Do professionalism, leadership, and resilience combine for professional identity formation? Evidence from confirmatory factor analysis.

Introduction: Professional identity formation (PIF) is an ongoing, self-reflective process involving habits of thinking, feeling and acting like a physician and is an integral component of medical education. While qualitative work has suggested that PIF is informed by professionalism, resilience, and leadership, there is a dearth of quantitative work in this area. Multiple methods build rigor and the present study aimed to quantitatively assess the relative psychometric contributions of professionalism, resilience, and leadership constructs to informing PIF, using a latent factor analysis approach. Methods: We analyzed data from the PILLAR study, which is an online cross-sectional assessment of a pre-clinical cohort of medical students in the RCSI University of Medicine and Health Sciences, Dublin, using established and validated quantitative measures in each area of interest: PIF, professionalism, leadership and resilience. A total of 76 items, combining four validated scales, along with a selection of demographic questions, were used. The hypothesis that PIF is informed by, and correlates with, professionalism, resilience and leadership was examined by conducting a confirmatory factor analysis of a proposed three-factor higher-order model. Model estimation used Maximum Likelihood Method (MLM) with geomin rotation. The hypothesized (measurement) model was examined against an alternative (saturated) model, as well as a three-factor model. Results: Latent variable analysis from 1,311 students demonstrated that a three-factor higher-order model best fit the data; suggesting PIF is informed by professionalism, resilience, and leadership, and that these constructs are statistically distinct and account for differential aspects of PIF. This higher-order model of PIF outperformed both the saturated model and the three-factor model. The analysis of which component may be the most or least influential was inconclusive, and the overall model was not influenced by year of training. Discussion: Building upon existing conceptual contentions, our study is the first to quantitatively support the contribution of professionalism, resilience, and leadership to the development of professional identity, and to delineate the inter-relationships between PIF and these constructs. This information can be used by medical educators when designing curricula and educational strategies intended to enhance PIF. Future work should seek to assess the influence of these constructs longitudinally.

"When we were allowed to go back the freedom, the vista, the delight It was just magic": Disruption and adaptation among people ageing-in-place in Ireland during COVID-19.

COVID-19 person-place disruptions may dislocate enabling resources and affect the short- and long-term wellbeing of individuals ageing-in-place. However, outcomes may vary according to individuals' personal experiences and capabilities to put in place adaptive strategies. Underpinned by the Conservation of Resources (COR) Theory, this study aimed to identify shifts in older people's relationships to place during the pandemic and to gain a deeper understanding of their adaptive strategies. We analysed data collected between April-May and October-November 2021 from the [Details omitted for double-blind reviewing], a qualitative investigation of community-dwellers based in Ireland and aged 65 years or over. Participants (n = 57) completed written submissions, narrative interviews and/or go-along interviews detailing their experiences during the pandemic. The mean age of participants was 74.9 years, 53% were female, 46% lived alone, and 86% lived in areas with high urban influence. Our framework analysis identified three thematic categories: 1) Characterization of individuals experiencing flow or disruption of place-resources; 2) Effects of place-resource disruptions; and 3) Adaptive strategies to manage disruption. Findings suggest that during the pandemic individuals ageing-in-place experienced trajectories of resistant flow, resilient flow, chronic disruption, or delayed disruption of place-resources, Participants' health and wellbeing was influenced in diverse ways by the threat of- and actual loss of material, social and affective resources. To compensate for disruptions, participants developed multiple adaptive strategies that highlight older people's potential to transform themselves, others, and their environments during times of adversity. These findings showcase the processes by which health enabling places may be maintained and generated, and present areas of opportunity for public health interventions seeking to support ageing populations during public health emergencies and beyond.

Varicose Vein Education and Informed coNsent (VVEIN) Study: A Randomized Controlled Pilot Feasibility Study.

