Background: In the last decades, litigation has been increasingly used to access medicines in Brazil. This phenomenon has led to the development of diverse strategies to reduce its negative impact on the organization of pharmaceutical services. In spite of that, managers still face difficulties dealing with lawsuits.Objective: This study aims to report the planning and implementation of strategies to approach medicines litigation in a municipality located in the southeast region of Brazil.Methods: Mixed methods were employed through an action research cycle. A network coordination team included researchers from university and municipal managers. The scenario analysis comprised the characterization of pharmaceutical services and the profile of medicines lawsuits. Afterward, strategies were planned to deal with the central problem identified. The action plan involved educational outreach visits and distribution of printed materials for health professionals, evaluated through opinion survey. Group conversations were conducted with the users of the public health system, followed by thematic analysis of reports.Results: The characterization of pharmaceutical services in the municipality revealed that treatments supplied were in accordance with the National Medicines Policy. In addition, a sector was implemented to attend demands for non-incorporated medicines. In spite of the services available, the characterization of lawsuits indicated that the main claimants were users of the public health system, requiring non-incorporated medicines, with therapeutic alternatives available. Thus, educational outreach visits were held in 14 health units . Everyone who answered the evaluation declared that they were very satisfied with the approach. Group conversations with the users of the health system reached 227 participants in total. In regard to users’ perception about pharmaceutical services, thematic analysis of reports identified three main categories including aspects related to medicines provided, users assisted, and quality of service.Conclusion: The study described the first cycle of an action research project to develop strategies to approach medicines litigation at the municipal level. The application of educational outreach visits for health professionals and group conversations with health system users is a promising approach to improve access to information about pharmaceutical services in Brazil. The lawsuits for access to medicines impact the structure, financing, and organization of healthcare services as they neglect the priorities established through public policies and force reallocation of financial and human resources with the potential to widen inequality . Brazil Therefore, efforts have been made to mitigate the negative impacts on the public health system by different institutions involved with the phenomenon. In response to litigation, health system managers had to remodel and structure new services to address the increasing demand of lawsuits to access medicines .In Brazil, the institutional response of the judicial branch included the Recommendation 31/2010  issued bFrom the legislative branch, the Federal Law 12.401/2011  clarifieDespite the current pharmaceutical policy and the strategies implemented by the legislation, medicines litigation is still a challenging topic for the various actors involved . It is bThis study used mixed methods with an action research design. This approach combines action and reflection, and it is recommended to identify deficiencies in the health services with a key aspect of allowing the emancipation of subjects, through their involvement in research and shared construction of knowledge .The study site was a municipality in the southeastern region of Brazil, located in the state of Rio de Janeiro with a population of 230,000 inhabitants . The heaThe network coordination team was composed of seven pharmacists: three researchers from the university and four municipal managers. The former with experience in public health and direct involvement in outreach projects, while the city managers have had hands-on experience working for at least 5 years in the PS department.The network coordination team initiated the diagnosis  by identifying the central problem, followed by a planning phase of the strategy to be implemented. Finally, the action research cycle involved the application of the developed strategy, its evaluation by health professionals, and reflection by the team.The identification of the central problem related to medicines litigation involved two main actions: an analysis of the organization of PS and the profile of litigated medicines in the municipality. To understand how PS was structured, the research group analyzed the municipality’s electronic address to check the legal documents available and current actions developed by the PS sector. The identified actions were classified according to the categories presented by To characterize the profile of medicines litigation, data were collected in the public pharmacy responsible for dispensing non-incorporated medicines to users of the municipal health system. All information collected were in accordance with the Brazilian Law of Access to Information (Law 12.527/2011) , which gThe following variables were collected: lawsuit register number, date of request, age of the patient, gender, prescriber(s) registration number, medical specialty(s), the type of service that provided the prescription, legal representation of the plaintiff, lawyer’s registration number, presence of prescription and medical report in the lawsuit, medicine(s), dosage form, and clinical indication. Descriptive analysis of the data was performed by determining the absolute and relative frequencies , means, medians, and standard deviation (quantitative variables).The requested medicines were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and the presence in one of the official lists of medicines funded by the municipality’s health system, namely, Brazilian National List of Essential Medicines , 2017 edition ; medicinIn order to better understand the reasons for the prescription of non-incorporated medicines, therapeutic alternatives were evaluated according to their availability in at least one of the lists. This analysis was according to the Manual of Indicators of Evaluation and Monitoring of Medicines Lawsuits, which suggests considering medicines in the same pharmacological subgroup at the ATC system as an alternative .The planning phase was guided by the central problem identification related to medicines litigation, and possible gaps in the PS organization were listed for which hypotheses were proposed to help the development of an action plan. The defined action plan involved educational interventions, both for health professionals and users of the municipal public health system .For health professionals, planned educational visits based on the principles of educational outreach, also known as academic detailing, and the development of printed educational materials were adopted. Academic detailing consists of educational encounters led by a trained facilitator held at the health unit aiming to stimulate behavioral changes, including the prescriptions practices . UndergrFor the health system users, group conversations were held at Family Health Strategies , which are Brazilian health units responsible for primary health care. The group conversations aimed to discuss PS organization in the SUS, especially how to access medicines in the public health system of the municipality. For the activity, a semi-structured script was proposed , and twoFor the educational outreach visits, at the end of the visits, the professionals were invited to fill out an evaluation form, which included six questions addressing 1) clarity of the proposal’s presentation, 2) duration of the visit, 3) appropriateness of the material, 4) clarification of doubts, 5) posture of the student, and 6) verbal expression. A 5-point Likert scale was used, ranging from very dissatisfied to very satisfied. The evaluation form also included three open questions that allowed the health professional to report suggestions or additional comments .In regard to group conversations, each report produced by the observer was reviewed and, if necessary, complemented by the other team participants who were present at the conversation. Thematic analysis of these reports was led with an inductive approach . The firThis study is approved by the Research Ethics Committee of the Federal University of Rio de Janeiro—Campus Macaé (Protocol number: 4.187.153)—and respected the ethical protocols recommended in Resolution no 466/2012  of the NIn Brazil, medicines funded by SUS are divided into three groups, called components, namely, basic, specialized, and strategic. The first encompasses medicines employed at primary health care, mainly acquired by the municipal government; the second includes high-cost medication, managed by each state government; and the strategic component, which comprises treatments for diseases with potential endemic impact and under federal responsibility .According to the National Medicines Policy, RENAME is the main reference for medicines selection in the public system. Municipalities are responsible for electing medicines according to the epidemiology of diseases affecting their citizens, resulting in the REMUME. At the time of the research, the REMUME had been updated in 2017, including 211 medicines for primary health care , 80.6% oPS also provided access to medicines from the strategic and specialized components. For the latter, the municipality had one public pharmacy dispensing high-cost treatments, managed by the state government . TherefoNot only did the municipal PS provide assistance for users claiming listed medicines but a special sector was also implemented to evaluate demands for non-incorporated products, called pharmaceutical support service. The sector was responsible for registering and evaluating requirements from administrative proceedings, in addition to attending cases of medicines lawsuits (compliance with court orders) . In regaIn spite of the local organization of PS available at the public health system, lawsuits continue to be employed as a strategy to access pharmacological treatments in the municipality. The study identified and analyzed 82 lawsuits requiring medicines, which were litigated from 2005 to 2018. The full description of demands can be found in n = 63) of the lawsuits were from the public sector, represented by the municipal public defender’s office and 18.2% were from private lawyers. Since the public defender’s office represents citizens of low income or high social vulnerability, the main litigants in the present study were from the lower social class.In relation to the legal representation, 81.8% (n = 68) of lawsuits included prescription from public health units, 11.0% (n = 9) from private health units, and 6.1% (n = 5) from both.In addition, litigants were mainly assisted by the public health system. In regard to the type of the service, 82.9%  were the most frequent conditions requesting treatments, with higher frequency for diabetes mellitus , followed by the disorders of other endocrine glands . The second and third most frequent conditions were the mental and behavioral disorders  and the diseases of the nervous system , respectively.The characterization of medicines required in the lawsuits according to the ATC classification system can be found in Medicines litigation demanded mainly products outside lists of funding in SUS. Only seven lawsuits (8.5%) demanded just incorporated medicines, prescribed in