There is a large assessment and treatment gap in child and adolescent mental health services, prominently so in low- and middle-income countries, where 90% of the world’s children live. There is an urgent need to find evidence-based interventions that can be implemented successfully in these low-resource contexts. This pre-pilot study aimed to explore the barriers and facilitators to implementation as well as overall feasibility of Parent–Child Interaction Therapy (PCIT) in South Africa. A reflective and consensus building workshop was used to gather South African PCIT therapist (N = 4) perspectives on barriers, facilitators, and next steps to implementation in that country. Caregiver participants (N = 7) receiving the intervention in South Africa for the first time were also recruited to gather information on overall feasibility. Facilitators for implementation, including its strong evidence base, manualisation, and training model were described. Barriers relating to sustainability and scalability were highlighted. Largely positive views on acceptability from caregiver participants also indicated the promise of PCIT as an intervention in South Africa. Pilot data on the efficacy of the treatment for participating families are a next step. These initial results are positive, though research on how implementation factors contribute to the longer-term successful dissemination of PCIT in complex, heterogeneous low-resource settings is required. Globally, there are challenges and on-going efforts to improve access to evidence-based and evidence-informed psychological and psychosocial treatments ,2. The mOne of the most common groups of mental health conditions is disruptive behavioural difficulties (DBD) which are a significant concern worldwide. Estimates in South Africa, for example, are that up to 6% of children have Oppositional Defiant Disorder . UntreatGiven the treatment gap in CAMH and the high rate of externalising behaviours in the country there is a pressing need to find evidence-based interventions to meet the significant need. In the context of ASD and neurodevelopmental disabilities, de Vries  recommenParent–Child Interaction Therapy (PCIT) is one intervention that addresses disruptive behaviours in children and has a large evidence base in a range of diagnostic populations and at primary, secondary and tertiary service levels ,25,26,27Based in attachment and behaviour theories, PCIT differs from many other parent training programs in a number of key ways. Rather than a primarily didactic approach, therapists coach parents in real time with their child, typically using a one-way mirror and earpiece . ParentsThere is some evidence of feasibility research on PCIT ,37, e.g.As described by Lieneman et al.  in theirThe evidence above suggests that PCIT can be delivered successfully in a range of contexts. While this indicates that PCIT may be a suitable intervention in LMIC, it requires thorough evaluation. There is therefore a critical need in the literature relating to the feasibility, effectiveness and acceptability of PCIT in LMIC, where cultural, linguistic, and socio-economic diversity and disparities are likely to be significant. Implementation evaluations in such contexts would prove invaluable.To integrate evidence-based interventions into multicultural global settings, implementation context must be considered . DamschrThe Consolidated Framework for Implementation Research (CFIR) is a comprehensive and popular framework that presents a taxonomy for distinguishing between a range of contextual determinants of implementation success . A recenTaking together the high rates of DBD and intervention gaps in LMIC, and the limited evidence base in these low-resource, highly diverse contexts, various authors have highlighted the benefits of a pragmatic evaluative approach that focuses on feasibility and acceptability during pilot testing phase of intervention studies ,57,58. APCIT has been identified by clinicians and researchers in a joint University of Cape Town and Duke University project as a possible intervention for use in South Africa. However, little is known about the efficacy and implementation of the intervention in a community setting in LMIC. A larger study aims to explore the feasibility, acceptability, and preliminary indicators of efficacy of PCIT in a South African setting, using an implementation science approach. South Africa is a diverse country of around 61 million people, with eleven official national languages . This cuThe study primarily employed a qualitative descriptive approach to explore the barriers and facilitators to implementation as well as elements of overall feasibility to determine next steps for the potential delivery of PCIT in South Africa. In addition, it gathered limited quantitative data relating to caregiver characteristics, treatment satisfaction and therapist fidelity.A child and adolescent mental health clinic based at a tertiary level Children’s Hospital in Cape Town, South Africa enrolled clinicians in training in PCIT. Four  Clinical Psychologists were selected through convenience sampling and invited to participate in the study. The clinical experience of these clinicians ranged from 15 to 41 years.The same clinic enrolled seven caregiver dyads, representing 14 caregiver participants in the study. The seven dyads each had a child in their care, ranging in age from 2½ years to 7 years.The current study formed part of a broader research project that aimed to evaluate the feasibility, acceptability and preliminary indicators of efficacy for PCIT in a South African setting, using an implementation science approach. That project came through an identified area of mutual interest between the University of Cape Town and Duke University. Following discussions and a collaborative meeting, PCIT was selected as a priority area. Pilot funding from Duke Global Health Initiative Cape Town priority partnership supported the training and supervision of the clinicians. As part of that effort, four South African Clinical Psychologists completed an initial 40-h PCIT training by a certified PCIT Global Trainer at a child and adolescent mental health clinic, in Western Cape, Cape Town. The Western Cape is a diverse province of South Africa, with 3 high-frequency languages  and many different cultures. The clinical head of the child and adolescent mental health clinic was included during the preparatory stages of the study and permission was sought to engage with the clinicians. Participating clinicians were provided with information about the study, and were asked to provide written, informed consent. Following the initial 40-h input, they continued the standard training process under regular online supervision from the Global trainer, as they worked toward formal PCIT certification during the course of this research study. This included seeing PCIT cases at the clinic, following the standard manual protocol and providing the supervisor with recordings of their sessions, allowing regular and direct feedback of their work. The clinicians kept reflective notes during the process, describing cultural and other barriers and facilitators relating to the implementation of PCIT in South Africa. The seven cases were selected using convenience sampling, and had been referred to the clinic for treatment. In some cases, they were specifically referred to the clinic with the intention of receiving PCIT as part of this study. They were not selected to be representative of the diverse South African population. Following consent from the seven families undergoing PCIT treatment in this study, data were collected from these cases, including pre, during and post-intervention. On completion of the cases, participating clinicians were invited to a stakeholder reflection and consensus-building workshop.Data were generated using a stakeholder reflection and consensus-building workshop approach. The facilitator of the workshop , generated a list of questions related to the clinicians’ experiences of using PCIT in their clinical practice, and examined the perceived barriers and facilitators to implementing PCIT. In addition, the clinicians were asked to reflect on the acceptability of the therapeutic modality in the community and context in which they work. The regular reflective diaries kept during the course of the work was also reviewed prior to the workshop. Using the suggestion by Peterson and Barron , sticky Though still under supervision and in the process of becoming certified, therapist fidelity data were gathered following each PCIT session, and therapists were recorded to what extent they had kept to the treatment manual. Caregivers were also asked to complete the Therapeutic Attitude Inventory and the four treatment satisfaction questions on completion of the treatment programme. Therapeutic Attitude Inventory and treatment satisfaction questions The TAI is a 10-item measure used to establish parents’ satisfaction with therapy . ParentsTherapist’s self-assessment of fidelity (Funderburk and Eyberg )The PCIT treatment protocol  includesAfter the workshop, the audio-recording was transcribed by an independent research assistant. In addition, all sticky notes were typed up into one document. The transcription together with the document containing all the points on the sticky notes were analysed by two researchers , first independently, and then together to reach consensus on findings.The data were analysed using framework