Experiences of Indigenous Patients Receiving Dialysis: Systematic Review of Qualitative Studies.

RATIONALE & OBJECTIVE: Indigenous People suffer a high burden of kidney disease. Those receiving maintenance dialysis have worse outcomes compared with similarly treated non-Indigenous patients. We characterized the experiences of Indigenous patients receiving dialysis in British-colonized countries to gain insights into which aspects of kidney care may benefit from improvement. STUDY DESIGN: A systematic review of published qualitative interview studies. SETTING & STUDY POPULATIONS: Indigenous Peoples aged 18 years and over, receiving hemodialysis or peritoneal dialysis in British-colonized countries. SELECTION CRITERIA FOR STUDIES: Search terms for Indigenous Peoples, dialysis, and qualitative research were entered into Medline, Embase, PsycINFO, and CINAHL and searched from inception to January 5, 2023. DATA EXTRACTION: Characteristics of each study were extracted into Microsoft Excel for quality assessment. ANALYTICAL APPROACH: Data were analyzed using thematic synthesis. RESULTS: The analysis included 28 studies involving 471 participants from Australia, New Zealand, Canada, and the United States. We identified four themes: centrality of family and culture (continuing dialysis for family, gaining autonomy through shared involvement, balancing primary responsibility to care for family); marginalization due to structural and social inequities (falling through gaps in primary care intensifying shock, discriminated against and judged by specialists, alienated and fearful of hospitals, overwhelmed by travel, financial and regimental burdens); vulnerability in accessing health care (need for culturally responsive care, lack of language interpreters, without agency in decision-making, comorbidities compounding complexity of self-management); and distress from separation from community (disenfranchisement and sorrow when away for dialysis, inability to perpetuate cultural continuity, seeking a kidney transplant). LIMITATIONS: We only included articles published in English. CONCLUSIONS: Indigenous patients receiving dialysis experience inequities in health care that compound existing accessibility issues caused by colonization. Improving the accessibility and cultural responsiveness of dialysis and kidney transplant services in collaboration with Indigenous stakeholders holds promise to enhance the experience of Indigenous patients receiving dialysis. PLAIN-LANGUAGE SUMMARY: Worldwide Indigenous populations suffer a high incidence of chronic disease leading to lower life expectancy, particularly for kidney disease, an insidious condition requiring long-term dialysis treatment. By listening to Indigenous dialysis patients' stories, we hoped to understand how to improve their experience. We gathered 28 qualitative research studies from four countries reporting Indigenous adults' experiences of dialysis. They described lacking awareness of kidney disease, poor access to health services, systemic racism, inadequate cultural safety, and being dislocated from family, community, and culture. These findings indicate that respectful collaboration with Indigenous Peoples to craft and implement policy changes holds promise to improve prevention, integrate culturally responsive health care practices, and provide better access to local dialysis services and opportunities for kidney transplants.

The cultural safety of research reports on primary healthcare use by Indigenous Peoples: a systematic review.

INTRODUCTION: Community-driven research in primary healthcare (PHC) may reduce the chronic disease burden in Indigenous peoples. This systematic review assessed the cultural safety of reports of research on PHC use by Indigenous peoples from four countries with similar colonial histories. METHODS: Medline, CINAHL and Embase were all systematically searched from 1st January 2002 to 4th April 2023. Papers were included if they were original studies, published in English and included data (quantitative, qualitative and/or mixed methods) on primary healthcare use for chronic disease (chronic kidney disease, cardiovascular disease and/or diabetes mellitus) by Indigenous Peoples from Western colonial countries. Study screening and data extraction were undertaken independently by two authors, at least one of whom was Indigenous. The baseline characteristics of the papers were analyzed using descriptive statistics. Aspects of cultural safety of the research papers were assessed using two quality appraisal tools: the CONSIDER tool and the CREATE tool (subset analysis). This systematic review was conducted in accordance with the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool. RESULTS: We identified 35 papers from Australia, New Zealand, Canada, and the United States. Most papers were quantitative (n = 21) and included data on 42,438 people. Cultural safety across the included papers varied significantly with gaps in adequate reporting of research partnerships, provision of clear collective consent from participants and Indigenous research governance throughout the research process, particularly in dissemination. The majority of the papers (94%, 33/35) stated that research aims emerged from communities or empirical evidence. We also found that 71.4% (25/35) of papers reported of using strengths-based approaches by considering the impacts of colonization on reduced primary healthcare access. CONCLUSION: Research on Indigenous PHC use should adopt more culturally safe ways of providing care and producing research outputs which are relevant to community needs by privileging Indigenous voices throughout the research process including dissemination. Indigenous stakeholders should participate more formally and explicitly throughout the process to guide research practices, inclusive of Indigenous values and community needs.

