This study was designed to analyze the effects of a bicycle training course on both adults’ environmental perceptions and their mode of commuting. Four bicycle training courses for adults were conducted in Granada, Spain in April 2015 and May 2016. The course program was focused on developing practical skills and attitudes on road. From the initial 65 adults who started the course, only 35 adults met the inclusion criteria and were included in the study. Participants completed twice  a questionnaire about their perceptions of the environment, usual mode of commuting to daily destinations, and sociodemographic characteristics. After finishing the initial questionnaire, the participants completed a bicycle training course based on the methodology “Bikeability” with a duration of 6 h. The results suggest that participants improved their safety perception in relation to the level of crime in the participants’ neighborhood after the bicycle training course. Cycling training courses should last longer in order to produce changes in the mode of commuting and in the environmental perceptions. Regular and sustained participation in physical activity is linked to reduced chances of acquiring numerous health conditions in adults ,2,3. HowActive commuting is a behavior that implies the performance of physical activity using ecological and non-motorized modes to move to a destination. A daily active commuting behavior is moving from/to home and workplace/school . Active Consequently, in order to achieve the physical activity recommendations, adults might choose to bicycle from home to their habitual destinations . HoweverSince cycling in a safe manner requires developing sufficient motor and cognitive abilities , bicycleIn the scientific literature, several studies have analyzed the effects of the bicycle training courses in the urban context for adults settled in Australia ,27 and tResearch on rates of cycling across countries is highly determined by certain con-textual elements , such asCycling behavior may be influenced by the environmental perceptions in adults . ActuallRegarding the recent changes of the current society into the environmental paradigm, whose worldwide framework is currently the Sustainable Development Goals (SDG) 2030 addressed by the United Nations , more evFour bicycle training courses implemented in April 2015 and May 2016 (two each year) were conducted in Granada, Spain. The cycling training courses are a part of the strategy of the city council of Granada to promote the bicycle as a mean of transport. It was announced to the population through promotional flyers, email, posters, and media releases. The courses focused on developing practical skills and attitudes on the road. They were free and voluntary courses for beginner and intermediate level urban cyclists, comprising 6 h of duration. The maximum number of participants allowed per course was eighteen, with an instructor for every six participants. Participants were selected following the order of registration.A total of 65 adults from Granada (Spain) participated freely in a bicycle training course. Participants met with the project coordinator who explained the nature of the study. They also completed a questionnaire on two occasions: (i) written on paper, 15 min before taking part in the course, and (ii) online, 15 days after finishing the course. To be included in the study, participants had to provide (a) valid questionnaire data on mode of commuting and perceptions of the environment at the two measurement times, and (b) data about age, gender, and socioeconomic status.The anonymity of the research participants was preserved at all times, as stated in the ethical considerations of Sport and Exercise Science Research  and the Participants were asked to complete a questionnaire on their perceptions of the environment , mode ofThe environmental perceptions of the neighborhood where the participants lived was assessed using the short version of the Assessing Levels of Physical Activity and Fitness (ALPHA) questionnaire . This quThe mode of commuting was assessed using five questions and seven response options see  in relatSocioeconomic data were assessed through the following questions: “Which is the maximum level of studies that you have?” ; and “Indicate your work activity” (response options: do not work and work). Socioeconomic data were adapted from the 2006 National Health Survey .The bicycle training course in the urban context took place for 6 h. This course was an adaptation of the Bikeability method . An actiThe bicycle training course has been previously described . Brieflyn < 50) was used to assess the normality of data. As normal distribution was not found in our data, non-parametric tests were used. Age, gender, and sociodemographic characteristics of the participants were analyzed using descriptive statistics. The data are presented as mean ± standard deviation for continuous variables and frequencies for categorical variables. The variable mode of commuting was recoded into a three categories multinomial variable: walking, cycling, and passive  and into three dichotomous variables: walking vs. not walking, cycling vs. not cycling, and active  vs. passive. To analyze the differences before and after the course in the environmental perceptions of the area in their neighborhood, we used the Wilcoxon signed-rank test. To determine age invariance, we used median as a criterion to create two groups. Effect sizes were assessed with the Pearson´s correlation (r) and Cramer’s V for continuous and categorical variables, respectively. Effect sizes were considered small, moderate, or large, when (r) was above 0.30, between 0.31 and 0.49, and 0.50 [p < 0.05.Firstly, the Shapiro–Wilk test  met the inclusion criteria and were included in this study. The average age of the participants was 34 years old (age range: 19 to 53 years old) and 74% were workers.p < 0.05), was found. In contrast, no significant differences were found for the other environmental perception variables .The different response options for each question of the environmental perceptions before and after taking part in the bicycle training course in the urban context are described in p > 0.05) was found for each question of the environmental perceptions before and after taking part in the bicycle training course in the urban context between the pre– and the post-intervention.p < 0.05). When the analysis was performed for each mode of commuting, significant differences were found in the mode of commuting to local shops and to local services, with a reduction in the walking trips  and an increase in passive trips . For cycling trips, no significant differences were found .The numbers of trips using different modes of commuting before and after taking part in the bicycle training course in the urban context are shown in In the present study, a bicycle training course was implemented to examine the changes in some environmental perceptions and the mode of commuting of Spanish young adults. Concerning the environmental perceptions, we found significant differences in safety perception regarding crime, which improved after the bicycle training course. Regarding the mode of commuting, we observed a significant decrease in walking trips and an increase in passive trips to local services and local shops after the course. Regarding cycling, there were no significant improvements.The results obtained in this study showed that the safety perception in relation to the level of crime in the participant’s neighborhood was improved after the bicycle training course. In the scientific literature, there are no studies reporting improvements in the safety perception in relation to crime after a course in adults. However, there are various studies in adults that closely correlated with confidence gained from the training ,51. RissAfter the intervention, our results showed a significant decrease in walking trips and an increase in passive trips to local services and local shops. In the scientific literature, few studies have addressed the effect of bicycle training courses on the urban context among the adult population. Indeed, to our knowledge, only one study reported the effects of the bicycle training courses in the urban context for adults . AttendiThe main strength of this study is to provide the first Spanish study about how to implement and analyze the effectiveness of a bicycle training course for adults in the urban context. In addition, a recognized methodology  was used to teach bicycle training courses, similar to other previous experiences in other countries. The main limitation is a lack of representative data at the national level because the study was restricted to a single geographical area, the city of Granada, in southern Spain. Moreover, the use of the Spanish version of the ALPHA questionnaire and the questions on mode of commuting for adults is another limitation of this study, since it has not been shown to be valid and reliable in healthy adults. However, the ALPHA questionnaire and the mode of commuting questions are reliable, and they have been associated with physical activity in women with fibromyalgia. In addition, the sample size is low, which hampers the application of powerful statistical analyses. Finally, other limitations are the lack of individual neighborhood data, weather conditions, the lack of motivations or concerns of the participants to take the course, and objective measures to collect data on modes of commuting.The present study showed how a bicycle training course can improve safety perceptions in relation to the level of crime in the participants’ neighborhood. However, a decrease in walking trips and increase in passive trips were found. In contrast, no significant results in cycling trips were observed. After this experience, we have concluded that changing commuting habits may require longer bicycle training courses over time and/or further follow-up measurements to assess the long-term effects of these cycling training interventions. Moreover, it is important that bicycle training courses focus on enhancing adult people’s cycling confidence by improving skills, practicing, and repeating.


