When large numbers of asylum seekers immigrate to a country, civil society is encouraged to contribute to their integration. A subgroup of asylum seekers comprising lesbian, gay, bisexual, transgender, or queer (LGBTQ) refugees are specifically deemed vulnerable to developing health and integration problems due to the double stigma of being a sexual/gender minority and a refugee. The Swedish Federation for LGBTQ Rights (RFSL) is a civil societal organization that has established the support group “RFSL Newcomers,” a health-related integration intervention that targets such refugees. The aim of the present study is reconstructing the subjective understanding of health of LGBTQ refugees.Eleven participants in Newcomers and eight organizers were interviewed about LGBTQ refugees’ experiences of migrating and participating in RFSL Newcomers. Qualitative content analysis was used to reconstruct subjective understandings of health that were constructed in these narratives. As the data did not originally concentrate on exploring understandings of health, a broad theoretical approach was used as a heuristic for the analysis, which focused on the common everyday approach of conceptualizing health as wellbeing.The narratives revealed three interconnected, interdependent categories of understanding health in which tensions occur between wellbeing and ill-being: belonging versus alienation, security and safety versus insecurity, and recognition versus denial. The categories contribute to an overarching theme of health as framed freedom – i.e., freedom framed by conditions of society.For our participants, belonging, recognition, and security/safety are conceptual elements of understanding health, not its social determinants. Thus, these understandings emphasize relational and existential meanings of health . As for practical implications, the understandings of health were connected to being either inside or outside the Newcomers group and a new society, depending on whether LGBTQ refugees comply with social requirements. As a significant actor that is representative of the cultural majority and a facilitator of LGBTQ refugees’ resettlement process, RFSL provides LGBTQ refugees with crucial orientations for becoming a “good migrant” and a “good LGBTQ person,” yet a “bad bio-citizen.” Generally, organizers of interventions may enhance the effectiveness of their interventions when relational, existential, and biomedical understandings of health are all incorporated. Migration has been a natural part of a globalized world, and more than 250 million people worldwide have migrated to achieve economic, political, and social objectives. Globally, 70.8 million people have been forcibly displaced from their homes due to conflicts and climate change . In 2015Civil society is highlighted as an important co-actor in the integration of newcomers –5 and caAmong migrants, lesbian, gay, bisexual, transgender, or queer (LGBTQ) refugees and other migrants (refugees hereafter) represent a subgroup whose number is hard to determine as the Swedish Migration Board does not publicize relevant statistics . NeverthDue to this double jeopardy, the health of LGBTQ refugees is generally considered a critical research interest. However, one barrier concerning current and future research may be the common reference to the biomedical health discourse, which defines how health is understood and framed. That presented “truth” about health might not match refugees’ understandings of health, which may impede the development of functional health-related interventions. However, there are few investigations on health understandings and discourses among migrants and hence LGBTQ refugees as far as we know. To fill this research gap, the aim of this explorative study is to reconstruct the understandings of health of LGBTQ refugees who participate in a Swedish health-related integration intervention group, “RFSL Newcomers,” and RFSL officials organizing the intervention.The study was conducted within the intervention “RFSL Newcomers,” which is run by RFSL, a Swedish non-profit and democratic organization founded in 1950. The federation aims to achieve the same rights, possibilities, and obligations for LGBTQ people as the rights enjoyed by non-LGBTQ people. RFSL is a Swedish civil society organization that has approximately 7,000 voluntary members . RFSL alThe RFSL Newcomers groups are health-related integration interventions that address issues of both health and integration. Presently, a total of 16 active local Newcomers groups are registered in Sweden. The study was conducted in three of the groups’ locations in the northern, eastern, and western parts of Sweden, which have different sizes and levels of support activities. Due to the variety of LGBTQ target groups in RFSL Newcomers, we could use different designations for their participants. However, the term “LGBTQ refugee” is preferentially used as it accurately describes most of the study participants. Furthermore, the word “Newcomers” with a capital N refers to the group, not individual members.a reference will be added after acceptance) that investigates the experiences of LGBTQ refugees during their migration process with focus on the role of the Newcomers groups, LGBTQ refugees’ thoughts about the future, and health’s implicit role. Due to this context, LGBTQ refugees’ understandings of health have been explored not by explicitly discussing health-related definitions and practices in the interviews, but by extracting information implicitly related to the refugees’ understandings of health from interview data on the migration process.This study is part of a larger explorative study . The organizers were all Swedish and had a few years of experience with meeting participants in Newcomers or coordinating Newcomers groups . Moreover, written informed consent was obtained from both the participants and organizers of Newcomers. In addition, the potential mental stress of the study participants was handled by offering counseling services from registered and context-aware counselors working at RFSL. This offer was introduced when informing participants about the study and its conditions before the interviews commenced. The study was approved by the Swedish Ethics Committee (Dnr 2018/734).The interview transcription formed a basis for a qualitative content analysis (QCA) , 30 withTo support the aim of the study and present an overview of the interviews, the transcribed data were first read individually by the two first authors who did the analytic groundwork. After the first naïve reading, interpretations were discussed to attain a shared initial understanding of the data. The next step was identifying and condensing meaning units , which sThe next step was categorizing different codes, resulting in three distinct categories, which were still at a manifest level of abstraction. The final step was creating an overarching theme at the latent level based on the three categories. The analysis process was nonlinear and shifted back and forth between the parts and the entirety of the data during the entire process. Codes, categories, and the theme were discussed among all four authors to ensure trustworthiness, while the two first authors integrated the results of these discussions in the analysis and completed it by engaging in a constant dialogue exchange.The data reveal three interconnected, interdependent categories: belonging versus alienation, security and safety versus insecurity, and recognition versus denial, in which tensions occur between wellbeing and ill-being. The three categories contribute to an overarching theme of health as framed freedom – i.e., freedom framed by requirements and environments of society. The categories are described and illustrated below using quotes that are characteristic of each category and indicate the interviews from which the quotes are retrieved .Belonging was connected to feelings and practices of human closeness, inclusion, and being responded to positively, with responses ranging from being seen at all  to recognizing people’s needs, as one of the participants stated: “we [the participants] all have different problems, but they [the organizers] try as much as they can to make us comfortable” (I-5). Belonging was also realized by appreciating people and generate energy, courage, and joy, as one participant described: “We have a lot of fun being here [at RFSL Newcomers]” (I-8). Belonging was elicited when existing members in a social context became involved with the newcomers, supported them, and provided an open, welcoming atmosphere. One of the participants (I-2) refers to this experience when he spoke of RFSL Newcomers, saying, “It felt like we got a new family.”I told my mom, “Mom, I feel like a girl.” But I felt really, really bad, so I went to the hospital (…) They did not have time to talk to me much (…) I have lived in the hospital, like for a while, like a month, and I have received a lot of tablets, and testosterone, and stuffs to be a man. (…) it was actually very difficult to experience [time] in the hospital, that I am not sick (…) why I am here, because I feel, I like guys, or, and I tried to take my life (I-1).The participants often generated images of wishing for belonging by describing adverse experiences of alienation in terms of conditioned inclusion, open exclusion, threat, or nonrecognition in different public and private social contexts.Contexts for adverse experiences span across nations and different group settings, relatives, friends, and the Swedish Migration Agency (SMA). According to the experiences of participants, being assigned an identity category that is fitting with one’s understanding of oneself by others functions as a condition of belonging and feeling well in all contexts. Overall, belonging exists in tension with alienation and is characterized by experiences of fitting in, being unconditionally accepted, or feeling activated, in contrast to feeling like a misfit, being merely conditionally accepted, or feeling passivized when alienated.… a lot of people feel very lonely… and a lot of people think it’s just them… “it’s just me in the whole world that is like this”… and many become friends and don’t have to feel so lonely and to understand that others/that there are others who have fled for the same reason; there are others who have also been imprisoned or have been subjected to murder attempts or been ostracized by their families, that you are not alone, and it is clear that it does something when you see it. Belonging was also highlighted by the organizers as one important condition for Newcomers. Participation inherently would lead to a sense of belonging:Some people were rather vulnerable and could not be in Sweden’s queer room – in other words, LGBTQ rooms – because they were exposed to racism and alienation, as well as cultural differences. And they couldn’t go to, for instance, the Somali association and hang there because they were LGBTQ, and that sexual orientation was not accepted. So that’s why we needed some kind of space for this target group. Like the participants, even organizers acknowledged a gap, where LGBTQ newcomers risked being alienated in the Swedish queer-community spaces and in their home-cultural setting, which eventually led to the formation of Newcomers:Belonging was thus risky and ambivalent. On the other hand, it might work as a social anchor and serve as a basis for other beneficial inputs to enhance wellbeing as well.Recognition was characterized by feelings of appreciative acknowledgment, acceptance, respect, and a mutual quality, as one of the participants puts it: “I… respect people and get respect back. When I came to Sweden, then it wasn’t a shock among the Swedish people (…) I opened up my sexuality (…) from the beginning. They helped, and there was no hatred or anything, but they accepted me” (I-11).Recognition was also received from other people and achieved for others and oneself, both as a person and for (representations of) personal identity. Thus, a legal, social, and self-referential dimension is part of the recognition, which assumes an important role in personal identity building and socially induced normalization within the RFSL context. One of them exemplified the individual dimension by claiming, “if you’re a self-seeker, [RFSL] is just [the] place to be” (I-8). Another illustrated the social dimension by stating, “By meeting people like me, I feel more comfortable and I feel comfortable when I open up my homosexuality status” (I-3), showing mutual acknowledgment in the Newcomers group and its empowering effect.