Process-of-care studies participate in improving the efficiency of the care pathway for patient with haemophilia (CPPH) and rationalize the multidisciplinary management of patients. Our objective is to establish a current overview of the different actors involved in the management of patients with haemophilia and to provide an accurate description of the patient trajectory. This is a qualitative exploratory research based on interviews of the principal health professionals of four haemophilia services, between November 2019 and February 2020, in France. Mapping of the CPPH processes within the different institutions and/or services, as well as the rupture zones, were identified. Treatment delivery and biological analyses were carried out exclusively in healthcare institutions. The main liberal health professionals solicited were nurses, physiotherapists and general practitioner. Obstacles and barriers within the specialized service, with other hospital services and external hospital or private services, community health care providers et community environment and individual one was complex and multiples. Our research identified potential concerns that need to be addressed to improve future studies to identify influential elements. Similarly, other qualitative studies will have to be conducted on the perceptions and literacy of patients with haemophilia to develop a global interactive mapping of their trajectories. Haemophilia A and B  encompass congenital deficiencies of the intrinsic pathway coagulation factors VIII (FVIII) and IX (FIX), respectively, with a variable risk for bleeding based on the type of haemophilia and the extent of factor deficiency ,4. SinceHaemophilia care is complex, often requiring health management beyond the prevention and treatment of bleeding . Over thIntegration, the coordination and alignment of tasks, has been promoted widely in order to improve the performance of hospitals . IntegraThe healthcare process of a patient with haemophilia is complex: it is dynamic, variable and multidisciplinary . The phaThis research aims to analyse, model, and provide decision support systems to institutional and field actors involved in the care processes and the global systemic hospital management of haemophilia patients established by the medical system in France. Its objective is to establish a current overview of the different actors encountered by patients with haemophilia throughout their life course, classified by family , and to identify potential or proven areas of disruption in the life course to improve knowledge of the trajectory of a patient with haemophilia.This is a qualitative exploratory research study. It is based on interviews of the principal actors in the organization of the patient course: health professionals from the hospital teams of four haemophilia services, located in three different regions between March 2019 and February 2020 in France. Using a mixed method, data were collected from the observations and interview manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. Data were used to perform a social network analysis and a structural and functional modelling of the hospital network.In France, the haemophilia Care Network is organized into haemophilia treatment centres (HTC). Consultations and care of patients are essentially performed in a haemophilia reference centre (HRC), or a resource and competence centre—constitutional haemorrhagic diseases (CRC-MHC), or a treatment centre for Constitutional haemorrhagic Diseases (CT-MHC). Drugs can be dispensed by hospital pharmacies (retrocession) and since 2021 by city pharmacies.−Hospices Civils de Lyon (HCL), Groupement Hospitalier Est, is a coordinator site from the HRC and the French network on inherited bleeding disorders (MHEMO) with 3000 consultations per year.−Assistance Publique des Hôpitaux de Paris (APHP)—Hôpital Bicêtre is a reference centre for haemophilia and other constitutional coagulation protein deficiencies. Nearly 600 patients with haemophilia are followed in this reference centre for rare haemophilia diseases.−The Lille University Hospital—Lille Regional Haemophilia Treatment Centre (CTL) is one of the five French sites labelled national reference centre for haemophilia and other rare coagulation deficiencies. This centre is composed of several functional units: (i) biological haemostasis; (ii) cardiological haemorrhagic pathology; (iii) haemorrhagic pathology Jeanne de Flandre; (iv) thrombotic pathology; (v) Willebrand UF, vi/Transfusion Safety & Hemovigilance; (vi) immuno-haematology. It should be noted that there is no doctor assigned to each patient, which favours the versatility of medical professionals. It is the doctor on duty who manages, with shared advice.−The Metropole Savoy Hospital Centre in Chambery  is a CRC-MHC. It should be noted that it is relatively rare to have a haemophilia service in a general hospital, as is the case here. The geography (mountains) partly explains this situation. The number of populations increases by a factor of 100 during the winter vacations (skiing).Four selected Hospital for our study were selected. Each centre specializes in the diagnosis and follow-up of constitutional haemorrhagic and thrombotic diseases:−Interview with the head of the department or his/her representative, who was able to explain the context and history of the organization.−Visits to the departments concerned: 30 min–1 h.−Interviews with the different actors of the pathway : doctor, nurse, paediatrician, haematologist, biologist, physiotherapist, pharmacist, etc.: 30 and 45 min.−Work observations (free time involved) : observations 1 h or more.−Debriefing with the Head of Department: 15 min or more depending on availability.A multidisciplinary research team composed of researchers with backgrounds in pharmacy, ergonomics, and public health policy was formed to enrich the free interviews, limit individual interpretations, and strengthen the analyses to meet with several haemophilia services. The planned organization of the day included:Face-to-face interviews were conducted with physicians, pharmacists, nurses, secretaries, physiotherapists, psychologists, clinical research officers, and nursing assistants. It should be noted that in two cases, the field conditions made it necessary to set up a group interview. A total of 31 people were interviewed. A team meeting was also observed as well as five consultations of patients with haemophilia.In order to validate, between August 2018 and November 2018, the social network by task was discussed face-to-face with four hospital staff members who also participated in observations and interviews. Some hospital staff members known to perform specific tasks were interviewed via email to obtain details about those tasks. A validation report was prepared to record the comments of the hospital staff.Two initial pilot interviews were conducted to assess the items for content and conceptual clarity. Results suggested that these items could be used in the specific context of haemophilia care. The study was based on semi-structured interviews with 31 health care professionals: 13 physicians, 3 pharmacists, 1 biologist, 6 registered nurses, 1 physiotherapist, 1 psychologist, 3 clinical research associate, 1 project manager and 2 assistants employed in the French health care system. The interviewees’ responses were analysed using directed content analysis. Maximum variation sampling inside professions were used to achieve diversity in size and performance. The process was set up and coordinated by an ergonomist specialized in the analysis of health trajectories. Individual interviews were conducted by authors  on behalf of the ergonomist.An inductive approach was applied using questions based on the existing literature on organizational process and patient trajectories and concerned participants’ experiences and perceptions of the structural organizations they considered to impact their care of patients with haemophilia. The different interviews conducted in these four haemophilia services were followed by discussion meetings within the research team. For each site, the specialist prepared a synthesis, the authors  meeting to enrich and validate the synopsis. A report of each site visit was written in a collaborative manner. Then, an overall analysis was formulated.The principal objective was to identify the different actors involved in the management of patients with haemophilia and to determine the similarities between them to provide an accurate description of the patient trajectory.The secondary objective was to determine any specificities, and their rationale, if applicable.The number of cases to be included in the study is defined by data saturation and not by a calculation of the number of subjects necessary a priori. Data saturation is achieved when no new concepts emerge from the interviews. In our study, we confirmed data saturation with two additional interviews that did not bring any new concept.The process describes all actors involved in the care of patients with haemophilia. It is described from the point of view of the hospital actors and the intra-site analyses. The weight of each actor is qualitatively weighted, by focusing on the first three sites visited (Lyon/Lille/Paris). The objectives of qualitative analysis were to define concepts, mapping range and nature of process, creating typologies, to identify associations, providing explanations. Framework analysis has been used. Mapping and interpretation involved analysis of key characteristics. This mapping provided a schematic diagram of the event, thus providing guidance to the researcher in their interpretations of the data package.Mapping of the “Care Pathway of Patient with haemophilia” processes within the different institutions and/or services, as well as the rupture zones, were identified .Following the visits to the four haemophilia hospital services, the following specificities emerge from this representation. For their haemophilia, patients receive support from healthcare professionals, most of whom are hospital-based: medical consultations, treatment delivery and biological analyses are carried out exclusively in healthcare institutions, and in some centres only. The main liberal health professionals solicited were−Nurses: mainly for treatment injections for patients who do not practice self-injection, or who do not have a caregiver for this practice.−Physiotherapists: although their role is recognized by caregivers in haemophilia services for managing the consequences of hemarthrosis, they are not very present in the institutions.−General practitioner is not very present; his or her interactions with the specialized service are very rare.−Patient’s close family and friends are particularly concerned by the disease, and even involved in its management.