Displaying publications 1 - 20 of 21 in total

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  1. Wireless gyroscope suit for gait stability estimation
    Gouwanda D, Senanayake NA
    Annu Int Conf IEEE Eng Med Biol Soc, 2011;2011:7824-8.
    PMID: 22256153 DOI: 10.1109/IEMBS.2011.6091928
    Gait stability is primary in assessing individuals with high risk of falling, particularly the elderly. Custom made self-adjustable wireless gyroscope suit is used as a sensing device to quantify gait stability. A nonlinear time series analysis i.e. maximum Lyapunov exponent (λ*) was employed to estimate the short term and long term stability and it is closely related to the ability of human neuro-muscular control system in maintaining gait stability. Experimental analysis and tests validated the efficacy of this novel approach. The results achieved are comparable with the findings of multiple kinematic and dynamic parameters derived from optical motion capture system and force platform which are widely used as gold standard.
  2. A robust real-time gait event detection using wireless gyroscope and its application on normal and altered gaits
    Gouwanda D, Gopalai AA
    Med Eng Phys, 2015 Feb;37(2):219-25.
    PMID: 25619613 DOI: 10.1016/j.medengphy.2014.12.004
    Gait events detection allows clinicians and biomechanics researchers to determine timing of gait events, to estimate duration of stance phase and swing phase and to segment gait data. It also aids biomedical engineers to improve the design of orthoses and FES (functional electrical stimulation) systems. In recent years, researchers have resorted to using gyroscopes to determine heel-strike (HS) and toe-off (TO) events in gait cycles. However, these methods are subjected to significant delays when implemented in real-time gait monitoring devices, orthoses, and FES systems. Therefore, the work presented in this paper proposes a method that addresses these delays, to ensure real-time gait event detection. The proposed algorithm combines the use of heuristics and zero-crossing method to identify HS and TO. Experiments involving: (1) normal walking; (2) walking with knee brace; and (3) walking with ankle brace for overground walking and treadmill walking were designed to verify and validate the identified HS and TO. The performance of the proposed method was compared against the established gait detection algorithms. It was observed that the proposed method produced detection rate that was comparable to earlier reported methods and recorded reduced time delays, at an average of 100 ms.
  3. Periodical gait asymmetry assessment using real-time wireless gyroscopes gait monitoring system
    Gouwanda D, Senanayake SM
    J Med Eng Technol, 2011 Nov;35(8):432-40.
    PMID: 22074136 DOI: 10.3109/03091902.2011.627080
    A real-time gait monitoring system that incorporates an immediate and periodical assessment of gait asymmetry is described. This system was designed for gait analysis and rehabilitation of patients with pathologic gait. It employs wireless gyroscopes to measure the angular rate of the thigh and shank in real time. Cross-correlation of the lower extremity (Cc(norm)), and normalized Symmetry Index (SI(norm)) are implemented as new approaches to periodically determine the gait asymmetry in each gait cycle. Cc(norm) evaluates the signal patterns measured by wireless gyroscopes in each gait cycle. SI(norm) determines the movement differences between the left and right limb. An experimental study was conducted to examine the viability of these methods. Artificial asymmetrical gait was simulated by placing a load on one side of the limbs. Results showed that there were significant differences between the normal gait and asymmetrical gait (p < 0.01). They also indicated that the system worked well in periodically assessing the gait asymmetry.
  4. Identifying gait asymmetry using gyroscopes--a cross-correlation and Normalized Symmetry Index approach
    Gouwanda D, Senanayake SM
    J Biomech, 2011 Mar 15;44(5):972-8.
    PMID: 21306714 DOI: 10.1016/j.jbiomech.2010.12.013
    Injury to a lower limb may disrupt natural walking and cause asymmetrical gait, therefore assessing the gait asymmetry has become one of the important procedures in gait analysis. This paper proposes the use of wireless gyroscopes as a new instrument to determine gait asymmetry. It also introduces two novel approaches: normalized cross-correlations (Cc(norm)) and Normalized Symmetry Index (SI(norm)). Cc(norm) evaluates the waveform patterns generated by the lower limb in each gait cycle. SI(norm) provides indications on the timing and magnitude of the bilateral differences between the limbs while addressing the drawbacks of the conventional methods. One-way ANOVA test reveals that Cc(norm) can be considered as single value indicator that determines the gait asymmetry (p<0.01). The experiment results showed that SI(norm) in asymmetrical gait were different from normal gait. SI(norm) in asymmetrical gait were found to be approximately 20% greater than SI(norm) in normal gait during pre-swing and initial swing.