analysis. Framework analysis affords researchers the freedom and flexibility to analyse data in a way that is best suited for the particular aim and is best suited to research questions that seek to contextualise and evaluate interventions ,65. FramTwo of the researchers  independently coded the data, they then met to establish an initial framework of the codes which emerged and generated initial overarching categories and codes. The two researchers then mapped the initial categories and codes along with the substantiated quotes from the consensus workshop discussion and sticky notes. They met and discussed the revised data codes and categories using the CFIR framework. One of the senior authors was available in case consensus was not reached by the two primary coders. However, the primary researchers were able to reach consensus on all items.Therapist self-reported fidelity scores were collated and percentages for each session captured. An overall average percentage for all the sessions was then captured. The average scores on the Likert scale for each of the caregivers who graduated and completed the TAI and treatment satisfaction questions was also calculated.The research protocol received ethical approval from the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee .The results in Based on the 219 recorded PCIT sessions, therapists rated sessions at an average of 97.4% integrity compared to the relevant integrity items included in the PCIT manual. Of the total sessions, 167 were rated as having 100% integrity. Only 20 sessions were scored below 90%.In the facilitators section, as shown in In the barriers section, as shown in As shown in The importance of making appropriate adaptations to ensure the intervention is a good fit in the context was highlighted. Expanding PCIT in South Africa was regarded as an important priority and is linked closely to other next steps of increasing access for a broader population and increasing awareness of the intervention in caregivers and clinicians. Training of trainers was regarded as one way of achieving this aim, as was obtaining sustainable funding. Continuing with research that focused on the implementation of PCIT in South Africa was also regarded as a critical and on-going step. Finally, the creation of a “PCIT hub” that could co-ordinate these next steps and link with relevant partners was determined to be a useful method of ensuring successful, sustained implementation of PCIT in the country.To establish the feasibility of the intervention more comprehensively, this pre-pilot study investigated the barriers and facilitators to implementing PCIT in South Africa as described by clinicians in the process of being certified as PCIT therapists, delivering the intervention. To further examine PCIT in this setting it also explored therapist fidelity scores in delivering the intervention. These scores relate to early-stage overall feasibility in this context. In addition, it examined broad acceptability of the intervention for caregivers receiving the programme. Both groups, caregivers and therapists, indicated largely positive views of PCIT, suggesting favourable prospects of the intervention in this LMIC setting. Suggestions for next steps were also examined.Caregiver reflections based on the TAI and therapy satisfaction questions were overwhelmingly positive. This is in line with previous literature on PCIT documenting the largely high rates of client satisfaction ,68,69. HRelating to fidelity, therapists demonstrated high fidelity scores. Though these scores were self-reported by clinicians and so may be an over-estimate, it nonetheless, suggests that they remained largely true to the PCIT manual, delivering it as intended. Fidelity is regarded as critical to the successful implementation of evidence-based interventions into practice ,71. In rTherapists reported both facilitators and barriers to implementation in South Africa. Consensus facilitators were most often assigned to Domain 1, ‘Characteristics of the intervention’. The strong theoretical basis and evidence-base for PCIT were described, along with the positive feedback from families and their commitment. PCIT’s self-generating evidence and its tradition of research were also regarded as facilitators. This is congruent with the literature on PCIT reporting its multiple advantages compared to alternative solutions ,25,26,27Barriers to implementation were also predominantly assigned to the “Characteristics of the intervention” domain. The limited evidence for PCIT in South Africa and that the intervention largely focuses on a limited 2–7-year-old population were considered barriers. As South Africa is a LMIC, evidence for PCIT in this and other low-resource settings is required. For example, previous research documents that low-income families might be more prone to drop-out ,73. As aSome reported barriers may reflect that the clinicians were being trained up as PCIT therapists during this process and so were relatively new to the intervention. For example, the reflection that it does not address caregiver psychopathology that could impact on its efficacy. While PCIT is not designed to directly address caregiver psychopathology there is some evidence that it reduces caregiver depression and stress ,74,75. IPrevious literature on implementation in South Africa has highlighted the multicultural nature of the country . For exaMany of the facilitators and barriers described by the participants have been reported in previous studies on PCIT . While sThe CFIR model proved useful in objectively stratifying the barriers and facilitators. The framework presented an opportunity to determine which of the domains were most prominent but further highlighted the importance of the newly proposed LMIC domains. Scalability and sustainability for example, are clearly salient for PCIT in South Africa. While the framework pointed to what domains were most prominently used it also highlighted, in their absentia, those domains that were not investigated. The “individuals involved in implementation”, “process of implementation”, and “characteristics of systems” domains had few codes assigned to them. While this early-stage study, necessarily prioritised other domains, it may be useful for future research to investigate these other areas.Implementation continues to be a critical feature of research determining feasibility of interventions in diverse, real-world settings . There iThe inclusion of stakeholders, as was the case in this project, is regarded as an important element of implementation research . ConsideSeveral consensus next steps were recommended by therapists in this study. None of those documented were considered the necessary priority, rather all were regarded as meaningful to the successful longer-term implementation of PCIT. Many could be implemented in parallel. Continued research, training, increased awareness of PCIT and sustainable funding are logical conclusions given the barriers and facilitators described. Initial funding through the Duke Global Health Institute Cape Town priority partnership enabled this pre-pilot study. Continued funding to allow the on-going development of this implementation research will be important and facilitate sustainability of the intervention. Costs, more broadly is a critical factor, particularly in resource-limited contexts. The recommendations for adaptation and expansion of PCIT in South Africa reflect both the positive view of the intervention and its potential. Since its initial development, PCIT has been adapted in multiple ways so that it can now be delivered in many settings  , throughNecessarily, as this was a first step pre-pilot into feasibility the number of participants included in the study was small. In addition, some of the caregiver participants dropped out of the intervention, this potential reporter bias may have impacted the interpretation of the acceptability scores that were only gathered for those who completed the programme. While not being representative, they nonetheless reflect the first evidence and positive support for the intervention in South Africa. It provides important guidance for next steps regarding research into PCIT in this context. Despite efforts, it was not possible to access the few caregiver participants who dropped out of the study early. This information may have provided a broader description of caregivers’ reflections on the intervention. Future and larger-scale pilot studies may allow for further exploration of caregiver perspectives.There is an urgent need for evidence-based interventions in child and adolescent mental health that can be feasibly implemented in South Africa. PCIT, in this early-stage, pre-pilot data shows promise as an acceptable and accessible intervention in South Africa. Therapist views indicated many facilitators for implementation, including strong evidence base, manualisation, and training model. Consideration for barriers, particularly relating to sustainability and scalability were highlighted. Largely positive views relating to acceptability from caregiver participants also indicated the promise of PCIT as an intervention in this context. Pilot data on the efficacy of the treatment for participating families are needed as a next step. While initial results are positive, on-going research of how implementation factors can contribute to the longer-term successful dissemination of PCIT in complex and heterogeneous LMIC settings is required.


