There are few studies on the influence of a cash transfer program on nutritional outcomes from pregnancy.To analyze how a Brazilian conditional cash transfer program  was associated with changes in body mass index (BMI) and food consumption among pregnant women.Cohort study on 250 pregnant women (≥ 18 years of age) in Brazilian prenatal services.A food frequency questionnaire was used to evaluate dietary intake. Weight was measured in each gestational trimester. Generalized estimation equations and structural equation modeling were used for statistical analyses. Correlations were analyzed using standardized coefficients (SCs).Women benefitting from the BFP were of greater age and had lower education. The BFP exerted a direct negative effect on the pregnant women’s consumption choices regarding refined grains, regional foods, vegetable oil, sausages, salted meats and snacks (SC = -0.10) and on maternal BMI (SC = -0.12). Among the intermediate variables, we observed that the time elapsed since pregnancy and the month of prenatal onset had direct negative effects; and that the number of visits to doctors, family income and number of years of education had direct positive effects.Beneficiaries were less likely to increase their BMI outside of the recommended standards and had a greater tendency to receive prenatal care. Participation in the BFP had a direct negative effect on adherence to unhealthy diets. These programs have important effects with regard to improving maternal and child health and nutrition and diminishing child and maternal mortality rates. However, there is an important gap in knowledge regarding interventions through such programs on the diets and gestational weight gains of women living in low and middle-income countries. Thus, epidemiological studies on the repercussions of social protection policies on the health and nutrition of pregnant women are important for evaluating these intervention programs.Social protection programs for health have grown in popularity around the world, especially for pregnant women within a context of vulnerability to hunger and food insecurity.There is evidence to suggest that social protection policies such as the Brazilian conditional cash transfer program  attenuate the effects of poverty and ensure the human right to adequate food, thereby promoting food and nutritional security (FNS).In order to remain in the BFP, families must comply with requirements within the areas of education and health. With regard to health, these requirements include prenatal monitoring for pregnant beneficiaries, attendance at scheduled visits to doctors and educational activities relating to breastfeeding and adequate and healthy feeding during pregnancy and early childhood. than those who are not program beneficiaries. The results indicate that the BFP constitutes a protective factor for the health of the mother-child binomial. This is due to early attention to improvement of health, thus resulting in adequate and healthy nutrition; and to adoption of preventive measures with regard to risk factors that compromise proper development of gestation, especially in the initial cycles of fetal formation.The results from some studies have shown that pregnant women in the BFP begin prenatal care earlier and have a greater number of visits to doctorsIn addition, beneficiaries of this program have made progress in seeking out nutritional care. In 2012, approximately 165,000 Brazilian pregnant women were monitored by healthcare teams. Among these women, 99% were up-to-date with their prenatal care and 80% had undergone evaluation of their nutritional status.Regarding the destination of the funds provided by the BFP, the results show that most families used the benefit to purchase foodstuffs. This proportion was higher in the northeastern region and among families in situations of greater food and nutritional insecurity (FNI). According to the beneficiaries, the food groups most consumed were rice and grains and milk, with a smaller percentage for vegetables and roots.An epidemiological survey conducted in Brazil revealed changes to the population’s diet after its integration into the BFP. This contributed to greater food and nutritional security among these households through increasing their access to foods such as vegetables, eggs, oils, fruits, beans, meats, grains, milk, biscuits, processed foods and sugars. reduced the prevalence of low birth weight and reduced the child mortality rate, both in general and due to poverty-associated causes. Information on the influence of the program on pregnant women’s food consumption and anthropometric patterns, however, is only just beginning to emerge.In relation to the maternal-infant group, studies have shown that the BFP had positive effects on maternal health conditions, improved children’s health and nutritional status,Given the impact of the BFP on pregnant women’s health, our key hypothesis was that women who were beneficiaries of the BFP would have greater number of consultations in prenatal services, which would provide these women with a greater amount of nutritional counseling and monitoring from the healthcare teams. Therefore, women who were beneficiaries would achieve a positive impact on their nutrition and the beneficiaries would attain better control of weight gain during pregnancy. In addition, we postulated that the cash transfers would increase pregnant women’s food and nutritional security, through their adoption of healthier eating habits during pregnancy.Thus, the BFP can be considered to be a social protection policy that contributes positively towards ensuring FNS. In addition, it is probable that the BFP can influence these relationships directly or indirectly, or in an intermediary fashion.The aim of this study was to examine whether the Brazilian conditional cash transfer program was associated with changes to body mass index, food consumption and prenatal care, among pregnant women.This was a prospective cohort study using a dynamic population of 250 pregnant women living in an urban area who were treated at Family Health Strategy (FHS) units in the city of Santo Antônio de Jesus, Bahia, in the northeastern region of Brazil. These women formed part of the NISAMI Cohort . The flowchart for the cohort is presented in Pregnant women were recruited at prenatal services between August 2013 and December 2014. The monitoring lasted for nine months. When a pregnant woman was enrolled in the study after the first trimester of pregnancy, previous weight data were collected from the medical records available at the prenatal health unit. Data on socioeconomic, demographic, health and obstetric status and access to the BFP were collected at the time of the pregnant women’s enrollment in the study.The study included women who lived in the municipality’s urban area, were aged 18 years or over, had gestational ages of up to 34 weeks at the time of enrollment and were receiving prenatal care through the public healthcare system.The criteria for exclusion after the baseline consisted of the following: twin/multiple pregnancy; adherence to a vegan diet; and renal, contagious, immunological and/or metabolic and HIV diseases confirmed via medical diagnosis. Absence of confirmation of gestational age through ultrasonography was also a reason for excluding pregnant women from the study. Gestational age was recorded from the first ultrasound, which was performed by the end of the first trimester and documented in the prenatal services.Thus, 379 pregnant women met these criteria and were invited to participate in the study. They were invited to answer a closed-end questionnaire and to send blood samples to a clinical laboratory in the city after overnight fasting. Among these women, 107 refused to have blood collected and another 13 women refused to answer the food frequency questionnaire (FFQ). Consequently, a total of 259 pregnant women were eligible to participate. There were nine losses during the follow-up. Among these, six pregnant women did not fully complete the questionnaires and three had miscarriages. After these exclusions, 250 pregnant women were effectively included in the study and monitored for nine months . The exposure variable consisted of receipt of BFP benefits.The Bolsa Familia Program (BFP) is a conditional cash transfer program that was created in October 2003 through Provisional Measure No. 132. It was aimed at poor and extremely poor families and used per capita family income as the inclusion criterion.We adopted two continuous response variables: gestational body mass index (BMI) variation during gestation ; and dietary intake pattern relating to fatty acid, at the time of enrollment.For maternal weight measurements in the