  5. A review on the mechanical design elements of ankle rehabilitation robot
    Khalid YM, Gouwanda D, Parasuraman S
    Proc Inst Mech Eng H, 2015 Jun;229(6):452-63.
    PMID: 25979442 DOI: 10.1177/0954411915585597
    Ankle rehabilitation robots are developed to enhance ankle strength, flexibility and proprioception after injury and to promote motor learning and ankle plasticity in patients with drop foot. This article reviews the design elements that have been incorporated into the existing robots, for example, backdrivability, safety measures and type of actuation. It also discusses numerous challenges faced by engineers in designing this robot, including robot stability and its dynamic characteristics, universal evaluation criteria to assess end-user comfort, safety and training performance and the scientific basis on the optimal rehabilitation strategies to improve ankle condition. This article can serve as a reference to design robot with better stability and dynamic characteristics and good safety measures against internal and external events. It can also serve as a guideline for the engineers to report their designs and findings.
  6. Postural Control and Adaptation Strategy of Young Adults on Unstable Surface
    Lai QQ, Gouwanda D, Gopalai AA
    Motor Control, 2023 Apr 01;27(2):179-193.
    PMID: 36216337 DOI: 10.1123/mc.2021-0138
    Balance control is essential for postural adjustment in physical activities. This study investigates the behavior of human postural control and the coordination and adaptation strategy of hip, knee, and ankle when standing on an unstable surface. Twenty participants were recruited. Four different conditions were investigated: a quiet bipedal stance with eyes open and eyes closed, and standing on an unstable surface with eyes open and eyes closed. Other than the joint angle, the standard body sway measures, such as sway area and sway velocity, were computed. A nonlinear time series measure, that is, sample entropy, was used to determine the regularity of the time series and body adaptability to change and perturbation. The results show that the body sway increases as the difficulty increases. This study also confirms the coordination of the hip, knee, and ankle to maintain body balance on the unstable surface by decreasing the joint angle and adopting a lower posture. Even though the individual joint has lower sample entropy value and is deemed to be rigid and less adaptive to perturbation, the postural control exhibits higher sample entropy value, particularly in the anterior-posterior direction, and has the ability to stabilize the body by manipulating the joints simultaneously. These outcomes suggest that an unstable surface not only challenges the human postural control, but also reduces the hip, knee, and ankle adaptability to perturbation, thus making it a great tool to train body balance.
  7. Real-time stability measurement system for postural control
    Gopalai AA, Senanayake SM, Kiong LC, Gouwanda D
    J Bodyw Mov Ther, 2011 Oct;15(4):453-64.
    PMID: 21943619 DOI: 10.1016/j.jbmt.2010.10.005
    A method for assessing balance, which was sensitive to changes in the postural control system is presented. This paper describes the implementation of a force-sensing platform, with force sensing resistors as the sensing element. The platform is capable of measuring destabilized postural perturbations in dynamic and static postural conditions. Besides providing real-time qualitative assessment, the platform quantifies the postural control of the subjects. This is done by evaluating the weighted center of applied pressure distribution over time. The objective of this research was to establish the feasibility of using the force-sensing platform to test and gauge the postural control of individuals. Tests were conducted in Eye Open and Eye Close states on Flat Ground (static condition) and the balance trainer (dynamic condition). It was observed that the designed platform was able to gauge the sway experienced by the body when subject's states and conditions changed.
  8. Determining level of postural control in young adults using force-sensing resistors
    Gopalai AA, Senanayake SM, Gouwanda D
    IEEE Trans Inf Technol Biomed, 2011 Jul;15(4):608-14.
    PMID: 21478080 DOI: 10.1109/TITB.2011.2140378
    A force-sensing platform (FSP), sensitive to changes of the postural control system was designed. The platform measured effects of postural perturbations in static and dynamic conditions. This paper describes the implementation of an FSP using force-sensing resistors as sensing elements. Real-time qualitative assessment utilized a rainbow color scale to identify areas with high force concentration. Postprocessing of the logged data provided end-users with quantitative measures of postural control. The objective of this research was to establish the feasibility of using an FSP to test and gauge human postural control. Tests were conducted in eye open and eye close states. Readings obtained were tested for repeatability using a one-way analysis of variance test. The platform gauged postural sway by measuring the area of distribution for the weighted center of applied pressure at the foot. A fuzzy clustering algorithm was applied to identify regions of the foot with repetitive pressure concentration. Potential application of the platform in a clinical setting includes monitoring rehabilitation progress of stability dysfunction. The platform functions as a qualitative tool for initial, on-the-spot assessment, and quantitative measure for postacquisition assessment on balance abilities.