accordance with the clinical criteria established by the Clinical Protocols and Therapeutic Guidelines . Among all medicines claimed, 60.7% were not incorporated in RENAME. In regard to presence in the local lists, only 13.3% of medicines were supplied by the State Secretary of Health and 20% were listed on the REMUME.The majority of lawsuits disregarded the existence of therapeutic alternatives in SUS. Among the 91 non-incorporated medicines, it was possible to identify therapeutic alternatives for 72 of them (85.7%), and only four (4.4%) were considered essential according to the WHO MLEM. For diabetes mellitus, metformin, glibenclamide, and gliclazide were listed at REMUME as blood glucose–lowering drugs (ATC A10A), while human insulin and NPH (ATC A10A) were the insulins available in SUS. In regard to nervous system agents, five lawsuits demanded three antipsychotics  with nine therapeutic alternatives . In addition, for the four antiepileptics (ATC N03A) litigated, 11 medicines were listed in RENAME . NeverthIn this context, medicines litigation predominantly demanded medicines unavailable in the public health system. Therefore, the network coordination team elected as the central problem for the first cycle of this action research the prescription of non-incorporated medicines with therapeutic alternatives in the public health system.Since medicines litigation is a complex phenomenon, secondary influencing factors were also listed and will be addressed in future stages of action research: 1) the appropriateness of medicines offered in SUS and 2) quality of PS offered at the municipality. These issues were not initially considered a priority for the following reasons: listed medicines were in accordance with the National Medicines Policy, and the results do not suggest that the majority of litigation had been a result of problems related to the management of PS, which could be observed if lawsuits claimed mainly incorporated products.Based on the central problem, the network coordination team proposed two hypotheses: 1) knowledge gap about medicines incorporated in SUS and 2) distrust in the available treatments. Since communication is a key issue on both hypotheses, strategies to improve access to information about the organization of PS, especially about incorporated medicines, were considered a priority. In order to strengthen primary health care, the network coordination team agreed to focus on wide dissemination of REMUME.Educational visits to discuss about REMUME were led between August 2018 and December 2019 in 14 health units where 24 medical specialties offered care for SUS. In total, 23 physicians participated in the visits, in which 80 brochures and 70 posters were distributed for consultation of REMUME. Among the 23 visited health professionals, 11 filled in the evaluation form. Everyone declared that they were very satisfied with the printed materials, two suggested that the same approach should be employed to the medicines of the specialized component of PS, and two mentioned the relevance of the initiative for the population.Group conversations with users of the public health system were conducted in 21 ESF. The discussions lasted from 20 to 60 min, varying from five to 23 participants, including 227 in total. In regard to participants’ perception about PS in the public health system, thematic analysis of reports identified three main categories, including aspects related to medicines provided, users assisted, and quality of service .It was observed that participants of group conversations had different perspectives about medicines supplied in the public health system. Some argued that all medicines should be available, while others recognized the need of a prioritization process.“The SUS, yes, it should give the treatment, the medicines that people need, because there are many medicines that we don’t have the money to buy.”“I don’t think that (the government) would have a budget for everything, so they would have to focus on the specific ones.”Demand on the prescriptions and cost (higher priority for the most expensive) were two criteria mentioned independently by participants during discussions to determine the importance of a specific medicine.“I think the government should give the most expensive medicines, because we can buy a dipyrone.”“It (the government) must supply the most used medicines that are prescribed by physicians”Under the category of users assisted, participants claimed that low-income citizens should be preferably supported.“They should analyze the person’s financial situation to provide medicine.”“We must think of people who are unable to buy the medicines they need.”In spite of that, equity was an issue raised during discussions. It was mentioned that non-incorporated medicines were prescribed only to people who could buy it because even if they were accessible by administrative proceedings or lawsuits, there is a risk of shortages in the public health system.“Special medicines are only taken by people who are rich. For poor people, physicians only prescribe the cheap insulin”In regard to quality of the service, a divergence in terms of satisfaction with PS in the municipality was also observed. While some declared that shortages were frequent, others affirmed that they had integral access to their treatments.“Whenever I go to the pharmacy, I can never get my medicines.”“When (medicine) is lacking in one day, the supply is soonly restarted.”The lack of information also emerged during discussions, either of the specialized component and the “Programa Farmácia Popular” (in Portuguese). The latter was created by the Brazilian government to complement access to medicines through provision of free or cofinancing items in private pharmacies affiliated to the program.“It was good, the Farmácia Popular I had already seen, but I didn't know I could get medicines for free.”“My husband uses atorvastatin and I buy it every month, I didn’t know it was available on the public system.”In addition, participants were frequently unsure about the quality of medicines provided. Some of them believe that products supplied in the public health system have lower quality and even reported that some physicians recommended them to buy, instead of taking it in the public pharmacy. Similarly, generic medicines were also perceived as less effective than brand products.“Some physicians ask us to buy, because the medicines given by SUS do not work.”“It is not possible to have this huge difference in price and have the same effect (generic medicines).”The misconceptions about the right to health definition in the Brazilian Constitution result in judicial decisions that privilege individual claims, obligating managers to provide all medicines required . As a coEssential medicines lists are worldwide used as a key strategy to enable universal health coverage; however, funded products may vary significantly between countries . In BrazIt is claimed that despite the adequacy of the National Medicines Policy, the perception that needs to access medicines in Brazil are not being fulfilled leads to the increasing use of lawsuits to provide treatments . NeverthFederal Law 12.401/2011  establisThe reasons for lack of adherence to medicines lists are multifactorial. It is reported that the prescription of non-incorporated medicines can be attributed to ineffective distribution of the lists, inadequate sensitization, lack of enforcement mechanisms, and influence of the pharmaceutical industry . In regaSurprisingly, while strategies involving training about PS are incipient , the advIn the present study, the implementation of educational visits was well accepted by health professionals, and it was even suggested that it should be expanded to include medicines provided by specialized component, reinforcing the importance of improving access to information about medicines provided in SUS.In regard to users, the World Health Organization highlights the importance of civil society participation in planning and evaluation of health system services . In addiThe activities developed on this study revealed interesting aspects related to users’ views about medicines availability. Most participants tended to believe that the medical prescriptions should define the supply of medicines in the public health system, and a higher number of products would improve care in SUS. In contrast, there were also complaints about drug shortages, which may sound contradictory since increasing the number of medicines in REMUME will potentially make management of supply chain even more challenging.This study is a partnership university–community which developed and implemented an innovative approach to address medicines litigation. Considering the context, how to plan and develop strategies to mitigate the threats imposed by lawsuits? The present characterization of litigation is similar to the previous studies conducted in Brazil , while oOne plausible explanation presented here is that prescribers demanded medicines outside the funded lists because they are not provided with adequate information about what is offered in the public system. Therefore, educational strategies are key to improve access to medicines. In spite of that, the use of educational visits for dissemination of medicine lists and strategies promoting dialogue with health system users about PS have not been reported previously.Despite the acceptability of the strategies, equally from health workers’ and users’ perspectives, some barriers were identified. In relation to prescribers, it was challenging to schedule educational visits with the health unity manager and adjusting with the number of consultations of each physician. In contrast, with group conversations, the lack of regular educational activities and an adequate place for discussions were the main difficulties faced.The present study has some limitations. The lack of an electronic database with information related to medicines litigation imposed challenges to data collection. Additionally, most of the lawsuits did not describe properly the reasons for litigation. Thus, it was not possible to identify, for most of the lawsuits, if the litigant had already used listed medicines before demanding non-incorporated products. Furthermore, the strategies did not include actions addressed to the judiciary sector; thus, they are not comprehensive in terms of all actors involved in litigation.In regard to the central problem, additional influencing factors were raised, but they were not tackled yet. Medicines lists should be submitted to a careful revision to confirm if they meet the needs of the population. Likewise, failures in PS should be assessed in future investigations. The impact of the educational visits on prescribing practices is under evaluation, and the results will be reported in a future study.It is hoped that this study can open space for new types of actions and discussion for facing medicines litigation. It is not only necessary to understand the profile of lawsuits, but it is also essential to create actions to deal with them. The group understands that empowering the society to enable them to be part of the solution to the infinite needs in the health system is a fundamental part of this process.The effectiveness of educational interventions with different actors involved in litigation is still an issue to be investigated to support managers to implement actions to deal with this phenomenon. In addition, future studies investigating the cost-effectiveness of educational interventions would advance the comprehension of how these strategies could lead to more rational use of financial resources.


