Soil moisture is one of the main factors in agricultural production and hydrological cycles, and its precise prediction is important for the rational use and management of water resources. However, soil moisture involves complex structural characteristics and meteorological factors, and it is difficult to establish an ideal mathematical model for soil moisture prediction. Existing prediction models have problems such as prediction accuracy, generalization, and multi-feature processing capability, and prediction performance must improve. Based on this, taking the Beijing area as the research object, the deep learning regression network (DNNR) with big data fitting capability was proposed to construct a soil moisture prediction model. By integrating the dataset, analyzing the time series of the predictive variables, and clarifying the relationship between features and predictive variables through the Taylor diagram, selected meteorological parameters can provide effective weights for moisture prediction. Test results prove that the deep learning model is feasible and effective for soil moisture prediction. Its’ good data fitting and generalization capability can enrich the input characteristics while ensuring high accuracy in predicting the trends and values of soil moisture data and provides an effective theoretical basis for water-saving irrigation and drought control. Water is the primary resource that determines the survival and development of the Earth's inhabitants. Soil moisture not only plays an important role in maintaining plant growth but also is a key link in the water cycle of soil-plant-atmosphere continuum systems –4. HowevAt present, the mainstream soil moisture prediction methods mainly use empirical formulas, linear regression, and neural networks to construct prediction models. The empirical formula model is the earliest. By analyzing the initial soil water content, daily rainfall, average temperature, and daily average saturation difference, and based on the multivariate linear relationship of soil moisture, Chen Xiaofeng  and otheWith the rapid development of artificial intelligence in recent years, in 2006, Hinton  proposedThe test area is located in Beijing, China , in Shunyi, Yanqing and Daxing. It represents a typical semi-humid continental monsoon climate in the North Temperate Zone. It is hot and rainy in summer, and is cold and dry in winter. Spring and Autumn are short. The soil texture is mainly sandy soil or resembles sandy soil. Regarding the two areas, Daxing is sandy loam, and Yanqing Shunyi is mostly medium loam. The main crops are winter wheat and summer corn. The average annual rainfall in Beijing is 585 mm, but the regional distribution is uneven, and the overall rainfall is increasing. From 2012 to 2016, the annual soil moisture change in Beijing was between 10% and 25%. The test area covers Beijing's main planting areas. The proposed model can provide a theoretical basis for water-saving irrigation strategies in Beijing.The data used in this experiment is provided by the Beijing Meteorological Bureau and is divided into two parts: meteorological data and soil moisture data. The data includes three areas, Yanqing, Shunyi and Daxing. The period covered by the meteorological data and soil moisture data is from 2012 to 2016.The meteorological data types include daily average temperature, daily average air pressure, daily average relative humidity, daily average wind speed, daily average surface temperature, and daily precipitation; soil moisture data includes soil average mass water content at 10 cm and 20 cm depth in farmland.Different sources of meteorological data and soil moisture data result in different data formats and lengths. Data integration and matching is required. The deep learning model requires a large amount of data for training purposes and a long time-span data set to ensure complete data characteristics. The method involves selecting the training set and test set according to the amount of soil moisture data from 2012 to 2016. The integrated data contains missing values. If the missing value is included, and induces a large error, it will cause interference in the model training. Therefore, we chose to eliminate data with missing values. The final data set contains six meteorological features, as well as an initial moisture feature, and a pending prediction feature of soil moisture. After processing, a total of 1,196 data samples from Yanqing area were obtained, including 954 sets of data from 2012 to 2015 to build a training set, 242 sets of data in 2016 to build a test set, and 50 data samples were randomly selected from the test set for model selection. At the same time, a total of 239 data from Shunyi area in 2016 and 235 data from Daxing area in 2016 were used to verify the extensibility of the model.To predict the data, we must first understand the trend of the predicted features. According to The regression prediction should be clear about the correlation between each variable and the predicted feature, so that reasonable parameter characteristics can be selected for model training. The first step is to analyze characteristics of the predicted variable. It can be seen from The results of the correlation analysis between the features of the data set and soil moisture are shown in The data analysis is summarized in Four evaluation measures were selected to indicate the performance of the different models.Mean Absolute Error(MAE) is:Mean Squared Error(MSE) is:Root Mean Squared Error(RMSE) is:2) is:R Squared is a multi-hidden layer (at least two layers of hidden layers) regression neural network. Compared with the single hidden layer perceptron, when the same data is fitted, the increase of hidden layer depth in DNNR means the reduction of nodes in each hidden layer, which can improve data fitting capability. The advantage of the DNNR model is that it can correlate or discover feature combinations that have not appeared before, and is good at fusing hidden feature attributes, reducing the complexity of feature engineering and improving the generalization capability of the model. The DNNR network structure is shown in From The number of input layer nodes is equal to the number of features of the input data. The more hidden layers, the higher the number of features needed to reduce the influence of underfitting or overfitting;Each hidden layer node is composed of neurons. The neurons contain both rectifier activation and aggregation function, when constructing the DNNR model, the activation function in the default neuron is the Rectified Linear activation function, making the deep learning network neurons have sparse characteristics, which reduces the influence of overfitting while increasing the depth of the network, improving the training speed of the model, and effectively overcoming the problem of gradient disappearance. The Rectifier activation function is defined as follows:i is the number of nodes in the previous layer and c is the bias:The regression model output layer is different from the classification model. It is a single node. The output of the previous hidden layer is multiplied by the weight and is added to a bias on the output node to obtain the regression prediction value. The function below describes the process, where x is the input feature in the function; w is the weight of the layer; and c and b are node biases.The overall function expression of the DNN model is a multi-level nested form, that is, the output of the previous layer is the input of the next layer, η is used for each training parameter. The Adagrad algorithm adaptively adjusts learning rate η, which must be reduced with the frequently occurring parameters to avoid parameter oscillation, and takes a larger η for less frequently occurring parameters to accelerate model update. It is suitable for optimizing any sparse data and perfectly matches the characteristics of the above Rectified Linear activation function. ∇i,tJ(θ) is the gradient of the i-th parameter in the t-th round; ε is the minimum value; Gi,t is the accumulation of the previous t-step θi gradient; The expression is as follows:The optimization function selected was the Adagrad algorithm. Compared to the traditional gradient descent algorithm (SGD), the same learning rate The DNNR model training involves supervised training, in that the training set and the test set features all need labels, and the model parameters (weights and biases) are adjusted according to the comparison between the model prediction results and the labels to minimize the error. Training is stopped when the maximum number of specified training steps is reached or the preset accuracy is met.The number of hidden layers and the number of hidden layer nodes can directly affect the training speed and prediction accuracy of the model. This paper uses six meteorological data features and one soil water content feature to predict soil moisture. So the number of input layer nodes is 7, which is equal to the number of features; the output layer sets the number