Objective: To resume each specialist’s role in the management of neurologic urinary tract symptoms (nLUTS) and sexual dysfunctions (SD) in patients suffering from multiple sclerosis (MS). Material and Methods: We asked a neurologist, a urologist and a gynecologist, experts on neuro-urology and sexual dysfunction at our hospital, to resume their role in the management of nLUTS and SD in MS patients based on the review of current evidence. PubMed was used to review literature with a focus on nLUTS and SD in MS patients. Conclusions: The difference in symptomatology in MS patients is very wide. The more the CNS is involved, the more the variations and severity of nLUTS is present. SD have numerous causes and should always be assessed. Urologists play the director’s role in evaluating and treating these patients. Neurologist should play an important role, they must evaluate the potential mutual interactions between disease manifestations of MS and their treatments. Additionally, gynecologists play an important information sharing role in the management of patients with multiple sclerosis. Multiple sclerosis (MS) is an autoimmune disease that affects the neurological system and can involve any part of the central nervous system (CNS). The estimated prevalence of MS worldwide is 250 per 100,000 people . There aThe urologist has an essential role in treating MS patients. Optimal evaluation tools and proper management options are important to acquire a thorough knowledge of the disease progression. Risk stratification of MS patients based on LUTS impact on the upper urinary tract deterioration and on patients’ QoL should be done routinely. Anticholinergics are the first line treatment for symptoms of overactive bladder (OAB). Second line therapies are advised if conservative therapies fail to reduce the potential damage of the upper urinary tract or to relieve patient’s symptoms. Intradetrusor injections of BTXA are a good option for treating refractory cases. However, more studies are needed to assess neuromodulation, BTX and anticholinergics efficacy in MS patients. Diminished sexual function is often described in MS patients and it is associated with more severe disability, pain and depression. Sexual function should be assessed during the follow-up and treatment options should be offered .Despite the high prevalence of LUTS and sexual dysfunctions and their impact on QoL in MS patients, only few neurologists appear to assess bladder, bowel or sexual dysfunction with their patients. Due to its predominant position in the management of MS patients, the neurologist should always assess the presence of LUTS and refer the patient to a urologist when necessary. Moreover, they are the joining link in the interdisciplinary communication about the potential mutual interactions between disease manifestations of MS and their treatments.Presence of LUTS and SD in MS patients should always be assessed through a complete anamnesis . Voiding diaries and questionnaires are useful tools to assess the bother of urological symptoms and the overall daily impact on QoL as well as SD, might be helpful .Neurologists may consider interactions between treatments and disease manifestations not targeted by the treatment. For example, amantadine, usually used in MS patients to treat fatigue, has side effects like bladder problems and acute confusion due to the anticholinergic effect. The neurologist’s role in the diagnosis and treatment of urinary tract dysfunctions and sexual impairment in MS patients cannot be overestimated but, they could have an important role in identifying early patients who need to be evaluated by urologists. Moreover, with management and treatment of MS patients generally coordinated by neurologists, it seems reasonable that they can be the contact person to whom other physicians can report on the dose and timing of all installed treatments. To date, despite the importance of these aspects, there is need for a better definition of the neurologist’s role in the management of these conditions in MS patients, to plan properly and for early management of LUTS and sexual impairment.Patients with MS can present lesions in any part of the CNS, although the spinal cord is most frequently affected. This explains the presence of neurogenic lower urinary tract dysfunction (NLUTD) in almost 80% of MS patients ,11. NLUTAs we already said frequently, MS patients report bladder dysfunction. At least 80% of these patients reported some degree of LUTS according to the National MS Society, which is three times more common than the general population . Common In 2020, a set of recommendations about LUTS in MS patients was generated and was published [MS patients with urological symptoms usually present other urological disorders: proststic hypertrophy in men, for example, and a differential diagnosis is recommended.To know the disease process is essential to determine which therapy and management options are to be offered to each MS patient. LUTS should be assessed and treated with the goal of identifying early those patients at high risk of upper urinary tract deterioration an/or impaired quality of life. Anticholinergics are the first line treatment for OAB . Second Diminished sexual function is often described in MS patients, and it is associated with more severe disability, pain and depression. Sexual function should be assessed during the follow-up and treatment options should be offered . AlthougExperience, supported by the current literature, reveals that gynecologists play an important information sharing role in the management of patients with multiple sclerosis (MS).Their expertise must involve a highly perceptive approach to the intimate sphere of the patient who is unlikely to express herself autonomously, but who often must cope with both an objectively evident disability status and the burden of the concern associated with her not knowing the underlying pathology. In fact, the MS patient needs the gynecologist not only to manage fertility and pregnancy, but also to share any concerns and assess any problems related to her sexual health and to evaluate the impact on her quality of life of any alterations in the intimate sphere. Often in pregnancy management, the role of the gynecologist is largely focused on containing anxiety, but in general, worries are expressed and shared by patients themselves. Sexuality, on the other hand, is a subject that tends to remain undisclosed unless the specialist takes it up first . The facA 2000 study revealed that 43% of the female population is affected by some form of sexual dysfunction, preventing a woman from having satisfying intimate experiences . This fiA 2019 Italian study conducted on 306 women highlighted and confirmed that the prevalence of SD and sexual distress is higher in women with MS compared to healthy patients, and that age, disability and depressive symptoms are associated with the worsening of sexual dysfunction . In femaPrimary sexual dysfunction would result from central nervous system alterations  that characterize the underlying disease and directly modify the sexual response: genital sensory alterations, decreased libido, arousal, and orgasmic disorders, reduced vaginal lubrication. Secondary sexual dysfunction, on the other hand, would be the result of MS-related physical disabilities, which indirectly influence sexual response: hypertonic perineal muscles, spasticity, sphincter dysfunction, muscle weakness.Finally, tertiary sexual dysfunction would be determined by the emotional impact of MS on patients, with the onset of mood disorders and depression that necessarily alter the sensory component. However, in multiple sclerosis, sexual dysfunction can occur even when there is no serious disability . TherefoAnother subject on which medical literature has focused on is the impact that being in a couple relationship can have on sexual disorders and their perception. In fact, it has been observed that single status and/or partnered status, as well as the quality of the relationship with the partner, are among the most significant factors in predicting the inability to achieve a satisfactory sexual arousal: women without partners are at 10-fold greater risk of having arousal disorders . Women wHowever, further studies are necessary to identify the most appropriate tools for the assessment of MS patients enduring sexual disorders.The authors have years of experience in treating patients with multiple sclerosis. Each one of them reviewed the literature and resumed it with their clinical experiences. This paper is not a systematic literature review and this could be seen as a limitation of the study.The difference in symptomatology in MS patients is very wide. The more the CNS is involved, the more the variations and severity of nLUTS is present. SD have numerous causes and should always be assessed. Urologists play the director’s role in evaluating and treating these patients. Neurologist should play an important role, they must evaluate the potential mutual interactions between disease manifestations of MS and their treatments. Additionally, gynecologists play an important information sharing role in the management of patients with multiple sclerosis.


In recent decades, networked smart devices and cutting-edge technology have been exploited in many applications for the improvement of agriculture. The deployment of smart sensors and intelligent farming techniques supports real-time information gathering for the agriculture sector and decreases the burden on farmers. Many solutions have been presented to automate the agriculture system using IoT networks; however, the identification of redundant data traffic is one of the most significant research problems. Additionally, farmers do not obtain the information they need in time, such as data on water pressure and soil conditions. Thus, these solutions consequently reduce the production rates and increase costs for farmers. Moreover, controlling all agricultural operations in a controlled manner should also be considered in developing intelligent solutions. Therefore, this study proposes a framework for a system that combines fog computing with smart farming and effectively controls network traffic. Firstly, the proposed framework efficiently monitors redundant information and avoids the inefficient use of communication bandwidth. It also controls the number of re-transmissions in the case of malicious actions and efficiently utilizes the network’s resources. Second, a trustworthy chain is built between agricultural sensors by utilizing the fog nodes to address security issues and increase reliability by preventing malicious communication. Through extensive simulation-based experiments, the proposed framework revealed an improved performance for energy efficiency, security, and network connectivity in comparison to other related works. Today, the Internet and the Internet of Things (IoT) dominate nearly everyone’s life. IoT is a paradigm that connects things, people, or networks and allows them to process and react precisely to any kind of physical or virtual communication ,2,3. IoTIt provides a strategy to effectively manage IoT resources, identify the redundant nodes that are collecting the same data and forbid using them. Such a scheme is efficient in utilizing the resources of the network and prolonging the system life cycle.It develops intelligent methods using distributed machine learning to predict routing decisions for the selection of optimal forwarders with increasing