“Migration” knows the story (…) in the interview, you said what happened, but they wanted to know the details when they raped you, what they were saying when they were raping you. It’s hard, I mean… they raped me… I told them [the migration officers] they hit me, everything they did to me, a bit like more and more details, it’s not so easy. And when they ask, it’s so hard you know, and they just say, “We need a strong story, like more” I say, “what more?,” they broke my arm, they had me one month, they raped me… what more can I say? (I-9)The legal dimension is important during the asylum process, especially during the interview at the SMA. Here, the tension between recognition and denial became visible. Most participants who were still seeking asylum described a lack of recognition from the administration regarding their story and the way they presented their lives. As this denial could lead to not being granted access to Swedish society, the construction of denial appeared as a feared antipode to recognition. One of the participants gave an example of this as a lack of acknowledgment and the helplessness it produced:We also have our counselor, who often has contact with those who are members of the Newcomers group too… because many need to get support on various issues. And partly because you think it is difficult in the asylum process, but also because of past experiences, you may need to talk about your identity to figure it out, and you may not have had words to express who you are before... we also have national lawyers within RFSL who can advise those who are in asylum processes. They do not take cases themselves, but they can help with consultation to the lawyer who has the case. .Here, the connection to questions of power becomes apparent as recognition cannot be performed by everybody, only those “in charge.” Moreover, acknowledgement of belonging to a category may be empowering or depowering. The legal, social, and self-referential dimensions of recognition were supported by organizers:In all cases, a person’s categorial belonging was investigated and determined. This indicates a close link between belonging and recognition. Thus, recognition is a result of determining who someone “really” is, as the organizer points out. Identity formation appears to be understood in two ways: the notion of a “real” identity reveals a basic essentialist assumption, whereas the need to negotiate one’s identity within a new linguistic space of possibilities highlights a processual and contextual character of identity formation. Both are represented in I-8’s aforementioned self-seeking: whereas the seeking represents the process, the self stands for the essential result expected to surface during the seeking process.The three processes of legal, social, and self-related recognition were described as co-occurring and lead to very different results. When these recognition dimensions work in harmony, wellbeing conditions are favorable. Whereas the SMA was described as a threat to that alignment and a representative of denial, RFSL presented themselves as non-judgmental as they were transparent about not being able to determine someone’s sexual orientation and gender identity. This was elucidated by one of the organizers: “We say that we cannot write a certificate that you are an LGBTQ person; I cannot certify it; only you have that identity, and you are the owner of that identity. However, we can certify that you are a member; we can certify that you have been here, and that is what we can do” .The category of security and safety was characterized as being free from threats with regard to either an existential or a spatial dimension and included participants’ commitment to cope with their vulnerability. Being safe and secure is critical to enhanced wellbeing. Moreover, being secure and safe from spatial threats  is the primary condition for feeling included in a social milieu and exploring one’s identity. As presented by one of the participants: “Yeah, first of all… the main thing is to be safe” (I-3). The participants did not feel safe and secure in unfavorable social circumstances, pointing to a counterpoint of insecurity that threatens wellbeing.Regarding the existential dimension of security and safety, the antipode of severe insecurity is described as a direct threat to physical life and mental health. Insecurity became apparent in participants' narration about their home country, family, and flight. For example, one of the them (I-4) was still afraid of his father, who joined him on his flight from a war-afflicted country to Sweden. The fear was associated with the force that his father may use to make him behave according to what his father considered manly.Immigrating to Sweden was often presented as reaching safety: “When I sat down on the flight, I felt my suffering was over” (I-11). That feeling was at times questioned by experiences of insecurity in the Swedish refugee camps, in which participants met people with the same derogative view of being LGBTQ as in their home countries. Here, the spatial and existential dimensions of safety, security, and insecurity overlap, providing a safe haven for personal existence – or precisely the opposite. One of the participants describes: “Actually, I don’t feel good at the camp, we are 20 people… from [2 countries], and they are Muslims, and I feel scared because I’m gay, and they don’t like homosexuals, they don’t like tattoos, and in some sense, I’m afraid (…) I don’t feel comfortable there” (I-10). Thus, both the LGBTQ refugees’ homelands and the refugee camps represented a potential danger as discursively constructed spaces of insecurity.Moreover, the availability and application of therapeutic and medical resources are critical to making LGBTQ refugees feel safe and secure since many must deal with trauma or illness. Here, some participants like I-4 described how they were helped by RFSL counsel in dealing with traumatic experiences.In addition, the tension between security and insecurity was highlighted in the spatio-cultural dimension, involving the task of occupying and orientating oneself with norms and values in certain milieus to feel safe. The goal was to feel secure and familiar with the required expectation “not to do stupid things that Swedes don’t accept” (I-2) in these living conditions. To feel safe and secure, it was expected of them to navigate Swedish society and become culturally and socially literate. One of the roles of the organizers was to facilitate contact with other agents in society: “It is really to get them out at workplaces or schools… to learn Swedish, meet Swedes…. Now they have met us a lot, but we are not enough, they need to meet even more Swedish friends” .Organizers took up roles as intermediaries, which matched the sentinel-like gatekeeper role they assumed during the data collection. Thus, they acted as buffers against society, and they are often considered as such by participants. For instance, regarding Swedish behavior and information about how Sweden functions, one of the participants explains: “(…) we have daily [RFSL-organized] training, where we can learn how Swedish society functions – how important it is to follow the law in Sweden… what you can do, and where you can ask for help” (I-8). Judging from these different ways of becoming safe and secure, “safety and security versus insecurity” are elements of wellbeing that represent not a status but a process that may be challenged in social situations.The three categories of belonging versus alienation, recognition versus denial, and security and safety versus insecurity are interrelated and social in nature. Their interrelation is mutually enhancing and results in increasing freedom as the overarching theme that comprises the ability to live ideally in a completely self-determined and self-realized manner after finishing a process of recognition by the LGBTQ refugees themselves and by the Swedish authorities. Recognition allows individuals to belong to the nation of Sweden and have a feeling of being safe and secure within its cultural frame. Hence, the theme focuses on framed freedom. One person elaborates that being free is synonymous with being safe, recognized, and belonging, which illustrates how the theme is built on the three categories: “I feel free here; I feel that I should not hide my identity; I am not ashamed that I am the way I am, and I feel safe doing what I want” I-10). Figure 0. FigureI have a lot to think about, so I can’t think about the future, and I can’t think of what my future will be like (...) I’m terrified. I’m afraid they’ll send me back to [my home country]. (I-10)Similar to these categories, framed freedom also includes a process-related component. In another part of the interview, one participant describes how he has little hope of being allowed to reside in Sweden permanently. This complements the potential to be free here and now with the notion of a change over time, eventually ending in a state in which a permanent resident permit serves as a final guarantor of safety and security. Thus, the freedom is also framed by demands for recognition and belonging, which are often represented by the “needle’s eye” of the migration interview, and the prospect of freedom exists in tension with a feared lack of prospects:Even when participants receive permanent permission to reside in Sweden, the prerequisites for freedom are still framed by circumstances connected to being LGBTQ: “some may feel that… outside Newcomers, you can’t be open to anyone, at least not someone who is from the same country, because you are afraid it [information] will reach your parents or others” . To sum up, freedom is framed by the results of the identity process and by the way in which LGBTQ people are received in society and blend in culturally.