−The estrangement in the relationship between patients and health care teams due to the development of prophylaxis with long-acting treatments.−Questions about the risk of patients escaping if new treatments are dispensed in pharmacies.−The haemophilia service sometimes has difficulty getting along with certain other services, particularly emergency rooms, where patients are occasionally poorly recognized and misdirected.−Poor recognition of women with haemophilia: not only “carriers” but also “affected”: 1/3 of them have factor 8 deficiency. Additionally, 90% of these women are not believed in the emergency room.−A loss of awareness of the disease on the part of patients, due to the lengthening of the time between treatments or easier administration methods, leading to risky behaviours .−The importance of therapeutic education of the patient, and of his entourage, to maintain an awareness of the disease and a good management of it.−The importance of broad-based support for haemophilia patients, including both physiotherapists and psychologists.−The link between hospital nurses and private nurses is almost non-existent.−The link between city doctors and hospital doctors is almost non-existent.−Adherence to medication was defined as satisfactory in children, average in adolescents, and poorer in adults.The processes are highly dependent on the organization of the team, the geographical situation, such as the location of centres on several sites, and the spatial location—proximity of the stakeholders. The factors for improving the trajectory are linked to the coordination of the actors because of the possible breakdown in access and the sharing of useful information regarding the patient between internal actors. The levers of multidisciplinary meetings within the CTHs organized around patients, therapeutic indications, and cross-referencing of different types of information are highlighted.Historically, relationships are more or less marked and have an impact on the structuring of the service and its organization, for example with the paediatric service at Kremlin Bicêtre. Other services are more in the forefront, such as the analysis laboratory in Lille, where referents participate in team meetings, and the pharmacy in Lyon, where a pharmacist is attached to the service. Relations with other hospital departments are strongly rooted in their collaborative work, depending on the number of staffs, profiles, historical functioning, organization, availability and facilitation of formal or informal exchanges. The aim of these close links is to improve patient care and to optimize it, such as “same-day factor VIII dosage”. In Lille, numerous meetings between manufacturers, pharmacists and doctors for the presentation of treatments have facilitated the work of both, and their collaboration “has simplified referral” and delivery methods based on simulations.The links with “more distant” services such as emergency services or with centres of complementary and necessary medical expertise (stomatologists) are complex. Difficulties arise from maintaining the skills of people who change and who do not “practice” haemophilia on a regular basis. In Lyon, for example, the CTH participated in the training of emergency physicians, but this action was not sustainable over time (multiple actors/turnover). Protocols were then put in place that necessarily involved the patients . In Chambery, before the implementation of an on-call duty, training was organized every 6 months. Since then, there have been some difficulties maintaining an adequate level of knowledge for emergency residents. In Lille, a briefing is planned every 6 months with the emergency physicians. Similarly, in KB, special orthopaedic consultations for patients with haemophilia are held; in Lille, stomatology consultations are held (once a month) to compensate for the lack of links with the outside world (“some dentists in town refuse to take patients with haemophilia”).The same necessary relations as with remote intra-hospital services are developed, with the additional difficulty of distance and the organization of processes (who is in charge/thinking about it/checking). Patients are regularly reminded to call the haemophilia service when they go to another institution . Patients with haemophilia also sometimes voluntarily hide their disease so as not to extend the length of their stay, for example.The pathway depends on the presence, training and knowledge of those involved in haemophilia and patient care, but also on the patient’s pathway.Many factors impact on good liaison between these players: distance, lack of training or collaborative tools, involvement in patient follow-up, knowledge of the specificities of haemophilia care. The distanced role of the general practitioner in relation to the patient’s course and the number of hospital consultations, for example (depending on the type of haemophilia), making the patient think that their general practitioner is less useful; this would be even more pronounced for women with haemophilia, as highlighted. This raises the question regarding the tools used between the city and hospital actors, via the injection follow-up booklet, the health booklet and the very variable methods of liaison . For example, in Lille, the service receives two to three calls from general practitioners per year.There are some exceptions depending on the site, notably in Lille, with physiotherapists (specific list of private physiotherapists—history and proximity link with a Belgian team which has developed many links with physiotherapists). This is not the case with psychologists, with whom attempts at cooperation envisaged in the past have not been satisfying. The avenues envisaged concern a potential mutualization with the rare diseases network.In Lyon, links are being created between associations of hospital practitioners  and associations of community practitioners, while emphasizing the absence of computer links and the digitization of the care record of patient with haemophilia, which is currently underway. For dental, dermatology and colonoscopy care, compliance with protocols is imperative.The measures envisaged include the mobilization of professional societies and the production and distribution of dedicated documents.The organization of the care pathway within the general medical practice should be developed in the questioning of patients.The important coordination and weight of the various associations and network organizations around patients and professionals were emphasized. However, although many associations exist, they are not always well identified by patients neither by community practitioners nor other hospital services.Difficulties related to a lack of knowledge about haemophilia, difficulties in providing care , stigmatization, choice of sports, etc., penalize the children’s trajectory. In Lille, a concern extends to the siblings of patients with haemophilia.There are weak links with health professionals, particularly occupational physicians. In Lyon, their importance was underlined, particularly in their necessary involvement in the constitution of files for persons with disabilities. Finally, the impact is weak and may raise the question of keeping patients with haemophilia in employment.The same level of requirements are necessary for education, and lifelong maintenance of skills is necessary. The understanding of one’s disease, the way one lives with it, beyond the cognitive capacity to understand it, is also an element that influences the course of the disease. The place where one lives and access to care are also parameters that influence the course of treatment. Some patients with haemophilia hide their disease to avoid prolonging a hospital stay when they are in an institution where they are not usually followed up. There is a need to educate the people around them in the same way as the patients, with a similar requirement, and to keep them competent to carry out the injections in the event of difficulty for the patient.Therapeutic innovations will have an impact on the treatment pathway, its structure and its actors, and both will have an effect at several levels. First, on the work of practitioners, particularly their medical and professional practices, as well as on dosages and analyses. Second, on hospital-city coordination and possible ambulatory risks linked to the distance of patients from hospitals, as the pathway is considered today. This refers to the structuring of ambulatory care, its coordination, its development, as well as the accessibility of treatments and care in case of delivery of treatments in city pharmacies. The necessary reinforcement of outpatient services and their reorganization so that they can respond to needs would be a real lever in the fight against areas of breakdown. The accessibility of information and the improvement of knowledge about haemophilia, and the resource people to whom one can turn, are issues. Similarly, the impact of the network on the territory may accentuate the disparities in patient care.Finally, in terms of the impact on patients’ lives and their apprehension of haemophilia, their “feeling” will be different, and their quality of life will be improved. For example, patients affected with a mild case of haemophilia may forget that they have this condition, and joint pain may not be caused by the disease. Other impacts may concern specific cases, such as patients with inhibitors.To the best of our knowledge, no literature has been published to date on the use and impact of clinical pathways on the quality of care for patients with haemophilia in healthcare settings. The present article provides a qualitative synthesis of the implementation of clinical pathway initiatives for patients with haemophilia in specialized French healthcare services. Its objective was to establish a current picture of the players encountered by patients with haemophilia throughout their life course, classified by family , and to identify potential or proven areas of disruption in the course. The method was to get a group of people to work on this picture, to have the elements that can vary the pathway of patients with haemophilia and, if fine, to identify all the impacts of therapeutic innovations on the trajectory.Centres of expertise reference networks for rare diseases, including haemophilia, are fundamental to EU health policy (Article 12) . StandarThe 2018 survey to assess the extent to which the 10 principles of haemophilia care were applied highlighted the principles of haemophilia treatment, and were generally applied across Europe .Our research targets care processes, which are certainly restrictive in relation to health or life pathways, but which are the response to health needs on a territory in relation to risk factors and diseases . They inWhereas until the 1960s, the median life expectancy for a patient with haemophilia was 30 years, the development of effective treatment based on prophylactic replacement of the missing factor, as well as a better knowledge of the disease, has changed the paradigm. Today, the quality of life and life expectancy for individuals with haemophilia is virtually normal .In France, a national pharmacosurveillance system for FVIII and factor IX products administered to haemophiliacs was founded by the public health authorities in 1994 . Renamedn = 2901), of which 1306 were severe, and haemophilia B (n = 605), of which 229 were severe. The median age of patients was between 20 and 26 years according to the type of coagulation disorder, with a median age at diagnosis of 0.7 and 0.8 years for patients with severe haemophilia A and B, 1.7 and 3 years for patients with moderate haemophilia A and B, and 7.6 and 6.7 years for minor forms [In 1999,1234 people affected had been registered in 39 haemophilia centres. At the time of admission, 50.2% of them were younger than 15 years of age . In 2005The French cohort provided in 2016 data from 9504 patients with hereditary bleeding disorders indicated that 60.5% were affected by haemophilia A and 13.7% by haemophilia B. Median age was 32 years (IQR: 18–50 years). At that time, a serum and plasma sample was available for 27.1% patients .