The World Health Organization (WHO) has collected information on policies on sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) over many years. Creating a global survey that works for every country context is a well-recognized challenge. A comprehensive SRMNCAH policy survey was conducted by WHO from August 2018 through May 2019. WHO regional and country offices coordinated with Ministries of Health and/or national institutions who completed the questionnaire. The survey was completed by 150 of 194 WHO Member States using an online platform that allowed for submission of national source documents. A validation of the responses for selected survey questions against content of the national source documents was conducted for 101 countries (67%) for the first time in the administration of the survey. Data validation draws attention to survey questions that may have been misunderstood or where there was a lot of missing data, but varying methods for validating survey responses against source documents and separate analysis of laws from policies and guidelines may have hindered the overall conclusions of this process. The SRMNCAH policy survey both provided a platform for countries to track their progress in adopting WHO recommendations in national SRMNCAH-related legislation, policies, guidelines and strategies and was used to create a global database and searchable document repository. The outputs of the SRMNCAH policy survey are resources whose importance will be enriched through policy dialogues and wide utilization. Lessons learned from the methodology used for this survey can help to improve future updates and inform similar efforts. A 2020 progress report on the GSWCAH found that while there has been progress overall, some key indicators, such as reducing neonatal mortality, are stagnating or even reversing for some areas, such as coverage for childhood immunization. To accelerate progress and improve in areas that remain stagnant, the adoption and implementation of evidence-informed and equity-focused laws, policies, and guidelines is required.Under the Sustainable Development Goals and the Global Strategy for Women’s, Children’s and Adolescents’ Health (GSWCAH) – 2016-2030,The World Health Organization (WHO) has collected information on laws and policies on maternal, newborn, child and adolescent health (MNCAH) and on sexual and reproductive health (SRH) for many years. In response to recent calls by countries for consolidation of separate data collection efforts, a comprehensive survey on sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) laws and policies was administered from 2018 to 2019. This survey built upon previous separate efforts and, for the first time, asked for source documents to be submitted, which allowed for responses to be validated against national laws, policies and guidelines. The questionnaire was updated to align with WHO recommendations and global strategies developed since the last enumeration in 2016, providing a platform for tracking country progress in adopting WHO recommendations in national SRMNCAH-related laws, policies, strategies and guidelines and a mechanism for understanding the broader context related to health outcomes under GSWCAH. A report detailing findings from the survey showed that over 80% of surveyed countries have national policies for most key SRMNCAH areas. The survey also found that over 90% of countries have policies on SRH, antenatal care, childbirth, postnatal care, and child health, but fewer have policies on adolescent health and violence against women.To optimize the approach used for SRMNCAH policy tracking, WHO established an SRMNCAH policy reference group to obtain external expert advice on the contents of the survey. The group’s members, via an online survey, identified priority areas within SRMNCAH to include in the survey and suggested topics that could be excluded. Concurrently, WHO researched existing global policy and legislative databases and found thirty SRMNCAH-related data sources, identifying key topics that could be eliminated from the SRMNCAH policy survey.To create a final questionnaire that combined previously separate data collection efforts, key focal points in multiple WHO departments and from all six WHO regional offices, along with stakeholders in partner organizations, reviewed the draft questionnaire and provided feedback on its content. As it was important to provide a common understanding of key technical terms used throughout the survey, a glossary was included in the questionnaire. The survey tool was available in all official United Nations (UN) languages  and Portuguese. health policy, law and healthy strategy/plan  or national agencies/institutions to complete the survey. In the majority of participating countries, the principal respondents were from the MoH. Multiple respondents may have been consulted on specific topics to assist in completion of the survey, including officials from other government agencies, WHO country offices and other UN agencies. For each module, there was slight variation in the affiliations of personnel who assisted the main MoH respondent in completing the questionnaire, however the majority of those consulted were others within the MoH or from WHO . Various approaches to administering the survey were employed by WHO regional offices and country teams based on whether WHO has a country office presence. In countries with WHO country offices, SRMNCAH focal points coordinated with the MoH and partners to complete the survey. In countries without a WHO country office, WHO regional focal points coordinated survey completion directly with the MoH and/or other national institutions. In the Western Pacific Region, after the MoH focal points were identified through coordination with WHO country offices, the regional office focal point provided a brief overview of the survey and monitored progress. Amongst countries within the Region of the Americas, Ministries of Health nominated a survey coordinator to organize inputs from colleagues and to review the responses before submitting. If the MoH requested support, the regional office provided an external professional to interview all relevant units and fill out the survey online. The survey was designed with the ability to be filled out by multiple respondents based on their area of expertise, allowing for specific respondents to be mapped to defined modules to complete just those sections. The questionnaire could also be completed offline by multiple respondents with a single respondent entering the responses into the survey platform. A limited number of countries were able to hold review meetings of the completed questionnaire with key stakeholders allowing for agreed revisions before submitting the final version though some countries reviewed the survey responses after submission and requested edits which were incorporated into the database used for final analysis by WHO. Variation in response rates were due to several reasons.Response rate to the SRMNCAH policy survey varied by region. Of all 194 WHO Member States, 150 completed the survey (77%) .9 Vari Survey enumeration lasted from August 2018 through May 2019. Several regional offices thought that the timing of the beginning of data collection, in coinciding with various holiday schedules and end of year administrative processes, factored into a low response rate by the end of that year. Due to this, the period of enumeration was extended through May 2019. Most regional offices listed staffing issues within each country as a main factor in why some were unable to complete the survey. The main issue cited was limited capacity amongst Ministries of Health to direct time towards completing the survey. Specific issues included staff turnover, dismissals, retirements; changes in leadership and internal restructuring in MoH and/other national institutions; and limited personnel covering the wide range of programs of SRMNCAH. In the Western Pacific Region, staff in a few countries were sometimes diverted to public health emergencies during the time of survey enumeration. Commitment from the MoH was another key factor in countries’ completion of the survey. The Regional Office of the Americas stressed the importance of informing countries of the potential benefits of the survey results for planning, updating current policies and strategies, and assessing SRMNCAH programs. In the South-East Asia Region, where all countries completed the survey, obtaining government agreement and identifying a focal point were key factors to this full response rate. The European Regional Office cited lack of official hard copy invitation letters as a possible reason for some Ministries not participating. MoH commitment also extended to the final step of authorizing submission of the survey responses. For example, in one country, the survey was completed but the MoH did not authorize its submission, citing that more time was needed to review the survey. Despite follow up from the regional office, the survey was not submitted. Connectivity issues were also a challenge across several regions, due to low bandwidth, outdated software, and high security settings that blocked access to the survey platform. Some regional and country offices offered to enter the survey responses into the online platform in these situations. Two countries within the African and Eastern Mediterranean regions had issues in submitting their completed surveys online and were unable to submit them within the deadline. Participating countries submitted national source documents used to support their answers to the survey. For each document, country respondents were asked to provide information on the type of document, year of publication and language when uploading the document. The cataloguing process involved several activities: standardizing file names; categorizing documents by key identifying characteristics; and creating a database which linked each document to the survey question(s) for which they were uploaded to be used as a key for validating survey responses against the source documents. Standardizing file names for the online repository was completed simultaneously with the larger task of cataloguing the documents based on key characteristics. Each document was reviewed to confirm its official title, topic, type, year of publication, and language as the initial categorization. Many documents fell under multiple topics, for example covering both child and adolescent health. It was also necessary to re-categorize some documents from the initial survey categorization. Despite providing definitions of the various types, many of the documents were mis-categorized, indicating that some respondents may not have been able to clearly distinguish between a law, policy, guideline, or strategic plan. The end result of the cataloguing process was the creation of a searchable repository of national laws, policies, guidelines, and strategic plans related to SRMNCAH accessible to the public. This repository allows for analysis of the content of