(...) the [RFSL Newcomers group] has been very helpful (...) I know how they helped me and checked on me, I know (...) I should also help other new people coming in, you understand? So, I should (?1) help them to help others. So, they give it to us, we should also give it to (1?). (I-6)Concerning freedom, the role of RFSL is changing from being a guardian-supporter to being equal. Often, participants position RFSL Newcomers as an organization to which they owe some debt that they must pay back:In such cases, they adopt the role of the organization without questioning. It may be assumed that paying back the “debt” is the last step of becoming truly free.The struggle, it’s not just saying at the Pride Festival: “okay, we have Newcomers, and we have the rainbow law; we are RFSL; we take care of them, we fight for rights for LGBTQ people and so on, but it’s not just a way to speak; so it’s not the words you say; you have to do something, that’s what I’m thinking. (I-1)Other participants in Newcomers talked about committing themselves to the political fight – either for LGBTQ or other people’s rights – and might intend to work for change within RFSL or on a broader societal level:The aim of this study was to reconstruct LGBTQ refugees’ understandings of health. Our data reveal three interconnected, interdependent categories that contribute to one overarching health theme. Belonging versus alienation, security and safety versus insecurity, and recognition versus denial must be navigated to achieve freedom framed by societal requirements and environments. Understandings of health and the identity of a healthy subject are constructed and developed in these tensions within the frame of the RFSL Newcomers groups, which has theoretical and practical implications.conceptual elements of health. As all of these categories are relational and have existential properties, the resulting theme of “health as framed freedom” transcends the role that typically is assigned to freedom regarding health. Usually, freedom is understood from an individualistic, neoliberal point of view, which is characterized by voluntarily demonstrating individual responsibility, prudence, health consciousness, health commitment and productivity regarding the construction of one’s healthiness. In doing so, such a person proves to be a good citizen in relation to health, a so-called good bio-citizen .However, there is still a potential inbuilt contradiction: adhering to the normative objections may promote the relational and existential health described by our participants, which challenges the normative expectations inherent to the hegemonic biomedical discourse with its individualized healthistic bio-citizens , 52. HenThis study is limited by the selection of participants from the Newcomers groups. It is evident that LGBTQ refugees feared being detected, and they were vulnerable to oppression and violence, which prevented some of them from participating and led to a limited number of study participants. Moreover, many of the (asylum-seeking) participants were in a position of dependency on RFSL during the interview. This position could have led them to present overly positive presentations of RFSL Newcomers. However, this is not deemed to be a limitation of our study as it does not question understandings of belonging, security/safety, and recognition within health as a framed freedom, judging from the contributions of participants with a permanent resident permit.This study does not explicitly explore LGBTQ refugees’ health understandings through health-related definitions, practices, experiences, and so on. Instead, the study explores health’s implicit relevancy and its role in LGBTQ refugees’ migration process. Thus, analytical attention must be directed towards health understandings. As we applied a broad and open approach to health, we regard our procedure as being able to meet the aim of this study. Not approaching the topic explicitly is actually deemed rather beneficial as we reconstruct how health as wellbeing is understood in everyday situations. We suggest that comparing explicit and implicit understandings of health could be an interesting task in future research.Using interpreters in some interviews is another presumable limitation as loss of information could have occurred. Moreover, the number of interpreters is limited, and they may be integrated into the respective ethnic minority culture, which may lead to a power imbalance and enhance feelings of vulnerability on the part of the LGBTQ person being interviewed , 55. We Following Mangrio et al. , we suggFuture research could focus on the relation between means of integration  and the From a public health perspective, this study provides useful knowledge about subjective understandings of health expressed by LGBTQ refugees (supported by organizers’ views) who participated in a Swedish health-related integration intervention, RFSL Newcomers, and the interplay between identity and health. The results could potentially be useful for increasing health literacy, as described in earlier research on refugees. Belonging, recognition, and security/safety are deemed conceptually relevant to experiencing health as framed freedom, which is simultaneously challenged by alienation, denial, and insecurity. This freedom is conditioned by societal and practical circumstances and requirements that give directions to health and identity, which may or may not allow access to the Newcomers group and the Swedish society.RFSL Newcomers appears to play a significant role as a representative model of the cultural majority and provider of directions, thereby facilitating a healthy resettlement process for LGBTQ refugees in Sweden. Determining what understanding of health to use as a basis for such interventions  is a task that needs to be consciously addressed by interventions organizers to support biomedically based bio-citizenship or create conditions for the promotion of a more relational, existential wellbeing. Generally, organizers of interventions may enhance the effectiveness of their interventions when relational, existential, and biomedical understandings of health are all incorporated.


Physical inactivity was identified as the prime behavior to change in order to reduce CVD risk in male taxi drivers. Male taxi drivers indicated a preference for an eHealth intervention to be delivered using smartphone technology, with a simple design, providing concise, straightforward, and relatable content, and with the ability to track and monitor progress.Taxi driving, a male-dominated occupation, is associated with an increased risk of cardiovascular disease (CVD). The increased risk is linked to a high prevalence of modifiable CVD risk factors including overweight/obesity, poor nutrition, smoking, excessive alcohol consumption and physical inactivity. Behaviour change interventions may prove advantageous, yet little research has been conducted to reduce CVD risk in this population. The purpose of this study was to co-design an eHealth intervention, ‘ManGuard’, to reduce CVD risk in male taxi drivers. The IDEAS framework was utilised to guide the development of the eHealth intervention, with the Behaviour Change Wheel (BCW) incorporated throughout to ensure the intervention was underpinned by behaviour change theory. Development and refinement of ManGuard was guided by current literature, input from a multidisciplinary team, an online survey, a systematic review and meta-analysis, and focus groups ( Globally, cardiovascular disease (CVD) remains the leading cause of mortality and morbidity . Men areDespite the well-reported risk of CVD associated with the occupation ,16,17,18One way to improve intervention uptake, adherence, and subsequent success is through electronic health  . eHealthCo-design, which involves an ongoing collaboration between researchers, developers, and end-users , allows In line with co-design, IDEAS draws on a human-centred design approach, through developing an understanding of the intervention’s end-users to ensure their needs are met . The fraGuided by IDEAS, ManGuard was developed through a robust co-design process, involving an iterative collaboration between interdisciplinary experts and end-users. This paper reports on the findings from phases 1–6 of the IDEAS framework, resulting in the development of a proof-of-concept (PoC) of the ManGuard intervention. A PoC is a theoretical demonstration of a product to ensure the idea is feasible and will function appropriately . The PoCReviews of eHealth interventions have reported an association between the inclusion of behaviour change theories and improved intervention effectiveness ,38. To pAligning with step 1 of the BCW , phase 1 of IDEAS aims to develop a greater understanding of the target population and their behaviours, allowing for the development of a more creative and motivating intervention . Phase 1Due to a lack of data available on taxi drivers working in Northern Ireland, an online survey was conducted to gain a greater understanding of the target population. Questions aimed to uncover their experiences of working as a taxi driver  and initial intervention preferences (format and content). The survey was conducted via two methods: (i) a Facebook group dedicated to male taxi drivers working in Northern Ireland (>1300 drivers); and (ii) through software used by those working for the country’s largest taxi company (>1200 drivers). The survey link was shared several times between September and November 2020 until responses ceased entirely. Survey responses were imported into Microsoft Excel to be assessed and reported descriptively.(i)A PhD student with expertise in clinical exercise physiology(ii)A nurse with expertise in cardiovascular nursing and rehabilitation(iii)A psychologist with expertise in cardiovascular care(iv)A health services researcher with expertise in developing and evaluating health/social care interventions(v)A computer scientist/software developer(vi)A mental health researcher and member of the Men’s Health Forum in Ireland (MHFI)(vii)Two male taxi drivers.Step two involved the formation and first of four meetings of the PAG, an interdisciplinary team of eight members, comprised of multidisciplinary experts:End-users involved in the PAG were sourced through a company memo, delivered directly to all drivers working for one of Northern Irelands largest taxi companies via software used by all employees. Those interested in taking part were instructed to contact JM using the email provided. Involving end-users from the outset has been reported to enhance the acceptability of the intervention, improving user engagement ,42. The Impact of behaviour change: The likely impact that changing the behaviour could have on the population;Likelihood of changing behaviour: The likelihood of the population being able to change the behaviour ;Spill over score: The possible spill over each behaviour change could have on another behaviour;Measurement score: How easy will it be to measure change in the behaviour.Phase 2 of IDEAS encompassed step 2 (select the target behaviour) and 3 (specify the target behaviour) of the BCW. The aim of phase 2 was to identify the behaviour(s) that the intervention would aim to modify for the greatest reduction in CVD risk for male taxi drivers, and the context in which the behaviour(s) should occur. The BCW recommends taking a “less is more approach, focusing on changing one or two behaviours” . Guided Next, the target behaviour(s) were specified by ascertaining the context in which it should occur for successful behaviour change to be achieved. Consideration was given to (i) who needs to perform the behaviour; (ii) what does the person need to do differently to achieve the desired change; (iii) when will they do it; (iv) where will they do it; (v) how often will they do it; and (vi) with whom will they do it .Phase 3 of IDEAS ensured the development of the intervention was grounded in behavioural theory, encompassing steps 4, 5, and 7 of the BCW. First, a behavioural analysis was conducted to identify the individual and environmental factors in need of modification to improve the likelihood of successful behaviour change occurring . The behavioural analysis was conducted using the findings from phase 1 and 2 of IDEAS, as well as existing literature, to aid a greater understanding of the taxi drivers’ capabilities, opportunities, and motivations. The BCW suggests that an individual needs to possess the capability, opportunity, and motivation to successfully change a behaviour (COM-B model) .Next, intervention functions that could foster