−The importance of the hospital in the current course with the predominance of its actors, who may differ from one site to another, and the close links occasionally difficult to establish with the patient’s life outside the hospital. This is a constant observed in industrialized countries. Procedures, rules for collaboration between EHTCs and EHCCCs must be written, shared and made available to the public . While t−Links outside the hospital of various categories. The links are occasionally not strong enough to be maintained in the long term, reinforcing the importance and the necessary autonomy of the patient in the management of their illness. The links are occasionally non-existent or created on the basis of opportunities or historical configurations and often dependent persons. Certainly, the World Federation of Haemophilia recommends that patients with haemophilia be managed in a specialized comprehensive care centre . However−Intra-hospital interactions linked to opportunities, specific historical organizations and collaborative choices that are not always possible (limited flexibility) in terms of time, human or financial resources, availability, etc. The mission of French clinical networks of reference centres is to structure and coordinate the activities between the national and regional centres, the technical platforms, or any other structure involved in care for patients. EHTC must have access to multidisciplinary support, locally or in conjunction with EHCCCs as orthopaedics and physiotherapy, dental care, surgery, obstetrics and gynaecology, hepatology, infectious diseases, paediatric, clinical psychology and social worker ,19,32.−There is considerable variability despite a willingness to describe a “meta-course”, a “standardized” description that makes it possible to visualize all of the participants who revolve around the patient and the places where patients with haemophilia go. Through daily self-management, patients with haemophilia become experts and partners in their own care. As such, they should be considered as separate essential members of the comprehensive care team . HoweverOur research identified four potential concerns that need to be addressed to improve future studies to identify influential elements:Certain points in this research have identified structural weaknesses that provide guidance and decision-making aids for the recommendation or improvement of operational axes. The so-called “specialty” reference centre is the guarantee of quality care for haemophilia, a rare disease that requires a concentration of the necessary targeted financial human resources for a country, France, whose hospital-centred health organization allows for territorial coverage and quality geographic access for patients. This, where the health actors do not have for this disease problems of financing care for the patients, is the state taking in its account the totality of the treatments.Within these reference centres, the complementarity between the expertise of the professionals and the experience of the patient accumulated through life with his or her health or psychosocial problems, the disease and its repercussions on his or her personal life and that of his or her families must be reinforced: personalizing care, developing and strengthening the patient’s skills in sharing decisions with caregivers, knowing how to pay special attention to the physical and psychosocial health of patients, and continuity of care over time are the principles that guide the patient-centred approach. Improving the training and awareness of a multi-professional and, if necessary, multi-disciplinary team, as well as those of associated professions outside the reference centre, remains a challenge. The priority is to ensure a fluid and secure reception of patients at the right time in a relationship within the emergency services.The expectation is that all members of the core team should be skilled and experienced in the treatment of bleeding disorders, but this must be accompanied by an awareness that patients with haemophilia do not have the same level of awareness/concern or perfusion capacity. Professionals need to be aware of the physical and psychosocial health of patients. As such, written management protocols are essential to ensure continuity of care, even if clinical staff changes. These protocols should be as personalized as possible, depending on age, venous access, bleeding phenotype, activity, and the availability of clotting factor concentrates. Recommendations for the management of patients with haemophilia are updated and disseminated by the various scientific societies identified.® (emicizumab), effective June 2021 [Continuity of care over time requires awareness and education of other health care providers who are not specialized in haemophilia care . It is aune 2021 . In pracAt least, improving recognition of the condition in women is a sensitive issue, especially when the screening is conducted in the office of a community health care provider who is unlikely to consider haemophilia simply because the patient is a woman ,43. One-This study presents strengths. The baseline assessment of quality performed in this review attempted to provide a quality minimum as well as identified a large range of items that may influence the course implementation. The methodology of interviews, whether conducted individually or in groups with health professionals, is adequate to assess and characterize a variety of unique influencers. Qualitative methodology may affect the type of barriers/facilitators identified, but it is more likely that the aims of the studies included, their population of interest, and/or the particular service/subject addressed by the study had a stronger impact on the type of obstacles or facilitators identified. This work was deliberately limited to the French context, which allows for directly relevant and applicable results. Thus, focusing only on France appears to be a wise decision and not a limitation because it allowed us to obtain data in a context of particular interest.A key limitation of this study was the selection bias associated with the identification and recruitment of participants. Volunteers may have been more positive about the expanding role of community professionals.This study has been a positive exercise in enabling a greater understanding of the current haemophilia care landscape in France. The identification of barriers and facilitators, including how they relate to or interact with each other in the trajectory care of patients with haemophilia, is a key step for developing suitable strategies and interventions to enhance health service performance. The best knowledge of the care processes of patients among the key stakeholders will help to optimize clinical outcomes while enhancing patient quality of life. The Principles of Haemophilia Care were generally applied in France. Some aspects of national organization of care, interrelationship between key stakeholders—healthcare professionals, patients and their caregivers, managed care professionals—may be improved. Future studies could explore the opinions of a wider range of patients and broaden the scope of research to health and life-course pathways.


This article illustrates a design approach for capturing, storing, indexing, and search of African traditional herbal medicine (ATHMed) framed on a hybrid-based knowledge model for efficient preservation and retrieval. By the hybrid approach, the framework was developed to include both the use of machine learning and ontology-based techniques. The search pattern considers ontology design and machine learning techniques for extracting ATHMed data. The framework operates on a semantically annotated corpus and delivers a contextual and multi-word search pattern against its knowledge base. In line with design science research, preliminary data were collected in this study, and a proposed strategy was developed toward processing, storing and retrieving data. While reviewing literature and interview data to reflect on the existing challenges, these findings suggest the need for a system with the capability of retrieving and archiving ATHMed in Ghana. This study contributes to SDG 3 by providing a model and conceptualizing the implementation of ATHMed. We, therefore, envision that the framework will be adopted by relevant stakeholders for the implementation of efficient systems for archival and retrieval of ATHMed. Countries worldwide are striving to promote good health and wellbeing for their citizens. Achieving universal healthcare by meeting United Nations' (UN) Sustainable Development Goal (SDG) 3 is the focus of many countries. The SDGs provide an ambitious and comprehensive plan of action for ending the injustices that underpin poor health and development outcomes SDGF, . It alsoIn the spirit of sustainability and standardization, WHO  has throFor many centuries, diverse methods have been applied in different cultures to provide healthcare. Popular amongst these forms of practice in Ghana is the orthodox and traditional herbal treatments. Traditional herbal medicine can help many countries to achieve SDG3, especially in the developing context. Traditional herbal medicine was the first method of healthcare practice in Ghana  has evolved since its inception