Correction: Patient education materials for non-specific low back pain and sciatica: A systematic review and meta-analysis.

[This corrects the article DOI: 10.1371/journal.pone.0274527.].

Interventions to improve primary healthcare in rural settings: A scoping review.

BACKGROUND: Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations. OBJECTIVE: Synthesize and categorize studies that examine interventions to improve rural primary care. ELIGIBILITY CRITERIA: Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison. SOURCES OF EVIDENCE: Pubmed, CINAHL, Cochrane Library, Embase. CHARTING METHODS: We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant. RESULTS: 372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017. CONCLUSIONS: Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Patshitinikutau Natukunisha Tshishennuat Uitshuau (a place for Elders to spend their last days in life): a qualitative study about Innu perspectives on end-of-life care.

BACKGROUND: Indigenous palliative persons and their families often have different values, spiritual traditions, and practices from Western culture and Canadian health systems. Additionally, many healthcare policies and practices have been established without adequate consultation of the Indigenous populations they are meant to serve. This can result in barriers to Innu receiving culturally safe end-of-life care. Innu community leaders from Sheshatshiu, Labrador, have identified a need for further research in this area. The purpose of this study is to: (1) describe the cultural and spiritual practices related to death and dying of the Innu in Sheshatshiu; (2) identify aspects of current end-of-life care delivery that serve and/or fail to meet the cultural and spiritual needs of the Innu in Sheshatshiu; and (3) explore ways to integrate current end-of-life care delivery practices with Innu cultural and spiritual practices to achieve culturally safer care delivery for the Innu. METHODS: This qualitative patient-oriented research study was co-led by Innu investigators and an Innu advisory committee to conduct semi-structured interviews of 5 healthcare providers and 6 decision-makers serving the community of Sheshatshiu and a focus group of 5 Innu Elders in Sheshatshiu. Data was analyzed thematically from verbatim transcripts. The codebook, preliminary themes, and final themes were all reviewed by Innu community members, and any further input from them was then incorporated. Quotations in this article are attributed to Innu Elders by name at the Elders' request. RESULTS: The findings are described using eight themes, which describe the following: relationships and visitation support a "peaceful death"; traditional locations of death and dying; the important role of friends and community in providing care; flexibility and communication regarding cultural practices; adequate and appropriate supports and services; culturally-informed policies and leadership; and Innu care providers and patient navigators. CONCLUSIONS: The Innu in Sheshatshiu have a rich culture that contributes to the health, care, and overall well-being of Innu people approaching end of life. Western medicine is often beneficial in the care that it provides; however, it becomes culturally unsafe when it fails to take Innu cultural and spiritual knowledge and traditions into account.

A qualitative study exploring perceived barriers and enablers to fidelity of training and delivery for an intervention to reduce non-indicated imaging for low back pain.

BACKGROUND: Non-specific low back pain (LBP) commonly presents to primary care, where inappropriate use of imaging remains common despite guideline recommendations against its routine use. Little is known about strategies to enhance intervention fidelity (i.e., whether interventions were implemented as intended) for interventions developed to reduce non-indicated imaging for LBP. OBJECTIVES: We aim to inform the development of an intervention to reduce non-indicated imaging among general practitioners (GPs) and chiropractors in Newfoundland and Labrador (NL), Canada. The study objectives are: [1] To explore perceived barriers and enablers to enhancing fidelity of training of GPs and chiropractors to deliver a proposed intervention to reduce non-indicated imaging for LBP and [2] To explore perceived barriers and enablers to enhancing fidelity of delivery of the proposed intervention. METHODS: An exploratory, qualitative study was conducted with GPs and chiropractors in NL. The interview guide was informed by the National Institutes of Health Behavior Change Consortium fidelity checklist; data analysis was guided by the Theoretical Domains Framework (TDF). Participant quotes were coded into TDF domains, belief statements were generated at each domain, and domains relevant to enhancing fidelity of provider training or intervention delivery were identified. RESULTS: The study included five GPs and five chiropractors from urban and rural settings. Barriers and enablers to enhancing fidelity to provider training related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Reinforcement, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Emotion, and [7] Behavioural regulation. Barriers and enablers to enhancing fidelity to intervention delivery related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Goals, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Social influences, and [7] Behavioural regulation. CONCLUSION: The largest perceived barrier to attending training was time; perceived enablers were incentives and flexible training. Patient pressure, time, and established habits were perceived barriers to delivering the intervention as intended. Participants suggested enhancement strategies to improve their ability to deliver the intervention as intended, including reminders and check-ins with researchers. Most participants perceived intervention fidelity as important. These results may aid in the development of a more feasible and pragmatic intervention to reduce non-indicated imaging for GPs and chiropractors in NL.

