With the continuous technological enhancement of banking services, customers can avail of better, more secure services which present improved opportunities and convenience. Of the many methods available to perform banking operations, customers commonly use traditional banking, online banking, and mobile banking. Each of these existing methods has advantages and limitations that affect customer experience, trust, satisfaction, and continued intention to use such services. In this study, an attempt was made to develop and fit a model to evaluate and measure the effect of perceived characteristics on banking services. To this end, a questionnaire was administered to 91 participants in Korea to investigate their experiences in the three types of services: offline banking , online banking, and automated teller machines (ATM). The factor design for evaluating the user experience through the perceived characteristics of the banking system was performed by conducting exploratory and confirmatory factor analyses. The proposed model exhibited validity and reliability to evaluate the user experience in the banking system. The results obtained can help banking specialists and professionals increase the level of customers’ trust, loyalty, and intention to use their services. As a component of the financial sector, banking is constantly undergoing technological changes . ServiceUser experience in different products and services, including the banking sector, is an important element affecting the perception and intention of use ,17. ResuThe present study aims to understand the relationship between perceived characteristics in banking services and to extract a mechanism of user experience evaluation in online, offline, and ATM services. Perceived trust, security, convenience, ease of use and usefulness  are considered to be factors affecting customer experience. The most dependent perceived characteristics on the type of banking service are also shown. The model thus developed proposes new knowledge and findings to help banking specialists and researchers improve service attractiveness among customers and increase trust in new banking technologies.The results expected in the course of this study may contribute to the problems of increasing the competitiveness in the financial sector among service providers, expanding the choice of convenient and reliable services for the consumer, as well as ensuring faster and more reliable implementation of new technologies in banking. In turn, the introduction of new technologies in the financial sector will contribute to the overall technical development of society.The present study evaluates user behavior in three predominant, different types of banking services  through PT, PS, PC, PEU, and PU. Based on previous studies, PT includes users’ expectations of system performance ,22. PS iFor the presented study, measurement methods and tools of the user-perceived characteristics were selected from previous studies and guidelines that have proven their validity ,7,8,9,10Based on PT in different types of banking services is a core element of the user experience and can be represented through various concepts and constructs .Two concepts of trust-affecting factors (vendor- and medium-based) were proposed . Vendor-Different perceived characteristics can relate to and represent PT in banking. It was confirmed that consumers’ trust in online technologies has a positive relationship with PEU and PU . A positA core research issue in electronic services (including online and Internet banking) is the PS level, because the use of a partially invisible service gives a feeling of uncertainty to users, with possibilities rife with system failures or unauthorized access. PS is dependent on online transmission conditions in electronic services . ScholarTime and effort are the basic characteristics of service convenience . ConveniPEU and PU are related to the productivity and efficiency of the service and can be studied simultaneously in relation to user experience . Task peFor the experiment, we randomly selected 91 users of the banking system in Korea . The average age of the participants was 30 (standard deviation: ±5 years). All the participants were regular users of online/offline banking and ATM services with over 5 years’ experience. The purpose and procedure of the survey were explained to the participants before the experiment. Participation in the experiment was voluntary.In the experiment, user attitude and experience in service were analyzed through PT, PU, PEU, PS, and PC according to the types of banking services . The questionnaire  was deveThe questionnaire was administered to the 91 participants, and each of them completed the survey within 1–2 days. The questions were not shown to the participants in advance. The evaluation of each banking service  by the users was performed using a scale from 0 (lowest) to 10 (highest). During the initial assessment of the results, the questionnaire submitted by one participant was removed from subsequent analysis due to invalidity; the survey was completed in a matter of a few minutes, and each answer was rated 10 points. It was obvious that the participant did not respond carefully.In the present study, exploratory and confirmatory factor analysis (EFA and CFA) were used simultaneously. Results from the EFA were considered as pre-established theory, and the CFA was applied to confirm the extracted factors and the item structure from EFA . This anEFA was performed using SPSS software  to identify the relationships between the measured variables and to determine the underlying structure of the existing set of variables. The initial factor model contained sets of manifest variables , which are functions of the common factors . The Kaiser–Meyer–Olkin measure and Bartlett’s test were used to evaluate the suitability of the data set for the factor analyses. EFA was performed using Varimax rotation, which allowed the extraction of the optimal three-factor solution. Common factors influenced the set of manifest variables, and factor loadings were obtained to measure the impact of the common factors on manifest variables.CFA was performed using AMOS software  to verify the factor structure based on manifest variables. The CFA used in this study is based on a three-factor solution proposed by EFA, and the results showed existing relationships between the factor and observed variables. Satisfactory results with goodness-of-fit (GOF) indexes were obtained.p-value The Kaiser–Meyer–Olkin Measure of Sampling Adequacy showed satisfactory results with a value of 0.824. The Bartlett’s Test of Sphericity gave a ser rule  was appl−Selecting questionnaire items whose loadings were above 0.5;−Screening out factors whose questionnaire items were less than 2;−Screening out questionnaire items whose loadings were above 0.5 in a few factors at the same time. Based on the above criteria, the three-factor model was extracted. The PT factor had four items; the PS and PC factors had three items. Cronbach’s alpha showed values above 0.65 for each factor, which indicated satisfactory correlations between a set of items as a group ,69.The extracted three-factor model  was analservices .Three-factor models have already shown their effectiveness in previous studies in different areas such as trade, shopping, medicine. A study  applied −Selection of a proven previous study on a similar topic as a prototype ;−Questions should be clear and direct;−Only one question can be asked at a time;−It is necessary to avoid bias and verbosity in matters;−The measurement scale should provide a differentiated assessment of the expressed opinion.The developed model unites PS, PC, and PT factors which allow the measurement of user attitude and experience. To obtain a valid model, a measurement instrument of perceived characteristics  was compiled based on the recommendations of various educational institutions and government organizations. The main guidelines for constructing questionnaires were discussed in previous studies ,74. The Existing research provides evidence that these factors are mutually influential. It was shown ,76 that PEU and PU did not show a significant connection with user attitude and experience in banking services. Previous studies have shown similar results in various research and service areas. A study  found thOne of the important issues related to banking services is the verification of the degree to which existing services meet the user’s requirements and expectation ,20. The The performance of the developed model was supported by satisfactory goodness-of fit indexes including the ratio CMIN/DF, the comparative fit index (CFI), the goodness-of-fit index (GFI), and the mean-square error of approximation (RMSEA) proposed by . A studyGenerally, the presented model shows effectiveness and reliability; however, there are a few limitations to be improved in future. Firstly, using qualitative data with quantitative data would increase the versatility of the model. The evaluation of subjective measurements such as PT, PC, and PS can be improved by prospect theory application based on a previous study . This thThe three-factor model with extracted units of PS, PC, and PT factors was obtained and allowed the measurement of user attitude and experience in financial and banking industries. Based on the above research, the results may contribute to the problems of increasing the competitiveness in the financial sector among service providers, expanding the choice of convenient and reliable services for the consumer, as well as ensuring faster and more reliable implementation of new technologies in banking. In turn, the introduction of new technologies in the financial sector will contribute to the overall technical development of society.The presented study has several limitations, which can be improved in future research. Limitations of this study include the number of banking services analyzed . In the future, the types of services will be expanded for analysis, including mobile banking and different banking electronic apps for customers. The developed model refers to the current period of using the banking service. The model can be extended to include past user experience with the banking service. The methodology can be expanded by including data from qualitative interviews with respondents. Analysis approaches can be supplemented by statistical data about survey participants  in the model variables, using regression and statistical methods. Participants can be divided into groups according to the type of professional activity , work experience, as well as experience in using banking services, for a more detailed analysis.The present study proposes a methodology that can be helpful to evaluate user experience, attitude, and intention through PT, PC, and PS in different banking service types. The EFA allowed the extraction of 3 factors and 10 items (variables) for the developed model. CFA supported the validity of the model through satisfactory factor loading and GOF values. It was shown  that proThese findings are important for new banking technology implementation supporting progress and development in the banking sector. The factors detected are motivators for the customer response toward new banking technologies and different service types. The obtained results can be extended to different types of services, such as online shopping and trade. The presented highlights can be used as guidelines to determine customer behavior, attitudes, and their perceptions toward services. The findings can offer researchers, service providers, and sellers assistance in understanding how to build customer trust and security in new types of services and ensure long-term loyalty. As it was demonstrated above, improving the quality of services is associated with strengthening customer satisfaction and expanding the customer base. In turn, customer loyalty and satisfaction help to introduce new types of services using new financial and technical innovations. Thus, the conducted research can be used locally in the banking and financial sector and help in the development of new technologies for the society as a whole.