as a concept in the 1990s into a full academic discipline, taking different dimensions of classification and study  is one of the fastest growing fields in computer science and has been applied diversely  to an output (Y) based on input-output pairs . Classification makes use of the initial data collected to train a machine learning algorithm (classifier) to predict unseen data. Classification involves training and prediction. At the training stage, the labeled data is classified into two forms being, training data, and testing data. With machine learning classification, the initial stages require labeling/ tagging of sample (training) data, thus n-dimensional vectors that have class association labeling. The sample or input data can be labeled manually (by a human expert of a specific domain), automatically  and semi-automatically (mixture of an expert and software)  data is used as input for learning to the algorithm. The training data is typically textual, and thus classification can be done at different levels, being at the word, sentence, and document levels  and output (Y) variables, the input variable is mapped to the output variable, i.e., Y = f(x). The rationale is to as accurate as possible map via the machine learning algorithm (model) such that for any new input data (x) the model can efficiently predict (≥70% accuracy) the output variables (Y) for that data such that the error on the output predicted is minimal. The predictive ability of the classifier , thus its quality, can be measured based on its recall, precision or f-measure. Other popular methods for measuring a classifier's quality include Cohen's Kappa scores, Receiver Operating Characteristic (ROC), among others. Several studies indicate the active adoption and integration of machine learning applications in traditional herbal medicine.At the test stage, the machine learning model generated will be given data to test if it is able to appropriately deduce correctly which class the extracted feature belongs to, in essence for it to predict the right output of the data. If this is correctly achieved at a satisfactory stage, learning ceases. Mathematically, for a given input , specifically in the area of Artificial Intelligence (AI) concentrated in the areas of knowledge management, knowledge engineering, information retrieval, natural language processing, intelligent information integration, etc.  process for developing a framework for the ATHMed. Design science research has largely been adopted in several disciplines, especially in the Information System domain. Horváth  and BaskThe environment constitutes the understanding of the application domain, which include the people, organization and the technical systems. The goal is to formulate objectives for developing solution through design and evaluate process. The design stage involves the actual development of the artifact. However, the design stage undergoes a vertical stepwise process . The environment and design stages iterate until a desirable outcome is attained and this constitute the relevance cycle. The artifact is expected to add knowledge to the domain for which the study was undertaken. Thus, contributing to the knowledge base largely relies on the developed artifact. The iterative process, at this stage is the rigor cycle.This article forms part of the relevance and rigor cycles where data was collected to understand the need for the system and the framework for future implementation. The development of the framework relied heavily on the need for it (stakeholders' acceptance). In view of this, the preliminary part of exploring the environment was through data collection. Diverse stakeholders in the herbal medicinal space in Ghana were purposively selected for an interview. The selection was based on their desire to advance research and promote ATHMed. Participants were selected from the Academic institutions advancing herbal medicine, Research institutions (CSIR), Local herbal practitioners, Herbal clinics, Food and Drugs Authority (FDA) and a selection of herbal medicine users in Ghana. The study complied with ethical standards. Thus, Ethical clearance from the University of Ghana ethics board was obtained before undertaking this study. An informed consent agreement form was signed by each participant before the interviews were conducted. A total of 20 stakeholders were interviewed. The interview was semi-structured that allows the participants to express their views by responding to the questions.This study adopts Initial data collected suggests a keen interest in the development of the computational framework for proper archiving and retrieving of ATHMed. The participants recognized computational systems for ATHMed as a way of contributing to practical knowledge sharing, socio-cultural sustainability concerns and healthcare delivery and accessibility issues especially to patrons and researchers in the domain. On the question of how herbal medicine practitioners are regulated in Ghana, one of the participants blamed the government for negligence in the influx of fake herbal medicine and practitioners in Ghana. One of the participants said:“I think the government is not doing enough to check the herbs and the herbal clinics in the country, every day and day out people bring new herbs and just go to the street to sell to the poor Ghanaian. Our country is been poisoned by these acts.”Nevertheless, the participants expressed their concerns about the rate at which herbal clinics and herbal practitioners are springing up without proper checks and documentation. We asked a question on their perception regarding a national database for archiving and retrieving traditional herbal medicine. Though the participants did not put the entire blame on the FDA, they rather believe that computational means to help curb the menace of fake herbal medicine is the way to go. One of the participants expressed that:“Taken the step to use a more sophisticated technique to help preserve the knowledge in the herbal medicine is the way to go. In fact, I don't entirely blame the authorities who mandated to check fake herbs in the market but making people aware through whatever means will automatically reduce the menace of fake herbs in the system”Inthe interview, asked whether there is existing database in pace for archiving herbal medicine. We found out that computational systems are available in specific places, but they are not integrated. These systems are built based on the traditional database system with simple query techniques. One of the participants agreed on the relevance of the development of knowledge-based system.“This will be a game changer. I think this will make a work flexible if a knowledge system can be developed to achieve and even help predict what herb to use for a particular ailment”On the question of whether the participants will be willing to participate, in terms of building the knowledge-based system, the responses were positive. However, they cautioned that some of the herbs are fake and do not treat the ailment that it has been purported to treat. They, however, recommended for thorough validation with the FDA, an authority mandated to validate drugs before it is put to the market. In future, the various stakeholders will be consulted for practically implementing the framework.Data, Logic, and Presentation Layers, and their associated components. As shown in via a data acquisition sub-component and knowledge base. The middle layer—logical layer—embodies the logic that performs reasoning capabilities such as inference and deduction, and extractions of data/information/knowledge based on queries (requests) received via the information extraction component. The information extraction component's function is implemented through two sub-components, thus a semantic reasoner and machine learning extractor. The third layer, the presentation layer, presents a means via a graphical interface for users to run or pass queries in natural language syntax against the knowledge base to retrieve relevant information on ATHMed. The rationale for the segmentation of the KB framework, is to achieve conformance with current KBS design and, also enable modularity and precision in delivery of a reliable system, serviceable in an integrated, adaptive and platform independent setting, while harnessing the hybrid capabilities (machine learning and ontology specifications) discussed  through lemmatization. The processed data, appropriately labeled/tagged will then be stored into the knowledge base considering possible association of data elements, corresponding with the ontology design adopted. By this a reliable level of accuracy in the anticipated prediction and association of data to label is provided as seen in Preprocessing involves cleaning and conversion of unstructured data into some structured form, reprocessed and then extraction of features where required. This processing is based on the elements relevant for ingredient selection and processing, mode of preparation and administration methods. Through expert domain  annotation, a predefine annotation scheme for the ATHMed data will be performed. This will enable the attainment of a good agreement score on what element goes where, to obtain a correctly annotated data for training the machine learning classifier as indicated in via a machine learning software . Literature indicates that different algorithms have been applied in THMed , we suggest an n-gram approach be used. This implies features may be in the form of a unigram, bigram, etc. to aid in storage and retrieval of multiword based expressions and search. The choice of machine learning algorithm to be used in implementing the classifier would require testing several algorithms possibly The ontology, the ATHMed Ontology model, is to capture all the knowledge into a structured, well-defined form. The ontology approach  is being adopted to enable the knowledge base possess semantic, extensible and reusable capabilities. The ontology considers the appropriate categorization of classes, anticipated instances, interrelationships and relevant axioms. The ontology approach has become popular in knowledge engineering and representation, yet it is novel in its application in various domains and its potential is still being explored. The ontology requires to be subjected to rigorous evaluation to verify functional specifications thereby ensuring consistency, reliability, accuracy, and extensibility.To obtain accurate representation, undertake maintenance and efficient dissemination of semantic data (knowledge), the application of computational ontology strategies is proposed and therefore relevant for storage of ATHMed knowledge. In conformance with the DSR method, an additional round of verification on the ontology is