the documents as well as validation of the survey responses against the source documents completed in 2020. Validation of the survey responses against the source documents was completed in 2020. The work was split between two institutes, one focusing on laws and one focusing on policies, guidelines and operational guidance. Each institute applied their expertise to reviewing the preliminarily catalogued documents to ensure that they were correctly categorized and to abstracting information from the documents to verify the responses to specified questionnaire items. A set of questionnaire items were selected from the full survey tool for inclusion in the validation exercise. For validation of laws, only documents in one of the six official UN language were included in the analysis. For validation of policies, guidelines, and operational guidance, in addition to the UN languages, documents in Danish, Serbo-Croatian, and Slovenian were included. This reduced the dataset for validation from the 150 WHO Member States that completed the survey to 99 countries for validation of laws and 101 countries for validation of policies, guidelines and operational guidance documents. Within both institutes, research assistants with qualifications in the respective languages conducted the validation. Study protocols were followed and all research assistants received training prior to starting the work. Project managers conducted regular quality checks. WHO provided the institutes with a database of the survey responses and a database of the source documents, mapping which documents were uploaded for specific content sections of the questionnaire. From the selected set of questions for validation, the institutes searched the documents for the relevant content necessary to check whether the responses were congruent with the text. This included searching the documents for selected key words or phrases specific to each survey question. As a first step, the document(s) specifically used to answer each survey section were searched. When a discrepancy was discovered, details documenting it were recorded. Confirmation of the survey responses as well as instances when no information was available in the document(s) to support the survey response were also recorded, hence, the following categories were used to classify the findings:Match – Survey response was consistent with or supported by information in the source document; Mismatch – survey response contradicted information in the source document, or; Unable to be validated ♦ Information not available in document - No relevant information was available in the source document that was uploaded for that question, or; ♦ Document not available - No source document had been uploaded to support the answer or no source document in UN language available.  Overall, of the 101 countries included in the validation of responses against policy, guideline, and operational guidance documents, a quarter of the validated survey responses (26%) corresponded to information found in the source documents (matches). Four percent of the responses contradicted information found in the source document (mismatches), whereas 53% of the responses could not be validated either because no document on the topic was uploaded (37%), or because the relevant information was not available in the document uploaded for the question (16%). For validation of responses against laws, 99 countries were included in the analysis. Fourteen percent of the validated survey responses corresponded to information found in the documents provided (matches). An inconsistency in response was found in 13% of responses (mismatches), due to information in the documents contradicting the responses or no information being found in the documents provided. Seventy-three percent of responses were unable to be validated primarily because no law documents were uploaded under that question; but also in cases where no law documents were submitted for that question in a UN language. The 2018-2019 enumeration of the SRMNCAH policy survey presented both challenges and successes at all stages, from development of the questionnaire and administration of the survey to validation of the responses against source documents. Rather than focusing only on the successes of the work, it is important to recognize the challenges inherent in this type of complex data collection and to share lessons learnt in facing these challenges with the hope this can help inform future efforts in this area. While the purpose of combining previously separate efforts in monitoring laws and policies for MNCAH and for SRH was to streamline data collection activities within WHO Member States, combining content greatly expanded the survey tool. Despite an attempt to limit the burden of data collection, through conducting a review of policy and legal databases to determine areas that, while important to SRMNCAH, already had available information and thus did not need to be collected through this exercise, the final questionnaire was very long and complex. Additionally, since the survey tool changed significantly from previous rounds and few countries participated in all survey rounds, limited trend analyses are possible. During enumeration of the survey, a key to success was the regular communication between WHO regional and country offices with MoH officials. Timely responses to respondent queries and regular follow-up were crucial to successful administration of the survey. Several regional offices stressed the importance of providing the background and purpose of the survey as well as the possible uses of the data in getting buy-in from the MoH. Focal points from the Western Pacific Regional Office communicated to countries that the survey would generate an open global database for the country’s reference. In the Eastern Mediterranean region, similar engagement led to the survey being perceived by many countries as a timely and comprehensive exercise. Interpretation of the questions, was a limitation of the survey in all languages. Beyond questions of the accuracy of the translation of the questionnaire, raised by WHO regional offices for the Region of Americas and the European Region, knowledge of the nuances between laws, policies, guidelines, and strategic plans, left room for respondents to interpret the questions differently. While technical experts were assigned for each survey module by the MoH and a glossary of key terms was provided, responses could vary based on the respondent’s knowledge of the national SRMNCAH policy landscape. Additionally, survey questions were framed towards national policies, so countries with a decentralized health system, which may also have decentralized policies, found it difficult to respond to some questions. Better capturing of the policy landscape in countries with decentralized health systems should be considered in future rounds of this survey. Finally, the survey purposely does not address implementation of policies, as this can be difficult to accurately assess. Therefore, findings must be understood to represent the legal and policy environment as it exists on paper with limited insight into the degree to which these are implemented. An online platform was used for the first time during the 2018-2019 policy survey, which allowed several opportunities to improve the enumeration. Past rounds of the policy survey were done using Microsoft Excel with no built-in skip patterns; using LimeSurvey software allowed for programming of skip patterns, creating mandatory data entry fields, and providing concurrent data entry capacity between the different survey modules. The Regional Office for South-East Asia noted that the policy survey served as capacity building for MoH and WHO country office staff in online survey administration. However, there were some issues with the online platform and, despite testing, there were complications in using it widely for the first time. Given the length and diversity of question types in the survey, the native features of LimeSurvey required heavy adaptation which, in some cases, led to information loss. Application of skip patterns from the questionnaire was not always consistently programmed across modules and while the platform allowed for concurrent data entry between the survey modules, this meant that users were able to skip between modules, which did not activate the mandatory field checks. Several country teams felt restricted by the mandatory fields though, noting that none of the response choices reflected their situation, however they were required to provide a response. Finally, once the survey was submitted, users could no longer edit their responses, which prevented them from making further revisions directly. Many of these challenges might be overcome in future survey rounds with additional pilot testing of the survey tool, fewer or simpler questions and different rules around mandatory fields. this repository, which contains all documents submitted by national respondents, will serve as a global resource for anyone interested in a better understanding of SRMNCAH-related legal and policy environments. These documents were also used to validate responses to selected questionnaire items, which is a significant improvement upon past iterations of the survey where this was not possible. This may help to address some data quality issues or provide additional information regarding the content of a national law, policy, or guideline if not directly asked in the survey. This exercise may also provide an example of a methodology to extract information directly from source documents rather than enumerating a full survey in the future.One major advantage of the online platform was the facility to upload source documents which were used to build a searchable repository of documents. Once publicly available through the WHO MNCAH data portal, The validation of survey responses against source documents also had limitations. One key constraint of the exercise was that it was limited to uploaded law, policy, guideline, and operational guidance documents, but not other documents referenced to complete the survey, such as strategic plans. Also, only documents in a limited set of languages were reviewed. It cannot be guaranteed that information relevant to the validation of the survey responses did not appear in other document types or documents in other languages. Furthermore, as the validation was done by two institutes based on their areas of expertise, there were minor differences in their protocol, such as the way they categorized mismatched findings, and there was no joint analysis of the results. This remains an outstanding step for complete validation. Based on the results of the validation of policies and guidelines, eight of the ten questions with the most mismatching responses in the questionnaire came from the maternal and newborn health module. For example, survey responses on the timing of postnatal care contacts did not match the information in the source documents, suggesting that these questions