There are many allusions to the role of this experience in the management of the COVID-19 outbreak response.12Although the 2016 Infectious Disease Vulnerability Index identifies that 22 out of the 25 countries most vulnerable to infectious disease outbreaks are in Africa, the COVID-19 pandemic on the African continent remains considerably less severe than predicted.11 Case reports from other countries highlight the key role of communication in the COVID-19 response,14 with countries adopting a wide range of strategies to strengthen risk communications systems, improve public communications, execute dynamic listening, and manage rumors, as well as to coordinate partners and stakeholders, placing communities at the heart of the response.The experience in communications from the Ebola outbreaks in West and Central Africa and other recent outbreaks particularly provide key lessons on the need for a strategic and responsive approach for effective communications during the pandemic.This paper aims to share the Nigerian experience in relation to SBCC interventions by the Nigeria Centre for Disease Control (NCDC) and partners during the COVID-19 pandemic and to highlight lessons learned.17 Nonpharmaceutical interventions have been prioritized globally as control measures for COVID-19, in the absence of an effective vaccine.18 The introduction of these interventions has required rapid behavior change through community engagement at all levels of the society.There has been a wide range of perceptions and emotions exhibited by people since the beginning of the COVID-19 pandemic. Fear, anxiety, distrust, and denial are all community perceptions and emotions that have characterized this pandemic.19 A risk communication and community engagement strategy for responding to the COVID-19 outbreak was developed by NCDC through robust multistakeholder collaboration. This strategy formed the operational roadmap of the Risk Communication Pillar of the national EOC. The foundation of the strategy was built on the 5 pillars of risk communications recommended by the World Health Organization20 and it employed an Extended Parallel Process Model theoretical framework.21 The strategy outlined SBCC interventions and approaches as a means of encouraging healthy individuals to adopt and maintain healthy behaviors grounded on evidence-based scientific knowledge.22The NCDC leads the public health response to the COVID-19 outbreak, through the national Emergency Operations Centre (EOC).24An array of health promotion theories are considered when implementing SBCC and risk communication approaches, with a shift from traditional narrowly conceived behavioral change models—which is characterized by victim-blaming and is most times ineffective—to self-empowerment and socioecological models that empower individuals to take control of their health, taking into account the interrelationship of individuals and their physical, socioeconomic, and political environment.25 Using this approach, communities were empowered to identify the risk communication challenges in their localities, proffer solutions, and develop their own risk communication messages.26 This implied that risk communication messages now differed in structure across various communities in the country, as these messages became more contextualized. The Risk Communication Pillar of the national EOC of the NCDC and the Risk Communication Unit of the Presidential Task Force on COVID-19, with the support of the government of the United Kingdom and NOI polls, provide weekly updates on risk communication and community engagement in some states in Nigeria.27 In Lagos state, data from the polls conducted in June 2020 revealed that less than two-thirds (59%) of 554 participants thought the COVID-19 was real . By August 2020, this percentage had increased to 81%, about 12 weeks into the implementation of the bottom-up approach . More communities across the country are being supported to develop their risk communication messages, identify strategies for dissemination, and implement these strategies.At the beginning of the pandemic and following confirmation of the first cases of COVID-19 in Nigeria, a top-down approach was used in the conceptualization and dissemination of risk communication messages by the NCDC. This was necessitated by the emergency nature of the outbreak. This approach required engaging with the Nigerian population, building trust, and disseminating messaging using a multimedia approach. Uniform messages were developed at the national level and disseminated to subnational levels for adaptation. This approach was not effective and did not lead to the desired behavioral change outcomes. The novelty of COVID-19 and its unprecedented spread, the overwhelming opportunities for misinformation, as well as a myriad of contributing sociocultural, political, and economic realities required an approach that factored in the complexity of social norms that influence behavioral change. A review of the strategy led to the adoption of a bottom-up approach in May 2020, when the country entered into the community transmission phase of the pandemic.The lessons learned can be categorized based on these 4Cs of communication: content, communicator, context, and channel.28 However, as the pandemic progressed, scientific evidence regarding the effectiveness of masks in combination with other nonpharmaceutical public health measures among healthy individuals started to emerge, and health authorities began to include the wearing of masks in public health advisories.30Given the novel nature of COVID-19 and limited point of reference, the response to this pandemic has been characterized by evolving scientific advice as new knowledge and evidence emerge. These factors have contributed to an unusual level of instability in communication messages, creating opportunities for mistrust, misinformation, and confusion among the public, who may not clearly understand the nuances and evolving nature of science. For instance, the use of face masks during the initial phase of the COVID-19 pandemic among healthy individuals was neither recommended nor adopted globally.A further lesson from the pandemic was the challenge posed by the acceptability of required behavioral change among the Nigerian population. In a country with a rich social capital, characterized by regular social gatherings and celebrations, the recommendation of physical distancing as a means of curbing the pandemic was met with some resistance. The wearing of face masks was seen as unnatural and uncomfortable with resulting widespread noncompliance.Convincing people to adopt these new measures demands an empathetic approach and calls for altruism. The choice of adopting a new and difficult behavior is dependent on the level of risk perception of the person involved and confidence in the prescribed strategies for mitigating the risk. An effective communication message should have enough content to increase risk perception while palliating the undesired effect of positive behavior. The risk communicator must empathize with the target individuals or communities. This is in addition to providing feasible and acceptable alternatives to the practices being discouraged.31 Individual behaviors are usually products of complex wider sociocultural, societal, economic, and political factors that must be considered in seeking to address risky behaviors.Communicating socio-behavioral change without providing an alternative could be disempowering. Effective risk communication must, therefore, be underpinned by the concept of “the other alternative.” We propose that for every desired behavioral change, there should be a reasonable and attainable alternative to the current behavior. Social and behavioral change interventions should provide practicable alternatives and communicate these pragmatically with adequate community participation to increase adoption. Adapting positive behavior in a vacuum without an alternative choice is impracticable. This also brings to fore the importance of a socioecological model for risk communication.Therefore, a shift from a victim-blaming approach toward individual and community empowerment is necessary for effective SBCC. In Nigeria, the shift in community engagement approach led to greater community participation and ownership; members of the target audience were involved in drafting messages and infographics, animations, and radio jingles tailored to their community at the latter phase of the response.The effectiveness of risk communication is not only defined by the content of the message but also by the communicator of the message. The key questions to be answered include: “Who is this change advocate?” “What is the track record of this change advocate?” “How well does the community trust this communicator?”32 The NCDC is a public health institute and also the government organization responsible for conveying public health messages. Given the importance of its role, NCDC prioritized building up the public's trust through transparent communication. This included daily publication of situation reports, updates on response challenges, and related issues. Due to existing mistrust, this transparency was largely misinterpreted by the public as part of government conspiracy.The track record and perception of the communicator is critical in the acceptance of the message being conveyed to the community. There is significant mistrust in the Nigerian government by its citizens.From NCDC's experience, the top-down approach in delivering SBCC messages has not been as effective. People have generally responded better to risk communication strategies codeveloped with the target community and conveyed by community gatekeepers and influencers that they can relate with. This has enabled other members of the society—outside of government—to be seen as the communicator.33 Such sociocultural diversity means that effective communication must be adapted to the relevant context. An acceptable risk communication approach must be culturally sensitive. This further highlights the importance of engaging the target communities, who best understand their local context, in identifying and prioritizing their health problems and working together to develop solutions. A contextual, culturally sensitive community engagement approach is being implemented currently by NCDC and its communication partners in Nigeria.SBCC must be tailored to the context of the target community. The same message may result in dissimilar interpretations across different sects of the population. Nigeria is a multicultural country with more than 250 distinct ethnic groups and over 500 languages.34 A contextual approach in identifying and engaging community influencers is, therefore, required for effective SBCC.A good example of sociocultural diversity that can affect risk communication is the governance structure in the various geopolitical zones of the country. For instance, in Northern Nigeria, and to some extent South West Nigeria, the monarchical system of governance is highly revered. Traditional rulers (Emirs and Obas) are considered important custodians of knowledge and trust with great influence on the majority of the population under their jurisdiction. However, in South East Nigeria, among the Igbos, the scenario is quite different. Monarchs are less influential and may not be effective means of SBCC compared to other community influencers, such as age-group leaders, women associations, traders' union, and religious leaders.Closely related to the context of communication is the channel of communication. The NCDC makes use of both contemporary  and traditional channels  in communicating evidence-based SBCC messages nationwide. The internet through social media is an effective means of communication for the upwardly mobile, younger, educated, and urban resident audience, while the use of town announcers, radio, and interpersonal communication could be more suitable for the older population and those in rural areas. In Nigeria, the NCDC utilized campaigns on Twitter, Facebook, and Instagram to boost the dissemination of messages on social media. Furthermore, the language of communication was identified as a key indicator for dissemination. The appropriate translation of messages into local dialects is important in ensuring that the target population understand the messages being conveyed. Many risk communication messages for COVID-19 in Nigeria were translated into at least 12 local languages. Factors such as age, gender, socioeconomic class, educational level, religion, and place of residence  influenced the type of channel used to effectively communicate SBCC messages. These factors, as well as the reach of the channel of communication, should be considered in the selection of appropriate media of communication.Lessons from previous outbreaks should be used to prepare for future outbreaks, especially in the context of emergencies that require rapid response. Community members and influencers who best understand their health needs and priorities should be involved in the planning and implementation of SBCC programs. The 4Cs of communication—content, communicator, context, and channel—should be considered when risk communication messages are being developed and disseminated. For risk communication to be effective, it should be supported by the concept of flexibility, adaptability, and “the other alternative.” Furthermore, socioecological models that incorporate sociocultural, economic, and political insights, should guide SBCC strategy development and implementation.Nigeria's experience has highlighted the importance of effective community engagement in achieving positive behavioral change through SBCC. The integration of social science through SBCC into the pandemic preparedness and response contributes to sustainable development by building resilience among individuals, communities, and health systems. Risk communication helps to achieve public health outcomes by promoting behavioral change and increasing support for scientific recommendations. The initial response to the COVID-19 pandemic in Nigeria was characterized by emergency risk communication activities that were top-down. As the transmission dynamics evolved, various risk communication and community engagement approaches that are community-driven and based on evolving evidence have been adopted. For SBCC to be effective, it should consider the wider social, societal, and economic determinants of risky behavior. Target communities must be empowered by supporting their participation in ideation, coproduction, and implementation of SBCC interventions so that they have greater ownership of the response. Sustainability in the public health response is critical. This requires sustained funding for risk communication, as well as building the capacity of local communities to maintain public health measures, while also taking responsibility for the response.