of nodes (according to the regression characteristics) to 1; and because the data size is medium, two hidden layers in the hidden layer structure are sufficient to meet the requirements. The numbers of first layer and second layer hidden nodes need to be evaluated and selected through multiple rounds of testing. The comparison results are shown in It can be seen from As can be seen from In order to prove the performance of the selected model, the sliding window with data length of 50 is set, the moving step is set to 10, in the case where the window slides to the end of the data and the amount of data is less than 50, the amount of missing data is complemented from the beginning of the test set. the method can select 25 sets of test data from the test set with the data length of 242, and the test data volume of each set is 50, and the performance is verified by inputting the model separately. The test results obtained 25 test loss values. The single sample t-student test was used to analyze the 25 test loss values and the training loss values. Under the premise of 95% confidence interval, the obtained bilateral Sig value was 0.51>0.05. At a significant level of 0.05, there was no significant difference between the test loss value and the training loss value, indicating that the trained model has good generalization ability. The specific analysis results are shown in To verify the generalization capability of the constructed model, all the 242 sets of data in the test set were selected for prediction experiments. The prediction results are shown in At the same time, the model is also used to predict soil moisture data in the Daxing and Shunyi areas. The previously constructed Shunyi area test set  and the Daxing area test set  were input into the prediction model for model scalability verification. The prediction results are shown in DNNR model error analysis results are in The above analysis can clearly see that because the soil moisture has regional characteristics, the predicted values of other regions contain different degrees of error, the further statistical analysis of the prediction for the three regions are shown in The above results indicate that the model has great generalization capability and remain within a stable acceptable error range, which ensure that the soil moisture data predicted by the model can be used in actual guidance in Beijing.The location of this test was in Beijing, because soil water movement is a complex time series system, and its changes are closely related to regional climatic conditions and ecological environments, with obvious random fluctuations, and the differences of soil moisture regression regular patterns have large divergence. Therefore the discussion in this paper is mainly focused on a domestic soil moisture model evaluation. The input variables of the existing soil moisture prediction model are selected from air temperature, air humidity, atmospheric pressure, soil moisture, daily precipitation, illumination duration, radiation intensity, average wind speed, and initial soil moisture –22. The 2) was 0.88, so the prediction model input only contained rainfall and initial moisture. After we analyzed the soil moisture data in Yanqing, Beijing, the correlation between rainfall and prediction characteristics is 0.17, and the standard deviation ratio is 1.5, indicating that the influence of meteorological parameters in different regions is significantly different. Hou Xiaoli [Using SPSS to analyze the autocorrelations of moisture data found that it is a non-stationary time series, indicating that the water content is affected by other meteorological parameters. Increases in air/soil temperature, light, and wind speed will accelerate the evaporation of soil surface water, which is a negative correlation parameter. Soil/air humidity, atmospheric pressure, and rainfall increase soil moisture, which is a positive correlation parameter. The rainfall factor has the most direct impact and greater amounts of rainfall can directly saturate the soil moisture. Existing models all select the initial moisture as the input feature, and other input feature selections will have larger differences. Ji Ronghua  and otheu Xiaoli  and otheu Xiaoli  et al. d2 of DNNR model is higher than SVM and ANN1 by 9% and 24%, the RMSE of DNNR model is less than SVM and ANN1 by 80.74% and 87.02%, the MAE of DNNR model is less than LR, SVM, ANN1 and AGNN by 91.73%, 84.38%, 88.51% and 54.76%, the comparison results are shown in To verify the superior performance of the DNNR model, we compared it with existing models, most of the soil moisture prediction models are LR(Linear Regression), SVM(Support Vector Machine), ANN and related improvement models, the RAlthough the model has certain advantages in specific measures, the conditions are different for each model, and the composition of the data set and regional differences are difficult to eliminate. To solve this problem, this paper constructs a neural network model using the same data set used for the DNNR for comparison purposes. MLP is one of the most widely used advanced models, and it is more convincing to choose this model for comparison.An MLP model was constructed using six meteorological features and an initial moisture feature. The MLP model is a 1-100-1 three-layer network consisting of a single hidden layer. The activation function of the hidden layer node is a hyperbolic tangent (Tanh). The training features types and quantities are the same as those in First of all, the soil moisture in Yanqing area, Shunyi area and Daxing area of Beijing was predicted and shown in The MLP model error analysis results are in The comparison between DNNR and MLP predicted value-real value sets are shown in The comparison between DNNR and MLP predicted residual-predicted value sets are shown in In summary, this paper uses the meteorological data and initial soil moisture data of Yanqing in Beijing to construct a DNNR model to predict soil moisture, analyze the correlation between various meteorological parameters, soil water content, and the characteristics of the moisture data. Based on the analysis results, the training set and test set are constructed. Then the training model obtains the ideal result by predicting the depth of the Yanqing 20 cm depth soil moisture and is then used to predict other areas. The prediction is acceptable and meaningful. Various comparison tests prove that the DNNR model has good generalization ability and fitting accuracy. However, this experiment still needs to proceed further: (1) it needs to be further applied to more areas to verify the effectiveness of the model in predicting soil water content under different climatic conditions; (2) using mixed data to construct data sets and training models, such as fusing meteorological data and remote sensing data to analyze model feasibility; (3) increase the control experiment by changing the input features, and further analyze the impact of different meteorological characteristics on the accuracy of soil moisture prediction.Soil moisture data is a non-stationary time series, which presents a periodic variation regular pattern involving large fluctuations. It is known from correlation analysis that each parameter characteristic has a correlation with the moisture parameter, which affects the predicted value, and that the initial soil moisture feature has the greatest weight. Humidity and temperature are second. Although the rainfall variable directly affects the soil water content, its distribution is highly random and noisy, leading to a low weight factor that cannot be used as the only fitting parameter. Therefore, the seven input variables discussed in this paper were selected as the inputs of the prediction model.The deep learning model is used to predict the soil moisture at a depth of 20 cm in the Yanqing area. It was proven by experiments that too many layers of the model can lead to too excessive training time and overfitting, the latter which affects training accuracy and generality. Finally, a two-layer hidden layer was considered most suitable for our model’s structure. The first layer is responsible for learning the input features, and the second layer is responsible for polynomial fitting of the learned features, and too many nodes will cause overfitting and reduce the prediction accuracy and generalization capability. Ultimately, after ten repetitions of training, the model structure was determined to be 7-100-50-1 and the DNNR model can ensure that the overall prediction error in the Yanqing area is controlled at ±1.At the same time, the DNNR model also can predict the moisture trends of other regions (Shunyi and Daxing), and has ability to keep prediction error near the zero point. All evaluation indicators are better than MLP model. The above results indicate that the DNNR model has excellent generalization capability and scalability. It is feasible to apply soil moisture prediction and provide technical support for irrigation strategies and drought control using this model.