The increased life expectancy for patients with Down Syndrome (DS) has elicited the need to improve their quality of life by enhancing functional outcomes and identifying the factors that contribute to their long-term cognitive decline. Although the majority of individuals with DS have issues with hearing impairment (HI) since early childhood, to our knowledge no study has investigated whether HI represents a potential modulator of cognitive decline over time. The present explorative cohort study, albeit very preliminary due to the limited cohort (17 children), highlights the significant relation of a significant HI not only with receptive language abilities, but also with mental age in young patients with DS. Additional studies are required to confirm the link between HI and mental age and to assess the impact of audiological treatment on the enhancement of functional outcomes and of cognitive decline in individuals with DS. The increased life expectancy for patients with Down Syndrome (DS) has elicited renewed interest in the factors that may contribute to their characteristic poor linguistic development, overall intellectual disability, and the developmental trajectory associated with long-term cognitive decline in this population , 2. In aA possible detrimental factor for language abilities is hearing impairment (HI) , presentAssociazione Sindrome di Down Onlus” rehabilitation center in Verona  at the end of 2019, 41 were referred for audiological evaluation at the Audiology Unit of the Institute for Maternal and Child Health IRCCS Burlo Garofolo of Trieste  because, for various medical or family reasons, they had not had previous access to audiological treatment. In order to obtain a more homogeneous group of young but nonetheless collaborative subjects who underwent auditory and language tests, we excluded children younger than 3 and older than 10 years, with native language other than Italian, with serious vision problems, and with severe cognitive (IQ < 40) or communication deficits . The final dataset thus included 17 patients .Among 150 children and adolescents with DS who were involved in the rehabilitation process at the “Parents were informed about the possibility to use clinical data for research purposes and gave their written consent to participate before the assessment. The study was conducted according to the 1964 WMA Helsinki declaration and its later amendments.All evaluations and data were obtained by a team of clinicians and therapists with specific expertise in DS and with particular attention to the audibility of the test stimuli. In addition to the audiological evaluation, auditory and receptive language skills, and cognitive abilities were measured. The information on chronological age, mental age, IQ, OSA, and HCI were collected from medical reports.Audiometry testing was performed in a soundproof booth; sound field air conduction hearing threshold was estimated and averaged over frequencies of 0.5, 1, 2, and 4 kHz. Participants with either sensorineural or conductive hearing loss and with a mean hearing threshold >40 dB HL were categorized as having a significant HI (SHI). Auditory skills in everyday life were categorized using the Categories of Auditory Performance (CAP), an index consisting of eight scores arranged in order of increasing difficulty . Receptit-tests controlled for multiple comparisons. Welch t-tests were used to control for the unequal variances of the sample.To describe the sample, IQ, PSQ scores, mental and chronological age, auditory performance and receptive language scores were compared in children with or without SHI using a series of Welch two sample https://osf.io/chw8n/.To assess possible relations between mental age and factors that potentially affect cognitive function, bivatiate correlations (Pearson method) between mental and chronological age in children with and without SHI were computed, as well as the correlations in children with and without HCI and OSA. Partial correlations were not possible since splitting variables were categorical, whereas multiple regression analysis did not result in constructing valid models due to the scarcity of the data. The anonymised dataset is publicly available at p = 0.05], but not in children with SHI . These results confirm that the presence of SHI may crucially affect auditory and language abilities in children with DS. Chronological age, mental age, IQ, CAP, and BVL scores were furthermore compared when children were split based on the presence or absence of OSA or HCI, but the differences were not significant.Nine out of 17 children in the dataset were affected by a SHI. Children with and without SHI did not differ in chronological age, mental age and IQ, the factors that otherwise affect auditory and language skills . Conversp = 0.033], indicating that mental age progresses steadily with growing. Conversely, children with SHI exhibited no significant correlation between the mental and chronological age , indicating the lack of progress in intellectual performance relative to the chronological age  = 2.752, ical age . Mental e of OSA . Howevere of OSA ; furtherThe present study highlights the significant impact of SHI not only on auditory and receptive language abilities, but also on mental age growth in young patients with DS.Our results confirm data from the previous DS cohort report in which children with DS and a history of HI had lower receptive and productive language skills than children without such a history . They alGrowing literature emphasizes the impact of HI on the outset and progression of dementia, but very little is known about its role in DS. The impact of SHI to mental age growth at an early age could have long-lasting consequences on autonomy and quality of life, and possibly also on the outset and progression of dementia in DS. Due to the numerically very limited cohort, the current results should be considered preliminary. Further research is needed to clarify whether hearing deprivation due to SHI represents a causal factor or a mediator of cognitive functioning in individuals with DS. Future longitudinal studies could concurrently evaluate the impact of audiological treatment on improving functional outcomes and progression of cognitive decline in individuals with DS .HI is a modifiable condition, and effective audiological treatment and rehabilitation are today feasible since the first months of life, minimizing the hearing deficit and its consequences. Yet, audiological assessment of patients with DS is frequently complex and severely delayed as a consequence of multiple life-threatening conditions that influence the clinical management in the first years of life. Nonetheless, professionals involved in the healthcare management of these patients should consider the possible presence of HI as a red-flag not only of a language disorder but possibly also of reduced mental age growth.https://osf.io/chw8n/.The datasets presented in this study can be found in the OSF repository at the following address: Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.AS, DB, GP, and EO: study concept and design. EB, SB, AS, DB, and GP: acquisition, analysis, and interpretation of data. DB, AF, MB, and GP: drafting of the manuscript. EO: study supervision. All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.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.


In order to improve students’ learning effect, more and more universities favor foreign language teachers who are native speakers of English. Based on the analysis and summary of the research status of emotion recognition, this paper proposes that, in college English classroom teaching, foreign language teachers can reduce the communication barriers with Chinese students through emotion recognition. Based on literature review and actual situation investigation, this study identified four influencing factors on emotion recognition of foreign language teachers, namely, interactive action, facial expression, vocal emotion, and body posture. In our opinion, in the teaching process, teachers can adjust the four factors of emotion recognition to achieve better teaching effect. Further, improve students’ learning efficiency. Analytic Hierarchy Process (AHP) is chosen as the research method in this study. After building the analysis model, we collected the questionnaire using the Questionnaire Star, and finally got 12 valid data. After determining the importance of different factors by pairwise comparison, we draw the following conclusions: the influence degree of emotion recognition factors of foreign language teachers is in descending order, interactive action (43%), facial expression (28%), vocal emotion (21%), and body posture (9%). Our research adds to the body of knowledge on emotion recognition among college English teachers. Furthermore, this research assists students in improving their grasp of course content based on the emotions of foreign English lecturers. Based on the findings, we recommend that foreign language teachers in college English classrooms alter their interactive behaviors, facial expressions, and vocal emotions in response to various instructional materials and emphases. From the perspective of internationalization, the exchanges in economy, culture, and other aspects of the world are deepening. Therefore, there are higher requirements for Chinese people’s intercultural and intercultural communication skills. English is the most common language in the international market. In China, the majority of universities set English as a compulsory course for students’ future development in the world, so as to improve students’ English level and enhance their ability to communicate in English. As an additional language course, English requires students to spend a lot of time learning basic vocabulary and sentences and applying them in daily life communication. However, it is challenging for students to express more specialized and special usages through word selection, sentence combination, and the use of the culture hidden behind the language . ForeignEmotion recognition  is consiWith the vigorous development of information technology , there iThe rest of the paper is arranged as follows: the second part describes the work related to emotion recognition of foreign language teachers; the third part presents