In the context of increasing urbanization and associated economic, social and environmental challenges, cities have increasingly acknowledged the importance of urban parks in delivering social, economic and environmental benefits to the population. The importance has been demonstrated also during the COVID-19 pandemic that generated lockdowns and reduced the capacity of urban inhabitants in accessing such benefits. The present study aims to determine how the presence in urban parks was reflected on social media during the pandemic period of 2020. We examined Instagram posts associated with a sample of eight urban parks in Bucharest, Romania and also the entire history of Google reviews between January and August 2020. The selection of parks was made according to their size, location in Bucharest, previous reported number of visitors and profile of attractiveness. Results revealed that the peak period of the COVID-19 pandemic and the first initiation of the lockdowns strongly affected the recreation and leisure activities that people performed almost daily in the parks of Bucharest. Reviews and comments of the population were not that focused on the pandemic even after the restrictions were lifted, but they evidenced the positive and negative aspects of each park. Our results can represent a useful instrument for local administrations in determining both the flow of visitors but also their perceptions towards the endowments, landscape and most important management of urban parks. As a response to increasing challenges of urbanization and changing weather and climate conditions, urban green infrastructure (UGI) has emerged as a concept to increase resilience within urban boundaries . Green sFor optimal planning and management of urban parks, an important step is to quantify users’ visits and to understand the driving factors of their visits . TraditiThe understanding of factors that influence park use is an ever-emerging research focus, with most studies demonstrating that visitation rates are positively influenced by recreational features such as trails, sports and pet-friendly facilities ,9, sociaAlthough they make a major contribution to the day-to-day activities, most parks do not serve everyone in the community equally . VisitorThe present COVID-19 pandemic represents an unseen before threat to the global human health, economy and societies , the impRecent research has shown that during the pandemic, people suffered behavioral changes , with anAccording to the data provided by the Our World Data platform, there were major changes in the number of park visitors throughout the pandemic in Romania. Data show that during the lockdown in March–May 2020, the number of visitors to parks decreased considerably. Bucharest, as of November 2020, has registered a 35% decrease in park visitation compared to the baseline of the Google Mobility Report, while in Romania overall the decrease is situated at 36% . While tGoogle Mobility Reports are sets of data based on location information from Google Users with purpose in showing how communities are moving around differently due to COVID-19 . For parThe attractiveness of green areas such as urban parks is often associated with residents’ preferences and expectations regarding among others the general landscaping of the park, its endowments or facilities for different recreation or leisure activities . The mosThe methods for classifying and quantifying the benefits offered by urban parks are either qualitative  or quantitative . An ecological benefit is improving urban air quality, conserving biodiversity by creating support habitats for local flora and fauna species. For social benefits, improving the aesthetics of the urban landscape, space for recreation, creating opportunities for socialization, spaces for playing sports and improving the health of the population. For economic benefits, increasing the property value of nearby properties, reducing energy consumption by maintaining constant local temperatures or direct incomes from activities in the park.Social networks offer many ways and opportunities to understand human–nature interactions. Photographs posted by people on social networks are useful indicators in the analysis of the ways of recreation in various places such as green spaces and parks . CurrentAccording to recent studies, the way of collecting data using social media platforms is considered a more simplified version that can obtain in an easy manner a large volume of data, although its precision is highly dependent on a sound methodological approach in the study design. Comparing the use of social media in data collection and analysis with classical methods such as questionnaire or observation sheets, it appears that the use of traditional methods requires a considerable amount of work . Most ofThe main aim of our study is to evaluate how the use of urban parks changed due to the COVID-19 pandemic and how it was reflected on social media. To fulfill the purpose of this study, we identified the main characteristics of eight selected case study parks in Bucharest (Romania), how they were used during the COVID-19 pandemic, as well as the typologies of activities carried out and we described them in the following paragraphs. The main objectives underlying this study are as follows: (i) to analyze the online presence of inhabitants in the eight selected urban parks; (ii) to evaluate the opinions and the main activities that visitors post about; (iii) to analyze the involvement of public and its general position on the subject as expressed in their posts and photos.Bucharest is the main urban center of Romania  being loCismigiu Park it is one of the oldest parks in Bucharest, dating back to 1854 . This PaCircului Park is a green space included in the municipal category of parks in Bucharest, having an area of 17.2 ha. The attractiveness of the park is given especially by the presence of a central lake, which is covered almost entirely by water lilies, an area with great natural landscape value. Drumul Taberei Park with an area of 11.8 ha is an important natural element within the urban landscape. .Tei Park is located in the northern part of Bucharest. With an area of 8.5 ha, it is one of the main green areas of sector 2, next to the Circului Park. Recently, the park has been re-designed with facilities similar to amusement parks and other attractions, which has led to an increase in the attractivity for children. Sebastian Park is a neighborhood park with an area of 2.5 ha located in the south-west area of the city. The park is most frequented by people who live nearby, especially the elderly or people who want to relax, to meditate.Păcii Park was founded during the communist period and has an area of 1 ha. It is a neighborhood park located in the 6th sector of Bucharest and represents the main green space in its western extremity . Izvor PWe examined Google Maps  for reviews of Bucharest’s parks and Instagram  for posts which had the selected parks as the tagged location. Such a method of collecting user-generated content for scientific research has been increasingly been used with large volumes of data available in this method . We distDatabases were built using Microsoft Excel Spreadsheet Software  for the data extracted from Google and Instagram, with extracted information regarding data relevant for conducting the relevant analysis for this study’s objectives.The database  includedFor Google Reviews we searched for information regarding the aspects addressed in the review , as well as extracting the exact body of text to search for specific aspects and those related to the COVID-19 pandemic. Using data derived from mobile phones of users has been increasingly been used for tracking down the effects of the COVID-19 pandemic on the behavior of visitors . For InsIn order to analyze the evolution of social media posts for the studied period, we aggregated data from the databases into a table with the monthly number of posts from both platforms, for each park. Then, for a better visualization of the phenomenon, we built charts and selected those which showed the highest variations in the number of posts. Using ArcInfo . we represented some of the parameters analyzed on maps of Bucharest.The low number of posts in March, April and May  coincideAlthough, in general, Cismigiu Park experiences a high number of visitors, especially on weekends, due to the high accessibility, but the restrictions imposed by the authorities during the pandemic have made it difficult for the population to access. In Cismigiu Park, the posts were fewer between January and July, because those who attended the park were mostly students, who since March have conducted their courses online and have returned to the province.Analyzing the results obtained from postings on social media, there is a trend of increasing the number of visitors to parks since June . This inThe large number of posts on social media in August associated with Cismigiu Park is due to the outdoor performance of the “Bucharest of Caragiale” Theatre Festival. The festival ran over 10 weekends from 18 July to 20 September. In the case of Tineretului Park, the situation after the lockdown seems to be similar to Cismigiu Park, so the high number of posts in June, July and August reflects the organization of outdoor events. Most events in the Tineretului Park are associated with a specially designed area for children’s activities.Following the analysis of the language of social media posts (Instagram) and reviews granted on Google, it emerged that a total of 346 posts were made on Instagram in Romanian and 329 in English, values related to the eight parks analyzed. On Google, people granted a total of 798 reviews in Romanian and 189 in English.The results obtained for each park analyzed reflect the following aspects: most posts on Instagram in Romanian referred to Cismigiu Park, at the opposite pole with the fewest posts is Circului Park. Regarding the reviews granted on Google in English for each park, it emerged that Izvor Park has obtained 112 reviews, and no English-language posts have been identified for the Tineretului and Pacii parks. We found the average reviews of parks in the months of lockdown due to the COVID-19 pandemic to be slightly higher than the ones from regular months before it .Of the posts on Instagram, it emerged that most are made from personal accounts, amounting to 624. Comparing the type of account related to each park, it follows that those 251 posts from personal accounts were made about Cismigiu Park and only 19 about Circului Park. In addition to posts on personal accounts, there were posts made by various pages, resulting in a total of 64 posts. It was noted that Circului Park was the only one about which there were no posts of the pages on Instagram.In general, social media posts come in association with check-in items to reveal a location where the person in question is located. Based on the results obtained by analyzing the posts on Instagram, we identified that a total of 640 posts that reflect photos or only a description was related to the location by using check-in. Of these, most