behaviour change were identified . Intervention functions are defined as “broad categories of means by which an intervention can change behaviour” . The ideThe remaining three phases of IDEAS addressed in this study (phases 4–6) are recommended to occur iteratively, involving input from an interdisciplinary team (PAG) and end-users for the development and refinement of the intervention . To ensuPrototypes provide an opportunity to test potential intervention content, design, and associated interactions , whilst Three semi-structured online focus groups were conducted to gather end-user feedback for the refinement of intervention prototypes and content, with each focus group discussing different content. Questions focused on gaining feedback on language used, design, and anticipated navigation, steered by a topic guide developed by the research team. Recruitment was conducted online using the same methods used for conducting the online survey during phase 1. Focus group one aimed to gather feedback on minimal sketches of the anticipated layout and design of the intervention, as well as content for one module. Modules would provide educational materials in the form of ‘tips and tricks’, utilising motivational language to promote behaviour change. Focus group two aimed to display refinements made following the first session, in addition to content for a second module. The third and final session began with a display of refinements made following focus group two, and content for the remaining modules of the intervention. The same participants were involved during each focus group, with a £25 voucher provided for each session as a financial incentive.Focus groups were conducted online using the Microsoft Teams platform, with each session audio and video recorded, and then transcribed verbatim using Microsoft Word. Transcripts were analysed using an inductive approach through conventional content analysis . As the 2). On average respondents had been working for 10.8 years. Respondents were working an average of 5.7 days per week, for 9.6 h per shift, spending an average of 8.4 h seated during each shift. A total of forty responses were retrieved from the online survey. Thirteen respondents were aged 30–40 years, ten between 40–50 years, and fifteen between 50–60 years. Two respondents were above 60 years of age. Respondents had a mean height and weight of 176.6 cm and 97.6 kg, respectively (average BMI = 31.2 kg/mTwo-thirds (67.5%) of respondents were not completing the recommended levels of physical activity, with most dietary habits rated between ‘average’ and ‘very poor’. One quarter of respondents were cigarette smokers. The overconsumption of alcohol did not appear to be of considerable concern, with one quarter presenting as current smokers, and an average alcohol consumption of 14.6 units/week. Knowledge of CVD was lacking, with over half (57.5%) of respondents knowing ‘a little’ about the condition. Physical inactivity and smoking were perceived by respondents as posing the greatest risk to their heart health, accounting for a quarter of responses each. Three-quarters (74%) of respondents were interested in engaging in an eHealth intervention to reduce their risk of CVD, with smartphones deemed the most appropriate mode of delivery (85%). Preferences for intervention length varied greatly between 4–10 weeks, with intervention interaction between 1–3 times per week. Almost half of respondents (47.5%) indicated a preference for each session to last ten minutes. Suggestions for improving participant motivation included progress tracking, reminders, discussing the intervention with others, and observing physical improvements.High stress levels were highlighted as an area of significant concern for taxi drivers working in Northern Ireland, caused by financial pressures, long working hours, and abusive customers. High levels of stress were stated to have a direct impact on the likelihood of engaging in risky behaviours such as overconsuming alcohol and gambling. Specific to Northern Ireland is the impact of ‘The Troubles’, a conflict that lasted more than three decades. Although the conflict ended more than 20 years ago, taxi drivers continue to feel unsafe transporting customers to certain areas, adding to their overall levels of stress. Loneliness and a lack of support were also mentioned as consequences of the job. Dietary habits were identified as a lifestyle habit in need of modification, with recommendations for healthy swaps whilst on the road being most appropriate. Module length was highlighted as being insignificant if the user had the ability to pause and re-access the content in their own time. However, session length should be no longer than 10–15 min for improved user engagement. It was recommended to keep concepts broad, and to utilise a straightforward and simplistic approach of delivery. The inclusion of gamification was of little interest unless a financial reward was involved due to a lack relationships between drivers. Guided by a search of previously published literature, and the findings from phase 1, the common CVD-related risk behaviours associated with taxi driving were identified: physical inactivity, poor dietary choices, overconsumption of alcohol, and cigarette smoking. Physical activity was deemed the most appropriate behaviour to target to reduce CVD risk of male taxi drivers .Next, it was necessary to specify the target behaviour and the context in which it should occur for behaviour change to be achieved . Recent The behavioural analysis revealed that changes could be made to four of the six COM-B components to improve the target behaviour: psychological capability, social opportunity, and both reflective and automatic motivation. The identified components, alongside a description of what needs to occur for successful behaviour change, and why, can be found in Of nine intervention functions, seven were selected to facilitate change in the identified COM-B components: education, enablement, environmental restructuring, training, incentivisation, modelling, and persuasion. As discovered during the previous phases, knowledge of CVD, the positive impact of physical activity on CVD risk, and how to be active, are lacking. Thus, education was deemed appropriate for improving psychological capability and reflective motivation. Training and enablement were identified as functions to further improve psychological capabilities, imparting skills on how to incorporate physical activity into their daily routine, whilst helping to remove barriers to engaging in the behaviour.Due to the lonely and isolated nature of the job, enablement, modelling, and environmental restructuring, could enhance their social opportunities. To enhance reflective motivation, education and persuasion were identified as having the potential to improve beliefs regarding the benefits of physical activity. Lastly, to enhance the automatic motivation of taxi drivers, persuasion, incentivisation, and training could stimulate a positive attitude towards being physically active.Next, BCTs to successfully deliver the intervention functions were identified. As the Behaviour Change Technique Taxonomy (V1) is comprised of 93 individual BCTs, they are organised into 16 groupings. Ten groupings were identified as containing BCTs suitable for inclusion in ManGuard: (1) goals and planning; (2) feedback and monitoring; (3) social support; (4) shaping knowledge; (5) natural consequences; (6) comparison of behaviour; (7) repetition and substitution; (8) reward and threat; (9) comparison of outcomes; and (10) antecedents. Examples of the specific BCTs mapped to the intervention functions and COM-B components can be found in Due to the iterative process between ideation, prototype development, and refinement, the findings of phases 4 and 5 are presented together. During the first of three meetings of the PAG during these phases, a flowchart was displayed to present the core sections of ManGuard. Members of the PAG were satisfied with the core sections and the anticipated navigation. A social forum was proposed to allow taxi drivers to communicate with each other for improving social support. However, although agreed that it may prove beneficial, concerns of undesirable messages posted to the forum were raised. The provision of goal setting and progress tracking were confirmed as positive features. The taxi drivers recommended that users can assess and modify their goals over time to improve sustained engagement.Guided by this feedback, content for one module, along with low-fidelity prototypes, were developed. During the second meeting, the taxi drivers emphasised the importance of all information being delivered in a simple, straightforward manner, and absent of technical jargon. The incorporation of positive and “punchy” wording, with images, was recommended to make the information more engaging. Although physical activity was identified as the most appropriate behaviour, taxi drivers may benefit from a holistic approach regarding the delivery of content due to the presence of several CVD-related risk factors. Thus, modules would be classified as either ‘core’ or ‘voluntary modules’. Core modules include: (1) heart disease, lifestyle, and goal setting; (2) physical activity; (3) nutrition; and (4) program re-cap. Voluntary modules include: (1) alcohol; (2) smoking; and (3) managing stress. It was recommended that users can access modules in an order they choose, except for the introduction and re-cap modules. Concerns were raised that a structured and linear approach may impact user satisfaction, engagement, and adherence.Guided by this feedback, modifications were made to the low-fidelity prototypes and displayed during the third and final meeting of the PAG. A newly developed design for the homepage was well-received, perceived as straightforward and self-explanatory. The provision of positive welcome message at the start of each module was appreciated, recommended to be delivered using a pop-up feature to make it more attractive and engaging. Rather than a traditional graph for displaying user progress, it was recommended to use a “petrol gauge”, making the process more relatable to taxi drivers. It was agreed that physical activity would remain a primary option offered to the user for goals setting and progress tracking, with diet, smoking, and alcohol available as additional options. The inclusion of ‘awards’, collected by the user as they progress and achieve specific milestones, were perceived as a suitable method for the delivery of incentivisation and positive reinforcement.Six male taxi drivers, working in NI, were recruited to take part in three online focus groups. However, only four participants attended the first focus group. Following a lack of email responses between the first and second session, three participants were deemed to have withdrawn from the study. Therefore, three participants took part in the remaining two focus group sessions, lasting an average of 74 min. Four categories emerged from the analysis process: (1) program design; (2) program features; (3) program content; and (4) program engagement. A concise overview of key findings across the three focus groups are presented below under the associated categories.Program design relates to comments made regarding aesthetic aspects of ManGuard, including the overall design and anticipated navigation. Participants highlighted the importance of ensuring a simple, straightforward, and self-explanatory design throughout.“Simpler the better.”Enhancing user experience is crucial for improving engagement. Participants perceived that having the ability to switch between a ‘light’ and ‘dark’ mode would improve readability and subsequent user experience.