the analytical method and experimental results; the fourth part discusses the results; and, in the fifth and last part, we put forward the research conclusions, limitations and possible future research directions.In the field of teaching, emotion recognition is often used to test students’ learning effect. For example, in the virtual teaching environment, Voice is an important part of emotion recognition. Teaching emotion recognition is an important research field in emotion recognition. According to the above literatures, teachers can adjust teaching methods and strategies by identifying students’ emotions. This provides theoretical reference for our research. Accordingly, can teachers adjust their teaching methods according to students’ identification and evaluation of teachers’ emotions? However, there are relatively few studies from this perspective. And, this is a question worth thinking about in college English courses. Because when students are faced with difficulties in learning a second language and communication barriers with foreign language teachers, foreign language teachers can help students to obtain better learning results by adjusting the expression forms of emotion recognition.Combined with literature research and practical investigation, we identify four factors of emotion recognition in college English classroom teaching. They are facial expression, voice mood, physical gestures, and body movement, as shown in In order to explore the influence of different factors on emotion recognition of foreign language teachers, we choose AHP as the main research method. AHP is a decision-making and selection method, which combines qualitative and quantitative research. This method is generally used to solve complex multi-objective decision issues. It takes the form of expert scoring by comparing different factors in pairs. Then calculate the influence weight of each factor according to the collected data.At present, the AHP is widely used in the research on the weight analysis of influential factors. For example, Based on the influencing factors of foreign language teachers’ emotion recognition identified above and the principle of AHP, we constructed an emotion recognition model of foreign language teachers in college English classroom teaching, as shown in After the model was built, YAANP software was used as a research tool and a questionnaire was designed, as shown in Students that match the following criteria are chosen to participate in the survey: (a) students who have taken 1-year college English courses and (b) the students’ foreign language teacher is a foreigner who speaks English as a first language. Questionnaires were sent by mail to students who met the requirements. The subject of the email is to evaluate the influence of four factors of foreign language teachers’ emotion recognition on the improvement of students’ learning effect in college English class. Finally, after half a month, 14 questionnaires were collected, in which the names and schools were replaced by numbers in the questionnaires.We imported the collected questionnaires into YAANP software. Furthermore, the consistency of the questionnaire data is tested. The results showed that two of the 14 questionnaires collected failed the consistency test (CR>0.1). Thus, we have a total of 12 valid data sets (CR<0.1). The original data we obtained are shown in In YAANP software, we used arithmetic average to process the 12 valid questionnaires collected. The judgment matrix of the target layer and criterion layer of emotion recognition of foreign language teachers in college English classroom teaching calculated by us is shown in According to the judgment matrix data in The vast majority of human communication is closely related to emotion recognition. For example, facial expressions, gestures, body posture, and tone of voice can reflect people’s emotions to a certain extent, thus affecting communication. More and more scholars are attaching importance to the research of emotion recognition in teaching application.Through literature analysis, this study identified four specific factors affecting the emotion recognition of foreign language teachers in college English classroom teaching, which are facial expression, voice mood, body movement and physical gestures. Then, we use the AHP and YAANP software’s group decision calculation method to determine the weight of the influence of each factor of foreign language teachers’ emotion recognition on students’ learning effect. Data analysis results show that when foreign language teachers take body movements in college English classroom teaching, they have the greatest influence on students’ learning effect, accounting for 43% of the emotion recognition. Facial expressions are much easier to regulate and control than voice mood. In this study, the facial expressions of foreign language teachers have 28% impact on students’ learning effect during the teaching process. The influence degree of voice mood on students’ learning effect was 21%. Finally, the teacher’s physical gesture had the least impact on students’ learning outcomes, at just 8%. The findings add to the body of knowledge on emotion recognition among college English teachers. In addtion, this study can assist students in improving their grasp of course content based on the emotions of foreign English lecturers.In order to ensure a high level of college English classroom teaching and improve the quality of teaching, foreign language teachers need to reasonably adjust the factors of emotion recognition to provide students with a better English classroom experience. First, from the above data analysis results, it is not difficult to find that body movements play an important role in the emotion recognition of foreign language teachers. Teachers should reasonably use interactive actions to create body context and guide students to understand complex language and the culture contained in language according to the teaching content and focus in class. This can help students to better understand the knowledge in class. For example, when explaining travel-related knowledge points, foreign language teachers can describe the differences between Chinese and foreign countries in taking taxis through body language. Chinese hail taxis by waving their hands. However, in parts of the United States, the thumbs-up is the correct gesture for getting a taxi. This teaching method can help students to enter the teaching situation faster and to better understand the teaching content.Second, we suggest that foreign language teachers interact with students through expressions such as eyes and smiles, so as to reduce the sense of distance with students. In the classroom, a teacher with a serious face tends to increase the sense of distance with students. Further, it will have a negative impact on the initiative of communication between students and teachers. A teacher who smiles and often makes eye contact with students will be more popular. In this teaching environment, students’ interest in learning and love for college English courses will be improved.Finally, voice mood can help students to establish associations . For theEnglish is a compulsory course for most Chinese college students in their first and second years. In order to improve the teaching quality, more and more schools choose to hire foreign teachers to teach English courses. However, the differences in teaching methods, teaching environment and classroom teaching habits between China and foreign countries inevitably cause difficulties for students in communicating with teachers and receiving knowledge. In order to reduce the barriers between teaching and learning, this paper studies the factors of emotion recognition of foreign language teachers in college English teaching. Through literature analysis, we believe that the influencing factors of foreign language teachers in emotion recognition include interactive action, facial expression, voice emotion, and body posture. In our opinion, in the teaching process, teachers can adjust the four factors of emotion recognition to achieve better teaching effect. The data analysis results show that the weight proportion of the four factors on students’ learning effect is body movements (43%), facial expression (28%), voice mood (21%) and physical gestures (9%). English courses play an important role in college courses. How to make students learn English better and improve their English scores is the focus of many colleges and universities. Therefore, we suggest that foreign language teachers should reasonably adjust their interactive behaviors, facial expressions and vocal emotions in college English classes according to different teaching contents and teaching emphases. This can improve students’ sense of immersion in class, so that students are better engaged in learning.It is worth noting that part of our research has not been fully considered, and there are many aspects that need to be further explored and analyzed. First, in terms of the influence of foreign language teachers’ emotion recognition on students’ knowledge mastery, our study ignores the differences between English majors’ learning in compulsory English courses and students’ learning in general English courses. Whether there is a difference between the two and how big the difference is, these are questions worthy of further study. Second, we consider four factors of foreign language teachers’ facial expressions, voice mood, body movements, and physical gestures, but the subdivision of each factor is also important. For example, sound includes speed, pitch, amplitude, etc., and it is also worth further studying to what extent these sub-factors influence foreign language teachers in college English classroom teaching. Third, our overall sample size is small, so we can increase the sample survey in the future. Finally, the interaction between the factors and the relationship between them and teacher’s emotion recognition is also worth discussing.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.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.LL was responsible for designing the framework of the entire manuscript from topic selection to solution to experimental verification.The author declares 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.