Barriers to reducing preoperative testing for low-risk surgical procedures: A qualitative assessment guided by the Theoretical Domains Framework.

INTRODUCTION: While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. AIM: Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. METHOD: We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. RESULTS: We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years' experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. CONCLUSION: These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.

Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework.

INTRODUCTION: Overprescription of antibiotics poses a significant threat to healthcare globally as it contributes to the issue of antibiotic resistance. While antibiotics should be predominately prescribed for bacterial infections, they are often inappropriately given for uncomplicated upper respiratory tract infections (URTIs) and related conditions, such as the common cold. This study will involve a qualitative systematic review of physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care settings and synthesise the findings using a theoretical basis. METHODS AND ANALYSIS: We will conduct a systematic review of qualitative studies that assess physicians' reported barriers to following evidence-based antibiotic prescription guidelines in primary care settings for URTIs. We plan to search the following databases with no date or language restrictions: MEDLINE, Web of Science, CINAHL, Embase, the Cochrane Library and PsycInfo. Qualitative studies that explore the barriers and enablers to following antibiotic prescription guidelines for URTIs for primary care physicians will be included. We will analyse our findings using the Theoretical Domains Framework (TDF), which is a theoretically designed resource based on numerous behaviour change theories grouped into 14 domains. Using the TDF approach, we will be able to identify the determinants of our behaviour of interest (ie, following antibiotic prescription guidelines for URTIs) and categorise them into the 14 TDF domains. This will provide the necessary information to develop future evidence-based interventions that will target the identified issues and apply the most effective behaviour change techniques to affect change. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. ETHICS AND DISSEMINATION: Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at conferences.

Patient education materials for non-specific low back pain and sciatica: A systematic review and meta-analysis.

