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ObjectivesSimulation is widely employed to teach a range of skills, across healthcare professions and is most effective when embedded within a standarised curriculum. Although recommended by many governing bodies, establishing a national programme of simulation presents many challenges. Successful implementation requires a clear understanding of the priorities and needs of those it seeks to serve yet there are limited examples of how best to do this. This study aimed to develop an integrated national simulation-based educational programme for junior doctors in Scotland through a structed, multistep prioritisation process.DesignA series of action research cycles were undertaken to develop and evaluate a national simulation programme. This paper describes cycle 1, which employed a six-step structured approach to understand and prioritise learner needs.SettingThe study considered the educational needs of Scottish junior doctors in the UK Foundation Programme (UKFP).ParticipantsMultiple stakeholder groups were involved in each stage of the process including recent Scottish UKFP graduates, clinical educators, UKFP programme directors and postgraduate deans.ResultsKey stakeholders reviewed the 370 competencies in the UKFP curriculum and identified 18 initial competency areas. These 18 areas were subsequently prioritised through the analytical hierarchy process, resulting in a carefully ordered list of 12 competencies from which a targeted simulation-based educational programme could be developed.ConclusionsTo our knowledge, this is the first study to outline the methods of competency prioritisation to create a simulation curriculum that is integrated within a national curriculum in the medical education context. As well as demonstrating the practical steps of such a process, key implications for practice are identified. This robust approach to educational design also resulted in unexpected benefits, including educator and clinician acceptance and programme funding sustainability.

ObjectiveTo identify factors associated with COVID-19 positivity among staff and their family members of icddr,b, a health research institute located in Bangladesh.SettingDhaka, Bangladesh.ParticipantsA total of 4295 symptomatic people were tested for SARS-CoV-2 by reverse-transcription PCR between 19 March 2020 and 15 April 2021. Multivariable logistic regression was done to identify the factors associated with COVID-19 positivity by contrasting test positives with test negatives.ResultForty-three per cent of the participants were tested positive for SARS-CoV-2. The median age was high in positive cases (37 years vs 34 years). Among the positive cases, 97% were recovered, 2.1% had reinfections, 24 died and 41 were active cases as of 15 April 2021. Multivariable regression analysis showed that age more than 60 years (adjusted OR (aOR)=2.1, 95% CI 1.3 to 3.3; pConclusionsThe study findings suggest that older age, fever, cough and anosmia were associated with COVID-19 among the study participants.

Funder: National Institute for Health Research (NIHR), OBJECTIVE: To explore the barriers to and options for improving access to quality healthcare for the urban poor in Nairobi, Kenya. DESIGN AND PARTICIPANTS: This was a qualitative approach. In-depth interviews (n=12), focus group discussions with community members (n=12) and key informant interviews with health providers and policymakers (n=25) were conducted between August 2019 and September 2020. Four feedback and validation workshops were held in December 2019 and April-June 2021. SETTING: Korogocho and Viwandani urban slums in Nairobi, Kenya. RESULTS: The socioe-conomic status of individuals and their families, such as poverty and lack of health insurance, interact with community-level factors like poor infrastructure, limited availability of health facilities and insecurity; and health system factors such as limited facility opening hours, health providers' attitudes and skills and limited public health resources to limit healthcare access and perpetuate health inequities. Limited involvement in decision-making processes by service providers and other key stakeholders was identified as a major challenge with significant implications on how limited health system resources are managed. CONCLUSION: Despite many targeted interventions to improve the health and well-being of the urban poor, slum residents are still unable to obtain quality healthcare because of persistent and new barriers due to the COVID-19 pandemic. In a devolved health system, paying attention to health services managers' abilities to assess and respond to population health needs is vital. The limited use of existing accountability mechanisms requires attention to ensure that the mechanisms enhance, rather than limit, access to health services for the urban slum residents. The uniqueness of poor urban settings also requires in-depth and focused attention to social determinants of health within these contexts. To address individual, community and system-level barriers to quality healthcare in this and related settings and expand access to health services for all, multisectoral strategies tailored to each population group are needed.