were either difficult to understand or that the respondents were only familiar with the content of these policies/guidelines to a limited degree. With regard to laws, the highest number of mismatching responses were found in the cross-cutting module. For example, survey responses on the existence of a legal requirement for training of health workers in filling out death certificates using the International Classification of Diseases appears to have been difficult for countries to answer. Examining the phrasing of the questions that were found to have the most mismatched responses is an important finding to try to improve the questionnaire in future rounds of the survey. The SRMNCAH policy survey has provided a wealth of information that will guide both immediate and forthcoming next steps. The findings from the validation exercise suggest that it might be possible to update the policy survey based on abstraction from source documents with confirmation from an MoH. Requesting respondents to upload source documents rather than responding to a questionnaire, and then having a team with relevant content knowledge review and extract the information from the documents might result in more precise survey responses and more detail on the content, while reducing the burden on country teams to complete a long questionnaire. Conversely, this method is resource intensive at the central level and it may be not feasible to abstract information from documents in all available languages. This method may also not facilitate country engagement or ownership of the survey results, which should ideally serve to improve understanding of SRMNCAH-related laws and policies in-country and generate interest about using this information to improve national responses within these areas of health. The outputs of the SRMNCAH policy survey, both questionnaire responses and the repository of national documents, are a resource whose importance will be enriched through wide utilization. The data have already been used in various regional activities. In the African region, results of the survey were presented and discussed at an annual RMNCAH Review and planning meeting involving SRMNCAH focal points from 36 out of the 47 WHO country offices. The survey has provided the WHO African Region and the individual countries with a baseline for systematic monitoring of availability of policies, from which aspects of implementation will be added. In the South-East Asia region, both country offices and the regional office have begun to use the data for decision-making, a trend that should hopefully continue throughout other regions. The Eastern Mediterranean region has developed thematic policy briefs based on the findings of the survey. Future country and/or regional policy dialogues can help to promote use of the results of the survey in informing policy and program development and in learning about use of policy data for program implementation and accountability. Lessons learned from the process and content of the 2018-2019 SRMNCAH policy survey can help to improve not only future rounds of this survey but also other initiatives to collect legal and policy data whether at global, national or sub-national level. The 2018-2019 SRMNCAH policy survey was completed by respondents across 155 countries. We gratefully acknowledge these respondents. Special thanks to Gloria Diamond, Michalina Drejza and Neha Jhaveri for their work in cataloguing thousands of documents for the searchable repository. We would like to thank Bernadette Daelmans, Blerta Maliqi and Marcus Stahlhofer for their technical advice and guidance. We also acknowledge the funding support from the Bill and Melinda Gates Foundation. The 2018-2019 WHO SRMNCAH policy survey followed necessary WHO protocols for non-emergency, non-human-subject data collection. Authors declare that they have no competing interests. Conception and design: TD, EK. Acquisition of data: GB, ZL, NF, SB, BBR, CAJ, DK, KS, and KD. Analysis and interpretation of data: AS, EK, LNH, LF, CAJ, RM, KS, JK, MRF, and TD. Drafting of the manuscript: EK and TD. Critical revision of the manuscript for important intellectual content: ZL, NF, SB, LNH, BBR, AS, LF, RM, CAJ, NR, KS, JK, MRF, TD, and EK. Administrative, technical, or material support: GB, CAJ, and NR. Supervision: CAJ and NR. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation [INV-009058]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.


Patients with psoriasis often have comorbidities and are at increased risk of developing several complications compared with the general population. Knowledge on the role of immune mediators and systemic inflammation in psoriasis has led to the hypothesis that early intervention with systemic therapy has the potential to modify the course of the disease and reduce the risk of long-term adverse outcomes. In this article, we address some potential issues that need to be considered before early intervention can be implemented routinely. The first is determining what constitutes “early” intervention for psoriasis. A second point is whether the intervention should be considered for patients with early disease or for selected subsets based on risk stratification. A third important consideration is defining success for early intervention. Finally, adoption of early and effective intervention should be based on high-level evidence. Ideally, randomized trials would be the best strategy to compare early vs. late systemic treatment in patients with psoriasis, probably using the frequency of long-term outcomes as primary endpoint, with cutaneous and pharmacoeconomic outcomes assessed secondarily. Psoriasis affects approximately 3% of adults across multiple countries, a prevalence that corresponded to approximately 7 million people in the United States in 2019 . PatientKnowledge about the role of immune mediators and systemic inflammation in psoriasis has considerably evolved over the past two decades, leading to the introduction of biological agents and the hypothesis that early intervention with systemic therapy has the potential to modify the course of the disease and reduce the risk of long-term adverse outcomes, such as psoriatic arthritis and cardiometabolic disorders , 9, 10. As in other medical fields, early intervention is an appealing concept in psoriasis and not a new idea . In discThe first point to consider in exploring the worth of early intervention is how to define it. At present, there seems to be no universally accepted definition. In principle, one approach could be the measurement of the time to intervention from different stages of the disease. For example, time since diagnosis is an obvious candidate, but no clear cutoff currently exists . In receIn patients with plaque psoriasis, the unpredictable course of the disease and development of complications make it challenging to base a definition of early intervention solely on time since diagnosis. In that regard, it will be important to establish whether prior topical therapy or phototherapy, when indicated, are a prerequisite for the definition of early intervention with systemic agents. The same reasoning can be applied when considering early change from conventional therapies to biologicals . Age of A second important point to discuss is whether early intervention should be considered for all patients with mild or moderate psoriasis or for selected subsets based on an increased risk. Risk stratification could be based on several factors, such as age, presence of comorbidities, disease severity, genetic profile, or other factors associated with likelihood of complications from psoriasis, including psoriatic arthritis . IdeallyThere is conflicting evidence in the literature regarding the prognostic role of age of onset. In adults, the relationship between age of onset of psoriasis and the development of arthritis, for example, is not clear , 31. LikWith regard to the severity of plaque psoriasis, which accounts for nearly 90% of all cases, the disease is typically mild and can be managed with topical treatment alone . NonetheDose tapering could serve as a potential model to attest the benefits of early intervention in modifying the course of psoriasis and psoriatic arthritis. Biologic tapering seems to be effective and safe in psoriasis patients with stable low disease activity or clinical remission, but consistent evidence is lacking . Atalay Metabolic risk factors are also candidates in the attempt to stratify risk because patients with psoriasis are at increased risk for major adverse cardiovascular events , 6, 39. Despite the well-known contribution of genetic factors to the pathogenesis of psoriasis , 39, mosA third important consideration is the definition of success for early intervention; without such definition, the value of early treatment cannot be ascertained. In that regard, psoriatic arthritis provides an interesting illustration because the definition of minimal disease activity as a valid treatment target allowed implementation of RCTs using it as an efficacy endpoint among patients with early-stage disease . Even thSystematic work has been done in the attempt to propose treatment targets in plaque psoriasis  29, 55––55–63. TIn summary, no universally accepted metric currently exists that could be used as either a therapeutic target in clinical practice or a preferred efficacy endpoint in clinical trials and, at the same time, serve as the overarching target of early treatment. From our assessment of the current literature, we believe this metric should be sensitive enough to capture commonly accepted success criteria related to skin involvement  and to pThe skin is the largest organ of the human body and contains an estimated 20 billion T cells, which are responsible for local defense against pathogens and tumors and for maintaining tolerance to self-antigens . When T There is increasing interest in better understanding the role of regulatory T cells (Tregs), which play a fundamental role in immune homeostasis by helping to prevent autoimmune disease through the suppression of immune responses . In psorEarly and effective intervention can be considered the standard of care for psoriasis only if based on high-level evidence. Ideally, such evidence should come from RCTs testing the value of early intervention in preventing adverse long-term outcomes, such as psoriatic arthritis and comorbidities associated with psoriasis, as well as their effect on the CLCI. These RCTs would compare the strategy of early vs. deferred treatment with systemic conventional or biological agents in patients with mild psoriasis, probably using as primary endpoint the frequency of long-term outcomes. At present, such trials are scarce and may be difficult to design and conduct. The phase 3b trial GUIDE (NCT03818035) aims to investigate the impact of early intervention with guselkumab, an IL-23 inhibitor, on the clinical response and maintenance of response after drug withdrawal in subjects with moderate-to-severe plaque psoriasis. This study has enrolled a total of 880 