The diagnosis and management of idiopathic intracranial hypertension (IIH) can be difficult and multiple medical subspecialities are often involved. Several national and international guidelines regarding the investigations and management of IIH have been published in recent years but still there is no consensus about the optimal organization of IIH-care. The objective of this review was to propose and describe a referral pathway and an organization scheme for diagnosis and management of IIH. An extensive search of existing literature was conducted and summarized. In total, 237 IIH-articles were identified and hereof 43 included. The clinical practice in our specialized IIH-clinic is characterized and described. We conclude that an educational campaign involving medical care providers and patients with chronic headaches is necessary. A detailed organizational proposal for a referral pathway and management of IIH patients based on the literature search and our clinical experience from a highly specialized IIH outpatient clinic is suggested and discussed. The identification and management of idiopathic intracranial hypertension (IIH) can be challenging and various medical specialties are often involved. A clear referral pathway from the initial symptoms to the final, correct diagnosis and treatment is not well characterized. Several national and international guidelines regarding the investigations and management of IIH have been published in recent years ,2 but thWith the close relation between IIH and obesity and the rapid increase in IIH incidence in parallel with pandemic obesity, the individual and the societal burden of IIH are also rapidly expanding as documented by Friesner et al. 2013  and MollAlthough the burden of IIH is alarming for the specialists within the field, we have to acknowledge that IIH remains a rare and often unknown disease in general practice and probably also occurs infrequently in most headache and eye clinics. A better quality of epidemiological studies is required to improve the burden of IIH and inform health policy about IIH management .So, what makes a person with an undiagnosed IIH aware that something is wrong and urge them to consult medical help? Additionally, vice versa, what makes a healthcare provider aware that their patient might have IIH?In addition, there is no early and reliable diagnostic test and the IIH-diagnosis is most often a diagnosis of exclusion. The revised diagnostic criteria from Friedman et al.  require So, although early diagnosis and treatment is crucial for favorable visual outcomes there is also a risk for over- and misdiagnosis in as many as 40% of patients initially diagnosed with IIH, as documented by Fisayo et al. . The potAt this moment, there is very limited evidence for the exact referral pathways and in clinical practice patients often have a long history of consultations with multiple contacts before they receive a correct diagnosis and treatment, which can be crucial for their visual outcome. Therefore, more awareness about the disease is needed.On this background, by the means of a literature search and clinical experience from our specialized IIH-clinic, we here aim to describe an organizational scheme for improved awareness, diagnosis and management of IIH.We searched MEDLINE and Embase databases for articles on the management of IIH. The first database search was performed twice on 18 and 22 April 2021, with the following MeSH search string and no restrictions in terms of the date of publication: idiopathic intracranial hypertension AND management; idiopathic intracranial hypertension AND treatment; idiopathic intracranial hypertension AND organization. The database searches were limited to articles that were published as full text in the English language except for one in Spanish with an abstract in English, and included clinical trials, meta-analysis, randomized controlled trials, reviews and systematic reviews.In total, we reached 237 articles. Only studies on adults and studies using the revised Friedman criteria (2013) were included and we excluded case reports and case series. Finally, 43 were suitable for the purpose of the study .In our literature search, we were unable to identify reports, surveys or national IIH campaigns targeting both the general public and/or health-care providers.Methods for “the clinical IIH setting”:Demographic data (sex and age) were retrieved from our clinical database (EPIC) system on patients referred to The Danish Headache Center under the diagnosis DG93.2 Benign Intracranial Hypertension.Forty three articles were identified and hereof 18 were focused on treatment, 23 on management and only 2 were related to organization and management. None were focused on awareness campaigns. Related articles from other specialties were thus included .The Danish Headache Center (DHC) is a public national referral center for severe and rare headache disorders and an integrated part of the Neurological Department, National Hospital, University of Copenhagen. The catchment area covers 2.7 mio inhabitants but patients can be referred from the entire country . DHC has a highly specialized clinical IIH-function and offers multidisciplinary therapy within a team of headache nurses, psychologists and physiotherapist, if needed. Furthermore, DHC is part of a dedicated IIH team within the National Hospital in collaboration with three neuro-ophthalmologists, one dietician, two neurosurgeons and one orbital surgeon. An IIH-research group is closely connected to the IIH team.The pathway for patients suspected of IIH is the following: general practitioners (GPs), neurologists, ophthalmologists, optometrists or other hospital departments refer the patients to the emergency room, the neuro-ophthalmology clinic or DHC. Hereafter, patients are admitted to our neurological department .A detailed and standardized work-up is performed and if IIH is confirmed, an individualized treatment is planned within the IIH-team. Surgeons are informed the same day if there is an imminent vision threat or within 2 days if there is a significant progression despite medical treatment. Optic nerve fenestration (ONSF) is offered as the first line surgical treatment. In cases where ONSF does not provide improvement, the patient is referred to the second line surgical treatment, i.e., ventriculoperitoneal shunting. All IIH-patients are offered a concerted follow up program in DHC and the eye clinic, with weekly–monthly follow up visits in the beginning of the disease course depending on the severity of the disease and up to 6 month intervals in later long-term follow-up. During the follow-up period, supplementary fundus photography and visual field assessment are available in DHC using an automated fundus perimetry device (COMPASS), which includes laser ophthalmoscopy and in the case of doubt the output is discussed with a neuro-ophthalmologist, who will see the patient acutely, if needed.Based on our recommendations that all suspected IIH patients should be referred to the DHC, the annual referral rate has doubled from 2017 to 2020. A total of 264 patients, 251 females and 13 males with an average age of 36.6 years suspected for IIH were admitted to DHC from January 2017 to March 2021. Hereof, only 133 patients (50.5%) fulfilled the criteria for IIH, whereas a variety of differential diagnoses were identified in the remaining patient group. This reflects the need for an IIH team that can provide an accurate diagnostic work-up and confirm or exclude the IIH diagnosis without delay. In the same period of time, a total of 10 IIH-patients (5.1%) were admitted to surgery: eight to ONSF and two to VP-shunts [The main barrier for an early detection and diagnosis of IIH is probably a lack of general knowledge of the disease. In our literature search, we were unable to identify reports, surveys or national IIH campaigns targeting the general public and/or health-care providers and to the best of our knowledge there are no existing campaign models. On the contrary, other awareness campaigns have been successfully conducted in the headache field with the initiatives of “Lifting The Burden: The Global Campaign against Headache” ,12, whicThe first step in an IIH awareness campaign should target the primary and secondary care level, the GPs, ophthalmologists, the optometrists, neurologists and the ear–nose–throat (ENT) specialists. There is no need to address the general population as the disease is still relatively rare compared to other more prevalent disorders, such as migraines and medication overuse headaches .Further, if the health care providers do not know the symptoms or the disease there will be no link to a diagnostic process. With the model described above a survey of the general knowledge of the disease, followed by written and spoken educational information  and followed by a new evaluation survey could be a useful model to pursue.However, such educational and awareness campaigns should be implemented in the curriculum for medical education and repeated on a regular basis to gain enough impact. In an interesting approach from the Birmingham IIH group, patients and physicians were also engaged to delineate their research priorities and their most important priorities were to understand the etiology and management of IIH . The refThe majority of IIH patients report that they must consult a high number of health care professionals before the right diagnosis is established. That is probably due to the lack of education as mentioned above but also due to the broad variety of symptoms they are presented with in the early stage. Here more education and more awareness of IIH among health care providers could be beneficial for the recognition of IIH but many GPs, private practicing ophthalmologists and neurologists will probably still be unable to manage these patients in their settings. Therefore, referral to a headache center with a specialized IIH team is recommended.The IIH patients that present a headache phenotype that mimics a chronic migraine and/or chronic tension-type headache may be exposed to migraine preventive medications and triptans for months or even years, but not treated for the underlying disease, and thus are at risk of permanent visual damage.For this reason, there is an imminent need for a clear referral pathway to a specialized care setting. Thus, when a clinician suspects IIH, the patients should be referred to a specialized multidisciplinary center for IIH. In this case it could be a headache center, an ophthalmological center or other settings with special interest in IIH. In the case of the presence of the two cardinal symptoms and signs, a headache and papilledema, the suspicion of intracranial hypertension, either secondary or primary, should