were identified for Cismigiu Park (278), the fewest being associated with Circului Park (13). In addition to the use of check-in, the analysis of the results revealed that 27 of the posts had tag elements, met only in the case of Circului Park and Drumul Taberei. A particular case is Tei Park, where it was observed that 21 posts were accompanied only by the text of the location.Analysis of the data obtained revealed that park visitors mentioned in their social media posts, pandemic and COVID-19 virus issues. On the Instagram platform, a total of nine mentions of the pandemic were obtained. Additionally, in the reviews on the “search engine”, Google, a total of six mentions of the virus were obtained. Thus, by reporting the total number of posts on social media, it emerged that most mentions of the pandemic were made in Cișmigiu Park (seven mentions). At the same time, these mentions were made in May and April—a period with drastic restrictions and lockdown. It is worth mentioning that the population was conditioned to stay in isolation, so people spent very little time in parks. The most encountered words in those comments included “pandemic”, “quarantine” and “mask”, others with lower frequency being: “distancing”, “lockdown”, “stay safe”, “freedom” or “Covid”.n = 506) with the higher number in the case of Cismigiu and Izvor Parks, followed by social activities (n = 369). High proportions are also represented by the inspirational values present in parks (n = 188) with lower proportions given to existence values (n = 89) and cultural aspects (n = 68).The main activities in parks , Table 5n = 333), selfies (n = 260) or general landscape of the park (n = 181). With lower frequency are present pictures of building or architectural monuments (n = 49), animals (n = 43), and plants (n = 42).The pictures posted on Instagram mainly depict personal activities , so in the end we decided to eliminate them from the study. For data analysis, we decided against using text-mining tools, as we considered them to be more suited for large bodies of text, such as when analyzing documents, policies or articles [Nita et al.], and as Instagram posts and Google reviews are usually reduced in size, we consider that direct coding of it suits our study better. In addition, with our current data more in-depth statistical analysis could have been realized (such as ANOVA), but we started from the assumption that we will have no significant differences between parks and we will have enough information to use words clouds as relevant for an overview of park usage during the pandemic period.Future research direction should mainly strengthen the limits of the data collection and analysis and include more statistically and logically advanced studies. Furthermore, methods of including the natural occurring variance of park visits due to other factors  should be included in order to improve the comparability of the analysis of the pandemic period with that of a normal year.In our study we made an assessment on how urban parks in Bucharest, Romania, were used during the COVID-19 pandemic, using data extracted from publicly available social media platforms (Instagram and Google Reviews). We analyzed the online presence of inhabitants in urban parks, evaluated their opinions as expressed in the text sections of the posts and analyzed the connection with the lockdown and restrictions imposed by the pandemic period.We found the online presence of visitors in urban parks to be highly connected with the restrictions of the COVID-19 pandemic, but the main typologies of activities carried in the urban parks have not changed, with a strong preference for posts depicting personal activities or selfies. The reviews people gave to the park evidenced both the positive and negative features of the parks.Further research should look upon improving the data collection procedure and including factors to differentiate park use during the pandemic from those naturally occurring variations due to external factors. Our results can be of high significance to public authorities in defining and applying their future policies related to urban green spaces. Specifically, they should consider allowing public access to parks even during pandemic periods, due to the high number of social, ecological, and economic benefits they provide to the population.


With the ongoing advances in sensor technology and miniaturization of electronic chips, more applications are researched and developed for wearable devices. Hydration monitoring is among the problems that have been recently researched. Athletes, battlefield soldiers, workers in extreme weather conditions, people with adipsia who have no sensation of thirst, and elderly people who lost their ability to talk are among the main target users for this application. In this paper, we address the use of machine learning for hydration monitoring using data from wearable sensors: accelerometer, magnetometer, gyroscope, galvanic skin response sensor, photoplethysmography sensor, temperature, and barometric pressure sensor. These data, together with new features constructed to reflect the activity level, were integrated with personal features to predict the last drinking time of a person and alert the user when it exceeds a certain threshold. The results of applying different models are compared for model selection for on-device deployment optimization. The extra trees model achieved the least error for predicting unseen data; random forest came next with less training time, then the deep neural network with a small model size, which is preferred for wearable devices with limited memory. Embedded on-device testing is still needed to emphasize the results and test for power consumption. Following the tremendous technological advances in the design of systems on a chip (SoCs), the development and use of wearable devices have remarkably achieved high growth rates in the last few years. Wearable devices for different biosignals’ acquisition have been researched , and chaOne of the main health issues that is usually ignored by many people, and which can lead to serious health consequences if ignored, is dehydration. While dehydration is more common in countries with very hot and humid weather where summer temperatures can reach 50 °C, it can also be seen in cold countries . The hydTo check the dehydration level of a subject, doctors often clinically use invasive methods  or offline methods  to obtain parameters such as plasma osmolality (PO), total body water (TBW), bioelectrical impedance (BIA), urine characteristics , salivary osmolality and flow rate , as wellOne approach is vision-based devices that use monitoring cameras to monitor the subject and record the eating and drinking moments . HoweverWe propose modeling the dehydration problem as a regression problem to predict the last drinking time using features extracted and constructed from multiple wearable sensors  sensor, photoplethysmography (PPG) sensor, temperature, and barometric pressure sensor);For this purpose, we recorded a total of 3386 min for these sensors for 11 subjects under fasting and non-fasting conditions;We compared different machine learning models for this task according to four metrics that evaluated the accuracy of the model, training time, and model size and for on-device personalization optimization through the transfer learning experiment;A comparison to the state-of-art research for this task was performed. Challenges and limitations were discussed, and further research directions were highlighted.The contributions of this research to the field of hydration monitoring can be summarized as follows:The rest of the paper is organized as follows. In There is ongoing progress in the development of biochemical sensors that can measure the concentration of different electrolytes in sweat and hence determine the hydration state of the human body . Side byAs discussed in the Introduction, dehydration detection has been researched using either invasive techniques in clinical setting or in a non-invasive way using machine learning techniques to learn from the features of some body signals. There are relatively few studies that have worked in this area, which we briefly review for the used features, techniques, and evaluation metrics.Features extracted from GSR sensors or sometimes called electrodermal activity (EDA) sensors have been used in most of the studies ,6,7,15. Many machine learning techniques have been tested in these studies. Linear discriminant analysis (LDA), quadratic discriminant analysis (QDA), logistic regression (LR), support vector machine (SVM), Gaussian kernel, k-nearest neighbor (KNN), decision trees, and ensemble of KNN were used in  with ensAll the aforementioned studies approached the problem as a classification problem, either as binary classification with hydrated/dehydrated labels or with more fuzzy levels. The problem with this approach is two fold, the difficulty of accurate reliable labeling of the data and neglecting the personal differences between subjects. The classification models in all the studies were evaluated according to the classification accuracy; some studies included other classification metrics such as sensitivity and specificity in  and precDeploying the machine learning model on the device has the advantages of keeping the data private and decreasing the latency for the prediction/classification as there is no need to transmit large amounts of data from the device to the cloud. Specifically, for healthcare applications, having the patient’s data and the machine learning model on the device is safer from a privacy-preserving perspective. Low latency and real-time feedback are also required for many healthcare applications that require immediate alert for the users or their care givers such as fall detection, stress detection, etc. On the other side, the main disadvantages for on-device computing include the limited device computing power, storage, and battery life. These obstacles are being addressed in the recently growing field pf tinyML  through The authors in  developeIn short, transfer learning can be employed in tasks when not many data are available for training, as well as for model personalization when the accuracy of the model is highly dependent on the subject under test. By performing this on-device , the priIn this paper, we first investigated the application of machine learning techniques for dehydration detection using body signals and features extracted from them. A comparison of different models was then performed based both on the average error across subjects, the accuracy of the transferred learned model from subjects to produce a personalized model for another subject, and the size of the model to be deployed on-device.This research paper proposes using machine learning to learn from sensors’ data recorded from different subjects and predict the last drinking time. The trained machine learning model was then to be deployed on-device to guarantee the privacy of data and to personalize the model according to the online learning from new recorded data, as mentioned in the last section. The