subjects with short (≤2 years) or longer (>2 years) disease duration and efficacy and safety results are expected for the near future . Given tEven though evidence from prospectively designed, large RCTs is not yet available, and given the importance of this issue, some insight can be obtained by examining the literature on psoriatic arthritis and other chronic immune-mediated disorders, as well as other types of evidence originating from research on psoriasis.Observational studies and retrospective analyses of clinical trials suggest that earlier introduction of systemic therapy is advantageous in patients with psoriatic arthritis , 75–77, The same rationale for early intervention exists for other immune-mediated chronic inflammatory diseases. Rheumatoid arthritis is the prime example of a disease for which a progressive shift to earlier treatment has led to improved results over time, with incorporation of early treatment into practice guidelines . Early tEven though large-scale RCTs do not seem to be on the horizon, except for the GUIDE study , smallerWe propose that the required framework for validating the concept of early intervention should be able to test the validity of the model depicted in Thanks to recent improvements in systemic treatment for mild to moderate psoriasis, it is now possible to envision prevention of long-term adverse outcomes and earlier intervention as laudable and achievable therapeutic goals. The challenges ahead include the definition of early intervention, the creation of risk stratification tools sufficiently predictive of long-term outcomes, and the implementation of RCTs using sensitive endpoints that are ultimately associated with those outcomes and that generate the evidence base currently missing. The overall effect of early intervention on the CLCI and cost considerations should be factored into the research agenda. There is ample scientific rationale, as well as some observational evidence, that early intervention could benefit patients and be cost-effective in different healthcare scenarios. Alongside wider awareness of the disease and its treatment, and the continued development of effective and safe agents, early intervention should be a next milestone in psoriasis research.AV and BS conceived the manuscript. AV drafted the manuscript. PF, AS, and BS provided literature search and reviewed the manuscript. All authors were involved in scientific discussion of the review. All authors contributed to the article and approved the submitted version.AbbVie funded medical writing services provided by Dendrix .PF has served as investigator and/or consultant to advisory boards and as paid speaker for AbbVie, Amgen, Boehring Ingelheim, Ely Lilly, Janssen, Leopharma, Novartis, Pfizer, Sandoz, Sanofi, and UCB. AS has served as consultant to advisory boards for Novartis and Janssen, and paid speaker for Novartis, Janssen, and Leopharma. AV is a former employee of AbbVie and may own AbbVie stock or stock options. BS is an employee of AbbVie and may own AbbVie stock or stock options. The authors declare that this study received funding from AbbVie. The funder participated in the interpretation of data and the review and approval of the content.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In urban settings in malaria-endemic countries, malaria incidence is not well characterized and assumed to be typically very low and consisting largely of imported infections. In such contexts, surveillance systems should adapt to ensure that data are of sufficient spatial and temporal resolution to inform appropriate programmatic interventions. The aim of this research was to 1) assess spatial and temporal trends in reported malaria cases in Maputo City, Mozambique, using an expanded case notification form and 2) to determine how malaria surveillance can be optimized to characterize the local epidemiological context, which can then be used to inform targeted entomological investigations and guide implementation of localized malaria responses. This study took place in all six health facilities of KaMavota District in Maputo City, Mozambique. A questionnaire was administered to all confirmed cases from November 2019 to August 2021. Households of cases were retrospectively geolocated using local landmarks as reference. Overall, 2,380 malaria cases were reported, with the majority being uncomplicated (97.7%) and a median age of 21 years; 70.8% of cases had reported traveling outside the city in the past month with nine reporting traveling internationally. Maps of the 1,314 malaria cases that were geolocated showed distinct spatial patterns. The expanded case notification form enables a more granular overview of the malaria epidemiology in Maputo City; the geolocation data clearly show the areas where endemic transmission is likely, thus informing where resources should be prioritized. As urbanization is rapidly increasing in malaria endemic areas, identifying systems and key variables to collect ensures an operational way to characterize urban malaria through optimization of routine data to inform decision-making. A central pillar of the global malaria burden reduction strategy is using surveillance as a core intervention.Anopheles mosquitoes in multiple African cities.,,In urban settings in malaria-endemic countries, malaria incidence is not well characterized.Therefore, the aim of this study was to 1) assess spatial and temporal trends in reported malaria cases in Maputo City, Mozambique, using an expanded case notification form and 2) to determine how malaria surveillance can be optimized to characterize the local epidemiological context, which can then be used to inform targeted entomological investigations and guide implementation of localized malaria responses.Plasmodium falciparum being the predominant species and an estimated prevalence in children aged 2 to 10 years of 5.2% (PfPR2-10) in 2019.Mozambique is among the countries with the highest malaria burden, and transmission is heterogeneous. Maputo City, the capital of Mozambique, is located in the southern area of the country on the west side of Maputo Bay, with a climate alternating between a cool, dry season extending from approximately April through October and a hot rainy season from November through March each year.This activity took place in the six primary health facilities of KaMavota District in Maputo City, Mozambique, where an expanded case notification form tailored to the urban environment was piloted as part of an initiative implemented by the National Malaria Control Program to improve surveillance in this urban district. All malaria cases reporting to the health facilities between November 2019 and August 2021 were administered a paper-based case notification form by trained health facility personnel to the patient or in the case of children, the parents or caregiver. Over the 2 years of data collection, information collected included age, sex, use of vector control interventions, and self-reported previous malaria infections, as well as any travel outside the city in the previous month, if traveled where they traveled to, and reasons for attending that specific facility. All patients were also asked to identify points of interest or unique landmarks, such as churches, schools, or shops, near their household to support programmatic mapping of cases. After data collection was completed, the records were double-entered using Excel-based forms by data clerks. Points of interest were located on freely available online maps , and points were digitized to represent the approximate location of the case household.This study was implemented by the National Malaria Control Program to pilot an enhanced case report form to improve malaria surveillance. The data were collected as part of routine health services and therefore in the public domain, and no informed consent was sought. Because this was a secondary analysis of program data that were collected to support programmatic decision-making, the malaria control program classified this analysis as nonresearch and exempt from receiving ethical approval.First, an exploratory analysis was conducted to assess trends in the data, including patterns of missingness to characterize the programmatic nature of this pilot data collection. Missing data were included as a separate category when summarizing the data or removed if required to implement the analysis.The subset of points that were successfully geolocated were compared with the full dataset to assess any potential selection bias. The case data were then summarized and visualized, including generating maps of case counts at multiple spatial scales: cases were aggregated to the health facility and neighborhood, also known as Bairro spatial resolution, and mapped to the point location to assess spatial trends. The trends and resulting inference associated with presenting the data at different spatial resolutions were compared to assess the advantages of collecting the location data according to the different spatial scales.Logistic regression was used to assess any factors associated with a case reporting travel outside the city in the previous month and used as a proxy for infections that may have been imported and not acquired locally. Variables tested include age as a continuous variable, sex, occupation, reason for attending a specific clinic, reported use of vector control, and epidemiological week. On the basis of the results of the initial models, occupation was aggregated into categories of student, unemployed, or other and reason for attending into visiting, local to the area (whether living or working there), closest emergency service, and other. Generalized linear models, mixed effects, and generalized additive models were tested, and the Akaike information criterion was used to determine the best model fit. All analysis, including generating the maps, was conducted using R statistical software (Version 4.1.1).Supplemental Figure 1). The highest malaria burden occurred during the summer months with the peak at epidemiological week 22, which coincides with the rainy season between April and October. The majority of malaria cases were uncomplicated, confirmed by rapid diagnostic test (RDT), and had not reported having a malaria infection in the previous month .Of all the cases, 70.8% reported having traveled recently and may have represented infections imported into the city. Interestingly, the age distribution of cases was similar, regardless of recent reported travel . Of noteIn total, 1,314 (55.2%) of the malaria cases were successfully geolocated and mapped to the reported point of interest. However, the trends in the clinical data were similar between all cases, and the subset that was successfully geolocated . In the Supplemental Figure 3). When comparing the spatial distribution of malaria burden with the proportion of the cases that reported recently traveling, a different pattern was evident. For example, in Bairros in the southwestern part of the city, all malaria cases that were geolocated to that area