always be raised. The diagnosis of IIH without papilledema (IIHWOP) is more challenging as the condition is rare and the neuroradiological signs are open for individual interpretation . Thus, tThe main targets in the early phase of the disease are to identify the disorder and preserve visual function.If a headache is the main symptom, the pathway from the GP to the neurologist and thereafter to a headache specialist can be long and troublesome. The early symptoms can be unspecific and vague and IIH in the early stages can be difficult to recognize. The cardinal symptom, a headache, affects up to 90% of IIH patients , but is Migraines affect up to 16% of the general population and tension-type headaches up to 76% ,24, and The initial visual disturbances that most patients with IIH may be presented with are vague, unspecific and sporadic. Patients complain of blurred vision, but this is also reported in 47% of other headache patients . FurtherThe diagnosis of papilledema is not always easy, especially in the emergency room and/or in the headache clinic. Many young doctors are unfamiliar with direct ophthalmoscopy and may overlook a mild papilledema. On the other hand, many optic disc anomalies might erroneously be misdiagnosed as papilledema, even by ophthalmologists. The most common diagnostic error in the diagnosis of IIH is actually inaccurate ophthalmoscopic examination in headache patients . On top Optical coherence tomography (OCT) is a rapid, non-invasive imaging technique increasingly used among private ophthalmologists and it is the standard in all eye departments. Although several pitfalls exist, OCT is probably one of the most useful tools to identify and quantify papilledema in IIH and provides important clues, such as peripapillary retinal nerve fiber layer (RNFL) thickness increase, peripapillary choroidal and/or retinal folds and wrinkles, which all point in the direction of true papilledema ,28.The diagnostic value of the optic nerve sheath diameter using an ultrasound could also be a valuable and atraumatic diagnostic tool for IIH ,30,31 buIn recent years a major technological development in cameras have enabled opticians to make high quality fundus photos and thereby identify suspected papilledema. A more widespread use of fundus photos in headache clinics and emergency rooms may also contribute to early screening and identification of suspected papilledema, especially if there is lack of access and/or long waiting time for neuro-ophthalmologists and headache specialists.IIH-patients may also report a variety of other unspecific symptoms, namely back and neck pain, dizziness, pulsatile tinnitus and sometimes cognitive symptoms like memory impairment and concentration difficulties ,33,34. TNeuroimaging is required for the exclusion of secondary causes of intracranial hypertension. Neuroradiological evaluation of signs suggesting elevated ICP can be complex and needs a specialized neuroradiological evaluation. The present neuroradiological criteria are only applied for IIH WOP and not for the more classic IIH patients with papilledema . Thus, tMeasurement of opening pressures and CSF analysis is required for a precise diagnosis but a lumbar puncture can be a challenging procedure. Patients often are afraid of lumbar punctures due to the myths about pain, repeated unsuccessful attempts and the risk of post lumbar puncture headaches . LikewisFurthermore, the measurement of opening pressure presents another common reason for overdiagnosis, as it is a snapshot and not always a true reflection of the real intracranial pressure ,35. PosiThus, there is a huge unmet need for better, valid and atraumatic diagnostic tools for IIH, especially in the early disease stages but certainly also later for follow-up visits.In a minority of suspected IIH patients, an atypical presentation can be seen. These are mostly young/elderly females with normal weight or males. In these cases, it is important to exclude secondary causes, such as rheumatological or infectious diseases. Additional blood tests are required and, if positive, referral to specialists is needed.The target points for the diagnostic process are summarized in When the patient has received the correct diagnosis, the question about treatment is naturally asked. The main target is to preserve vision but also to reduce the headache and the other debilitating symptoms. The present recommended strategies are a combination of medication, life-style changes and weight loss in the vast majority of patients. Suggestions for management have been published ,2 but onEffective treatment is an unmet clinical need in IIH. Current medical management remains centered around weight management, which is challenging. Identification of novel molecular targets thought to underlie IIH pathology is now being translated to clinical trials ,38.The most frequent medication used in treating IIH, acetazolamide, is unspecific and is not well tolerated, causing up to half of the patients to discontinue their treatment ,40. TopiComorbidities to obesity are well documented, such as depression and anxiety . HoweverSince obesity and recent weight gain are major risk factors, weight management is always recommended and an important part of the management of all patients ,43,44. PObesity is in itself a disorder that has a complex pathogenesis and can be caused by genetic disposition or psychiatric disorders but the rapid increase of obesity can probably best be explained by environmental factors in terms of easy access to food rich in fat and sugar combined with lifestyle changes towards more immobility. Reducing weight may thus seem the most obvious goal to set but maintenance of weight loss is the main challenge both in IIH and in obesity in general .In the subset of patients presenting with an imminent visual threat it is urgent to identify and refer them to the right surgical intervention, either shunts, optic nerve fenestration or venous stents.The surgical procedures are needed when vision loss is rapidly progressing and medical treatment and weight loss has proven insufficient. The advantages and disadvantages have been extensively studied and also reported in this issue . HoweverAn early surgical intervention should definitely be avoided in the majority of cases, especially if the IIH-diagnosis is unconfirmed, the vision is not acutely threatened and a possible secondary cause as cerebral venous thrombosis or other organ diseases is not investigated or identified. Further, the effect of surgical interventions on the headache outcome has not been confirmed and therefore the general recommendation is that surgical interventions should be reserved for patients with an imminent threat to their vision and are not needed for the headache . In addiFrom the above it is obvious that uncertainty about the cause(s) in IIH exists and that the evidence for treatment is evolving but not yet specific or firm. For the patient getting the correct diagnosis and a treatment plan this can also be a challenge. It is therefore essential with long term follow up until the situation is stable and patients are properly educated in their condition.Based on the estimation of the stage and burden of the disease, an IIH patient can be followed-up more closely in the beginning (3–5 days) and in later stages with more remote controls. In cases of visual improvement on the first two controls, which are 2 months apart in most cases, further controls can be with 3–4 months intervals. High CSF opening pressure, worsening vision/papilledema, rapid progression, severe papilledema with greater RNFL thickness and abnormal VEPs may be some of the alarming signs for physicians, but none of these parameters can be used as an independent predictor for visual outcome in isolation. Visual field loss at presentation is probably the most important predictor of the final visual outcome in these patients ,52. The Furthermore, relief from headache and additional symptoms is warranted. Close monitoring of laboratory parameters is needed , especially if acetazolamide is introduced at a high dosage. Potassium substitution and in some cases sodium bicarbonate are needed, too. During the follow-up, especially in the first phase, the IIH specialist, the IIH nurse and the ophthalmologist should have a possibility for close consultations and adjustments in the treatment plan.As the disorder is so complex and can be difficult to manage, a multimodal treatment strategy is needed and a dedicated team consisting of neurologists, neuro-ophthalmologists, neurosurgeons and dieticians are therefore recommended in most guidelines. The documentation for these multimodal structures is now evolving. By means of a structured follow-up protocol at 3, 6 and 12 months for IIH in the neuro-ophthalmological unit in a tertiary hospital in Spain the number of LPs was significantly reduced, the outcome was markedly improved. Thus, it was concluded that optimization of follow-up could lead to reduced use of resources and better care . LikewisIt is also important to address the patient’s comorbidities such as depression or eating disorders, along with help from the dietician but more evidence is also needed here.The management of an IIH-headache is often reported to be complicated and for unknown reasons the headache does not follow the visual improvement. When the intracranial pressure is normalized, usually the diplopia, tinnitus and neck pain resolve, whereas the headache does not improve to a similar level ,52,53. IThus, there is an unmet need for a mechanistic insight and larger randomized treatment studies with a focus on the entire IIH-disease as the present strategy on the visual outcome and headache phenotype alone may be incomplete. The target points of multimodal management are displayed in Much more awareness about IIH is needed as the disease still is relatively unknown, at least in the primary and secondary health care system and in the general population. It is well documented that an early diagnosis leads to a better visual outcome but there is a significant risk of misdiagnosis and under- and overtreatment. On the basis of the literature and our experience, a structured educational campaign and a clear referral pathway to highly specialized national IIH-centers are suggested. Such initiatives may ensure better care and outcome but proper large-scale testing hereof is needed. Further, it is important to have a certain critical mass of IIH patients. A clear referral pathway to a specialized center for suspected IIH will enable the physicians to revisit the multiple differential diagnoses that affect up to half of our patients. Further a specialized IIH center can and should also be a promotor for research and the development of new and better treatment strategies.