data delivery and load balancing.Another aspect of the proposed framework is the usage of a fog system to establish a secure chain in the presence of unidentified and faulty nodes by establishing a reliable group of nodes.We verified the proposed framework with other work and the results demonstrate enhanced performance for various network parameters.Furthermore, several IoT policies and standards have been developed in the agriculture sector in numerous nations and organizations worldwide. Due to the limited boundaries of IoT devices, sensors, and actuators, a detailed study of IoT in the context of agriculture is required to understand the present state of research ,14,15. TThis paper is further organized as follows: the discussion for related studies is presented in The smart city emerged as a concept with the fast growth of dependable information and communication models and the combination of sensor technologies ,25,26. MThe summary of relevant studies shows that the IoT has grown significantly in creating and developing smart agriculture systems. It aids the farmers in monitoring soil conditions and water supply and increases productivity with the management of costs. It gathers the agricultural data and sends them to cloud databases to take the necessary actions accordingly. Numerous solutions have recently been proposed to deal with intelligent data monitoring with improved latency using machine learning techniques. However, many of the existing systems do not make it apparent how different connections are handled when there are redundant data. Moreover, efficient load balancing with the collaboration of mobile sensors is another significant research challenge ,41. AlthThis section presents a detailed discussion of the proposed framework with the system model. Additionally, its algorithm and developed components are explained.The system model consists of sensors, fog nodes, and the sink node. They are deployed at random positions and the sink node is mobile. The fog nodes are considered more intelligent and have sufficient resources as compared to ordinary sensors. The mobile sink has a direct association with cloud systems. Initially, IoT sensors are arranged in an undirected graph Based on the undirected graph, the proposed framework identifies the initial and temporary routes After determining the candidate nodes, the proposed framework updates the routing table of source node True” or “False”, as given below:The proposed framework only allows one node in the transmission radius for sensing and forwarding the agricultural data. To achieve this, it determines the node scoreThe In the proposed framework, the fog nodes performed the role of the intermediate system between the data originating network and cloud services. Firstly, it received all the data and stores it in memory for further analysis and processing. It then confirms the data authenticity to forward it towards the cloud system in the multi-hop discipline. Then, the aggregated dataUpon receiving, fog nodes decrypt it to retrieve the aggregated data and the identity of the data-originated node. After the decryption process, the fog nodes verify the identity of the nodes with their stored information, and if it matches positively, then it will look up its routing table for the selection of the next hop among the neighboring fogs. Moreover, the cloud system On the other side, the cloud system first authenticates the digital signature using the public key of the fog nodes and upon successful verification, it is further forwarded to the connected end users with the IoT system. The flow between the developed techniques for intelligent agricultural routing is shown in -Sensor’s deployment: In this state, agriculture nodes are randomly dispersed in the targeted area. They have limited constraints and not enough memory, transmissions, and processing resources. They are not able to communicate with the sink node directly;-Data sense: All the deployed sensors, actuators, and IoT devices collaborate in collecting the data. In addition, the data are transferred to the sink nodes through integrating fog systems. The fog nodes are explored for reducing communication delays;-Relay node: The data are obtained from the deployed sensors and forwarded towards the relay node. The roles for relay nodes are not predefined, they are chosen using quality-aware parameters;-Decision making: In this state, a distributed machine learning technique is applied using network statistics to offer the optimal results for attaining a reliable communication system;-Data security: In this end, security actions are performed in this state. It identifies faulty nodes and false messages to detect the comprised data using private values. It increases the reliability of remote users that are connected to cloud systems.Moreover, the functioning of the proposed framework consists of many states, as depicted in This section presents the simulation environment and a discussion of the various tests. We ran the simulations of a core i7 laptop with 64 GB RAM and 1 TB hard drive. 20 trials of the simulations were performed. Between 150 and 750 sensor nodes were used in each simulation experiment. Zigbee technologies were used in the testing, and experiments were carried out in 1000 m × 1000 m area with a variety of configuration settings. For sensing the agricultural environment, numerous sensor categories were utilized, including temperature, air humidity, soil moisture, and water quality. Two sink nodes, between ten and fifteen 15 fog nodes, and various relay nodes were also deployed. Sensor nodes collected the agriculture data and forwarded them to the relay nodes for aggregation and data routing. The fog nodes existed between sensors and sink nodes. The duration of the experiments was 2000 rounds and each round had a time interval of 20 s. The sensors were equipped with GPS. Communication channels were scattered with certain malicious nodes to test the system’s security. The results analysis was obtained based on the packet delivery, energy efficiency, network connectivity, and reliability metrics. All the network metrics were evaluated under scenarios of varying sensors and distances from the sink node. We evaluated the performance of the proposed framework with other studies in terms of energy efficiency. The performance evaluation of the proposed framework against those of related works is shown in With an emphasis on green energy and remote monitoring, smart technologies and agricultural systems have grown significantly in recent years. It controls the plants, soil characteristics, water pressure, and weather-related information, which benefits farmers and increases production. However, limited solutions have been proposed to enhance production in precision agriculture while reducing latency and information disturbance. Furthermore, protecting agricultural data while utilizing the insecure Internet is another significant research challenge. In this study, we presented a framework for providing a farmer communication system to enhance timely delivery through the cooperation of fog systems. This system also incorporates redundant information detection, which reduces network bandwidth inefficiencies. Additionally, the proposed framework employs security methods to counter privacy attacks on sensing data. The performance results showed the good outcomes of the proposed framework with maximum energy efficiency and delivery ratio. Furthermore, its performance has proven the improved processing usage in the existence of malicious devices. In the future, we intend to cope with the proposed framework’s scalability and load-balancing issues with the support of a multi-cloud architecture. Moreover, we would like to integrate security to maintain cloud integrity from the point of users’ perspective.


This study explores the interrelationship among the current sustainability agenda of the pharmaceutical industry, based on the United Nation sustainable development goals (SDGs), the elements of the Joint External Evaluation (JEE) tool, and the triad components of the One Health approach.A cross-walk exercise was conducted to identify commonalities among SDGs, JEE assessment tool, and One Health approach. An in-depth study of 10 global pharmaceutical firms' corporate sustainability reports and COVID-19 response plan for 2019–2020 was also conducted.The result of the exercise showed the existence of a direct and indirect relationship among the SDGs, elements of JEE assessment tool, and One Health approach. For example, both no poverty (SDG 1) and zero hunger (SDG 2) are linked with food safety targets under the JEE and with human and animal health under the One Health approach.This study adds a new dimension emphasizing the possibility of tailoring the pharmaceutical industry's activities under the sustainability agenda to strengthen global health security while remaining consistent with the One Health approach. In the era of globalization and advancement of information technology, diseases such as Ebola virus disease (EVD), Zika virus, and COVID-19 continue to pose a threat to the world. The EVD epidemic in West Africa 2014–2016) is a lesson to be learned when it comes to identifying the key measures needed to boost public health and prevent future outbreaks. A disease outbreak causes death, loss of livelihood, community upheaval, and wider socioeconomic ramifications. The recent COVID-19 pandemic has caused not only severe disruption of normal daily life but also an increase in unemployment and mental illness 014–2016 , 4. The When it comes to corporate social responsibility (CSR) and sustainability, the pharmaceutical business has always been scrutinized. Smith emphasized the incorporation of CSR in the business strategy to have a competitive advantage . AlthougBuilding resilient health system has become a priority following COVID-19. The recent Global Health Security Conference 2022 emphasized resilient health systems . Under tPost-EVD most countries joined the GHSA an initiative started by the USA in collaboration with other international organizations to improve global health security as required under the umbrella of International Health Regulation , 19. TheAdditionally, the sustainable development goals (SDGs) advised by the United Nations Global Compact aim to provide a comprehensive approach to building a healthy and secure environment, therefore providing basic support to increase global health security . Though Table 2)  , 26. TheIt is also important to note that the pharmaceutical industry encounters challenges when it comes to aligning their activities with the 17 SDGs. These challenges include a lack of effective leadership, budgetary restrictions, harmonious partnerships, exhaustiveness and complexity of interlinkages among the goals and their targets, and a lack of monitoring and evaluating methods for assessing the progress of implementation .The COVID-19 pandemic led to increased awareness about health security and the One Health approach. The study by Dixon showed the necessity of global system changes in the setting of the SDGs as per emerging needs to the COVID-19 pandemic . SimilarBased on the literature review, a gap analysis was conducted to identify the critical findings followed by the development of the research questions . Table 1the relationship among the SDGs, key elements determining health security, and One Health approach remains unclear.The preceding literature review justifies the need for an in-depth study into the relationship among sustainability, health security, and the One Health approach to identify commonalities and a point of intersection. To aid this study, the research questions were formed through problematization as recommended by Alvesson and Sandberg  and by iBased on the gap analysis, the following research questions were formed:RQ1. Is there any relationship between the SDGs and development of National Action Plan for Health Security (NAPHS) based on the JEE assessment tool and One Health approach?RQ2. Do the activities under the COVID-19 response plan directly or indirectly contribute to the fight against the pandemic thereby increasing health security?