Changes noted within the aging population are physical, cognitive, as well as emotional. Social isolation and loneliness are also serious problems that the aging population may encounter. As technology and apps become more accessible, many basic services, such as those offered by social services, well-being organizations, and health care institutions, have invested in the development of supportive devices, services, and Web-based interactions. Despite the perceived benefits that these devices and services offer, many aging individuals choose not to engage, or engage in a limited manner. To explore this phenomenon, we developed a theory to describe the condition for engagement.The main objective of this study was to understand the perceptions of an aging South African population regarding Web-based services and technologies that could support aging in place (AiP). Although the concept of AiP speaks to a great number of everyday activities, this paper explores aspects of health and well-being as being central to AiP.The study used a grounded theory (GT) methodology, relying on an iterative and simultaneous process of data collection, coding, category development, and data comparisons. Data were collected through qualitative methods, including interviews (13 participants aged between 64 and 85 years), 2 participatory workshops (15 participants), and observations. The study focused on Charmaz’s approach to constructivist GT, which puts forward the premise that theory or knowledge cannot take shape in a purely objective manner. Instead, theory is constructed through the interaction of the researcher and research participant. Coding and data analysis were supported with ATLAS.ti (ATLAS.ti Scientific Software Development GmbH).Ageing User Decision-Driven Engagement (AUDDE), explored the elements that support engagement with technology and supportive apps, which could offer access to required health and wellness services.The study resulted in a substantive theory exploring the process of interaction and engaging factors through user insights and experiences. The emerging design theory, In AUDDE, the perceived value of the interaction is a crucial catalyst for engagement. Aging users continuously make meaning of their experiences, which affects their current and future actions. Globally, health care systems have to deal with the exponential growth of the aging population, adding strain to health care service provision while still having to commit to achieving the sustainable development goal of the right to good health for all ages . There iGerontechnology is a concept for considering the impact of technology on the QoL of the aging population, where technology has the ability to enable services [The danger of fast technology advances is that they could potentially widen the gap between younger and older population groups, especially considering the diversity and multitude of cognitive and physical abilities and health status associated with aging groups, which may make adoption of technology more difficult . Effortsservices . When coservices .Many gerontechnology research studies deal with the design processes and methodologies . Both paThe aim of this study was to propose a theory that can be used when designing health and well-being services with the aging population as a target group. Findings from the study contribute a substantive theory to the service design body of knowledge, which explains the engagement of older individuals with Web-based services . The study adds value to Web-based health care service design practice by developing a deeper understanding of user perceptions and experiences within a sociotechnical context.Decreased physical mobility, eyesight, and cognitive processing may impact the QoL of older individuals. These individuals require support from family, friends, or the community to complete basic daily tasks and activities relating to their health and well-being. Technology and devices that support health care could offer alternative solutions to these challenges. These technologies can range from services that enable increased socialization  to health monitoring devices and emergency notification services.The Web-based market for an aging population has been an area of research interest for a long period, but it has not yielded many insights into user-driven design in collaboration with older users . This maThe influence of age on the likelihood of engaging with technology is less extreme than once imagined ,21, but From an economical perspective, it is crucial to consider the global growing aging community within our technological society ,22. If nage-based innovations, which are defined as products and services specifically designed to acknowledge the needs of older users. Irrespective of the assigned title, these products and services focus on enabling an aging community to remain autonomous and contribute to a greater sense of well-being . A possible contribution of supportive technology and access to Web-based services is facilitating aging in place (AiP) of aging individuals.Gerontechnologies offer technologies and innovations specifically designed for an aging community ,24,25. AA lack of understanding specific user needs can have a major impact on the innovation of various technologies that can support AiP . This unOnly when the real needs of the elderly are correctly understood by innovators, fully specified in AiP digitalization, together with stakeholders’ inclusion in the innovation process and proper consideration of human factors and other contextual factors…can then ensure the success of AiP implementation .To encourage continued engagement among aging users who can benefit from technology that facilitates AiP, the nature of their Web-based interaction, as well as the process of learning how to engage, must be considered. Aging individuals and those who care for them will embrace technological products and services that support AiP .Grounded theory (GT) emerged from the research and practice of Glaser and Strauss in 1967 . Since tThe process aims to conceptually explain how participants respond to a certain concept, phenomenon, or challenge . The devParticipants were recruited through a gatekeeper organization, which has a broad reach throughout the Western Cape and South Africa and attracts individuals from varying ethnic and socioeconomic backgrounds. Presentations were made to members to introduce the project and highlight the parameters of participation. The parameters were that the participants had to be over 65 years and have access to Web-based services through a personal or shared device. The study did not explore problems with connectivity or internet penetration within South Africa. Following the presentations, 23 individuals requested to collaborate on the study, out of which 13 were interviewed . The 2 wvalid. The validity of consent was defined through the work of Ratzan [Ethical considerations were a primary focus in the study, and recruitment was dependent on the participants’ ability to give informed consent. Furthermore, 3 aspects contributed to the concept of informed consent practiced in the project: (1) participation was voluntary, (2) the nature of the project  was explained before commencement of the research activities, and (3) participants’ consent was f Ratzan , which pparticipant coding and information form. The form was part of a research process map and toolkit document, which supported the gathering of informed consent and first stage research observations  the gathering and analysis of workshop data , followed by (2) the reflection and code review phase. In total, 2 workshops were completed, one with 7 and another with 8 participants. The workshops included 3 activities. The first activity was an introduction to a range of Web-based services, demonstrated on different devices and operating systems . At the interactive demonstration session, participants shared their own experiences. The second set of activities focused on the creation of a collaborative persona. The collaborative persona template , discussion transcripts for each of the 4 working groups, and observational notes were analyzed and coded. During the analysis and coding of data from the second workshop, no new codes emerged. The analysis and coding of workshop data were followed by a review of the captured initial codes. As part of the review, each code was assigned an introductory word or phrase, which identified the larger focus area and the theme of which the code was a part , the focused coding process resulted in a set of core categories. All initial 135 codes were absorbed within the emerging core categories, and they reflected a more conceptual connection and relationship of themes noted during the code review. The core categories descriptions are grounded in the original comments and perceptions shared by participants. Through the coding process, the data gathered were deconstructed into essential elements, reviewed for patterns and relationships, and then constructed into more complex concepts. The core categories are Aging users viewed technology as products and services that allow access to both convenience and information. Participants felt that products, apps, and services were not designed specifically with aging users in mind. Factors noted in this study that impact user engagement and willingness to interact relate to personal perception, emotional responses, and how each individual views his or her own ability to learn and master new technology.Diverse learning networks were noted in the study. When new skills, ways of working, and ways of learning are introduced, users must adapt their cognitive understanding to engage with the process. Cognitive ability plays a role not only in an aging user’s willingness to engage but also in the long-term usage. Olphert and Damodaran  hypothesforced to engage with new technologies and services. The sense of frustration that they felt was heightened if their immediate network either could not or chose not to offer support and tutelage. Hellet (a pseudonym selected by the participant) noted the following:Both positive and negative emotions were observed when participants discussed engaging with new technologies. One of the key emotional triggers noted by participants was that they often felt I really think I need to go for lessons. My daughter always says “what lessons? Just sit and try” like I’m not trying in the first place.These early reactions to the use of a Web-based service can influence the way that older users experience the technology as a whole.The requirements of aging users are often overlooked by developers and vendors as they do not play an active role in the conceptualization or design of Web-based services and other technologies . ParticiPrograms are often designed by people who are too clever. Sometimes, I don’t know what’s going on, then what do you do? Explain to people. As we work, we learn...I need to learn by doing it myself.Acknowledging the unique personal context of an aging user is a key factor in facilitating Web-based engagement. The impetus to engage, the perceived value of