Disease transmission simulation programs in veterinary epidemiology in general and in simulation of African swine fever in particular are often very diverse and require great computing power. However, such programs often share similar workflows from processing input/output data, performing simulations, or storing data. Our paper proposes a common architectural framework for livestock disease transmission simulation programs in order to both improve simulation performance and reduce the effort of developing new simulation programs. Our framework was evaluated with a simulation program of African swine fever transmission currently raging in Vietnam and some other countries around the world. The results from the evaluation experiments not only demonstrate the effectiveness of the framework in terms of performance but also have practical consulting value for decision makers in Vietnam and for international colleagues.The spread of disease in livestock is an important research topic of veterinary epidemiology because it provides warnings or advice to organizations responsible for the protection of animal health in particular and public health in general. Disease transmission simulation programs are often deployed with different species, disease types, or epidemiological models, and each research team manages its own set of parameters relevant to their target diseases and concerns, resulting in limited cooperation and reuse of research results. Furthermore, these simulation and decision support tools often require a large amount of computational power, especially for models involving tens of thousands of herds with millions of individuals spread over a large geographical area such as a region or a country. It is a matter of fact that epidemic simulation programs are often heterogeneous, but they often share some common workflows including processing of input data and execution of simulation, as well as storage, analysis, and visualization of results. In this article, we propose a novel architectural framework for simultaneously deploying any epidemic simulation program both on premises and on the cloud to improve performance and scalability. We also conduct some experiments to evaluate the proposed architectural framework on some aspects when applying it to simulate the spread of African swine fever in Vietnam. The spread of diseases in livestock is an important research topic in veterinary epidemiology in order to provide warnings or advice to regulatory bodies responsible for the protection of public health in general and animal health in particular in terms of trends in the spread of diseases in herds . As an eThe study of applying computer technologies to decision making on disease control in livestock has been conducted by many research groups around the world, mainly focusing on building toolkits to identify characteristic epidemiological features ,3,4 (e.gMycobacterium avium subsp. paratuberculosis) conducted on clusters at Oniris Nantes take days or even weeks to produce simulation results that have practical advice value [While the benefits in terms of assisting policymakers in designing disease surveillance and control strategies are substantial, the simulation and decision support tools often face some computational power limitations, especially with input data sets that may involve tens of thousands of herds with millions of individuals distributed over a large geographical area such as a region or a country. For example, simulations of the transmission of bovine viral diarrhea in dairy cows or gastroenteritis due to the ruminant bacteria , a standard for animal disease input data .Simulation Programs Management is a module for managing and distributing resources on premises as well as on the cloud for automatic and high-performance execution of simulations and centralized collection of outputs. This module also makes it possible to integrate different epidemic simulators on the same platform that manages and distributes resources for simulation computation, regardless of whether using a mathematical  or an agAnalysis and Visualization is a module for handling data analysis on the output results stored centrally in the form of files or in the databases and is responsible for displaying the results in the form of tables, charts, histograms, or epidemiological maps using popular data representation programs in epidemiology, such as QGIS  or Epi IIn order to partially solve these challenges, the article introduces a novel framework that can be used for executing many different programs of livestock disease simulation at the same time, with new features offered in the following framework modules:The paper is structured as follows: Our proposed framework is illustrated in A program that simulates the spread of disease in the herds, whether using synthetic or real data, may have to take input from multiple sources. These data sources are diverse and can include private data directly collected on the farm, traditional archives of local authorities, publicly available data on the internet, data collected from Internet of Things (IoT) sensors, and location data from a global geographic information system (GIS). These data sources, in addition to having different ownership rights, are not identical in terms of data format and description (metadata). Current decision-supported epidemic simulation tools are underutilizing these data sources. Using interoperable data standards and incorporating both public and private/copyrighted data can improve the overall advisory value of data and enhance our ability to share and reuse these data.The number of data acquired by sensors has risen dramatically since the advent of digital agriculture . Data stThere are several main data sources used for veterinary disease management: from farm management information systems, from veterinary laboratories, or from veterinary clinics. On farms, automatic monitoring data of herd management and production quality indicators have been reported and reviewed in the article of Bartlett et al. . HoweverVeterinary laboratory testing requirements are one type of data of interest. They appear earlier than laboratory results and can be grouped into syndromes according to the nature of the disease and/or the symptoms observed by the veterinarian . Stone iIn contrast to human medicine, in veterinary clinics at the time of service, in most cases, there is no requirement to transfer data to third party payers, such as insurance companies. This has resulted in veterinary clinic records being largely focused on client and billing management, and there is little incentive to develop and implement disease coding standards . DespiteThere are several agricultural metadata standards, such as Agricultural Information Management Standards (AIMS) . XML schEpidemic simulation programs in livestock can use a variety of models, such as mathematical models, network-based models, or agent-based models. Each type of livestock can have simulations with different types of models using different programming languages  or different simulation platforms/tools  and resource allocation management in order to improve the performance of the simulation. In order to achieve performance gains, the simulation computations must be broken down into specific tasks and distributed to compute nodes  in different compute infrastructures at the same time either on premises  or on the cloud. The module also needs to support the execution of multiple model types at the same time, while ensuring the necessary independence/isolation between these models. A specialized platform that supports the integration and high-performance execution of many simulation programs such as OpenMole  or Repas-The population module: This module can describe the entire population or describe individual livestock . The population needs to be generated at the beginning of each simulation run and assigned macro attributes such as quantity and composition or micro attributes such as age, gender, or medical history, etc.-The contact module: There are many ways that diseases can be transmitted in livestock, either by direct contact  or by indirect contact . At the farm level, indirect transmission can also be caused by trade, grazing practices, or seasonal movements of livestock. Contacts also have properties such as duration or intensity.-The disease module: The task of this module is to deal with everything related to diseases. An agent-based model, for example, has individual-level information that may be divided into three parts: first, animal disease and health state; second, contact-causing state changes; and third, contact-independent state change . A disease might alter animals’ everyday habit, for example, making them lie still or stop eating. Animal death that is managed by the population module may result from the disease.In order to render the integration of epidemic simulation programs easier, we recommend that these programs should at least implement the following specialized modules:While running simulation models, it may be necessary to extract instantaneous information; thus, some temporary data can be saved in the temporary storage or memory of the workers and will be collected by the master immediately upon request. In particular, agent-based models can benefit from this functionality to show the simulation of disease transmission while the model is still running.This module is responsible for analyzing the resulting data collected after running the simulation. There are two methods to collect the results: (1) Either a monitoring module periodically watches and logs the steps and states of the simulation components, or (2) the agents themselves are in charge of reporting all information of interest. Often, the information of interest of a disease transmission simulation is not only about the number of infected individuals but also about the state of each individual or how the herd evolves over time cycles. In this manner, we can observe how a part of the population is affected by changes in the pattern at certain time intervals . The resulting data collected from multiple simulations can be used independently or in combination in order to provide valuable statistical information or warnings and forecasts for farm owners or policymakers. Some result analysis methods such as sensitivity analysis are also useful for determining the impact of specific parameters on the model to adjust the input parameters of the simulation, making the simulation model more dependable.In terms of data visualization, simulation results can be exported as files for use by desktop epidemiological analysis