BACKGROUND: The primary aim of this study was to assess the feasibility of introducing a digital health education tool (dHET) for varicose vein surgery. METHODS: This randomized, feasibility study allocated 40 patients, into dHET (n = 20) or standard consent (SC) (n = 20) groups. Primary outcomes were related to feasibility. Secondary outcomes were knowledge recall, anxiety, and satisfaction. RESULTS: Recruitment and retention rates were 100% and 97.5%, respectively. Acceptability was also rated high, confirming feasibility. There was also no evidence of a difference between groups for early knowledge recall (14 [12-17] vs. 14 [11-16]; P = 0.72) or delayed (at 2 weeks) knowledge recall (15 [13-16] vs. 15 [13-16]; P = 0.89). The dHET module took significantly longer to complete compared to SC (13 min [12-18] vs. 9 min [8-12]; P < 0.01). However, the control group asked significantly more questions about the intended procedure (P = 0.03). There was no evidence of a difference between groups for patient anxiety or satisfaction. CONCLUSIONS: This trial shows that the addition of a dHET is feasible and noninferior to SC. Digital consent provides a unique opportunity to promote patient education and autonomy for better shared decision making. It also offers better documentation of the consent process.

Feasibility of Using an Artificial Intelligence-based Telephone Application for Dietary Assessment and Nudging to Improve the Quality of Food Choices of Female Adolescents in Vietnam: Evidence from a Randomized Pilot Study.

Background: Adolescent nutrition has faced a policy neglect, partly owing to the gaps in dietary intake data for this age group. The Food Recognition Assistance and Nudging Insights (FRANI) is a smartphone application validated for dietary assessment and to influence users toward healthy food choices. Objectives: This study aimed to assess the feasibility (adherence, acceptability, and usability) of FRANI and its effects on food choices and diet quality in female adolescents in Vietnam. Methods: Adolescents (N = 36) were randomly selected from a public school and allocated into 2 groups. The control group received smartphones with a version of FRANI limited to dietary assessment, whereas the intervention received smartphones with gamified FRANI. After the first 4 wk, both groups used gamified FRANI for further 2 wk. The primary outcome was the feasibility of using FRANI as measured by adherence (the proportion of completed food records), acceptability and usability (the proportion of participants who considered FRANI acceptable and usable according to answers of a Likert questionnaire). Secondary outcomes included the percentage of meals recorded, the Minimum Dietary Diversity for Women (MDDW) and the Eat-Lancet Diet Score (ELDS). Dietary diversity is important for dietary quality, and sustainable healthy diets are important to reduce carbon emissions. Poisson regression models were used to estimate the effect of gamified FRANI on the MDDW and ELDS. Results: Adherence to the application was 82% and the percentage of meals recorded was 97%. Acceptability and usability were 97%. MDDW in the intervention group was 1.07 points (95% CI: 0.98, 1.18; P = 0.13) greater than that in the control (constant = 4.68); however, the difference was not statistically significant. Moreover, ELDS in the intervention was 1.09 (95% CI: 1.01, 1.18; P = 0.03) points greater than in the control (constant = 3.67). Conclusions: FRANI was feasible and may be effective to influence users toward healthy food choices. Research is needed for FRANI in different contexts and at scale.The trial was registered at the International Standard Randomized Controlled Trial Number as ISRCTN 10681553.

Validating a theory of planned behavior questionnaire for assessing changes in professional behaviors of medical students.

Introduction: Teaching professionalism is a fundamental aspect of medical undergraduate education, delivering important domains of professional attitudes, ethics, and behaviors. The effects of educational interventions can be assessed by measuring the change in such domains, but validated assessment tools for these professionalism domains are lacking. In this study, we constructed and conducted expert validation of a modified theory of planned behavior (TPB) questionnaire to assess changes in professional behaviors (PBs) in medical students. Methods: To validate that, we modified an existing TPB questionnaire, and an 18-item questionnaire was subjected to expert panel evaluation using the content validation method. The clarity and relevance of items were assessed using a four-point rating scale (i.e., 1 = not relevant to 4 = highly relevant). Ratings of experts and free-text comments were analyzed. Quantitative evaluation of relevance and clarity was undertaken through analyses of the Item-level Content Validity Index (I-CVI) and Scale-level Content Validity Index (S-CVI). A qualitative assessment of the comments of experts was conducted to refine items, any disagreements were discussed, and a consensus decision was developed among authors for item changes. Results: Quantitative evaluation of the Item-level Content Validity Index (I-CVI) scored 0.9-1 for relevance and 0.7-1 for clarity. Qualitative evaluation resulted in (i) changes to the wording of items (e.g., choices such as "worthless/worthwhile" were replaced with "not important/important"); and (ii) suggestion of the addition of social media in the construct of subjective norms. Discussion: The proposed tool exhibits content validity and can assess TPB constructs in professionalism education. This study of content validity may help to ensure the modified TPB questionnaire accurately measures the TPB constructs, ensuring its effectiveness in accurately measuring the TPB constructs for PB in diversified educational medical institutions.