Web-based engagement, and the design characteristics of an enabling environment must all be considered.The rise of Web-based activity among aging users is linked to their perception of services, technologies, and apps as tools to support everyday activities. One participant (with the pseudonym Victoria) noted the following:So the value is when you have limited mobility, when you're housebound…You could have your Skype, which you can use to check in with your neighbors. If you are housebound and you can contact your friends or family. You can phone your neighbor. So the access is absolutely brilliant. You have unlimited access, you can access anybody, your children, anybody and let them know your situation.burden of care often associated with an aging population [In the context of an everyday tool, supportive devices and services can offer users clear value propositions. Digital technologies and Web-based services play a major role in addressing the so-called pulation . Participulation .fourth digital divide, which is not characterized by a lack of access or skill but rather by a lack of clear motivation or interest [Once the perceived value of the interaction is high enough for an aging user to engage, even though he or she may have negative perceptions, the nature of the interaction space and platform may still impact continued engagement. In many cases the emotions noted included frustration at one’s own inability to understand and successfully navigate a Web-based service and supportive devices, the fear of the unknown, and feelings of frustration when forced by family or community members to engage with digital technologies. These emotional reactions form part of the human experience of a technological interaction. Digital interaction and the design of this interaction may influence the user experience, as well as the process through which the user learns to navigate the interaction. If not considered during the conceptualization and design of Web-based services, it can be hypothesized that aging users who do not feel confident would cease to use the services that could possibly improve support for their everyday activities . This reinterest .Web Accessibility Initiative: Ageing Education and Harmonisation [excessive complexity of the technology [Using devices and services does pose a number of challenges to aging users, including limited experience with devices, limited experience with Web-based services, or a lack of interest . It is nnisation —a Europechnology . ParticiDuring the focused coding process, memos allowed the researcher to keep track of considerations and decisions. The writing up of memos also provides for a structured moment to pause and reflect on the process, encouraging a holistic reflective practice. Finally, the process of theoretical coding responded to the 2 coding aims stated by Flick . First, Ageing User Decision-Driven Engagement (AUDDE).During the theoretical coding process, the emergent core categories were reviewed from a structural perspective to understand the relationships between categories and the nuances at play when considering core categories as part of a whole and not individual sectors. The result of the theoretical coding process was the substantive theory, which explored the process and factors that impacted an aging individual’s willingness to engage with technology and services. Saturation was explored at data level  and again at theoretical level . Through the process of theoretical coding, these categories formed the foundation for the emerging theory of cyber-seniors refers to 2 emerging groups of aging users, the first is that of the technology lovers (who engage willingly and are fascinated by technology) and the second is that of the technology users [technology users. Only 1 participant in the study could be defined as a technology lover; all other participants commented on the tool nature of Web-based services or their ability to help you do something. AUDDE  or self-exploration. These learning experiences may happen before engagement or may take the form of coached support while using a device or service. How an aging user interacts, the cognitive experience of the interaction, and the emotional consequences and resulting learning process are all interwoven elements of an iterative cycle. A user may go through multiple cycles within this sociotechnical experience before reaching the end of the interaction. The outcome of the interaction could be a successful task completion, an unsuccessful task completion, or an interrupted task (ended before either a successful or unsuccessful task completion). Irrespective of the nature of the outcome, the experience of the interaction will result in the user’s reflection on the perceived value expectation in relation to the interaction experience. This process will inform the future When reflecting on the emerging AUDDE theory, the complex nature of the networked society becomes clear. Knowledge and experience within the Web-based and digital service realm transcend single disciplines to create service systems:Actual service systems can be described as complex sociotechnical systems, being approached in an interdisciplinary vision that integrates business functions, technology, and human resources, with the final aim of creating value and benefit through the generated services.Acknowledging this complexity is crucial when conceptualizing and designing devices, technologies, app, and Web-based services, which aim to support the health and wellness of aging individuals. Researchers and designers must systematically review both the technical and social systems that are at play during an interaction . The tecmore institutionalized traditions or regulations inside various user communities [End users are social beings, who evolve and grow. As such, it is impossible to define social value as a constant, and the social impact on interactions must be considered within the munities . To undemunities , as wellIt must be emphasized that AUDDE is firmly grounded in the perceptions and shared stories of a specific group of aging users living in Cape Town, South Africa. The relevance of this theory to aging users’ experiences outside this geographic area must be verified. The regularity of participants’ use of supportive technologies was not a consideration within the delimitations of the study. AUDDE is a substantive theoretical contribution to the body of knowledge of design, but it has the potential to be explored within the context of other studies. To ensure that the emerging theory represented the views and shared experiences of participants, an interactive discussion session was conducted with a participant who took part in the interview and workshop. The session was discussion driven and presented the research process and emerging theory before requesting feedback and comments from the participant. The feedback supported the emerging theory, but feedback from a larger audience will be beneficial.As the global health care systems become strained with growing aging populations , technol


Nutritional management is an important component of the treatment of pediatric overweight and obesity, but clinicians struggle to keep abreast with the abundant literature. Therefore, our aim is to provide a tool that integrates the current recommendations and clinical expertise to assist dietitians and other practitioners in their decision making about the nutritional management of pediatric overweight and obesity. To construct this practice-based evidence-informed framework, we conducted a systematic review of the guidelines on nutritional management of pediatric overweight or obesity in 2 databases and in the grey literature. We analyzed and synthesized recommendations of 17 guidelines. We selected the recommendations that were common to at least 30% of the guidelines and added by consensus the recommendations relevant to clinical expertise. Finally, we structured the framework according to the Nutritional Care Process in collaboration with a specialized team of dietitians who assessed its validity in clinical practice. The framework contributes to facilitate the integration of evidence-based practice for dietitians by synthesizing the current evidence, supporting clinical expertise, and promoting structured care following Nutrition Care Process model for children and adolescents with obesity. Obesity in children and adolescents reaches alarming rates and the World Obesity Federation and the World Health Organization are calling to action in order to reduce the prevalence of pediatric obesity and its many associated physical, psychological, and social consequences . Risk faTo provide effective care, dietitians adhere to evidence-based practice (EBP) that is about, according to the International Confederation of Dietetic Associations, “asking questions, systematically finding research evidence, and assessing the validity, applicability and importance of that evidence. This evidence-based information is then combined with the dietitian’s expertise and judgment and the client’s or community’s unique values and circumstances to guide decision-making in dietetics” . RegardiWith the number of clinical guidelines expanding rapidly, practitioners struggle to stay abreast. Time is often cited as a major barrier for integrating research into practice ,15 and sWith a focus on EBP, the Academy of Nutrition and Dietetic has developed the Nutritional Care Process (NCP), a systematic approach contributing to high quality nutrition care. This approach helps dietitians structuring their actions in four distinct but interrelated steps: nutrition assessment, diagnosis, intervention and monitoring/evaluation ,20. In oWe conducted a systematic literature review of the literature reviews and guidelines on nutritional management of pediatric overweight or obesity in two databases commonly used in healthcare (PubMed and Cochrane Library). In order to improve exhaustiveness, and specifically to avoid missing guidelines emanating from expert groups that have not been published in peer reviewed journals, grey literature was also included. The research equations are detailed in An evaluation of the methodological quality of the guidelines was conducted using a simplified grid inspired by the AGREE tool  assessinTwo members of the team independently extracted the recommendations regarding the nutritional management of pediatric overweight and obesity from the 17 included guidelines. The recommendations were isolated, categorized by theme and organized following the 4 steps of Nutritional Care Process (NCP).n = 9) of a specialized group for the prevention and treatment of pediatric obesity recognized by the Swiss Association of Registered Dietitians reviewed the preliminary framework, as well as the table listing all individual recommendations emerging from the guidelines. Based on their clinical expertise, recommendations that are regularly used in clinical practice were identified among the individual recommendations from the guidelines. Even if those recommendations were not mentioned in at least 30% of the guidelines, they were included in