Due to the recent technological revolution that is centered around information technology, the Internet of Medical Things (IoMT) has become an important research domain. IoMT is a combination of Internet of Things (IoT), big data, cloud computing, ubiquitous network, and three-dimensional holographic technology, which is used to build a smart medical diagnosis and treatment system. Additionally, this system should automate various activities, such as the patient's health record and health monitoring, which is an important issue in the development of modern and smart healthcare system. In this paper, we have thoroughly examined the role of a smart healthcare system architecture and other key supporting technologies in improving the health status of both indoor and outdoor patients. The proposed system has the capacity to investigate and predict (if feasible) the clinical application and nursing effects of totally implantable intravenous port (TIVAP) in pediatric hematological tumors. For this purpose, seventy children with hematologic tumors were treated with TIVAP, and IoMT-enabled care was provided to them, where the occurrence of adverse events, specifically after the treatment, was observed. The experimental results collected after the 70 children were treated and cared for by TIVAP show that there were five cases of adverse events, whereas the incidence rate of the adverse events was 7.14%. Moreover, TIVAP has significant efficacy in the treatment of hematologic tumors in children, and it equally reduces the vascular injury caused by chemotherapy in younger patients. Likewise, targeted care reduces the incidence of adverse events in children with expected ratio. A serious and challenging issue to the health of individuals is generated because of the current industrialization, urbanization, population aging, changing disease spectrum, and ecological changes. Additionally, a smart healthcare system has various problems such as rapid cost growth, poor accessibility, uneven resource allocation, inefficient services, and uneven service quality. To cope with these problems, an intelligent medical or Internet of Medical Things (IoMT) network was introduced in the literature , 2. WithIn foreign countries, the smart healthcare domain is assumed to be a mature research field and is efficiently utilized in the smart healthcare system to automate various activities that are tightly coupled with patients and doctors. The Institute of Medicine of the United States (IOMI991) has developed a prototype of intelligent medical care. It has the capacity to automate various activities with available resources in the hospitals, such as the electronic medical records that exist in a special system. It provides support to its users to obtain complete and accurate information. Also, it provides alerts to the medical personnel and various medical decision support systems. In 2004, Japan's Ministry of Internal Affairs and Communications (MC) held a policy forum on the realization of a ubiquitous network society and proposed the “u-Japan strategy.” In 20l1, Japan's strategic headquarters and the Ministry of Internal Affairs and Communications (MC) proposed the concept of “My Hospital Everywhere,” , 6 whereIntelligent medical care is still in the preliminary stage, particularly in China, and it is moving from clinical automation to regional automation. The Health and Welfare Commission has formulated corresponding policy plans after the pilot work of regional healthcare repository in Shanghai and Guangdong –9. We shThe implacable intravenous port, which is medically known as a port, is shown in The advantages of an implacable IV port are as follows: (i) it is implanted once, (ii) it reduces the pain and difficulty of repeated punctures, and (iii) the implantation procedure is simple. As it is implanted subcutaneously, it reduces the risk of infection. It can be retained for a longer period of time (10 to 20 years). The injection area can be punctured approximately 2000 times, thus avoiding repeated peripheral venous punctures and making it ideal for the intravenous treatment of patients with malignancy , 13. It The development of an Internet of Medical Things (IoMT) based smart healthcare system that is designed for the treatment of pediatric hematologic tumors, specifically in childrenTo resolve the problem of 100% cure rates per child per day in an effective manner, preferably in the smart healthcare systemTo investigate the clinical application and effectiveness of the completely implantable intravenous port (TIVAP) in pediatric hematologic tumorsTo achieve the expected reduction ratio of pediatric hematologic tumors, particularly in childrenIn this paper, we are exploring the role of the smart medical healthcare system architecture and key supporting technologies that are needed to realize this system in a real environment of hospitals. For this purpose, seventy children with hematologic tumors were treated with TIVAP and provided with targeted care, where the occurrence of adverse events, particularly after treatment, was observed. The experimental results after the 70 children were treated and cared for by TIVAP show that there were 5 cases of adverse events, and the incidence rate of adverse events was 7.14%. Thus, TIVAP has significant efficacy in the treatment of pediatric hematologic tumors. Also, it reduces the vascular injury caused by chemotherapy in younger patients, whereas targeted care can reduce the incidence of adverse events in children. The main contributions of this paper are as follows:The remaining part or sections of our manuscript are organized according to the given format and guidelines. In the subsequent section, the general architecture of the intelligent and smart healthcare system is described in detail.The structure of the intelligent medical healthcare system mainly includes the standard specification and security systems that consist of hardware, data, business, exchange four levels, and software. A standard specification system is the data standard that must be followed and managed in the intelligent medical platform. This is the platform operation and application of the database , 15. SecRadio Frequency Identification (RFID) smart shake caller is an extension of the door controller, which is realized by an HF-RFID solution . To ensu  Step 1: the hospital selects this HF card tag as the child's card and preloads all card tag IDs into the hospital's database.  Step 2: the hospital installs a smart shake in each ward and configures the IP network. The computer central server receives the healing information. In short, each word is realized as an IoT architecture for RFID smart rollers.  Step 3: remember to bring your child's card. When treating each child, the hospital will look at the child's card to confirm the healing status of each child.One of the main contributions of this paper is to solve the problem of 100% cure rates per child per day. The question to be considered now, particularly in this paper, is how to help all the children to enhance their core by high cure rate. The systematic operation or procedure of the proposed mechanism is divided into the following three steps:Finally, through these three steps, the hospital will obtain a cure rate for each child. Figures   Part 1: LED display that is used by the system to display the child's name and count the number of people in the ward when the child puts the card into the second part.  Part 2: multiantenna card slots, the system uses these slots to cycle through each RFID patient card and read the tag ID as their patient number to log into the O1 subsystem.  Part 3: card reader module, the roll call system uses the card reader module to control all antenna card slots and save the patient card ID data to the buffer memory. The card reader module transmits the cure to O1 when O1 leaves the ward.  Part 4: embedded system is where the system communicates with a computer center server through a LAN environment. In other words, the IP-based roll call system is connected to a switched network.A new architecture is introduced to collect the correct cure information of each child from each ward in different hospital buildings to confirm their right to learn. The proposed system consists of four main parts: LED display, multi-antenna card slot, card reader module, and embedded system. These parts are described as follows :  Part 1Child Nurse Desk, this subsystem records the cure rate for each child and saves it as the treatment rate for each child. Then, the child and the doctor will receive the last core record from the system at the same time.Medical Service, the subsystem calculates the class statistics, departmental statistics, and time period statistics through the system. This real time information will help everyone remember to help the affected child to go to treatment.Computer Center, this subsystem manages the installation status of each roll called and sets the configuration of the IP parameters. It also synchronizes the real time clock in each roll-caller and simultaneously sends the healing of each class back to Subsystem-A.The functions of the roll call system were developed on a server installed in the university computer center using Microsoft VB and .NET programming tools. Microsoft SQL 2018 was used as the database to create and manage the IDs and IPs of the patient cards for the RFID controllers on campus. The three functions and processes of the roll call system are as follows:The Internet of Medical Things (IoMT) is a collection of various electronics devices, preferably with embedded sensors and actuation modules, to form an operational networking infrastructure, specifically without human intervention.The IoT is mainly used to help the intelligent perception of medical objects  to support