INTRODUCTION: Guidelines recommend patient education materials (PEMs) for low back pain (LBP), but no systematic review has assessed PEMs on their own. We investigated the effectiveness of PEMs on process, clinical, and health system outcomes for LBP and sciatica. METHODS: Systematic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, trial registries and grey literature through OpenGrey. We included randomized controlled trials of PEMs for LBP. Data extraction, risk of bias, and quality of evidence gradings were performed independently by two reviewers. Standardized mean differences or risk ratios and 95% confidence intervals were calculated, and effect sizes pooled using random-effects models. Analyses of acute/subacute LBP were performed separately from chronic LBP at immediate, short, medium, and long-term (6, 12, 24, and 52 weeks, respectively). RESULTS: 27 studies were identified. Compared to usual care for chronic LBP, we found moderate to low-quality evidence that PEMs improved pain intensity at immediate (SMD = -0.16 [95% CI: -0.29, -0.03]), short (SMD = -0.44 [95% CI: -0.88, 0.00]), medium (SMD = -0.53 [95% CI: -1.01, -0.05]), and long-term (SMD = -0.21 [95% CI: -0.41, -0.01]), medium-term disability (SMD = -0.32 [95% CI: -0.61, -0.03]), quality of life at short (SMD = -0.17 [95% CI: -0.30, -0.04]) and medium-term (SMD = -0.23 [95% CI: -0.41, -0.04]) and very low-quality evidence that PEMs improved global improvement ratings at immediate (SMD = -0.40 [95% CI: -0.58, -0.21]), short (SMD = -0.42 [95% CI: -0.60, -0.24]), medium (SMD = -0.46 [95% CI: -0.65, -0.28]), and long-term (SMD = -0.43 [95% CI: -0.61, -0.24]). We found very low-quality evidence that PEMs improved pain self-efficacy at immediate (SMD = -0.21 [95% CI: -0.39, -0.03]), short (SMD = -0.25 [95% CI: -0.43, -0.06]), medium (SMD = -0.23 [95% CI: -0.41, -0.05]), and long-term (SMD = -0.32 [95% CI: -0.50, -0.13]), and reduced medium-term fear-avoidance beliefs (SMD = -0.24 [95% CI: -0.43, -0.06]) and long-term stress (SMD = -0.21 [95% CI: -0.39, -0.03]). Compared to usual care for acute LBP, we found high to moderate-quality evidence that PEMs improved short-term pain intensity (SMD = -0.24 [95% CI: -0.42, -0.06]) and immediate-term quality of life (SMD = -0.24 [95% CI: -0.42, -0.07]). We found low to very low-quality evidence that PEMs increased knowledge at immediate (SMD = -0.51 [95% CI: -0.72, -0.31]), short (SMD = -0.48 [95% CI: -0.90, -0.05]), and long-term (RR = 1.28 [95% CI: 1.10, 1.49]) and pain self-efficacy at short (SMD = -0.78 [95% CI: -0.98, -0.58]) and long-term (SMD = -0.32 [95% CI: -0.52, -0.12]). We found moderate to very low-quality evidence that PEMs reduced short-term days off work (SMD = -0.35 [95% CI: -0.63, -0.08]), long-term imaging referrals (RR = 0.60 [95% CI: 0.41, 0.89]), and long-term physician visits (SMD = -0.16 [95% CI: -0.26, -0.05]). Compared to other interventions (e.g., yoga, Pilates), PEMs had no effect or were less effective for acute/subacute and chronic LBP. CONCLUSIONS: There was a high degree of variability across outcomes and time points, but providing PEMs appears favorable to usual care as we observed many small, positive patient and system impacts for acute/subacute and chronic LBP. PEMs were generally less effective than other interventions; however, no cost effectiveness analyses were performed to weigh the relative benefits of these interventions to the likely less costly PEMs.

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework.

BACKGROUND: Low back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL). METHODS: This was an exploratory, qualitative study describing family doctors' experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging. RESULTS: Nine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation. CONCLUSIONS: Family physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don't have enough time to counsel patients about why they don't need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process - identifying the contextual barriers and the domains to which they are related.

Exploring factors influencing chiropractors' adherence to radiographic guidelines for low back pain using the Theoretical Domains Framework.

BACKGROUND: The inappropriate use of lumbar spine imaging remains common in primary care despite recommendations from evidence-based clinical practice guidelines to avoid imaging in the absence of red flags. This study aimed to explore factors influencing ordering behaviours and adherence to radiographic guidelines for low back pain (LBP) in chiropractors in Newfoundland and Labrador (NL), Canada. METHODS: We conducted two focus groups in December 2018 with chiropractors in different regions of NL (eastern, n = 8; western, n = 4). An interview guide based on the Theoretical Domains Framework (TDF) served to identify perceived barriers to, and enablers of, target behaviours of guideline adherence and managing LBP without X-rays. We conducted thematic analysis of chiropractors' statements into relevant theoretical domains, followed by grouping of similar statements into specific beliefs. Domains key to changing radiographic guideline adherence, LBP imaging behaviours, and/or informing intervention design were identified by noting conflicting beliefs and their reported influence on the target behaviours. RESULTS: Six of the 14 TDF domains were perceived to be important for adherence to radiographic guidelines and managing non-specific LBP without imaging. Participating chiropractors reported varying levels of knowledge and awareness of guidelines for LBP imaging (Knowledge). Many chiropractors based their decision for imaging on clinical presentation, but some relied on "gut feeling" (Memory, attention, and decision processes). While chiropractors thought it was their role to manage LBP without imaging, others believed ordering imaging was the responsibility of other healthcare providers (Social/professional role and identity). Contrasting views were found regarding the negative consequences of imaging or not imaging LBP patients (Beliefs about consequences). Communication was identified as a skill required to manage LBP without imaging (Skills) and a strategy to enable appropriate imaging ordering behaviours (Behavioural regulation). Chiropractors suggested that access to patients' previous imaging and a system that facilitated better interprofessional communication would likely improve their LBP imaging behaviours (Behavioural regulation). CONCLUSION: We identified potential influences, in six theoretical domains, on participating chiropractors' LBP imaging behaviours and adherence to radiographic guidelines. These beliefs may be targets for theory-informed behaviour change interventions aimed at improving these target behaviours for chiropractors in NL.