the framework while distinctly labeled.In a first step, recommendations that were present in at least 30% of the guidelines were used to construct a preliminary framework. Because we could not find previous work publishing on the cut-off point, we chose 30% based on the descriptive analysis of our data. This allowed a selection of a large panel of recommendations. In a second step, the members  [n = 2 in 2009 and 2016) [Ultimately, no reviews met the inclusion criteria and we included 17 guidelines, issued by 14 different scientific societies  ,23,24, And 2015) , Canadiand 2015) , Endocrind 2015) , Europeand 2015) , Haute And 2015) , Institund 2015) , Institu015 ,23,2nd 2015) , Nationand 2015) , Nationand 2015) , New Zeand 2016) ,34, Scotnd 2016) , Societànd 2016) .Most guidelines had a good methodological quality. Shortcomings related to the presentation of the methodology used to search and select the evidence. The detail of the evaluation is presented in In total, 344 recommendations were extracted, from which 36 (10%) were present in at least half of the guidelines, and 57 (17%) in at least 30% of the guidelines. A summary of the recommendations classified by theme is presented in The items related to general recommendations of treatment were similar across all guidelines, while precise recommendations were less common. The levels of evidence reported in the guidelines were mostly low and the recommendations were often based on expert consensus. A comparison of the different levels of evidence across guidelines was impossible because each guideline had a different grading scale. All guidelines considered the treatment of both pediatric overweight and obesity.The final framework  includesThe retrospective analysis of four cases revealed that the framework was complete, usable and coherent with clinical practice. Each nutrition intervention retrieved from the 4 patients’ records was already present in the framework and no new recommendation had to be added. The interviewed dietitian highlighted that the framework was helpful to structure the dietetic treatment while leaving enough liberty to adjust the treatment modality to the patient. She used the framework as a checklist to make sure that she did not miss any component. She emphasized that clinical expertise was essential to apply the framework effectively. Also, the framework was perceived as a communication tool that highlights the evidence supporting her practice to external stakeholders.Dietitians have an essential role in the treatment of obesity among children and adolescents. In this project, we identified the most common recommendations for nutritional management of pediatric overweight and obesity from guidelines and clinical expertise and organized them according to the NCP-model in order to propose a framework assisting expert decision-making.Our analysis of current guidelines revealed a commonality of many general principles for the dietary and nutritional management of pediatric overweight and obesity, but also a lack of research on specific detailed questions related to everyday practice, such as age-based nutritional intervention or follow-up. While more research on nutrition interventions is necessary, it has to be recognized that this is also very challenging, because food-based or public health interventions involve too many components interacting in complex pathways ,13. DietMost of the included guidelines targeted medical treatment of pediatric overweight and obesity, resulting in few details of the nutritional management. Only 17% of the recommendations were commonly to 30% or more of the guidelines. The expertise of clinical dietitians seems essential to apply the framework with specific, pragmatic, and detailed advice. Since no guideline indicated durations of the first or following visits, the dietitians will have to adapt the content to their time constraints and the individual possibilities of their patients. In fact, the adaptation of knowledge to local context, or to dietetic practice in this case, is part of the steps of knowledge transfer process ,41. Of cNevertheless, the strength of this paper is to provide a framework synthesizing the current literature based on a systematic analysis of each guideline, the extraction of each single recommendation and the expertise from clinical professionals. Our framework is coherent with the NCP and reinforces the use of this structured four-steps process to promote high quality of dietetics and nutrition care. Finally, the retrospective validity assessment demonstrated the relationship between the framework and the clinical practice and suggested a high potential of use by clinical dietitians.This paper synthesizes the current recommendations on nutritional management of pediatric overweight and obesity with the expertise from experienced dietitians in an attempt to create a tool aiming to facilitate the integration of EBP for dietitians and to promote structured care following NCP-model.


Background: Unraveling the relationship between health-related quality of life (HRQOL) instruments and the International Classification of Functioning, Disability, and Health (ICF) seems essential due to the increasing importance of quality of life evaluations in patients with heart failure (HF) and the use of the ICF for comparative purposes. The aim of this study is to identify and compare the content of HRQOL instruments for HF using the ICF coding system.Methods: In a 2-stage design, first we will identify all measures used to assess HRQOL for patients with HF and second we will compare the content of those measures using the ICF coding system. Systematic search will be performed in in MEDLINE, CINAHL, and Scopus databases using a combination of free texts and MeSH terms between January 1960 and January 2017. All instruments will be linked to the ICF separately by 2 reviewers according to 10 linking rules developed for this purpose. The degree of agreement between the reviewers will be calculated via the kappa statistic.Discussion: The results of this study may help clinicians and researchers to select the most appropriate outcome measure according to the ICF-based content validity.  Ware (1987) introduced 5 health inherent concepts: physical health, mental health, social functioning, role functioning, and general well-being. He investigated quality of life (QOL) in health sciences through a conservative approach. Because the goal of health care is to maximize the health component of QOL, he suggested the restriction of measures for assessing health status.12 QOL is a broad concept covering all aspects of human life whereas, health-related quality of life (HRQOL) focuses on the effects of illness and specifically on the impact of treatment on QOL. Regarding health outcomes, most indicators reflect a disease model, whereas HRQOL provides a comprehensive evaluation encompassing all the important aspects of QOL related to health. It has generated a new focus on a broader and more positive concept of health rather than a narrow and negative focus (disease-based).13 The primary focus of medical care is the management of chronic diseases, including HF. This program is developed not only to prolong life but also to relieve symptoms and improve overall health.14 The measurement of HRQOL in adults with chronic conditions in primary care settings can support patient management and intervention and contribute to service evaluation.15HRQOL is the main concern of health-care professionals and is becoming an important health outcome indicator.16 The choice of instruments by researchers seems essential in the measurement of HRQOL in patients with HF.17Asking patients how they are or about the effectiveness of treatments is nothing new. HRQOL instruments, however, can provide a formal, standardized, valid, and reliable way of gaining patients’ perspective as to the benefits and limitations of a specific intervention.18, 19 These outcomes help patients and clinicians make better decisions.20 The impact of HF on HRQOL is signiﬁcant21, 22 in comparison with several other common chronic conditions such as hypertension, diabetes, arthritis, chronic lung disease, and angina.23, 24 HRQOL is substantially worse among patients with HF than among individuals without HF and even among patients with other chronic diseases.25, 26Patient-reported outcomes such as HRQOL measures have proven useful in evaluating the achievement of these goals from the patient’s perspective.27 Furthermore, as treatment in HF is mainly symptomatic, there has been an increase in interest in assessing HRQOL in patients suffering from HF. Several HF-speciﬁc HRQOL instruments have been developed. Thousands of health status and HRQOL measurement instruments are used in research and clinical practice. Both general and disease-targeted questionnaires are helpful in increasing the understanding of HRQOL outcomes in patients. General instruments, involving health profiles and assessments of the overall health state, compare the relative burden of illness in the general population and between different diseases. Disease-targeted instruments, on the other hand, may be implemented to elucidate the specific domains of particular importance to the patient.28A multidimensional construct, HRQOL is deﬁned as patients’ perceptions of the impact of a medical condition or its treatment on the different aspects of their life including physical functioning, symptom status, psychological status, and social interactions.12 Clinicians have only recently begun to use these instruments and, therefore, may not yet be completely au fait with the criteria for selecting the most appropriate instrument.29Measures may focus on the symptoms, complaints, disabilities, and disruptions in life that are specific to the clinical condition under study. Indeed, the disease-specific approach has been advocated in the study of arthritis and heart disease as well as the evaluation of chemotherapy.30The patient’s perspective is the core of health-care provision and research. From the patient’s perspective, functioning and health are of utmost importance. Generally, any health-care intervention is aimed at restoring impaired body structures and functions, reducing activity limitations and participation restrictions, and preventing the development of new symptoms and disabilities. The increased recognition of the patient’s perspective and, more specifically, functioning and health has brought about an impressive effort in research to develop concepts and instruments to measure them.31 The most comprehensive effort to classify health concepts is the WHO’s International Classification of Functioning, Disability, and Health (ICF).32Integrating the many competing health status frameworks is possible by linking concepts in one instrument to concepts in another framework using common meaningful terms. Such mappings would augment understanding of the individual concepts upon which the frameworks are built as well as the respective overarching frameworks.33 The ICF is a multi-purpose classiﬁcation developed to provide a universal language for the explanation of a wide range