Professional Identity Formation, Professionalism, Leadership and Resilience (PILLAR) in Medical Students: Methodology and Early Results.

Objectives: The fundamental role of medical education is the transformation of students to doctors, through a process of education and professional identity formation (PIF), which can be informed by several educational, behavioural and emotional factors. PIF has been deemed to be of equal importance to the acquisition of clinical knowledge and skills and includes constructs such as professionalism, leadership and resilience. We aimed to assess professional identity formation, professionalism, leadership and resilience (PILLAR) in the junior years of medical school in the 2020/2021 academic year and illustrate the potential role of quantitative assessment to demonstrate progression in these areas. In this research, we provide the methods and baseline results for the PILLAR study. Methods: We implemented a compulsory assessment in pre-clinical years of graduate entry and direct entry medicine at the Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland. Validated scales were used to assess students' PILLAR. Descriptive and univariable statistical techniques were used to compare student scores between respective years. Results: A total of 1311 students (92% response rate) provided their consent for research. For the psychometric scales, there were no evident trends among the years on these assessment measures. Results indicated significant differences in all measures, however, these did not correspond to ascending years of seniority. Conclusion: The PILLAR methodology provides important information on the challenges of quantitatively assessing medical students in the four key areas of PIF, professionalism, leadership, and resilience. Our cross-sectional results point to cohort effects, without the expected progression per year in the cross-sectional data, or suggest that the chosen quantitative measures may be problematic for these constructs in pre-clinical students. Therefore, while we believe that PILLAR has potential as a progress test for these constructs, this will only truly be elucidated by repeated measures of each cohort over time.

The effects of advanced factor analysis approaches on outcomes in randomised trials for depression: protocol for secondary analysis of individual participant data.

BACKGROUND: Modern psychometric methods make it possible to eliminate nonperforming items and reduce measurement error. Application of these methods to existing outcome measures can reduce variability in scores, and may increase treatment effect sizes in depression treatment trials. AIMS: We aim to determine whether using confirmatory factor analysis techniques can provide better estimates of the true effects of treatments, by conducting secondary analyses of individual patient data from randomised trials of antidepressant therapies. METHOD: We will access individual patient data from antidepressant treatment trials through Clinicalstudydatarequest.com and Vivli.org, specifically targeting studies that used the Hamilton Rating Scale for Depression (HRSD) as the outcome measure. Exploratory and confirmatory factor analytic approaches will be used to determine pre-treatment (baseline) and post-treatment models of depression, in terms of the number of factors and weighted scores of each item. Differences in the derived factor scores between baseline and outcome measurements will yield an effect size for factor-informed depression change. The difference between the factor-informed effect size and each original trial effect size, calculated with total HRSD-17 scores, will be determined, and the differences modelled with meta-analytic approaches. Risk differences for proportions of patients who achieved remission will also be evaluated. Furthermore, measurement invariance methods will be used to assess potential gender differences. CONCLUSIONS: Our approach will determine whether adopting advanced psychometric analyses can improve precision and better estimate effect sizes in antidepressant treatment trials. The proposed methods could have implications for future trials and other types of studies that use patient-reported outcome measures.

Validation of Mobile Artificial Intelligence Technology-Assisted Dietary Assessment Tool Against Weighed Records and 24-Hour Recall in Adolescent Females in Ghana.