the digital collection, processing, and storage of equipment, drugs, personnel information, and other information. This information is used to achieve the visualization of medical management, digital information, closed-loop processes, scientific decision-making, and humanized services. Additionally, it is used to solve the problems of weak support, low-level medical safety, etc. In the intelligent medical healthcare systems, the IoT perception system is an important part of the system that enhances the perception of the environment and activities through sensors, RFID, 2D codes, collectors, and other perception technologies and devices to achieve intelligent , 18.Big data not only provides scientific basis for single disease diagnosis and treatment but also improves the intelligence of management, decision-making, and evaluation in the medical field. By establishing a big data analysis system based on classification estimation, prediction, association rules, clustering, description, and visualization technologies, we can mine and analyze the huge amount of medical and health big data. The system provides quantifiable decision support for the unified planning and allocation of medical resources, disease occurrence, and epidemic trends, and thus, it improves the management, decision-making, and evaluation in the medical field . At the The application of shared cloud computing expands the commonality of medical resources and services and provides an intelligent, efficient, and highly integrated data sharing platform for intelligent healthcare. Cloud computing distributes services on demand across a pool of resources consisting of a large number of computers. Users can access storage and read data and run software anytime and anywhere using large-scale server clusters on the internet, thus expanding the terminal computing capacity and storage space , 21.The application of three-dimensional holographic technology has created new changes for surgery, diagnosis, and telemedicine. The application of three-dimensional holographic technology mainly includes two aspects: one is to receive the dimensional holographic data and calculate the hologram; second, the photoelectric system can print or reproduce the image in real space according to the hologram. The real reproduction of 3D holographic technology can replace the previous two-dimensional, clearer observation and analysis of organs and can penetrate, touch, and observe the interaction with the surrounding tissue. It provides great convenience for doctor-patient interaction and surgery , 23.Children were diagnosed with hematologic tumors according to WHO hematologic tumor diagnostic criteriaChildren aged 3 to 7 yearsChildren whose parents understood the content of the study and signed the informed consent formFrom January 2015 to January 2018, 70 children with hematologic tumors treated with fully implanted intravenous infusion ports in our hospital were selected as observation subjects (inclusion criteria):There were 34 male children and 36 female children; age ranged from 3 to 7 years (average 5.36 ± 1.71 years); there were 6 cases of lymphoma, 6 cases of nephroblastoma, 27 cases of neuroblastoma, and 31 cases of leukemia .Ultrasound-guided internal venous implantation was used, i.e., the catheter was drawn into the ipsilateral clavicle of the child along the subcutaneous path via ultrasound guidance. Moreover, the tip of the catheter was adjusted to the connection of the right atrium and superior vena cave by C-arm fluoroscopy. The infusion port and the catheter were connected, and the infusion port was implanted subcutaneously and closed with sutures. A postoperative X-ray was taken to confirm that the catheter was in the correct position.Preoperative care: preoperative blood routine and coagulation function checks should be performed on the child, and if the child's platelets are lower than 30 × 109/L, platelets should be given before surgery. The parents should be informed of the purpose and significance of TIVAP, postoperative care methods, possible adverse reactions, and preventive measures before surgery to improve their cooperation. The parents should be informed of the purpose of TIVAP, its significance, postoperative care, possible adverse effects, and preventive measures.Intraoperative care: during the operation, adhere to the aseptic procedure and pay attention to the child's posture at all times and make good risk plans. Before pushing the medication to the child, the skin around the injection base should be carefully evaluated for swelling and pus. Then, the injection base should be disinfected three times in a clockwise and counterclockwise manner, and the needle should be punctured with a butterfly-wing needle. At the same time, if the child has no need for infusion for a short period of time, then the tube should be flushed with 20 ml of saline, and subsequently, it has to be sealed with 100 U/L of heparin solutions.Postoperative care and daily care: parents should be instructed to restrict the child from strenuous exercises after the implantation of the intravenous port. The nursing staff should change the child's medication for the first time after 24 hours and pay close attention to the child's vital signs within 3 days.Daily care: the catheter must be thoroughly flushed before and after the infusion, and the bevel of the nondamaging needle should be back to the catheter interface at the base of the infusion port before extraction. The tube must be sealed by positive pressure before extraction to prevent blood reflux. Saline should be flushed at intervals when there is antagonism or incompatibility between the two infusion solutions before and after. The operation related to the infusion port should be strictly aseptic, and once the child shows the symptoms of infection, blood should be taken for poetry dish test first. After the child is discharged from the hospital, an information file on the child's TIVAP should be established  along with a perfect follow-up system, and a maintenance manual should be issued to the parents with instructions on the maintenance of the TIVAP so that the parents will insist on bringing the child to the hospital every 4 weeks for a heparin-saline flush tube.Care should be given to children with hematological tumors when implanting infusion ports in the following manner:We have evaluated the effectiveness of TIVAP application and care by observing the incidence of adverse events in the treatment and care of children.After 70 children were treated and cared for with TIVAP, there were 5 adverse events, with an incidence rate of 7.14%, and the distribution of adverse events by age is shown in k on the error rate (due to misclassification); note that the error is minimized when k is 3.Furthermore, K on the error rate is shown in K = 3, the algorithm selects K = 6 for optimal clustering based on the overall fitness. Among these 6 clusters, 3 are composed of a single class in which there is no export network. Needed . The other three clusters in the image have expert networks of 72, 17, and 8 classes, reducing the classification error for each cluster by more than 10%.The confusion is provided in Mengmeng (pseudonym), 6 years old, presented 20 days ago with no obvious cause for an external supraocular swelling in the right eye, accompanied by multiple skin petechiae. After examination, the diagnosis of acute myeloid leukemia was finally confirmed, and the doctor decided to follow-up with a chemotherapy regimen. Faced with chemotherapy, the family was a bit overwhelmed by the small size of the child, fine blood vessels, and poor cooperation. After being introduced to the doctors and nurses, Mengmeng's mother learned about the relevant vascular accesses, among which, an infusion port could help solve the problem. It is implanted in the child under anesthesia, and all devices are subcutaneously implanted. They can be retained for a long time and maintained once a month. The port does not affect the child's bathing, gets rid of the strange eyes of small partners, does not hurt the child's self-esteem, reduces the child's psychological burden, and significantly improves the quality of life of the child and parents. Mengmeng's parents decided to implant the infusion port for their child. The schematic diagram of body placement in infusion port is as shown in Our hospital has been using infusion port technology for many years. To standardize this technology and reduce the occurrence of clinical complications, an infusion port MDT team was formed by the hospital's medical office. It is led by the vascular surgery department with the participation of the interventional department and PICC clinic to jointly manage the whole process of infusion port, as shown in TIVAP is a simple and well-maintained method of drug delivery that protects the patient's blood vessels and significantly improves the quality of life of children with hematomas . IntraopIn this paper, we have focused on the role of smart medical healthcare system architecture and key supporting technologies to improve the expected level of traditional treatment carried out in the hospitals. The proposed scheme explores the clinical application and nursing effect of totally implantable intravenous port (TIVAP) in pediatric hematologic tumors and describes how the proposed mechanism is used in speeding up the recovery process of the underlined patients in the hospitals. TIVAP has a significant efficacy in the treatment of pediatric hematologic tumors, and also, it reduces the vascular injury caused by chemotherapy in younger patients. Targeted care can reduce the incidence of adverse reactions in children.In future, we will explore the potentials of the proposed mechanism in speeding up the recovery process in other diseases as well.