IntroductionBig data technologies have been talked up in the fields of science and medicine. The V-criteria (volume, variety, velocity and veracity, etc) for defining big data have been well-known and even quoted in most research articles; however, big data research into public health is often misrepresented due to certain common misconceptions. Such misrepresentations and misconceptions would mislead study designs, research findings and healthcare decision-making. This study aims to identify the V-eligibility of big data studies and their technologies applied to environmental health and health services research that explicitly claim to be big data studies.Methods and analysisOur protocol follows Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Scoping review and/or systematic review will be conducted. The results will be reported using PRISMA for Scoping Reviews (PRISMA-ScR), or PRISMA 2020 and Synthesis Without Meta-analysis guideline. Web of Science, PubMed, Medline and ProQuest Central will be searched for the articles from the database inception to 2021. Two reviewers will independently select eligible studies and extract specified data. The numeric data will be analysed with R statistical software. The text data will be analysed with NVivo wherever applicable.Ethics and disseminationThis study will review the literature of big data research related to both environmental health and health services. Ethics approval is not required as all data are publicly available and involves confidential personal data. We will disseminate our findings in a peer-reviewed journal.PROSPERO registration numberCRD42021202306.

ObjectiveTo identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review.Setting/participantsPrimary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded.Study selectionSeven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types.OutcomesNarrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries.ResultsSearches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews.DiscussionA heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included.ConclusionsA combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes.PROSPERO registration numberCRD42020210183.

IntroductionThere is a surplus of information and communication technology (ICT)-based interventions for suicide prevention. However, it is unclear which of these ICT-based interventions for suicide prevention have been implemented in clinical settings. Furthermore, evidence shows that implementation strategies have often been mismatched to existing barriers. In response, the authors recognise the critical need for prospectively assessing the barriers and facilitators and then strategically developing implementation strategies. This review is part of a multiphase project to develop and test tailored implementation strategies for mobile app-based suicide prevention in clinical settings. The overall objective of this scoping review is to identify and characterise ICT-based interventions for all levels of suicide prevention in clinical settings. Additionally, this review will identify and characterise the barriers and facilitators to implementing these ICT-based interventions as well as reported measures and outcomes. The findings will directly inform the subsequent phase to maximise implementation and inform future efforts for implementing other types of ICT-based interventions related to suicide prevention in clinical settings.Methods and analysisThis review will adhere to the methods described by the Joanna Briggs Institute for conducting scoping reviews. The reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review checklist. The following databases will be searched: Medline, PsycInfo, Embase, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science and Library, Information Science & Technology Abstracts (LISTA). Two reviewers will independently screen the articles and extract data using a standardised data collection tool. Then, authors will characterise extracted data using frameworks, typology and taxonomies to address the proposed review questions.Ethics and disseminationEthics approval is not required for this scoping review. Authors will share the results in a peer-reviewed, open access publication and conference presentations. Furthermore, the findings will be shared with relevant health organisations through lay language summaries and informal presentations.

ObjectiveTo evaluate service use, clinical outcomes and user experience related to telephone-based digital triage in urgent care.DesignSystematic review and narrative synthesis.Data sourcesMedline, Embase, CINAHL, Web of Science and Scopus were searched for literature published between 1 March 2000 and 1 April 2020.Eligibility criteria for selecting studiesStudies of any design investigating patterns of triage advice, wider service use, clinical outcomes and user experience relating to telephone based digital triage in urgent care.Data extraction and synthesisTwo reviewers extracted data and conducted quality assessments using the mixed methods appraisal tool. Narrative synthesis was used to analyse findings.ResultsThirty-one studies were included, with the majority being UK based; most investigated nurse-led digital triage (n=26). Eight evaluated the impact on wider healthcare service use following digital triage implementation, typically reporting reduction or no change in service use. Six investigated patient level service use, showing mixed findings relating to patients’ adherence with triage advice. Evaluation of clinical outcomes was limited. Four studies reported on hospitalisation rates of digitally triaged patients and highlighted potential triage errors where patients appeared to have not been given sufficiently high urgency advice. Overall, service users reported high levels of satisfaction, in studies of both clinician and non-clinician led digital triage, but with some dissatisfaction over the relevance and number of triage questions.ConclusionsFurther research is needed into patient level service use, including patients’ adherence with triage advice and how this influences subsequent use of services. Further evaluation of clinical outcomes using larger datasets and comparison of different digital triage systems is needed to explore consistency and safety. The safety and effectiveness of non-clinician led digital triage also needs evaluation. Such evidence should contribute to improvement of digital triage tools and service delivery.PROSPERO registration numberCRD42020178500.