reported traveling within the past month, and thus there may not be significant local transmission in the area .Maps of burden, or the number of malaria cases at the Bairro level, showed cases distributed across most of the city, but there was a higher burden of malaria in the northeastern Bairros . The burthe area . Within Finally, to assess the additional information gained by geolocating cases to the household, we mapped malaria burden at varying degrees of spatial resolution. Maps of malaria cases based on the location of the health facility show high burden in the northeastern area but also that there is a reasonable burden in the rest of the city despite being in Bairros where few malaria cases were reported . Collect,In this case study, we present demographic and spatial trends in 2,380 malaria cases presenting for care in KaMavota District of Maputo City, Mozambique. Here, transmission is consistent with other low-endemic settings with a broad age range of clinical malaria infections (as opposed to young children in high-endemic settings), and cases were highest during the months that coincide with the rainy season.Critically, 30% of cases reported not having traveled recently, indicating that endemic transmission in this urban environment is likely. Therefore, malaria programs should target activities to determine the proportion of endemic infections that are seeded by imported infections so appropriate transmission reduction strategies  can be implemented accordingly. Furthermore, the majority of malaria cases that reported traveling recently had traveled to other parts of Mozambique, highlighting that in high-burden countries, unsurprisingly, imported infections into urban areas, are more likely to come from internal movement within national borders. In this population, children also traveled more frequently than was expected. The findings from other studies are that adults make up more of the population that travels as they seek work and children stay home.Maps of the 1,314 cases that were successfully geolocated showed distinct spatial patterns within the city. Even after accounting for the proportion of cases that traveled, the additional geolocation data clearly showed the areas in the city where endemic transmission is likely thus informing where more detailed entomological investigations and interventions should be prioritized. Conversely, when the spatial information on residence and travel history were combined, distinct areas of the city where cases are all likely imported from outside the city were detected.This is the first attempt in Mozambique to introduce enhanced routine case data procedures. The additional data collection as part of routine practice proved to be feasible in this setting when the weekly number of malaria cases was low, meaning there was sufficient time to complete the case notification form. Despite the missingness in the data generated, it enabled a better characterization of malaria epidemiology in the urban setting of Maputo.The more granular data collected as part of this enhanced surveillance protocol provided important insight into the microepidemiology of malaria in this urban setting. Household retrospective geolocation activity was not perfect with both respondents’ not being able to identify a point of interest or that point of interest not located on the map. However, it enabled a more granular assessment of malaria patterns in the city. Moving forward, the resolution of data to collect will depend on the intended use of those data. The household location is the most precise to create a map of malaria risk but requires additional analytical steps to convert the point data into inferences about malaria risk.Furthermore, the additional data collected provided a more detailed overview of the malaria epidemiology in Maputo City. To enhance this malaria surveillance platform further, use of an electronic data capture system recording information on each case would facilitate both the quality of the data and support built-in real-time analytical and data visualization functions and ensure that malaria programs can quickly respond and adapt to changing malaria trends.The study has some limitations to note. First, this characterization of the urban malaria epidemiology was based on routine surveillance data. By definition, passive surveillance does not account for non–care-seeking infections, and the current system does not capture cases confirmed in nongovernmental facilities  and thus may underrepresent the true scale of the malaria burden.Routine malaria surveillance data are an imperfect but valuable source of data with which to characterize trends and on which to base decision-making to further reduce transmission. In Maputo or other urban areas where malaria transmission is low, adapting the case report form currently being used as part of routine malaria surveillance to include additional variables, particularly information on recent travel and the location of the household of cases using a digital platform, programs can gain valuable insight for decision-making. Furthermore, if geolocation information is collected routinely for those testing negative for malaria and/or other illnesses, malaria results could be interpreted within the context of the broader population distribution, strengthening the inferences that can be made. Such an enhanced surveillance system could identify areas where local transmission is likely for targeting entomological surveillance or focal interventions as well as monitoring trends to adapt quickly as the context changes. As urbanization is rapidly increasing in malaria-endemic areas and the climate is changing, understanding the malaria epidemiology in such environments is important to ensure that interventions and surveillance systems are adequate to respond to the unique risks in these urban settings. The results from this study may be useful for countries considering approaches to characterize urban malaria and target interventions through the optimization of routine data to inform decision-making.Supplemental materials


Since the beginning of the COVID-19 pandemic, preoperative care, also termed prehabilitation, has become increasingly relevant due to the decreasing functional and psychosocial health of patients with cancer, which is a result of the pandemic restrictions. Concurrently, access to telehealth has improved; telehealth comprises all remote care delivery facilitated by information technologies .The aim of this protocol is to describe the rationale and methodology for a major trial investigating the feasibility and safety of multimodal virtual prehabilitation services .This single-arm feasibility trial aims to recruit 100 patients with cancer to receive teleprehabilitation throughout their preoperative period. The inclusion criteria are as follows: (1) 18 years of age or older, (2) scheduled for elective cancer surgery and referred by a surgeon, (3) medically cleared by the referring physician to engage in physical activity, and (4) have a good comprehension of the English or French language. Feasibility will be assessed by documenting recruitment, adherence, and retention rates, in addition to patients’ motives for not participating in the trial, low participation, or discontinuation. The secondary outcome of safety will be assessed by reporting program-related adverse events.The Montreal General Hospital Foundation funded the project in August 2020. The protocol was then approved by the Research Ethics Board of the McGill University Health Centre in January 2021 (ID No. 2021-6730). The first patient was recruited in March 2021, and recruitment is expected to end in September 2022. As of March 2022, 36 patients have been recruited, including 24 who have completed their participation. No adverse events have been reported. Data collection is expected to conclude in November 2022. Data analysis will be performed, and the results will be published by the beginning of 2023.This trial will provide guidance on the use of telehealth in the administration of prehabilitation services. The trial will provide a large amount of information that will respond to gaps in the literature, as there are minimal reports on the use of telehealth rehabilitation and prehabilitation services among elderly populations and in acute contexts, such as the preoperative period.ClinicalTrials.gov NCT0479956; https://clinicaltrials.gov/ct2/show/NCT04799561DERR1-10.2196/29936 The COVID-19 pandemic prompted many health disparities globally. Notably, the World Health Organization has warned of the possible postponement or cancellation of cancer surgery and the risk of death of many patients awaiting surgery . The potTeleprehabilitation was defined in a previously published commentary by our group in 2020  as the uThis proposal has been set up to investigate the use of technologies, such as videoconferencing and training watches , to enabThe trial protocol was approved by the Research Ethics Board (REB) of the McGill University Health Centre (MUHC), Montreal, Quebec, on January 5, 2021 . The trial was registered prospectively on March 16, 2021, on ClinicalTrials.gov (NCT04799561).The protocol is for a single-arm feasibility study. It involves patients who will receive distance-delivered support for all components of the home-based prehabilitation program following a baseline health evaluation, in addition to 2 months of follow-up postsurgery. The program includes a personalized exercise program, nutrition support, mental well-being consultations, and, if needed, smoking cessation support. The technologies  will be used to provide personalized counseling and patient education remotely and to assess program adherence. Informed consent will be obtained from all patients, as per the Health Canada regulations enforced by the REB, and will precede any assessments.Patients will be deemed eligible for the study if they are 18 years of age or older, have been referred for elective surgical management of thoracoabdominal cancer at one of the MUHC sites, and have been medically cleared for exercise by their surgeons. The research staff will not contact patients who are anticipated to receive surgical interventions in less than 4 weeks from the referral date.Prior to recruitment, the medical research team will screen all patients for health conditions that might preclude their participation in the prehabilitation program by reviewing their medical files and, if necessary, contacting them over the phone.Exclusion criteria for participation in the study are as follows: comorbid medical, physical, or psychological conditions, whereby exercise and oral nutrition is contraindicated; acute or unstable cardiac conditions; American Society of Anesthesiologists physical status class of IV or V; disabling orthopedic or neuromuscular disease; psychosis; dementia; cardiac failure ; severe chronic obstructive pulmonary disease (forced expiratory volume in first second of expiration <50% predicted); end-stage liver or kidney disease; and severe anemia (symptomatic or hematocrit <30%). Patients with poor comprehension of the English or French language will not be recruited.The recruitment process will begin at the MUHC following cancer diagnosis by surgical investigators. Surgeons will refer prospective study candidates to the study coordinator in the prehabilitation unit, who will then screen and contact patients and explain to them the nature of the study. If the patients express interest, they will be scheduled for an initial visit at the prehabilitation unit to review the study, provide consent, and undergo a baseline health evaluation. During the initial visit, the coordinator will review the details of the study with the patient, provide clarifications as needed, and acquire informed consent in accordance with good clinical practice guidelines. It will be reiterated that participation in the trial is voluntary, and involvement will not affect the quality of care that patients receive. Following the acquisition of informed consent, the baseline evaluation will be conducted by a physician, exercise physiologist, and dietician.Prior to performing the baseline assessment, basic health information will be obtained, including the following: (1) prior medical history, (2) standardized anthropometric measurements , (3) a bioelectric impedance analysis, and (4) a basic blood test . The baseline assessment will include functional tests, a nutritional consultation, and self-reported questionnaires.The clinic will have all patients perform a battery of tests, which will be used to assess functional capacity, facilitate the personalization of their respective exercise prescriptions, and help in evaluating progress throughout the continuum of care. The battery of tests will include the following: (1) the 6-minute walk test performed in accordance with the recommendations of the American Thoracic Society , (2) the1C), and an MUHC abridged Patient-Generated Subjective Global Assessment (aPG-SGA)  priThe technologies in this project  use confidential information . Patients will receive the materials  with preset accounts from the MUHC IT department, fully coding their identity, where both their names and emails will be coded. Patients will be encouraged to read the privacy notices for both the Polar and Zoom apps. Further, the Polar Ignite watch has a GPS that will record location and distances traveled when activated during cardiopulmonary training sessions. This information will be disclosed to patients, as it may play a role in patients’ willingness to participate.The research coordinator (BT) and the principal investigator (FC) will assign identifiers to each study participant. These ID numbers  will not contain any protected health information .The information collected for the purpose of the research study will be kept strictly confidential and locked in a cupboard within a locked room in the prehabilitation clinic at MGH. All staff, including students, have signed a confidentiality agreement. The password-protected computer where data will be entered is located in a locked room and is not accessible to patients or external members of the hospital.Since the tablets will be provided with internet data and connection, the cookies will be disabled by the MUHC IT department. Additionally, patients will be asked to close their internet browser after each counseling appointment in order to maximize privacy and data protection.All information  will be entered and managed in REDCap (Research Electronic Data Capture), a secure clinical trials management system. Data will be stripped of any identifying information , and each subject will be assigned a study number. All of the information obtained will be treated in a confidential manner.Study investigators, approved staff, collaborators, and the local REB will have access to review records for research, quality assurance, and data analysis. Data collected before the moment when patients express their wish to stop participating or when patients are lost to follow-up will be able to be analyzed in a confidential manner unless otherwise specified by the patients.Following the closure of the study, the principal investigator will maintain all study records in a safe and secure location for 7 years, as specified by local regulations. The records will be accessible to allow for appropriate audits and investigations.The MGH Foundation funded the project in August 2020. The study recruitment period started on March 12, 2021, with the first patient also recruited in March 2021. As of March 2022, 36 patients have been recruited, including 24 patients who have completed their participation, 6 of whom were unable to complete their 4- and 8-week postoperative evaluations. Currently, there are 12 active participants who are still a part of the teleprehabilitation pathway. None of the participants reported any program-related adverse events. Recruitment is expected to conclude in September 2022, and data collection is expected to conclude in November 2022. Data analysis will be performed, and the results will be published by the beginning of 2023. Following the completion of the study, the results will be communicated in a peer-reviewed journal.This study is a single-arm clinical trial that aims to investigate the safety and feasibility of delivering teleprehabilitation to patients with cancer who will undergo surgery. There are currently 36 patients recruited, 24 of whom have completed their participation. This is one of the first studies to use technology-assisted interventions in the preoperative setting. Due to the nature of the research, this study may face several challenges and limitations pertaining to (1) the study design, (2) public health measures and disease management, (3) and technologies.The study design used is inherently subject to various biases due to the lack of a control group or randomization. First, selection bias may be of concern because the study may involve individuals who are more able to participate in the program, especially regarding the exercise component, or who are motivated and, hence, they may be part of a more compliant population. To mitigate the risk of selection bias, we offered participation in the study to all eligible patients who were referred to the clinic, providing technologies for all patients, including those with precarious socioeconomic status. Additionally, to mitigate the risk of misrepresentation of the population, baseline characteristics of patients will be analyzed in order to determine if the observed demographic and exercise capacities are comparable to other trials with surgical oncological candidates. Second, patients involved in the trial may have distinct levels of adherence to the different interventions. To prevent misrepresentation, adherence will be assessed separately for the different components of the program.The COVID-19 pandemic has impacted the lives of millions of people around the world. COVID-19 pandemic restrictions are still being implemented and will likely remain for the foreseeable future. Upon the new waves due to emerging variants, two potential limits can be foreseen. First, it is possible that patients with cancer may be reluctant to come to the clinic for assessments. To mitigate this challenge, the multidisciplinary prehabilitation team will try to time in-person assessments to coincide with the patients’ other medical appointments. Second, the surgical backlog associated with the first waves of COVID-19 have led to patients missing their window for curative tumor resection of early-grade malignancies . This maThe technologies in the study constitute another challenge that may limit both data collection and interpretation. There are three technology-related limitations that can be foreseen for data collection. First, patients may not wear the wearable device  for the same number of days or hours within a day. Second, the battery in the device could run out. Third, patients could forget to record their training sessions . All of In conclusion, this trial will provide important insights into the use of telehealth in the administration of prehabilitation services. The trial will provide a large amount of information that will respond to gaps in the literature, as there are minimal reports on the use of telehealth rehabilitation and prehabilitation services among elderly populations and in acute contexts, such as the preoperative period . Further


Considerable research has been performed on smart working environments in the architecture, engineering, and construction industry, with building information modeling considered as a critical element for implementing intelligent working systems. Although much software has been developed, a lack of understanding inhibits a user-centered approach to the application of building information modeling in architectural design offices. This study focuses on usability factors for the development of software and proposes a direction for the adoption of building information modeling in architectural design offices. This study adopts a persona method that focuses on user experience, starting with a survey conducted in two large domestic architectural offices. For developing the persona scenarios, this study provides a conceptual framework of usability, identifies user demands, and characterizes user experience. Four representative personas were developed for the representative types of users in smart working environments. The persona scenarios provide a basis that directly reflects user needs and experiences regarding the use of building information modeling software in architectural design offices. Two implications of the application of building information modeling are proposed based on the scenarios: a user-friendly working environment for smart workflows and a customized training program focusing on user experience for the use of building information modeling software. Over the past decades, building information modeling (BIM) has shown promise in applications in the architecture, engineering, and construction (AEC) industry. BIM has the capacity to enhance industry performance by decreasing inefficiencies, reducing delivery time, and improving productivity. BIM utilizes information throughout the life cycle of buildings to evaluate design options, automatically generate accurate 2D CAD (computer-aided design) drawings from 3D models, effectively deliver information between design disciplines, and enable communication with customers, thereby reducing project costs and improving quality ,2. Thus,In South Korea, the need for smart working environments in the AEC industry is increasing in line with the rapid aging of the population and the associated decline in skilled workers along with low productivity. In particular, the construction market has focused on projects requiring more advanced or complex technology, such as urban infrastructure and aging facility improvement. Safety is being strengthened in such projects because of a higher accident rate compared with other industries but is yet to show an improvement. In light of all of the