BACKGROUND: Important gaps exist in the dietary intake of adolescents in low- and middle-income countries (LMICs), partly due to expensive assessment methods and inaccuracy in portion-size estimation. Dietary assessment tools leveraging mobile technologies exist but only a few have been validated in LMICs. OBJECTIVE: We validated Food Recognition Assistance and Nudging Insights (FRANI), a mobile artificial intelligence (AI) dietary assessment application in adolescent females aged 12-18 y (n = 36) in Ghana, against weighed records (WR), and multipass 24-hour recalls (24HR). METHODS: Dietary intake was assessed during 3 nonconsecutive days using FRANI, WRs, and 24HRs. Equivalence of nutrient intake was tested using mixed-effect models adjusted for repeated measures, by comparing ratios (FRANI/WR and 24HR/WR) with equivalence margins at 10%, 15%, and 20% error bounds. Agreement between methods was assessed using the concordance correlation coefficient (CCC). RESULTS: Equivalence for FRANI and WR was determined at the 10% bound for energy intake, 15% for 5 nutrients (iron, zinc, folate, niacin, and vitamin B6), and 20% for protein, calcium, riboflavin, and thiamine intakes. Comparisons between 24HR and WR estimated equivalence at the 20% bound for energy, carbohydrate, fiber, calcium, thiamine, and vitamin A intakes. The CCCs by nutrient between FRANI and WR ranged between 0.30 and 0.68, which was similar for CCC between 24HR and WR (ranging between 0.38 and 0.67). Comparisons of food consumption episodes from FRANI and WR found 31% omission and 16% intrusion errors. Omission and intrusion errors were lower when comparing 24HR with WR (21% and 13%, respectively). CONCLUSIONS: FRANI AI-assisted dietary assessment could accurately estimate nutrient intake in adolescent females compared with WR in urban Ghana. FRANI estimates were at least as accurate as those provided through 24HR. Further improvements in food recognition and portion estimation in FRANI could reduce errors and improve overall nutrient intake estimations.

Primary care-based models of care for osteoarthritis; a scoping review.

OBJECTIVE: To identify and describe the extent, nature, characteristics, and impact of primary care-based models of care (MoCs) for osteoarthritis (OA) that have been developed and/or evaluated. DESIGN: Six electronic databases were searched from 2010 to May 2022. Relevant data were extracted and collated for narrative synthesis. RESULTS: Sixty-three studies pertaining to 37 discrete MoCs from 13 countries were included, of which 23 (62%) could be classified as OA management programmes (OAMPs) comprising a self-management intervention to be delivered as a discrete package. Four models (11%) focussed on enhancing the initial consultation between a patient presenting with OA at the first point of contact into a local health system and the clinician. Emphasis was placed on educational training for general practitioners (GPs) and allied healthcare professionals delivering this initial consultation. The remaining 10 MoCs (27%) detailed integrated care pathways of onward referral to specialist secondary orthopaedic and rheumatology care within local healthcare systems. The majority (35/37; 95%) were developed in high-income countries and 32/37 (87%) targeted hip/and or knee OA. Frequently identified model components included GP-led care, referral to primary care services and multidisciplinary care. The models were predominantly 'one-size fits all' and lacked individualised care approaches. A minority of MoCs, 5/37 (14%) were developed using underlying frameworks, three (8%) of which incorporated behaviour change theories, while 13/37 (35%) incorporated provider training. Thirty-four of the 37 models (92%) were evaluated. Outcome domains most frequently reported included clinical outcomes, followed by system- and provider-level outcomes. While there was evidence of improved quality of OA care associated with the models, effects on clinical outcomes were mixed. CONCLUSION: There are emerging efforts internationally to develop evidence-based models focused on non-surgical primary care OA management. Notwithstanding variations in healthcare systems and resources, future research should focus on model development alignment with implementation science frameworks and theories, key stakeholder involvement including patient and public representation, provision of training and education for providers, treatment individualisation, integration and coordination of services across the care continuum and incorporation of behaviour change strategies to foster long-term adherence and self-management.

Varicose Vein Education and Informed coNsent (VVEIN) study: a randomised controlled pilot feasibility study.