of health-related phenomena.34 The ICF is suggested as a highly useful tool for the comparison of HRQOL instruments. Using the ICF category system as an independent reference to present the contents of measures makes it possible to understand these contents in a comprehensive and standardized manner, thereby facilitating the selection of assessment instruments.34, 35With the ICF, a universal framework exists in which the items and scales of various HRQOL instruments can be compared in a more desirable way.Due to the increasing importance of HRQOL assessments in patients with HF and due to the increased use of the ICF, it is necessary to find out the relationship between HRQOL instruments and the ICF for comparative purposes. This article is a protocol for a systematic review to appraise the relationship between HRQOL instruments in HF and the ICF. The aims of this study are to identify all the existing disease-speciﬁc questionnaires to measure HRQOL among patients with patients and compare the content of those measures using the ICF coding system.Rationale20, 36 In the past reviews, the validity, practicability, and discrimination of the potential HRQOL instruments were considered and compared. Nevertheless, content comparisons were never represented in the literature as HRQOL instruments for HF. The results obtained by the instruments are used by researchers, physicians, and policymakers for further research, evidence-based patient-centered care, guideline development, and evidence-based policymaking. A content comparison is one of the suitable methods that can be applied to select the best available measurement instrument. Moreover, content comparison is a useful tool to see the differences in content between several questionnaires or several performance-based tests. Several reviews deal with the selection of HRQOL instruments for HF, mainly by describing their psychometric properties and other characteristics of the instruments.Aims The objectives of our study are to identify all the existing disease-speciﬁc questionnaires to measure the HRQOL among patients with HF and to compare the content of those measures using the ICF coding system. To that end, we will seek to determine whether the content of HRQOL instruments is represented by the ICF categories and whether the ICF can serve as the common framework when comparing HRQOL instruments. Additionally, areas of the ICF that fail to provide enough detail will be identified in a future revision of the ICF and differences in the contents covered by HRQOL instruments will be examined based on the linkage of their content to the ICF.https://bit.ly/2BhRru2. The review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P) flow diagram and guidance set out by the Centre for Reviews and Dissemination.37This is a protocol for a systematic review. The protocol has been registered with PROSPERO  (Reference/ID No CRD42015025380). It can be accessed at Study design30, 34 The frequencies of the ICF categories demonstrate the concepts contained in the instruments built on the basis of the descriptive analysis and content comparison.To approach these 2 objectives, the study will have a 2-stage design. Phase I will identify all measures used to assess HRQOL among patients with HF. We will conduct a systematic literature review to identify disease-specific HRQOL instruments for HF. Phase II will compare the content of those measures using the ICF coding system. We will examine the contents of these instruments by extracting the meaningful concepts contained in the items of the instruments and linking them to the ICF via established linking rules.Inclusion criteriaStage I addresses our first objective. We will include cohort studies, case-control studies, clinical trials, and cross-sectional studies on development study, validation study, reliability, and responsiveness, all of which contribute to HRQOL instruments for HF. These studies will be included because they are the main measurement instruments for the assessment of QOL in patients suffering from HF. Therefore, all articles aimed at reporting or evaluating the measurement properties of the measurement instruments will be included in the present investigation. Linguistic validation studies, all instruments about signs, disease severity measure, disease control measure, and physiology of the heart will be excluded. The study population will consist of patients suffering from HF . Participants with other heart diseases like coronary artery disease, myocardial infarction, pectoral angina, atrial fibrillation, peripheral artery disease, stroke, and vascular disease will be excluded. This is a development and validation study. The outcome will contribute to HRQOL, QOL, and health status. The full text of all the instruments should be available. The selection of the studies will be restricted to those published in the English language between January 1960 and January 2017.Search strategy38 Additionally, citation tracking with references from each article will be performed. Hand searching the reference lists and bibliographies of the included articles, implementation reports, Cochrane Databases of Systematic Reviews (CDSR), Centre for Reviews and Dissemination (CRD), and Cardiovascular Section of the Patient-Reported Outcome and Quality of Life Instruments Database (PROQOLID) (https://eprovide.mapi-trust.org/) will also be considered. Recent systematic reviews that are known to the investigators will be incorporated as well.The aim of this search strategy is to find published studies. In order to identify the existing HF-speciﬁc HRQOL instruments, we will conduct a broad search in MEDLINE (via PubMed), CINAHL (via EBSCO), and Scopus (via Elsevier) databases using a combination of free texts and MeSH terms between January 1960 and January 2017. Filters developed for use with PubMed will be used to search for records relating to patient-reported outcome measures (PROMs). The filters are based on extracts from the search strategy developed for the PROM group bibliography. The Patient-Reported Outcome Measurement Group Department of Public Health FEBRUARY (2010) Citation searches are more sensitive than keyword searches in identifying studies through speciﬁc measurement instruments.Screening and data extraction3039The retrieved literature will be screened in a 4-stage process. First, all the retrieved literature will be imported into Endnote  to facilitate the identification and removal of duplicates. Second, 2 reviewers (MM and AK) will independently assess all the retrieved literature for eligibility by title and abstract using the inclusion checklist to ensure accuracy. Any discrepancies in reviewer selections will be resolved through discussion and settled where necessary by a third reviewer (SM). Third, full texts will be obtained for all the remaining citations and reviewed for eligibility by 2 reviewers (MM and AK) and any discrepancies in selection will be resolved through discussion and recourse to a third reviewer (SM), where required. The PRISMA Flow Diagram will be applied to record the number of the studies included and excluded at each stage of the review process . In data40 For each of these instruments, we will calculate the reported frequency and the frequency with which its items address b, s, d, and e as well as pf, nc, and nd. If a category is assigned repeatedly in a measure, the category will be counted only once.41, 42 The coding and the linking procedure are depicted in A data extraction tool will be used for the linkage of HRQOL instruments to the respective ICF categories in the component b, s, d, and e .40 For eSynthesisThe synthesis of the results will be presented in 2 stages. First, a descriptive summary including the relevant data that are extracted from eligible studies will be presented, tabulating details about study type, outcome measures, type of participants, sample size, gender, age groups, nationality, HF class, and ejection fraction. Second, a narrative synthesis will be presented and the concepts identified from the instruments will be described according to their frequency distribution across the ICF components. Then, the identified concepts from the instruments will be described according to their frequency distribution across the addressed ICF chapters (first level), categories (second level), third level, and fourth level. Finally, the strengths and limitations of the review will be reported and the implications of the review’s findings for future research, education, policy, and practice will be discussed.Validity and rigorSix steps have been taken to increase the rigor of the review. First, librarian expert advice was obtained prior to the development of the search strategy and will be applied throughout the systematic review. Second, the filters developed for PubMed will be used to search for records relating to PROMs. Third, validity will be ensured through the use of the PRISMA-P guidelines(41) to ensure the transparent reporting of the review process and findings. Fourth, reliability will be improved through independent assessments of all the retrieved studies for inclusion based on title and abstract, and then full text by 2 reviewers. Fifth, quality assessment will be conducted by 2 reviewers, independently linking all HRQOL instruments to the ICF separately, according to 10 linking rules developed for this purpose and any discrepancies in the linking process will be resolved through discussion and settling where necessary by a third reviewer. The degree of agreement between the reviewers will be calculated by means of the kappa statistic. Sixth, the systematic review is registered with the PROSPERO.30With all the possible instruments available, sometimes it is difficult to opt for the right measurement instrument. The ICF can be a very useful tool because it provides information about the content addressed in the different instruments. According to the linkage, it is possible to assess the heterogeneity of HRQOL instruments in HF regarding the presentation of b, s, d, and e. The comparison of HRQOL instruments in HF may provide nurses, clinicians, and researchers with new insights when selecting HRQOL measures for clinical research.Moreover, the ICF provides a suitable framework when comparing the content of HRQOL instruments. Content comparison of HRQOL measures in HF confers insights into their differences with respect to the breadth and precision of their coverage of specific concepts.To our knowledge, this is the first protocol for a systematic review of international evidence concerning the content comparison of HRQOL measures based on the ICF in HF. However, our review has several limitations. First, formulating search terms to only capture HRQOL in HF proved challenging. Nonetheless, we will draw upon filters developed for use with PubMed in order to search for records relating to PROMs. Second, the review will only include studies published in the English language. The inclusion of studies in languages other than English is beyond the scope of the present review because the review team members are not fluent in languages other than English.