“You know what’s good as well, I like apps… during the night if I’m reading… the writing turns white and all the white that you have there is black which makes it easier to read… if it’s all lit up like, it’s more annoying.”To improve the process of goal setting, a ‘slider’ option was included in place of the user manually typing their goal. Although participants agreed that this would make the process more engaging and visually attractive, it was recommended to provide an option to type the goal as the slider may not be acceptable to all users.“So, would you also have an option for someone to type it in? ‘Cos some people aren’t very good with sliders? Sliders is definitely more visual, but if you have like, if you’re using your mobile phone for it and you’ve got arthritis or something it can be very hard using those slider things…”“Yeah, I like it (slider), but as (P1) said, you can get some people who want to be really specific and you’re trying to get it right in the middle but struggling.”Between the first and second focus group, several logos for ManGuard were developed by a graphic designer. A design was chosen by the PAG, with all participants in agreement due to the plain, simple, and relatable design chosen, with “flashy” designs deemed less desirable.“I think it looks perfect. I think it looks clean, plain, it’s simple, you know, ManGuard, driving men’s wellbeing… like what else could you want? And then you’ve got a taxi logo there in the middle to act as an A as such, so no I think that’s perfect.”“All black the way it is, white writing, suits me down to the ground, that’s simple and clean.”“Yeah, I like that. I don’t like those flashy ones with loads of colour. It stands out well.”Program features relate to comments made on the characteristics of ManGuard, such as performance and functional capabilities. The utilisation of pop-ups with positive welcome messages at the start of each module was well received. Such a feature was highlighted as acting as an incentive to continue engaging with the module.“It makes it a bit more interesting I think than going onto a page that’s just full of static text… The pop-up thing is an added bonus to stay on the page, you know?”Concerns raised by the PAG members regarding the social forum, and it’s use for posting potentially offensive content, was further supported by the focus group participants.“Who’s going to monitor that messaging system?… All of us will know about taxi forums… there’s no concern to anybody… So, somebody needs to, you know, stop that.”In response to feedback regarding the social forum, a question and answer (Q&A) page was developed. During the testing of the MVP, this feature would allow users to message the research team, with the common queries and answers used to form a frequently asked question (FAQ) if ManGuard progressed beyond an MVP. Participants were in favour of this addition, perceiving this as a more acceptable option than the social forum. “What you’re saying is, if we have a problem that you would normally put on a forum for people, we would just send the question to you and… Yeah, probably better [than a social forum].”Awards, as a method of stimulating motivation and improved engagement, was not seen as a feature of great significance. It was highlighted that observing progress towards their goal would be sufficient motivation.“You know you’ve got one award, you might be a wee bit motivated to get two, but personally, I’d just be happy enough… if my target was 400 steps a day, if I hit that target that’s fine, you know what I mean?”Nonetheless, participants stated that it may prove motivational for others and recommended to retain awards in the final version.“I would keep them in because I know that there is people who like to see that stuff.”Program content relates to comments made on any information provided to the user, including text and imagery. Content across each page was recommended to remain concise to ensure users remained interested in the information. In addition, concise sections were deemed necessary due to the unpredictable nature of the job, allowing the user to better locate their place if they must leave the module due to work demands.“We have to remember its aimed at taxi drivers, so a lot of taxi drivers are going to be using this app in between jobs. So, you start reading something, then a job pops up. Say you have to go for straight away, so you don’t wanna be halfway down a three-page item that you lose your place when you come back to it… So nice short, concise paragraphs.”Following feedback from the PAG, imagery was incorporated throughout the content to accompany related information, highlighted as being appreciated by taxi drivers.“Or just put pictures in, taxi drivers love pictures.”Importantly, images should remain static, absent of links to external sites to prevent the user from becoming overwhelmed with information.“…if there’s too much to click, too much information… you can get lost… Keep the two things just as static pictures.”Feedback regarding clarity of information highlighted the need for minor modifications to be made. In particular, the phrase “we’re going to be with you all the way…” was deemed misleading and indicated that someone would be monitoring and providing direct advice throughout. “If you’re going to say we are going to be with you all the time… I mean, is somebody monitoring this in the background? Because if you’re not, you’re not with us all the way…”“… that implies that you or somebody associated with you is going to be more or less monitoring what we’re putting in.”Incorporating content throughout that was relatable to taxi drivers was perceived to be a method of improving user satisfactions and engagement. Focus group participants agreed, specifically highlighting the relatability of the diet and physical activity content, respectively.“I think that’s extremely realistic… I think that’s bang on.”“Have you been following me around or something? I eat and drink all of them.”Of significant importance was the feedback gathered on the module for coping with stress. It was indicated that due to the impact of the COVID-19 pandemic on the taxi industry, this module was more important now than ever.“Really, I would say that’s the most important one to be honest here.”“Particularly over COVID, that one’s really brilliant… they were a forgotten industry and support… really were terribly supported.”The final category, program engagement, regards comments made on aspects of ManGuard that could both positively and negatively impact accessibility and usability of ManGuard. Financial incentives were stated as a tool that would stimulate motivation and sustained engagement.“…maybe, it’ll motivate us more if it was like when you get to level one you receive a £10 voucher, level 2 it’s £20…”Whilst engaging with the content, it was recommended to minimise the amount of ‘scrolling’ and ‘clicking’ throughout to prevent the user from losing interest and enhancing satisfaction. “… keep it as little as possible on each page and you have to click to go to the next one. If you’re scrolling, again me personally, I get bored and start flicking through it and miss sections.”The provision of informational pop-ups, discussed previously, were deemed as being a more interesting method of delivering content, providing an incentive to remain on the page and engage with the content.“It makes it a bit more interesting I think than going onto a page that just full of static text with maybe the odd video… The pop-up thing is an added bonus to stay on the page you know?”This paper describes the robust step-by-step development, guided by the IDEAS framework, of an eHealth intervention (ManGuard) to reduce CVD risk in male taxi drivers. Additionally, to ensure the development of an intervention underpinned by behaviour change theory, the BCW was incorporated throughout the relevant phases of IDEAS. Intervention development involved an iterative process, guided by current literature, input from a multidisciplinary team (PAG), an online survey, a systematic review and meta-analysis, and focus groups with end-users. Survey responses support reports of male tax drivers engaging in higher levels of CVD-related risk behaviours. Such behaviours include physical inactivity ,11,15,51It appears that although NI taxi drivers engage in greater levels of CVD-related risk behaviours, they are aware of the negative impact this has on their CVD risk. Interviews with taxi drivers report that the long shifts cause fatigue and a subsequent lack of energy for engaging in physical activity . A lack The online survey and input from the PAG further support previously reported associations between taxi driving and higher perceived levels of psychological stress ,56,57,58Although associations between stress and greater levels of engagement in CVD-related risk behaviours such as physical inactivity, poor diet, alcohol consumption, and smoking is well reported in the general population ,60,61, aThe online survey and conversations held with taxi drivers during PAG meetings helped uncover knowledge regarding the working lives of taxi drivers in Northern Ireland, data previously unexplored. Similar to previous research conducted with taxi drivers in other countries ,14,56,57Findings from this study revealed the preferences of male taxi drivers for a novel eHealth intervention. Identified preferences of male taxi drivers in Northern Ireland are similar to those expressed previously by male taxi drivers in New York City, such as the intervention being delivered using smartphones  , with a There are some limitations to consider. First, and most important, was the participant attrition during the collection of qualitative data through online focus groups. Although risk management strategies were in place to reduce attrition, these were unsuccessful. As the study suffered from time-constraints due to the COVID-19 pandemic, it was not possible to delay data collection to allow for further recruitment to replace those that had withdrawn. Additional time may also have strengthened the study further, allowing for the conduction of qualitative interviewing during phase 1 to gain a further understanding of the target population. Second, although many taxi drivers expressed an interest in taking part in the study, recruitment to the online focus groups was poor. It is possible that taxi drivers dislike focus groups, or the online approach that was utilised due to COVID-19 restrictions. Future research should consider uncovering taxi driver preferences for engaging in research, including recruitment methods and data collection techniques.This paper has reported on the utilisation of the IDEAS framework, incorporating the BCW throughout, for the co-design of an eHealth intervention (ManGuard) to reduce CVD risk in male taxi drivers working in Northern Ireland. Taxi driving as an occupation is associated with an increased risk of developing CVD. Yet, there are few interventions developed to reduce this risk, with poor participant attrition and intervention engagement reported. Co-design is one such way to develop an intervention that will be better accepted by the end-user. Male taxi drivers indicated a preference for an eHealth intervention delivered using smartphone technology, with a simple design, providing concise, straightforward, and relatable content, and with the ability to track and monitor progress. Next, in line with IDEAS, the PoC of ManGuard will be developed into an MVP to undergo feasibility testing (Phase 8). A protocol for the proposed feasibility trial has been published online .