A systematic review of migrant women's experiences of successful exclusive breastfeeding in high-income countries.

The World Health Organisation recommends exclusive breastfeeding for the first 6 months after childbirth. However, since breastfeeding is influenced by cultural practice, it differs between migrant mothers and nonmigrant mothers. This systematic review examined migrant mothers' perceptions and experiences impacting achievement of exclusive breastfeeding after immigration from a low-middle-income country to a high-income country. CINAHL, Medline, Scopus, Web of Science, PsycINFO and Emcare were searched for qualitative studies published from 2010 to August 2022. Eleven studies met inclusion criteria. We used meta-ethnographic synthesis to identify overarching themes, resulting in five themes: Migrant mothers (1) 'recognised the differences in breastfeeding practice between their home and host country'. During acculturation, mothers modify or stick to their breastfeeding practice in their host country based on their (2) 'breastfeeding knowledge' by combining their (3) 'original ethnic identity' with the (4) 'influence of family members, healthcare workers, infants, peers and workplace'. Although they face barriers, their (5) 'autonomy' motivated them to continue breastfeeding in a country where the breastfeeding norm differs from where they come from. Intrapersonal and interpersonal socio-ecological factors played a significant role in their breastfeeding practice in the host country. Findings indicate public health policy and practice to support breastfeeding for migrant women in high-income countries can be improved, particularly by emphasising the importance of providing affirmative, comprehensive and practical support from healthcare professionals.

A HIV diagnosis and treatment cascade for Aboriginal and Torres Strait Islander peoples of Australia.

Aboriginal and Torres Strait Islander (hereafter Aboriginal) people are a priority population for HIV care in Australia; however, no HIV cascade exists for this population. We developed annual HIV cascades for 2010-2017 specific to Aboriginal peoples. By 2017, an estimated 595 Aboriginal people were living with HIV (PLWH); however, 14% remained undiagnosed. Cascade steps below global targets were: PLWH aware of their diagnosis (86%), and retention in care (81% of those who had received any care in previous two years in a sentinel network of clinics). For people retained in care, treatment outcomes surpassed global targets (92% receiving treatment, 93% viral suppression). Increases occurred across all HIV cascade steps over time; however, the least improvement was for retention in care, while the greatest improvement was achieving viral suppression. The HIV cascade for Aboriginal peoples highlights both gaps and strengths in the Australian HIV care system, and importantly highlights where potential interventions may be required to achieve the global UNAIDS targets.

Cranberries for preventing urinary tract infections.

BACKGROUND: Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p-fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. OBJECTIVES: To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register Search Portal (ICTRP) and ClinicalTrials.gov. SELECTION CRITERIA: All randomised controlled trials (RCTs) or quasi-RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. DATA COLLECTION AND ANALYSIS: Two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: For this update 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty-six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty-seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty-five studies compared cranberry products with placebo or no specific treatment in six different groups of participants. Twenty-six of these 45 studies could be meta-analysed for the outcome of symptomatic, culture-verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture-verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, in low certainty evidence, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture-verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture-verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. AUTHORS' CONCLUSIONS: This update adds a further 26 studies taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture-verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women.

Cranberries for preventing urinary tract infections.

BACKGROUND: Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p-fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. OBJECTIVES: To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: All randomised controlled trials (RCTs) or quasi-RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. DATA COLLECTION AND ANALYSIS: At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty-six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty-seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty-five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty-six of these 45 studies could be meta-analysed for the outcome of symptomatic, culture-verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture-verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture-verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture-verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. AUTHORS' CONCLUSIONS: This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture-verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women.

Assessing the appropriateness of the management of otitis media in Australia: A population-based sample survey.

AIM: Acute otitis media (AOM) is the most common infectious disease for which antibiotics are prescribed; its management is costly and has the potential to increase the antimicrobial resistance of this infection. This study measured the levels of adherence to the clinical practice guidelines (CPGs) of AOM and otitis media with effusion (OME) management in Australian children. METHODS: We searched for national and international CPGs relating to AOM and OME in children and created 37 indicators for assessment. We reviewed medical records for adherence to these indicators in 120 locations, across one inpatient and three ambulatory health-care settings. Our review sample was obtained from three Australian states that contain 60% of the nation's children. RESULTS: We reviewed the records of 1063 children with one or more assessments of CPG adherence for otitis media. Of 22 indicators with sufficient data, estimated adherence ranged from 7.4 to 99.1%. Overuse of treatment, particularly overprescribing of antibiotics, was more common than underuse. A frequent lack of adherence with recommended care was observed for children aged between 1 and 2 years with AOM. Adherence varied by health-care setting, with emergency departments and inpatient settings more adherent to CPGs than general practices. CONCLUSIONS: Our assessment of a number of indicators in the common settings in which otitis media is treated found that guideline adherence varied widely between individual indicators. Internationally agreed standards for diagnosis and treatment, coupled with clinician education on the existence and content of CPGs and clinical decision support, are needed to improve the management of children presenting with AOM and OME.