The HIV epidemic in the Philippines is one of the fastest growing epidemics globally, and infections among men who have sex with men are rising at an alarming rate. The World Health Organization recommends the use of mobile health  technologies to engage patients in care and ensure high levels of adherence to antiretroviral therapy (ART). Existing mHealth interventions can be adapted and tailored to the context and population served.This study aims to create a locally tailored intervention using a mobile phone platform to support treatment adherence for HIV patients on ART in the Philippines.A mixed methods approach guided by the Behavior Change Wheel framework was used to adapt an existing mHealth adherence support platform for the local setting and target population. A literature review, retrospective clinical record review, and focus group discussions with patients were conducted to understand the drivers of ART adherence and tailor the intervention accordingly. The resulting intervention was pilot-tested for 8 weeks, followed by focus group discussions with patients who received the intervention to assess the acceptability of the design.Key issues contributing to nonadherence included side effects, lack of behavioral skills for pill taking, social support, mental health, and substance use. Patients identified mHealth as an acceptable mode of intervention delivery and wanted mHealth services to be highly personalizable. The study team, clinicians, and software developers integrated these findings into the intervention, which included a menu of services as follows: pill reminders, health tips, adherence feedback, appointment reminders, and symptom reporting. During the pilot phase, technical issues in the interactive voice response system (IVRS) were identified and addressed. Patients who participated in the pilot phase expressed a preference for SMS text messaging over the IVRS. Patients responded positively to the appointment reminders and health tips, whereas patient feedback on daily and weekly pill reminders and adherence feedback was mixed.The mobile phone–based SMS text messaging and IVRS intervention was acceptable to men who have sex with men in Manila, the Philippines, and qualitative analysis suggested that the intervention helped promote ART adherence and appointment attendance. The Philippines has the fastest growing HIV epidemic in the Asia-Pacific region -3. NatioThe group most impacted by HIV in the Philippines is men who have sex with men (MSM), representing 84% of new diagnoses since 2015. The median age of new cases is 28 years, and >80% of people living with HIV/AIDS in the Philippines are aged <35 years . In 2015As the burden of HIV increases, it is imperative that as many HIV-infected people as possible are diagnosed, started on treatment, and successfully retained in care. Achieving adequate viral suppression through the use of antiretroviral therapy (ART) will be one of the key tools in ending the HIV epidemic in the Philippines. Unfortunately, widespread stigma, lack of knowledge, and barriers to accessing care pose a challenge to engaging patients in testing and ensuring high levels of adherence to ART and retention in care ,10,11. AEvidence-based public health interventions are required. However, a 2015 report by the World Health Organization highlights that the body of HIV research conducted in the Philippines has been limited , and a sAs mobile phone technologies have become widespread in low- and middle-income countries, mobile phone interventions have become increasingly popular in the global health and development sectors as a potentially inexpensive and efficient way to communicate with and deliver services to people.Mobile phones are multifunctional tools that can be used for a variety of functions that range from simple alarm functions, SMS text messaging, calls, interactive voice response systems (IVRSs), and complex apps and games. People usually have their mobile devices with them; therefore, using mobile technologies allows the timing of the intervention delivery to be synchronized with the most relevant time to claim the attention of the recipient . MoreoveIn the Philippines, 99% of the population is reached by mobile cellular network coverage and mobile phone use is among the highest in the world, with 155 mobile connections per 100 people ,18. AlthThe 2016 World Health Organization Consolidated Guidelines on the Use of ART for the Treatment and Prevention of HIV Infection promoted the use of SMS text messaging to improve adherence to therapy .Mobile phone interventions have proven successful in improving ART adherence in Africa, South Asia, and Latin America -28. SeveP=.006). Suppressed viral loads were reported in 57.1% (156/273) of patients in the SMS text messaging group and 48.3% (128/265) of patients in the control group  . In. In45]. What conditions internal to individuals and in their social and physical environment need to be in place for a specific behavioral target to be achieved? On the basis of the formative research findings, the components of capability, opportunity, and motivation that interact to account for behavior in the BCW approach were summarized [The first stage of intervention development is to understand the behavior. In this case, the specific target behavior is optimal adherence to ART, defined as taking at least 95% of the prescribed ART doses on time. To understand behavior, the BCW approach starts with the question, mmarized -45. UsinThe second stage of intervention development in the BCW model is to identify the intervention options. In this case, we planned to use an mHealth platform that would be tailored to the setting and population.The third stage is to identify the content and implementation options, including BCTs and mode of delivery. To better understand the most appropriate BCTs, we referenced the BCW taxonomy of BCTs  and IMB The intervention services were tailored based on input from the IMB skills model, input by SHIP patients during FGDs, and information from clinical service providers at the study site. The study team and clinicians worked together to write 210 health tips, script the reminder messages, and map the call flows. The lead clinic physician created a symptom-reporting algorithm. A local voice talent agency was engaged to record the content. From 2015 to 2016, SHIP staff worked with internet technology specialists and public health professionals from the study sponsor Janssen Global Public Health to adapt the Connect for Life platform for use at the SHIP clinic. Connect for Life is a technology built on the Mobile Technology for Community Health (MOTECH) open-source software platform . It enabThe platform has the following functionalities: pill reminders, visit reminders, symptom reporting, health tips, and adherence feedback messages. The study team collaborated with clinic physicians and software developers to adapt the various functions of the Connect for Life platform to align with the needs of the patients, as documented in the formative research phase.During the first 8 weeks of piloting the intervention, 62 patients were enrolled in the study. These patients received adherence reminder calls and health tips and reported their adherence via IVRS. During this pilot test phase, the feasibility and acceptability of the intervention were analyzed before moving to a larger scale implementation phase.To assess the feasibility of the intervention, use data from the Connect for Life platform were analyzed. This included the number of calls generated from the platform, the number of calls answered by the participants, and the outcomes of those calls.To assess acceptability, 2 FGDs were held to assess user experience. All eligible study participants were invited to participate in the focus groups, of which only 5 agreed to participate in a FGD (the major barrier to participation in these FGDs was the difficulty of transport owing to the traffic congestions in Metro Manila). Participants discussed their experience with Connect for Life; their reactions to the reminders, health tips, and adherence feedback; their feedback on the call length and call frequency; and their suggestions for improving the system.Globally, approximately 40% of patients report suboptimal adherence to ART ,54. In tSeveral key factors influencing ART adherence are well documented in the literature, including medication side effects, substance abuse, presence of social support, and time spent on treatment ,28,54-57On the basis of the pharmacy refill forms for SHIP clinic patients, 67.7% (317/468) of patients reported perfect adherence in the 30 days before their most recent refill, 31.8% (149/468) reported suboptimal adherence <100%, and 20% (94/468) reported adherence <95%. A retrospective review of pharmacy refill data is summarized in We also conducted FGDs with 1.8% (12/682) of the participants regarding their adherence challenges. All participants were male, 75% (9/12) were homosexual, 25% (3/12) were bisexual, and 67% (8/12) had full-time employment. The time patients had been on ART ranged from 5 months to 6 years, with a median time of 4 years. Overall, 83% (10/12) of the participants reported that they sometimes forgot to take their medications and 42% (5/12) had missed a dose within the past 2 weeks.FGD findings on the causal factors for ART adherence are summarized in The intervention services were tailored based on the input from SHIP patients and clinicians during formative research.On the basis of the formative research findings, the various components of the COM-B framework were summarized, incorporating the aspects of the IMB skills model of adherence .The focus group findings suggested that mobile phones would be an acceptable mode of delivery for HIV interventions targeting young MSM in the Philippines. During the FGDs, participants provided detailed input about the acceptability of various intervention aspects, including pill reminders, health tips, visit reminders, adherence feedback, and symptom reporting.Patients reported that they would like mHealth services to be personalizable. For example, patients requested to be able to select whether they receive pills and visit reminders via SMS text messages or via calls, as well as to determine the frequency and the time of the day that they receive reminders. Participants believed that newer patients who recently started ART would benefit most from daily pill reminders and experienced patients would prefer less frequent reminders. They stated that it would be important to be able to opt in or out of any call or SMS text messaging services at any time.Patients expressed a strong interest in health tips that covered a variety of topics, not strictly HIV disease, and they wanted to personally select which categories of health tips they would hear.In summary, patients suggested that an ideal mHealth service should be personalized based on the following factors: (1) call or SMS text messages, (2) timing of calls or messages, (3) frequency of calls or messages, and (4) content or topic areas for health education messages.pill reminders for all patients. As focus groups and literature review suggested that more intensive adherence support is required in the early stages of HIV treatment while forming of habits, ART-naïve patients and patients in their first 24 weeks of ART received reminders daily for the first 24 weeks and weekly for the next 24 weeks. Patients who were experienced with ART received weekly reminders for 24 weeks and no reminders after 48 weeks.The investigators created a standard service scheme  that coureport symptoms or side effects of medications using an IVRS touch-tone menu. The patients received SMS text message recommendations for over-the-counter medications and advice depending on the algorithm outcome. The system automatically generated an alert for the clinician of any symptom reports that required urgent attention.During IVRS pill reminder calls, patients were prompted to appointment reminders at 2 set times in advance of their scheduled clinic visit date.All patients received SMS adherence feedback message informing them of their score—from 0 to 7—based on the number of days they reported taking their doses in the prior week via the IVRS platform. The adherence feedback score was followed by a short motivational message to encourage improvement among patients with low