ObjectivesTo understand the rationale, implementation and early impact of vertical integration between primary care medical practices and the organisations running acute hospitals in the National Health Service in England and Wales.Design and settingA qualitative, cross-comparative case study evaluation at two sites in England and one in Wales, consisting of interviews with stakeholders at the sites, alongside observations of strategic meetings and analysis of key documents.ResultsWe interviewed 52 stakeholders across the three sites in the second half of 2019 and observed four meetings from late 2019 to early 2020 (further observation was prevented by the onset of the COVID-19 pandemic). The single most important driver of vertical integration was found to be to maintain primary care local to where patients live and thereby manage demand pressure on acute hospital services, especially emergency care. The opportunities created by maintaining local primary care providers—to develop patient services in primary care settings and better integrate them with secondary care—were exploited to differing degrees across the sites. There were notable differences between sites in operational and management arrangements, and in organisational and clinical integration. Closer organisational integration was attributed to previous good relationships between primary and secondary care locally, and to historical planning and preparation towards integrated working across the local health economy. The net impact of vertical integration on health system costs is argued by local stakeholders to be beneficial.ConclusionsVertical integration is a valuable option when primary care practices are at risk of closing, and may be a route to better integration of patient care. But it is not the only route and vertical integration is not attractive to all primary care physicians. A future evaluation of vertical integration is intended; of patients’ experience and of the impact on secondary care service utilisation.

ObjectivesThe COVID-19 pandemic significantly affected the provisions of health services to necessary but deprioritised fields, such as transplantation. Many programmes had to ramp-down their activity, which may significantly affect transplant volumes. We aimed to pragmatically analyse measures of transplant activity and compare them by a country’s income level and cumulative COVID-19 incidence (CCI).Design, setting and participantsFrom June to September 2020, we surveyed transplant physicians identified as key informants in their programmes. Of the 1267 eligible physicians, 40.5% from 71 countries participated.OutcomeFour pragmatic measures of transplant activity.ResultsOverall, 46.5% of the programmes from high-income countries anticipate being able to maintain >75% of their transplant volume compared with 31.6% of the programmes from upper-middle-income countries, and with 21.7% from low/lower-middle-income countries (p75% of their transplant volume, compared with programmes in high-income countries. Again, this could be attributed to lower-income being associated with 3.3–3.9 higher odds of performing no transplantation/s, 66%–68% lower odds of maintaining prepandemic donor offers and 37%–76% lower odds of avoiding ramp-down of transplantation. Overall, CCI was not associated with these measures.ConclusionsThe impact of the pandemic on transplantation was more in lower-income countries, independent of the COVID-19 burden. Given the lag of 1–2 years in objective data being reported by global registries, our findings may inform practice and policy. Transplant programmes in lower-income countries may need more effort to rebuild disrupted services and recuperate from the pandemic even if their COVID-19 burden was low.

BackgroundIn Bihar, one of the most populous and poorest states in India, caesarean sections have increased over the last decade. However, an aggregated caesarean section rate at the state level may conceal inequities at the district level.ObjectivesThe primary aim of this study was to analyse the inequalities in the geographical and socioeconomic distribution of caesarean sections between the districts of Bihar. The secondary aim was to compare the contribution of free-for-service government-funded public facilities and fee-for-service private facilities to the caesarean section rate.SettingBihar, with a population in the 2011 census of approximately 104 million people, has a low GDP per capita (US$610), compared with other Indian states. The state has the highest crude birth rate (26.1 per 1000 population) in India, with one baby born every two seconds. Bihar is divided into 38 administrative districts, 101 subdivisions and 534 blocks. Each district has a district (Sadar) hospital, and six districts also have one or more medical college hospitals.MethodsThis retrospective secondary data analysis was based on open-source national datasets from the 2015 and 2019 National Family Health Surveys, with respective sample sizes of 45 812 and 42 843 women aged 15–49 years.ParticipantsSecondary data analysis of pregnant women delivering in public and private institutions.ResultsThe caesarean section rate increased from 6.2% in 2015 to 9.7% in 2019 in Bihar. Districts with a lower proportion of poor population had higher caesarean section rates (R2=0.45) among all institutional births, with 10.3% in private and 2.9% in public facilities. Access to private caesarean sections decreased (R2=0.46) for districts with poorer populations.ConclusionMarked inequalities exist in access to caesarean sections. The public sector needs to be strengthened to improve access to obstetric services for those who need it most.