Operationalizing a patient engagement plan for health research: Sharing a codesigned planning template from a national clinical trial.

INTRODUCTION: Engaging with patients about their lived experience of health and illness and their experience within the healthcare system can help inform the provision of care, health policies and health research. In the context of health research, however, operationalizing the levels of patient engagement is not straightforward. We suggest that a key challenge to the routine inclusion of patients as partners in health research is a lack of tangible guidance regarding how this can be accomplished. METHODS: In this article, we provide guidance on how to codesign and operationalize a concrete patient engagement plan for any health research project. RESULTS: We illustrate a seven-step approach using the example of a national clinical trial in Canada and provide a patient engagement planning template for use in any health research project. CONCLUSION: Such concrete guidance should improve the design and reporting of patient engagement in health research. PATIENT OR PUBLIC CONTRIBUTION: The De-Implementing Wisely Research group is informed by a national 9-member patient partner council (PPC). The research team includes three lead patient partners who are coinvestigators on the grant that funds the program of research. Members of the council advise on all aspects of the study design and implementation. The ideas presented in this paper were informed by regular communication and planning with the PPC; specific contributions of lead patient partner authors are outlined as follows: Brian Johnston, Susan Goold and Vanessa Francis are patient partners with a wide breadth of experience in the healthcare system and health research projects. The guidance in this article draws on their lived and professional expertise. All patient partner authors contributed to the planning of the manuscript, participated in meetings to develop content and provided critical manuscript edits and comments on drafts.

What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging?

BACKGROUND: Despite international guideline recommendations, low back pain (LBP) imaging rates have been increasing over the last 20 years. Previous systematic reviews report limited effectiveness of implementation interventions aimed at reducing unnecessary LBP imaging. No previous reviews have analysed these implementation interventions to ascertain what behaviour change techniques (BCTs) have been used in this field. Understanding what techniques have been implemented in this field is an essential first step before exploring intervention effectiveness. METHODS: We searched EMBASE, Ovid (Medline), CINAHL and Cochrane CENTRAL from inception to February 1, 2021, as well as and hand-searched 6 relevant systematic reviews and conducted citation tracking of included studies. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study and intervention characteristics. Study interventions were qualitatively analysed by three coders to identify BCTs, which were mapped to mechanisms of action from the theoretical domains framework (TDF) using the Theory and Techniques Tool. RESULTS: We identified 36 eligible studies from 1984 citations in our electronic search and a further 2 studies from hand-searching resulting in 38 studies that targeted physician behaviour to reduce unnecessary LBP imaging. The studies were conducted in 6 countries in primary (n = 31) or emergency care (n = 7) settings. Thirty-four studies were included in our BCT synthesis which found the most frequently used BCTs were '4.1 instruction on how to perform the behaviour' (e.g. Active/passive guideline dissemination and/or educational seminars/workshops), followed by '9.1 credible source', '2.2 feedback on behaviour' (e.g. electronic feedback reports on physicians' image ordering) and 7.1 prompts and cues (electronic decision support or hard-copy posters/booklets for the office). This review highlighted that the majority of studies used education and/or feedback on behaviour to target the domains of knowledge and in some cases also skills and beliefs about capabilities to bring about a change in LBP imaging behaviour. Additionally, we found there to be a growing use of electronic or hard copy reminders to target the domains of memory and environmental context and resources. CONCLUSIONS: This is the first study to identify what BCTs have been used to target a reduction in physician image ordering behaviour. The majority of included studies lacked the use of theory to inform their intervention design and failed to target known physician-reported barriers to following LBP imaging guidelines. PROTOCOL REGISTATION: PROSPERO CRD42017072518.