adherence or support continued good adherence among patients with high adherence scores.All patients who received IVRS calls for their pill reminders could receive a weekly health tips when they received pill reminder calls, or they could opt to receive health tips via SMS text messages. For patients new on ART, there was a tailored set of health tips that explained the basics of HIV and ART. In addition, we created tips on a variety of other health topics based on the suggestions of patients from the FGDs. The following five broad categories were selected for health tips: (1) HIV disease and treatment, which include tips about HIV testing and diagnosis, transmission of HIV, coinfections, and laboratory tests for people living with HIV; (2) fitness, nutrition, or lifestyle, which included tips for exercise and eating healthy; (3) mental health or well-being, which included tips on acceptance and disclosure of HIV status, and approaches for understanding and dealing with depression, anxiety, and stress; (4) drug use and harm reduction, which included medical information about common recreational drugs, safer injection, and hepatitis C; and (5) sexual risk reduction, which included tips on condoms and lubricants and tips on leading a healthy sex life with HIV.Patients would automatically receive audio The investigators worked with 2 clinic providers and a local voice talent agency to write and record 210 health tips that related to the common questions and issues raised by patients and tips that incorporated the themes that emerged from the focus groups. The messages were crafted ensuring that they not only provided didactic information related to the health topic but also ended with a specific action or behavior that the patient could adopt to improve or to minimize the impact of a specific behavior.jingle, a song that was associated with the Connect for Life system. Upon hearing the jingle, they would enter a personal identification number to advance to the next step of the call. No health-related information would be transmitted unless the personal identification number was keyed in, to protect patient privacy and confidentiality.The system was configured to protect patient privacy and prevent unintended disclosure of health information. Upon answering any call from the system, the patient would immediately hear a Services in the intervention package address the 3 main components of the COM-B model. Capability is addressed through health tips, which aim to improve knowledge regarding ART and HIV disease and improve behavioral skills. Opportunity is addressed through the pill reminder service, which provides an external prompt or cue for pill taking and supports habit forming through the appointment reminder service, which prompts attendance at the clinic for refill, thereby increasing accessibility and availability of medications; and through the symptom-reporting algorithm, which addresses the medical barriers to pill taking by expediting a response to side effects or medication reactions. Motivation is addressed through health tips  and adherence feedback messages, which reward and reinforce high adherence and encourage improvement for low adherence.A pilot test phase was conducted from October 2017 to January 2018, in which 62 patients were enrolled in the service. During the pilot test period, we received reports of several technical issues that affected the functionality of the system. In all, 2 FGDs were held in January and February 2018, after approximately 3 months of the pilot project implementation. There were 5 participants—3 in one discussion and 2 in the next. FGD findings on the themes that emerged from the pilot test are summarized in On the basis of the findings from the pilot phase FGDs, enrollment in the study was suspended because of pending solutions to technical issues. The study team worked with software developers to trace the source of the technical issues. It was determined that the platform was functioning well and that the technical failures were because of issues within the local telecommunications infrastructure . After the team addressed all the technical issues on the software development side, enrollment continued with SMS text messaging services only.Since mid-2019, we have found that as telecom services improved in the Philippine setting, voice calls in the Connect for Life system can now be delivered with fewer technical issues. Following the initial pilot study, the intervention was scaled up at the SHIP clinic and currently serving 1491 patients at 2 HIV clinics. The platform is being further developed to move from the MOTECH base to open medical record system. We plan to pilot test the new version in several HIV treatment sites across the Philippines.The intervention development approach resulted in an mHealth intervention tailored to the information needs and communication preferences of MSM in the Philippines. The intervention was designed to address various aspects of capability, opportunity, and motivation to achieve optimal adherence to ART.The formative research found that mobile phone use is widespread in the Philippines and that mobile phones are an acceptable mode of communication for health information and adherence support. The literature review and FGDs revealed that in our patient population, key behavioral barriers to adherence included challenges around forming consistent routines and habits, low social support, stress and mental health issues, substance use, and social stigma of living with HIV. Focus group participants strongly emphasized the need for social and family support to enable and encourage good adherence to ART. Key clinical issues affecting adherence included medication side effects  and shorter duration on ART.Following the pilot test, recipients of the intervention reported that the tone, frequency, and content of the voice messages were acceptable and appropriate. In the prepilot focus groups, participants preferred the male voice actor whose voice sounded more “attractive” according to several participants, whereas in the postpilot groups, several participants mentioned that they preferred the female voice actor because her tone was warmer and she came across as a trusted friend. This finding indicates that more iterations of recording should be tested in future implementations before a full-scale roll out and that budgets and project work plans should allow for several rounds of recording. The accounts of the focus group participants indicated that the intervention increased their knowledge and adherence behaviors. However, a large-scale cohort is needed to assess the intervention’s effectiveness.In the prepilot focus groups, participants were enthusiastic about receiving voice reminders via phone calls, following their experience of participating in the pilot most participants expressed a preference for SMS text messaging over voice calls. This preference may have been related to the inconvenience of answering phone calls, and it may also have been related to the technical problems experienced with the IVRS. These technical challenges posed a significant challenge to the feasibility of the intervention, and delivery would need to be adapted to allow for SMS text messaging options to achieve full-scale implementation.The strength of the intervention development process was the participatory approach, which included the beneficiaries or users of the potential intervention, clinical service providers, and developers of the technology platform. The views of the target audience were collected during focus groups, which informed the tone, style, frequency, duration, and content of the intervention.The BCW is a robust intervention development approach that provides a comprehensive understanding of the sources of a behavior, spectrum of intervention functions, and environment in which the behavior occurs. A strength of this approach is the COM-B model at the hub of the BCW. By identifying the capabilities, opportunities, and motivations behind a behavior, we can clearly identify the most relevant intervention approaches and BCTs. This approach allowed us to develop a solid intervention plan that described the technique, mode, and content to address each identified barrier to or enabler of ART adherence.out as people living with HIV, indicating that individual interviews may be an option in future studies. The patients who agreed to participate may not be representative of the wider patient population, introducing a degree of selection bias to the process. The study only included patients >18 years and the patients were almost exclusively male; thus, the findings do not address the distinct needs and challenges of adolescents and women living with HIV. In addition, there was low attendance among those who confirmed their intention to participate in the focus groups. This is reflective of the larger need to provide differentiated models of care in the Philippines, as transportation to the clinic site is not easy in Metro Manila because of traffic congestion.A weakness of our approach was the sampling and recruitment strategy for the participants in the focus groups. It was a challenge to identify patients who were willing to participate in a group where everyone had a HIV-positive status because many patients were not publicly Another weakness of our approach was that we had an intervention mode in mind—mobile phone—at the outset of the intervention development process. Although there are several key determinants of adherence that the Connect for Life platform can address , there are other factors that the mHealth approach does not address .Notably, the technical challenges experienced in delivering the intervention during the pilot phase made it difficult to assess the true acceptability and feasibility of the planned intervention. Feedback received after the pilot phase focused largely on the mobile phone functionality issues, which then limited the discussion regarding the content and design of the intervention as it was intended to be delivered. Conducting a small pilot phase with a few participants allowed us to identify the problems with functionality and adapt the intervention before scaling up the intervention to the larger cohort; however, a more iterative process with several pilot stages would have been advantageous if budget and timeline had allowed us to do so.treatment fatigue [Research on ART adherence has shown that less time on ART is associated with an increased risk of poor adherence ,65-67. W fatigue . This hiBefore this study, 2 other projects using the same technology that the Connect for Life program was built on were implemented and evaluated in India and Uganda. First, a program called Treatment Advice by Mobile Alerts (TAMA), provided people living with HIV in India with daily or weekly pill reminders, adherence feedback, automated algorithms for managing clinical events for patients being initiated on ART, health tips, appointment reminders, and real-time reporting to the clinics of patient interaction with TAMA. Evaluation of the TAMA pilot found that patients gave the platform a high system usability score and gave generally positive feedback about their experience with using the technology. In TAMA, patients could call a toll-free number to access health tips and a clinical event algorithm. Health tips were used by 76% (42/55) of the patients, and automated clinical advice was accessed by 64% (35/55) of the participants in the pilot study. In the Philippines, these functions were available only through outgoing system-generated calls and SMS text messaging because of the prohibitive cost of toll-free inbound telephone lines in the Philippine setting ,69.The second project, the Call for Life Uganda program, also found good uptake, acceptability, and positive response to the system. In Uganda, there was a strong preference for interactive voice response over SMS text messages, which was different from the Philippines where participants preferred SMS text messages ,71.Our research found that a mobile phone–based SMS text messaging intervention and IVRS intervention were acceptable to MSM in Manila, the Philippines, and the FGDs suggested that it helped promote ART adherence and appointment attendance. A randomized controlled trial is required to establish the effects of the intervention on the clinical outcomes of HIV care and treatment.