Acceptability and use of HIV self-testing among young people in sub-Saharan Africa: a mixed methods systematic review.

BACKGROUND: Young people (YP) are disproportionately affected by the HIV pandemic in sub-Saharan Africa (SSA), but testing rates remain low despite global targets of testing 95% of people with HIV infection by 2030. HIV self-testing (HIVST) has been recently introduced to reach high-risk population groups such as these. Thus, synthesis of emerging evidence on the acceptability and use of HIVST among YP in SSA is needed so that comprehensive information can be generated to inform policy and practice. METHODS: We employed a mixed methods systematic review of quantitative and qualitative literature reporting on HIVST among YP involving any design and published in English by 31st of October 2023. The review synthesized quantitative evidence on acceptability and use of HIVST, and qualitative evidence on perspectives of YP about HIVST. We searched databases of published articles (e.g. MEDLINE, CINAHL) and Gray literature sources (e.g. Google, Google Scholar). The concepts for the search included self-testing, HIV/AIDS, and countries in SSA. Two authors independently screened, retrieved full-text, and assessed quality of the studies. RESULTS: A total of 4150 studies were retrieved and 32 studies were finally included in the review. Acceptability of HIVST computed from a single item asking YP on their preference or willingness or demand for HIVST was moderate (34-67%) to high (≥ 67%) among YP in SSA. Nine of the fourteen studies that reported on acceptability found high acceptability of HIVST. Use of HIVST ranged from 0.8 to 100% while in most studies the use rate was below 50%. Key barriers to HIVST use were coping with a positive test in the absence of counselling and support, physical discomfort, and cost of kits. Perceived enablers included perceptions of HIVST as promoting personal empowerment and autonomy; privacy and confidentiality; and convenience in location, time, and skill. CONCLUSIONS: HIVST was highly accepted but not well utilized among YP in SSA. YP showed diversified needs with mixed preferences for location, and modalities of service provision. Overall, the review identified heterogeneous evidence in terms of methods, population, outcome measures, and results. The review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO: ID = CRD42021278919).

A community-based study of intention to use HIV self-testing among young people in urban areas of southern Ethiopia.

In sub-Saharan Africa, young people are at high risk of HIV infection, representing nearly 4 out of 5 new infections. HIV self-testing (HIVST), a new and proactive testing scheme that involves self-collection of a specimen and interpretation of results, is deemed potentially helpful for increasing testing amongst population groups like young people who do not frequently use routine testing services. This study assessed young people's intention to use HIVST in urban areas of southern Ethiopia drawing on the Theory of Planned Behaviour. A community-based cross-sectional study was conducted with 634 participants aged 15-24 years from six town administrations of two zones in January to February 2023. The participation rate was 634/636 yielding 99.7%. The OraQuick HIVST kit was demonstrated to young people recruited in a door-to-door survey with a face-to-face interview using an electronic questionnaire in a mobile phone-based application. Intention to use HIVST was measured from a 6-point Likert scale with scores of agreements ranging from 1 to 6. Descriptive statistics and ordinal logistic regression analysis were done using STATA version 18. Most of the participants agreed that they would use HIVST if it was available (86.3% agreeing or strongly agreeing). Interestingly, young people who perceived themselves at some to high risk were 0.51 times less likely to be in the higher order of intention to use when HIVST is available to them than those who perceived themselves at no to low risk. Intention to use HIVST increased by a factor of 1.29, 1.84 and 2.35 for every one-unit increase on the mean favourable attitude, perceived behavioural control, and acceptability scores, respectively. The majority of young people intended to use HIVST. Young people's perceived behavioural control, and acceptability of HIVST affected their intention to use. Intention and subsequent use of HIVST can be enhanced through an understanding of the role of risk perception and positive attitude, confidence to perform and acceptance of the test. Implementation studies are required to examine the actual uptake of HIVST among young people.

Barriers Preventing Access by Men who have Sex with Men to HIV-related health services in Southeast Asia: A Scoping Review.