Evaluating the impact of a champion on implementation of the Back Skills Training (BeST) programme in Canada: a mixed methods feasibility study protocol.

INTRODUCTION: There is global recognition that low back pain (LBP) should be managed with a biopsychosocial approach. Previous implementation of this approach resulted in low uptake and highlighted the need for ongoing support. This study aims to explore the feasibility of (i) training and using a champion to support implementation, (ii) using a cluster randomised controlled trial (RCT), (iii) collecting patient reported outcome measures in a Canadian public healthcare setting and to identify contextual barriers to implementation. METHODS: A pragmatic cluster RCT with embedded qualitative study with physiotherapists treating LBP in publicly funded physiotherapy departments in Newfoundland and Labrador, Canada. Participants will complete a previously developed online training course to equip them to deliver a biopsychosocial intervention for LBP. Clusters randomised to the intervention arm will receive additional support from a champion. A minimum champion training package has been developed based on known barriers in the literature. This includes strategies to target barriers relating to group-based scheduling issues, lack of managerial support, perceived patient factors such as addressing patient expectations for other types of treatments or selecting which patients might be best suited for this intervention, and anxiety about delivering something new. This package will be further codeveloped with study champions based on identified implementation barriers using the Behaviour Change Wheel. Clusters will be monitored for 6 months to assess champion and physiotherapist recruitment and retention, acceptability and implementation of the champion training, and the viability of conducting a cluster RCT in this setting. A purposive sample of physiotherapists will be interviewed from both arms. ETHICS AND DISSEMINATION: This study was approved by Newfoundland and Labrador Health Research Ethics Authority in December 2018. Results will be disseminated to academic audiences through conferences and peer reviewed publications; to all study participants, their clinical leads, and patients with LBP. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT04377529; Memorial University of Newfoundland Protocol Record 20190025; Pre-results.

Patient education materials for non-specific low back pain and sciatica: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Low back pain accounts for more disability than any other musculoskeletal condition and is associated with severe economic burden. Patients commonly present with negative beliefs about low back pain and this can have detrimental effects on their health outcomes. Providing evidence-based, patient-centred education that meets patient needs could help address these negative beliefs and alleviate the substantial low back pain burden. The primary aim of this review is to investigate the effectiveness of patient education materials on immediate process, clinical and health system outcomes. METHODS AND ANALYSIS: The search strategy was developed in collaboration with a librarian and systematic searches will be performed in MEDLINE, EMBASE, CINAHL, PsycINFO and SPORTDiscus. We will also search trial registries and grey literature through the OpenGrey database. Study selection will include a title and abstract scan and full-text review by two authors. Only randomised controlled trials will be included in this review. Trials must include patients with low back pain or sciatica and investigate educational interventions with at least one of the following contrasts: (1) education alone versus no intervention; (2) education alone versus another intervention; (3) education in addition to another intervention versus the same intervention with no education. Data extraction, risk of bias and grading of the quality of evidence will be performed independently by two reviewers. Risk of bias will be assessed using the PEDro scale, and the quality of evidence will be assessed with the Grades of Recommendation, Assessment, Development and Evaluation approach. A random-effects model will be used for each contrast, and results will be pooled if the participants, interventions, and outcomes are homogeneous. If heterogeneity is high (I2 >75%), we will evaluate the magnitude and direction of the differences in effect sizes across studies to determine if it remains reasonable to pool the results. Analyses of acute and subacute low back pain (less than 12 weeks duration) will be performed separately from chronic low back pain (12 weeks or greater duration). Likewise, analyses of short-term (less than 6 months) and long-term (6 months or greater) follow-up will be performed separately. Subgroup analyses will be performed on non-specific low back pain, sciatica and mixed populations. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. This study, along with its results, will be published in a peer-reviewed journal.