  9. Fulltext Parkinson's Disease Diagnosis and Severity Assessment Using Ground Reaction Forces and Neural Networks
    Veeraragavan S, Gopalai AA, Gouwanda D, Ahmad SA
    Front Physiol, 2020;11:587057.
    PMID: 33240106 DOI: 10.3389/fphys.2020.587057
    Gait analysis plays a key role in the diagnosis of Parkinson's Disease (PD), as patients generally exhibit abnormal gait patterns compared to healthy controls. Current diagnosis and severity assessment procedures entail manual visual examinations of motor tasks, speech, and handwriting, among numerous other tests, which can vary between clinicians based on their expertise and visual observation of gait tasks. Automating gait differentiation procedure can serve as a useful tool in early diagnosis and severity assessment of PD and limits the data collection to solely walking gait. In this research, a holistic, non-intrusive method is proposed to diagnose and assess PD severity in its early and moderate stages by using only Vertical Ground Reaction Force (VGRF). From the VGRF data, gait features are extracted and selected to use as training features for the Artificial Neural Network (ANN) model to diagnose PD using cross validation. If the diagnosis is positive, another ANN model will predict their Hoehn and Yahr (H&Y) score to assess their PD severity using the same VGRF data. PD Diagnosis is achieved with a high accuracy of 97.4% using simple network architecture. Additionally, the results indicate a better performance compared to other complex machine learning models that have been researched previously. Severity Assessment is also performed on the H&Y scale with 87.1% accuracy. The results of this study show that it is plausible to use only VGRF data in diagnosing and assessing early stage Parkinson's Disease, helping patients manage the symptoms earlier and giving them a better quality of life.
  10. Fulltext Muscles Affecting Minimum Toe Clearance
    Perera CK, Gopalai AA, Ahmad SA, Gouwanda D
    Front Public Health, 2021;9:612064.
    PMID: 34136448 DOI: 10.3389/fpubh.2021.612064
    The aim of this study was to investigate how the anterior and posterior muscles in the shank (Tibialis Anterior, Gastrocnemius Lateralis and Medialis), influence the level of minimum toe clearance (MTC). With aging, MTC deteriorates thus, greatly increasing the probability of falling or tripping. This could result in injury or even death. For this study, muscle activity retention taping (MART) was used on young adults, which is an accepted method of simulating a poor MTC-found in elderly gait. The subject's muscle activation was measured using surface electromyography (SEMG), and the kinematic parameters (MTC, knee and ankle joint angles) were measured using an optical motion capture system. Our results indicate that MART produces significant reductions in MTC (P < α), knee flexion (P < α) and ankle dorsiflexion (P < α), as expected. However, the muscle activity increased significantly, contrary to the expected result (elderly individuals should have lower muscle activity). This was due to the subject's muscle conditions (healthy and strong), hence the muscles worked harder to counteract the external restriction. Yet, the significant change in muscle activity (due to MART) proves that the shank muscles do play an important role in determining the level of MTC. The Tibialis Anterior had the highest overall muscle activation, making it the primary muscle active during the swing phase. With aging, the shank muscles (specifically the Tibialis Anterior) would weaken and stiffen, coupled with a reduced joint range of motion. Thus, ankle-drop would increase-leading to a reduction in MTC.
  11. Fulltext Joint angle estimation with wavelet neural networks
    Sivakumar S, Gopalai AA, Lim KH, Gouwanda D, Chauhan S
    Sci Rep, 2021 05 13;11(1):10306.
    PMID: 33986396 DOI: 10.1038/s41598-021-89580-y
    This paper presents a wavelet neural network (WNN) based method to reduce reliance on wearable kinematic sensors in gait analysis. Wearable kinematic sensors hinder real-time outdoor gait monitoring applications due to drawbacks caused by multiple sensor placements and sensor offset errors. The proposed WNN method uses vertical Ground Reaction Forces (vGRFs) measured from foot kinetic sensors as inputs to estimate ankle, knee, and hip joint angles. Salient vGRF inputs are extracted from primary gait event intervals. These selected gait inputs facilitate future integration with smart insoles for real-time outdoor gait studies. The proposed concept potentially reduces the number of body-mounted kinematics sensors used in gait analysis applications, hence leading to a simplified sensor placement and control circuitry without deteriorating the overall performance.