required with the aid of domain experts. Hence, a further validation, involving verification and evaluation tests for reliability Preece,  to ascerTo derive the ontology, notable metadata representation tools, from authoring to languages for design and writing machine-readable and machine-understandable notation must be employed. This would require the use of Protégé, XML and extensible markup language (XML) Schema, resource definition framework (RDF) and Web Ontology Language (OWL-DL). This is to define appropriate metadata descriptions, structure and storage, and web resources for describing knowledge interrelation. In addition, these tools facilitate the definition of the ontology structure and semantics. Wollersheim and Rahayu  suggest via a machine learning extractor that runs query requests against the ontology-based knowledge base. Thus, the information extractor is implemented via a machine learning-based (ML-based) extraction algorithm and an inference engine. The overall design is to enable the ML extractor work seamlessly on the ontology to produce semantically oriented results, based on the features stored in the ontology, taking critical considerations of class types, their relationships, instances, connotations and semantics. The ML extractor interacts with the inference engine to deduce new knowledge from the knowledge base (KB) to ensure accurate prediction and determination of appropriate treatment, association to ailment, preparation methods, and other relevant inferences. This, is anticipated, would yield relevant search results as the ontology is formulated on formalized, explicit relationships and axioms, and as such suited for knowledge-based systems especially in knowledge retrieval . Retrieval, on the other hand, involves the submission of queries posed against the knowledge base that leads to retrieving  of content items (knowledge).Hersh  views inThe information extraction's machine learning extractor sub-component is designed to interact semantically with the ontology based on the principle of finding and retrieving knowledge (content items) that fit the search description (query) passed by the user based on the metadata (ontology metadata) of the data (items) stored in the knowledge base. Metadata here focuses on Greenberg's  descriptIndexing plays a critical role in the information retrieval process. Indexing can be done manually or automatically Hersh, , with thSeveral indexing approaches have been suggested in literature. Most indexing approaches are perceived to match terms from some document to those of a query Soe, . Some ofThe rate of success of the information extractor also is measured by what information/knowledge is retrieved. During retrieval, the relevant information searched and found is returned and/or presented to a user after a given query is submitted. In the retrieval process, an exact or partial match of search approaches can be used with each having its own constraints. However, since a careful annotation of data is to be presented for the classifier to learn, coupled with the need for accurate prediction of terms and concepts notable in healthcare delivery, the exact match search approach would be most suitable. This approach is considered to achieve a more precise prediction of terms relating to THMed knowledge while considering semantics and relevant association of concepts. As earlier indicated, the semantic reasoner presented in the framework acts as the inference engine. The inference engine structure is expected to work on the Java-based framework, Apache Jena. Machine learning techniques mainly to improve the efficiency of predictability, deduction accuracy and an extensible deeper learning approach shall be considered. This shall support the making of inferences whiles deducing new knowledge in a contextual form. This requires that the selected machine learning classifier be trained, initially on some rule-based approach before a well-structured corpus for ATHMed is defined and extended with the algorithm.via a graphical interface that is facilitated via the web or mobile platform. The aim is to achieve a high level of accessibility as these technologies are deemed ubiquitous and have shown the capacity to support use, anywhere and at any time with ease. Both platforms have the ability to support machine learning and ontology-based applications. Preferably, Android and J2EE technologies are proposed for the design and implementation of the mobile and web solutions, respectively. Users will be provided with simple interactive interfaces that communicative satisfactorily for them to pass simple to expressive statements as queries which will be received as natural language expressions. The use of natural language processing tools and techniques can facilitate efficiently such manipulations. This is to facilitate the extraction of relevant knowledge in the form required for adequate interpretation and understanding to the user. To this end, representation of the extracted knowledge must be textual and visual where required. Similar interface shall be presented to provide new knowledge to the knowledge base.Subsequently, as depicted in the application layer, interaction with the knowledge base system is suggested to be performed Based on the core components discussed in the previous sections, a conceptual framework is presented. The framework seeks to provide an approach toward the implementation of a hybrid AI-driven (ML and Ontology) sustainable development of African traditional medicine. The framework envisages an effective and sustainable approach to safeguarding, promoting, and disseminating ATHMed knowledge. The pragmatic approach to identifying, capturing, storing, and retrieval of knowledge on the preparation, application (use), and dissemination of traditional medicines will ensure its continuity, especially for the indigenous use of ATHMed. As earlier discussed, tacit knowledge of ATHMed held exclusively by some traditional healers can be captured and preserved using intelligent computing approaches such as knowledge-bases with AI approaches. Such an approach will enable the use of explicit ATHMed knowledge for formally training health workers in traditional medicine preparation and treatment. It is also geared toward facilitating the discovery of new medicinal properties of medicinal herbs and plants, and helping in advancing research into producing new medicines to serve the healthcare needs of ATHMed patrons. Potentially, this may lead to the conservation and preservation of flora and fauna that could be potential medicinal plants and thereby helping to sustain the local ecology of the communities where these herbs and plants are found. This, in effect, yields a more sustainable approach to healthcare delivery in the African context. Additionally, where the ATHMed knowledge bearer dies, the knowledge still exists in the KBS for future practitioners to learn, harness, and extend the practice of traditional herbal medicines with the needed scientific rigor that ensures safe and standardized preparation and use of ATHMed. This requires consistent collaboration between stakeholders within the domain and AI technology solution providers. This requires consultative engagement involving participatory problem identification, knowledge sharing, and feedback on solutions for ATHMed challenges. Thus, the concept of co-creation of a KBS based on a robust ML and Ontology strategy with stakeholders forms the basis of a sustainable approach to preserving and disseminating knowledge in the ATHMed domain. Consequently, this will help shape learning and training, drug preparation and standardization, and policy formulation within the ATHMed domain.The application of sustainable strategies to promote good healthcare is crucial in maintaining the wellbeing of a person. WHO  reports To help salvage the situation, deliberate calls and attempts have been made, by academia and research institutions worldwide, to help formalize and train THMed professionals. As custodians, these professionals will not only guide the processes and procedures to the preparation, preservation and administration of THMed, but also ensure the knowledge is not lost  for application and dissemination through a formalized teaching and learning curriculum, while employable for healthcare service delivery. This will form a base for extending research in the area of documenting, preserving, and sharing knowledge on ATHMed and its practices. Machine learning and ontology strategies were presented as a hybrid approach for the framework. This presents a novel approach to tackling issues involving the development of the knowledge-based system that seeks to formally and explicitly preserve and efficiently retrieve ATHMed knowledge in a semantically oriented pattern. The research culminates with an implementation of a framework for ATHMed.This current study confirms these challenges and finds that the traditional herbal medicine space in Ghana is not well-regulated and guided. The system allows fake and untested herbal medicine that are not monitored in the country. Our precipitants agreed that there is no robust and integrated system for the archival and retrieval of traditional herbal medicine in Ghana. They however blamed these challenges on the mandated regulatory bodies in Ghana. This brings to fore the relevance of the proposed framework in the study. The framework, to the best of our knowledge, is the first to address the challenge by bringing to the fore a via the hybrid approach is novel in the Ghanaian and largely African context particularly to the application of knowledge-based approaches to safeguarding traditional herbal knowledge. The literature reviewed suggests the integration of machine learning and ontology approaches in the preservation and retrieval of traditional medicine focusing on herbal medicine practices. This article, therefore, suggests useful approaches to consider within the knowledge management domain regarding knowledge-based systems and its application in safeguarding critical knowledge assets. Albeit the framework requires development, implementation and evaluation to ascertain its efficacy and veracity, it provides useful insights for further work. Additionally, the framework is targeted at archiving knowledge relevant for research and training of qualified herbal medicine professional who will ensure continuity and formalization of THMed practices in Higher Learning Institutions. The resulting output from academia will feed the pharmaceutical industry with the requisite knowledge on THMed. Causally, it is hoped that the development of the knowledge base will assist in the conservation of biodiversity, discovery of new bioactive agents and investigation of new herbal drugs for treatment  to share their knowledge and also the acceptance and use of the stored knowledge for a more formalized training and standardized preparation of traditional medicine would determine the practical application, and in effect, the successful implementation of the framework. As this study is ongoing, we intend to automate this framework by leveraging the Design science research framework. Thus, stakeholders of traditional herbal medicine will be made to participate in the co-creation process.