Communication of bad news plays a critical role in the physician-patient relationship, and a variety of consensus guidelines have been developed to this purpose, including the SPIKES protocol. However, little is known about physicians’ attitudes towards breaking bad news and to be trained to deliver it. This study aimed to develop and validate a self-report questionnaire to assess physicians’ attitudes towards principles of the SPIKES protocol and training on them.The Breaking Bad News Attitudes Scale (BBNAS) was administered to 484 pediatricians and 79 medical students, recruited at two scientific conferences and two medical schools in Brazil. The questionnaire structural validity, reliability, and associations with other variables were tested.The BBNAS showed adequate validity and good reliability, with two factors measuring attitudes towards the SPIKES strategy for braking bad news (α = 0.81) and the possibility to be trained on it (α = 0.77), respectively.The novel questionnaire is a psychometrically sound measure that provides information on physicians’ agreement with the SPIKES protocol. The BBNAS can provide useful information for planning training and continuing education programs for clinicians on communication of bad news using the SPIKES as a framework.The online version contains supplementary material available at 10.1186/s12909-021-02636-5. In the context of medical communication, bad news has been seen as any information that negatively and seriously alters the patient’s view of his or her future, even if temporarily . Bad newBBN is even more critical in pediatrics, as the patient is not the recipient of the communication nor is able to understand the information given and its consequences . BesidesIn recent years, a variety of consensus guidelines for communicating bad news to patients have been published –15. One Several studies have shown the beneficial effects of implementing a guidance on how to systematize breaking bad news in enhancing physicians’ self-confidence and abilities and reducing anxiety concerning BBN –22. ProtAlthough the controversy over whether it is possible to develop BBN abilities , severalDespite the fact that other tools were developed in order to assess medical communication , 36, conFinally, the choice for pediatricians as the main professional was because the characteristics and particularities of BNC for this audience is difficult in many ways, because it is a “person-oriented” specialty  and are The sample size was defined through a minimum of 10 participants per item and 100 per factor for exploratory factor analysis (EFA) and a sufficient number of cases to run confirmatory factor analysis (CFA) and for the CFA model to converge without improper solutions .Data collection was carried out between November 2018 and June 2019, mainly at two national pediatric conferences and two medical schools in southeast and northeast of Brazil. Regarding the curricula in Brazil, the medical schools have five to 6 years in duration, and student will have supervised and restricted contact with patients during the internship in the fourth year and on, without prior involvement with patients . It was The questionnaire was developed and applied in Brazilian Portuguese. The items of the self-report Braking Bad News Attitude Scale (BBNAS) were generated a priori to evaluate two attitudes among clinicians: their level of agreement with the strategy recommended in the SPIKES protocol  to propeAn initial pool of 15 items was generated by researchers and clinicians referring to the two dimensions described above with the main content taken from the SPIKES protocol. The SPIKES goal is to enable the clinician to fulfill the four most important objectives of the interview for disclosing bad news. These objectives include gathering information from the patient, providing medical information to the patient, offering him or her support, and eliciting the patient’s collaboration in developing a treatment plan. The name SPIKES is the acronym describing the six consecutive steps of a BBN conversation. Setting up (S) describes the process of preparing for the talk; Perception (P) is the parts in which the physician determines the patient’s perception of the situation; Invitation (I) refers to the invitation of the patient to receive the news; Knowledge (K) is the information breakout; Emotions (E) refer to the proper way of responding to patient’s emotions. Finally, Strategy and Summary (S) aim to ascertain whether the patient has adequately understood the situation and the treatment plan .The 15 generated items were piloted among 30 residents. They were asked to evaluate the clarity of instructions and items, relevance, and appropriateness of items content in relation to the SPIKES protocol. The participants’ feedback was mostly related to the instructions and phrasing, and few suggestions regarding the conceptual correctness of the content were given in person. This final version was used in the present validation study.Participants responded to a survey containing a sociodemographic part including age, sex, and pediatrician or medical student position, the Breaking Bad News Attitude Scale (BBNAS), the Jefferson Scale of Physician Empathy (JSPE), and three questions to self-assess the participants’ BBN skills.strongly disagree) to 4 (strongly agree). The BBNAS items are reported in detail  to 7 (strongly agree). The Brazilian version . SeveraThe present study has several limitations. First, the self-assessment nature of the BBNAS could be criticized, because of the attendant possibility of reporting biases. However, other strategies, based on various sources of observable information, like, for example, the Implicit Association Test (IAT), are not very practical to work with, especially when involving large samples. Second, the small number of medical students involved in the study and the overrepresentation of females, that did not allow to assess invariance of the measurement across gender and physician/student position. Third, the sample was not representative of the country population, since there was a prevalence of participants from the north or northeast regions of Brazil. Fourth, test-retest reliability of the BBNAS was not assessed. Finally, the limited response rate is expected since there is no compensation for volunteers for participation by any means. Therefore, the BBNAS psychometric characteristics are to be further investigated using a larger and more balanced sample across physicians/students, sexes, and geographical areas, and other specialty physicians should be involved. Furthermore, longitudinal studies are needed to assess the BBNAS sensibility to change and the related usefulness in the context of continuing education.The BBNAS is a newly developed scale to measure the level of agreement that physicians and medical students have with the principles of the SPIKES protocol to deliver bad news. It allows measuring attitudes towards BBN as described by the SPIKES protocol and towards training to learn and implement BBN strategies. Its psychometric characteristics are promising and encourage the use of this measure in other medical contexts.The information that can be collected by the BBNAS is relevant to the development and planning of effective educational interventions in BBN both for medical students and professionals. Indeed, individuals who have a positive attitude towards the strategy to better communicate bad news to patients and are favorable to training for the delivery of bad news could be more supportive of the strategies proposed in the training process. Efficiency in BBN may benefit both patient and parents and has the potential to change the way how the news is received. It may also enhance patients’ adherence to treatment, their physical and mental health outcomes and decreases physicians’ levels of stress generated by the necessity to communicate bad news. These gains can be promoted through continuing education ensuring that the educational interventions are planned, executed, and evaluated based on evidence.Additional file 1. The Breaking Bad New Attitude Scale (BBNAS) content of items.Additional file 2. BBNAS Scoring Calculator. A spreadsheet to calculate the BBNAS score.Additional file 3: Supplementary Table 1. Descriptive statistics of items of the Breaking Bad News Attitude Scale.Additional file 4: Supplementary Table 2. Parallel analysis for exploratory factor analysis of the BBNAS.Additional file 5: Supplementary Table 3. Correspondence between percentage and raw scores of the Breaking Bad News Attitudes Scale.