ObjectivesTo delineate hospital service areas (HSAs) using the Dartmouth approach in China and identify the hypothesised demand-side, supply-side and region-specific factors of health expenditure within HSAs.DesignPopulation-based descriptive study.SettingWe selected the metropolis of Chengdu, one of the three most populous cities in China as a case for the analysis, where approximately 16.33 million residents living.ParticipantsIndividual-level in-patient discharge records (n=904 298) during the fourth quarter of 2018 (from 1 September to 31 December) were extracted from Sichuan Health Commission. Cases of non-residents of Chengdu were excluded from the datasets.MethodsWe conducted three sets of analyses: (1) apply Dartmouth approach to delineate HSAs; (2) use Geographic Information System (GIS)-based method to demonstrate health expenditure variations across delineated HSAs and (3) employ a three-level multilevel linear model to examine the association between health expenditure and demand-side, supply-side and region-specific factors.ResultsA total of 113 HSAs with a median population of 60 472 (ranging from 7022 to 827 750) was delineated. Total in-patient expenditure per admission varied more than threefold across HSAs after adjusting for age and gender. Apart from a list of demand-side factors, an increased number of physicians, healthcare facilities at higher levels and for-profit healthcare facilities were significantly associated with increased total in-patient expenditures. At the HSA level, the proportion of private healthcare facilities located in a single HSA was associated with increased total in-patient expenditure generated by that HSA, while the increased number of healthcare facilities in a HSA was negatively associated with the total in-patient expenditures.ConclusionHSAs were delineated to help establish an accountable healthcare delivery system, which serves as local hospital markets to provide in-patient healthcare via connecting demanders with suppliers inside particular HSAs. Policy-makers should adopt HSAs to identify variations of total in-patient expenditures among different areas and the potential associated factors. Findings from the HSA-based analysis could inform the formulation of relevant health policies and the optimisation of healthcare resource allocations.

ObjectiveLittle is known about barriers to healthcare access for two-spirit, gay, bisexual and queer (2SGBQ+) men in Manitoba.DesignData were drawn from a community-based, cross-sectional survey designed to examine health and healthcare access among 2SGBQ+ men.SettingCommunity-based cross-sectional study in Manitoba, Canada.ParticipantsCommunity-based sample of 368 2SGBQ+ men.OutcomesLogistic regression analyses assessed the relationship between sociodemographics, healthcare discrimination, perceived healthcare providers’ 2SGBQ+ competence/knowledge and two indicators of healthcare access (analytic outcome variables): (1) having a regular healthcare provider and (2) having had a healthcare visit in the past 12 months.ResultsIn multivariate analyses, living in Brandon (adjusted OR (AOR)=0.08, 95% CI 0.03 to 0.22), small cities (AOR=0.20, 95% CI 0.04 to 0.98) and smaller towns (AOR=0.26, 95% CI 0.08 o 0.81) in Manitoba (compared with living in Winnipeg), as well as having a healthcare provider with poor (AOR=0.19, 95% CI 0.04 to 0.90) or very poor competence/knowledge (AOR=0.03, 95% CI 0.03 to 0.25) of 2SGBQ+ men’s issues (compared with very good competence) was associated with lower odds of having a regular healthcare provider. Living in Brandon (AOR=0.05, 95% CI 0.02 to 0.17) and smaller towns (AOR=0.25, 95% CI 0.67 to 0.90) in Manitoba (compared with living in Winnipeg) was associated with lower odds of having a healthcare visit in the past 12 months, while identifying as a gay man compared with bisexual (AOR=12.57, 95% CI 1.88 to 83.97) was associated with higher odds of having a healthcare visit in the past 12 months.ConclusionsThese findings underscore the importance of reducing the gap between the healthcare access of rural and urban 2SGBQ+ men, improving healthcare providers’ cultural competence and addressing their lack of knowledge of 2SGBQ+ men’s issues.