pipeline for the machine learning stages is shown in All the dehydration monitoring/detection research work referenced in the last section ,7,14,15 Differently, in this paper, we approached the dehydration monitoring problem as a regression problem. The problem was represented as a prediction problem for the number of hours since the subject last drank water. Ten hours of fasting does not necessarily lead to dehydration. Many Muslims usually fast, sometimes for 16 h a day or more, without any water or food intake and without suffering from dehydration or related symptoms. Additionally, dehydration differs greatly from one person to another according to personal characteristics and other health conditions. With IRB approval, subjects were asked to voluntarily participate and record data normally at different times, some while they had their last water intake within an hour, others during Muslim fasting days , and some during intermittent fasting hours after waking up and before any water intake. Sensors’ data, as well as some subject characteristic data were collected as discussed in the next section. Following the data collection process, preprocessing of data, feature extraction, and analysis took place in the preprocessing step in the pipeline in On-device machine learning can take place in three different settings. Firstly, this can occur through having a pretrained model with the whole set of features deployed on the device, which can be used directly for inference, and the model’s parameters are updated through online learning with confirmations from the user for the predicted output. The second setting is a transfer learning setting where a pretrained model is deployed and either the same set of features is fed or an extra set of features is extracted to train a new model that is different in parameters and/or structure . Finallyhttp://www.shimmersensing.com/products/gsr-optical-pulse-development-kit (accessed on 18 February 2022)). The device was calibrated according to the procedure provided by the Shimmer Calibration User Manual. Subjects who were likely fasting during Ramadan or were voluntary fasting wore the device in two scenarios during fasting hours in the month of Ramadan or in an intermittent fasting scenario with no food or water intake after waking up in the morning for a few hours, recording the last time for water and food intake. No restrictions on movement or the time of wearing the device were applied to represent a real-world scenario. Some data were collected while a subject was driving a car or walking, but most of the data were recorded while the subjects were sitting at their desks. The Shimmer GSR unit was worn on the subject’s wrist with two electrodes attached to the index and middle finger of the left hand and the PPG clip on the left ear lobe. All data collection was subject to Qatar University Institutional Review Board (IRB) approval procedures covered by the IRB approval: QU-IRB 1538-EA/21. The raw dataset has been made available at Zenodo (https://zenodo.org/record/6299964).For data collection, we used the Shimmer Galvanic Skin Response (GSR) unit (https://shimmersensing.com/support/wireless-sensor-networks-documentation/ (accessed on 18 February 2022)).Data collected from the Shimmer3 GSR unit included different sensors’ data: accelerometer, magnetometer, gyroscope, GSR sensor, PPG sensor, temperature, and pressure sensors  was calculated as in Equation  was performed as in Equation (The magnetometer data were measured from three channels for the Equation  from theEquation .(3)|MAGx, y, z gyroscope with the magnitude, as shown in x, y, z) was performed as in Equation  that measures changes in the arterial translucency using a light emitter and detector. Arteries absorb less light when the heart pumps blood to the different body parts, and so, less light is received by the detector. This change in the amount of light absorbed and reflected is used to measure changes in blood volume in the arteries and capillaries, which can be used to estimate heart rate and heart rate variation. The specification of the PPG sensor used in Shimmer is added in The PPG signal is greatly affected by motion artifacts, as shown in Shimmer3 uses the BMP280 barometric pressure and temperature sensor for measuring barometric pressure with a ±1 hPa absolute accuracy and temperature with a ±1.0 °C accuracy. Atmospheric temperature and pressure can affect the hydration state of a person, especially in hot weather and very cold weather, as previously mentioned [The data were collected from 11 healthy subjects  with no underlying known health problems in a desk working conditions scenario. Though we approached the problem as a regression problem, we split the data into fasting and non-fasting samples. Non-fasting samples included data collected when the subject was hydrated and drank water within the last hour. Fasting samples contributed to the data collected from fasting subjects as mentioned before. The data collection was challenging due to COVID-19 restrictions. A total of 3386 min (56.4 h) was recorded using the Shimmer 3 GSR Development Kit. A summary of the duration of samples collected from each subject and some descriptive statistics are presented in Based on the raw sensors’ data features (48 features) recorded by the ShimmerCapture software, we selected some of the raw calibrated version of the signals in addition to some extracted features, as mentioned in the last subsection, and some personal characteristic features to have a feature vector with a total length of 19. A list of the used features (we refer to it as FEAT1 in the rest of the paper) is listed in To analyze these features (FEAT1) and understand the inter-dependencies among them, basic correlation analysis was performed. According to these results, eliminating some features and combining some features were performed. Height and weight were replaced by the body mass index (BMI). The accelerometer, magnetometer, and gyroscope features of the magnitudes and cumulative sum were replaced by a summation of the ratios of the cumulative sum of the magnitude to the magnitude feature of each. The ibi feature was eliminated as bpm was linearly calculated from ibi, so including one of them was sufficient. The new feature set had 12 features, and it is referred to as FEAT2. We did this in favor of overcoming the multicollinearity, as well as to follow the Occam’s razor principle, which means in this case that fewer features were preferred as long as they do not affect the model’s accuracy, as will be shown in the next section. Using fewer features means simpler models, which require less memory for storing features and parameters and less training time, which were desirable for the case at hand of limited resources in wearable devices. A comparison of the performance using the two features sets is presented in the next section.In the first set of experiments, comparing the different machine learning algorithms was performed with the whole dataset (FEAT1) of the 11 subjects with a 70/30 training/testing split with the baseline of predicting with the median value. The averaged results over 10 runs are shown in Using FEAT2 was found to achieve less error, as shown in To evaluate how these three models  performed in a transfer learning setting with a fixed structure and features, another experiment was performed with the models trained with data for all subjects except one and retrained with part of the data as a training set to tune the parameters of the mode to personalize it, which can represent the labeled data that the user or his/her caregiver provide as the input or correction to the predicted output. The random forest model was found to achieve good comparable accuracy with respect to the prediction error, as well as the least training time, which is preferred for wearable devices with limited computational resources. It inherits interpretability and explainability from decision trees and is recommended to be used in different healthcare applications. With respect to the model size, more optimization can be performed by applying TinyTL techniques to reduce the training memory footprint by an order of magnitude for efficient on-device learning through quantization and other strategies  and testIn this section, the results of this research are compared to the related papers in the literature reviewed in The first point of comparison is how the problem was modeled. All the other studies modeled it as classification into two, three, or four classes, as summarized in Features extracted from GSR/EDA were used in most of the studies ,6,7,15, All the studies experimented with different types of models; they reported the best accuracy for different models according to the data used: random forest in , decisioAs mentioned in the last section, optimization techniques for on-device deployment to decrease the models’ sizes are essential for the limited memory resources on wearable devices. Optimizing the training time and inference time consequently is important due to the computational resources’ limitations. Regarding the model size and training time comparisons, the other studies did not report their results in this aspect. Only  performeRegarding the dataset size, our dataset was second in terms of the total minutes recorded after , but we Summing up, this study modeled the problem of hydration monitoring as a regression problem rather than classification for the reasons highlighted in the paper. It integrated sensors of multiple modalities, and new features were constructed that have not been used in previous studies. The model evaluation based on accuracy, training time, and model size for optimization for on-device deployment, as well as testing the best models in a transfer learning setting were performed. The main shortcomings are the limited dataset size and missing the representation of important target users of the application. Testing on an embedded prototype was important to evaluate power consumption and gain more confidence in the applicability of the solution.In this paper, the problem of dehydration monitoring was approached as a regression problem. The integration of different sensor modalities was employed, and new features were constructed from sensors’ data, besides using some personalized features. Machine learning techniques were compared according to the error in prediction metrics, as well as the training time and model size to optimize for on-device deployment. The evaluation was based on an on-device learning scenario to guarantee privacy preservation of the subjects’ data. In conclusion, hydration monitoring and prediction of the last drinking time with medical wearable data are feasible. This can help elderly people who cannot communicate their feeling of thirst, people with adipsia, and those working in very hot or very cold weather to be alerted when they need to drink water. The results presented in this paper encourage testing with a larger dataset for more subjects with a higher diversity in different working conditions and benchmarking on an embedded wearable hardware to gain more confidence in the results.