Protocol for assessing the determinants of preoperative test-ordering behaviour for low-risk surgical procedures using a theoretically driven, qualitative design.

INTRODUCTION: Current evidence suggests that preoperative tests such as chest X-rays, electrocardiograms and baseline laboratory studies may not be useful for healthy patients undergoing low-risk surgical procedures. Routine preoperative testing for healthy patients having low-risk surgery is not a scientifically sound practice. In this study, we will interview healthcare providers working at medical facilities where low-risk surgical procedures are carried out. This will allow us to gain insight into the determinants of preoperative testing behaviours for healthy patients undergoing low-risk surgeries and their barriers and enablers to guideline adherence. METHODS AND ANALYSIS: We will use semistructured interviews with anaesthesiologists, surgeons and preadmission clinic nurses to assess the determinants of preoperative testing behaviours. The interview guide was designed around the Theoretical Domains Framework (TDF), developed specifically to determine the barriers and enablers to implementing evidence-based guidelines. Interviews will be audio-recorded, transcribed verbatim and coded according to the TDF. Key themes will be generated for each of the identified domains. ETHICS AND DISSEMINATION: We have received ethics approval from the Health Research Ethics Board in Newfoundland and Labrador (HREB #2018.190) for this study. The results of this work will be disseminated through a peer-reviewed publication, presentation at a healthcare forum and plain-language infographic summaries. Additionally, deidentified data collected and analysed for this study will be available for review from the corresponding author on reasonable request.

What do we really know about the appropriateness of radiation emitting imaging for low back pain in primary and emergency care? A systematic review and meta-analysis of medical record reviews.

BACKGROUND: Since 2000, guidelines have been consistent in recommending when diagnostic imaging for low back pain should be obtained to ensure patient safety and reduce unnecessary tests. This systematic review and meta-analysis was conducted to determine the pooled proportion of CT and x-ray imaging of the lumbar spine that were considered appropriate in primary and emergency care. METHODS: Pubmed, CINAHL, The Cochrane Database of Systematic Reviews and Embase were searched for synonyms of "low back pain", "guidelines", and "adherence" that were published after 2000. Titles, abstracts, and full texts were reviewed for inclusion with forward and backward tracking on included studies. Included studies had data extracted and synthesized. Risk of bias was performed on all studies, and GRADE was performed on included studies that provided data on CT and x-ray separately. A random effect, single proportion meta-analysis model was used. RESULTS: Six studies were included in the descriptive synthesis, and 5 studies included in the meta-analysis. Five of the 6 studies assessed appropriateness of x-rays; two of the six studies assessed appropriateness of CTs. The pooled estimate for appropriateness of x-rays was 43% (95% CI: 30%, 56%) and the pooled estimate for appropriateness of CTs was 54% (95% CI: 51%, 58%). Studies did not report adequate information to fulfill the RECORD checklist (reporting guidelines for research using observational data). Risk of bias was high in 4 studies, moderate in one, and low in one. GRADE for x-ray appropriateness was low-quality and for CT appropriateness was very-low-quality. CONCLUSION: While this study determined a pooled proportion of appropriateness for both x-ray and CT imaging for low back pain, there is limited confidence in these numbers due to the downgrading of the evidence using GRADE. Further research on this topic is needed to inform our understanding of x-ray and CT appropriateness in order to improve healthcare systems and decrease patient harms.

Status of global health fellowship training in the United States and Canada.