ObjectivesThis study aimed to examine the prevalence of peritraumatic stress symptoms (PTSSs), perceived threat, social support and factors contributing to clinically significant PTSS among frontline COVID-19 healthcare workers (HCWs) in China.Design and settingAn online survey through self-administered questionnaires was conducted from 18 February to 4 March 2020, during the outbreak of COVID-19.Outcomes measuresPTSS was assessed using the post-traumatic stress disorder (PTSD) self-rating scale. Demographic and socioeconomic characteristics, self-reported health, physical/psychological symptoms, perceived threat from frontline work and perceived social support were investigated. Multivariable line regression analysis distinguished factors associated with HCWs’ PTSS scores.ResultsA total of 676 (58.1%) HCWs have shown clinically significant high levels of PTSS. Only 441 (37.9%) self-reported good health. Most had physical symptom(s) (915 (78.7%)), psychological symptom(s) (906 (77.9%)), inability to vent emotions (284 (24.4%)), emotional exhaustion (666 (57.3%)) and 1037 (89.2%) needed professional respect. Moreover, social support received was less than expected, and the receipt of psychological services/help scored the lowest (3.11±1.73). Combined psychological and physical symptoms, difficulty in releasing tension and venting emotions timely, fear of infection, emotional exhaustion and depersonalisation are significantly associated with PTSS scores among frontline HCWs. Working ≥8 hours, having the senior professional title, self-reported health, enjoying perfect protection and control measures, economic subsidy and control policy on reducing discriminatory practices are negatively correlated with PTSS scores.ConclusionsDuring the outbreak of COVID-19, frontline HCWs experienced clinically significant high levels of PTSS and heavy workload, and the emergency resulted in their inadequate psychosocial support. If this is left unchecked, HCWs have a higher risk of developing PTSD. Early detection, identification and person-directed, targeted multidisciplinary interventions should be undertaken to address various influencing factors. Comprehensive measures, including setting up emotional release channels, as well as providing psychological and social support intervention for HCWs globally, are highly recommended.

ObjectiveTo evaluate the validity of COVID-19 International Classification of Diseases, 10th Revision (ICD-10) codes and their combinations.DesignRetrospective cohort study.SettingAcute care hospitals and emergency departments (EDs) in Alberta, Canada.ParticipantsPatients who were admitted to hospital or presented to an ED in Alberta, as captured by local administrative databases between 1 March 2020 and 28 February 2021, who had a positive COVID-19 test and/or a COVID-19-related ICD-10 code.Main outcome measuresThe sensitivity, positive predictive value (PPV) and 95% CIs for ICD-10 codes were computed. Stratified analysis on age group, sex, symptomatic status, mechanical ventilation, hospital type, patient intensive care unit (ICU) admission, discharge status and season of pandemic were conducted.ResultsTwo overlapping subsets of the study population were considered: those who had a positive COVID-19 test (cohort A, for estimating sensitivity) and those who had a COVID-19-related ICD-10 code (cohort B, for estimating PPV). Cohort A included 17 979 ED patients and 6477 inpatients while cohort B included 33 675 ED patients and 18 746 inpatients. Of inpatients, 9.5% in cohort A and 8.1% in cohort B received mechanical ventilation. Over 13% of inpatients were admitted to ICU. The length of hospital stay was 6 days (IQR: 3–14) for cohort A and 8 days (IQR: 3–19) for cohort B. In-hospital mortality was 15.9% and 38.8% for cohort A and B, respectively. The sensitivity for ICD-10 code U07.1 (COVID-19, virus identified) was 82.5% (81.8%–83.2%) with a PPV of 93.1% (92.6%–93.6%). The combination of U07.1 and U07.3 (multisystem inflammatory syndrome associated with COVID-19) had a sensitivity of 82.5% (81.9%–83.2%) and PPV of 92.9% (92.4%–93.4%).ConclusionsIn Alberta, ICD-10 COVID-19 codes (U07.1 and U07.3) were coded well with high validity. This indicates administrative data can be used for COVID-19 research and pandemic management purposes.