Early progressive mobilization is a safe strategy in the intensive care unit (ICU), however, it is still considered challenging by the inherent barriers and poor adherence to early mobilization protocol. The aim of this study was to evaluate the effectiveness of a quality improvement (QI) multifaceted strategy with implementation of a specific visual tool, the “mobility clock”, in reducing non-compliance with the institutional early mobilization (EM) protocol in adult ICUs. A single-center QI with a retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases. Patients from different periods presented similar baseline characteristics. After the QI strategy, a decline in “non-compliance” with the protocol was observed compared to the previous period . The proportion of patients walking was significantly higher  and the ICU readmission rate was lower in the “after” period . The multifaceted strategy specifically designed considering institutional barriers was effective to increase out of bed mobilization, to reduce the “non-compliance” rate with the protocol and to achieve a higher level of mobility in adult ICUs of a tertiary hospital. At present, ABCDE bundle is considered a remarkable strategy to optimize ICU care recovery and outcomes2. Early progressive mobilization, represented as the “E” bundle component is a safe strategy to reduce ICU-acquired weakness (ICU-AW), which can cause a direct impairment of functional status. That condition can perpetuate after hospital discharge, affecting the quality of life and social reintegration9.The continuous improvement in critical illness survival has led to increasing recognition of the long-term consequences of therapy in intensive care unit (ICU). This repercussion goes beyond the physical aspect and extends to social, cognitive, and mental health function11. In the ICU environment there are multifactorial barriers related to the structural context, process, culture, in addition to patient-related factors15. The improvement of patient’s mobility level must consider all those barriers present at the moment14 and, therefore, setting strategies to overcome them with a multidisciplinary approach towards early mobilization (EM) is recommended24.Although mobilization is considered essential and recommended to start immediately after physiologic stabilization, the number of patients in compliance with this recommendation that are mobilized out of bed is considered low and is less than predicted by known safety criteria and patient clinical condition25.The first EM protocol in our institution was developed in adult ICUs in 2011, and its use started in that same year. It contained four progressive intervention plans, the Medical Research Council (MRC) grading system and the Surgical Unit Optimal Mobilization Score (SOMS) were used, respectively, in patients who are alert and attentive and in those who were unable to follow commands16. After this update in the EM concept, we started to monitor the proportion of patients mobilized out of bed in the institutional indicator named as “verticalization” rate. Likewise, the proportion of patients who do not have contraindications but are not mobilized out of bed as prioritized in our EM protocol, came to be accounted by the indicator named as “non-compliance” rate. These indicators are collected monthly by a physical therapist through the patient’s medical record from the preceding 24 h, without the team’s previous knowledge in a one-day point-prevalence. The reasons not to mobilize as well, the barriers perceived by the physical therapist on duty are investigated at this moment. For any data uncertainties, the responsible physical therapist could question the health employees on duty.In 2018, ICU physical therapy team, based on the current literature, updated their EM knowledge. Due to that process, in our institution, EM came to be defined as activities with axial loading (sitting on the edge of the bed or greater levels of out of bed mobilization) as proposed by Harrold et al. in 2015 24.The preliminary data analysis of this indicator demonstrated that our “verticalization” and the “non-compliance” rate was 36.3% and 24%, respectively. This result was considered as a nonconformity, since some level of out of bed mobilization was expected from those patients considering they had clinical conditions to be “verticalized” without any contraindications Based on the data provided from the institutional mobilization indicator and the multidisciplinary perception consolidated in a workshop, a multifaceted improvement strategy was proposed. The aim of our study was to evaluate the effectiveness of these strategies in reducing non-compliance with the institutional EM protocol in adult ICUs of a tertiary hospital.26 (Supplementary).This study was a QI project that followed the revised Standards for Quality Improvement Reporting Excellence (SQUIRE2) guidelinesThis QI project received ethics approval from the research ethics committee of the Hospital Sírio Libanês/Sociedade Beneficiente de Senhoras (CEPesq/HSL), with a reference number: CEPesq HSL2019-84. This committee in addition to releasing the research protocol, waived the need of informed consent form since the study is a retrospective review of data from medical records and hospital electronic database. The methods were carried out in accordance with the relevant guidelines and regulation.This single-center QI with retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases in 2019 at the Sírio-Libanês Hospital, São Paulo, Brazil , one neurological ICU (8 beds), and two cardiologic ICUs (20 beds). The ICU staffing comprised of a physician (staff-to-patient ratio 1:5), registered nurse (staff-to-patient ratio 1:2), and physiotherapist (staff-to-patient ratio 1:5). A daily multidisciplinary round to determine the goals of care was performed in both periods, considering the ABCDE bundle. The EM goal in the before period was one of the discussion topics among the team during the rounds but without the use of a mobility tool to guide that decision.®.Data was retrospectively collected from admission to hospital discharge from medical records and hospital electronic databases. Patient baseline information including demographics, comorbidities, and severity of illness at ICU admission and readmission was obtained from Epimed Solutions27. SOMS scale was applied only to patients unable to follow commands, and the presence or absence of this form of evaluation was assessed on both groups.Using a standardized checklist (Supplementary), the same professional already in charge of the institutional indicator was responsible for the “verticalization” and “non-compliance” rate collection, in order to maintain greater reliability and validity. The “verticalization” and “non-compliance” rate were monitored for a period of four months before and after the QI initiative. The presence of ICU-AW was assessed as well with MRC in patients alert and able to follow commands, as recommended by the institutional mobilization protocol. It was defined by MRC < 48 in patients that had no plausible etiology for weakness other than critical illnessVariables related to ICU-AW risk factors as mechanical ventilation > 72 h, use of sedation, analgesia, neuromuscular blockers, corticosteroids, sepsis, septic shock, and immobilism (defined as the permanence on bed for more than 50% of the day) were collected.The project researchers, through our institutional electronic medical records, also collected variables related to the outcomes as ICU length of stay, mobilization barriers and the highest achieved mobility landmark of the day. All mobilization’s barriers perceived by the physical therapists during their care were also recorded; as presence of sedation, patient’s devices , mechanical circulatory assist device, vasoactive drugs, renal supplementation therapy, presence of pain, weakness, endotracheal intubation, tracheostomy, mechanical ventilation, non-invasive ventilation or high flow nasal cannula.If any patient’s information was missing, the researchers or the professional in charge of the institutional indicator could access the assistance team to resolve relevant queries. The checklist and the spreadsheet used to compute the data were double-checked to avoid any data loss or incomplete data.28.To elaborate the improvement strategy, initially, we performed a summary of the evidence considering out-of-bed mobilization. Posteriorly, we optioned to understand the problem from the perspective of the multidisciplinary team. We organized a brainstorming during a workshop freely listed by the participants (the results were grouped in an Ishikawa diagram) and an online multiple-choice questionnaire. Both addressing the modifiable barriers related to environment, patient, staff, and process. Finally, the team perception was paired with the data obtained from a meticulous verification of the patient’s medical records to elucidate modifiable barriers involved in the cases of patients who were moveable and those who were not29.After analyzing the results of these activities, we verified the importance of improving communication between the characters involved, planning, and process individualization considering the specific barriers, in addition to patient and family participation. Considering these points, a visual tool was developed named as “mobility clock” Fig.  to simulAn action plan was prepared and set in motion to inaugurate the “mobility clock” during the “mobilization week”. It consisted in various activities created for the multidisciplinary team regarding the importance of ICU mobilization. To sensitize the team about the importance of EM, the week initiated with a talk show from a patient who developed quadriplegia due to immobilization. The patient, his family members and the professionals involved shared their personal experience during the period of ICU hospitalization and the impact after hospital discharge. During that week, a lecture with updated literature data on out-of-bed ICU mobilization was ministered.28.The internal audit results along with institutional modifiable barriers were presented along with the “mobility clock” through an animation specifically produced to explain its development and application. To conclude it, the “mobilization challenge” was released. It consisted in a four-week competition between the ICU units with the purpose of establishing the use of the “mobility clock” by the team. The winning unit would be the one that mobilized the largest number of eligible patients using the “mobility clock”. During this period, a podcast explaining how to use the “mobility clock” and the challenge rules was broadcasted on the institution’s channels. Banners referring to mobility were displayed at the entrance of each unit. To motivate the staff to the cause, stickers encouraging mobilization and chocolate treats were distributed The “mobility clock” was placed in the ICU rooms to be visible to the patient, family, and staff. One clock pointer marked the mobility level that was set as the goal and the other the landmark that the patient achieved. To improve communication in the multidisciplinary round, the expected goal per patient was determined considering the barriers presented, as well as the physical condition of each individual. At this time, if possible, the importance of reaching the chosen mobility landmark on the day was explained to the patient and family. The clock hand that corresponded to the landmark achieved by the patient was moved during the day as soon as the mobility level was reached.During the before-after period, no other institutional strategy regarding EM was employed.The sample size (at least 88 patients per period) was calculated based on a previous pilot study considering the number necessary to reduce the “non-compliance” with the protocol on 10%, given a two-tailed type 1 error of 5% and a power of 80%. Quantitative continuous variables were compared using the Mann–Whitney U test for non-normally distributed variables with interquartile values used to represent data dispersion. The means of normally distributed variables were compared using Student’s t-test. Pearson’s chi-squared test and Fisher’s exact test were used to compare the categorical variables. The significance level was set at p ≤ 0.05 (two-tailed).The EM protocol “verticalization” rate was monitored for a period of four months before and after the strategy to achieve the sample. In the “before” period, 179 patients were screened. Of these, 90 were excluded because they presented at least one mobility contraindication. During the “after” period, 177 patients were screened, with the exclusion of 88 patients, for the same reason as mentioned above, remaining 89 patients on this period Fig. . Both grThe risk factors for ICU-AW presented at indicator data were similar between the groups except for the use of corticosteroids that was significantly greater in the “after” period  Table .Table 2RThe ICU-AW identified by means of an MRC < 48 was similar between the groups. The proportion of patients whose MRC was not possible to be applied, requiring SOMS to be performed, was higher in the “after” period but without statistical significance  Fig. .Figure 4No differences between the periods were observed in the hospital and lCU length of stay, as well as in the mortality rate. However, the ICU readmission rate was lower on the “after” period  , one year mortality was approximately 28% and was related to age, disease severity, comorbidities, and ICU re-admissionsA limitation of our study was the before-and-after design that carries the biases inherent to the temporal variation and the impact of confounders that were not considered, as well as the single-center QI limiting the external validity. Further research on this topic should be implemented, including multicenter prospective randomized studies focusing on the clinical and economic outcomes of mobilization QI projects.The multifaceted strategy was effective to reduce “non-compliance” rate to EM protocol of a tertiary hospital. In addition, promoted a higher level of mobility landmark. In further research, it would be interesting to study the effectiveness of these strategies in different centers, with more suitable study designs involving clinical outcomes as the readmission rate. Furthermore, considering hospital and ICU length of stay, the economic impact of these mobilization-QI projects is also an important field of study and may encourage future investigations.A QI multidisciplinary approach in a brief period can positively influence patient mobilization and team engagement without additional costs for the service and with a simple and intuitive tool.Supplementary Information.