and visualization programs such as QGIS or Epi Info. These results can also be displayed in web-based form as a SaaS service in the cloud. The visualization services can be directly accessed in order to obtain data in permanent storage for displaying static information after the simulation is finished or for displaying real-time dynamic information while the simulation is still running .Cattle and pigs are an essential and direct source of nutrition for humans, and some diseases from livestock can infect humans if there is no timely intervention policy. Current common disease such as African swine fever in even-toed ungulates is a concern of many countries. In Vietnam, within a month of its appearance (February 2019 in Hung Yen), ASF alone broke out in nearly 15 provinces and cities, causing more than tens of thousands of pigs to be culled. Since then, ASF has spread to over 7700 communes in 600 districts of 63 provinces and cities with the total number of pigs culled being approximately 6 million equivalents to over 230 thousand tons . By May 2020, more than half of the provinces and cities had not recorded an epidemic for more than 30 days. Due to the topicality of this epidemic in Vietnam, we chose ASF as the focus of this article.We proceeded to build a model of the spread of ASF on all farms of Hanoi city, the capital of Vietnam with nearly 10 million people (2019). The total pig production of Hanoi is about 1.4 million (accounting for 4.7% of the whole country). The number of pigs of large farms outside residential areas is more than 700,000, accounting for more than 50% of the city’s total pig herd. The farm locations and characteristics are required to construct the ASF transmission models. At provincial level, the number of livestock smallholdings and farms is 131,756 (figures for 2021 from the Hanoi Department of Livestock and Veterinary Medicine). Since there are no specific farm locations, random points for all farms in every commune are created by QGIS see . The cooIn Vietnam, ASF is often transmitted by indirect contact due to vehicle/human movements as well as swill feeding. For this reason, the model used for the ASF simulation in this article is the model of the trade network of domestic pigs in Vietnam with the particularity that large farms are a direct source of supply to medium farms and do not directly supply to small farms. Medium farms will be a direct source of supply for small farms, and pigs from small farms are barely transferred to larger farms. This is consistent with the actual situation of pig production in Vietnam because a system for continuous flow (CF) is employed in small farms, meaning that pigs from various sources which are medium farms with uncertain infection status are regularly replaced. While at big and medium-sized farms where state of infection and superb biosecurity are known, the all-in-all-out (AIAO) method is followed, and those farms bring in fresh pigs in batches. These factors are used in our estimations of the infectious life for the three farm types in which big and medium-sized farms may stay infectious for a shorter period. Small farms, however, remain infectious throughout the entire simulation period because of the continual reintroduction of pigs.In the ASF model used, there are three main parameters to consider: (1) mean contact rate per week (CR), (2) transmission probability (TP), and (3) contact distance between farms (CD). Details of these parameters will be discussed in the following section.We developed implementations of the ASF model mentioned in Actual data from an agency survey on population, size of herds, pig farm health conditions, number of pigs, and interaction with other farms have been used to determine trustworthy parameters of the mean contact rates per week (CR) between various farms in Hanoi. The CR parameters with their Poisson distributions amongst various farm categories are shown in The simulation model is performed for one year, which is sufficient to encompass an entire cycle of pig production (6–8 months in Vietnam). Since ASF vaccination does not exist, we evaluate the efficiency of the restriction of movement in reducing contact rates for direct and indirect contacts by 20%, 40%, and 80%. It is assumed that movement constraints will be applied within 6 weeks following the pandemic announcement for the baseline scenario.We deployed a prototype of the proposed framework with open sources software components such as OpenStack for cloud resource management, HTCondor for on-premises cluster management, and OpenMole for simulation programs management. In terms of virtualization, result files are outputted in the formats supported by desktop-based programs such as QGIS and Epi Info. We also developed a web-based application that supports rendering of the epidemic simulation interface and graphs from GAMA . While oEstablishments: Any premises, buildings or any habitat or location where animals or germinal products are kept temporarily or permanently, excluding houses in which pets are kept as well as veterinary offices or clinics;Sub_units: Animals management group as part of an establishment such as flocks, pen, herds, houses, sheds, etc;Animals: Any terrestrial human-kept and registered animal that has a single identity number;Geo_locations: Positioning in the greatest possible resolution of the unit of interest, i.e., an establishment or a single animal;Disease_detections: Information string on probable epidemic reports, as documented in government veterinary agencies’ information system where accessible or in other public systems ;Production_types: Type of the establishment’s finished product or objective for which animals are maintained and/or raised;Species: The name, genus, species, and breed of the sub-unit of interest. This is especially significant in instances where the individual animals have no animal identification;Diseases: Disease to be reported;Countries: The ISO code of the country of birth or farm of the kept animal;Monitoring_data: Data from the surveillance or monitoring of kept animals, farms, diseases, and others.As mentioned in In Vietnam, it is a fact that digitized data at the individual animal level or even at the livestock farm level is quite rare. Therefore, in the ASF model used for the experiments, some entities of the SIGMA data model are not used, especially the Animals entity where data about each individual animal are stored. However, for disease outbreak simulations in Europe or America where sources of data at individual animal level are well defined and collected, it is possible to standardize the data by using the Animals entity such as our previous study in the simulation of spread of bovine viral diarrhea virus  on dairy cattle herds .We developed an open-source software  helping In this section, we perform a couple of experiments in order to evaluate the performance and functionality of the proposed framework when implementing the simulation of the ASF disease transmission model.With a realistic simulation of ASF outbreak, we assessed our proposed framework as a field trial in veterinary epidemiology. In each cycle  of the ASF model, all farms participate in contacting the network and change the network together; thus, operations on farms must be executed sequentially, farm after farm. However different scenarios of the simulation as well as their repeats can be run independently and distributed to different local or remote processes for running in parallel.The performance of running ASF simulation was compared in various environments using on-premises and cloud resources. With on-premises resources, the repeats are (I) conducted sequentially in a regular computer  where all four cores are allowed to be use for the simulation or (II) conducted in a cluster of the HTCondor batch system. In the (I) environment, our proposed framework is not used whereas OpenMole asks HTCondor to manage and distribute simulation jobs including repeats to compute nodes  in the cluster of the (II) environment see . We deplOpenMole is responsible for measuring the execution time of the ASF simulation and its repeats. We implemented three parameter sets for three movement control strategies on reducing contact rates by 20%, 40%, and 80%. Each movement restriction also has three parameter sets for timing controls which are 3, 6, and 9 weeks of postponement of movement restriction after detection of outbreaks. Each of nine scenarios is repeated 50 times in order to obtain the statistical mean. One parallel simulation repeat is guaranteed to run in one core of participating nodes by OpenMole and HTCondor. Each repeat involves a calculation of 23,162 farms in every single 364 cycles. Firstly, the following formula is used to calculate the performance of each simulation in the environments from (I) to (IV).We have utilized a modified version of Formula (1) to assess cost-effectiveness:azon EC2 . For theazon EC2 . DetailsWe also conducted another experiment to evaluate the scalability of our framework on both shared and distributed memory architectures. We proceeded to simulate a medium-scale ASF propagation comprising of all 467 communes in Hanoi. This setup allows us to assess the scalability of the framework by increasing the number of processes progressively. We take the execution with four CPU cores for each node as base, both for the distributed and the shared configurations. With distributed configuration, we reuse the HTCondor cluster of three Dell PowerEdge R740XD rack servers. With shared configuration, we picked one out of three Dell PowerEdge R740XD servers and limited the number of CPU cores allowed to use for the simulation. The number of cores doubled until 32 in both configurations.We ran this experiment on the distributed memory systems such as the cluster, cloud, and hybrid environments mentioned in 4.4.1. Each simulation job includes a batch of processes which are simulation repeats. In the distributed environments, these processes are delivered to a pool of CPU cores according to a specific method. In the first method, the processes of repeats are distributed in a batch-based manner in which batches of a fixed number of processes are allocated to the compute nodes in the round. This distribution may cause difficulties if some repeats of batches performed in a node take longer than other nodes to complete. This results in some nodes always seeming busier than the other ones.The second method provides more fine-grained batches in order to compute nodes. In fact, only one process is sent to the nodes in round-robin manner. The waiting time for long-running repeats is shortened, but