*–Research Question.RQTo explore the possible solution to the identified gaps, a cross-walk exercise was performed to map the links among the SDGs, key elements of the JEE assessment tool , and triThe cross-walk exercise was performed by conducting online group discussions with experts from the fields of medicine, pharmaceutical sciences, and management. Two experts were chosen from each area, depending on their knowledge and willingness to participate voluntarily. The experts were asked to link each element in the SDGs, JEE, and One Health with specific reasoning. At the end of the discussion, a consensus was built within the expert group to finalize the cross-mapping. In this study, we used the group discussion technique and post-collating the views of experts build up a consensus within the group to finalize the cross-mapping. Initially, we recorded all the opinions of experts individually for the cross-mapping. Each identified linkage was given a score in terms of how many experts agree to the linkage. Later, the captured linkages were discussed in the group and particularly those ones that scored very less . A consensus was built upon the final cross-mapping result. This technique is a modified version of nominal group technique .Selection criteria for sample from pharmaceutical industries: The sample size was confined to 10 considering the requirement of the sample set to conclude significant results A detailed analysis of corporate sustainability reports of the selected pharmaceutical companies for the year 2019 was conducted to classify the activities under the corresponding SDGs, JEE assessment tool elements, and One Health approach.Sustainable development goals (SDGs) as advised by the UN Global Compact  are giveCross-walk exercise was conducted among the 17 SDGs, various categories under the JEE assessment tool, and triad components of the One Health. The recent COVID-19 pandemic has shown the importance of the pharmaceutical industry in confronting a pandemic. Without their significant contribution in particular rapid development and deployment of vaccines, it would have not been possible to overcome it. Additionally, their support to achieve the SDGs cannot be ignored. Among the few to mention are initiatives to improving access to medicine, promoting eco-friendly agricultural practices, distribution of food in the community, and supporting infection, prevention, and control activities, such as hand sanitation in hospital and healthcare settings. Johnson & Johnson developed a PRISMA health device distribution network that allows a single ventilator to support respiratory action in two patients at the same time . Pfizer The sustainability report for the year 2019 of the 10 sample companies representing Asia, Africa, Europe, and the USA was studied, and the number of activities was mapped on the SDGs along with the corresponding JEE categories under prevent, detect, response, and other IHR-related hazards as given in Interesting results were found after the classification of the activities under the corresponding SDGs, JEE, and One Health approach. Johnson & Johnson, AstraZeneca, and Sun Pharma lead in taking the initiatives to fulfill the sustainability goals. However, few SDGs remain unaddressed such as no poverty, reduced inequalities, and peace and justice strong institution. The key activities undertaken by each of the companies to meet their sustainability agenda are summarized in the following. Their COVID-19 response plan is also given in Under the SDG 3, vaccine distribution and setting of new health centers under the Janssen CarePath program were key highlights. Drug innovation and remote training system were set up to facilitate training and development. Earthwards program to develop sustainable products remains a priority for Johnson & Johnson. A number of partnerships came into play to achieve the objective of developing new treatment and sustainable production .As part of the SDG 3, Pfizer launched the development of a digital health application and a global health innovation grant program to address primary healthcare. Education on vaccination for the community was a key highlight. Wastewater management, water recycling, and application of green chemistry aimed to address environmental issues .Eli Lilly activities in the year 2019 showed alignment with good health and well-being, quality education, gender equality, clean water and sanitation, affordable and clean energy, life on land, and building partnership. The activities related to good health and well-being included donating essential medicines, improving diabetes care, and developing the serological test for the COVID-19 pandemic .In 2019, Bayer supported food production by providing measures for sustainable farming, distribution of high-yield seeds, integrated weed management, and crop science development. Bayer demonstrated its responsible production intent by developing computer-aided chips to reduce animal testing and hazardous chemical use in various manufacturing processes in 2019 .Under good health and well-being, GSK used a value-based approach to lower the price of medicines in 2019. In addition to it, medical treatment and vaccine distribution, special Dengue fever services, and healthcare workers training programs were set up across India and Africa. GSK continues to undertake measures to recycle water used in process of manufacturing. A number of partnership and collaboration in the area of functional genomics, vaccine development, and saving the children were done in 2019 .Sanofi in 2019 continued to support good health in the community by providing inactivated polio vaccine through GAVI to ~70 million children worldwide. It also provided treatment to children suffering from cancer through the Sanofi Espoir Foundation. New programs were developed to increase a number of internship opportunities for both students and employees. Constant efforts were made to increase environmental awareness and reduce greenhouse gas emissions .To promote good health and better access to healthcare, various health programs such as health heart Africa, young health, healthy lung, and mental well-being program were launched in 2019. A global workforce well-being program provided employee health coverage. To make more sustainable cities, a sustainable matter week conference was organized in 2019. Green lab program and assessment of 131 manufacturing sites using a supplier sustainability framework was also done .Aspen is a leading pharmaceutical industry in the African continent when it comes to sustainability. To promote good health in African society, low-cost antiretroviral therapy for HIV, a special disease management program, and mental health problems advice were provided under the CSR agenda. Solar energy projects and water recycling plants were set up across manufacturing units to conserve essential natural resources .Navya online expert opinion were major SDG 3 measures. Water conservation project and energy conservation measures were implemented to have a responsible production and consumption process  based on the JEE assessment tool and One Health approach?The SDGs and set targets under prevent, detect, response, and other IHR-related hazards in the JEE assessment tool  are two For potential growth in any industry, a healthy, well-diversified workforce is essential, and it relates to both SDGs and human health component of the One Health approach triad. Natural resource conservation and responsible use remain one of the most important SDGs. It includes the use of clean water and responsible consumption of natural resources in the process of manufacturing. This is closely related to the set targets in the JEE for the surveillance of zoonotic diseases, chemical events, food safety, and all triad components of the One Health approach. According to the JEE, the goal for zoonotic disease surveillance is to prevent zoonotic disease transmission from animals to humans through contaminated water and food chain. This not only causes food scarcity and wastage, but also increases poverty and difficulty in achieving SDG 2 “zero hunger.” Hence, a comparable surveillance and response system should be in place to prevent foodborne infections. This is directly related to the One Health approach as the transmission of zoonotic diseases remains a challenge to overcome. Urbanization and industrialization are one of the contributing factors for increasing zoonotic diseases, thereby affecting both animal and environmental health under the One Health approach. Production processes often use natural resources and their by-products damage microecosystems, causing zoonotic illnesses. Pharmaceutical industries' by-products and waste are known to damage the marine flora and fauna. Pharmaceutical waste from antibiotic production and its unregulated use is the main cause of antibiotic resistance. Antimicrobial resistance remains a challenge and comes directly under the One Health approach. The JEE set targets in this reference for food safety, zoonotic diseases, and chemical events are important in achieving the SDGs. To achieve this set target, the One Health approach needs to be adopted at all levels of policymaking.A proper national policy and partnership building is required not only to attain the SDGs but also to fulfill the targets mentioned in the JEE assessment tool. To fulfill both the SDGs and the JEE targets, there is a need for interlinkage across several sectors, such as finance and agriculture, and other stakeholders . The OneEminent researchers such as Smith  and KickRQ2. Do the activities under the COVID-19 response plan directly or indirectly contribute to fight against the pandemic?Sustainability reporting among the selected 10 multinational pharmaceutical firms is comprehensive and systematic. However, there is always a scope of standardization when it comes to reporting those SDGs. The activities reported were categorized against the 17 SDGs as recommended by the UN Global Compact .The COVID-19 pandemic garnered global attention, and its response planning became a priority. The 10 selected companies' action plans shared a few commonalities, such as boosting access to essential medicines and supporting diagnostic and therapeutic research and development. However, the individual companies used their area of expertise to support communities in their own peculiar way. For example, Bayer used drones to improve distribution of essential COVID-19 kits to the farmers . Pfizer'Even though the activities done differed significantly, all 10 selected companies focused their efforts on the SDGs. This shows that the pharmaceutical sector holds the potential to contribute to global health security.Cross-walk exercises show that all activities undertaken by the pharmaceutical companies under their sustainability agenda directly or indirectly contribute