first, second and third gestational trimesters, we used a scale with a capacity of 150 kg and sensitivity of 100 g . To measure height, a stadiometer was used, with a capacity of 2000 cm and sensitivity of 0.1 cm . Anthropometric measurements were made in duplicate. A maximum variation of 0.5 cm was accepted for length measurement, and a maximum variation of 100 g for weight. This instrument assesses 89 dietary sources of these lipids, with 13 possible responses for consumption, ranging from rarely/never to ≥ 3 times per day.To evaluate fatty acid consumption, the semi-quantitative FFQ was used.A photograph album of food portions and kitchen utensils was used to assist in making estimates of the portion sizes consumed, from the interviewees’ memory. Data on frequencies of consumption of foods and the portions consumed were inserted into a spreadsheet and calculated, using an adaptation from Santana et al. In this, daily food intake frequency was assigned a value of one. For the weekly and monthly time intervals, the mean of the interval was divided by the period of fatty acid consumption: when weekly, it was assigned the value of 7, and when monthly, the value was 30.To analyze consumption, we used daily food consumption. Thus, all time intervals relating to polyunsaturated fatty acid consumption were converted into the daily frequency of polyunsaturated fatty acid consumption.The daily frequency of consumption of each food was used to form food groups that had the same nutritional characteristics, namely: milk and dairy products, fish, fruits and vegetables, olive oil, oilseeds and whole grains, refined grains, foodstuffs that were part of regional dishes, vegetable oil, sausages, salted meats and foods belonging to the snack and processed foods group.The power of this sample to detect an association between the Bolsa Familia Program and a pregnant woman’s nutritional status was 96%. This calculation was based on the prevalence of excess weight gain of 48.1%, among pregnant women in the municipality of the present study.Descriptive analyses were used to characterize the sample. Mean and standard deviation (SD) were used for the continuous variables . The sociodemographic and anthropometric characteristics of the pregnant women according to the BFP exposure variables were compared using Student’s t test.In this study, the BFP was adopted as a categorical dependent variable, dichotomized into (0) beneficiaries of the program and (1) non-beneficiaries of the program. The main exposure variables were the fatty acid consumption pattern and gestational BMI, and these were used in a continuous form. The following covariates were considered in continuous format: maternal age, number of years of education, family income, number of residents, number of gestational weeks, BMI, body weight (BW), birthweight gain, prenatal visits and time when prenatal services started.The BMI variable was constructed longitudinally, considering weight variation in the first, second and third gestational trimesters using generalized estimation equations. Later on, this variable in its continuous form was exported to the structural equation model (SEM) in order to evaluate the influence of the BFP on BMI variation during gestation. This strategy was adopted because the model in the SEM did not fit when the variable “gestational weight gain variation over time” was included in the confirmatory equation of the factorial analysis.Dropout analyses were performed to investigate the presence of selection bias, through comparing the mothers who completed the study with those who were lost or excluded during the monitoring. The following variables were considered: age and consumption of mono and polyunsaturated fatty acids.The baseline consumption of polyunsaturated fatty acids gave rise to two latent variables. These two variables are here denominated “Pattern 1”  and “Pattern 2” . These patterns were established internally in SEM by using confirmatory factorial analysis and were included in analyses in the continuous form. The composition of the fatty acid consumption pattern and its respective standardized coefficients are presented in  The RMSEA model (root of the mean square error of approximation) was used to evaluate goodness of fit. The statistical analyses were carried out using the Stata software .The direct, indirect and total effects of the relationships studied were evaluated through standardized coefficients (SCs), and these were interpreted as a small effect , medium effect  or strong effect .This study was approved by the Ethics Committee for Research involving Human Beings of the Universidade Federal do Recôncavo da Bahia (UFRB), under the number 241.225, dated April 9, 2013. All study procedures were carried out in accordance with the code of ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans. Informed consent was obtained for experimentation with human subjects and the privacy rights of human subjects were observed.Out of the 259 pregnant women considered for the study, 250 women were included , and theThe sociodemographic and anthropometric characteristics of the pregnant beneficiaries (28.8%) and non-beneficiaries (71.2%) of the BFP are presented in Information on the daily frequencies of consumption of food groups that were present in the diet of the pregnant beneficiaries and non-beneficiaries of the BFP is set out in The composition of the fatty acid consumption pattern and its respective standardized coefficients are shown in caruru, vatapá, vegetable oil, sausages, salted meats and snacks) and presented lower BMI during the gestational cycle  and on BMI during pregnancy . This indicated that pregnant women who were beneficiaries of the program had lower adherence to pattern 2 fatty acid dietary intake  and time when prenatal care started  on the relationship between the BFP and anthropometric status and fatty acid dietary intake conditions throughout gestation, thus indicating that the beneficiaries were younger and began prenatal care earlier. In this relationship, the following variables showed positive effects: number of prenatal consultations , family income  and number of years of schooling  showed positive effects. This indicated that the BFP had a positive impact on increased income, greater maternal education and greater number of prenatal consultations .This study was one of the first in Brazil to investigate the influence of pregnant women’s participation in the Bolsa Familia Program on BMI during pregnancy. The results indicate that pregnant beneficiaries of the BFP had lower adherence to food consumption pattern 2, composed of foods and preparations containing high concentrations of fatty acids, vegetable oil, sausages, salted meats and salty snacks than non-beneficiary pregnant women.In this context, the results suggest that, as a social policy, the Bolsa Familia Program exerts a protective effect on maternal nutritional health, through increasing access to and consumption of the traditional basic foodstuffs within a healthy diet among Brazilian families, consisting of milk and dairy products, beans, meat, eggs and grains. These food groups have an outstanding physiological function within the development of adequate gestation and maintenance of women’s weight throughout pregnancy. It is also worth noting that the results from this study can be interpreted in the light of proposals for social protection programs (PTCRs). These programs focus not only on direct cash transfers to families in order to alleviate poverty over the short term, but also on requirements that encourage beneficiaries to access healthcare and educational services. Accordingly, the results from this study substantiate the direct relationship between the protective aspect of cash transfer programs and the underprivileged population’s health and nutrition.Population-based studies have shown that PTCRs improve the economic conditions of poor households, which in turn promotes greater access to food and contributes towards ensuring these households’ FNS.Among the direct effects of these programs are those relating to the gestational cycle, which ensure that pregnant women have access both to food and to prenatal and postpartum consultations, in addition to ensuring their participation in educational interventions relating to nutrition and health within the public healthcare network. There was greater monitoring of its requirements, specifically in the area of healthcare, in municipalities where the Family Health Strategy covered more than 70% of the population. This showed that dialogue between these two public health programs favored interaction between positive health and nutritional actions in the population.In a qualitative and quantitative