Digitalized independent workers, known as gig workers, have been shown to work under high-pressure, with a lack of autonomy, a lack of feedback and perceived competence, and a high level of isolation. We conducted a literature review to investigate how gig workers cope with these sources of stress. We identified primary sources of psychological stress in gig work and the main strategies used by workers for coping with them. We show that focusing solely on identifying coping strategies depicts a fragmented literature, making it impossible to compare, link, or aggregate findings. We suggest a radar classification of coping based on the motivational action theory of coping and self-determination theory that defines coping as a process to adapt to the environment and maintain well-being. We argue that this framework is both relevant and necessary for developing research on gig-worker coping. Like any species, we are hard-wired to protect ourselves from threats to health and safety to survive . ThreatsResearchers on new forms of work have identified “paradoxes” regarding organizational health and safety (OHS). For instance, one of the most studied yet conflicting areas of the literature on new digital forms of labor, namely, gig work, concerns the “autonomy paradox”. Employees wanting to work anytime, anywhere end up working every time and everywhere . “The giGig workers’ behavior, compared to traditional employment settings, is not controlled by managerial interactions, and in theory, they can choose when to work. However, platforms enable control of these workers through regulations on how the work should be done and the penalization of workers. Platforms can collect a variety of data from workers and monitor many aspects of worker behavior, setting goals that workers usually have little freedom to accept or decline. They have little time to decide, and both their performance rate and future assignments get affected if they refuse the task . Gig worWe suggest that the current approach in the study of gig workers’ coping strategies will lead to a lack of consensus on coping, which impedes the development of the field, practically, theoretically, and methodologically. While the literature on gig coping is still young and growing, scholars in this field are borrowing theories from more mature streams in the literature and are following their approach to examining coping. This can lead the coping literature in the gig-work context to face the same problems as those existing in mature contexts . For instance, the coping literature in the academic context has shown that the concept of coping is fragmented due to relying on lists of multidimensional lower-order categories  that likely serve many functions without making efforts to explain how they are functionally related or different. This approach has made it difficult to scrutinize, aggregate, or compare this knowledge and will lead to a fragmented view of coping . In a seOur aim is to empower future research with a categorization process of coping based on empirically tested theories of behavior to avoid conceptual fragmentation of coping and produce knowledge that can be compared and integrated. Our radar framework extends research with a framework for data analysis, particularly for examining online forum comments. Propositions developed in this paper can be tested using validated measures of the constructs (see ).One of the most studied concepts in almost all situations concerns “how people cope with stressful situations”. The study of coping is fundamental because researchers agree that coping can reduce or amplify the effects of negative events and conditions on emotional distress and well-being . As SkinThe motivational conceptualization of coping formulated by Skinner et al.  defines Through multiple deductive and inductive studies (starting from the academic context of children), Skinner and their colleagues ,17,18 inGig work involves at least three stakeholders, including the platform, clients, or “buyers”; independent workers or “suppliers”; and the digital labor platform organization, which serves as an intermediary coordinating buyers and suppliers . PlatforKellogg, Valentine, and Christin’s  influentThe gig work literature has shown that gig workers are not passive regarding need frustration, and they respond in a variety of behaviors ,9,28,29.In another study on coping with algorithms, Jarrahi and Sutherland  found thPregenzer and their colleagues  have stuThe six studies of coping that we reviewed in the previous paragraphs resulted in fourteen coping strategies, so it is likely that relying on lower-order categorizations for coping will make it difficult to aggregate the literature. We used data (findings and interpretations) on gig-worker coping strategies to investigate whether gig-worker coping strategies can be categorized into the hierarchical structure of coping proposed by Skinner and their colleagues ,18 in thSelf-determination theory (SDT) argues that humans have the potential for growth, integration, and well-being while also being vulnerable to defensiveness, aggression, and ill-being . Within The current list of these needs consists of the need for autonomy or experiencing volition and willingness; relatedness or experiencing warmth, bonding, and care from significant others; and competence or experiencing mastery and ability to cause desired outcomes ,34,35,36The hierarchical structure of coping is based on a motivational action theory of coping that argues that three classes of concerns related to individuals’ basic psychological needs  trigger organized biobehavioral responses or “families of coping” ,17,18. IRockmann and Ballinger  tested tSpecies face multiple fundamental adaptational problems that need to be addressed for their survival ,16, and The hierarchical structure consists of two intermediate levels. Lower-order categories or “ways of coping” are categories that classify “instances of coping” (items or observations) into mutually exclusive categories . Higher-order categories are “families of coping” that classify ways of coping according to their adaptive functions. Each family of coping is organized around (1) whether the concern is appraised as a challenge versus a threat and (2) whether the ways of coping are targeted at oneself or one’s context. The criteria for family membership are behaviors, emotions, and orientations that each pattern of appraisal triggers. For instance, an appraisal of a “challenge for autonomy” will be accompanied by an “Accommodation” or a “Negotiation” coping family. Still, if the level of stress related to the concern increases such that it becomes appraised as a “threat to autonomy,” it will be accompanied by “submission” and “opposition,” depending on whether a person decides to target the self or the context. The result is higher-order families of coping organized around three basic psychological needs, two appraisals of challenge vs. threat , and twoBorrowing from Skinner et al. ,17,18 thWe believe a radar arrangement of the dimensions of coping makes it easier to understand, remember, and interpret. Our proposed radar of copings in gig work includes 12 families of coping identified based on (a) three basic psychological needs, (b) two appraisals of challenges or threats, and (c) two targets, self or context. These 12 families of coping connect first-order instances of coping to higher-order adaptive processes of coping, and each involves a set of related behaviors, emotions, and orientation, and they are arranged in three sets of four. The radar is designed to highlight the critical roles of three basic psychological needs and constructive coping families, those that are triggered as “challenge” appraisals of contextual factors. These coping families are highlighted in our framework. In the radar, the first set involves concerns for autonomy and is triggered when workers feel pressured to act against their will. The second set of coping families involves concerns about competence and is triggered when workers perceive a lack of information to predict work outcomes in the context. The third set of four involves challenges and threats to relatedness and is triggered when workers feel that they are not trusted or cannot trust important others.According to self-determination theory, contexts that frustrate the needs for autonomy, competence, and relatedness will lead to high levels of psychological stress and consequently to decreased motivation and well-being ,18,19,22Similarly, we can see from the gig worker literature that rewards and incentives to motivate them to show specific behaviors (accept more tasks and create specific results) can undermine autonomy. In the same way, lack of feedback and lack of information about how to perform the task undermines the need for competence, and finally, a cold working climate for gig workers  undermines the need for relatedness. Some need-depleting factors are identified in the gig literature that does not relate to the academic context. In the work context, an important controlling factor is compensation and payments. Platforms undermine autonomy through controls on pay rates and the financial dependency of workers on the platform to motivate them to work more.Contexts that threaten the need for “autonomy” for children and adults are characterized as those that pressure them with rules or rewards to enact specific behaviors, express certain feelings, or accept certain goals or courses of action [f action ,18. Jabaf action  argue thf action . When anf action ,9,24, anf action ,9,24, leContexts that threaten the need for “competence” for children and adults are characterized as those that lack the information about producing desired effects and are inconsistent, random, discriminatory, or unfair [r unfair ,18. In tr unfair . WorkersContexts that threaten the need for “relatedness” for children and adults are characterized as those in which they do not receive enough care, respect, communication, and affection from their teachers, classmates, or parents [ parents ,18. Plat parents ,12. ZhanThe gig-worker coping literature uses the terms “challenge” and “threat” interchangeably, whereas the established literature of academic and traditional work context suggests that risk factors, demands, or negative experiences differ based on whether they are perceived as challenges or threats ,43,45,46These studies suggest that appraisals of challenge versus threat can affect well-being and health either directly by frustrating basic psychological needs or by triggering ways of coping that deal harshly with the self  or with a stressful situation  that are instrumental for managing stress and negative emotions, but they are detrimental for health over time. The first group of ways of coping contributes to well-being through the construction of coping resources, such as self-reliance, confidence, and interpersonal trust. In contrast, the prolonged use of the second group of ways of coping, over time, contributes to the accumulation of vulnerabilities, such as low self-efficacy or interpersonal hostility . For insWe argue that it is