BACKGROUND: Increasing numbers of residency graduates desire global health (GH) fellowship training. However, the full extent of training options is not clear. OBJECTIVE: To identify clinical GH fellowships in all specialties in the U.S. and Canada and to describe their demographics, innovative features, and challenges. METHODS: The authors surveyed program directors or designees from GH fellowships with a web-based tool in 2017. RESULTS: The authors identified 85 programs. Fifty-four programs (63.5%) responded confirming 50 fellowships. One- third of fellowships accepted graduates from more than one specialty, and the most common single-specialty programs were Emergency Medicine and Family Medicine. Fellowships most commonly were 24 months in duration with a median size of one fellow per year. Funding and lack of qualified applicants were significant challenges. Most programs were funded through fellow billing for patient care or other self-support. CONCLUSION: The number of U.S. and Canadian GH fellowship programs has nearly doubled since 2010. Challenges include lack of funding and qualified applicants. Further work is needed to understand how best to identify and disseminate fellowship best practices to meet the diverse needs of international partners, fellows, and the patients they serve and to determine if consensus regarding training requirements would be beneficial.

CONTEXTE: Un nombre croissant de diplômés des programmes de résidence optent pour une formation complémentaire en santé mondiale. Cependant, la pleine mesure des possibilités de formation n'est pas claire. OBJECTIF: Identifier les formations cliniques complémentaires en santé mondiale pour toutes les spécialités aux États- Unis et au Canada et décrire leur démographie, leurs caractéristiques novatrices, et leurs défis. MÉTHODES: En 2017, les auteurs ont interrogé les directeurs de programmes de formation complémentaire en santé mondiale ou leur représentant à l'aide d'un outil en ligne. RÉSULTATS: Les auteurs ont identifié 85 programmes. 54 programmes (63,5 %) ont répondu et confirmé 50 programmes de formation. Un tiers des programmes acceptaient des diplômés provenant de plusieurs spécialités, et les programmes offerts à des spécialités uniques étaient plus fréquemment ceux en médecine d'urgence et en médecine familiale. Les programmes étaient généralement d'une durée de 24 mois avec une capacité d'accueil d'un moniteur (fellow) par année. Le financement et le manque de candidats qualifiés étaient des défis de taille. La plupart des programmes étaient financés par la rémunération des moniteurs (fellows) pour les soins qu'ils prodiguaient aux patients ou via d'autres aides financières individuelles. CONCLUSIONS: Le nombre de programmes de formation complémentaire en santé mondiale a presque doublé depuis 2010. Les défis sont notamment le manque de financement et de candidats qualifiés. Il est nécessaire de poursuivre le travail pour pouvoir bien identifier et transmettre les meilleures pratiques en matière de formation complémentaire afin de répondre aux divers besoins des partenaires internationaux, des moniteurs (fellows) et des patients qu'ils soignent, et déterminer si un consensus concernant les exigences de formation serait bénéfique.

Using theatre as an arts-based knowledge translation strategy for health-related information: a scoping review protocol.

INTRODUCTION: Substantial delays in translating evidence to practice mean that many beneficial and vital advances in medical care are not being used in a timely manner. Traditional knowledge translation (KT) strategies have tended to target academics by disseminating findings in academic journals and at scientific conferences. Alternative strategies, such as theatre-based KT, appear to be effective at targeting broader audiences. The purpose of this scoping review is to collate and understand the current state of science on the use of theatre as a KT strategy. This will allow us to identify gaps in literature, determine the need for a systematic review and develop additional research questions to advance the field. METHODS AND ANALYSIS: This review will follow established scoping review methods outlined by Arksey and O'Malley in conjunction with enhanced recommendations made by Levac et al. The search strategy, guided by an experienced librarian, will be conducted in PubMed, CINHAL and OVID. Study selection will consist of three stages: (1) initial title and abstract scan by one author to remove irrelevant articles and create a shortlist for double screening, (2) title and abstract scan by two authors, and (3) full-text review by two authors. Included studies will report specifically on the use of theatre as means of KT of health-related information to any target population. Two reviewers will independently extract and chart the data using a standardised data extraction form. Descriptive statistics will be used to produce numerical summaries related to study characteristics, KT strategy characteristics and evaluation characteristics. For those studies that included an evaluation of the theatre production as a KT strategy, we will synthesise the data according to outcome. ETHICS AND DISSEMINATION: Ethical approval was not required for this study. Results will be published in relevant journals, presented at conferences and distributed via social media.