study carried out in municipalities of the state of Bahia, it was found that the Bolsa Familia Program was one of the programs within the National Food and Nutrition Policy that had the greatest coverage in the municipalities evaluated.Thus, adherence to the population’s traditional diet and reduction of consumption of industrialized and processed foods, along with improvement of anthropometric conditions, may reflect the actions of the Bolsa Familia Program. These actions do not mitigate the social determinants but provide guidance that promotes adoption of health and nutritional practices that lead to a healthier lifestyle. The results from the Bolsa Familia Program are consistent with those from other studies conducted elsewhere in the world. In this regard, a randomized, cluster-controlled clinical trial found that both direct income interventions and direct food interventions improved the nutritional consumption and nutritional status of low-income pregnant women in Nepal, Asia. In addition, conditional cash transfers further improved food diversity in family units.However, a randomized clinical trial that was conducted to evaluate the effectiveness of cash transfers in relation to searching for higher-level infrastructure and equipment services, among low-income African pregnant women in Nairobi, Kenya, did not observe any positive impact on their search for quality services for childbirth delivery. Those families invested an average of US$ 61.61 more per year for purchasing food than did non-beneficiary families. Reports from beneficiaries have indicated that families increase their purchases of rice, beans, chickenmeat, grains, milk, sugar, cookies, meats, oils, eggs, fruits, roots and processed foods after being included in the Bolsa Familia Program. It was seen that the food groups most frequently purchased were sugars (78%), rice and cereals (76%) and milk (68%), with lesser acquisition of foods in the vegetable group (40%).Nonetheless, the results from a study on Brazilian families who were in situations of poverty corroborated previous results.Research results from a region close to that of the present study showed that beneficiary families’ diets improved after the program had been established in that region, and that the money received was mainly spent on food (76.4%). There was also an increase in the variety of the foods consumed.Although the pregnant women of the present study included the Brazilian population’s basic healthy food groups in their daily diet , low consumption of fruits and vegetables was registered. These results were similar to those of other investigations carried out among adult Bolsa Familia Program women, and indicated that there was greater access to food after they had been included in the Bolsa Familia Program. Nevertheless, their consumption of vegetables, fruits and legumes remained lower than expected.The results from the investigations have highlighted social, economic and cultural influences, as well as the geographical region’s dietary habits, in constructing the population’s dietary patterns. Accordingly, in less favorable socioeconomic contexts such as that of Brazil’s northeastern region, families have tended to adapt to subsistence mechanisms and buy the basic and cheaper foodstuffs that are part of the population’s diet, while those living in economically more developed regions have adopted greater consumption of processed foods. This result may also be expressing a positive effect from interaction between the Bolsa Familia Program and the FHS program, with greater access to prenatal care for pregnant Bolsa Familia Program beneficiaries and implementation of nutritional and health monitoring interventions throughout the prenatal care period. The net result is a protective impact on maternal and fetal health.Thus, we have highlighted the monitoring and follow-up of pregnant Brazilian beneficiaries of the Bolsa Familia Program through the Family Health Strategy program, with regard to prenatal care actions, with more pronounced insertion in the northeastern region.Certainly, the focus of the Bolsa Familia Program has enabled increased family income, which is a major factor in expanding beneficiaries’ access to food. Thus, the beneficiaries’ average family income was slightly higher than the minimum wage at the time , although, as expected, below the income of non-beneficiaries . In addition, the program has had a positive influence on children’s nutritional status and health, as a result of greater monitoring and mother-child bonding, achieved through actions to prevent risk factors and promote a healthy lifestyle.The Bolsa Familia Program has also had impacts on the health of the maternal and child populations registered in epidemiological studies, which consisted of reducing the prevalence of low birthweight and the mortality rate among children under five years of age, both in general and due to poverty-related causes such as malnutrition and diarrhea. In this light, the Bolsa Familia Program stands out as an intersectoral strategy for social inclusion of vulnerable families, thereby promoting the human right to adequate food (HRAF) through the FNS guarantee.Thus, it has been found that the Bolsa Familia Program has had a positive impact on the health of the population served, through contributing to reduction of malnutrition and FNI, increasing monthly family income and allowing access to food, for previously invisible vulnerable population groups.In this way, the decision of the United Nations Food and Agriculture Organization (FAO) to exclude Brazil from the hunger map in 2014, owing to an 82% reduction in the prevalence of malnutrition in the population, can be understood. In the FAO report, the Bolsa Familia Program was highlighted as one of the social interventions that was able to contribute results with social and human importance at a global level, given that it has played an important role in guaranteeing FNS and promoting HRAF among Brazilian families.This study had some limitations. For instance, information provided by Bolsa Familia Program beneficiaries was used. This may have led to information errors, since these women receiving the benefit may have felt uncomfortable about giving information or may have felt threatened by loss of the benefit if they talked about their condition. Moreover, the pregnant women’s level of physical activity was not analyzed. In our study, however, these differences may not have been significant, given that Family Health Strategy units that serve the population through health monitoring programs, including prenatal care, also exist in rural areas of the municipality. Regarding the losses during the follow-up, we can attest that these were small and were unlikely to have introduced any selection bias in the study.Another limitation related to non-inclusion of rural pregnant women in the study sample. Inclusion of rural pregnant women in the sample should be considered in the future, since groups may have different access to healthcare services according to where they live. This can also occur with regard to food consumption. In studies in other countries, with different epidemiological contexts, it has been reported that pregnant women have differing health and nutrition vulnerabilities according to their area of residence.The robust statistical analysis in our study was a strength. It can thus be concluded that studies that address the Bolsa Familia Program’s impact on pregnant women’s diet and nutrition are at an early stage. We also noted that there was a lack of study designs with robust methodology for dealing with primary data. From this perspective, the present investigation has contributed to filling the gap, through a longitudinal study on the influence of the Bolsa Familia Program on pregnant women’s diets and on maternal weight during pregnancy.This study showed the important role of health conditionalities in expanding access to prenatal services and nutritional guidance during pregnancy, as well as for monitoring and controlling weight gain during pregnancy. Accordingly, the improvement of pregnant women’s parameters may have resulted from the Bolsa Familia Program’s impact on families’ economic conditions, through increasing the population’s access to food staples and providing orientation sessions for improving the beneficiary population’s health and nutrition.This study advances the understanding of the positive influence of a social protection policy on the food and nutrition of specific populations, such as the group of pregnant women in urban areas. However, further studies are needed, especially among pregnant women in rural areas, since these women may have different access to healthcare services.