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.EK, SD, and RA conceptualize the idea of the article, contributed to the drafting of the introduction, the background of the study, and reviewed and edited the article. EK and SD developed the framework and wrote the methodology. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The population is aging worldwide, creating new challenges to the quality of life of older adults and their families. Falls are an increasing, but not inevitable, threat to older adults. Information technologies provide several solutions to address falls, but smart homes and the most available solutions require expensive and invasive infrastructures. In this study, we propose a novel approach to classify and detect falls of older adults in their homes through low-resolution infrared sensors that are affordable, non-intrusive, do not disturb privacy, and are more acceptable to older adults. Using data collected between 2019 and 2020 with the eHomeseniors platform, we determine activity scores of older adults moving across two rooms in a house and represent an older adult fall through skeletonization. We find that our twofold approach effectively detects activity patterns and precisely identifies falls. Our study provides insights to physicians about the daily activities of their older adults and could potentially help them make decisions in case of abnormal behavior. According to studies conducted at the World Health Organization , a largeWith advancing age, diseases begin to appear, characterized by a gradual deterioration of older adults’ physical and mental health , where fAdvances in technology and lower hardware costs have made it possible to address the problems of older adults through information technologies from a preventive, rather than reactive, perspective . In thisThe technologies that support smart homes range from electronic medical devices to sensors. In this regard, presence sensors are electronic devices that run internal systems that detect movement in the area or environment where they are located . In smarBecause of this scenario, we proposed eHomeseniors , a platfIn this paper, we describe an extension of the eHomeseniors platform which addresses human behavior by capturing, analyzing, and permanently monitoring basic and instrumental activities of daily living in older adults through non-intrusive and low-resolution thermal infrared sensors. These sensors are specially designed for object detection, classification, and positioning, and the detection of shapes, colors, and surface differences, even under extreme environmental conditions. We analyzed two methods to evaluate the daily activity of the older adult, which are the analysis of the presence of the older adult in rooms and skeletonization techniques. We applied our proposal to older adults who are users of the eHomeseniors platform and analyzed the results obtained.The paper is structured as follows: Using sensors to detect, react to, and mitigate falls is relevant to improving the quality of life of older adults ,13,14,15De Miguel et al.  proposedNahian et al.  discusseGalvao et al.  describeAzeem et al.  proposedSantos et al.  proposedhttp://www.ehomeseniors.cl, accessed on 7 March 2022) is a non-invasive monitoring platform aimed at preventing falls and caring for older adults both at home and outside the home by installing sensors and portable devices explicitly designed for emergencies [EHomeseniors )-based dataset. This dataset contains 33 columns corresponding to the timestamp and 32 to measurements. Algorithm A2 (see https://numpy.org (accessed on 7 March 2022)). The dataset consists of an array containing the number of frames (matrices) captured in a given h. Finally, Algorithm A3  is performed differently (1D vs. 2D), so the calculation of the activity score differs for each case. In this regard, Algorithm A1 see  capturesm A2 see  capture m A3 see  calculatscore dataset and 22,200 bytes for filtered_dataset are obtained. We also produce 51.5% as average compression rate for 1D array and 51.64% for 2D with an average CPU usage time of 0.009 s. The compression algorithm is applied after the filtered_dataset array formation process to optimize the process, generating a new array called compressed_dataset, which will be available and consumed by the messaging process. The decompression process is performed in the subscriber; therefore, on some occasions, it will be convenient to decompress data using Algorithm A5.The datasets generated in Algorithm A1 are composed of 33 characters, while Algorithm A2 generates 32 lines of 24 characters. These lines are fixed arrays with several decimal values. However, the last five digits of the arrays generated by the sensors correspond to non-significant zero values for measurement purposes, which increase the volume of data for storage and transport by 20%. Therefore, in order to optimize the system’s performance concerning RQ1, we developed two algorithms to compress . We empirically found that this approach performs as well as determining this threshold according to the Otsu statistical criterion that is typically used for this task. We preferred the user-defined criterion in order to reduce the computational burden.We used a series of morphological operations in binary images computed on each time frame with the purpose of preparing data provided by the sensors for the classification into the falling and non-falling classes. Thus, the binary objects within the images were transformed into their single-pixel-wide skeleton representations .Skeletonization is commonly used in morphological image processing for determining rough features of the objects present in the image, e.g., the length of an object, differences in object shapes, among others . SkeletoSkeletons are the center line of an object that are obtained as a two-step process by repeated thinning and pruning skeleton candidates that do not contribute to preserve connectivity. These two steps are repeated iteratively until convergence. This work resorts to the widely used algorithm proposed by Zhang and Suen ,23. An eThe next step is to represent the obtained skeletons as graphs. In this regard, the obtained skeletons were subsampled in order to define graph nodes. The vertices of the graphs were determined according to connected components in the non-subsampled skeleton. Additionally, the graphs (subsampled skeletons) were connected along the selected time span for combining into a single graph the temporal dynamic of the object and its morphology.k, i.e., number of neurons within the hidden layer of Graph2Vec, was set to 30. This value was determined by a grid search strategy. The final step is to evaluate the Graph2Vec neural network . Graph2VWe identify potential threats to the internal, external, conclusion, and construct validity of our study. In the following sections, we describe the threats and how we mitigate them.The main threat detected is the apprehension of older adults to be evaluated. It is natural for older adults to be afraid of being evaluated with instruments and technological infrastructure within their homes. To mitigate this threat, we have mentioned to patients that the results obtained in this study are strictly for research purposes. Throughout the process of explaining the objectives of our study, a medical team guided us to answer more specific questions. In turn, the data obtained are confidential. Regarding the installation of sensors, we have created a non-invasive technological infrastructure in order to safeguard the privacy of older adults in their homes.The threat to the internal validity of our study is the different behavior of each subject in their homes. It is natural that each older adult has his or her routine at home and that there may not necessarily be behavioral patterns that help us infer when an older adult suffers a fall or not. On the other hand, it may be that each older adult understands the instructions differently, i.e., not everyone has the same ability to execute the instructions in the case study. To mitigate these threats, we have studied each patient’s profile and clinical records. We have created a mobile application that allows us to assess the clinical profile of the elderly patient in order to enable them to participate in the study. The results delivered by the mobile application allow us to identify and categorize patients in order to obtain more precise sensor data.The identified threat to external validity is having an unrepresentative group of subjects to generalize the results, i.e., having the wrong subjects to participate in the case study. We have consulted with medical teams on what type of older adults can participate in our research to mitigate this threat. As a result, we identified and characterized variables to select older adults for the case study. These variables were validated by a medical team specialized in older adults.We have identified heterogeneity of the study group as a potential threat. In case the study group is very heterogeneous, there may be a risk of variation in the results of our study. To mitigate this threat, we have defined inclusion and exclusion criteria to select subjects. These criteria allow us to select homogeneous subjects in order not to affect the validity of our study.The geographical area where the sensors and the technical infrastructure of the case study are located leads to several challenges. The cities where the study subjects live are characterized by mountainous terrain. This implies that 3G and 4G signals present connectivity problems in some homes. Therefore, in this study, we selected homes of older adults whose connectivity to 3G and 4G networks were robust enough to conduct the case study. We propose a 5G-based connectivity solution for those homes with problems, which will be addressed in future work.https://pandas.pydata.org (accessed on 7 March 2022)) and numpy (https://numpy.org (accessed on 7 March 2022)) libraries, we can describe the presence scores through a stakeholder-friendly dashboard. This dashboard is composed of days, weeks, and months.The calculation of presence scores potentially allows obtaining important information in order to classify the daily activities of older adults. In order to have a better insight about