INTRODUCTION: Doctors have a legal requirement and duty of care to ensure patients are enabled to make an informed decision about their treatment, including discussion of the benefits, risks and alternatives to a procedure. A patient-centred approach to consent has been firmly established in Ireland, and fundamental to this is the ability to engage in a dialogue that offers comprehensible information to patients. Telemedicine has revolutionised the way we can deliver care to patients in the modern era of computers, tablets, and smartphones, and its use has been rapidly expanded. Novel digital strategies to improve the informed consent process for surgical procedures have been increasingly under investigation over the last 10-15 years and may offer a low cost, accessible and tailored solution to consent for surgical interventions. Within vascular surgery, superficial venous interventions have been associated with a high number medicolegal claims and also represents an area within the specialty with rapidly evolving technology and techniques. The ability to communicate comprehensible information to patients has never been greater. Thus, the author's aim is to explore whether it is feasible and acceptable to deliver a digital health education intervention to patients undergoing endovenous thermal ablation (EVTA) to supplement the consent process. METHODS: This is a prospective, single centre, randomised controlled, feasibility trial recruiting patients with chronic venous disease deemed suitable to undergo EVTA. Patients will be randomised to receive either standard consent (SC) or a newly developed digital health education tool (dHET). The primary outcome is feasibility; assessing the recruitment and retention rate of participants and assessing acceptability of the intervention. Secondary outcomes include knowledge retention, anxiety and satisfaction. This feasibility trial is designed to recruit 40 patients, which will allow for a moderate dropout rate. This pilot study will inform the authors of the appropriateness of an adequately powered multicentre trial. DISCUSSION: To examine the role of a digital consent solution for EVTA. This may improve and standardise the consent dialogue with patients and may have the potential to reduce claims related to poor consent processes and disclosure of risks. ETHICAL COMMITTEE REFERENCE: Ethical approval has been sought and received from both the Bon Secours Hospital and RCSI (202109017), on 14 May 2021 and 10 October 2021, respectively. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05261412 , registered on 1 March 2022.

Is the public ready for a tobacco-free Ireland? A national survey of public knowledge and attitudes to tobacco endgame in Ireland.

AIM: Ireland will not meet the tobacco endgame goal set in its 2013 Tobacco-Free Ireland (TFI) policy of reducing smoking prevalence to less than 5% by 2025. Public opinion on tobacco endgame, a key lever to realise this goal, is uncharted in Ireland. This study aimed to measure public knowledge and attitudes to tobacco endgame. METHODS: A telephone-administered cross-sectional survey of 1000 randomly dialled members of the general public was conducted in 2022. Prevalence of awareness, perceived achievability and support for the TFI goal and tobacco endgame measures was calculated and compared across tobacco product use status. Logistic regression identified factors independently associated with goal support. FINDINGS: Although TFI goal awareness was low (34.0%), support was high (74.6%), although most (60.2%) believed it achievable beyond 2025. Product-focused measures were popular while support for supply-focused measures was mixed: for example, 86.1% supported nicotine content reduction while 40.3% supported user licencing. Phasing out tobacco sales was highly supported (82.8%); for most, this was contingent on support for currently addicted users. TFI goal support was independently associated with female sex (adjusted odds ratio (aOR) 1.47, 95% CI 1.05 to 2.07), higher education (aOR 1.80, 95% CI 1.21 to 2.66) and non-tobacco product use (aOR 2.67, 95% CI 1.66 to 4.30). CONCLUSIONS: Despite low awareness, tobacco endgame support is strong in Ireland. Public appetite for radically reducing tobacco product appeal and availability combined with public views on endgame achievability subject to extended timelines should be used to re-invigorate tobacco endgame discussion and planning in countries at risk of failing to meet declared targets.

Socio-ecological determinants of older people's mental health and well-being during COVID-19: A qualitative analysis within the Irish context.