Infodemic management is an integral part of pandemic management. Ghana Health Services (GHS) together with the UNICEF  Country Office have developed a systematic process that effectively identifies, analyzes, and responds to COVID-19 and vaccine-related misinformation in Ghana.This paper describes an infodemic management system workflow based on digital data collection, qualitative methodology, and human-centered systems to support the COVID-19 vaccine rollout in Ghana with examples of system implementation.The infodemic management system was developed by the Health Promotion Division of the GHS and the UNICEF Country Office. It uses Talkwalker, a social listening software platform, to collect misinformation on the web. The methodology relies on qualitative data analysis and interpretation as well as knowledge cocreation to verify the findings.A multi-sectoral National Misinformation Task Force was established to implement and oversee the misinformation management system. Two members of the task force were responsible for carrying out the analysis. They used Talkwalker to find posts that include the keywords related to COVID-19 vaccine–related discussions. They then assessed the significance of the posts on the basis of the engagement rate and potential reach of the posts, negative sentiments, and contextual factors. The process continues by identifying misinformation within the posts, rating the risk of identified misinformation posts, and developing proposed responses to address them. The results of the analysis are shared weekly with the Misinformation Task Force for their review and verification to ensure that the risk assessment and responses are feasible, practical, and acceptable in the context of Ghana.The paper describes an infodemic management system workflow in Ghana based on qualitative data synthesis that can be used to manage real-time infodemic responses. The COVID-19 pandemic has led to an unprecedented global “infodemic,” which refers to an abundance of rapidly spreading fake news, misinformation, disinformation, and conspiracy theories related to the pandemic. In the ever-expanding digital world, the infodemic has become increasingly problematic as misinformation spreads rapidly through social media channels -4 and reInfodemic management has been acknowledged by many public health organizations as an important emerging scientific field and critical area of practice during epidemics . It inclA growing body of literature on social media platforms has been used to address the infodemic -14. SociInfodemic management benefits from human-centered approaches that encourage knowledge sharing and knowledge cocreation. While definitions vary widely, knowledge cocreation is essentially the bidirectional, interactive development of new knowledge created with input and perspectives from diverse stakeholders including experts and the public. It allows for the development of acceptable and practical interventions that can be better sustained than those that are developed by public health experts alone .In March 2021, Ghana was the first country worldwide to receive COVID-19 vaccines from the COVAX facility. However, by the beginning of 2022, less than half of the target population of 20 million people had received at least one vaccine dose and only about 13% were fully vaccinated. To increase vaccination rates, the GHS instituted a national COVID-19 vaccination day in February 2022 and inaugurated a second campaign coinciding with Africa immunization week in March of the same year . SurveysSocial listening to web-based sources is important in Ghana as the number of social media users has increased significantly in recent years. Currently, over 50% of the population has access to the internet and 140% of the population has a mobile phone connection. In early 2022, there were approximately 8.80 million social media users in Ghana, which is approximately 27.4% of the total 32 million total population. WhatsApp is used by almost 90% and Facebook by over 70% of social media users followed by Instagram by approximately 60% of the users and Twitter and Snapchat are used by approximately 45% of the users . TwitterThe Health Promotion Division of Ghana Health Services (GHS) together with the UNICEF Country Office has established an infodemic management system that combines information identification through the Talkwalker platform and knowledge cocreation among a National Misinformation Taskforce to verify potential misinformation and respond to it appropriately. The system was created to strengthen COVID-19 vaccine programming and to combat vaccine hesitancy, which is defined by WHO as a “delay in acceptance or refusal of vaccines despite availability of vaccination services” . This paThe infodemic management system was developed by the Health Promotion Division of the GHS and UNICEF Ghana Country Office to effectively identify, analyze, and cocreate content to respond to misinformation during the pandemic. The objectives were to improve compliance with public health safety measures, support COVID-19 vaccine programming, and identify factors that may increase vaccine hesitancy and lead to vaccine refusal.The data collection system was based on Talkwalker, a commercial social listening software platform. It uses machine learning and artificial intelligence to consolidate publicly visible occurrences of given keywords on the internet. Talkwalker functions like a search engine and provides the ability to filter, contextualize, export, and analyze large data sets. It gathers Ghana-specific COVID-19–related posts from open Twitter, YouTube, and other websites by monitoring keywords, phrases, and hashtags. It categorizes relevant posts by sentiment: neural, positive, or negative. Negative posts are of particular interest as they may contain rumors, misinformation, or disinformation. In addition, the platform includes a feature to categorize data as misinformation; another point of interest to infodemic management. It deepens the understanding of the circulating narratives by aggregating numbers related to the total reach, engagement, and demographic information about those who are engaged in these discussions. The limitation of the tool is that it cannot access conversations on Facebook, Instagram, and WhatsApp owing to privacy restrictions. Approximately 70% of the posts retrieved by Talkwalker in relation to COVID-19–specific information in Ghana are published by men, almost half of which were published by adults aged 25-34 years.The analysis utilizes qualitative methods to classify a post as misinformation and to assess the risk level of the post. It uses Talkwalker algorithms to identify posts, but the final assessment is based on assessing the post given the local context. In particular, the risk level of particular misinformation requires a qualitative assessment of the situation using applied content analysis .The methodology also relies on knowledge cocreation, which is referred to as collaborative knowledge generation by various stakeholders. Knowledge cocreation is a participatory approach to enhance the value and reliability of outcomes and ensure that they benefit all parties ,29. The A multi-sectoral National Misinformation Task Force was established to implement and oversee the process developed by the GHS, which also appointed members for the task force. The task force was established on the basis of the membership of an existing task force of Risk Communication and Social Mobilization experts and expanded to include other public health experts, media, development partners, and an organization of Ghana fact-checkers, UNICEF, and other critical partners. Since the beginning of the pandemic, the task force has held biweekly web-based meetings with approximately 20 experts. The head of the Health Promotion Division of GHS is the chairperson of the group. UNICEF has provided technical assistance to the group, including capacity-building training on how to use Talkwalker to identify misinformation, how to assess the risk level of misinformation, and how to respond to misinformation.The infodemic management system includes 4 interlinked steps that are carried out by selected members of the task force on a biweekly basis, including social listening to identify misinformation, risk assessment, and proposal for appropriate information; verification; cocreation of appropriate responses; and infodemic response. The first step is to identify and analyze misinformation through the Talkwalker social media and web-based monitoring platform. Two members of the task force are responsible for carrying out the analysis. They used Talkwalker to determine the number of results  during a specific period of time, which is usually a week. The analysts gained an overall understanding of the results by looking into the demographics of those who have generated the results (gender and age) and creating a word cloud to see how the results are thematized. Then, the analysts assessed the engagement rate and potential reach of the results, followed by a review of the results that convey negative sentiments to determine the significance of each individual result. The analyst read each headline of the posts (results) or the entire tweet to decide if it contains misinformation to be included in the analysis. If so, the entire post is extracted from Talkwalker and pasted into a document for further risk analysis and response. Then, the analysts reviewed the rest of the results because even if the reach or the engagement is not high, a result may be potentially risky in the context of Ghana. For example, a post may relate to a historical or political event that is significant in the context of Ghana. At the end of the analysis, the analysts had a list of posts extracted from Talkwalker, which requires verification from public health experts and fact-checkers. If confirmed as misinformation, they are included in the list of misinformation.The second step includes assessing the risk level of all the posts that were classified as misinformation based on the UNICEF risk assessment matrix that classifies misinformation into low, medium, or high risk levels based on 5 criteria . See TabThe analysts presented the analysis in a PowerPoint presentation during the task force meetings. The presentation is discussed jointly with the original post, analysis of the risk level, and proposed response. The discussions are the core of the knowledge cocreation during which the task force members view the contents of the posts and the related risk assessment and proposed interventions and actions to ensure that they are appropriate, culturally acceptable, and practical in the context of Ghana . DecisioThe evidence and the systematic process of verification, risk assessment, and response proposal are provided to the management for approval. There is also a Message Box containing prepared responses to frequently asked questions including rumors, misinformation, and disinformation. Responses may include press releases, social media posts, and direct communication, among others. The GHS is responsible for implementing the response.Through Talkwalker, the analysts identified a post that included complaints about negative attitudes of health care staff toward patients in one particular health center. The owner of the post was a young social media influencer with over 10,000 