Introduction: Mandated restrictions on outdoor physical activity (PA) during the coronavirus pandemic disrupted the lifeworld of millions of people and led to a contradictory situation. On the one hand, PA was perceived as risky behaviour, as it might facilitate transmission of the virus. On the other hand, while taking precautions, regular PA was an important tool to promote the population's health during the lockdown.Methods: This paper examines the differences in government restrictions on PA in France, Germany, and Italy during the first wave of the COVID-19 pandemic. We draw on techniques of qualitative content analysis and apply a critical theoretical framework to assess the countries' restrictions on PA.Results: Our analysis shows that the restrictions on PA varied in the three countries, in all three countries. This variance is attributed both to differences in the timing and severity of the pandemic in the countries analysed, as well as to the divergence in the relationships between the countries' sport and health systems.Conclusion: At the national level, the variance in restrictions on PA reflect the differences in the spread of the coronavirus and in the health systems' understanding of and approach to PA. The global scientific discourse on the pandemic represents a further key influencing factor. The management of the coronavirus pandemic has demonstrated that the extreme complexity of societies in terms of public health, politics, and the economy pose challenges and unsolvable contradictions. This report analyses governments' decisions on PA during the first wave of the COVID-19 pandemic (February to April 2020) in France, Germany, and Italy. Guided by a Habermasian theoretical approach, the critical analysis of these communications lays at the core of this paper. According to recently published research agendas in the sociology of sport  epidemic, for example, find that the community in Hong Kong responded by adopting healthier behaviours  and theoretical approach is based on critical theory. Habermas , which does not require parliamentary approbation. Such a declaration allows ministers to adopt exceptional measures in case of natural disasters, such as earthquakes and floods, but it is questionable whether limitations on civil liberties are justified for dealing with a pandemic. Despite this emergency declaration, no significant measures were introduced in the following weeks. On 23 February 2020, some municipalities in Lombardy were locked down and the Ministry of Health suspended all sport events in most parts of northern Italy.On 1 March 2020, a decision of the Prime Minister confirmed the previous measures, which had ordered the closing of gyms, swimming pools, and other sport facilities in Lombardy and parts of the Emilia Region. Skiing was still permitted under the condition of “social distancing,” and 3 days later, it was decided that also “sport for all” activities (outdoor and indoor) were allowed only under this condition. On 8 March, Lombardy, Emilia, parts of the Veneto and the Piedmont regions were locked down, and all sport competitions were prohibited. The skiing areas in those regions were also closed, causing a tourist migration to the adjacent ski areas. On 20 March, the Ministry of Health ordered the closure of parks and green spaces, banning outdoor play and recreation. PA (but not jogging) was allowed within a 200-metre radius from home, always respecting the social distancing rules. On 26 April 2020, the Prime Minister announced that the parks and green spaces would reopen as of 4 May, and that sport for all—under the condition of social distancing, of course—would be permitted, and that professional athletes in some sport disciplines could resume training under given guidelines developed by the medical commission of the Italian Olympic Committee.untorn modern witch hunt.During the lockdown, Italians generally refrained from PA, limiting PA to either exercising at home or taking very short walks in close proximity to their homes . Some peTo understand the situation in France, it must be framed within the context of recent government policies on health [“health democracy” ], and thThe COVID-19 pandemic reached France on 24 January 2020, when the first case in Europe was confirmed in Bordeaux. However, only at noon on 17 March 2020, in the wake of the crisis in Italy, did France enter a confinement mechanism, which included the implementation of specific measures. The Ministerial Order of 14 March closed all sport facilities. The Decree of 16 March introduced the concept of self-certification, and the Decree and subsequently the Law of 23 March “normalised” the applicable regulations: people were allowed to take short walks, which were limited to 1 h daily within a maximum radius of one kilometre from home. Individuals could also engage in “basic PA,” respecting the rules on social distancing, but any collective “sport activity” and proximity to others was forbidden. People could only take walks with those who lived in the same household; walking a pet was also allowed. A self-certification form was drawn up that differed from Italy's and included additional “reasons” for leaving one's home: individuals had the option of leaving their home to run or to take a walk, either alone, or with family members.The Decree of 14 April 2020 extended the provisions of both the Decree and Law of 23 March. Toward the end of that month, on 28 April, the French Prime Minister gave a formal address about the country's re-opening strategy, explaining that it would be gradual, and that it would vary depending on the region. In the most affected ones (the “red zones”), parks would remain closed, but individual PA (excluding sport and collective PA) would be possible, even beyond the initially established one kilometre radius from home.As is the case in many developed countries, the promotion of PA is an important objective of German health policies. Amongst other initiatives, the National Action Plan IN FORM , launcheThe first COVID-19 case was identified near Munich, Bavaria, on 27 January 2020. The Infection Protection Act  establisThe coronavirus pandemic dramatically intensified government intervention in the lifeworld of populations . HeedingDivergent relationships between the sport and health systems may also be an explanation for the differences. In France and Germany, for example, PA is treated as a key component of the health system and is perceived as a protective factor. In Italy, PA was ultimately not considered crucial and, paradoxically, represented an element of potential corrosion of social consensus on the lockdown.From a Habermasian point of view, the pandemic poses major challenges  in termsThe problem, in particular, of truthfulness emerges in relation to the rapid implementation of political decisions based on scientific knowledge. In an ideal speech situation, all arguments presented in the discussion should be factually correct, verifiable, and scientifically based. Yet several issues affected the truth of scientific rationality beyond the justifications of the approach to contain the pandemic. From an epistemological perspective , scientiAside from these inherent limitations, scientific knowledge is sometimes used misleadingly to implement political decisions. This was particularly evident in the context of the strict “Italian lockdown.” Despite the low risk for spreading the virus, individual outdoor running was completely prohibited in Italy. The rationale for this was the concern that too many people would have used outdoor running as a way to evade the lockdown restrictions. In other words, scientific evidence was misrepresented to support strategic aims. The prohibition of outdoor PA is an extraordinary interference of the system on the population's lifeworld. Because of the state of emergency, and with the legitimation of the medical-scientific domain, the political system was successful in exerting its power. Indeed, leveraging on medical, moral and patriotic argumentations, the restrictions during the first wave of the COVID-19 pandemic were met with less resistance by the population in the three countries covered in our study. Protests against the restrictions arose during the second wave and were associated with the prevalence of “pandemic fatigue” in the general population rather than with the severity of the restrictions .Despite these critical considerations of the trade-offs between the benefits and detriments associated with the restrictions on PA, the dramatic and rapidly evolving course of the pandemic in the period considered here was acknowledged as being perhaps the most serious challenge Europe has faced since the Second World War. In this context, policymakers may have not taken adequate heed of the risks associated with the lockdown, but they did not take the decision lightly, and had to juggle the different risks. In hyper-complex societies and in critical situations, political communication cannot be ideal. Nonetheless, some recommendations can be formulated. Specifically, public communication needs to be separated from regulatory activity. The former must be disseminated unambiguously, promptly and adequately with regard to the situation at hand. The rapid dissemination of information through different media  may have a negative impact on the information's reception. Furthermore, regulatory activity must take account of the temporal dimension of the emergency through the possible minimal use of extraordinary regulatory instruments. The habitual  decision processes through the entrusted political bodies should be restored as soon as the emergency permits.To conclude, the coronavirus pandemic is an ongoing critical event, which indubitably needs to be further analysed and reflected upon based on different perspectives. Critical sociological research on health and PA policies may contribute to reflections on and to safeguarding the rationality of the political discourse . While pThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Mining dam failures have increased worldwide since the 1980s. Two large mining dam failures occurred recently in Mariana and Brumadinho, both in the state of Minas Gerais, Brazil. We hypothesize that there were significant differences in legal post-disaster decisions. The aim of this article is to understand the similarities and differences of post-disaster actions and controversies in Mariana and Brumadinho. We reviewed 686 news reports about court decisions and settlement agreements from the websites of state and federal courts and judicial institutions. After classifying the reports using an adapted protocol from a media health observatory, we conducted a thematic analysis. Our analysis suggests that there were significant differences in legal post-disaster decisions in the cases of Mariana and Brumadinho. In Mariana, there was privatization of post-disaster management, with the creation