The HMP aimed to provide new COs with emotional and tangible forms of support during their first year of employment, including peer coaching to prevent early decline in physical fitness and health. The development and implementation of the HMP occurred across five main steps: (1) participatory design focus groups with key stakeholders; (2) adaptation of an existing mentoring handbook and training methods; (3) development of mentor–mentee recruitment criteria and assignment; (4) designing assessment tools; and (5) the initiation of a mentor oversight committee consisting of union leadership, corrections management, and research staff. Correctional employee engagement in the design and implementation process proved to be efficacious in the implementation and adaptation of the program by staff. Support for the HMP remained high as program evaluation efforts continued.Correctional officers (COs) are exposed to a number of occupational stressors, and their health declines early in their job tenure. Interventions designed to prevent early decline in CO health are limited. This article describes the development, implementation, and evaluation of a one-year peer health mentoring program (HMP) guided by Total Worker Health Correctional officers (COs) are front-line employees who work in prisons and jails and are exposed to many unique risks that can jeopardize their safety and well-being ,2,3. COs® initiative of the National Institute for Occupational Safety and Health (NIOSH) recognizes work as a social determinant of health and aims to protect the safety and health of workers, and advance their well-being by creating safer and healthier work [Health Improvement Through Employee Control (HITEC) II, currently in its third phase, was a partnership with the Department of Correction (DOC) in a Northeastern state that was formed to develop, implement, and evaluate interventions intended to improve the health, safety, and well-being of correctional employees ,4. The Tier work . HITEC Iier work . Furtherier work ,2.In a preliminary study of 326 COs conducted in 2008, HITEC research staff found that CO health declines rapidly early in work tenure . DespiteIn the past decade, the public safety sector has applied and recommended peer mentoring to facilitate an easier transition for new recruits on the job ,17. ThroRecognizing the potential decline of CO health during the first years of employment, HITEC II research staff partnered with union leadership, line-level staff, and managers in the DOC in the development, implementation, and initial assessment of a one-year peer-to-peer health mentoring program (HMP) for newly hired COs  using a Total Worker Health participatory approach. The idea of developing a HMP came directly from the three regional union leaders representing line-level staff. Union leaders were concerned about the health of their members and recognized that newly hired COs may be less resistant to on-the-job training and preventative health programs, compared to more tenured staff.The HMP concept can be contrasted with traditional workplace mentoring programs that largely focus on supervisors guiding or enhancing junior employees’ (mentees) personal and career development, where there is a large gap between short-term on-the-job mentoring and later selection for eventual promotion . DespiteThe main goals of the HMP were to help newly hired COs develop positive health behaviors, and to provide them with peer coaching on health topics to prevent early decline in physical fitness and promote healthy eating, stress management, and work–family balance. In this article, we describe the five steps that were used to design and implement the HMP.The HMP was developed in five major steps , as detailed below. The overall process and design of the HMP is depicted in a logic model . The proA core planning group met regularly during the development of the HMP  and consisted of research staff and union presidents for line-level correctional staff and some of their designees. The meetings focused on the development of the mentoring program and review of draft materials. Additionally, a series of participatory design focus groups were organized with correctional officers who potentially could become mentors. The participatory design focus groups were conducted differently than conventional focus groups and were used to inform ongoing design and development of the HMP and associated materials. Summary findings of suggestions from these participatory focus groups were immediately reported back to the core planning group by research staff in order to inform ongoing program design efforts.The following results highlight the process of development and implementation of the HMP, which occurred across the following five main steps:Step 1. Designing the HMP through Participatory Design Focus Groups.In line with PAR techniques, the participatory design focus groups provided the means for engaging DOC staff as equal partners in all aspects of program design and implementation ,26,27. AFocus group participants were chosen based on their tenure and rank at DOC. Specifically, participants had to have at least 5 years on the force and prior experience in training newly hired officers on the job. One participatory design focus group consisted of members of the supervisory staff (captains and lieutenants) and two participatory design focus groups consisted of COs, representing two of the three union locals in the state. Participatory design focus groups met at local union offices; 23 officers and five captains and lieutenants participated.someone to whom one can speak freely, someone who sets a good example, and someone who demonstrates good work quality and good communication skills. Confidence was expressed among all participatory design focus groups that a well-conceived mentor training program could be developed and sustained. They also felt that the training should be jointly designed with the research team, COs, and Training Academy personnel .Participatory Design Focus Group Findings: There were differences between the groups in their recommended weighting of experience and personal qualities of prospective mentors, but there were also noted differences of this weighting among members of each participatory design focus group. For example, some considered interpersonal qualities to be more important than technical skills in prospective mentors. The interpersonal skills identified as significant were as follows: Although all such ideas gathered in the participatory design focus groups were carefully considered, some of the ideas, although desirable, would have faced structural obstacles if implemented. For example, there was a strong desire for all mentor training to occur at the Training Academy, and for mentors to meet each other monthly in order to share the knowledge gained. However, these ideas proved infeasible due to the geographic dispersion of the correctional facilities and staffing limitations for coverage of those who would be meeting. The participatory design focus group members also recommended matching the gender of mentor and mentee because of the specific challenges to women in the male-dominated workforce but this was not always possible. One unforeseen barrier identified by the participatory design focus groups involved the tenure requirement for mentors and how this would affect shift alignment. In the participatory design focus groups, it was contended that to be a mentor, a CO needed at least 7 years of tenure and a disciplinary record that was currently clear. It was argued that mentor/mentee pairs would not need to be limited to working the same hours, and that they could instead work on adjacent shifts and meet at shift change. However, the arrival of the first mentees revealed this was an unworkable plan when it became apparent that most new officers worked the third shift whereas officers with 7 years of tenure worked the first shift. The SWSC offered a solution to this problem, which was to reduce the tenure requirement to 3 years, allowing for more within-shift mentoring to occur. One principle that could not be similarly compromised by the SWSC was the provision that mentor supervision would be handled by line-level COs, rather than supervisory staff. An important participatory design focus group recommendation was that, although supervisory staff could participate in establishing formal mentor selection criteria, the actual selection of mentors needed to fall under the authority of the COs. One remaining concern that needed to be addressed was the possibility that a mentor might be contested by management because of an undisclosed disciplinary action that was pending, or investigation of potential criminal activity that was ongoing. As the program was further developed through participatory design over time, resolutions on such process issues were worked out within labor leadership meetings. A management oversight committee structure that was proposed and eventually adopted was found to be effectively preventive; it had yet to be convened to resolve a labor-management conflict at the time of this writing.Step 2. Adaptation of an Existing Mentoring Handbook and Training.Building on the information generated from the participatory design focus groups, the research team and frontline COs modified an existing career mentoring workbook from the Southern Region of the National Institute of Corrections Academy Division’s Regionalization Project of 2002 . The resThe subsequent training of mentors by HITEC II research staff relied on several approaches tailored to adult learners. A presentation using Microsoft PowerPoint was developed that included both lessons from the Handbook and interactive scenarios and scripts. To accommodate agency stipulations on educational travel and release time, the training session was developed to last 1 to 1.5 h with provision for later in-person follow-up. Training delivery at a centralized facility was not feasible due to the geographic distribution of mentors across 18 facilities. Consequently, training sessions were scheduled at each correctional facility during normally assigned shifts. In addition to the Handbook, mentors received a binder that included the initial goal-setting contract, record keeping forms, and materials for quarterly evaluation of their mentee’s personal development and career goals.Step 3. Mentor–Mentee Recruitment Criteria and Assignment.An important consensus recommendation from earlier participatory design focus groups was that supervisory staff could participate in establishing formal mentor selection criteria and in making mentor recommendations, but that the actual selection of mentors should fall under the authority of the COs. Focus group participants had also recommended that mentor supervision should not be handled by supervisory staff.COs working in the cadets’ destination facilities were first introduced to the HMP and the role of mentors at roll call, a regular event that is held at the start of all shifts. Research staff delivered a short presentation on the purpose of the HMP program, on the desired qualifications for mentorship, and on mentors’ obligations and their expected time commitment. Interested prospective mentors signed up either with research staff, through a confidential channel at onsite locations, or via e-mail. Requirements to become a mentor included having worked as a CO for at least 5 years (later reduced to 3) and having remained in good disciplinary standing with the DOC. Because of the unexpectedly high level of interest on the part of mentor candidates, union leadership regularly reviewed individual qualifications, although rejection was uncommon.To help avoid treatment bias and minimize the effects of a wide range of confounding variables, successive cadet classes were recruited into either the Personalized Follow-up Program (PFP) as the mentored group, or into the Standard Follow-up Program (SFP) as the non-mentored control group. Those in the SFP received conventional on-the-job training (OJT) that all new cadets receive upon transfer to a facility. In the project years 2013–2014, there were five classes matriculating at the Officers’ Training Academy, the inception point for new officers. Three of these classes were assigned to the PFP condition, and two were assigned to the SFP condition. All cadets in each class were invited to participate in the study, as either mentees or controls depending on the inception class, or to decline the invitation without consequence. Those choosing to participate were consented into the study.n = 11).Among 406 eligible cadets in the PFP classes, 183 (45.1%) elected to participate in the study. Thirteen corrections facilities