followers, many of whom also actively retweeted the post within their own networks. Analysts considered that a risk, though the allegations of the post itself were not considered particularly threatening as it related to one particular health center. The analysts suggested taking localized action to address the issues with that particular health center. During Misinformation Task Force cocreation, the members rated the post as medium risk in consensus and agreed to take targeted action by training all staff members of that particular health care center in service delivery and customer care.Through Talkwalker, analysts identified a post on popular news sites about an interview with a local premier league football team coach in which he claimed that the team had lost a game because of their weak physical status after they received the COVID-19 vaccine. Analysts noted that the engagement rates were high and this spread rapidly on social media platforms, particularly on Twitter. The analysts rated it as high risk because it was from a national web-based news outlet, because the interview was with a local celebrity, and because football is a popular sport in Ghana and many fans may be influenced by the post. The analysts suggested taking action on the web in the same news outlet where the post was published. The task force agreed with the high risk level but instead of responding on the web, they decided to contact the football coach directly to gain clarification on his statement, to educate him about the side effects of the COVID-19 vaccine, the Adverse Effects Following Immunization protocol, and, most importantly, to recruit him as a vaccine supporter and encourage him to speak publicly to deliver pro–COVID-19 vaccine messages.Using Talkwalker, the analysts identified a retweet about a post that claimed to be published by an award-winning doctor who warned that those who take the COVID-19 vaccine will die within 2 years. The analysts checked with Ghana fact-checkers about the post and learned that it had been viral worldwide for some time already and it had been fact-checked as false. The analysis rated the post as high risk owing to the global spread and because it referenced death. They proposed to the task force that action should be taken to clarify that this was fake news. The task force agreed that the post should be rated as high risk because it described a severe adverse effect, which is known to promote vaccine hesitancy, and because the disinformation claims to have originated by a doctor—a highly respected profession in Ghana—which could contribute to the spread of this misinformation in Ghana. The task force decided to circulate the post with a “Fake News” stamp across various GHS social media channels. At the same time, they posted factual information about the COVID-19 vaccine and had it circulated across social media channels.Through Talkwalker, the analysts identified a Tweet that accused the GHS of not sharing information about COVID-19–related mortality on its website in a timely manner. It was created by a political activist, with over 20,000 followers, who is known to initiate discussion against the government. The analysts assessed the risk as medium as they did not find any tangible accusations in the post and suggested that no action be taken at this time as a response would only bring more attention to the post. The task force assessed the risk level as high because the post could encourage more politically driven rumors to further spread mistrust against the government. The task force response included issuing an official press release that clarified the data verification process of any statistics displayed by the GHS on its website and highlighting the importance of publishing accurate information. A summary of the examples is provided in This paper described an infodemic management system developed and implemented in Ghana. The system relies on data collection through a digital platform and on human-centered approaches to verify the findings with appropriate response mechanisms. The system has been used to identify COVID-19 misinformation, disinformation, and rumors, which were addressed in a timely manner.The implementation of the infodemic management system in Ghana highlights the critical role of qualitative inquiry in social listening as it allows for a greater understanding of the positions, perceptions, and potential misinformation and disinformation among population groups in order to assess the potential risk and take appropriate action in a timely and targeted manner. For example, a post from a football coach may not be significant in a country where football is less popular, but in the context of Ghana, it was assessed as a high risk that has the potential to spread fast and raise high emotions. Talkwalker cannot carry out such an interpretation, which aligns with a number of studies that have pointed out the limitations of machines. Although machine learning methods have been developed to solve real-world problems, they are not sufficient by themselves in critical decision-making approaches ,39. DigiThe implementation of the infodemic management system in Ghana has also highlighted that knowledge cocreation can be implemented even in crisis situations. Knowledge cocreation has been identified in a number of studies as an effective approach to discover, share, and blend knowledge for practical use, allowing stakeholders to learn about the applied implications of knowledge use and to collectively create actionable recommendations ,42. CocrThe infodemic management system in Ghana also has limitations. The Talkwalker posts and interactions are mainly published by men and young adults, excluding the voices of women, youth, and older people. In addition, here are still significant numbers of people, particularly in vulnerable populations such as low-income individuals and those who cannot read and write, who are not reached by digital platforms . AccordiThe paper has described an infodemic management system workflow based on a mix of digital and human-centered methods, including effective social listening through a social media management platform, qualitative analysis process, and cocreation through a national task force of experts, resulting in context-specific, real-time infodemic responses.


Health has always been recognized as the imperative parameter to excel in any field whether professional or personal. People with sound health having regular habit of physical activities show more potential in their professional and personal lives than the people who do not participate in the physical activities. Many state-of-the-art studies exist in the literature where researchers have proved the significance of physical activities as supportive treatment for the existing ailments and in improving the overall health of human beings. Our research aims at accessing the correlation between physical activities carried out by the students and its impact on the success rate of academic achievements. The study is using computational techniques to investigate the relevance of physical activities on the academic achievements of middle school children. The study employs data mining techniques for processing the data. The computational methods are used in a multimodal environment where the surrounding parameters of the environment are considered before performing computational techniques on the subjects (participants in terms of sample for the study). In this cross-sectional study, we have considered the data on various physical activities such as aerobic fitness, running, playing, and participation in extracurricular activities. After collection of data in a real multimodal environment from middle school students, the data preprocessing is performed to handle the missing values. Then, the computational techniques are applied in a step-by-step approach using regression and the bootstrap methods to examine the data and predict the outcome. The correlation is assessed between academic achievements and physical activities. The outcome predicts that physical activities promote the success rate of academic achievements including extra-curricular activities. As the focus on academic achievement has increased in the schools, physical activities have reduced. Health is the most important criterion, which impacts the human performance in all fields. Diet and physical activities play equally important role in the overall health of human beings . ChildhoPA exerts the greatest effect on middle school and elementary students . Among tIn reference , authorsThe cross-sectional study uses computational techniques to investigate the relevance of PA on the AA of middle school children and employs data mining techniques for collection of data and processing of data.The study is aimed to identify the effect of PA on the academic performance of the school going kids.The study also evaluates the correlation between MVPA (moderate-to-vigorous PA) and performance for mathematics scores of the participantsThe study uses multiple regression (MR) analysis and bootstrap analysis (BA) to conduct the experimental analysis.The next section discusses about the proposed method.The proposed study uses regression analysis and BA to conduct the experimental analysis. The samples of the school going kids are collected to prepare the dataset. In order to evaluate the data, methods such as MRA and BA are applied as explained further in this section.It is an assessment of MR in statistics. It is an advancement of linear regression (LR). In statistics, LR is the used to forecast the value of one variable dependent on another variable. In MR, dependent variable depends on values of two or more variables. The MR analysis (MRA) estimates the information using regression.The bootstrap method is a resampling technique. It is used for the estimating the statistics on a population by sampling a dataset with replacement. It can be used to estimate mean or standard deviation (summary statistics).This study uses MR analysis and BA to conduct the experiment of 176 seventh and eighth-grade students from USA and analyze the relationship between their mathematics scores and other measurements stated below. The following part will specifically introduce the research participants, measurement, study procedure, and data analysis process.About 176 middle school students (from the 7th and 8th grade) from the school located in Salt Lake City, UT, USA are selected as subjects according to the cluster sampling technique . Among tThe specification of the measurement for each of our parameters has been explained as follows:PA was estimated (maximum of 7 days per student) with a pedometer (NL-1000). Two PA measures were used as an independent variable: average number of steps for 1 week (steps) and average duration of moderate-to-vigorous PA (MVPA) for 1 week .2) and standardized; BMI z-score was obtained.Height and weight were measured using a portable scale with an accuracy of 0.1 kg  and a portable stadiometer with an accuracy of 0.01 m , respectively. BMI was calculated . The original test was developed by Partington . The tasAA was measured based on the students' mathematics score. The New York Test, which was designed by the New York State Education Department for testing students' mathematics level, was employed. There were 30 questions in the grade 7 edition and 27 in the grade 