating in Australia, Europe, New Zealand and the UK.

Portugal has been experiencing a continuous growth in tourism activity, with hospitality industry as one of the main tourism sectors. Therefore, the assessment of hotel companies’ performance is very important to assist decision processes. The purpose of this paper is to assess the financial performance (FP) of 570 hotel companies operating hotel units in Portugal in 2017. To explore the question of brand affiliation, a comparison was made between hotel companies with similar stars rating and market orientation. In addition, this paper intends to fill a gap in literature studying the Portuguese reality on the subject of brand affiliation.

The present study uses a methodology based on data envelopment analysis (DEA) to assess the overall performance for each company, which further decomposed into the within-group performance and the technological gap. The performance of the hotel company is assessed through the aggregation of multiple financial indicators using the composite indicator (CI) derived from the DEA model. A bivariate analysis based on the Tobit regression to test the robustness of brand effect on FP of hotel companies (HC) was also included.

The empirical results show that branded companies, on average, have significantly better overall FP than non-branded companies. On the one hand, the brand effect tends to improve the within-group FP of HCs and the brand presents a statistically significant positive effect on the FP. On the other hand, the best practices are observed in both branded and non-branded companies.

The results of this study illustrate that, globally, the better FP of the branded companies is because of their individual relative companies’ performance and a better model of operation given by the brand effect. Brand affiliation will generally allow for a better FP and essentially a better profitability for invested equity, a higher return on sales and a higher value added per employee.

The study provides important theoretical and practical contributions that can assist the strategic decision of the HCs in choosing to operate independently or to adopt brand affiliation. Also, it is innovative because the FP of branded and non-branded HCs is measured not using a set of individual financial ratios but through a single CI that aggregates those financial ratios, using a DEA model.