within the state had mentors and mentees in the HMP . Four faParticipants completed the baseline survey and physical assessment. The ratio of mentors to mentees ranged between 1:1 and 1:3. The majority of mentees were male (76.4%), which was representative in this working population of officers. The results from the surveys and physical assessments at baseline and follow-ups are presented in a separate article reporting on the efficacy of the program .Mentees were assigned to facilities after their academy-based orientation and training was completed. Their orientation and training included a brief internship placement at a facility that may have been different from their final (destination) facility. Research staff assigned mentors to each mentee following their graduation from the training academy and being posted at their destination facility. Mentors and mentees working the same shifts were paired to allow and optimize scheduled meetings. Supervisors at the designated facilities provided relief time for these on-site mentor–mentee meetings. Following mentor–mentee assignments, study staff conducted follow-ups, usually one week later, to ensure that initial contact between mentors and mentees had occurred successfully. These and subsequent follow-ups were initiated through reminder e-mails and phone calls with the mentors. Study staff also sent mentors a reminder e-mail that reiterated the importance of the record-keeping process for study integrity. Additionally, study staff visited each facility every three months to conduct a scheduled follow-up with the mentors that included refresher training with review of the existing materials from the initial training. To support further communications and provide technical assistance, there was also ongoing phone and internet access to the study team that was made available throughout this period.Step 4. Health Mentor Program Assessment.n = 183) and in the conventional SFP arm  completed a survey and were offered a brief physical exam on a voluntary basis. Based on the initial follow-up results, and previously existing studies on declining health of COs, it was evident and necessary to evaluate the mentee outcomes after around 3–5 years of employment [At intake and at one-year post-assignment, all participants in both the PFP arm , topics discussed, health goals, perceptions of mentoring, and barriers and facilitators of peer health mentoring. The quality of the mentor–mentee relationship, and the frequency and quality of mentoring, was also assessed with a survey with mentees during their evaluation at the end of the one-year HMP. The aim of the process was to evaluate the quality of relationship overlaps and discrepancies with dual source data.Step 5. Mentoring Oversight Committee.Two different groups, separated by chronology, were charged with oversight of the HMP. In the first 2 years of the program, the major impetus came from regular meetings with the bargaining unit presidents and their representatives. The HMP was one of two major projects generated by HITEC II, and a Study Wide Steering Committee (SWSC) which was in place from 2007, beginning with HITEC I . The SWSPrograms supporting mentor–mentee relationships, based on consensual health-related goals, are relatively novel in the occupational health literature , and rar® principles, which requires an integration of individual health with working conditions and work organization. PAR methods were used to actively engage union leadership, COs, and managers in the design and implementation of Total Worker Health interventions. The presumptive value of incorporating bottom-up workforce knowledge of the stages of adaptation and of pitfalls and barriers was implicit. Another presumption, also consistent with PAR principles, was that correctional employee-driven design and involvement offered a heightened potential for participation, effectiveness, and sustainability [Key to the development of this HMP were the two concepts that define CPH-NEW. These two concepts are PAR methods, based around active participation at the line level in program design and implementation efforts, and adherence to Total Worker Healthnability . Given iSupport for organizational change was maintained through the SWSC. The SWSC provided ongoing program oversight pertaining to allocation of compensated time for training, mentoring, and evaluation, and instructed supervisory staff in program accommodation. As noted, the SWSC had a normalizing function. It assumed the ad hoc introductory work performed by the bargaining unit presidents, the study team, and DOC administration, when the start-up phase was complete. This two-part maturation process grew naturally as the bargaining units pursued initial dominance of design and implementation. It was found that many of the predictions of conflict did not arise, even though the developmental process of the program was largely exclusive of supervisory representation. Whether or not a more direct preliminary action phase is a necessity will likely depend on local, rather than elemental, conditions. However, it is clear that the autonomous contributions of the line workforce, even if temporarily in isolation, are elemental.More than a decade before the HMP, the DOC had introduced a more traditional but concerted mentoring program which was principally top-down in its implementation. It proved to be unsustainable. The HMP offered a different level of engagement in which line-level staff, union leaders, and DOC management worked together in program design and took responsibility for its continuity. The HMP within HITEC II could not have been, however, a purely bottom-up creation. Bargaining unit leadership is largely consumed in contractual affairs, and program management is a learned and selective skill. Moreover, the constraints over aligned scheduling, coverage, and compensation fall outside of bargaining unit jurisdiction. A high level of programmatic autonomy had been negotiated and maintained through the SWSC. Thus, there was always an institutional readiness to address critical barriers and promote engaged activity. Conversely, a purely line officer program is likely to fail because officers change facilities and have insufficient administrative experience and authority to manage a complex program such as the HMP. The ability of administrators and supervisors to flexibly facilitate, rather than direct, within defined parameters, is essential to program success and has required a sophisticated SWSC.Additionally, the HMP was part of a research study requiring the support of HITEC II research staff. HITEC II research staff presented a research design and created a battery of process assessment tools that were vetted through the participatory design focus groups and the SWSC, but which would not have evolved without academic engagement. The goal of the HMP program was to help COs develop and maintain positive health behaviors; to provide COs with peer coaching around physical fitness; to prevent early decline in fitness; and to improve stress management. HITEC II research staff also provided support with training mentors, and baseline and follow-up assessments. Further, research staff created a website for COs with customized health information, in addition to a newsletter that was circulated to various facilities on a quarterly basis. The HITEC II research team has placed its methods in the public domain with the development of a toolkit to guide peer mentoring in correctional workforce , but it Certain adaptations also occurred during program implementation. These included changes to mentor eligibility criteria and supervisor involvement. Initially, eligible mentors were required to have had five years of experience or more on the job. However, it become evident early in the program initiation that interested tenured staff at various facilities were in the process of retirement, which resulted in scheduling problems. To increase the pool of mentors interested in the HMP, the eligibility criteria changed from five to three years’ experience, and even less in some cases. It became clear that highly motivated younger officers were capable of superior performance. As the selection process matured, a more personalized approach to admission replaced rigid guidelines, in some cases. Additionally, younger, less tenured COs were considered to suffer from less burnout and could be expected to provide a more positive and healthy perspective on the job. In later program review, there was a realization that the process of development from engaged mentor to health and well-being advocate and champion was continuous, and in the long run may be constructed along continuous improvement lines.During program design, the supervisors’ role in program implementation was secondary to that of CO leadership. However, during implementation, supervisors played a key role in relieving mentees and mentors from their shift assignments in order for them to meet during work hours. Supervisors also helped recruit mentors, and their possible role in training mentors was also discussed by the SWSC. Ultimately, the supervisors developed their own health promotion programs for supervisors. The traditional division between supervisory and CO staff softened on issues involving health and well-being. The need for changes in program design for continuous improvement played a key role in determining the important function that the SWSC played, especially during implementation of the HMP.It is also important to highlight some of the barriers that were overcome in the process of developing the mentoring program. First, there was a lack of precedent materials for a CO mentoring program. As such, it was necessary to bring all levels of correctional staff to work together in creating and formatting the training materials. Second, COs have limited formal administrative and/or organizational experience in conducting and evaluating programs. This necessitated union leadership and SWSC engagement, in addition to engagement of study staff to design and conduct this participatory program. Third, problems of vetting and confidentiality during the recruitment of mentors were handled with an elaborate mitigation process that was acceptable to the administration and the union, which initially followed the formal administration-union grievance practices. Over time, actual working relations softened these restrictions. Finally, barriers around varying shift and work slots between mentors and mentees were identified and addressed early during the design and implementation of the mentoring program. Considerations over scheduling meeting time and shift alignments of mentors and mentees were discussed at labor management to maximize the amount of time available for mentors and mentees to meet.The HMP benefited from being introduced in the context of the ongoing HITEC II study that included efforts to compare two different means of engaging employees in the participatory design of Total Worker Health interventions . SeparatPromoting employee efficacy in the design of Total Worker Health interventions and programs such as peer health mentoring has important implications for the future of work. With so many internal and external factors impacting present-day workplaces in ways that critically affect health, including COVID-19 and the accelerating pace of technological change, work organizations must not only respond quickly but also in a manner that draws upon expertise from all levels of their organization. Peer-to-peer programs have gained recognition in addressing job satisfaction and worker health ,24,38. HIn the first wave of practice, the preparation proved to be effective because of its reach; nearly 100 mentors were trained, and 269 participants (mentees and controls) signed up and completed baseline testing. Evaluation findings of the HMP are discussed in a separate article within this Special Issue .CO involvement in participatory design efforts can serve to overcome widespread resistance and distrust by COs towards preventive health and work programs. CO involvement could also be effective in alleviating the culture of reluctance by COs to share health and well-being issues of a confidential and personal nature with their peers/DOC staff. In addition to initial planning efforts with union leaders and corrections management, support for the HMP remained high as program evaluation efforts continued, suggesting the likelihood of program sustainability. HMP has shown promise as an intervention within the correctional sector; further evaluation is needed to demonstrate generalizability and adaptability of such programs across state lines and specific correctional settings (such as jails).