the overhead for inter-process communication increases accordingly.The third method uses our previous job-based algorithm introduced in . The disThe percentage reduction for the total execution time of the round-robin and job-based distributions in comparison to the batch-based version is shown in We spend this section mainly discussing similar studies in the development of architectures, platforms, and tools for performing high-performance simulations of disease outbreaks.In order to complement pandemic simulations and leverage multi-core CPUs, Eriksson et al.  employedIn order to increase performance, several solutions use parallelism at the distributed level. Perumalla and Seal  reportedZou et al.  suggesteA cloud-based framework for the simulation of epidemic disease spread has been proposed by Sukcharoen et al. . The fraTo the best of our knowledge, our work is the first to propose a complete practical solution for building and executing high-performance simulations of livestock disease outbreaks on both on-premises and cloud environments at the same time. Moreover, the proposed framework is also the first one allowing the realization of any epidemic simulation model in livestock as well as combine simulation results from these models simultaneously.Applying computing technology to simulate the spread of epidemic diseases presents multiple challenges. First, simulation data, models, and tools are typically diverse and tied to specific diseases and concerns of research groups, hindering research collaborations and decreasing the quality of decisions. Second, running epidemic simulations needs large amounts of computational power, practically requiring the combination of on-premises resources with cloud resources. Finally, storing data, managing simulation runs, and analyzing results can be complex and error-prone, requiring guidance and automated support.To address these challenges, the paper proposed a novel framework for managing and executing epidemic simulation programs. The framework supports transforming heterogeneous data into uniform data models that are stored in standardized databases, thus facilitating data reuse. The framework also supports integrating different simulators and data analysis and visualization programs into a common platform, enabling sharing of models and tools, and facilitating decision making. Importantly, the framework includes automated support for simultaneously deploying simulation programs on various types of resources, both on-premises and cloud resources, in order to improve performance and reduce costs.In order to evaluate the proposed framework, the paper described a prototype implementation and its application in simulating the spread of ASF in Vietnam. Based on this application, a number of experiments were performed. The experiments demonstrated that the framework supports simulation execution in different environments , enabling users to optimize performance and cost. They also demonstrated the scalability of the framework to large numbers of processors and the efficiency of its process distribution method. In future work, we plan to apply the framework to further case studies and perform a larger-scale evaluation of its usefulness and usability.


An aging population, accompanied by the prevalence of age-related diseases, presents a significant burden to health systems. This is exacerbated by an increasing shortage of aged care staff due to the existing workforce entering their retirement and fewer young people being attracted to work in aged care. In line with consumer preferences and potential cost-efficiencies, government and aged care providers are increasingly seeking options to move care and support to the community or home as opposed to residential care facilities. However, compared to residential care, home environments may provide limited opportunity for monitoring patients’ progression/decline in functioning and therefore limited opportunity to provide timely intervention. To address this, the Smarter Safer Homes (SSH) platform was designed to enable self-monitoring and/or management, and to provide aged care providers with support to deliver their services. The platform uses open Internet of Things communication protocols to easily incorporate commercially available sensors into the system.Our research aims to detail the benefits of utilizing the SSH platform as a service in its own right as well as a complementary service to more traditional/historical service offerings in aged care. This work is anticipated to validate the capacity and benefits of the SSH platform to enable older people to self-manage and aged care service providers to support their clients to live functionally and independently in their own homes for as long as possible.This study was designed as a single-blinded, stratified, 12-month randomized controlled trial with participants recruited from three aged care providers in Queensland, Australia. The study aimed to recruit 200 people, including 145 people from metropolitan areas and 55 from regional areas. Participants were randomized to the intervention group  and the control group . Data on community care, health and social-related quality of life, health service utilization, caregiver burden, and user experience of both groups were collected at the start, middle (6 months), and end of the trial (12 months).The trial recruited its first participant in April 2019 and data collection of the last participant was completed in November 2020. The trial eventually recruited 195 participants, with 98 participants allocated to the intervention group and 97 participants allocated to the control group. The study also received participants’ health service data from government data resources in June 2021.A crisis is looming to support the aging population. Digital solutions such as the SSH platform have the potential to address this crisis and support aged care in the home and community. The outcomes of this study could improve and support the delivery of aged care services and provide better quality of life to older Australians in various geographical locations.Australian New Zealand Clinical Trials Registry ACTRN12618000829213; https://tinyurl.com/2n6a75emDERR1-10.2196/31970 Globally, the population is aging. It is expected that by 2050, 1 in 6 people will be over the age of 65 years, representing a significant increase from the current rate of 1 in 11 . CurrentWith a large percentage of our aging population facing injury, disability or chronic disease, and requiring regular medical care, health expenditure is rising faster than economic growth . SeveralIn line with consumer preferences and potential cost-efficiencies, government and aged care providers are increasingly seeking options to move care and support to the community or home. In Australia, the provision of home-based care has previously been shown to not only significantly cost less (AUD 6.7 billion=US $4.9 billion) compared to residential aged care (AUD 13.6 billion=US $9.9 billion)  but alsoThe use of assistive technologies has the potential to support home-based care for older Australians in the community, deliver reduced savings in health expenditure, and increase functional independence . For exaTo address issues of limited family support, residential care placement availability, and the impending shortage of the aged care workforce and associated health and aged care costs, we developed a smart home platform called “Smarter Safer Homes” (SSH), which features a lifestyle-based approach in the design and implementation to enable older people to live longer in their own homes, with their choice of how they interact with the technology and engage family and/or aged care support. The SSH platform integrates wireless home sensor and health monitoring devices to allow engagement of informal  support and formal aged care services. One of the novel features of the platform is the analytics that capture an individual’s profile of activities of daily living (ADL) from which personal-level functional independence or ability can be determined. The “smart home” concept was introduced in the 1980s when it was used to support independent living and older peoples’ health and aging . Along wTo evaluate our smart home platform for its use in supporting aged care for residents living at home, an RCT was undertaken. The aim of the study was to evaluate the SSH platform to support remote care delivery and management of home-based aged care. To our knowledge, our trial is the first RCT to evaluate changes in the health and well-being of older adults living independently using clinically validated instruments. It is also the first to conduct a health care cost-utility analysis to compare the cost-effectiveness of a smart home intervention.The key research question of this trial is whether implementing smart home technology–enabled self-management and care delivery can maintain or improve the impact of care provided by aged care service providers to older people living independently in their own homes.The aims of the trial were to evaluate the impact of implementing an innovative home care service delivery model via technology on: (1) the impact of care provided by aged care service providers in response to needs arising from physical or sensory impairments for older people living independently in their homes; (2) quality of life for older people living independently in their own homes; (3) factors associated with ADL and instrumental activities of daily living (iADL); (4) depression in older people living independently in their own homes; (5) health service utilization, including presentation to hospital (admitted and emergency department), attendances to general practitioners, and other Medicare-funded community health services; (6) existing model of care, service design, adoption, and aged care service provider experiences; (7) carer burden ; and (8) costs to the government as a result of deployment of the SSH platform.The trial was designed as a single-blind, stratified RTC. Participants were divided into two groups with an allocation ratio of 1:1. Trial participants could not be blinded as the intervention required physical installation of equipment in their homes. Researchers undertaking data analyses are blinded to which participants received the intervention. Access to community health services has previously been identified to vary by geographic location . To ensuParticipants living in community independent dwellings were recruited from two geographic areas, metropolitan and regional, based on the Rural Remote Area and Metropolitan Area classification criteria . Three