An infodemic is an overflow of information of varying quality that surges across digital and physical environments during an acute public health event. It leads to confusion, risk-taking, and behaviors that can harm health and lead to erosion of trust in health authorities and public health responses. Owing to the global scale and high stakes of the health emergency, responding to the infodemic related to the pandemic is particularly urgent. Building on diverse research disciplines and expanding the discipline of infodemiology, more evidence-based interventions are needed to design infodemic management interventions and tools and implement them by health emergency responders.The World Health Organization organized the first global infodemiology conference, entirely online, during June and July 2020, with a follow-up process from August to October 2020, to review current multidisciplinary evidence, interventions, and practices that can be applied to the COVID-19 infodemic response. This resulted in the creation of a public health research agenda for managing infodemics.As part of the conference, a structured expert judgment synthesis method was used to formulate a public health research agenda. A total of 110 participants represented diverse scientific disciplines from over 35 countries and global public health implementing partners. The conference used a laddered discussion sprint methodology by rotating participant teams, and a managed follow-up process was used to assemble a research agenda based on the discussion and structured expert feedback. This resulted in a five-workstream frame of the research agenda for infodemic management and 166 suggested research questions. The participants then ranked the questions for feasibility and expected public health impact. The expert consensus was summarized in a public health research agenda that included a list of priority research questions.The public health research agenda for infodemic management has five workstreams: (1) measuring and continuously monitoring the impact of infodemics during health emergencies; (2) detecting signals and understanding the spread and risk of infodemics; (3) responding and deploying interventions that mitigate and protect against infodemics and their harmful effects; (4) evaluating infodemic interventions and strengthening the resilience of individuals and communities to infodemics; and (5) promoting the development, adaptation, and application of interventions and toolkits for infodemic management. Each workstream identifies research questions and highlights 49 high priority research questions.Public health authorities need to develop, validate, implement, and adapt tools and interventions for managing infodemics in acute public health events in ways that are appropriate for their countries and contexts. Infodemiology provides a scientific foundation to make this possible. This research agenda proposes a structured framework for targeted investment for the scientific community, policy makers, implementing organizations, and other stakeholders to consider. A pneumonia of unknown cause detected in Wuhan, China, was first reported to the World Health Organization (WHO) Country Office in China on December 31, 2019. The disease, caused by a novel coronavirus (SARS-CoV-2), was subsequently named COVID-19, and it was declared a Public Health Emergency of International Concern on January 30, 2020. On March 11, 2020, the WHO characterized the outbreak as a pandemic. Globally, as of August 23, 2021, 211,373,303 confirmed cases of COVID-19, including 4,424,341 deaths, had been reported to the WHO [On February 15, 2020, WHO Director-General Tedros Adhanom Ghebreyesus raised the concern that the epidemic was accompanied by an infodemic . An infoThe International Health Regulations 2005) list risk communication as one of eight core capacities that WHO Member States need to build and sustain as part of a global agreement to strengthen national and global systems to detect and respond to public health threats  list ris. ExperieOverall, health emergencies give rise to information overload, which has been shown to influence people’s behavior, risk perception, and protective actions during health emergencies  and subsAlthough rumors and health misinformation have been around for as long as diseases, today’s environment is different. The COVID-19 infodemic has been an unprecedented challenge because we are experiencing an epidemic in a digitized globalized society. Digital tools and technologies have not only changed the way we communicate but have also changed our lives, altering the way we live, work, interact, and build our social identities and sense of community. For example, rumors and information have travelled across borders very quickly and influenced traditional media news cycles and coverage, emotive misinformation travels much more quickly across the digital media than fact-based health information, and epidemic control decisions or controversy in one country can cause debate and comparison with responses in other countries [This infodemic has placed strain not just on how to communicate the evolving scientific knowledge but also on how public health authorities can implement a nimbler pandemic response that addresses the needs and concerns of local communities. During the COVID-19 response, health authorities have faced full-on the changed information and communication ecosystem  and its Computational amplification of polarizing messages over factual ones, and use of bots and cyborgs to manipulate the outcome of online petitions, change search engine results, and boost certain messages on social media;Widespread microtargeting of social media users that is enabled by the social media and search engine platform business models, putting individuals into their own personalized “information bubbles”;Changed practices in TV and radio newsrooms that enable dissemination and amplification of poor-quality information that originates online;Weakened local media and collapse of local journalism, which have enabled mis- and disinformation to take hold.information disorder) are major and growing challenges, not only for emergency response but also for other societal actions [In response to the infodemic, health authorities have needed to build partnerships beyond their usual networks—with fact-checkers; broader groups of media and journalists; social media, search engines, and digital interaction platforms; community organizations; civil society; and others. However, there is still room for improvement based on experience from the COVID-19 response. For example, although fact-checking organizations are relatively mature worldwide, half of them do not work with health professionals when fact-checking and debunking health-related claims, leaving room for better collaboration with health authorities and medical associations . Moreove actions .Because of these challenges, the COVID-19 infodemic is not only a communication challenge but a challenge for the whole information ecosystem. Already at the beginning of the COVID-19 pandemic in April 2020, the WHO had crowdsourced a framework for managing infodemics that calls for whole-of-society involvement and response . This frBetween June and October 2020, the WHO Information Network for Epidemics (EPI-WIN) organized a global online technical conference followed by an asynchronous expert review exercise to develop a public health research agenda for infodemic management ,13-17. TThe research question prioritization exercise was designed in line with the WHO research agenda development guide for staff . Held inThe 110 invited participants represented over 35 countries across 19 time zones, with a 56% to 44% gender split in favor of women . They were academics selected by the organizers for the relevance of their publication record in the past two years for the purpose of this consultation, or practitioners who were working in pandemic response. A total of 60 additional invited academics were not available to participate. The conference participants represented 20 different academic and professional fields, such as digital health, computer science, communications and graphic design, media studies and journalism, history, applied mathematics, information science, data science and computational social sciences, complexity science, social and behavioral sciences, ethics, governance, marketing, and user experience and design; they were joined by colleagues from the fields of risk communication and community engagement, epidemiology, and public health, as well as by global public health implementing partners. Conflicts of interest were reviewed in accordance with WHO procedures for the management of declaration of interest for expert consultations . The conThe meetings took the format of plenary sessions at the beginning and end of the conference and an in-between working session with four discussion sprints. Each participant was engaged in the meeting process for 18 hours (10 hours in plenary and 8 hours in topic discussions). Participants were split into four teams, grouping by similar time zone location but ensuring academic and practitioner diversity of the teams. Each team met four times for 2-hour “sprint sessions” of intense discussion on one of four topics, led by dedicated “topic masters” (scientific facilitators). The topic masters were scientists established in their scientific disciplines; 7 were academics employed by universities, and 1 was a WHO staff member with an academic affiliation. As the teams rotated from topic to topic, the topic masters facilitated discussions to collect insights from the discussion and validate expert opinion they had collected from discussion with preceding teams. By the end of the process, each team had discussed each topic, and each topic was discussed with four teams in an additive fashion—a total of 32 sprint hours of expert discussion.The discussion sprints were oriented around four topics that mirror the epidemiological method for outbreak detection and management across the phases of the epidemic curve, enabling the actions of “preparing, monitoring, detecting, intervening, strengthening, and enabling” infodemic management. The topics were (1) how to measure and monitor digital and physical information environments; (2) how information originates and spreads; (3) how information affects individuals and populations; and (4) what interventions work to protect and mitigate against mis- and disinformation. By the end of the working session, a frame for a research agenda emerged based on the feedback from all the team discussions, seeded with draft research questions that were identified by the discussion facilitators.In addition, the facilitator leaders of each of the four discussion streams at the conference summarized the discussions they had with all four teams of participants. Their reports summarized discussions about the main suggested research questions for the research agenda as well as enablers and challenges to researching them. This initial collected set of research questions became the basis for the follow-up process after the conference.After the virtual conference, the same participants were led through a 3-month asynchronous structured exercise that aimed to collect and rank research questions and to guide the participants toward a refined research agenda. In the exercise, structured expert judgment was collected through an adapted Delphi consultation using the Investigate Discuss Estimate Aggregate (IDEA) protocol . The metA list of candidate research questions was built by combining the questions that were proposed by the topic facilitators based on the discussions at the conference and those that were collected through the survey round after the conference. The collected candidate research questions were assessed for topic overlap and scope, and they were edited and merged for clarity by three reviewers. The three experts were present in the discussions during the conference and are coauthors of this paper. Two are staff members of health authorities, and one is an academic. This reduced the questions to a consolidated list that was used in the research question ranking exercise.The questions in the consolidated list were then anonymously