of the Renova Foundation, a mediated indemnity program, lack of access to information for those affected, and uncertainties in health and resettlement issues. In Brumadinho, there was faster implementation of the recovery and compensation measures, faster recognition of affected parties, and stronger participation of the population since the first hearings. Even though there were particularities in post-disaster management, the ultimate goal of the corporations responsible for the disasters was to protect their profits. According to Pádua , the BraAfter observing the environmentally unfriendly practices of unskilled and poorly educated Brazilian miners, Lisboa  noted thNavarro  criticizThe dependence on the exploration and export of minerals in Latin American countries is a remnant of the colonial period. Brazil is one of the world’s largest iron ore producers and holds a large part of the world’s iron ore reserves. Most current large-scale iron mines produce significantly more wastes than in the past and also compared to other minerals. Mining tailings are stored in dams that are some of the largest engineering structures in the world and pose a high risk for fenceline communities ,5,6.According to the International Commission on Large Dams , all 221Similar factors may be responsible for the mining disasters in Mariana and Brumadinho, both in the state of Minas Gerais, where there were also failures in monitoring and emergency warning systems . We hypoIn this article, we describe and compare the legal post-disaster decisions involving the corporations Samarco in Mariana and Vale S/A in Brumadinho. Our analysis was based on the four directives proposed by the Sendai Framework for Disaster Risk Reductions , focusin3 of iron ore tailings, which destroyed important tributaries of the Doce River and contaminated 415 miles of the basin before reaching Regência in Espírito Santo and the Atlantic Ocean [Mariana is a city located in the central region of Minas Gerais, where on 5 November 2015, the Fundão Dam, owned by the company Samarco Mineração S/A ruptured. Samarco is a joint venture between Vale S/A and B.H.P Billiton and one of the largest mining exploration conglomerates in the world. The rupture of the Fundão Dam is one of the largest environmental disasters in the mining sector in Brazil’s history. The dam failure released more than 40 million mic Ocean   east of Brumadinho, had a catastrophic failure. The dam is also owned by Vale S/A, one of the corporations involved in the disaster in Mariana. According to the national registry of the National Mining Agency (ANM in Portuguese), the Córrego do Feijão dam, built in 1976 by the Ferteco Mineração and acquired by Vale in 2001, was classified as a small structure with low risk of high potential damage. In December 2018, Vale obtained a permit to reuse the dam waste (about 11.7 million cubic meters) and to shut it down . Dam B1 In contrast to the Mariana case, there were 270 casualties in Brumadinho: 131 employees and 139 outsourced workers or residents of the nearby communities . The higInstitutional negotiations and agreements also had different dynamics in Mariana and Brumadinho. In the case of Mariana, in October 2016, the State Prosecution Office of MG publicized nine class-action lawsuits it had filed against Samarco in the Judicial District of Mariana. Thousands of individual lawsuits were also filed in both Minas Gerais and Espírito Santo . BetweenThis extrajudicial agreement created the Renova Foundation, a private foundation governed by an executive office, which would answer to a board of trustees, an advisory board, and a fiscal council. External monitoring and control fell under the responsibility of auditors chosen by the foundation, the advisory panel of experts, and the inter-state committee (IFC in Portuguese), a body comprising representatives of government departments . The TACIn the case of Brumadinho, there was a meeting on the same day of the disaster involving different legal institutions to discuss collaborative measures . ImpactsLegal institutions rejected the involvement of the Renova Foundation in post-disaster management. Instead of an extrajudicial agreement, Vale and the legal institutions opted for mediated negotiations. There were many meetings between the parties, and agreements were discussed in public hearings before a judge. Unlike the Doce River case, where Renova Foundation produced all data, the judge hired the Federal University of Minas Gerais (UFMG) at Vale’s expense to collect evidence about social and environmental damages .There was no direct community participation during legal procedures because legal institutions (particularly the SPM-MG) officially represented affected communities. By the end of February 2019, those legal institutions requested that impacted people or their representatives be present in the hearings. When attendance increased in March, the judge complained that a high turnout created “difficulties” to procedures and required individuals to register in advance. When community representatives were present, they had to sit behind a glass window and could not openly display their demands . Later, attendance criteria became stricter. The judge required the Brazilian Bar Association to nominate five lawyers to be allowed to attend hearings in the courtroom. As people who were not included demanded participation, the judge decided that community representatives had to take turns in attending hearings . As a reOur data sources included official news reports about court decisions and settlement agreements published on the websites of the following state and federal courts and legal institutions: State Court of Minas Gerais (TJMG) and Espírito Santo (TJES), Federal Public Ministry (MPF), and State Public Ministries of Minas Gerais (MPMG) and Espírito Santo (MPES). Those legal institutions were chosen because they were in charge of deciding on post-disaster legal remedies to punish environmental and workplace violations, compensation for affected parties, and payment for environmental recovery associated with the dam ruptures in Mariana and Brumadinho.We used the SigDesastre Information System to collect information from the official MPES and TJES websites . The SigNext, the selected reports were read in detail, and sections of the texts related to chosen themes were recorded in Excel spreadsheets and texts grouped according to themes . We follThe protocol used the following categories to classify the reports: source of report, data of publication, report title, site page, social actors involved, themes addressed, and report section .The quantitative description of themes according to their frequency in reports about settlement agreements and court decisions is shown in When themes were analyzed according to the institution that issued the legal decisions about the Mariana disaster, we noted a marked difference in frequency between the two disasters. The MPES addressed lawsuits about water supply (24%), but the news reports also mentioned water quality in the Doce River basin. The TJMG, on the other hand, addressed compensation issues more often (46%), as indicated in When we conducted the same analysis for the disaster in Brumadinho, compensation was frequent, though it was not the most common theme. The MPF, for example, emphasized environmental issues (28%), while the MPMG focused on socioeconomic issues (29%), as shown in After conducting descriptive statistical analysis, we developed a timeline for post-disaster lawsuits and settlement agreements to assess when they appeared in the reports, which might indicate changes in post-disaster debates, and the chronology of implementation of legal decisions in the two cases . This tiThis timeline reveals that the dam failure in Mariana led to legal decisions to block assets of Samarco, concerns about the environmental impact on the Doce River basin and water supply to the counties affected, and the beginning of settlement agreements with the population of those counties. After 2016, other themes concerned legal institutions, such as jurisdictional disputes, institutional agreements on compensation values, and the creation of the first consent decree involving federal and state governments, corporations, and environmental agencies. Since representatives of local communities were not included in the discussions about the terms of the decrees, which established the creation of the Renova Foundation to manage victim compensation resources, the courts did not endorse the decree.After 2017, technical assistance was often mentioned in the news reports reviewed. Consultants helped the courts and the local communities to decide on post-disaster measures. In 2018, the focus of the reports changed to the inclusion of affected communities in hearings and in the administrative structure of the foundation, as well as establishing the TAC-Governance. This TAC created the Mediated Compensation Program (PIM in Portuguese) to compensate communities and micro and small enterprises that “suffered losses or damages related to their economic activities as a direct result of the Fundão Dam failure in Mariana, without bureaucracy and the cost of a lawsuit” . This prIn 2019, news reports focused on discussions about compensation values, conciliation hearings about water supply, especially in the city of Governador Valadares (MG), and rebuilding the village of Bento Rodrigues, renamed as New Bento. In 2020, after five years of the Mariana disaster, there were still debates about health studies, hiring of technical advisors and the results of studies conducted, and even the creation of the Renova Foundation.In Brumadinho, post-disaster managerial procedures were different from Mariana. The legal institutions involved took different positions in several issues, such as the determination of affected parties, the inclusion of community representatives from the beginning of post-disaster litigation discussions (though this did not mean that they effectively participated in it), and support for health, economic, and environmental needs. Conciliation hearings were held throughout 2019 to negotiate settlement agreements with indigenous communities, families who lost loved ones, and affected communities and counties, in addition to the participation of faculty and staff from the UFMG as expert consultants.As far as corporate responsibility is concerned, employees of Vale S/A and the German engineering company TüdSüd, responsible for auditing the dam in Brumadinho, were held accountable and charged with criminal misconduct. Employees were detained for a few months for further investigation. The same accountability did not happen in Mariana. At the beginning of 2021, after monthly conciliation hearings, a historic settlement agreement in the amount of USD $7.1 billion was signed between Vale S/A, state, and federal institutions. The agreement “aimed at socio-environmental