pAnglicare Southern Queensland is a member of the Anglicare Australia Network providing support to aged Australians in partnership with government and other support organizations in response to identified care needs throughout southeast QLD. They offer a range of specialist services within indigenous, homeless, multicultural, and rural and remote communities. The workforce of Anglicare Southern Queensland stretches from Cairns to Coolangatta, and from Birdsville to Brisbane. Recruitment included participants from metropolitan and regional areas in QLD.integratedLiving Australia receives funding from the Australian and state governments to provide care services. They provide in-home support services to older people in regional, rural, and remote Australia (including northern and eastern QLD) and have been focusing on ensuring equitable access for health support to these communities. Recruitment included participants from regional areas in QLD.All About Living partners with federal, state, and local government departments, along with several community organizations to deliver a range of high-quality services. All About Living has developed governance, management, and service delivery expertise and excellence that enables consistent service delivery. Recruitment included participants from metropolitan areas in QLD.It was anticipated that the trial would include 200 individuals (see the Sample Size subsection below) aged 65 years and older. One of the unique features of this RCT is the collaboration between the researchers and the aged care service providers. The relationship was established as a true partnership with a representative of each aged care service provider attending monthly project meetings, the risk and safety committee meeting, and regularly being consulted with as the experts on their own participants. Additionally, while asked to record certain data points, the aged care service providers were asked to develop their own workflows in how they respond to trends produced by the SSH platform and how they check on their participants if flags are raised by the data from the SSH platform. Aged care service providers reported any concerns about data  to the project manager and these were reported to the engineering team immediately. The aged care service providers are also involved in all reviews of reports, case studies, and documents associated with the project. A true teamwork collaboration was formed between the researchers and the aged care service providers, which is key to the success of the research as a whole.In addition to the aged care service providers, the project team was fortunate to have the input of a consumer representative . The consumer representative also attended monthly project meetings and was able to provide guidance on how participant information should be written and delivered, how professionals should approach research participants, and provide the lived experience viewpoint to the research. Unfortunately, the consumer representative ceased attending meetings when the COVID-19 lockdowns commenced in March 2020. The team recognizes the contribution of the consumer representative during the time they were involved and how their influence enhanced the development, design, and implementation of the recruitment phase in particular.The inclusion criteria for this trial were people aged 65 years and older; living at home, in the care of a designated aged care service provider; and English-speaking with proficiency in written English. The exclusion criteria were people residing in long-term residential care, not able to give informed consent due to reasons such as severe cognitive impairment, not willing to leave their electricity on overnight, and people residing with others.The intervention involved use of the SSH platform to assist aged care service providers to monitor and provide timely support to their clients. As shown in The intervention also provided participants the choice to view their data/progress on the tablet app. This intervention was not a real-time solution, with all data viewed in the platform being from the previous 24-hour period. Participants and aged care service providers were made aware of this multiple times in multiple ways, as there was a risk they would rely on the system as an alert if an adverse incident occurred in the home, such as a fall. All usual care was maintained for all participants, regardless of their allocation to the research groups. Therefore, for those in the intervention group, the SSH installation was an added layer of care intervention.The interface of the app was co-designed with a network of similar cohorts during the inception of the SSH platform . An examThe features of the SSH platform include a sensor-based in-home monitoring system (data collection), a cloud computing server , and novel analytics to determine functional independence. The novel measure of functional independence features the provision of an objective and personalized measure of ADL components and scoring through nonwearable and nonintrusive sensors in the home environment, and the ability to correlate this measure with self- or care-reported status of health and well-being. The domains  of the ADL score are derived through aggregation and artificial intelligence analytics from a range of sensors deployed in the home . Individualized functional independence (Objective ADL [O-ADL]) is measured using the same framework as the ADL assessment performed in clinical settings. This O-ADL is not only an objective clinical assessment using home environmental sensors but is further personalized through learning an individual’s activity and profile relative to their health and functional status. This then references their ongoing functional status over time, enabling timely intervention.Baseline characteristics were collected to facilitate the identification of systematic differences between study groups that may increase the risk of bias.The primary outcome was the Australian Community Care Outcome Measurement tool (ACCOM) .The secondary outcomes included change in health-related quality of Life, as measured by the Five-Dimension EuroQuol (EQ5D 5-L) questionnaire ; Katz AD. The study received participants’ health service utilization data in June 2021.The trial recruited its first participant in April 2019 and data collection of the last participant was completed in November 2020α≥.05, effect size of 0.5 (0.08/0.16), and the same allocation ratio of the two groups in our trial. The primary outcome of this trial, the impact of community care for older people, will be evaluated using the ACCOM tool , a set oTo achieve 80% statistical power, we needed a total of 134 participants. Allowing for a 30% attrition rate, the sample size of this trial was computed to be 200 participants. We did not anticipate an attrition rate greater than 30% as all participants were existing clients of the participating aged care service providers and received regular visits throughout the trial period. The intervention and outcome measurement collection processes were designed to minimize participant burden. In addition, the power analysis did not consider the repeated-measures design of the trial. Repeated measures increase the power of the trial to find a significant result and appropriate statistical techniques will be applied to ensure that all data available are used in the analyses.Three project officers were employed to recruit and consent participants for the trial. The project officers made contact with potential participants, after introduction by the aged care service provider. The project officer, via phone call, briefed the individual on the trial, assessed their interest in participating, and checked their eligibility. If the individual agreed to participate, they were asked to nominate their witness, who could be the informal carer (which could include family members or another person that they hold a close relationship with such as a friend or neighbor) to be included in a future face-to-face meeting. During the face-to-face meeting, the project officer confirmed the internet connectivity at home and the cognitive awareness of potential participants. At this point, cognition levels were assessed according to the participant’s ability to demonstrate understanding of what the project officer was saying and how the potential participant responded to questions. It was identified during the planning of the trial that research participants would incur a small out-of-pocket fee for the use of their own electricity and internet data. This was calculated to be less than AUD 5 (US $3.6) per month. The budget allowance was established to ensure that all individual participants were repaid for this out-of-pocket expense after their contribution to the research was complete. For example, a participant received an AUD 60 (US $43.20) gift card for 12 months of participation (5×12 months=60).Stratified randomization was used with the strata defined by geographical areas . Within each area, simple randomization  was perOnce participants had been consented, a set of surveys was administered by the project officer. The participants allocated to the intervention group received an SSH kit. Installation of the SSH kit  was coordinated by the project officer, typically within 2 weeks of consent and randomization. A user sheet that describes how to interact with the tablet and interpret the information presented on the tablet SSH app was included with the kit. The project officer also demonstrated to the participant how to use the tablet and the SSH app during installation. To obtain valid baseline data after installation, the SSH system gathered 14 days of the participants’ normal living routines in their homes. After the baseline data had been gathered, the identified aged care service providers and the nominated family portal users were notified of their user ID, password, and access instructions. During the trial period, the project officer was the point of contact for any problems or questions. Technical issues that were not easily addressable were escalated to the research technical team who worked to find efficient and effective solutions. All reported issues, no matter how minor, were reported to the project manager for inclusion in the monthly project reports. If a participant wished to withdraw from the trial, the project officer arranged for an uninstall to occur as quickly as possible from the home. Upon completion of the project, all homes had their trial equipment removed by the project officer. Participants allocated to the usual care group continued to receive their existing