Background: Evidence indicates that older people with biological and social vulnerabilities are at high risk of short- and long-term consequences related to the COVID-19 pandemic. However, studies have also highlighted that the crisis may present opportunities for personal growth if older individuals are met with appropriate resources and support. Objective: The aim of this study was to explore the perceptions of older people regarding how individual, social, and environmental factors have supported or hindered their well-being and health during COVID-19. Methods: We analyzed data collected between April-May and October-November 2021 from the Well-being, Interventions and Support during Epidemics (WISE) study, a qualitative investigation of community-dwellers based in Ireland and aged 65 years or over. Participants (n = 57) completed written submissions, narrative interviews and/or go-along interviews detailing their experiences during the pandemic. Framework analysis was carried out in NVivo 12 to identify determinants, linkages, and explanations within Bronfenbrenner's socio-ecological model. Results: The mean age of participants was 74.9 years, 53% were female, 45% lived alone, and 86% lived in areas with high urban influence. Our findings highlight the heterogeneous effect of COVID-19 across diverse older individuals who held distinct concerns, capabilities, and roles in society before and during the pandemic. Multi-scalar contextual characteristics such as individual's living arrangements, neighborhood social and built environments, as well as social expectations about aging and help seeking, had an influential role in participants' well-being and available supports. We identified mixed views regarding public health restrictions, but a consensus emerged questioning the suitability of one-size-fits-all approaches based on chronological age. Conclusions: Our results suggest that some negative pandemic consequences could have been avoided by increasing collaboration with older people and with the provision of clearer communications. The interdependencies identified between individual characteristics and socio-ecological factors that influenced participants' availability of supports and development of adaptive strategies represent areas of opportunity for the development of age-friendly interventions during and beyond public health crises.

Public attitudes to implementing financial incentives in stopsmoking services in Ireland.

INTRODUCTION: Financial incentives improve stop-smoking service outcomes. Views on acceptability can influence implementation success. To inform implementation planning in Ireland, public attitudes on financial incentives to stop smoking were measured. METHODS: A cross-sectional telephone survey was administered to 1000 people in Ireland aged ≥15 years in 2022, sampled through random digit dialing. The questionnaire included items on support for financial incentives under different conditions. Prevalence of support was calculated with 95% Confidence Intervals (CIs) and multiple logistic regression identified associated factors using adjusted odds ratios (AORs) with 95% CIs. RESULTS: Almost half (47.0%, 95% CI: 43.9-50.1) of the participants supported at least one type of financial incentive to stop smoking, with support more prevalent for shopping vouchers (43.3%, 95% CI: 40.3-46.5) than cash payments (32.1%, 95% CI: 29.2-35.0). Support was similar for universal and income-restricted schemes. Of those who supported financial incentives, the majority (60.6%) believed the maximum amount given on proof of stopping smoking should be under €250 (median=100, range: 1-7000). Compared to their counterparts, those of lower education level (AOR=1.49; 95% CI: 1.10-2.03, p=0.010) and tobacco/e-cigarette users (AOR=1.43; 95% CI: 1.02-2.03, p=0.041) were significantly more likely to support either financial incentive type, as were younger people. CONCLUSIONS: While views on financial incentives to stop smoking in Ireland were mixed, the intervention is more acceptable in groups experiencing the heaviest burden of smoking-related harm and most capacity to benefit. Engagement and communication must be integral to planning for successful implementation to improve stop-smoking service outcomes.

A modified Delphi process to form an expert consensus in Ireland on the essential information to be included in shared decision making for varicose vein surgery.

OBJECTIVE: To reach consensus on a core set of essential information for inclusion in the informed consent process to standardize consent for VV surgery. METHODS: Using a modified electronic Delphi (e-Delphi) method, a panel of experts in Ireland, were asked to rate statements of essential information to include in the informed consent process with patients. Statements were rated using a 5-point Likert scale. The definition of consensus was declared at 70% agreement by the panel. RESULTS: Twenty-three panel members accepted the invitation to participate across three e-Delphi rounds. Consensus was reached on 33/42 statements, covering general and procedural information and the risks, benefits and alternatives of varicose veins (VV) surgery. Several statements remained equivocal, having not met consensus by the panel. CONCLUSION: Considerable consensus was reached within the panel of experts but some gaps in available research were also highlighted. This consensus may provide the framework to aid physicians to deliver a standardized discussion of the key elements of consent and shared decision making with patients.

Integrated care for older multimorbid heart failure patients: protocol for the ESCAPE randomized trial and cohort study.

ESCAPE: Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients. THERAPEUTIC AREA: Healthcare interventions for the management of older patients with multiple morbidities. AIMS: Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients. HYPOTHESIS: A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months. METHODS: Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan-customized to the patients' individual needs and preferences-into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months. CONCLUSIONS: If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond.

Digital technology in informed consent for surgery: systematic review.