The effectiveness of a proven chronic disease prevention and screening intervention in diverse and remote primary care settings: an implementation study on the BETTER 2 Program.

BACKGROUND: The Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) randomised control trial (RCT) showed that the BETTER Program improved chronic disease prevention and screening (CDPS) by 32.5% in urban team-based primary care clinics. AIM: To evaluate outcomes from implementation of BETTER in diverse clinical settings. DESIGN & SETTING: An implementation study was undertaken to apply the CDPS intervention from the BETTER trial to diverse settings in BETTER 2. Patients aged 40-65 years were invited to enrol in the study from three clinics in Newfoundland and Labrador, Canada. METHOD: At baseline, eligibility for 27 CDPS actions (for example, cancer, diabetes and hypertension screening, lifestyle) was determined. Patients then met with a trained provider and prioritised goals to address their eligible CDPS actions. Providers received training in behaviour change theory and practice. Descriptive analysis of clinical outcomes and success factors were reported. RESULTS: A total of 154 patients (119 female and 35 male) had a baseline visit; 106 had complete outcome assessments, and the remainder had partial outcome assessments. At baseline, patients were eligible for a mean of 12.3 CDPS actions and achieved a mean of 6.0 (49%, 95% confidence intervals [CI] = 24% to 74%) at 6-month follow-up, including reduced hypertension (86% of eligible patients, 95% CI = 67% to 96%), weight control (51% of eligible patients, 95% CI = 42% to 60%), and smoking cessation (36% of eligible patients, 95% CI = 17% to 59%). Male, highly educated, and lower income individuals achieved a higher proportion of CDPS manoeuvers than their counterparts. CONCLUSION: Clinical outcomes from this implementation study were comparable with those of the prior BETTER RCT, providing support for the BETTER Program as an effective approach to CDPS in more diverse general practice settings.

Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework.

BACKGROUND: Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP. METHODS: We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach. RESULTS: Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies). CONCLUSIONS: Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption. REGISTRATION: PROSPERO 2017, CRD42017070703.

Primary care of adults with severe and profound intellectual and developmental disabilities: Family physicians' perspectives on patient-physician relationships.

OBJECTIVE: To explore family physicians' perspectives on the development of the patient-physician relationship with adult patients living with severe or profound intellectual and developmental disabilities (IDD). DESIGN: Constructivist grounded theory. SETTING: St John's, NL, and across Canada. PARTICIPANTS: Fifteen family physicians currently caring for patients with severe or profound IDD. METHODS: Data were collected via in-depth, semistructured interviews conducted in-person or by telephone. Interviews were audiorecorded and transcribed verbatim. Field notes were documented immediately by the interviewer and discussed with the research team. Memos in the form of reflective notes served as additional sources of data. MAIN FINDINGS: From the perspective of family physicians, the core process in the development of the patient-physician relationship was acceptance. This acceptance was bidirectional. With respect to family physicians accepting patients, family physicians had to accept that their patients with severe and profound IDD were as equally deserving of their respect as any other patient-as unique individuals with their own goals and potential. With respect to patients accepting their family physicians, family physicians had to seek out signs of acceptance from their patients to fully appreciate and develop a trusting relationship. This bidirectional process of acceptance required family physicians to adapt the way they practised (eg, by spending more time with the patient and finding alternate forms of communication). It also required family physicians to define their role (eg, building trust and being an advocate) in a relationship that had the patient as the primary focus but simultaneously acknowledged the important involvement of the caregiver. CONCLUSION: For family physicians, the process of acceptance seems to underpin the development of the patient-physician relationship with adult patients with severe or profound IDD. Findings highlight the need for family physicians to adapt the way they deliver care to these patients and define their role in these complex relationships. Ultimately, this study highlights family physicians' acceptance of their patients' humanity regardless of the nature of the relationship that was created between them.