above, digitalization and automation in construction through BIM are expected to provide a smart working environment, thus leading to a new solution for the safety issue in the domestic construction market . As showThe South Korean government has actively promoted policies and R&D to activate BIM for competitiveness in the global market and to respond to domestic market change since 2009. Recently, the government presented the phasing in of mandatory BIM for public buildings and expansion of design support for target buildings; thus, the adoption of BIM became compulsory in the architecture industry. Accordingly, many architectural design offices in South Korea have rapidly adopted BIM to implement smart working environments since BIM enhances collaboration and knowledge sharing among team members . HoweverMuch software has been developed that may serve as promising BIM tools for architectural work. However, software engineers have mainly focused on technology development and have not fully considered critical factors such as usability and experience of the BIM tools via a user-centered approach. Many researchers have discussed various barriers that block BIM adoption in the AEC industry, which continue to exert an impact despite the application of BIM having critical advantages throughout the entire building life cycle. Such barriers include a lack of understanding of user demands, lack of users’ intention to adopt new workflows, high start-up and training costs, and uncertainty about ROI ,9. UsersAccording to the results of a worldwide survey of contractors in the AEC domain, nearly half of North American respondents adopted BIM in 2012 or earlier. Meanwhile, in France, Germany, Australia/New Zealand, and the United Kingdom/Ireland, BIM adoption has increased significantly since 2013 and is growing steadily. The use of BIM is accelerating in other countries, such as Scandinavia and Japan, and has demonstrated a rapid increase in recent years . For exaBIM users and non-BIM users have different positions on technological barriers in terms of the use of BIM. While BIM users have no problem using BIM technology, non-BIM users claim that hardware requirements, especially the complexity of BIM software, are a major obstacle . In the Apeesada et al.  noted thBIM technologies should be designed to be convenient, easy to manipulate, and useful ; usabiliANSI 2001 and ISO 9241-11:1998  defined Hierarchical software quality models are composed of various levels; for example, metric levels, criteria levels, and factor levels. They are highly complex because they are correlated with each other and can influence or be influenced by more than one variable . The eleTo improve the usability of the software, an understanding of the system and the circumstances in which it is used is required . Shakel This study adopts a persona method, which focuses on UX; that is, the totality perceived by the end-user while interacting with a product or service. The term “personas” means imaginary persons who are representative characters for target groups. Through personas for a service or product, we can anticipate how target users respond to a specific context. The persona-based scenario is a technique that specifically reflects a user’s purpose and behavior based on the background, needs, behavior, experience, and knowledge of the persona . Two larThis research sought to recognize crucial factors to improve UX and support the architectural design process. Customized questionnaires were developed based on the interview, and a survey was conducted focusing on representative user groups of BIM software. By analyzing data from the interviews and the survey, persona-based scenarios were developed to determine the usage status and demand for BIM software as shown in The usability of modeling tools plays an essential role in the acceptance of conceptual modeling because usability refers to the degree to which users of modeling tools can achieve their goals appropriately and effectively. Therefore, to increase the usability of a modeling tool, it should be designed with a user-friendly interface . HoweverTo develop a conceptual framework of usability for smart working environments, works related to BIM were reviewed in light of international standards for usability characteristics ,31,50, aThe component “application” was divided largely into users and workplaces, where interactions between users and their workplace are the most essential element to consider in the design of user interface and system optimization from the cognitive perspective.While the terms are often used interchangeably in the HCI field, the focus of UX differs from that of software usability because, as a result of human–machine communication, UX is determined by users of various backgrounds , whereas usability is closely associated with the software itself . TherefoA survey was conducted in architectural design offices to investigate users’ experiences, and the current status and needs of BIM were identified to suggest a plan for improving the usability of BIM software. Two offices, S and H, were selected as survey targets; for the development of a customized questionnaire centered on representative user groups, interviews were conducted with experts to derive important factors and determine the field and scope of the survey. These two offices introduced BIM-related software for their smart working environments over ten years ago, but only started using it in earnest around 2016, when the PPS made it mandatory to apply BIM to all construction projects. However, there was a difference in the proportion of BIM software used in their work. For example, while architectural office H uses Revit as a primary design tool, architectural office S still uses AutoCAD as a basic design tool; it is however increasing its use of Revit based on the compelling needs of public institutions and clients. The two offices use different BIM software for each stage of work depending on the ease of use and the needs of the work. They are continuously seeking to improve their employees’ capability for BIM software and have hence designed a technical training program to improve work efficiency.The survey was conducted with three different types of users of BIM software—managers, advanced BIM users, and BIM users—who rated project experience using BIM software on a scale of 1–5, where 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree. Managers showed significant differences compared with other users in terms of usage period, level, and utilization of software, and this affected not only operational aspects such as the need to hire experts, but also the functions required to use the tool for its intended purpose. However, all managers strongly agreed on the need for the training program on BIM software use to follow government policies, strengthen competitiveness, and respond to changing markets. As shown in “Advanced BIM users” and “BIM users” often use BIM in conjunction with other software in DWG format for ease of drawing work; 43% of them use Rhino, Navisworks, and Twinmotion for parametric modeling and quality control. All users rated functionality for responding to government permission standards at lower than 2.5; many (75%) also felt negatively about artificial intelligence (AI)-based techniques because such techniques incorporate many variables, wasting time. However, there was a difference between the two groups in the average score for questions about tool use in the early stage, modeling support function, and software support community. BIM users rated these at 3.7 points, while advanced BIM users rated these at 2.4 points, which is relatively negative. This difference in response is due to dissatisfaction of process aspects such as difficulty in performing tasks rather than using the tool itself. It is not easy for advanced BIM users to proceed with the project with BIM software because the schedule and method tailored to the existing 2D process are still in force. Further, an appropriate collaborative environment has not been created because of a lack of BIM users of a sufficient level.Many users wanted software features to reduce their time and effort in performing tasks for the efficiency of task performance. For example, advanced BIM users gave the highest score (4.5 points) to reduce paperwork time, reflecting the easy information retrieval. BIM users placed a higher value (4.4 points) on the library feature, reducing repetitive tasks. These findings indicate that users are more interested in devising a way to facilitate task performance. However, the two types of users exhibited a different reaction to multidimensional convergence information technology, which is not directly related to a task. Multidimensional convergence information technology was the most preferred function for advanced BIM tool users (60.0%), but BIM users prefer functions required for building construction permissions such as automatic law checks to reduce simple and repetitive tasks (41.2%) and design quality evaluation and performance reviews (23.5%) rather than information technology (11.8%).Personas were developed for the representative users based on the information identified through the survey see . The perWe included two examples of persona scenarios in BIM is used for 3D modeling in the AEC industry as a major tool for advancing construction technology because it encompasses the entire life cycle of a building. The government is gradually expanding the application of BIM use in the AEC industry, and design offices are evolving quickly to adopt this as a primary design tool for their work. However, even considering that it takes time for people to become accustomed to a newly developed technology, users are generally negative about using BIM and still prefer CAD drawings, since they have difficulties in inputting the significant quantity of information required for new software when working on their projects. Although UX has a significant effect on the adoption of BIM in design offices, most adoption still proceeds from a technology-oriented point of view, which is not appropriate for some users, and this is one of the factors that hinders the application of BIM focusing on usability. This study aims to provide critical information on UX and demands for implementing a smart working environment in architectural design offices. We assume that the BIM software and UI developers lack an understanding of users and the environment they operate; thus, it is important to provide a basis that directly reflects users’ perceptions and behaviors when developing the software. This research proposed a direction that could improve the convenience of use of BIM and efficiently support the architectural design process, focusing on the problems posed in the persona scenarios as follows.Implementing a User-friendly Working Environment for Smart WorkflowsThe design office is a creative and flexible workplace, and problems caused by software or tools, and ways to solve them, vary depending on the personal