  12. The effect of asymmetrical gait induced by unilateral knee brace on the knee flexor and extensor muscles
    Yap YT, Gouwanda D, Gopalai AA, Chong YZ
    Med Biol Eng Comput, 2021 Mar;59(3):711-720.
    PMID: 33625670 DOI: 10.1007/s11517-021-02337-7
    Asymmetrical stiff knee gait is a mechanical pathology that can disrupt lower extremity muscle coordination. A better understanding of this condition can help identify potential complications. This study proposes the use of dynamic musculoskeletal modelling simulation to investigate the effect of induced mechanical perturbation on the kneeand to examine the muscle behaviour without invasive technique. Thirty-eight healthy participants were recruited. Asymmetrical gait was simulated using knee brace. Knee joint angle, joint moment and knee flexor and extensor muscle forces were computed using OpenSim. Differences inmuscle force between normal and abnormal conditions were investigated using ANOVA and Tukey-Kramer multiple comparison test.The results revealed that braced knee experienced limited range of motion with smaller flexion moment occuring at late swing phase. Significant differences were found in all flexormuscle forces and in several extensor muscle forces (p<0.05). Normal knee produced larger flexor muscle force than braced knee. Braced knee generated the largest extensor muscle force at early swing phase. In summary, musculoskeletal modelling simulation can be a computational tool to map and detect the differences between normal and asymmetrical gaits.
  13. Estimation of vertical ground reaction force during running using neural network model and uniaxial accelerometer
    Ngoh KJ, Gouwanda D, Gopalai AA, Chong YZ
    J Biomech, 2018 07 25;76:269-273.
    PMID: 29945786 DOI: 10.1016/j.jbiomech.2018.06.006
    Wearable technology has been viewed as one of the plausible alternatives to capture human motion in an unconstrained environment, especially during running. However, existing methods require kinematic and kinetic measurements of human body segments and can be complicated. This paper investigates the use of neural network model (NN) and accelerometer to estimate vertical ground reaction force (VGRF). An experimental study was conducted to collect sufficient samples for training, validation and testing. The estimated results were compared with VGRF measured using an instrumented treadmill. The estimates yielded an average root mean square error of less than 0.017 of the body weight (BW) and a cross-correlation coefficient greater than 0.99. The results also demonstrated that NN could estimate impact force and active force with average errors ranging between 0.10 and 0.18 of BW at different running speeds. Using NN and uniaxial accelerometer can (1) simplify the estimation of VGRF, (2) reduce the computational requirement and (3) reduce the necessity of multiple wearable sensors to obtain relevant parameters.
  14. The influence of different solid-liquid ratios on the thermophilic anaerobic digestion performance of palm oil mill effluent (POME)
    Khadaroo SNBA, Grassia P, Gouwanda D, Poh PE
    J Environ Manage, 2020 Mar 01;257:109996.
    PMID: 31868647 DOI: 10.1016/j.jenvman.2019.109996
    An alternative method was proposed to optimize the treatment process of palm oil mill effluent (POME) in an effort to address the poor removal efficiencies in terms of the chemical and biological oxygen demand (COD and BOD), total suspended solids (TSS) as well as oil and grease (O&G) content in treated POME along with many environmental issues associated with the existing POME treatment process. The elimination of the cooling ponds and the insertion of a dewatering device in the treatment process were recommended. The dewatering device should enhance the anaerobic digestion process by conferring a means of control on the digesters' load. The objective of this study is to identify the optimum solid: liquid ratio (total solids (TS) content) that would generate the maximum amount of biogas with better methane purity consistently throughout the anaerobic digestion of POME, all while improving the treated effluent quality. It was established that a 40S:60L (4.02% TS) was the best performing solid loading in terms of biogas production and methane yield as well as COD, BOD, TSS, and O&G removal efficiencies. Meanwhile, at higher solid loadings, the biogas production is inhibited due to poor transport and mass transfer. It is also speculated that sulfate-reducing bacteria tended to inhibit the biogas production based on the significantly elevated H2S concentration recorded for the 75S:25L and the 100S loadings.
  15. Musculoskeletal Gait Simulation to Investigate Biomechanical Effect of Knee Brace
    Yap YT, Gouwanda D, Gopalai AA, Chong YZ
    J Biomech Eng, 2023 Feb 01;145(2).