daily activity evolution along the year, we calculate mean hourly activity for each month, i.e., the activity at each hour of the day and each room is averaged over one month. Furthermore, if we extend Both figures show the difference between an older adult with a lot of movement in a home versus an older adult with little movement. In The validation of the fall detection system was performed using a dataset acquired in our laboratory. This dataset contains 120 falls and 120 non-falls data frames from 10 subjects. The expected precision of the proposed fall detection model is 90.8% (sensitivity: 90.8% and specificity: 90.9%) according to the training performed using the abovementioned dataset. Additionally, a total of 12 falls has been alerted by our falling detection system. From these alerts, the call center confirmed one effective fall . The rest of the alerts corresponded to false positives.During 2019, out of a total of 12 fall alerts, one effective fall was detected, and 11 false positives were detected as falls events, such as turning on (or moving) a cooker, cleaning, and 8 other events that were not specified in the system by the telephonists. The response time between the detection of the events and the call from the call center  was, on average, 4 min and 48 s.During 2020, in order to recognize more movement patterns in falls, the thresholds and the classifier developed were modified, which resulted in several other actions of older adults being detected as false positives, such as coming to rest (sitting or lying down) and picking up objects from the floor. However, during this period, there were no positive alerts as no older adults suffered from falls. In mid-2020 and analyzing the alerts received, the classifier was modified again in order to filter out the actions of older adults that were causing false positives. These modifications were successfully performed, and in the following months, alerts for activities such as picking up objects, sitting, lying down, housekeeping activities, and moving/lighting a cooker were reduced (and even completely filtered out).The results obtained by the activity scores allow the visualization of periods of time in which the older adult presents an abnormality  in their daily activities. The data generated by the daily visualization of the older adult’s activities allow us to infer patterns of behavior of the older adult in order to estimate a fall at a certain point in time. In our experience, this information is advantageous in determining protocols and processes for immediate action to assist the older adult. Although the strategy of using activity scores may be straightforward, this method allows us to generate significant knowledge regarding fall prevention. In this regard, some of the results we have analyzed are related to determining trends in the charts illustrated in On the other hand, Regarding the use of infrared sensors to detect falls through skeletal analysis of the patient, the results obtained in our study reveal that our proposal delivers promising results for fall estimation. The falls detected between 2019 and 2020 allow us to analyze and evaluate the benefits of using infrared sensors as variables to detect and react to falls. In this regard, other studies such as  discuss The skeletal analysis and the diagram of the older adult’s daily activities that we have proposed allow us to define a more precise protocol for informing family members and clinical units in the event of a fall at home. On the one hand, the skeletal analysis gives us the first alert about a human body presenting an anomaly in the patient’s morphology that could be a potential fall. On the other hand, the daily activity analysis reveals, in real time, a low score of the patient in a period of time where the patient usually presents a higher score. These variables are input to define action protocol and alert all stakeholders about a potential fall. This protocol takes data from the daily activity of the older adult and data from the skeletal representation in order to provide early warnings. The protocol considers the following data: (i) the person who receives the fall alert, whether or not they respond to the call, (ii) the start date of the potential fall , (iii) the end date (when the older adult was attended to or stood up on their own), (iv) the notification date, and (v) comment on the fall entered by an analyst on the eHomeseniors platform.The main advantage of our proposal is that we can obtain promising results regarding the detection of falls in older adults through a cost-effective platform based on infrared sensors. The use of this type of sensors allows us to create concrete technological solutions that are able to analyze different behaviors of older adults and, at the same time, optimize costs to be affordable to the budget of older adults. At the same time, the implementation of this platform becomes a support for both the older adult and their social environment, reducing the need for caregivers in their daily activities. On the other hand, the main limitation is related to the geographic difficulty in which the older adults who participated in our study live. The vast majority of the homes are located in a hilly and mountainous area, which limits the communication between the sensors and the eHomeseniors platform. In addition, although older adults accepted the installation of the sensors in their homes, it is not possible to prevent them from disconnecting the sensors themselves, either intentionally or unintentionally. Therefore, an expert clinical accompaniment in the psychological treatment of the older adult is significant to avoid disrupting the communication between the sensors and the eHomeseniors platform and thus not altering the fall detection processes and algorithms.Regarding the lessons learned in our study, we realized that it is also necessary to know the trajectory of the older adult within the home to improve the results of fall detection. The results obtained in the research questions, together with the entropy in the trajectories of the older adult, can optimize the action plan to detect a potential fall. According to ,26, if wTo further our research, we aim to use the data from our proposal to calculate the entropy in the trajectories of the older adult to detect abnormal behavior patterns that can be associated with symptoms of chronic diseases. Additionally, we want to evaluate the implementation of gas sensors  for early detection of gas leaks and/or lack of oxygen.In this paper, we presented an approach to classify and detect falls of older adults in their homes through infrared sensors. We applied this extension to the eHomeseniors platform, which aims to monitor older adults at home. On the one hand, we proposed an activity measurement algorithm that compares the temperature of each sensor pixel with the temperature to calculate the activity scores of an older adult in a room. On the other hand, we used graph techniques to represent the human body as a skeleton in order to propose an algorithm to establish the fall of an older adult by checking the positions that belong to the skeleton. For both cases, we used non-invasive infrared thermal sensors to respect the older adult’s privacy. We evaluated both methods with a group of older adults who are users of the eHomeseniors platform. The results of our study describe that by combining both methods, it is possible to establish more precise alerts to classify and detect falls. We also identified that the falls detected between 2019 and 2020 were indeed real falls. This implies that the older adult’s families and the emergency network can act early in the event of a fall and thus improve the older adult’s quality of life.


The objectives of this scoping review are to investigate the characteristics assessed by existing vulnerability indices and the health outcomes achieved by applying them to people experiencing homelessness. This review forms part of the development and implementation of a novel tool to prioritise people experiencing homelessness for healthcare based on their need and capacity to access healthcare.Included papers were primary research, published in the English language, participants were experiencing homelessness and aged over 18 years at the time of the study, a vulnerability index was used in the study, sample size was greater than 30, and the study had a health focus. Databases searched were MEDLINE, Embase, CINAHL, Scopus, PubMed and Web of Science, between January-April 2020. The Joanna Briggs Appraisal criteria were used to quality appraise the included studies. Results were synthesised narratively.Six papers were included, a total of 27,509 participants. The reported use of the indices varied; they included screening and profiling homeless populations, comparing homeless populations, and two studies evaluated the predictive capacity, reliability and validity of the indices. One vulnerability index focused on screening for human immunodeficiency virus, one used a 50-item index and four used a nine-item index. No direct health outcomes were reported from applying the vulnerability indices. The studies identified limitations of using vulnerability indices, including the potential bias of relying on self-reported data and two studies highlighted the need for further psychometric testing to ensure validity and reliability of the indices.The sample of included studies was small. Vulnerability indices are reportedly a useful and easily accessible method of gaining valuable data on the health status and health needs of people experiencing homelessness. The variety of characteristics included in the vulnerability indices suggests the importance of tailoring vulnerability indices to the needs of the population to which it is to be applied. Conducting appropriate psychometric testing is critical so that an index can be used to accurately inform decision making and accurately prioritise people experiencing homelessness who are most at risk of mortality and morbidity. A specific tool that prioritises people experiencing homelessness for access to health care is not yet available. The review was funded by a St Vincent’s Network Inclusive Health grant. This scoping review investigates the characteristics assessed by existing vulnerability indices and the health outcomes achieved by applying them to people experiencing homelessness. Vulnerability indices are used to assess mortality and morbidity of people experiencing homelessness in order to prioritise them for housing. Defined further below, vulnerability indices ask a series of questions relating to a person’s health and wellbeing and populate a risk score based on self-reported data, to prioritise people for housing. This review underpins the