The objective of this scoping review was to identify and describe barriers experienced by men who have sex with men (MSM) when accessing HIV-related health care in Southeast Asia. A systematic search identified thirteen papers, which were full text reviewed and data extracted. An intersection of stigma and discrimination, fear and shame, cultural norms and societal expectations coalesce to influence the ability, either physically through lack of service provision or emotionally through personal restraint, of MSM to access HIV-related health services. Many of the factors continuing to drive the ongoing HIV epidemic across the Southeast Asia region have humanitarian origin - access to safe and non-discriminatory healthcare, education on sexual health, and not being persecuted for having a health condition. These must be addressed with an interdisciplinary response at local, government and regional level.

Community Engagement and Psychometric Methods in Aboriginal and Torres Strait Islander Patient-Reported Outcome Measures and Surveys-A Scoping Review and Critical Analysis.

(1) Background: In healthcare settings, patient-reported outcome measures (PROMs) and surveys are accepted, patient-centered measures that provide qualitative information on dimensions of health and wellbeing. The level of psychometric assessment and engagement with end users for their design can vary significantly. This scoping review describes the psychometric and community engagement processes for PROMs and surveys developed for Aboriginal and Torres Strait Islander communities. (2) Methods: The PRISMA ScR guidelines for scoping reviews were followed, aimed at those PROMs and surveys that underwent psychometric assessment. The Aboriginal and Torres Strait Islander Quality Appraisal Tool and a narrative synthesis approach were used. (3) Results: Of 1080 articles, 14 were eligible for review. Most articles focused on a validity assessment of PROMs and surveys, with reliability being less common. Face validity with Aboriginal and Torres Strait Islander communities was reported in most studies, with construct validity through exploratory factor analyses. Methodological design risks were identified in the majority of studies, notably the absence of explicit Indigenous knowledges. Variability existed in the development of PROMs and surveys for Aboriginal and Torres Strait Islander communities. (4) Conclusions: Improvement in inclusion of Indigenous knowledges and research approaches is needed to ensure relevance and appropriate PROM structures. We provide suggestions for research teams to assist in future design.

What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project).

STUDY DESIGN: Multiround wiki-based Delphi expert panel survey. OBJECTIVE: To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The provision of inappropri ate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recom mendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care." METHODS: Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators. RESULTS: From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators compris ing screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided. CONCLUSION: These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

COVID/HIV Co-Infection: A Syndemic Perspective on What to Ask and How to Answer.

The present commentary explored the intersecting nature of the COVID-19 and HIV pandemics to identify a shared research agenda using a syndemic approach. The research agenda posits the following questions. Questions around HIV infection, transmission, and diagnosis include: (i) molecular, genetic, clinical, and environmental assessments of COVID-19 in people living with HIV, (ii) alternative options for facility-based HIV testing services such as self- and home-based HIV testing, and (iii) COVID-19 related sexual violence and mental health on HIV transmission and early diagnosis. These and related questions could be assessed using Biopsychosocial and socio-ecological models. Questions around HIV treatment include: (i) the effect of COVID-19 on HIV treatment services, (ii) alternative options for facility-based treatment provision such as community-based antiretroviral therapy groups, and (iii) equitable distribution of treatment and vaccines for COVID-19, if successful. Bickman's logic model and the social determinants of health framework could guide these issues. The impact of stigma, the role of leveraging lessons on sustained intra-behavioral change, the role of medical mistrust and conspiracy beliefs, and the role of digital health on integrated management of HIV care and spectrum of care of COVID-19 need assessment using several frameworks including Goffman's stigma framework, Luhmann's Trust theory, and Gidden's theory of structuration. In conclusion, the potential research agenda of this commentary encompasses a variety of research fields and disciplinary areas-clinicians, laboratory scientists, public health practitioners, health economists, and psychologists-, and suggests several theoretical frameworks to guide examination of complex issues comprehensively.

Chronic disease prevention programs offered by Aboriginal Community Controlled Health Services in New South Wales, Australia.

OBJECTIVES: To identify and describe chronic disease prevention programs offered by Aboriginal Community Controlled Health Services (ACCHSs) in New South Wales (NSW), Australia. METHODS: ACCHSs were identified through the Aboriginal Health and Medical Research Council of NSW website. Chronic disease programs were identified from the Facebook page and website of each ACCHS. Characteristics, including regions, target population, condition, health behaviour, modality and program frequency were extracted and summarised. RESULTS: We identified 128 chronic disease programs across 32 ACCHSs. Of these, 87 (68%) programs were broad in their scope, 20 (16%) targeted youth, three (2%) targeted Elders, 16 (12%) were for females only and five (4%) were for males only. Interventions included physical activity (77, 60%), diet and nutrition (74, 58%), smoking (70, 55%), and the Aboriginal and Torres Strait Islander Health Check (44, 34%), with 93 programs (73%) of ongoing duration. CONCLUSIONS: Chronic disease prevention programs address chronic conditions by promoting physical activity, diet and nutrition, smoking cessation and health screening. Most target the general Aboriginal community, a few target specific groups based on gender and age, and more than one-quarter are time-limited. Implications for public health: Chronic disease programs that are co-produced with specific groups, based on age and gender, may be needed.