8 edition.Information about the study was shared with the students during their physical education (PE) classes. Consent forms were sent to the parents through the students; the parents had the chance to ask questions before starting the study. Child assent was completed during PE classes. During the first week, participants' height, weight, and aerobic fitness through a running test (PACER) were determined. During the second week, the PA test  was performed; measurement was obtained for 7 consecutive days. Starting from Monday, students started wearing a pedometer once they arrived at school and were required to wear the monitor all day until bedtime. The attention of the students was also evaluated. The participants were asked to complete the Stroop test and TMT; their mathematics scores were identified during their PE classes. BMI was calculated using height and weight measurements.t-test, multivariate regression, and BA were conducted. These methods could help us understand the degree of the assumed positive correlation between PA and AA. We conducted the experiments with a sample size of 176 students, which was the average number in a typical public middle school in Utah; our study thus has sufficient statistical power. The sample size was also determined based on the number of schools willing to participate and their respective student membership size.All data were analyzed by SPSS 26.0 . Variance analysis, least significant difference MR analysis was used to analyze the relationship between mathematics scores of grade 7 and 8 students and MVPA, number of steps, aerobic fitness, selective attention 1, selective attention 2, sustained attention, and alternating attention; the final regression equation was obtained. Regression analysis was performed by progressive stepwise regression and expressed as 95% confidence interval.BA was used for analyzing mediating effects and was considered appropriate for the expected non-normality of the sampling distribution of the mediation effect . Based oDescriptive statistics are presented in According to the World Health Organization (WHO) Growth Reference , pupils'The sample characteristics for middle school students in grades 7 and 8 are listed in The sample characteristics for middle school students in grades 7 and 8 are listed in The distribution of BMI in male and female students in grades 7 and 8 is listed in X1: MVPA, X2: steps, X3: aerobic fitness, X4: selective attention 1, X5: selective attention 2, X6: sustained attention, X7: alternating attention, and X8: BMI. For BMI, dummy variables were recorded: X8: severe thinness, X8: thinness, X8: normal, X8: overweight, and X8: obesity. Regression analysis was performed to construct a MR model to test the interconnection between PA, potential mediating variables, and total academic scores.Using experimental research, we have measured the indicators of each student, which are forming a categorical variable of BMI and multiple continuous variables. The forward stepwise regression method was used for the dependent variable Y: math and the independent variables MVPA and steps played a common role among the seventh and eighth-grade students and always had a positive effect on mathematics scores. In males, sustained attention had an effect on mathematics scores; selective attention 1, selective attention 2, alternating attention, and BMI were eliminated in the equation. The final equation of the multiple LR of the independent and dependent variables of males is written as follows:It could explain 47.7% of the total variation of the dependent variable . Thus, MThis could explain 60.1% of the total variation of the dependent variable . TherefoThe regression coefficient of the final model of boys' regression equation is listed in The regression coefficient of the final model of girls' regression equation is listed in The histogram has been plotted for the standardized residuals of the regression equations. The histograms of standardized residuals of the regression equations, from which standardized residuals showed normal distribution, conform to the hypothesis test condition Figures  and 2. Fx axis and ∗ZPRED on the y axis. The two variables were in a straight-line trend.Figures Therefore, step, MVPA, and sustained attention could predict mathematics score to a certain level. In males, the lower the average number of steps, the shorter the duration of MVPA, and the shorter the sustained attention time, the worse the mathematics score, which is contrary to the assumption. Moreover, the greater the average numbers of steps and longer the duration of MVPA, the better the total mathematics score. In females, sustained attention time did not influence the mathematics score. However, similar to males, the greater the average numbers of steps and longer the duration of MVPA, the better the total mathematics score.We plotted the scatter plot of regression-standardized prediction values for boys and girls as shown in We have carried out the BA to find out the mediating effect of MVPA on the mathematical achievement of students and the same has been explained as below.X is the independent variable (MVPA) and Y is the dependent variable (mathematics achievement). The direct effect of MVPA on mathematics achievement in males and females was significant . The indirect effect of each mediating variable was not significant; thus, MVPA has no mediating effect on mathematics achievement.X is the independent variable (step) and Y is the dependent variable (mathematics achievement). The direct effect of step on mathematics achievement of male and female students is significant . However, the indirect effect of each mediating variable is not significant; thus, step has no mediating effect on mathematical achievement.Analysis of the mediating effect of MVPA on mathematical achievements is listed in Analysis of the intermediary effect of step on mathematical achievement is listed in We have used empirical research to explore the correlation between PA and AA and it has been found that PA could affect students' mathematics performance to a certain extent. In males, the multiple LR equation has shown that mathematics scores were related to MVPA steps and sustained attention. In females, the multiple LR equation has shown that mathematics scores were related to MVPA and steps. To summarize, PA has a direct effect on AA and there are no mediating effects between PA and three kinds of attention, namely, selective attention, sustained attention, and alternating attention.One possible explanation of our findings is that individuals with more agile bodies have higher flexibility and achieve greater number of steps. Mathematics requires higher mental function and coordination between the hands and brain. The ability to solve mathematics problems requires using the brain and the using a paper, pen, and tools for calculations .Moreover, MVPA has an effect on mathematics performance because proper PA could improve blood circulation, thereby fully mobilizing the functions of various organs of the body, including the brain . PA has BMI and aerobic fitness do not have any effect on mathematics scores because these obesity indicators have little effect on the students' willingness to exercise and exercise preferences, and the ability to solve mathematical problems is more related to the understanding and application of mathematical knowledge . In thisTherefore, the level of sustained attention did not produce a prominent effect in this study.Furthermore, alternating attention was a form of selective switching attention. In our study, the effect of divergent attention on the student's learning process was not significant. For students, learning for or taking exams is what they usually have to face. The diversion of attention and demand for attention distribution are not high. The time for a person to complete a color test could only reflect his/her sensitivity to color. Thus, Stroop test results are not associated with mathematics scores. For selective attention, selective attention could be correlated with AA to a certain extent. However, AA could not be predicted with selective attention, which is consistent with the finding of our study. Moreover, although selective attention has no direct influence on AA, it has an indirect effect on working memory when it is needed, which is used as a mediating variable. Thus, AA could be influenced by the combination of sustained attention, alternating attention, and selective attention as mediating variables of PA. However, based on the BA, we found no mediating effects between PA and the three kinds of attention. Hence, whether selective attention, sustained attention, and alternating attention have direct or indirect effects on PA and AA requires further investigation, and future studies on other mediating variables between the three kinds of attention and AA are warranted. There are some limitations to this study. First, the sample in our study involved only one school. This study would need to be replicated in other areas in the USA and around the USA for greater transferability. Moreover, more factors regarding PA and psychology could be explored and considered for a more accurate statistical analysis.This research study has carried out the empirical research on the identified population. The findings of the paper state that PA has a direct effect on AA. There are no mediating effects between PA and three kinds of attention, namely, selective attention, sustained attention, and alternating attention. No mediating effects are observed between PA and the three kinds of attention, namely, selective attention, sustained attention, and alternating attention. In males, the multiple LR equation has shown that mathematics scores were related to MVPA and sustained attention. In females, the multiple LR equation showed that mathematics scores were related to MVPA and steps. From the above findings, it can be concluded that the short time spent on physical activities during PE classes and sports related activities impacts positively on the academic performances of middle school students. It is found that there is a strong correlation between the physical activities and overall performance of the participant subjects. This is due to the hormones, which are released by the body during physical activities that relieve stress and increase concentration levels. This has resulted into the greater success in terms of mathematics scores of the middle school children. This study is applicable to all the age groups but in this research study, we are focusing on the school going kids and the impact of physical activities on the academic performance is remarkable as per the research study. The study of biomarkers also show that the relevance of physical activities on the overall performance of the students. The computational techniques like regression were used in predicting the performance on the basis of input activity data of the participants. The future study will concentrate on analyzing the impact of physical activities on the participants by considering the most relevant biomarkers of health analysis. We will introduce better computational techniques with different datasets to draw conclusive remarks to analyze the impact of physical activities on the academics. Furthermore, we will explore more factors related to PA and psychology in the future.