to fulfilling the targets in the JEE assessment tool. These activities also related to the triad components of the One Health approach as given in This study is a beginning step in the subject of health security; more in-depth studies can be undertaken based on this study to explore the following:(a) Sustainable development goals and health security are closely related to each other and(b) Activities performed by the pharmaceutical industry as part of their sustainability agenda can be tailored to increase health security and fight against the pandemic.Based on this study and previous research, we propose that pharmaceutical companies need to be more transparent, communicative, and collaborative to contribute maximum toward the SDGs. An interesting study conducted by Sinkovics and coworkers provided a matrix that can help pharmaceutical companies to classify their activities into positively, neutrally, or negatively influence particular SDGs . AdditioTherefore, on the basis of this study, we propose that pharmaceutical industries should do activities in the area of unaddressed SDGs beyond SDG 3 which is good health and well-sbeing. These include quality education (SDG 4), clean water and sanitation (SDG 6), sustainable cities and communities (SDG 11), and life below water (SDG 14).This study is based on the lessons learned from the recent COVID-19 pandemic and the urgency to develop a resilient health system and be prepared for future pandemics/public health emergencies. When it comes to building robust health security, it is a well-known fact that resources are limited. Hence, this study explores how pharmaceutical industries' sustainability initiatives may be utilized or tailored to increase health security and combat pandemics. To achieve this goal, it is required to first identify whether there is any cross-link among sustainable development goals and various laid down frameworks important for health and well-being, such as the joint external evaluation tool recommended by the WHO and One Health approach. Although in the past, researchers advocated the inclusion of health as a separate SDG or applying the One Health approach globally to enhance health security; however, this study closely interlinks the SDGs, health security, and One Health. This study will be helpful not only in utilizing resources toward the development of health security but also in formulating public health policies, particularly in emergency preparedness.This study is descriptive in nature. Due to the ongoing pandemic and limited resources, only 10 companies could be included in this study. Selection bias cannot be ruled out because this study is based on voluntary disclosures of the activities and published reports. The limited literature and data are available in this domain.This study provides an insight into the activities and measures adopted by 10 multinational pharmaceutical companies under their sustainability agenda and as part of the COVID-19 response plan. An attempt to cross-link the 17 SDGs, the JEE assessment tool, and the triad components of the One Health approach has been made to show the possible future scope of integrating pharmaceutical companies' expertise in building resilient health system. This study opens a window in this area and can be helpful to various government and non-government stakeholders to consider the integration of the pharmaceutical sector to increase health security.The original contributions presented in the study are included in the article/This study does not include any human, patient, or animal data and there is no experimental work or clinical trials involved. It only includes the information on policy making available in the public domain. Hence, formal approval from the ethics committee is not required for this study.KS has done the conceptualization, written the original draft of the article, and addressed critical points raised by PS. Further inputs provided by SB and PS on methodology and discussion. KS is responsible for all correspondence regarding this article. All authors approved the submitted version.This is a self funded study.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Effective supervision is a key component of the development of effective and ethical behavior analytic repertoires. However, the provision of supervision may be challenging in countries where behavior analysis is an emerging profession and there are few qualified practitioners. We conducted a mixed-methods survey study to examine the supervision practices of board certified behavior analysts (BCBAs) in Australia, and perceived challenges related to the provision of supervision. Respondents reported using a variety of supervisory practices to meet the demand for supervision, but a lack of time, resources, and geographical location posed challenges. Based on these findings, we provide several recommendations for addressing identified challenges. Although each recommendation has been contextualized to meet the needs of the Australian behavior analytic community, these recommendations may be useful in other parts of the world where behavior analysis is an emerging profession or there are few BCBAs to meet the needs of a growing behavior analytic workforce. Over the past decade, opportunities and government support for the professional practice of applied behavior analysis (ABA) in Australia have increased in the education sector , as part of their professional work. Second, the trainee must ensure that the supervisor is knowledgeable about the local policies, procedures, and cultural considerations that influence and inform their professional work. Third, the trainee and supervisor must ensure that consent is obtained from clients to share client-specific information and that client-specific information is shared in a way that protects client privacy and confidentiality, in accordance with local laws. Finally, the use of videoconferencing to deliver remote supervision may limit the degree to which the trainee and supervisor can incorporate modelling and rehearsal of new skills into direct observations and supervision meetings. This may also make it difficult for the supervisor to support the trainee during high-risk situations, such as effectively and safely responding to behaviors of concern  the education and training experiences of ABA practitioners; and (2) the barriers ABA practitioners faced when designing, supervising, and delivering ABA-based programs in Australia. From the survey of 152 program supervisors, 80% reported having a graduate degree, but only 31% reported holding the BCBA credential. These findings may reflect the fact that some practitioners in Australia have difficulty accessing supervision to meet the eligibility requirements to sit for the professional certification exam, and/or that there are not currently enough BCBAs to meet the demand for ABA-based services. In addition, the findings of the survey highlighted specific challenges related to the provision of supervision. The most common barriers identified by survey respondents were access to high quality and cost-effective training, supervision, and professional development. Practitioners indicated that their current supervision and professional training opportunities were inadequate, and they highlighted a need for high-quality training programs, qualified supervisors in the field, more supervision hours and more professional development opportunities such as conferences, workshops, and webinars. The need for access to supervision as a matter of priority was evident especially considering that the majority of survey respondents had less than 5 years of experience working in the field, with many reporting only 1–2 years of professional experience.Given the recent increase in demand for behavior analytic services in Australia and the recent establishment of two verified university course sequences in ABA, it is anticipated that the demand for supervision will continue to grow. To date, no research has explored the provision of supervision to trainees in Australia. However, there is a need to identify how many BCBAs in Australia are currently providing supervision, how these supervision experiences are structured, and whether these supervisors have the capacity to increase the amount of supervision they provide as demand continues to grow. Therefore, the purpose of the current study was to survey BCBAs in Australia to determine their current and future capacity to deliver supervision to trainees. To this end, we aimed to identify the proportion of BCBAs who currently deliver supervision as part of their role, and the number of trainees they currently supervise, and their estimated capacity to supervise new or additional trainees in the future. A second aim of the study was to identify and describe the models that Australian BCBAs currently use to deliver supervision to trainees, including mode  and format . A third aim of the current study was to identify the barriers that Australian BCBAs face when delivering supervision to trainees, and to propose potential solutions to commonly identified barriers.We used a custom online mixed-methods survey to examine the supervision practices of BACB certificants  in Australia.Participants were recruited for this study via email and social media. The first and third author sent email invitations to complete the survey to Australian professionals with a BCBA qualification  and to Australian organizations that employ BCBAs. Snowball sampling was used, in which respondents were invited to share the survey link with other potential respondents. Emails contained a brief summary of the purpose and aims of the study, contact details of the authors, and a link to access the survey on REDCap. In addition, a link to the survey was shared by the first and third author on LinkedIn, and to two Australian ABA Facebook pages. Potential respondents were invited to click a link to access the electronic survey at a time and place of their choice. They were first asked to read a short explanatory statement describing the aims of the survey, the potential benefits and risks of participating, the voluntary nature of participation, and how to contact the research team with questions. To be eligible to participate in the survey, respondents were required to hold an active professional credential as BCaBA, BCBA, or BCBA-D. BACB certificants were invited to participate if they were or were not currently delivering supervision to trainees. Allied health professionals or professionals with a master’s degree in ABA who supervised ABA-based programs in Australia but who did not hold a BACB credential were excluded from participating. Finally, respondents were asked to electronically provide their consent to participate. Once consent was provided, respondents were able to view and answer the survey questions.Data were retained and analyzed for 39 participants. At the time that the survey closed (August 2020) there were 149 BCBA, BCaBA, and BCBA-Doctoral certificants listed on the BACB certificant registry in Australia, meaning that 26.2% of eligible Australian certificants completed the survey. Table A custom online survey comprising 36 questions and distributed via REDCap was developed by the authors to address the research aims  for analysis. Descriptive statistics were used to summarize quantitative data in relation to the study aims. Where exploratory analyses were conducted to further elucidate the findings, nonparametric tests were used  due to the small sample size