care and social services in line with local aged care service provider protocols for the 12 months of the trial. They did not have any SSH equipment installed in their homes.Data were collected from participants, informal carers, and aged care service providers from state and national government data sources and home-based sensor systems. These included surveys, raw sensor data, and interview information. The state and national government data sources included hospital linkage data and MBS/PBS data. The measure, context, score meaning, and time points of collection are presented below.The project officers administered a baseline survey to all consented participants. Questionnaires included in the baseline survey are listed in Participants were contacted by a project officer to complete the same surveys at mid-trial and end-trial. These were preferably conducted over the phone, and particularly during imposed COVID-19 safety measures. For the intervention group, an uninstall of the SSH kit typically took place at the same time as the end-trial survey was administered. Follow-up was systematized through the REDCap system. For participants who withdrew from the trial, all data collected up to the point of withdrawal are included in the analysis of the study, unless formally requested not to be by the participant. This was outlined in the Participant Information and Consent Form  and partAll in-home raw sensor data were transferred to the IoT router and then collected directly to a secured server where all sensor and participant data were gathered. Storage of and access to the project data within the data center were governed by privacy policy and procedures, and limited to the investigators on this project. Data center operations staff had access to the data to perform their normal duties .The data gathered through the in-home sensors were categorized into daily living activity domains, as listed in The data were not live-monitored in the trial. Participants were made aware of this prior to the trial commencing to ensure that a false sense of security was not assumed.Data on the burden experienced by the informal carers of the people participating in the trial were collected using the 4-item Zarit Screen (ZBI-12) survey  at all tThe outcomes collected from the respective aged care service providers at the end of the trial are shown in The outcomes collected from the Commonwealth Government Department of Health  and the QLD Government Department of Health  at the end of the trial are shown in Data were predominantly captured in the ethics-approved and secure REDCap system. All survey responses were collected through REDCap with the exception of interviews that were captured through recordings. Health services utilization data, already captured through business-as-usual processes of the relevant health services, were utilized in the analysis. Every participant was allocated a REDCap identifier. Once allocated, REDCap numbers were the only identifier of research participants. Interviews with aged care service providers were performed one-on-one with participants and therefore the interviewees were identifiable to the interviewer. Survey results were collected at three time points: at the baseline, middle, and end of the study. The final survey data included in our analyses contain results from participants with a baseline survey and at least one follow-up and middle/end survey. For missing responses in surveys, we will conduct a case-by-case retrospective analysis with project officers and aged care service providers, and/or use multiple imputation methods to replace missing data.χ2 tests and Wilcoxon rank-sum tests. If significant differences in survey results are observed, a log-binomial regression model will be further used to estimate the relative risk of each group to changes of survey results. Within each group, for all three surveys, the Friedman nonparametric test will be used to understand intragroup differences in survey results. Similarly, if significant differences in survey results are observed, the Wilcoxon signed-rank test with Bonferroni correction will be used to further investigate pairwise differences between surveys.At each survey time point, intergroup differences in survey results between the intervention and control groups will be analyzed by A within-trial cost-utility analysis will be performed to assess the value for money of the intervention. The time frame will be the end of the trial, consistent with the trial, and the base case perspective will be from the government as the primary funder of health and social services. An incremental cost-effectiveness ratio will be calculated by collating the costs for the intervention and control groups, and using quality-adjusted life years (QALYs) gained as the outcome in the equation. QALYs will be derived using an area under the curve approach based on the health-related quality of life utility index values derived from responses to the EQ-5D-5L. Costs will comprise the costs of the intervention plus health resource use collected through routine databases  with patient consent and community services support  collected during the trial period. Appropriate techniques to account for uncertainty in the estimates  will be implemented. Costs will be summed and compared between groups, adjusting for baseline differences.Regular sensor data monitoring was undertaken by engineers in the team. Data checks occurred every 1-2 days. The organizational cybersecurity team was included to support the constant monitoring for cybersecurity threats throughout the data collection period. This monitoring included checking the functional integrity of the REDCap research database.Any identified issues that required follow up were reported to the project manager for dissemination to the project steering group and/or the risk and safety committee. Due to the governance structures in place across expert engineering teams, and the two project governance committees, a separate data monitoring committee was not identified as a requirement.A risk and safety committee was established from the commencement of the project. This committee consisted of an aged care service provider representative from each stakeholder partner, key project staff, and an expert geriatrician to provide any medical oversight required. This committee met bimonthly throughout the project and was available for assessing any unintended effects of the trial intervention or conduct.Two types of audits occurred throughout the trial. An audit of all documentation occurred at regular intervals. This was to ensure all consent forms were completed correctly and any errors could be addressed appropriately and in a timely manner.Additionally, at the end of the installation phase, an audit was undertaken of sensor placements in the homes. This occurred to ensure consistency of sensor placements across homes.Ethics approval was obtained from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Human and Medical Research Ethics Committee (CHMREC) on November 26, 2018 .After the original submission of ethics, which granted approval for the project to commence, there were amendments sought throughout the implementation stage. Amendments typically included additions and/or removal of researchers to the project and extension of approval dates.Informed consent was obtained from all research participants, including the older adult participants, carers, and aged care service providers who were interviewed at the end of the trial. During the meeting, the project officer discussed the trial and its requirements with participants and their informal carer(s). Individuals who agreed to participate were asked to sign the ethics-approved Participant Information and Consent Form see . The parPersonal information was collected through surveys approved by the ethics committee. Survey responses were collected via REDCap and did not contain names. Access to demographic information about participants that had potential to identify the participant was restricted. Those conducting the analysis were not provided with this information and only the project officers and engineers (who provided maintenance to the system) had access to individual information. These research professionals are experienced in dealing with sensitive information and they are aware of the implications of accessing this type of information unnecessarily and without reason.The trial results will be communicated through media release, conference presentations, journal publication, and a final report to all stakeholders involved in the research.The aim was to recruit 200 participants and a total of 195 participants were finally recruited, with 97 randomized to the intervention group. The study also received participants’ clinical service data from government data resources in June 2021. Final data analysis is underway at present and final outcomes will be presented in a future publication.A crisis is looming with the increase in an aging population presenting a large burden on the health system and aged care services unable to support them. Digital technology solutions such as smart homes present real opportunities to address this crisis. Australian aged care reforms have focused on providing aged care support in older peoples’ homes. CSIRO has developed a co-designed digital solution, the SSH platform, which features a novel functional independence measure to monitor and support people living in their own home setting. To test this, an RCT was undertaken to evaluate the implementation of this platform in assisting aged care providers to provide timely care and support and improve the lives of older Australians in various geographical settings. The findings of this study will inform the benefits of digital solutions in the support of people aging in the community and defining new age care delivery pathways for more effective aged care in the home.This RCT was designed to investigate whether the implementation of the SSH platform for independent-living older adults improves care service delivery, social and health-related quality of life, and reduces the carer burden and the cost to public health services.To the extent of our knowledge, this is the first large RCT to comprehensively assess the impact of a smart home–based technology on aged care service delivery, quality of life, and public health service costs. However, during the trial, the participants experienced several weeks of lockdowns in March, May, and August of 2020 due to the COVID-19 pandemic. Whether these unprecedented environmental changes had an impact on the study results is yet unknown.