scored and ranked through another exercise using the LimeSurvey platform . There, To reduce potential survey fatigue and to avoid systematic missingness in the rankings , the order of the research questions to rank was randomized within each research stream. The randomization was conducted via the LimeSurvey platform. Following the ranking exercise, four experts reviewed the questions that fell outside the prioritization area—below the 3.5 consensus impact rank and with feasibility of >1 year. The four experts were three researchers that had previously reviewed the submitted research questions, with an additional staff member of a health authority who was not a coauthor on this paper. The fourth health authority staff member was added because the research agenda questions were meant to be feasible in a short time frame or highly important to the health authority response to the infodemic. The experts reviewed the questions outside the cutoff and, on consensus, they identified prerequisites or parts of these research questions that could be delivered with quicker feasibility and high public health impact. These research components were added to the research agenda as research questions.This exercise reduced the number of questions to a shortlist of top priority and second tier priority questions per work steam, totaling 49 priority research questions. The remaining questions that were part of the exercise and did not make the prioritization cutoff were retained for reference, and they can be used for future reviews. The results of the recursive refinement of research questions through structured expert judgment exercise are summarized in The discussion at the virtual conference reflected the complexity of the information ecosystem and the way it influences the strategies for managing the COVID-19 infodemic and other infodemics to support health behaviors and the management of epidemic risk. Several themes surfaced in the topic discussion sprints, as follows:A common theme across discussions was that it is necessary to identify reproducible patterns and crossdisciplinary metrics for the science of infodemiology. Because access to full data sets from social media is rare and they do not represent the engagement of all populations, and because metrics vary from platform to platform, it is difficult to produce generalizable or comparable results. Mathematical modeling, such as epidemiological modeling, does not necessarily take human behavior into account, which can limit its efficacy to predict future human behavior and the impact thereof on an outbreak; however, modeling can aid the development of hypotheses for how information/infection flows, how networks might respond, and how interventions should be designed to test them. There are also limits to applying the epidemiological framework as a way to monitor and measure spread, especially if we assume that the unit we are working with is information instead of a virus, because viruses do not have an agenda and they infect opportunistically. Detangling the differences between rumors, misinformation, and disinformation requires a common taxonomy of information classification, some of which may be labelled as more harmful or less harmful. This could inform identification of the “tipping points” or when action needs to be taken to address more harmful misinformation by offering a more tailored and effective response.Although it is important to describe the flow of health information, there needs to be a balance between a system-level understanding that “washes over” details and a case-study understanding that captures details but may miss the “bigger picture.” Substantial amounts of social and behavioral and health data are available; however, determining which data sources and types of analyses would improve a response needs a clearer definition. The degree of detail is needed to understand the infodemic while balancing privacy and ethical concerns, and managing limited analytic capacity in short time frames should be discussed. Amid a pandemic, speed is of the essence, and balancing rapid data collection and analysis methods with the desire for rigor may mean prioritizing specific kinds of data for short-term operational use versus longer-term, longitudinal trend analysis and use. Understanding the diffusion of information through certain networks may require other data collection approaches and discussion of how closed messaging apps and offline networks challenge this.One area of research that needs further study is the extent to which offline behavior is being influenced by online behavior (and vice versa). There is limited research on how exposure to information or misinformation affects behavior because behavioral processes can be quite complex. Amid a crisis, people might use cognitive shortcuts and rely on the first information they hear; also, they may be less adept at processing more complex information. At the same time, there is little known about the longitudinal effects of the exposure to false claims that may not seem harmful at any one point in time but could have a cumulative harmful effect over time. In addition, when misinformation is easy to spread, this can create a harmful mixture. Anecdotal evidence suggests that people can exhibit negative health behaviors because of misinformation they heard during the COVID-19 outbreak; however, we need better measures of how knowledge connects to intent and behavior, both online and offline. For example, does increased exposure to misinformation make it more likely that someone will exhibit a behavior that is detrimental to their health? Further research is needed to develop better monitoring metrics, in addition to consolidated and validated indicators that predict behaviors or serve as proxies for specific behaviors.The participants also emphasized that there is an interplay between information ecosystem actors and the resilience of communities and individuals. It was agreed that trust is a key element of building resilient communities. This leads to the need to establish and maintain trustworthy information sources. Some work must be done to identify these sources of information and to ensure easy and equal access. The discussions also highlighted the urgent need to empower communities to manage infodemics and build resilient communities through co-designed interventions. This would be made possible by understanding the context in which infodemics occur and spray. Community engagement goes along with building self-efficacy and self-capability through practice. It should focus on the “middle ground,” as in, the majority of “silent lurkers”—those who have not yet formed strong opinions. Besides individuals, communities, and states, members of the private sector should be regarded as actors. Internet platforms can be active vectors or targets of campaigns and can also be influential members of communities.When considering long-term interventions, critical thinking and literacy  play important roles as a basis for interventions to address infodemics. Health literacy is a major topic in health communication research and practice. It includes critical literacy as the ability to evaluate and apply health information, and it is considered a major asset in managing an infodemic. Similarly, information, news, digital, and media literacies contribute to individuals’ ability to distinguish high- from low-quality information, especially online, and to the ability to improve their offline lives through digital technology use. Research into each type of literacy has developed in isolation, and questions remain on how to empower populations to think critically; what normative models of thinking are most appropriate for an infodemic; who is responsible for building literacy; and how literacy efforts can be integrated into existing societal systems  and be adapted to reach populations outside of the traditional educational settings.To help prioritize interventions and actions, it is also necessary to identify priority populations based on key vulnerabilities. Population studies need to be conducted to identify specific individuals and groups of individuals who are at the greatest risk of not being able to critically assess misinformation and of spreading it. This approach should include studying people’s perceptions, beliefs, and knowledge, as well as the barriers and facilitators that can affect the access to and evaluation of credible health information as well as its use in offline life. Additionally, the alignment of information vulnerabilities with disease vulnerabilities should be considered.In addition to reviewing the current evidence and research gaps across different scientific fields, the conference participants sought to identify a research frame that could structure a public health research agenda for infodemic management. The aforementioned themes that emerged converged to broader landscaping of research gaps . The themes also focused on some specific areas of knowledge gaps or promising interventions . An agenda for future research should not only aim to fill gaps in the existing evidence base but, at high priority, also to link research evidence to public health practice. Therefore, the conference participants agreed to establish the research agenda frame analogous to the lens of epidemic management and to fit the identified themes, issues, and gaps to this epidemiological frame see . The fraStream 1 supports the preparedness and monitoring of infodemics through measurement and monitoring of impact of infodemics. Standardized metrics and measurement tools can help characterize infodemics online and offline, identify absence of information where misinformation can gain more traction, and help recognize tipping points when detailed investigations need to take place. Last, evaluation of infodemic management interventions needs more elaboration.Stream 2 addresses the need to detect and understand the spread and impact of infodemics. In the context of infodemics, communities and vulnerable groups are no longer defined only in terms of geographies but can also be formed through shared values, goals, or motivations. Development of interventions therefore needs localized contextualized understanding of the infodemic, how misinformation affects behaviors in vulnerable groups, and understanding of the ethical and regulatory approaches needed to mitigate the spread of misinformation.Stream 3 addresses the response and deployment of interventions that protect and mitigate the infodemic and its harmful effects. Thinking about implementation of interventions needs to be built into the infodemic management activities and research so that the research is linked to what health authorities need to respond. To achieve this, behavior/change models relevant to infodemic management need to be developed, and interventions need to be designed.Stream 4 aims at research that strengthens infodemic management by development of common frames to improve intervention development and programmatic response to infodemics. Using the continuum of community engagement, local cultural context, and building resilience to infodemics and misinformation at individual, community, platform, and societal levels are addressed.Stream 5 supports the overarching aim to strengthen infodemic management practice by enhancing transferability of lessons learned and evidence-based interventions between contexts, countries, and infodemics. The information ecosystem and socioeconomic determinants of access and use of health information differ across countries; we therefore need to understand how interventions can be successfully transferred across countries and what impact they will have in other settings.At the conclusion of the conference, 42 research questions were collected from the topic discussions, as curated by the scientific topic facilitators. During the follow-up research question generation exercise, 38 experts submitted an additional 124 research questions across 5 research streams and 16 subcategories. This added up to 166 candidate research questions. These research questions were reviewed and merged for repetition, overlap, and scope; they were then edited for clarity by three reviewers. Suggestions that were not formulated