and use of Likert scale interval data. Interpretation of these tests focuses on effect sizes  as opposed to k = 0.801, p < .001), barriers for supervisees in accessing supervision , and proposed strategies to support supervision  reflecting moderate to strong agreement . Optional potentially identifying demographic information was not provided by one participant. Data were missing for three questions regarding the provision of in-person  and/or telehealth , and whether the cost of supervision is likely to rise (q31) but in each case could be explained by prior questions . One participant did not respond to the question regarding future supervision capacity (q43).SD = 7.44, range: 1–30) supervisees. This included 26 of 36 BCBAs and the two BCBA-Ds. At the time of the survey, 29 respondents  were offering supervision and 36 (including 1 of 2 BCaBAs) indicated that they intended to offer supervision in the next 3 years. As illustrated in Fig. SD = 4.11, range: 0–20) to the anticipated mean of 4.79  in 2022. Note that the survey was completed mid-2020, hence the difference between the number identified as current and the anticipated total for 2020. Figure The first aim of the study was to identify the proportion of suitably credentialled respondents who had provided supervision, or anticipated doing so, in the ensuing 3-year period 2020–2022). Twenty-nine of the 39 respondents indicated that they had previously provided supervision, with a mean of 7.28  than those who were not  with a small effect size, U = 91, z = -2.143, p = .032, n2= 0.118. There was a positive correlation between the respondents’ years of experience and the number of people they were currently supervising to become BCBAs, r = 0.475, p = .005. Twenty-four of the 40 participants were providing supervision currently and had done so in the past, 5 were supervising currently but had not done so in the past, 5 had done so in the past but were not currently, and 6 participants had not offered supervision.We completed exploratory analyses to examine the possible association between demographic characteristics  and current supervision practices. A Mann-Whitney-U Test revealed that as a group, respondents who were currently offering supervision had more years of professional experience . A total of 10 respondents indicated that they would provide supervision for the first time in the ensuing 3-year period, whereas two respondents who had previously provided supervision did not intend to do so in the same period.We completed similar analyses of these factors in relation to the respondents’ plans for future supervision. There was again a small difference in the years of professional experience between groups, with those indicating that they would offer supervision in the ensuing period having marginally more experience  than those who did not anticipate offering supervision , with a small effect size, The second aim of the study was to identify and describe the models that Australian BCBA certificants currently use to deliver supervision to trainees.Figure Figure SD = 44.14, range: 40–215). Two of the 16 respondents provided separate amounts for individual versus group supervision, which in both cases were $40 for individual and $25 for group. One participant (in addition to the 16 respondents) indicated that the amount charged is “depending on continent and current role.” Exploratory analysis revealed a small negative correlation between the amount charged and full-time equivalent years of experience as a BCBA certificant , and a moderate negative correlation between the amount charged and the number of people previously supervised .Respondents were asked to indicate yes/no in relation to each of four potential payment arrangements. In the most common arrangement people accessed supervision as part of their employment (70.59%), followed by direct payment (35.29%), payment to the supervisors’ organization (11.76%), and access as part of their employment but with an additional fee (2.91%). Sixteen respondents provided a monetary figure for the cost per/hour of supervision they provided, with a mean value of $100.47 AUD , and two respondents indicated they would increase their fee but did not specify by how much. The remaining six respondents indicated they would increase their fees by 50%, 25%, 19%, 25%, and 25%, equating to an increase of between $10 and $50 per hour.The third aim of the study was to identify perceived barriers and solutions related to the successful delivery of high-quality supervision in Australia into the future. Respondents were asked to rate their level of agreement on a 5-point Likert scale  to four statements regarding supervision capacity. The median response was “disagree” for statements “there are currently enough supervisors in Australia to meet student demand”  and “In the next 3 years, there will be enough supervisors in Australia to meet future demand” . The response was more positive in relation to respondents indicating both knowledge and confidence to provide supervision (irrespective of whether they were currently doing so) with consistent findings .Table The overarching purpose of the current study was to examine the supervision practices of BCBA certificants in Australia, the perceived challenges related to the provision of supervision, and possible solutions to perceived challenges. We found that most respondents were currently providing supervision or planned to provide supervision in the next 3 years. There was an observed positive correlation between the years of experience of the supervisor and the number of trainees they were supervising, suggesting more experienced BCBA certificants may have more interest in supervising or more capacity to deliver supervision. Respondents reported using a variety of supervisory practices to meet the demand for supervision, including providing “on the job” and external supervision using both in-person and telesupervision models. However, several barriers related to the provision of high-quality supervision were identified, including a lack of time and resources on part of the supervisor, and geographical location of both supervisors and trainees. The most commonly identified barrier for people seeking supervision  was a lack of qualified supervisors in Australia. Survey respondents suggested that access to support for supervisors in the form of training, resources, and networking opportunities, as well as the provision of supervised experiences via university run clinical placements, practicums, or fieldwork, might address identified barriers. In what follows, we provide a discussion of these findings and provide recommendations for addressing potential barriers to delivering supervision to trainees in Australia.The first purpose of the current study was to survey BACB certificants in Australia to determine their existing and future capacity to deliver supervision to trainees. Nearly three quarters of respondents indicated that they were providing supervision, with the same proportion indicating they had done so in the past. It is encouraging that 90% of respondents indicated that they intended to offer supervision in the ensuing 3 years, and the mean number of intended supervisees was also anticipated to increase over this time period. Although it is possible that the high proportions reflect respondent bias to the survey  it is nevertheless apparent that a substantial proportion of the relatively small overall population of behavior practitioners in Australia are committed to supporting the training of future practitioners.A second purpose of the study was to identify and describe the models that Australian BACB certificants currently use to deliver supervision to trainees, including mode  and format . The majority of respondents reported offering only individual supervision, or a mix of individual and group supervision. Telesupervision was as frequently used as in-person supervision to deliver both individual and group supervision, with a small number of respondents who reported delivering only group supervision using telesupervision models. It is noteworthy that data collection occurred during the first wave of COVID-19, which may have influenced the strong support for telesupervision. However, other factors in the Australian context, such as the relatively small number of supervisors and supervisees distributed over a large geographical area, likely also contributed to support for telesupervision. The apparent support for the use of telesupervision can also be viewed as encouraging in that it should serve to reduce a key barrier to the establishment of the profession across a large geographical area, meaning that services are more likely to reach communities seeking support from behavior practitioners.A third purpose of the current study was to identify the barriers that Australian BACB certificants face when delivering supervision to trainees, and to propose potential solutions to commonly identified barriers. The most commonly identified barrier to delivering supervision was time. Respondents noted that the delivery of supervision was challenging because of caseload sizes for BCBAs. Given the relatively small number of BACB certificants in Australia and the increasing demand for ABA-based services, it is likely that Australian BCBAs are experiencing significant pressure to design and supervise the implementation of client programs. One respondent noted that they were unable to allocate time for supervision due to the amount of time that was required to supervise client programs. Another respondent noted that little time was provided to prepare for and deliver high quality supervision. These findings echo those of Sellers et al. , who surand the quality of clinical programming for clients. If trainees cannot find supervisors or are dissatisfied with their supervised experience, they may work outside their scope of practice or competence, deliver lower quality programs to clients, and/or leave the profession entirely. These challenges may pose a risk to the growth of the profession in Australia because both may directly result in client dissatisfaction with ABA-based programs. However, this challenge is not unique to Australia. In fact, Sellers et al.  in the interests of developing, sharing, and adopting sustainable models more widely.Based on the findings of this study, we offer three recommendations for addressing potential barriers to delivering supervision to trainees in Australia. These recommendations represent a synthesis of solutions proposed by survey respondents and recommendations or actions described in previous research. Each recommendation has been contextualized to meet the needs of the Australian behavior analytic community. However, these recommendations may be useful in other parts of the world where behavior analysis is an emerging profession or there are few BCBAs to meet the needs of a growing behavior analytic workforce.Our first recommendation is that a national supervision taskforce be established to support the growth of supervision capacity in Australia. The taskforce could fall under the auspice of the peak national body—the Association for Behaviour Analysis Australia (ABAA)—and comprise practitioners, representatives of university programs and other relevant organizations, and consumers of behavior analytic services. Possible functions of the taskforce could include (1) developing a strategic plan for growing supervision capacity in Australia; (2) systematically identifying and addressing barriers to