The aim of this study was to estimate out-of-pocket expenditures incurred by individuals with HIV in the Dominican Republic. The study utilized different definitions and components for these expenditures and differentiated the results by wage ranges.Data was obtained from an in-person survey of people living with HIV. The study was developed and implemented in collaboration with Dominican grassroots organizations and networks of people with HIV, through a process of community-based participatory research.The mean HIV-related expenditure reported by individuals in the sample in the last six months prior to the survey was in US$ 181; 15.4% of this total was spent for transportation and housing and costs to access the HIV facility. The mean expenditure reported by individuals for their current visit to an HIV center was US$ 10. These out-of-pocket expenditures exhibited regressivity, with lower-wage patients spending proportionally more to receive care. The results highlight the importance of considering other resources required to access treatment, such as lodging expenses and the time needed to travel to an HIV center and then to wait to be seen by a care provider.There should be more focus on expenditures made directly by people with HIV in the Dominican Republic so that these payments do not become a barrier to accessing health care. Using a community-based participatory design can ensure that such data can be leveraged to address the specific barriers to care that are faced by individuals with HIV. With an estimated adult human immunodeficiency virus (HIV) prevalence of 1.2% in 2017, the Caribbean is the second most affected region in the world after sub-Saharan Africa  in the Dominican Republic and to analyze the characteristics of that spending for different groups of that population, especially across different wage ranges. Primary data was gathered using a community-based participatory research (CBPR) design. This data allowed us to develop a broader understanding of HIV care and treatment costs in the country, to be used as evidence to support national policy discussions as well as to serve as an advocacy tool for communities and individuals with HIV.The Dominican research project was implemented between July 2014 and June 2016, applying a community-based participatory research (CBPR) design. In CBPR, researchers partner with community members, bridging both worlds’ expertise through shared knowledge and capacity-building .The project was led by two advocacy groups, with oversight from a steering committee. The advocacy groups, AID FOR AIDS and the International Treatment Preparedness Coalition, work on access to HIV care in the Dominican Republic (among other countries). Members of both organizations were involved in the core project team, working in close collaboration with an experienced external researcher. All members of the core project team worked collaboratively to develop a survey for use among individuals living with HIV.The steering committee was composed of community treatment activists as well as officials from United Nations agencies, the Pan American Health Organization (PAHO), and the Dominican Ministry of Health. The steering committee provided guidance regarding the study design and data collection.Grassroots organizations, including networks of PLHIV, female and male sex workers, and transgender women, were invited to participate in a two-day workshop in May 2015. The first day of the workshop included a capacity-building component focused on how to conduct CBPR, as well as participatory sessions to review and validate the survey questionnaires and the data collection implementation strategy. After these meetings, small changes were introduced . The second day focused on training participants in survey methods, such as interview skills, research consent and ethics, and sampling selection strategy. The workshop was followed by a pilot study in a health center in the country’s capital, Santo Domingo.All the participants who completed the entire workshop were invited to collaborate in the data collection process. The pilot study and the data collection process were supervised by two members of the AID FOR AIDS Dominican Republic office, who were present during the entire workshop and received additional training as supervisors. Approval for the study was obtained from the Dominican Republic’s National Council on Bioethics in Health (CONABIOS) on 10 March 2015.In October and November of 2015, a cross-sectional survey was conducted among 191 individuals with HIV in the Dominican Republic. ART is currently free of cost in the 72 public HIV treatment and care units around the country , as wellAt each site, an average of 20 individuals responded to a short interview (< 30 minutes). Participants were randomly selected out of all HIV patients who met the following criteria: a) have a confirmed HIV infection, b) be over 18 years old, and c) be currently enrolled in ART or pre-ART services or have been enrolled within the last six months prior to the interview.Interviews were offered at the end of the individual’s visit at the HIV-care site. The trained community-member interviewers used printed questionnaires to interview study participants. Interviews were conducted in a private space to respect the participant’s confidentiality. In compensation for their time, survey respondents received 860 Dominican pesos (RD$ 860) . At the end of every day, the community-member interviewers entered the collected responses in an Excel database. A supervisor later cross-checked the database against the printed questionnaire, to eliminate any data entry mistakes.The survey questionnaire used with the PLHIV interviewees included a mix of multiple-choice and binary questions, as well as an open-ended comments section. The information collected focused on four themes: 1) basic sociodemographic characteristics, including gender, age, education, and health insurance status; 2) health status and general HIV services utilization, including the time since HIV diagnosis, current antiretroviral treatment, and reported adherence to treatment; 3) the current visit to the HIV facility, including its primary purpose and OOP expenditures for this visit; and 4) OOP expenditures associated with various expenditure categories related to HIV treatment and care in the preceding 6 months .All the data collected was merged, cleaned, and analyzed, using Stata software. The analysis included statistics on the mean OOP payments made by the survey respondents during the preceding six months and for the current visit; the distribution of OOP payments among expenditure categories; and wage ranges.The study coauthors made several important choices during the analysis. One decision concerned the data collected, which allowed for an analysis of health expenditures for the current visit and the last six months. Both pieces of information are interesting, but they present a trade-off between accuracy  and representativeness of an individual’s “average” expenditure. Therefore, we used both pieces of information to present different calculations related to the financial burden of obtaining HIV treatment in the Dominican Republic.Similarly, we coauthors made an important decision related to which categories of OOP expenditures should be included in our calculations. The World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD) define OOP expenses as direct payments made by individuals where insurance does not cover the full cost of the health good or service, including cost-sharing, self-medication, and other outlays paid directly by private households , 18. ForFinally, although most calculations are presented at the aggregate level, others were categorized by wage ranges in order to explore potential income inequalities in paying for HIV treatment in the Dominican Republic.One important limitation of the data is that neither income nor expenditures were collected as specific numbers; instead, ranges were used. One of the challenges with CBPR is resolving potential trade-offs between methodological choices to increase the study’s validity and incorporating the communities’ interests and concerns . In thisWritten consent was obtained prior to all interviews. The consent form described the study goals, stated that participation was voluntary, and explained the strategy used by the research team to guarantee data anonymity.Descriptive statistics for our study are presented in Study participants had been diagnosed with HIV for a mean of 7 years and had started treatment a mean of 6 years prior to the interview. In terms of antiretroviral treatment, 97.1% of respondents said they were receiving antiretroviral treatment at the time of the interview. The