as research questions were excluded. This review identified a high degree of overlap and repetition, pointing to a saturation of topics submitted for the ranking exercise. It resulted in a consolidated list of 65 questions that were subjected to the ranking exercise.The research questions to be ranked were evenly distributed, with at least 10 questions included for ranking in each of the five research streams . The ranking exercise results for these questions are depicted in Following the ranking exercise, four experts reviewed the results. Based on the ranking exercise, only 8 research questions covering streams 1, 2, and 3 were prioritized with a consensus rank greater than 3.5 and feasibility of <1 year. Therefore, the experts reviewed the 8 ranked questions and the remaining 57 questions that fell outside the cutoff limit. Based on their expert judgment and guidance from the reports of topic discussions during the conference, they identified precursor questions or components of these research questions that could be delivered with quicker feasibility or higher public health impact. The experts worked with the goal to use the questions and the feedback collected in the ranking exercise and used them as a guide to formulate research questions that could be their precursors. They worked on consensus and formulated the final list of 49 research questions, and they retained the additional 65 questions for future reference.Expert review of the results of the ranking exercise identified 3 top research questions per work stream, resulting in a list of 15 top priority research questions for the public health research agenda for infodemic management . FurtherThroughout the consultation, the discussions built progressively; participants shared a wealth of experience, discussed the challenges and benefits of various approaches, clarified the initial topics, and ultimately achieved a high degree of consensus about the needs that the research agenda would have to meet. The overarching conclusion was the need to complete and implement the research agenda along with the framework for action ,13. The Information, misinformation, and public health are intertwined by nature: the WHO has dealt with issues at the intersection of misinformation, trust, and demand for health services since it was founded. Lessons from this experience have led to evolved epidemic response methods, tools, and the global response community over time. The WHO and other partners who work in the fields of public health communication, risk communication, and community engagement have been challenged by the scale of the COVID-19 infodemic, which has been amplified by the global digitized information ecosystem. In a new century, addressing new types of outbreaks requires innovative and precise public health tools . DiffereAt the same time, infodemic management must broaden its tools beyond communication and consider all components of the information ecosystem ,26,27. BAddressing the harms of infodemics is important because they impact health behaviors and are barriers to healthy life and well-being. It is important to better understand proactive strategies that apply social inoculation theory or literacies theory in building resilience. Developing health literacy is critical and includes access to health services literacy, and it is dependent on digital nativity/technological skills, access to information, and media literacy/interrogative skills. The reasons why mis- and disinformation spread are complex; therefore, it is important not to reduce that complexity by framing infodemic management as simply a battle against misinformation ,30-34. Iand research that prioritizes questions to inform operations and improve contemporary practice, foregrounding the pragmatic needs of people in the field and on the ground.Given the urgency of pandemic response, the new transdisciplinary practice will have to learn from practice and iteration even as it develops, reporting experience gained through implementation to provide more evidence on what works and what does not . UltimatWe also need to think about how to build systems for social listening, signal detection, and the analysis of infodemics and misinformation. For example, investment is needed to develop a shared, open reference database for characterizing misinformation (including examples) to identify appropriate interventions and when and how to deploy them . EffectiThe community of research and practice could also develop and use a shared “living systematic review” for interventions measured in terms of effectiveness on a set range of criteria, strength of evidence, generalizability, and likely contexts for application. Interventions across disciplines could be collected, with a rubric describing the outcomes against which the intervention has been tested, its generalizability or application to specific populations, the contexts in which it has been tested, its feasibility and costs, and the confidence in the findings. This could include determining the consistent metrics appropriate to evaluating the success of an intervention to prioritize efforts. However, it is unlikely that only one intervention will be successful; a toolkit of different approaches will likely be appropriate. This living systematic review could be aligned with the misinformation reference database to identify gaps where good evidence-based research does not exist to address certain types of misinformation.The resulting public health research agenda for infodemic management will be maintained on the WHO website as a living document; its implementation and priorities will be reviewed and adjusted regularly.Infodemics impact people, including health professionals, globally. Although infodemics are not new, addressing them in the new digitized society is a different and centrally important challenge in responding to the COVID-19 pandemic as well as future pandemics. The research agenda that emerged from this consultation crystallizes themes that can inform initiatives to build the foundations of effective infodemic management in all countries. The main target audience for these research questions are researchers and practitioners. They will also be of interest to public health experts, nongovernmental organizations, the media, and other stakeholders.There is a large gap between infodemiology research and evidence that has been generated by the academic disciplines and the response to the infodemics. Tools and interventions that are grounded in this evidence are sorely needed by health authorities worldwide. This is partially because scientific disciplines have worked in a mostly disconnected fashion on addressing the challenge of information overload, communication, design, media studies, sociobehavioral factors, misinformation, and the ethics and regulation of the information ecosystem. The WHO and its Member States and partners must close this gap by developing and adopting evidence-based tools that are appropriate for their local contexts. This consultation and the previous infodemic management meeting ,13 may hFollowing the conference, the WHO partnered with five scientific journals in a joint call for papers for special issues on infodemiology , two of The challenge of a novel pandemic pathogen intertwined with an infodemic is a double burden that demands action-oriented research to inform public health response. The new research agenda will strengthen the scientific understanding of how infodemics impact populations and their health, but it will also serve as a basis for action and learning for future preparedness, strengthened through cross-sectoral pilot projects and continuous after-action reviews to build capacity. After the acute phase of the COVID-19 pandemic, we need to shift the focus to strengthening longer-term capacities and advocating for the inclusion of new tools and indicators. When applied to acute health events, the evolving research discipline of infodemiology can provide crucial evidence and facilitate multidisciplinary expertise and coordination.


It is necessary to develop a method that allows detecting, on clinical grounds the area of the lesion in which it is more feasible to find such structures. Thus to increase the sensitivity of the biopsy, in AP cheilitis to accurately identify where the lymphoid follicles reside, based on the higher concentration of DNA in such structures and thus confirm the diagnosis. In this study, staining was positive in 85% of patients with AP cheilitis, in 14 of whom 82% lymphoid follicles were observed by histopathology. One of the pathologist’s problems in establishing the diagnosis of AP is that the main histopathological characteristics are not always identified in the submitted samples because it is not easy to clinically identify the most representative site of the lesion selected for performing a biopsy. Based on our results, we propose using toluidine blue as an auxiliary method to choose a tissue sample to facilitate the diagnosis and allow clinicians to make clinical correlations between the histopathological and therapeutic findings.Actinic prurigo (AP) is a type of photodermatosis that primarily affects the Latin American mestizo population. Histologically, AP cheilitis exhibits acanthosis with spongiosis and vacuolation of the basal cell layer overlying a dense lymphocytic inflammatory infiltrate that forms well-defined lymphoid follicles. Toluidine blue is a thiazide, acidophilic, and metachromatic dye used  AP is related to genetic susceptibility, specifically in the HLA-DRThe skin lesions in AP are polymorphic and include erythematous macules, papules that converge and form plaques, serohematic crusts, lichenification areas, scarring and hypopigmentation or residual hyperpigmentation. Further, lower lip involvement at the vermillion border is common in a high percentage of the affected individuals and maybe the only expression of the disease, when is commonly termed as AP cheilitis; in this location, it is characterized by edema, cracks, fissures, ulcers that are covered by serohematic crusts, erythema and areas of residual hyperpigmentation. that is associated with intense pruritus that extends to the adjacent skin.Histologically, AP cheilitis exhibits acanthosis with spongiosis and vacuolation of the basal cell layer overlying a dense lymphocytic inflammatory infiltrate that forms well-defined lymphoid follicles (comprising B lymphocytes in the center and T lymphocytes at the periphery), macrophages, eosinophils, and mast cells .2AP cheilitis affects 85% of patients and is the sole manifestation of the disease in 27% of those who are affected.in vivo, to selectively stain the acidic components of tissues such as sulfates, carboxylates, and phosphate radicals that are incorporated into DNA and RNA.,Toluidine blue is a thiazide, acidophilic, and metachromatic dye used As only 63.8% of biopsies of AP cheilitis have lymphoid follicles,We included 20 patients (11 women and 9 men) aged between 7 and 45 years (mean 25.7) who presented clinically with AP cheilitis . The detThis region was then injected with 0.5 cc of 2% xylocaine solution with epinephrine, distal to the area where the incisional biopsy was performed, which included a spindle-shaped fragment of tissue of approximately 5 mm in length, fixed in 10% formaldehyde, and processed for hematoxylin and eosin staining.Toluidine blue is already used to identify malignant/premalignant lesions in the oral mucosa; although no risk of malignant transformation has been reported in actinic prurigo cheilitis, it can be considered as an aid to decide the site to take the biopsy due to the dense lymphocytic inflammatory infiltrate that forms well-defined lymphoid follicles pick up the dye.One of the pathologist’s problems to establish the diagnosis of PA is that the main histopathological characteristics are not always identified in the submitted samples because it is not easy to clinically identify the most representative site of the lesion selected for performing a biopsy.Based on our results, we propose using toluidine blue as an auxiliary method to choose a tissue sample to facilitate the diagnosis and allow clinicians to make clinical correlations between the histopathological and therapeutic findings.