characteristics of BIM users. For example, according to their roles in the office, users’ goals for using the software differ substantially, as do the problems that arise. Even if users have similar goals, the scope of application at work can differ with the level of their ability to control the software, and as a result, their perspective and experience of software differ. As shown in the persona scenarios, managers, advanced BIM users, and BIM users have different problems regarding their needs and experience of BIM use. Customization of the working environment is one effective way to engender smart workflows among different user groups and provide a better working experience. Users can select preferred functions that suit their needs, leading to the personalization of the working environment and the improvement of the work efficiency that way.Providing a Customized Training Program to Support UXMany complaints about BIM are caused by problems in the working environment, such as a poorly developed community deriving from a lack of skilled tool users when working with partners as well as inside the design office. Not all users need cutting-edge technologies and UI. Beginner, moderate, and advanced users, regardless of tool use level, often cite difficulties in learning new tools. Insufficient BIM training programs comprise a critical barrier to BIM adoption in design offices. Practitioners revealed a difference regarding how to train, but most agree that training is necessary. Most companies rely on limited BIM experts for much of their work; in the long run, it is necessary to train the majority of employees in BIM skills. This requires a customized training program suitable to specific processes and techniques required as the project progresses. In line with the nature of BIM, where the level of use varies according to work, the user’s tool level or purpose of use should be clearly reflected in the quality of BIM courses for supporting UX.Developing a University Curriculum to Establish a Theoretical Base of BIMTo improve the use of BIM in the field, appropriate education and training for future designers are essential. Many universities or colleges operate BIM courses, but this is often not a required course. Moreover, unlike Auto CAD, which is actively used in design classes, it is difficult for students to gain practical experience of BIM because they are familiar with other CAD software and find this easy to work with for 3D modeling. Since each company uses specific BIM processes and tools, new employees are required to have conceptual knowledge of BIM rather than experience in using particular tools . TherefoThe significance of this research is that it specifically reflects the behavior and demands of various users in suggesting the direction of the working environment for smart workflows. A conceptual framework was proposed for the optimal implementation of the software, and the personas were developed, serving as an effective means for design offices to provide a customized training program for supporting UX. A limitation of this research is that it conducted a survey based on two offices in the Republic of Korea. Hence, only a small number of personas were developed based on the data analysis. Further, there was a lack of female representation in our interviews and surveys because most workers in the two offices were male. Thus, it would be difficult to generalize the results of the research. A further limitation is that this research focused on the BIM software, emphasizing usability in terms of the application of BIM in smart working environments. In future research, we plan to investigate more office cases to validate the implementation of the smart working environment focusing on UX for the promising application of BIM. Further, we will explore a broader application of BIM in architectural design offices rather than limiting the application to BIM software.


Pregnancy is characterized by hormonal and physiological changes; some of these changes cause changes in sleep, presenting excessive sleep in early pregnancy due to the action of progesterone, and difficulty sleeping at the end of pregnancy due to weight gain and frequency of urination. Objective: to identify and systematize the evidence on the association between sleep quality and perinatal depression in pregnant and postpartum women. Methods: an integrative literature review was carried out with a search in the CINAHL, MEDLINE, and SCOPUS databases using the PRISMA flowchart. Results: Of the 92 articles, 10 studies were included according to the eligibility criteria. Results indicate that poor sleep quality during pregnancy is predictive of prenatal and postnatal depression. Sleep quality worsens with increasing gestational and maternal age. Conclusions: Sleep quality during pregnancy is associated with perinatal depression, a global public health problem with high prevalence. Due to its severe consequences for women, children, and families, perinatal depression needs to be identified early, preferably during pregnancy or soon after childbirth, justifying the priority of screening and prevention. Perinatal depression is a global public health problem with an estimated prevalence of 11.9%  according to a metaregression that included 96 studies . Mood chThe integrative literature review can contribute to the discipline of nursing, namely, to the development of theory and with direct applicability to health practice and policies. It enables the synthesis of generalized knowledge on a given topic, presenting different perspectives and consequently identifying knowledge gaps . Thus, tConsidering the theme, the following review question was defined: what is the association between sleep quality and perinatal depression (O) in pregnant women and women in the postpartum period (P)?Adapted from the PICO acronym, we used PO: P = population—pregnant women and women in the postpartum period; O = phenomenon outcome—sleep quality and perinatal depression.The inclusion criteria of the studies were: (1) studies that included pregnant participants and women in the postpartum period; (2) studies that included the sleep quality result measured by the Pittsburgh Sleep Quality Index and the assessment of depressive symptoms measured by the Edinburgh Postpartum Depression Scale, also admitting studies that included other measurement instruments as long as at least one of those was the Pittsburgh Sleep Quality Index or the Edinburgh Postpartum Depression Scale. As exclusion criteria, we defined: (1) studies whose participants were pregnant women with a depressive illness diagnosed before pregnancy, and (2) studies in which the exposure of interest was sleep respiratory pathology.A three-phase search was carried out: (1) a comprehensive and exploratory search on PubMed to identify evidence on the subject and consequently identify the most used terms for the further development of the search strategy; (2) an exhaustive search in the following databases (via the EBSCO service): Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with Full Text, Medical Literature Analysis and Retrieval System Online (MEDLINE) with full Text, and SCOPUS; (3) the bibliographic references of the included studies were screened to identify possible studies of interest on athematic studies that were not screened in the performed search. The search formulas were adapted to each database as shown in For the selection of studies, two reviewers read the titles and abstracts in an initial phase. These potentially relevant studies were then read in full, and selected according to the inclusion and exclusion criteria. In the absence of disagreement, including a third reviewer was unnecessary. The PRISMA flow diagram for determining articles for review is shown in For data extraction, an instrument was built that addressed the following topics: title, author, and year; periodical; type of study and level of evidence; objective; and main results. In interpreting the results, similarities were identified, and a synthesis of knowledge was carried out considering the main results of the included studies that answered the review question.The selected articles were evaluated according to the level of evidence that they presented according to the hierarchical classification of evidence by Melnyk and Fineout-Overholt : Level IThe main results extracted from the included studies in this integrative literature review are presented in One of the first questions that arise is the accuracy of the definition of sleep quality itself when assessing sleep quality. This is because there is, in fact, a set of indicators of good sleep, that is, a group of objectively identifiable indicators of sleep characteristics underlying its quality. However, there are also subjective sleep quality factors that greatly influence individual sleep satisfaction . The prePoor sleep quality was significantly associated with increased symptoms of depression and anxiety . StudiesSleep quality worsens with increasing gestational and maternal age ,16,20. AResults indicate that poor sleep quality is expected during pregnancy  and may Depressed pregnant women are not only underdiagnosed but also reluctant to seek help. So, it is essential to identify variables that may reveal prenatal symptoms of depression, and this can be an effective strategy to signal women who need additional care throughout the perinatal period . In addiThe present review has limitations: most of the included studies were carried out in China, which could bias the results for the culture and practices in that region of the globe. Multiculturalism influences sleep patterns, so the particularities of the target population to whom care is provided should be considered when extrapolating the results of this review. Two secondary studies were included that summarize many primary studies on the subject. For this reason, the primary studies that constituted these meta-analyses were not included in this review. On the basis of the interpretation and synthesis of the identified evidence, a construct is presented with the particularities to be considered during prenatal and postnatal evaluation by health professionals in maternal and obstetric health .Due to its severe consequences for women, children, and families, perinatal depression needs to be identified early, preferably during pregnancy or soon after childbirth, justifying the priority of screening and prevention. This review found that the issue of sleep quality has been explored for its relevance as a protective factor for mental health. Regarding health and the implementation of good practices in detecting signs and situations of risk, it is essential to emphasize the relevance of interventions that promote mental health in pregnancy. During pregnancy, poor sleep quality increases the risk of perinatal depression, even controlling for risk factors such as psychological distress and stress. Treatments for prenatal sleep should be explored, such as stress reduction using mindfulness and/or psychoeducational programs.