average number of comorbidities reported in the sample was 0.9. Half of the interviewees said they had health insurance.Almost 60% of the respondents said they had a mean monthly wage of US$ 110 (RD$ 5 000) or less, while 29.8% of the sample said they had no wages at all. These earnings are low compared to the average monthly income per capita of US$ 338, as calculated by the National Statistics Office (ONE) . More thStudy participants reported mean HIV health-related expenditures of US$ 153.0 during the preceding six months (about US$ 26 per month), and mean OOP expenditures for the current visit of US$ 3.6. In comparison, according to the 2013 Demographic and Health Survey (DHS) for the Dominican Republic , the infExpenditures from our survey were large, considering they included only HIV-related costs and were only based on individual expenditures, while the Dominican DHS presented statistics at the household level. When including other costs incurred in obtaining treatment (transportation and housing), expenditures reported by the survey participants for the preceding six months increased to a mean of US$ 181 and OOP expenditures for the last visit reached a mean of US$ 10. The large fraction attributable to transportation and housing in the last visit is mostly explained by the fact that most people reported positive expenditures for some of these items, while the percentage of the sample reporting positive expenditures for other items was lower.The numbers reported for our survey had limitations, including the use of individual wage ranges instead of household income. Therefore, the numbers should be interpreted with caution. However, the estimates are useful, since they provide an order of magnitude and reveal an interesting trend.A similar pattern exists when comparing our results with national health expenditure data from the DHS survey. The DHS survey found that Dominican families’ health expenditures as a share of income decreased as income rose, with the share being 35.9% for households with an income lower than US$ 110 (RD$ 5 000) and about 13.0% for higher income categories . The resFinally, just as nonhealth costs proved to be important when accounting for the total cost of receiving HIV care in the Dominican Republic, nonmonetary costs should also be considered. When discussing access to treatment, an important factor to bear in mind is time. No clear relationships emerged between wage ranges and time spent traveling to and waiting at the HIV facility. However, all groups reported waiting and traveling times close to three hours, representing a significant loss of productivity, especially for those with lower wages .To our knowledge, this study is the first ever to collect such detailed information regarding patterns of private spending associated with HIV care and treatment in the Dominican Republic. Its findings provide a better understanding of the sociodemographic characteristics of people with HIV currently enrolled in care, as well as the level and distribution of their OOP expenditures.It is also important to note that the study proposes a different approach—community-based participatory research—that can be used to draw lessons about the benefits and challenges of involving and empowering communities in research. We hope this experience will encourage more researchers to work for and with communities in the future.The Dominican Government tries to provide HIV treatment free of charge. Nevertheless, our study reveals that PLHIV in the country still spend a large amount of money on items related to their HIV treatment, such as nutritional supplements and transportation to and from health facilities. Furthermore, these additional expenditures are not evenly spread across our sample. The regressivity of the OOP HIV expenditures shows the importance of focusing on barriers to access and of considering social needs and the social determinants of health in health care costs, particularly when thinking of low-income patients.These findings are relevant for two key reasons. First, the results highlight the need to adopt a holistic approach to HIV expenditures when discussing shifts in HIV funding for countries of Latin America and the Caribbean. The National AIDS Spending Assessment (NASA), an HIV resource-tracking tool developed by UNAIDS, does not include private OOP expenditures in its assessment of resources devoted to HIV. As a result, most studies of Latin American and the Caribbean countries that draw on NASA data do not include this expenditure category in their analyses , 28. FurSecond, our results show the high heterogeneity found in OOP expenditures among individuals with HIV in the Dominican Republic. The study clearly indicates that some groups are more vulnerable than others to incurring high levels of expenditures when accessing HIV treatment. Such granular analysis can provide insights beyond health spending, such as reasons for lack of adherence and retention. Since these findings were developed in close collaboration with grassroots organizations in the Dominican Republic, they can be used by both policymakers and communities themselves to design programs and initiatives specifically targeted to addressing these additional barriers to care, such as by developing transportation voucher programs or additional financial support for nutritional treatment, as is being done in many countries.This study had several limitations. First, there was a potential for recall bias, especially with regard to expenditures in the preceding six months. This limitation was partially addressed by using two types of spending—current visit and last six months—to capture different dimensions of HIV-related expenditures.A second limitation was the lack of information on income and expenditure. Using wage ranges allowed some descriptive analysis but limited other analysis to better understand the sources of differences in OOP spending among different groups in the country. As stated before, results must be interpreted with caution—particularly when comparing them with other estimates—given the differences arising from the unit of analysis, individual wage versus household income, especially when looking at the results for participants with no wages.Third, due to budget and logistic constraints, the number of facilities selected was limited and their selection made purposively. Consequently, the results are not statistically representative of the Dominican reality. However, the information presented is valuable as it gives, for the first time, an estimate of the financial burden faced by PLHIV in the country.Finally, our sample only includes individuals with HIV already accessing HIV treatment and care. In 2017, UNAIDS estimated that 68% of individuals with known HIV were then on ART  . For theThis study has shown that OOP expenditures still represent a significant burden for PLHIV in the Dominican Republic, particularly those with lower wages. Regressivity in OOP spending should be considered when debating access to care. This is particularly true, given that some other costs—both monetary  and nonmonetary —are unevenly distributed among participants. Ensuring that such expenses are part of an open, national discussion can ultimately guarantee effective access to HIV care and treatment.This study is a concrete example of the use of CBPR in public health research. It shows that while community involvement can constrain the research process, it also presents clear opportunities for co-learning. Using CBPR can also facilitate the use of financial and cost data for advocacy purposes, as it facilitates research ownership by community-based organizations. Finally, and most importantly, CBPR can ensure that the voices and priorities of those most directly affected by changes in HIV funding can be heard.CC and CO conceived the original idea. CC, CO, EC, and JV participated in the study design and implementation. CC and PVD performed the analysis and wrote the first draft. All the authors reviewed and approved the final version.RPSP/PAJPH.The authors want to thank Sergio Bautista Arredondo for his comments on the study design and survey instrument. We are grateful to all the workshop participants for their valuable feedback on the study design and tools and their involvement during data collection, as well as to Virginia Moreno and Kiara Mariano, from the AID FOR AIDS Dominican Republic office, for their help coordinating the data collection process. Bill Black and Sadiya Muqueeth provided valuable suggestions for improving the manuscript. We also appreciate the comments and suggestions given by three anonymous reviewers and an editor for the RPSP/PAJPH and/or PAHO.The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the