    PMID: 36082472 DOI: 10.1115/1.4055564
    Musculoskeletal modeling and simulation have been an emerging trend in human gait analysis. It allows the user to isolate certain biomechanical conditions and elucidate the dynamics of joints and muscles. This study used an open-source musculoskeletal modeling and simulation tool, opensim to investigate the biomechanical effect of knee brace. It collected gait data from thirty-eight participants and examined the gait spatio-temporal parameters, joint angles, and joint moments. Static optimization was performed to estimate the lower extremity muscle force. Statistical analysis was conducted to identify the difference between normal and braced gaits. The results demonstrated the feasibility of this method to investigate the interaction and coordination of lower extremity joints and muscles. The knee brace constrained the range of the motion of the knee during walking. It also changed the walking speed, step length, and stance-to-swing ratio. Several significant differences were found in the joint moments and muscle forces of the rectus femoris, gastrocnemius, soleus and tibialis anterior. Musculoskeletal modeling and simulation tool offers a less invasive and practical alternative to analyze human motion. It also provides a means to investigate the effect of medical devices such as knee brace, which can be potentially beneficial for the future design and development of such devices and for the derivation of future rehabilitation treatment to improve patient's gait.
  16. Fulltext The effects of mechanical noise bandwidth on balance across flat and compliant surfaces
    Khor JZS, Gopalai AA, Lan BL, Gouwanda D, Ahmad SA
    Sci Rep, 2021 06 10;11(1):12276.
    PMID: 34112840 DOI: 10.1038/s41598-021-91422-w
    Although the application of sub-sensory mechanical noise to the soles of the feet has been shown to enhance balance, there has been no study on how the bandwidth of the noise affects balance. Here, we report a single-blind randomized controlled study on the effects of a narrow and wide bandwidth mechanical noise on healthy young subjects' sway during quiet standing on firm and compliant surfaces. For the firm surface, there was no improvement in balance for both bandwidths-this may be because the young subjects could already balance near-optimally or optimally on the surface by themselves. For the compliant surface, balance improved with the introduction of wide but not narrow bandwidth noise, and balance is improved for wide compared to narrow bandwidth noise. This could be explained using a simple model, which suggests that adding noise to a sub-threshold pressure stimulus results in markedly different frequency of nerve impulse transmitted to the brain for the narrow and wide bandwidth noise-the frequency is negligible for the former but significantly higher for the latter. Our results suggest that if a person's standing balance is not optimal (for example, due to aging), it could be improved by applying a wide bandwidth noise to the feet.
  17. Fulltext Quantification of muscles activations and joints range of motions during oil palm fresh fruit bunch harvesting and loose fruit collection
    Teo YX, Chan YS, Gouwanda D, Gopalai AA, Nurzaman SG, Thannirmalai S
    Sci Rep, 2021 07 22;11(1):15020.
    PMID: 34294775 DOI: 10.1038/s41598-021-94268-4
    Although global demand for palm oil has been increasing, most activities in the oil palm plantations still rely heavily on manual labour, which includes fresh fruit bunch (FFB) harvesting and loose fruit (LF) collection. As a result, harvesters and/or collectors face ergonomic risks resulting in musculoskeletal disorder (MSD) due to awkward, extreme and repetitive posture during their daily work routines. Traditionally, indirect approaches were adopted to assess these risks using a survey or manual visual observations. In this study, a direct measurement approach was performed using Inertial Measurement Units, and surface Electromyography sensors. The instruments were attached to different body parts of the plantation workers to quantify their muscle activities and assess the ergonomics risks during FFB harvesting and LF collection. The results revealed that the workers generally displayed poor and discomfort posture in both activities. Biceps, multifidus and longissimus muscles were found to be heavily used during FFB harvesting. Longissimus, iliocostalis, and multifidus muscles were the most used muscles during LF collection. These findings can be beneficial in the design of various assistive tools which could improve workers' posture, reduce the risk of injury and MSD, and potentially improve their overall productivity and quality of life.
  18. Fulltext Sit-to-walk strategy classification in healthy adults using hip and knee joint angles at gait initiation
    Perera CK, Gopalai AA, Gouwanda D, Ahmad SA, Salim MSB
    Sci Rep, 2023 Oct 03;13(1):16640.