and socioeconomic reparations as an anticipation for compensation of damages” .In the case of Mariana, the criminal prosecution was on hold for over two years, despite the complaint filed by the Office of the Public Prosecutor. Only six of those charged remain as defendants . In the The mining disasters described in this article have similarities not only because both are mining dam failures but also due to similar outcomes. Both led to a great loss of life, environmental pollution as well as triggered citizen lawsuits and penalties against Vale S/A for violation of administrative procedures enforced by the Brazilian organization responsible for regulating securities and exchanges (CVM in Portuguese). Both disasters also caused federal and state prosecutors to file civil action lawsuits and establish consent decrees that included state governments, corporations, and state departments of the environment . Both diRojas and Pereira  discuss Although the quantitative analysis suggested that the frequency of themes in both disasters were similar, the qualitative analysis suggested otherwise. Differences in themes mentioned in both disasters became notable.In Mariana, the consent decree that established the creation of the Renova Foundation, a private concern, and the mediated compensation programs demonstrate the innovative and sophisticated legal and institutional architecture organized by the corporations to manage post-disaster damages. Thus, at the macro level, a number of agreements were negotiated through the TACs, whose stipulations have been continuously ignored by the corporations. At the micro level, compensation of affected parties was negotiated at the individual level and made difficult by victim registration methods incompatible with the context of local residents. Three years after the disaster, news reports mentioned that many people still waited to be recognized by the courts as affected parties , and thoThe strategy used by the Renova Foundation to negotiate the compensation of individuals through mediation increased the existing inequality between the parties because the ability of poor residents to negotiate fair compensation for losses and damages was quite limited due to their urgent survival needs . In addiSamarco’s management of the registry of claimants and the Emergency Relief Program were denounced early by public prosecutors for their lack of transparency regarding eligibility criteria for emergency relief and differential treatment of residents. The lack of transparent criteria for emergency relief created conflicts in the communities and left many people clearly impacted by the disaster without any compensation . AlthougThe PIM was also criticized by social movements and civil society organizations, who claimed that corporate interests had captured the judicial branch and the set of tools and mechanisms available within the Brazilian legal system. According to authors such as Rojas and Pereira , all proIn the case of the disaster in Brumadinho, our timeline shows faster outcomes deriving from the participation of legal institutions in the governance model adopted to discuss collaborative institutional agreements . The legThe compensation agreement of February 2019 in Brumadinho, less than a month after the disaster, established an emergency relief payment for impacted communities as a way of preserving their income. All residents in Brumadinho and those who lived up to 1 km from the river margins received a monthly payment during the following 12 months. This agreement differed from the one in Mariana since in Mariana, the Renova Foundation was in charge of deciding who was eligible for financial support through special forms and numerous criteria, while in Brumadinho, geographic criteria prevailed. Furthermore, in the latter, the payment was per capita, while for families who lived alongside the Doce River, payment was per family unit .There was limited participation of impacted communities in decision-making in both disasters.In the case of Mariana, there was some representation in the governance of the Renova Foundation, but only after changes in the TAC-GOVERNANCE in 2018 did two community representatives become part of the Board of Curators, and four were accepted in the advisory board of the foundation . HoweverFurthermore, the hierarchic structure of several technical subcommittees, councils, the inter-state committee, beyond the many challenges of the foundation about results of studies conducted by experts, produced endless debates and delays, a situation that could be summarized as “paralysis by analysis” . In turnIn the case of Brumadinho, communities were invited to participate in the first meetings and hearings but were surprised by the limited number of people allowed to attend them. As a result, many were not able to have access to decisions. Those restrictions increased the influence of legal institutions and reduced the power of communities to shape the results of negotiations. Even though community representatives were strongly in favor of collective negotiations because they understood that they would be disadvantaged if families had to negotiate separately with attorneys from Vale, in February 2019, Vale demanded that negotiations had to be conducted with each impacted family ,50.While health issues were urgent, the theme was not common in legal actions in both disasters . Yet, stThe affected populations did not trust the information and technical reports published by the foundation, which kept communicating “the nonexistence of causal associations between the disaster and the majority of symptoms and disorders identified in the population” . In the The disasters reviewed in the news reports caused incalculable public health impacts. According to Freitas et al. , lessonsOur analysis suggests that in the Mariana case, Samarco bet on managing the reparation of damages through corporate management lenses  as a strIn the Brumadinho case, the evidence presented in news reports confirms that Vale knew that the Fundão Dam had structural failures that could have been mitigated through adequate drainage . The conBased on the directives proposed by the Sendai Framework , the firThe news reports also suggest that mining corporations were the dominant power while the state allowed and participated in solutions that did not address the inequalities between the parties. In addition, the Brazilian environmental legislation has been weakened, and there was a lack of investment and shortage of human resources in the National Mining Agency, which is responsible for inspecting mining dams in Brazil . AlthougThose management policies and practices are standard operating procedures for disaster risk management in the mining industry in Brazil. The less risk is known, the greater the corporate power over fenceline populations to build and operate hazardous facilities such as tailings dams. On the other hand, transparent risk communication may help local populations in decisions about how to live in a territory with a potential risk of disaster. Disclosure of risks and transparency can also help governments approve mining projects.Our results indicate that the disasters in Mariana and Brumadinho uncovered poor risk management and oversight of iron mining practices as well as post-disaster mismanagement. While there were significant differences in post-disaster measures, the main source of socio-environmental problems is the same, i.e., lax mining exploration policies adopted in Brazil since colonial times. Those lax policies were poorly enforced by the state over the years and became toothless during the last two decades when neoliberal Brazilian governments strengthened the country’s dependency on exports of raw materials ,59,60.Our study has strengths and limitations. We accessed official news reports from the legal institutions in MG and ES, which are based on a large amount of evidence provided to the courts. Legal standards of proof had to be followed by all parties involved. The evidence had to be substantiated by scientific findings and testimony of a broad variety of organizations and individuals, which strengthens the reliability and validity of the data and information available in the news reports reviewed. However, we were not able to interview stakeholders involved to obtain an in-depth perspective about the interests at play in the meetings and hearings held in both disasters.We analyzed in this article the differences and similarities in post-disaster management according to news reports of legal actions taken in the disasters in Mariana and Brumadinho. Our study suggests that there were significant differences in legal post-disaster decisions in the cases of Mariana and Brumadinho. In Mariana, there was privatization of post-disaster management, with the creation of the Renova Foundation, a mediated indemnity program, lack of access to information for those affected, and uncertainties in health and resettlement issues. In Brumadinho, there was faster implementation of the recovery and compensation measures, faster recognition of affected parties, and stronger participation of the population since the first hearings. Yet, speeding up individual settlement agreements, reducing the lag time to compensate losses and damages, and including community representatives in discussions and decisions did not substantially change the usual mining production procedures and storage of mining wastes nor provided adequate resources to the affected populations.In both cases, we observed the same mining production procedures based on dilapidation of mineral and environmental resources, exploitation of labor and communities, and manipulation of the state and its enforcement procedures. Samarco and Vale are powerful polluting corporations able to obtain flexible public policies favorable to their commercial interests; nature is thus treated as a commodity and source of profits above all ,60.Our study contributes to increasing the understanding of post-disaster legal decisions and agreements and a better understanding of dam tailings post-disaster management and the consequences for nearby communities. We hope that future studies deepen the understanding of post-disaster legal decisions, including the perspectives of the multiple parties involved in post-disaster litigation.Our conclusions are similar to the one stated by Feitosa, a resident in the local district Juatuba:“The agreement only rewards the mining corporation Vale, which solves a problem with shareholders, leaving affected people and their demands out of it. This once more demonstrates that Vale is rewarded. It is already a repeat offender for the crime that occurred in Mariana. It killed additional 272 people, and again it comes out on top; it comes out well, doing whatever it wants, and we feel that the State is not concerned with doing justice”, testimony of Ms. Joelisia Feitosa, resident in Juatuba .