BACKGROUND: Informed consent is an ethical and legal requirement in healthcare and supports patient autonomy to make informed choices about their own care. This review explores the impact of digital technology for informed consent in surgery. METHODS: A systematic search of EBSCOhost (MEDLINE/CINAHL), Embase, Cochrane Central Register of Controlled Trials and Web of Science was performed in November 2021. All RCTs comparing outcomes of both digital and non-digital (standard) consent in surgery were included. Each included study underwent an evaluation of methodological quality using the Cochrane risk of bias (2.0) tool. Outcomes assessed included comprehension, level of satisfaction and anxiety, and feasibility of digital interventions in practice. RESULTS: A total of 40 studies, across 13 countries and 15 surgical specialties were included in this analysis. Digital consent interventions used active patient participation and passive patient participation in 15 and 25 studies respectively. Digital consent had a positive effect on early comprehension in 21 of 30 (70 per cent) studies and delayed comprehension in 9 of 20 (45 per cent) studies. Only 16 of 38 (42 per cent) studies assessed all four elements of informed consent: general information, risks, benefits, and alternatives. Most studies showed no difference in satisfaction or anxiety. A minority of studies reported on feasibility of digital technology in practice. CONCLUSION: Digital technologies in informed consent for surgery were found to have a positive effect on early comprehension, without any negative effect on satisfaction or anxiety. It is recommended that future studies explore the feasibility of these applications for vulnerable patient groups and busy surgical practice.

Designing stroke services for the delivery of cognitive rehabilitation: A qualitative study with stroke rehabilitation professionals.

This qualitative study explored the potential to deliver cognitive rehabilitation for post-stroke cognitive impairment (PSCI), with a specific focus on barriers and facilitators to its delivery from the perspective of Irish stroke rehabilitation professionals. Sixteen semi-structured interviews were completed with healthcare professionals in both hospital and community settings. The sample comprised physiotherapists, occupational therapists, nurses, a stroke physician, a psychologist, a neuropsychologist, a speech and language therapist, a dietician, and a public health nurse. Interviews were audio-recorded and analysed in NVivo using inductive Thematic Analysis. Barriers and facilitators to the delivery of cognitive rehabilitation were identified and described under four key themes: (i) Cognitive screening; (ii) Cognitive rehabilitation: no one size fits all; (iii) Psychology: the lost dimension of stroke rehabilitation; and (iv) Joining the dots in the community. Staffing required to deliver cognitive rehabilitation for PSCI was highlighted as under-resourced in the Republic of Ireland. Inadequate resourcing of neuropsychology and stroke-related psychological services, in particular, has had negative implications for the delivery of cognitive rehabilitation. Stroke-specific cognitive rehabilitation expertise is virtually inaccessible in the community, highlighting an urgent need for investment in specialist rehabilitation teams to deliver cognitive rehabilitation in this setting.

Medical students, mental health and the role of resilience - A cross-sectional study.

BACKGROUND: Medical students have reported high prevalence of mental health difficulties and burnout. However, there are limited investigations examining the association between resilience and these difficulties. We investigated: (1) depression, anxiety, personal and professional burnout, and comorbidity; (2) demographic and education characteristics associated with these outcomes; (3) the association between resilience and these outcomes; and (4) whether these results were attributable to sampling bias. METHODS: Participants were n = 521 medical students from RCSI University of Medicine and Health Sciences. Outcomes were measured using validated scales. We report descriptive statistics, and risk factors for the difficulties were investigated using generalized linear modelling. RESULTS: One-in-three students reported incidence of depression or anxiety (24.5% co-morbidity). 8.9% of students reported all four difficulties. Difficulties were more common in female students and those in middle years of the programme. Resilience was negatively correlated with all outcomes and stable across demographic and educational variables. Weighting the data for sampling bias did not affect these results. CONCLUSIONS: Our results emphasise the high incidence of depression, anxiety, burnout, and comorbidity in students. We advocate for further investigation into the role of resilience as a modifiable factor that may ameliorate the incidence of depression, anxiety, and burnout in medical students.

Measuring adherence, acceptability and likability of an artificial-intelligence-based, gamified phone application to improve the quality of dietary choices of adolescents in Ghana and Vietnam: Protocol of a randomized controlled pilot test.