important to differentiate coping strategies that are initiated based on perceptions of challenges from threats in gig work, since it would help researchers to identify those characteristics of an algorithm that should be changed or intervened, as they can only usefully be perceived as threats when considering those they affect, and with thoughtful design of the algorithm, challenging aspects of the job may even elicit engagement and well-being. Negative feedback, time pressure, and cognitive demands have good potential to be perceived as challenges, whereas role ambiguity, job insecurity, and interpersonal issues are more likely to be perceived as threats by workers . For insMost typologies of coping involve distinguishing coping based on whether the coping targets the self or the context. For example, within appraised challenges to autonomy, one can target the self by attempting to accept and accommodate control We searched for gig-worker coping literature to see how authors conceptualize coping strategies in response to the frustration of each basic psychological need and what dimensions were identified. For the purpose of this study, we selected a handful of studies that had enough explanations and participant quotations to help us identify the “emotions, orientations, and behaviors” of strategies and classify them based on Skinner’s  hierarchAn overview of the selected papers, their coping strategies, and the corresponding “coping families” based on our interpretation is presented in The first set of four on our radar relates to the need for autonomy. When a challenge to autonomy is appraised, individuals either “accommodate” (self-targeted coping) or “negotiate” for their autonomy. When the source of stress is appraised as a threat to autonomy, two rigid families of coping may arise based on the target of coping. “Submission” is a more rigid form of “accommodation” when one gets obsessed with negative thoughts related to loss of autonomy, and “opposition” is a more rigid form of “negotiation,” where “revenge, anger, and aggression” help the individual with extreme loss of autonomy.As a higher-order family of coping, “submission” refers to pressuring the self to respond in overregulated ways; thus, it is a pattern of emotion regulation of “self-blame or disgust” and regulates “rumination and obsession” and behaviors such as “rigidity”. Rumination refers to a passive and repetitive focus on the negative and damaging features of a stressful context . “I don’In the context of gig work, Walker et al.  describeAs a higher-order family of coping, “accommodation” refers to adjusting one’s preferences to current constraints; thus, it is a pattern of emotional regulation of “acceptance,” an orientation regulation of “commitment or endorsement,” and behaviors such as “committed compliance or cooperation”. “I will decide” is a sample pattern of appraisal for “accommodation” and contributes to an endorsement of control and showing flexibility in behavior. These individuals emotionally “accept” the context and reflect and rely on its benefits and responsibilities.Compliance is a prevalent theme in gig work literature, but it is important to differentiate different forms of compliance based on whether it is oriented toward endorsement and commitment  or self-doubt and staying away from the threat . Bucher et al.  showed tFamilies of coping that promote constructive engagement with stressors and are triggered in response to an appraised challenge to autonomy are “Accommodation” and “Negation”; the former concerns targeting the self to “accept” the situation and endorses its benefits, and the latter concerns targeting context by taking to account other’s perspective, setting priorities based on available options and making compromises according to the priorities. As a higher-order family of coping, “negotiation” involves actions such as proposing a compromise, bargaining, and persuasion. Individuals, through these strategies, deal with the context to generate more options for themselves. “I will reduce the pressure” is a sample pattern of appraisal for this category.In the context of gig work, Bucher et al.  found thWhen individuals appraise the context as a threat to their autonomy, and they target the context for coping , a set of action regulations focusing on orientation of “reactance or revenge,” emotions of “anger or blaming others,” and “aggressive behaviors” will be triggered. In the context of gig work, workers show high-intensity resistance to remove themselves from control and are unable or unwilling to find mitigating tactics to engage in the “opposition” family of coping, which includes behaviors such as voicing allegations and resentment, quitting, or destructive behavior accompanied by distrust and disgust towards the platforms—and sometimes the users . Such agWhen workers appraise a “threat” to competence, they will trigger extreme forms of regulation, such as the emotion of “self-doubt” relative to “challenge” appraisals that trigger constructive coping regulations, such as the emotion of “determination”. “As a higher-order family of coping, helplessness refers to a set of actions organized around relinquishment of control”  (p. 27).In the context of gig work, Walker et al. , in theiIn the case of challenged competence, if workers target the self and engage in individualized actions to respond to psychological stress, they will use the “problem solving” family of coping. The orientation is to gain “mastery” in work with active attempts to produce effects and determination. “I will accomplish that” is an example of an appraisal pattern associated with this family of coping that includes “problem-focused” ways of coping discussed by almost all categorizations of coping . In the context of gig work, researchers report high levels of information asymmetry and opaqueness in ways to earn higher ratings ,13,24. JWhile workers appraised “threats” to competence trigger rigid families of coping such as “helplessness,” a “challenge” appraisal of sources of psychological stress triggers constructive coping families. In the case of challenged competence, they are “information seeking” and “problem solving”. As a common way of coping in response to disease, information seeking, as a family of coping, “refers to attempts to learn more about a stressful situation or condition, including its course, causes, consequences, and meanings and strategies for intervention and remediation”.  (p. 27).In the context of gig work, Jarrahi and Sutherland  showed tWhen workers appraise a “threat” to competence and target the context for coping, they will act based on another rigid form of coping, namely, “escape,” which “includes efforts to disengage or stay away from the stressful transaction”  (p. 27).In the context of gig work, Bucher et al.  found thThe next set of four families of coping is centered around the psychological need for relatedness or the need to “love and be loved”. When the context is perceived as a threat to relatedness and the individual targets the self to cope , a set of regulations will be triggered to cling to and be dependent on someone close to them. As a higher-order family of coping, “delegation” refers to attempts to get someone else to do the work  centeredIn the case of a challenged relatedness, individuals can target the self rather than context and turn to themselves  or those they love to receive emotional support . In the In the case of appraised “challenge” to relatedness, the coping families triggered are constructive, and unlike “delegation” or its opposite rigid form of regulation, “isolation,” the regulations involve optimistic emotions, such as acceptance and trust. The  support seeking family of coping has been studied under labels such as social support, proximity seeking, or help seeking  and invoIn the context of gig work, the work being performed separately from coworkers, compared to traditional forms of work, makes it challenging to enable feelings of stable personal connection and belonging ,7,50. AsWhen a context is perceived as a threat to relatedness and the individual targets the context to cope , a set of regulations will be triggered to isolate the self from the context that is the source of threat, and there is no hope for any support from it. As a higher-order family of coping, “isolation” refers to attempts “aimed at staying away from others or preventing other people from knowing about a stressful situation or its emotional effects”  (p. 27).In the context of gig work, we did not find studies reporting “isolation” as a coping strategy in the sense that these strategies “isolate workers from their context in response to lack of care from the context”. While isolation is a prevalent theme in the studies of gig work, they mainly refer to the physical separation of workers due to the nature of their job, or Uber’s desire to keep its workforce individually isolated from each other and the company itself by legal actions and creating the impression that the company is inaccessible . HoweverThis study is limited, as it is only an introduction to the motivational action theory of coping in the gig work context and is based on a selective list of literature to show the relevance of the theory to the context. The theory needs to be refined, as our investigation of some families of coping  resulted in questions rather than answers. This paper extends the literature theoretically and methodologically. Theoretically, it shows that self-determination theory can be a unifying theory for the study of gig workers’ experience and their well-being, due to its explanation power at different levels of analysis, from work characteristics to intrinsic psychological transactions and consequent coping regulations linked to both our basic psychological needs and evolutionary adaptive processes. Methodologically, it introduces an inductively and deductively generated categorization system for the study of coping that can be used in multiple methodological approaches. It can help qualitative researchers in generating coding schemes for data analysis, especially in the analysis of online forum comments. Future quantitative studies can also test the theory both from a variable-centered view and study predictors and consequent coping regulations with need frustration through empirically tested measures of these constructs (see ) borroweThe study also has important practical implications. The rhetoric of gig work is mostly concerned with debates about its benefits and threats to the work contexts and solutions that are compatible with the environment and expectations of work . Our RadResearch on coping with stress is crucial, especially in the context of gig work, where the arrangements of the work itself seem to be a source of mild to extreme levels of stress and may contribute to worker ill-being. Lack of consensus on coping can impede the development of the field, theoretically and methodologically, and this is extremely important for the immature studies of the gig-worker context. Our exhaustive and comprehensive framework of coping families borrowed from Skinner et al. ,18 inclu