Digital self-help interventions for reducing the use of alcohol tobacco and other drugs (ATOD) have generally shown positive but small effects in controlling substance use and improving the quality of life of participants. Nonetheless, low adherence rates remain a major drawback of these digital interventions, with mixed results in (prolonged) participation and outcome. To prevent non-adherence, we developed models to predict success in the early stages of an ATOD digital self-help intervention and explore the predictors associated with participant’s goal achievement.We included previous and current participants from a widely used, evidence-based ATOD intervention from the Netherlands . Participants were considered successful if they completed all intervention modules and reached their substance use goals . Early dropout was defined as finishing only the first module. During model development, participants were split per substance  and features were computed based on the log data of the first 3 days of intervention participation. Machine learning models were trained, validated and tested using a nested k-fold cross-validation strategy.From the 32,398 participants enrolled in the study, 80% of participants did not complete the first module of the intervention and were excluded from further analysis. From the remaining participants, the percentage of success for each substance was 30% for alcohol, 22% for cannabis and 24% for tobacco. The area under the Receiver Operating Characteristic curve was the highest for the Random Forest model trained on data from the alcohol and tobacco programs (0.71 95%CI 0.69–0.73) and (0.71 95%CI 0.67–0.76), respectively, followed by cannabis (0.67 95%CI 0.59–0.75). Quitting substance use instead of moderation as an intervention goal, initial daily consumption, no substance use on the weekends as a target goal and intervention engagement were strong predictors of success.Using log data from the first 3 days of intervention use, machine learning models showed positive results in identifying successful participants. Our results suggest the models were especially able to identify participants at risk of early dropout. Multiple variables were found to have high predictive value, which can be used to further improve the intervention. Alcohol, tobacco, and other drugs (ATOD) use are among the leading risk factors for morbidity and mortality worldwide  and can Different types of data can be used to predict adherence or dropout in eHealth interventions. A study by Log data often shows high predictive value. It consists of records of actions performed by the user when using the intervention and can provide new insights into the actual usage of each individual module . Log datCognitive Behavioral Therapy (CBT) and motivational interviewing (MI) based digital self-help interventions have been developed to help treat people suffering from diverse conditions including problem drinking , tobaccoThe large number of variables available in log data, that are collected during a digital self-help intervention make machine learning especially suitable for the prediction task since they are capable of handling high-dimensional data and discover previously unknown relationships between variables by adding non-linearity to the learning process.In this study, we aim to use machine learning models to predict participant success using data from the early stages of a digital self-help intervention for problematic substance use  and explore the components that are associated with the success of participants in reaching the goals that they set at the start of the intervention. We also explored model interpretability, since understanding the factors associated with participant adherence can subsequently lead to implementation research, investigating changes to improve relevant adherence patterns, and thus, improve success rates of the intervention .We included all participants enrolled between January 2016 and October 2020 in a widely used, evidence-based unguided digital self-help intervention for alcohol, cannabis, and cocaine use, tobacco smoking, and gambling , which is based on CBT and MI techniques and is composed of 6 modules. The intervention covers at least 30 days (5 days per module). Each module consists of an animation video, a reading assignment and an at least one writing assignment. Automated feedback is given by the program based on the results and progress from the participant. A forum and a personal diary are also available in the intervention. Based on the principles of CBT, the user is also encouraged to register their substance use or craving on a daily basis. More details about the intervention can be found in the diagram of At the start of the online intervention, the participants can choose their goal for the intervention. They can choose if they want to  stop or reduce their substance use. They can also set the target maximum daily consumption (in units) they want to reach by the end of the intervention. We use this target number of units defined by the participants combined with the prescribed use of the intervention to define success. We excluded a large number of participants who did not complete module 1 of the intervention. Based on inspection of the data, we defined intervention success as completing all 6 modules of the intervention and reaching the daily substance use goal for the last 7 days before discontinuing the intervention. We defined early dropout as completing module 1 but not going further than module 2.I will save more money if I spend less on alcohol”), and writing agreements for themselves . Besides these tasks, other modules were available at all times such as the Forum  and the diary. Daily consumption registration, logins, and forum access were also computed for the same time frame. A complete table with all the features computed and their explanation is available in We selected log data from the first 3 days (72 h) of intervention use of all participants. We selected this number of days after discussion with the program designers, to keep a balance between collecting as much relevant information about the usage of the intervention as possible while keeping the window for action as early as possible. Nevertheless, we explored other time windows (48 and 96 h) in a sensitivity analysis. In the first 72 h, the participants had tasks from the first module available to them, namely: watching the start video (introduction), writing pros of stopping and cons of continuing substance use  and finished at least 4 out of the 6 modules  of the intervention, were also considered successful in reaching their goals. We also assessed the influence of shorter and longer time periods for data extraction (48 and 96 h). Finally, our definitions of success  and early dropout (reaching no further than module 2) do not include a group of participants who finish the intervention but do not achieve their target consumption goal. A total of 41% of the participants who reached module 6 of the alcohol intervention did not reach their target consumption goal and therefore, are not included in the successful group. The percentages were 33 and 39% for the cannabis and tobacco interventions, respectively. Since we defined success as a combined measure of prolonged participation and, meeting pre-set goals and given the low percentages for the cannabis and tobacco interventions  available in this sub-group, we did not include it in the analysis.Given the large number of machine learning models available in the literature, we selected a subset that has shown state-of-the-art results in recent applications. Moreover, since the learning process can be very different for each model, we aimed at including models with different learning processes to increase generalizability and the chances of new findings . Therefo1We used a nested k-fold cross-validation strategy to train, validate and test the models. In the outer cross-validation loop, the data was split into 10 stratified  folds. In each cross-validation iteration, onefold was used as test set while ninefold (the training set) were used in the inner cross-validation loop. The inner cross-validation loop was used for hyper-parameter optimization, where the training data was split again into threefold, where two were used to train the model with a given set of hyper-parameters, while the one left was used to validate them. The best set of hyper-parameters was the one with the highest average Area Under the Receiver Operating Characteristic Curve (AUROC). The model trained with the best set of hyper-parameters was applied to the test set, and the evaluation measures were computed. We present a list of hyper-parameters used for model optimization in Class imbalance was present in all experiments and it can lead to biased results. Therefore, we applied balanced class weights during model training to address this issue . Class wFor each machine learning method, 10 models were optimized and tested using our nested k-fold cross-validation strategy. We report the average across all cross-validation iterations and the 95% Confidence Intervals (CI) for the following evaluation measures: AUROC, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We also present a confusion matrix with the results from all folds. The threshold of 0.5 was used for converting the probabilities to class predictions.For feature importance visualization we used SHAP (SHapley Additive exPlanations), which is a unified approach for explaining