Skin cancer is one of the most common cancers worldwide and the number of patients is steadily increasing. In skin cancer care, greater interdisciplinary cooperation is required for prevention, early detection, and new complex systemic therapies. However, the implementation of innovative medical care is a major challenge, especially for rural regions with an older than average, multimorbid population, with limited mobility, that are long distances from medical facilities. Solutions are necessary to ensure comprehensive oncological care in rural regions. The aim of this study was to identify indicators to establish a regional care network for integrated skin cancer care. To capture the perspectives of different stakeholder groups, we conducted two focus groups with twenty skin cancer patients and their relatives, a workshop with eight physicians, and three semi-structured interviews with health insurance company representatives. Qualitative data were recorded, transcribed, and analyzed following Mayring’s content analysis methods. We generated ten categories based on the reported optimization potentials; five categories were assigned to all three stakeholder groups: Prevention and early diagnosis, accessibility of physicians/clinics, physicians’ resources, care provider’s responsibilities, and information exchange. The results indicate the need for stronger integration of care in the region. They provide the basis for regional networking as, for example, the conception of treatment pathways or telemedicine with the aim to improve a comprehensive skin cancer care. Our study should raise awareness and postulate as a demand that all patients receive guideline-based therapy, regardless of where they live. Skin cancer is one of the most common cancers, with an incidence that has been increasing for decades . Non-melTaking the example of Germany, two nationwide evaluations of cancer registry data show that the opportunity of an initial diagnosis of malignant melanoma at an early stage is unequally distributed. In Western Germany, this opportunity is significantly higher compared to Eastern Germany . In addiSince 2011, the availability of new, effective, but also toxic, drug-based tumor therapies for melanoma and non-melanoma skin cancer has increased. For the success of the therapy, multiple aspects are relevant: the knowledge of new therapies, side effect management, interdisciplinary therapy, and patient competence. These are not only important in comprehensive cancer centers, but also particularly in a local presence close to the patients. For the early detection of skin cancer, physician competence and patient awareness are also relevant.To cope with these challenges in healthcare provision for patients with skin cancer, regional care networks have been suggested to improve access to high-level clinical care, irrespective of the place of residence of patients. Various networks and integrated forms of care worldwide are dedicated to the care of patients in rural areas or tumor patients ,17,18,19Here, we present the methodological design and results of our qualitative needs analysis. We focus on the extent to which the participants see potential for improvement in the healthcare provision of skin cancer patients in the study region. We also report on the experience we have gathered during the project and derive recommendations for the design of a network.We used a qualitative study design to explore the perspectives of different stakeholder groups on integrated skin cancer care. The study region of Eastern Saxony is characterized by larger rural areas in the east, with approximately 552,000 inhabitants and the city of Dresden with about 561,000 inhabitants . The melPatients were interviewed in focus groups because this methodology allows for group interaction and can thus increase diversity of opinion ,26. The Inclusion criteria were established for patient selection: (a) diagnosis of malignant melanoma , (b) current/past treatment in the study region, and (c) health and basic cognitive ability to participate in the study, according to the patient’s medical history. Potential study participants were identified via the Skin Cancer Center of the University Hospital Dresden and invited to participate in the study by mail (n = 83). A total of 46 patients indicated a preferred date to participate in a focus group. Due to the explorative approach, as well as research economic reasons, two focus groups (with 9 and 11 participants each) were conducted. In order to capture as many perspectives as possible and to obtain a heterogeneous sample, sampling was performed using the maximum variation method ,30. For For the workshop, only primary, secondary, and tertiary care physicians with practical experience in the diagnosis and treatment of patients with skin cancer working in Eastern Saxony were included. The sampling procedure was multi-stage. First, the most frequent referring physicians of the Skin Cancer Center of the University Hospital Dresden (dermatologists in outpatient practices (n = 33), general practitioners (n = 12), internists/oncologists in outpatient practices (n = 8), and clinicians (n = 5)) were informed about the study by mail and invited to the workshop. In addition to the most frequent referring physicians, further physicians were invited to the workshop in a second step (dermatologists in outpatient practices from the study region (n = 17) and clinicians from the field of dermatooncology researched online (n = 5)). Analogous to that for patients, two workshops were planned, each with 10 physicians. Due to the low number of registrations (n = 16) and limited time resources of the physicians, a workshop with 8 participants was finally organized. For this purpose, (a) the date was chosen from all registrations, on which most physicians of different disciplines and places of practice agreed by vote, and (b) a venue (Bautzen) was determined, which also seemed to be easily accessible for participants outside the city of Dresden. Study participants were offered a travel allowance of EUR 50.For the semi-structured interviews with health insurance company representatives, a search was conducted for statutory health insurance companies in Germany with a large number of insured persons, from which a high number of insured persons with skin cancer was determined. At the same time, a search was conducted for private health insurance companies in Germany, as their perspective was also to be considered within the framework of the study. The representatives researched were informed about the study by mail, e-mail, or telephone, and invited to participate in an interview. The interviewer arranged individual appointments with the health insurance company representatives. Our study focused mainly on the patient´s perspective. However, we also wanted to engage the other stakeholders involved in skin cancer care to gain insights into their views as well. When planning the sample size, we focused on purposive selection of different stakeholders rather than on the size of the individual groups. Thus, a total of 31 subjects participated in the study.Interview and moderation guidelines with openly formulated guiding questions were developed in advance . The preData collection took place from May 2018 to January 2019 in a conference room at a hotel (first focus group and workshop) and at Dresden University Hospital (second focus group). The semi-structured interviews were conducted in the buildings of the health insurance companies and at Dresden University Hospital. Basic patient and physician demographics were collected via a questionnaire. Since the health insurance company representatives were interviewed as representatives of their organization, not as private individuals, no demographic information was requested. Therefore, they were asked to answer the guiding questions from the perspective of the health insurance company . Focus gAll audio recordings were transcribed verbatim and anonymized. The analysis of the transcripts was based on the qualitative content analysis of Mayring . In orieA total of 19 patients and one relative (as a proxy for one patient) participated in the two focus groups (duration of audio recordings: 122 min and 130 min). In addition, five relatives participated as accompanying persons. For the stakeholder group of patients, a heterogeneous sample was obtained regarding the characteristics age, gender, stage of disease, and size of the place of residence . Eight pOptimization potential was identified by all three stakeholder groups, while some participants expressed satisfaction with care structures and processes, e.g., because information was provided in a timely manner. In addition, two health insurance company representatives reported that they were only able to assess the cooperation between disciplines, facilities, or help offers to a limited extent or with additional analysis effort. Therefore, the guided question on cooperation was not answered by all health insurance