development of a novel tool to prioritise people experiencing homelessness for healthcare (rather than housing) based on an assessment of their healthcare need and their capacity to access healthcare.People experiencing homelessness have poorer health outcomes than the general population , 2. ExpeThere is disproportionate use of acute health services by those experiencing homelessness . People In the context of homelessness, the first vulnerability index was developed in 2007 by Common Ground, a homelessness service in New York City, for the purpose of assessing medical vulnerability and to prioritise housing for people experiencing homelessness . Based oAccording to the Australian Bureau of Statistics’ (ABS) definition, homelessness is when a person has no suitable accommodation and lives in an inadequate dwelling, has no or limited/non-extendable tenure, and has no control of/no access to or space for social relations . HomelesIn Australia, more than 116,000 people are experiencing homelessness . The CitThe authors of this review practice at St Vincent’s Hospital Homeless Health Service, Sydney, Australia. Established in 2010, the Homeless Health Service consists of a multidisciplinary team of nurses, doctors, allied health professionals, drug and alcohol clinicians, oral health educators, peer support workers, and Aboriginal health workers. The service provides holistic, multidisciplinary healthcare and support to people experiencing homelessness in the City of Sydney Local Government Area (LGA). To date, the Homeless Health Service has not employed any form of assessment tool to identify clients experiencing homelessness at particular risk of mortality and morbidity. This review is the first stage of a project to develop and implement a tool to prioritise people experiencing homelessness for access to healthcare services based on their health need and their capacity to access healthcare.A scoping review was undertaken to synthesise current evidence on the characteristics included in existing vulnerability indices and their application to people experiencing homelessness , 23. TheIn the context of homelessness, what characteristics, health conditions and comorbidities are assessed by existing vulnerability indices?What health outcomes have been achieved by applying vulnerability indices to people experiencing homelessness?The population of interest was people experiencing homelessness in any country of the world. The intervention was any type of vulnerability indices. The outcomes of interest were the characteristics included in each vulnerability index and any health outcomes achieved from applying a vulnerability index.10.15124/CRD42020166983) in January 2020, and later amended to a scoping review on account of the breadth of the research questions.A scoping review of the literature was conducted between January and April 2020, reported here in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses Scoping Review extension (PRISMA-ScR) guidelines . A studymeasure* OR risk factor* and resulted in a diverse range of papers that were non-applicable to the research questions and were therefore excluded. The final search terms are shown in The search strategy was identified by the authorship team, a multidisciplinary team of clinicians and academics with considerable knowledge of health service delivery to people experiencing homelessness. Prior to agreeing to the selected search terms  a scopinVulnerability Index AND Homelessness were searched through Google Scholar. Saturation was reached after the first four pages of results.A search of prominent authors in the field of homelessness was also undertaken . In addition, the search terms All search results (n = 430) were exported to EndNote X8 for eligibility assessment. After removing duplicates (n = 213) the abstracts were screened against the inclusion and exclusion criteria, shown in Given that the results of this scoping review were to be used to underpin the development of a clinical tool, the research team undertook a critical appraisal of the included studies. The critical appraisal was undertaken using the Joanna Briggs Analytical Cross Section Design Appraisal criteria . Two autA data charting form was developed by two of the authors (EG & JC) and reviewed by all authors, there was unanimous agreement in the characteristics extracted from the included studies. The data charting was undertaken independently by two authors (EG & JC) and then findings were compared and discussed. There were no disagreements between the two authors and the findings extracted were extremely similar. Data extraction included author, year, country, participants, study design, results and conclusion. Also extracted from the studies were the characteristics included in each vulnerability index, including the demographic data, health history and health service usage.This scoping review investigated the characteristics assessed by vulnerability indices and the health outcomes achieved by applying vulnerability indices to people experiencing homelessness. There was unanimous agreement that six studies met the inclusion and exclusion criteria and were included in this systematic review. The results of the search process are outlined in Overall, the selected papers were of a high quality and therefore none of the studies were removed on the basis of rigour . Each stIn one other study the description of the settings from which the subjects were drawn was unclear . This stThe final analysis included six studies , all quaThe aims of the studies varied. One study used a vulnerability index to establish a health profile of a homeless population,  one studWhere reported, the mean age of participants was 48 years , 25 and The included studies used different vulnerability indices and included different characteristics, as shown in The health history reported through the four studies using the original vulnerability index was similar and included cold injury (frostbite) , 25, 26.The health service usage reported by each of the studies varied, reflecting the different aims of the studies. For example, in their examination of the reliability and validity of the VI-SPDAT, Brown and colleagues (2018) elicited detailed data relating to the frequency of participants’ attendance to ED, crisis services, inpatient services, ambulance attendances, treatment for drug or alcohol dependence, and mental health review in the past six months. Two studies did not report health service use , 28.While none of the studies identified any specific health outcomes achieved by applying a vulnerability index, the studies highlight specific risk factors for increased morbidity and mortality, such as being female, prior military service, continuous homelessness of greater than five years, prior incarceration, lower levels of education and a history of substance use . The stuThe included studies identified limitations of using vulnerability indices. Studies using the original vulnerability index highlighted the self-report nature of data collection as a limitation due to the potential subjectivity of responses , 25, 26.Another limitation highlighted was the predictive capacity of the original vulnerability index. In their postdictive validity study of the vulnerability index, Cronley and colleagues 2013) suggest that their findings offer ‘…tentative support…’ for the validity of the vulnerability index and its capacity to predict hospital admissions, in so far as individuals who scored higher on the vulnerability index had more frequent hospital admissions [ suggest The authors using the VI-SPDAT reported a tendency for participants to over-report and recommended triangulation of sources of data other than self-report . The autIn relation to the research questions posed by this scoping review, the characteristics included in the vulnerability indices used in the studies, the most common demographic characteristics were age and housing status/history, most commonly included health history characteristics were trimorbidity, substance use, mental health, liver, kidney and heart disease, emphysema and asthma, cold weather injury, diabetes and cancer. There were no specific health outcomes reported from applying any of the vulnerability index tools, as this was not an aim of any of the included studies.This paper reports a scoping review of the application of vulnerability indices to people experiencing homelessness. In developing and implementing a tool for the Australian context, we identified three translational findings from this review.Our first finding is that the breadth of characteristics included in existing vulnerability indices suggest that an index can be tailored to the context and service in which it will be used . The mosSecondly, our project requires that we develop a vulnerability index designed specifically to prioritise clients for access to health care. Both the VI-SPDAT and the original vulnerability index have been successfully applied to homelessness services across Australia to prioritise clients for housing , 27. NowThirdly, the tool needs appropriate psychometric testing. Whilst proven valuable as a data collection tool, the capacity of the original vulnerability index to predict outcomes is less certain , 25, 26.The overall findings of this scoping review demonstrate the use of vulnerability indices as tools to identify the health status of homeless populations. In our St Vincent’s Hospital project, we have gained permission to modify the VI-SPDAT to develop a specific health version of this existing tool.This scoping review has some limitations. Using articles and databases in English language meant relevant non-English studies were not identified. The search was limited to peer-reviewed publications. In the search there were several government reports identified, and these were excluded. The sample of identified studies was relatively small. Only six studies met the inclusion criteria for this review, indicating the need for more peer-reviewed publications that apply a vulnerability index to homeless populations.People experiencing homelessness are known to be vulnerable to poor health outcomes. Vulnerability indices are a proven method of gaining data on the health status and health needs of people experiencing homelessness. In developing and implementing a vulnerability index as part of this St Vincent’s Hospital project, the findings of this scoping review indicate that existing indexes have been tailored to the needs of the population to which it is to be applied. Furthermore, conducting thorough psychometric testing is important so that an index can be used as an accurate predictor of risk of mortality and morbidity.S1 Checklist(PDF)Click here for additional data file.S1 File(DOCX)Click here for additional data file.