the predictions of any machine learning model . SHAP vaLog data from 32,398 participants enrolled from January 2016 to December 2020 in the Jellinek self-help intervention was available. Around 80% of the participants did not reach further than the first module of the intervention and were excluded from further analysis. This group of participants possibly included many individuals that only wanted to take a look at the intervention, rather than having the intention to actually follow the intervention.The remaining 20% of the participants were divided based on the five different addiction programs available in the online intervention, namely: alcohol, cannabis, tobacco, gambling, and cocaine. Since the number of participants in the gambling and cocaine intervention was relatively low for developing machine learning models, we did not include these programs in the analysis. In We present in successful and early dropout groups.early dropout participants. Prevalence of successful participation was 29, 28, and 29%, in the alcohol, cannabis and tobacco programs, respectively.We present in early dropout outcome were correctly identified, while 323 (50%) participants with a successful outcome were correctly identified. The same can be observed in the cannabis intervention, where 283 (78%) participants with an early dropout outcome and 49 (47%) participants with a successful outcome were correctly identified. Finally, in the tobacco intervention, 287 (73%) participants with an early dropout outcome and 66 (47%) participants with a successful outcome were correctly classified by the RF model.In We present the results for the sensitivity analysis using other time windows for feature engineering besides 72 h 48 and 96 h) in  h in 6, y-axis, we have the features based on the first 72 h of participation in order of importance from top (most important) to bottom (less important) and in the x-axis their respective SHAP value which indicates their association with success  or early dropout  participant outcomes. The color legend on the right shows how large and low values of a given feature relate to the SHAP values. For example, Number of Logins is at the top as the most predictive feature. High values for Number of Logins have positive SHAP values, which indicates an association with the success outcome in the alcohol intervention. Most engagement-related features  appear at the top with high values being associated with success. Moreover, not drinking on the weekends (Saturday Target) was also associated with success in the alcohol intervention. The Total Units Consumed in the first 72 h was also considered an important predictor, with lower values associated with higher success rates. Another relevant finding is that having your target goal set to reduce  was associated with the early dropout outcome for the alcohol and cannabis interventions. Finally, low initial daily consumption values  were associated with success as outcome.In Number of Diary Entries being associated with participant success.In Total Units Consumed was the most important variable for the tobacco intervention, with low values being associated with success. Having the target goal set to stop instead of slowly stop was also an important predictor. Finally, as also observed in the other interventions, engagement variables such as Number of Logins, Forum Visits and Number of Participation Badges were highly predictive with high values associated with success.success. Thus, our findings have important implications for implementation trials geared at increasing adherence and success in ATOD self-help programs.We have shown that machine learning models can accurately identify participants that will be successful in reaching their goals in the online self-help intervention for alcohol, cannabis, and tobacco. The best AUROC values were 0.71, 0.67, and 0.71 for the alcohol, cannabis, and tobacco interventions, respectively, which shows moderate predictive value. Despite all models having similar performance, the AUC was the lowest for the cannabis intervention. This is likely due to the small number of samples available for training since this was also the intervention with the least participants. Moreover, the high negative predictive values reported suggests that our models were better at identifying participants at risk of early dropout, while the high specificity shows that the early dropout predictions were often correct. Such findings could be used in practice, to offer extra support for this risk group. We have identified that engagement with the intervention, alongside with having the target goal to quit immediately instead of gradually quitting or moderating substance use, and not drinking on the weekends were all important predictors of participant The prediction of participant adherence and success to addiction treatments (including CBT) has been previously explored in the literature  since itTotal Units Consumed was the most important predictor, while in the alcohol and cannabis interventions, it was the Number of Logins. The reasoning behind this difference is not entirely clear, but a possibility is that it is related to the possible goals of each intervention. For tobacco, only completely quitting can lead to a successful outcome. Therefore, the association between tobacco use quantities and success is much stronger, as success can only be achieved when tobacco use goes to 0 at some point. For alcohol/cannabis, this association is slightly less strong as moderate use of these substances  can still lead to a successful outcome and goal achievement. Finally, quitting is more difficult for heavy smokers than for people who smoke less, making it a strong predictor of success (Our results suggest that users of the Jellinek online intervention that are more engaged (and probably more motivated) with the intervention in the first 3 days of participation tend to reach their goals more often. Having the goal of immediately quitting rather than gradually quitting or moderating use, and the goal to quit using substances on the weekends also correlates with success. These findings correspond with previous studies that investigated differences between gradually vs. abruptly quitting , while t success .early dropouts or successful participants. In our case, we aimed at prioritizing the correct identification of participants at risk of early dropout (NPV), which was higher for the standard 0.5 cut-off, while other approaches such as the Youden Index  and/or availability of novel assignments each day, and encouraging therapy continuation by positive feedback on their progress, may have a positive effect for participants. Explaining how choices between quitting and controlled use as a treatment goal, and in case of controlled use, how substance use during weekends may affect their goal attainment might assist the participant in making better-informed decisions, ultimately leading to improved outcomes. Such amendments to the intervention and how these might affect participant success will be the topic of future studies. Finally, regarding the methods, one could consider different optimization strategies or probability cut-offs to prioritize the identification of either en Index  led to mA strong point of this study is the large sample size, which includes all participants that used the intervention since 2016 and indicated their data may be used for research purposes, making the data to a large extent representative of the full population that participates in the Jellinek ATOD online intervention. Our approach included multiple validation steps to reduce the risk of overfitting and biased results. Furthermore, we increased model transparency by using SHAP for model interpretation, which makes our results clearer and more actionable. A limitation of this study is the lack of demographic variables since these have previously been shown to be strong predictors of participant success . HoweverLog data analysis with machine learning yielded positive results for the prediction of participant success in the digital self-help Jellinek intervention, with the models being especially accurate in predicting patients at risk of early discontinuation. We also identified multiple relevant predictors of outcomes and how participants’ choices regarding goals may affect goal achievement. Whether this information can lead to improvements to the intervention will be the subject of future studies.The data analyzed in this study is subject to the following licenses/restrictions: Given the sensitive nature of the data, and to preserve the identity of the participants the data cannot be made publicly available. Requests to access these datasets should be directed to MB.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.LR: lead author, study design, analysis and interpretation of results, and critical revision of the manuscript. MB: data extraction, study design, analysis and interpretation of results, and decision making and critical revision of manuscript. GW and SP: study design, analysis and interpretation of results, and decision making and critical revision of manuscript. TB: result interpretation, analysis and interpretation of results, and decision making and critical revision of manuscript. AG: study design, analysis and interpretation of results, and decision making and critical revision of the manuscript. All authors contributed to the article and approved the submitted version.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.