company representatives interviewed. A total of ten categories could be generated from the quotations on optimization potential across all perspectives . The catAll three stakeholder groups wanted more information and education of the population about skin cancer . In parallel, patients and health insurance company representatives also discussed skin cancer screening. One patient considered the two-year cycle of screening to be too long. In addition, patients remarked that skin changes were not taken seriously at the beginning or were not recognized as potential skin cancer. Representatives of health insurance companies demanded the general promotion of screening and the lowering of the age limit for the assumption of costs.One health insurance representative made the criticism that general practitioners would refer their patients too late to dermatological outpatient practices. This was also associated with the delayed referral to tumor centers. The reasons for this were seen in the competitive situation between the treatment providers and in the budget constraints.The interviewed physicians sometimes found the accessibility of physicians’ outpatient practices and the clinic difficult. However, some of the patients criticized in particular the local accessibility of medical facilities  and the sometimes difficult access to dermatologists in outpatient practices . One health insurance company described the difficult accessibility of physicians’ outpatient practices  and the problem of long waiting times for an appointment. A health insurance company representative stated that the accessibility of a dermatological outpatient practice could be a challenge, especially for patients from rural areas. As a result, the physicians’ visit would sometimes not take place.There were reports among patients and physicians that indicated a  physician shortage in Eastern Saxony . The density of care was also discussed among health insurance company representatives, although there were different perspectives on this. On the one hand, a  physician shortage was seen . On the other hand, the supply density of physicians in eastern Saxony is officially optimal to oversupplied (according to the demand planning guidelines). It was pointed out that neither the accessibility of care services nor mobility and morbidity are taken into account in the official demand planning guidelines, and that these guidelines have been the subject of political discussion for some time with regard to their topicality.From the patient’s point of view, it was regrettable that an examination that had previously been offered in a hospital close to the patient’s home was later rejected there and the patient was referred to a hospital further away from the patient’s home. One patient described his impression that a hospital does not want to hand over the therapy or examinations to other care services. Patients also criticized the fact that practitioners frequently change or that they lack a fixed contact person. In contrast to the patients, there were statements among the physicians that indicated different expectations regarding the areas of responsibility of care institutions or service providers . With reference to interdisciplinary cooperation, it was described that dermatologists are sometimes not taken seriously by other disciplines. A health insurance company representative described “vanity” between physicians, to the effect that only one’s own opinion is considered the correct one. Treatment pathways with clear guidelines could improve cooperation here. Furthermore, another health insurance company representative doubted whether general practitioners were qualified to perform skin cancer screening is sufficient professionally.Some of the physicians criticized the diagnosis and indication by general practitioners. Patients particularly criticized the quality of treatment by physicians  and psychologists . In Some participants in all three groups consistently suggested that patient information  was sometimes not shared with co-/continuing care providers and patients, or not shared in a timely manner. Patients also criticized the way in which findings were communicated .One physician criticized that interdisciplinary cooperation in the tumor boards is not guaranteed in some cases and that there would be disciplines that stick to their methods. In addition, outdated specialist knowledge and insufficient exchange between the specialist disciplines when presenting patients were criticized.One relative and one physician criticized the fact that aftercare was sometimes lacking or not carried out at the scheduled times. One physician also reported patient feedback that skin cancer screening by general practitioners did not currently meet official guidelines.Patients criticized that physicians’ letters are sometimes not written in layman’s language, which causes anxiety. In addition, patients would like to receive more information about care services and psychosocial support services, more support and assistance in everyday life , and a simplification of bureaucratic procedures. Furthermore, an insecurity within the population, as well as the medical staff, towards this potentially fatal disease was mentioned. One patient expressed a desire to reduce uncertainty in dealing with patients.National and international cancer care goals call for greater integrated oncological care ,10. ThisDeficiencies were seen for example in the diffuse responsibilities between care providers. Particularly when different specialists are involved in the provision of care, problems in the transmission of findings, the coordination of appointments, and the treatment processes can impair the quality of care. The results of several studies indicate similar problems to those identified by our participants. The lack of communication and unclear responsibilities between providers can lead to uncertainty and dissatisfaction among patients ,37,38,39In the statements of several participants, discrepancies between their practical experience and the officially communicated specialist density within the study region became clear . On the This practical experiences described in our analysis support the assumption that rural regions are confronted with various challenges in skin cancer care (including scarce resources with steadily rising skin cancer incidences and long travel distances to care providers). One possible solution could be telemedicine, which is an approach that enables rural coverage and faster information exchange. Telemedical care in rural areas opens up a broad field of new care approaches that cannot be discussed in detail here. For example, telemedicine applications for digital side effect monitoring are currently being implemented ,46 to suOncological care networks represent another approach to a solution, which aims to improve communication between care providers and provide care close to home ,17,48. WOne strength of our study is that we involved the views of different stakeholder groups and worked through proposals with physicians in a workshop on how stronger networking could be designed in the region. In our experience, physicians are not easy to recruit for such a time-consuming workshop because of their limited time resources. Due to the exploratory study design, a limited number of potential study participants were invited to participate in the study. A larger sample might have helped to identify further categories. At the same time, we found that despite the open-ended questions , some ofAlthough the health insurance company representatives were interviewed as representatives of their organization, they also expressed their personal opinions. We have included these in the evaluation in addition to the official positions of the health insurance companies. In the qualitative needs analysis presented here, further questions were also investigated . Thus, tIn summary, it is clear that a lack of resources is often the cause of the reported problems. These cannot be remedied with stronger networking; however, resources can be pooled and existing structures expanded, which are of direct benefit to medical cooperation and patient care. The assignment of the categories to the individual phases of treatment makes it possible to improve care at this point. For example, following the project, a digital tumor board was initiated at the Skin Cancer Center of the University Hospital Dresden, which enables physicians from different hospitals to present their patients in an easy way to an interdisciplinary team. Furthermore, we established a newsletter on current topics, courses, and workshops, and telephone conferences with physicians to discuss urgent topics directly.We would be very interested to learn from others who have organized regional healthcare for skin cancer or other dermatological conditions (please email corresponding author) and believe that this is a field with a high potential to attain further benefits to patients’ routine clinical care.