Unhealthy diets are a critical global concern while dietary measure methods are time consuming and expensive. There is limited evidence that phone-based interventions can improve nutrition data collection and dietary quality, especially for adolescents in developing countries. We developed an artificial-intelligence-based phone application called Food Recognition Assistance and Nudging Insights (FRANI) to address these problems. FRANI can recognize foods in images, track food consumption, display statistics and use gamified nudges to give positive feedback on healthy food choice. This study protocol describes the design of new pilot studies aimed at measuring the feasibility (acceptability, adherence, and usability) of FRANI and its effects on the quality of food choice of adolescents in Ghana and Vietnam. In each country, 36 adolescents (12-18 years) will be randomly allocated into two groups: The intervention group with the full version of FRANI and the control group with the functionality limited to image recognition and dietary assessment. Participants in both groups will have their food choices tracked for four weeks. The control groups will then switch to the full version of FRANI and both groups will be tracked for a further 2 weeks to assess acceptability, adherence, and usability. Analysis of outcomes will be by intent to treat and differences in outcomes between intervention and control group will use Poisson and odds ratio regression models, accounting for repeated measures at individual levels. If deemed feasible, acceptable and usable, FRANI will address gaps in the literature and advance the nutrition field by potentially improving the quality of food choices of adolescent girls in developing countries. This pilot study will also provide insights on the design of a large randomized controlled trial. The functioning and dissemination of FRANI can be an important step towards highly scalable nutrition data collection and healthier food choices for a population at risk of malnutrition. The study protocol and the methods and materials were approved by the Institutional Review Board (IRB) of the IFPRI on April 29th, 2020 (registration number #00007490), the Thai Nguyen National Hospital on April 14th, 2020 (protocol code 274/DDD-BVTWTN) and the University of Ghana on August 10th, 2020 (Federalwide Assurance FWA 00001824; NMIMR-IRB CPN 078-19/20). The study protocol was registered in the International Standard Randomized Controlled Trial Number (ISRCTN 10681553; https://doi.org/10.1186/ISRCTN10681553) on November 12, 2021.

Effective maNagement of depression among patients witH cANCEr (ENHANCE): a protocol for a hybrid systematic review and network meta-analysis of randomised controlled trials of interventions for depressive symptoms.

BACKGROUND: Depression is common among patients with cancer and is associated with lower treatment participation, lower satisfaction with care, poorer quality of life, greater symptom burden and higher healthcare costs. Various types of interventions (e.g. pharmacological, psychotherapy) are used for the treatment of depression. However, evidence for these among patients with cancer is limited. Furthermore, the relative effectiveness and acceptability of different approaches are unknown because a direct comparison between all available treatments has not been carried out. We will address this by conducting a network meta-analysis (NMA) of interventions for depression among people with cancer using a hybrid overview of reviews and systematic review methodology. METHODS: We will search for and extract data from systematic reviews of randomised controlled trials (RCTs) of depression interventions for patients with cancer from inception, before performing a supplemental search for more recent RCTs. We will include RCTs comparing pharmacological, psychotherapy, exercise, combination therapy, collaborative care or complementary and alternative medicine interventions with pill placebo, no treatment, waitlist, treatment as usual or minimal treatment control groups, or directly in head-to-head trials, among adults who currently have cancer or have a history of any cancer and elevated depressive symptoms (scores above a cut-off on validated scales or meeting diagnostic criteria). Our primary outcomes will be change in depressive symptoms (standardised mean difference) and intervention acceptability (% who withdrew). Our secondary outcomes will be 6-month change in depressive symptoms, health-related quality of life, adverse events and mortality. We will independently screen for eligibility, extract data and assess risk of bias using the RoB 2 tool. We will use frequentist random-effects multivariate NMA in Stata, rankograms and surface under the cumulative ranking curves to synthesise evidence and obtain a ranking of intervention groups. We will explore heterogeneity and inconsistency using local and global measures and evaluate the credibility of results using the Confidence in NEtwork Meta-Analysis (CINeMA) framework. DISCUSSION: Our findings will provide the best available evidence for managing depression among patients with cancer. Such information will help to inform clinical guidelines, evidence-based treatment decisions and future research by identifying gaps in the current literature. SYSTEMATIC REVIEW REGISTRATION: Submitted to PROSPERO (record number: 290145), awaiting registration.