supervision; and (3) liaising with other peak bodies  with the view to learning from, and contributing to, the existing body of knowledge and practices for supporting the supervision of allied health practitioners in the Australian context.Our second recommendation is that a supervisor registry be established in Australia to make it easier for supervisors to advertise opportunities and for trainees to find supervisors. The register could be developed in conjunction with the development of a national registry of BCBAs, that is currently underway as part of the development of an Australian system of professional self-regulation. Although an international register already exists BACB,  the findOur third recommendation is that relevant universities and peak bodies work together to establish a support network for supervisors in Australia. The network would provide opportunities for more experienced supervisors to assist in developing training and professional development opportunities for new BCBAs, and to provide mentorship in the area of supervision to new BCBAs. This network could (1) develop telesupervision guidelines that consider Australian regulatory requirements and privacy rules; (2) develop resources to support the practical aspects of supervision  to reduce time and support barriers that inhibit or reduce behavior analysts’ capacity to supervise; and (3) create a community of practice to share ideas, and generate local solutions to challenges.This study was the first to systematically explore the supervision practices of BACB certificants in Australia. Given the recent establishment of two verified university course sequences in Australia, it is anticipated that the demand for supervision will continue to grow. The current study extends the findings of Leif et al. , who fouThe findings of this study, although providing the first insight into supervision in the Australian context, is not without its limitations. First, with a geographical focus on Australia only, there is naturally some limitations to the broader relevance of the findings internationally. However, we suggest that this study in fact provides insights into the opportunities and challenges that come with establishing a workforce, along with the supervision support required for this to occur, and that these findings are thus relevant to the expansion of ABA service provision globally. Second, as noted, there is a risk of sampling bias in the current study, in that it is possible that people who currently provide supervision may be more likely to respond. Furthermore, the response rate is not known, as the invitation to participate was shared via professional networks and social media. Future studies could include a direct approach to behavior analysts: a strategy that should be feasible once national registration in Australia is established.A third limitation is the difference in timing and reporting of the survey findings. As noted, the survey was completed in 2020, meaning that the findings may not fully represent current practice. Since the time of the survey, the number of BCBAs  listed on the Australian certificant registry has grown to 216. However, we suggest the findings are nevertheless valuable in exploring the range of issues facing the profession in relation to supervision, including many of which  could not conceivably be resolved in the relative short time frame of 2 years. Furthermore, the findings provide a baseline against which the evolution of supervision capacity and practices in Australia can be compared. It is clear that further studies are warranted to document this evolution, and to identify the most current opportunities and pressing barriers related to the delivery of supervision in Australia.The findings of this study indicate that there is a strong commitment among behavior analysts in Australia to providing high quality supervision that meets the needs of the growing workforce and as the basis for high-quality clinical services to the community. Nevertheless, a range of barriers to providing, and accessing, supervision were identified including workforce capacity, time, financial considerations, and support for supervisors. Based on the solutions offered by participants, we put forward three recommendations to help grow and support supervision in Australia including establishing a national supervision taskforce, a supervision registry, and a supervision network with each serving complementary roles ranging from strategy to coordination and in person mentoring and support.


Diagnostics by Odusami et al. [There is considerable interest in developing effective tools to detect Alzheimer’s Disease (AD) early in its course, prior to clinical progression. Among efforts is to predict the conversion of Mild Cognitive Impairment (MCI) to AD . Althougi et al.  utilizinhttp://adni.loni.usc.edu/ (accessed on 1 October 2021)). For subjects who had multiple scan dates, the earliest scan was used to avoid duplicates. According to baseline diagnosis, 436 subjects were controls, 199 had Mild Cognitive Impairment (MCI), 88 had early MCI (EMCI), 37 had late MCI (LMCI), and 62 had Alzheimer’s Disease (AD). Considering the width, height, depth and time dimensions, the shape of each BOLD image was either  or , therefore generating either 18,715 or 92,720 slices. Twenty five subjects were randomly selected from each diagnostic group. Each rsfMRI image was sliced along the depth and time dimensions, and to only keep slices with prominent features, we calculated the mean BOLD signal of each slice and only kept slices with means in the 90th percentile for each subject. This filtering process manifested in around 1871 or 9270 slices per subject, and 700 slices were randomly selected from each subject for binary classification. The fMRI images were not further processed, and the images were enhanced in the way described in the original study to enable inputting of the dataset into the pretrained ResNet-18 model. We acquired the functional magnetic resonance imaging (fMRI) scans of 822 subjects from the Alzheimer’s Disease Neuroimaging Initiative 3 (ADNI-3) dataset  and 8 subjects the test set (5600 slices per diagnosis). The performance of each model was assessed using accuracy, specificity, and sensitivity, averaged over.We used the same neural net architecture described in the original study, ResNet-18, with a remodeling of the final dense layer to enable binary classification, and the addition of a non-linear ReLU activation function and a Dropout of 0.2. The layers were unfrozen to update the parameters of the pretrained model based on the new dataset. In order to allow for faster learning and utilize the large memory of our GPU, we also increased the batch size to 256 and learning rate to 1 × 10As seen in We subsequently experimented with an alternative holdout strategy. Instead of splitting the data into train and test sets by subject, we split them by fMRI slices along the axial axis, taking 70% of slices for training, and 30% of slices for testing. As a result, the train and test sets could have slices from the same subject. As seen in the performance metrics in It is therefore clear that splitting the data into train and test sets by fMRI slices resulted in significantly better performance. However, it is crucial to note that that this splitting method is invalid as it manifests in data leakage, whereby information from the test set leaks into the dataset used to train the model. The model is therefore likely recognizing the patients it has already encountered in the training set, rather than recognizing the features of MCI or AD. While these models may appear to perform successfully, if presented with data the model has never encountered, such as in our first replication experiment, performance would drop. In the real world however, a diagnostic problem would be similar to this first replication experiment where the model has not previously encountered the patient’s data and would need to be robust enough to classify the patient into a diagnostic category. Models with data leakage, therefore, provide a false sense of performance and are likely not robust enough for use in the clinical environment.We herein demonstrate that a replication of the methods proposed by Odusami et al. fails to achieve the impressive performance reported by the authors. Although our results came close when using an invalid hold-out strategy, the original study reported that data were split by subjects rather than slices. We are therefore unable to identify the reasoning for the discrepancy between our results. While some level of discrepancy was expected given the known difficulty of replication with deep learning models, we are unable to explain the vastness of the difference reported. We were also unable to gain access to the original code used in the study, making it difficult to understand the reasoning behind the misclassification. The unavailability of the code also makes it difficult to be certain that our methods were an exact replica, but we aligned as closely as possible to the described methods in the paper. One difference between our methods and the original study was the utilization of the ADNI-3 dataset rather than ADNI-2. We used the ADNI-3 dataset as it had the 25 subjects per each diagnostic category without relying on repeat scans where subjects converted between categories longitudinally as in ADNI-2. We do not believe this would have impacted the validity of our replication, as the described method should be capable of replication in any similar dataset. The utility of a diagnostic tool should also not be dependent on the dataset used, as this speaks directly to the external validity of the tool in practice. Nonetheless, the stark contrast in results between the two hold-out strategies demonstrates the importance of using test sets which have never been encountered by the model and avoiding data leakage, which may ultimately compromise the applicability of the results.The utilization of ResNet-18, including with the modifications proposed in the original paper, may also be too reductionistic for use in fMRI data, resulting in the misclassification results we have encountered. ResNet-18, or even other methods which have been applied to fMRI, ignores the time and depth dimensions of fMRI, treating the problem the same as any other image classification. This may however manifest in information loss, which may be crucial for detecting the features of pathology early in their course. Future studies should aim to utilize models incorporating the entire four dimensions of fMRI data in order to improve classification by considering the entirety of the information available.Our results speak to the replication crisis in machine learning, which presents one of the foremost barriers to translating these methods to clinical practice. While models provide a fast and potentially accurate means of diagnosis, there are also difficulties with generalizing methods to new datasets, especially in cases where there is overfitting of the model to the training data, and proper precautions are not taken to prevent data leakage with consequent unreliable performance metrics. This remains one of the limitations of studies utilizing machine learning models, and a barrier slowing down clinical translation. Misclassification and reproducibility can, however, be improved in future studies if the field prioritizes translatability as much as, if not more than, novelty and outperformance. As echoed by Heil et al. , to prev