    PMID: 37789077 DOI: 10.1038/s41598-023-43148-0
    Forward continuation, balance, and sit-to-stand-and-walk (STSW) are three common movement strategies during sit-to-walk (STW) executions. Literature identifies these strategies through biomechanical parameters using gold standard laboratory equipment, which is expensive, bulky, and requires significant post-processing. STW strategy becomes apparent at gait-initiation (GI) and the hip/knee are primary contributors in STW, therefore, this study proposes to use the hip/knee joint angles at GI as an alternate method of strategy classification. To achieve this, K-means clustering was implemented using three clusters corresponding to the three STW strategies; and two feature sets corresponding to the hip/knee angles (derived from motion capture data); from an open access online database (age: 21-80 years; n = 10). The results identified forward continuation with the lowest hip/knee extension, followed by balance and then STSW, at GI. Using this classification, strategy biomechanics were investigated by deriving the established biomechanical quantities from literature. The biomechanical parameters that significantly varied between strategies (P 
  19. Fulltext Simulation of passive exotendon assistive device for agricultural harvesting task
    Chan YS, Teo YX, Gouwanda D, Nurzaman SG, Gopalai AA
    Phys Eng Sci Med, 2023 Dec;46(4):1375-1386.
    PMID: 37493930 DOI: 10.1007/s13246-023-01305-9
    This study proposes and investigates the feasibility of the passive assistive device to assist agricultural harvesting task and reduce the Musculoskeletal Disorder (MSD) risk of harvesters using computational musculoskeletal modelling and simulations. Several passive assistive devices comprised of elastic exotendon, which acts in parallel with different back muscles (rectus abdominis, longissimus, and iliocostalis), were designed and modelled. These passive assistive devices were integrated individually into the musculoskeletal model to provide passive support for the harvesting task. The muscle activation, muscle force, and joint moment were computed with biomechanical simulations for unassisted and assisted motions. The simulation results demonstrated that passive assistive devices reduced muscle activation, muscle force, and joint moment, particularly when the devices were attached to the iliocostalis and rectus abdominis. It was also discovered that assisting the longissimus muscle can alleviate the workload by distributing a portion of it to the rectus abdominis. The findings in this study support the feasibility of adopting passive assistive devices to reduce the MSD risk of the harvesters during agricultural harvesting. These findings can provide valuable insights to the engineers and designers of physical assistive devices on which muscle(s) to assist during agricultural harvesting.
  20. Fulltext Heat literacy and adaptation among semi-rural community in Malaysia
    Nellis S, Thu M, Ismail MR, Barteit S, Gouwanda D, Bärnighausen T, et al.
    Lancet Planet Health, 2024 Apr;8 Suppl 1:S8.
    PMID: 38632923 DOI: 10.1016/S2542-5196(24)00073-1
    BACKGROUND: Heatwaves present health risks globally but there is limited evidence on how temperature perceptions affect activities. This study aimed to examine community perceptions of heat as a potential health hazard and ascertain the current heat protection measures of the residents of the South East Asia Community Observatory (SEACO) in Malaysia.

    METHODS: In this longitudinal study, we randomly selected community members aged between 18 and 70 years who resided in Segamat district of Johor state, Malaysia. Over 21 days, we conducted three home visits to each participant. During each visit, participants completed a questionnaire consisting of Likert scale, multiple choice, and free text questions and we collected quantitative and qualitative data. These inquiries assessed the participants' perception of heat as health threat, whether or not they took heat preventive measures, and the specific protective measures they routinely employed. Descriptive data analyses were conducted and patterns of protective measures were investigated.

    FINDINGS: Between March 29 and July 31, 2023, 120 participants (72 women and 48 men) completed 360 questionnaires over three home visits. Initially, 58% participants recognised heat hazards to daily activities, decreasing to 42% and 35% by visits 2 and 3. Participants took preventive measures throughout the day, which was consistently high between 1200 h and 1400 h, with 77% of participants taking preventive measures on visit 1, 82% on visit 2, and 82% on visit 3. Use of preventive measures was also high between 1400 h and 1730 h, with 77% using preventive measure on visit 1, 81% on visit 2, and 79% on visit 3. The most common protective measures were fans (used by 68-88% of participants), drinking more water (70-78% of participants), and resting (44-72% of participants). The least common were relocating to cooler places, removing clothes, and using wet towels (0-2·5%). Despite high temperatures, perceptions of heat risks decreased over time. Participants took basic protections, especially at midday, but improved literacy and affordable cooling options are needed to protect vulnerable rural populations.

    INTERPRETATION: Our findings underline the need to improve heat literacy and adaptation as only half of the population assessed perceived heat as a potential health hazard and practised limited heat protective measures. Addressing climate change and health necessitates fundamental behavioural changes on the part of individuals and communities, to protect them against the adverse effects of heat.

    FUNDING: Monash University Malaysia and Heidelberg Institute of Global Health, Heidelberg University.

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