Parents Need More Support: A Qualitative Study of the Experiences of Australian Parents Who Are Waiting for Surgical Intervention for Their Children With Otitis Media.

OBJECTIVE: To explore the experiences, expectations, and motivations of parents/caregivers of children with otitis media who were booked to undergo tympanostomy tube insertion. METHOD: A cross-sectional cohort study was conducted using semistructured interviews with 39 parents. Interviews were conducted via telephone and analyzed for key themes. RESULTS: Three themes emerged that incorporated a range of subthemes: (1) the impact of the child's underlying condition on the family, (2) the cues and prompts that influenced parents to seek intervention, and (3) the parents' expectations of the health-care system. The child's otitis media disrupted the day-to-day functioning of the family and the child's well-being, but despite this, the families found ways to adapt and cope. Parents were influenced by their friends, family, and medical practitioners when making treatment decisions and had differing expectations of the health-care system. CONCLUSION: Parents need support during their child's illness to help with pressures placed on the family and also in making health-care decisions for their child. Clinicians should consider these issues when discussing treatment options with parents.

Sources of information used by patients prior to elective surgery: a scoping review.

OBJECTIVE: To describe the range and nature of available research regarding sources of information that patients access to inform their decisions about elective surgery. DESIGN: Scoping review. DATA SOURCES: Peer-reviewed studies published until February 2019 from the six scientific literature databases were searched and included in the study: Medline, PubMed, CINAHL, Academic Search Premier, EMBASE and SCOPUS. Web searches for grey literature were conducted in Google, South Australia Department of Health, Commonwealth Department of Health (Australia) and My Aged Care from the Department of Social Services (Australia). ELIGIBILITY CRITERIA: Studies with a focus on elective surgery information sources oriented to patients were eligible for inclusion. Only studies written in English were sought and no publication date or study restrictions were applied. DATA EXTRACTION AND SYNTHESIS: Included literature was described by National Health and Medical Council hierarchy of evidence, and data were extracted on country and year of publication, type of literature, who provided it and any information on end users. Information sources were categorised by type and how information was presented. RESULTS: A pool of 1039 articles was reduced to 26 after screening for duplicates and non-relevant studies. Face-to-face exchanges were the most likely source of information prior to elective surgery (59.3%), printed information (55.6%) followed by e-learning (51.9%) and multimedia (14.8%). The face-to-face category included information provided by the physician/general practitioners/specialists, and family and friends. Printed information included brochures and pamphlets, e-learning consisted of internet sites or videos and the use of multimedia included different mixed media format. CONCLUSION: There is considerable variability regarding the types of information patients use in their decision to undergo elective surgery. The most common source of health information (face-to-face interaction with medical personnel) raises the question that the information provided could be incomplete and/or biased, and dependent on what their health provider knew or chose to tell them.

Assessing the Quality of the Management of Tonsillitis among Australian Children: A Population-Based Sample Survey.

OBJECTIVE: The aims of this study were twofold: (1) to design and validate a set of clinical indicators of appropriate care for tonsillitis and (2) to measure the level of tonsillitis care that is in line with guideline recommendations in a sample of Australian children. STUDY DESIGN: A set of tonsillitis care indicators was developed from available national and international guidelines and validated in 4 stages. This research used the same design as the CareTrack Kids study, which was described in detail elsewhere. SETTING: Samples of patient records from general practices, emergency departments, and hospital admissions were assessed. SUBJECTS AND METHODS: Patient records of children aged 0 to 15 years were assessed for the presence of, and adherence to, the indicators for care delivered in 2012 and 2013. RESULTS: Eleven indicators were developed. The records of 821 children (mean age, 5.0 years; SD, 4.0) with tonsillitis were screened. The reviewers conducted 2354 eligible indicator assessments across 1127 visits. Adherence to 6 indicators could be assessed and ranged from 14.3% to 73.2% (interquartile range 31.5% to 72.2%). CONCLUSION: Our main findings are consistent with the international literature: the treatment of many children who present with confirmed or suspected tonsillitis is inconsistent with current guidelines. Future research should consider how the indicators could be applied in a structured and automated manner to increase the reliability and efficiency of record reviews and help raise clinicians' awareness of appropriate tonsillitis management.