IntroductionMany women in frontline healthcare positions face work demands that are incompatible with their needs and aspirations, resulting in poorer work satisfaction and engagement, and greater probability of leaving their jobs. Proactive career management is associated with elevated well-being and career success but may not be accessible to female health professionals who encounter social, cultural and structural barriers. The complex and diverse nature of proactive career management and absence of a comprehensive review on the topic necessitates a synthesis of extant literature. This study aims to identify (i) proactive career management behaviours and activities among female health professionals and (ii) outcomes of proactive career management initiatives. This study will contribute to a larger study on encouraging proactive career management behaviours among Singapore female health professionals.Methods and analysesScoping review is used as our method of evidence synthesis to provide a comprehensive overview of all available constructs and markers of interest. This study started in January 2022. Original research, reviews, short reports, letters, methodologies and case studies relevant to our objectives will be examined with guidance from Arksey and O’Malley’s framework. The literature contained in scientific databases and grey literature sources will be thoroughly searched. Two independent reviewers will screen citations for eligibility and extract data from the included articles. Extracted data will be narratively synthesised by two independent reviewers using Braun and Clarke’s six steps of thematic analysis. We will observe the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews standards in reporting the results. An advisory panel will provide insights on the applicability of the results to negate confirmation bias.Ethics and disseminationEthics clearance is not required. Dissemination plans include peer-reviewed journal publication and conference presentations.Registration detailsThis review was registered on open science framework (Registration DOI:https://doi.org/10.17605/OSF.IO/2SY8V).

ObjectiveTo better understand how to undertake valuable, ethical and sustainable randomised controlled clinical trial (RCT) research within Aboriginal and Torres Strait Islander primary health services.DesignIn a qualitative approach, we utilised data collected between 2013 and 2020 during the planning and implementation of two RCTs. The data comprised agreed records of research meetings, and semistructured interviews with clinical trial stakeholders. The stakeholders were parents/carers of child participants, and site-based research officers, healthcare providers and community advisory groups. Our thematic analysis was informed by constructivist grounded theory.SettingThe RCTs investigated the management of otitis media in Aboriginal and Torres Strait Islander children, with the first RCT commencing recruitment in 2014 and the second in 2017. They took place in Aboriginal Medical Services (AMSs), large primary health services for Aboriginal and Torres Strait Islander people, based in urban and regional communities across two Australian states and one territory.ResultsWe analysed data from 56 meetings and 67 interviews, generating themes on making research valuable and undertaking ethical and sustainable RCTs. Aboriginal and Torres Strait Islander leadership, and support of AMSs in their service delivery function were critical. The broad benefits of the trials were considered important to sustainability, including workforce development, enhanced ear healthcare and multidirectional research capacity building. Participants emphasised the long-term responsibility of research teams to deliver benefits to AMSs and communities regardless of RCT outcomes, and to focus on relationships, reciprocity and creating positive experiences of research.ConclusionWe identify principles and strategies to assist in undertaking ethical and sustainable RCTs within Aboriginal and Torres Strait Islander primary health services. Maintaining relationships with AMSs and focusing on mutual workforce development and capacity building creates opportunities for long-term benefits so that health research and RCTs work for Aboriginal and Torres Strait Islander peoples, services, communities and researchers.Trial registration numberACTRN12613001068752 (Pre-results); ACTRN12617001652369 (Pre-results).

IntroductionImproving discharge information dissemination may improve patients’ health literacy of self-care and health outcomes, avoid unnecessary healthcare utilisation, and reduce the healthcare cost. This study aims to use an implementation science theory guided approach to examine the beliefs and behaviours of healthcare professionals regarding postdischarge information summary (PDIS) implementation in a public inpatient setting.Methods and analysisA multistage study design involving qualitative inquiry and Delphi expert discussion will be used to systematically explore the perceived barriers in the four implemented hospitals and enable the full implementation of the PDIS in geriatric and medical care. The theoretical domains framework (TDF), behavioural change wheel and realistic evaluation framework will be used to guide the investigation of implementation. This study consists of three steps: (1) identifying barriers and enablers from an implementation perspective using a TDF-informed interview guide; (2) devising theory-based implementation strategy packages to facilitate the adoption and enhancement of PDIS by performing a strategy mapping exercise and (3) developing an effective implementation strategy package for scaling up PDIS in other target hospitals as well as other specialities using the Delphi expert discussion. The goal of this multistage study design is to identify the perspectives from healthcare professionals towards the PDIS implementation and explore their barriers and facilitators of the process in the pilot phase. The invited healthcare professionals would share their daily experience on providing PDIS to patient in various study hospitals with similar ward setting. The implementation of discharge intervention in a study setting through different steps to aid in the exploration and development of the modified implementation strategies for the adoption and enhancement of PDIS in the discharge process.Ethics and disseminationEthics approval for the study was obtained from the Joint Chinese University of Hong Kong—New Territories East Cluster Clinical Research Ethics Committees. Results of the study would be released as a report submitted to the Health and Medical Research Fund of Food and Health Bureau of the Hong Kong Government. The result would also be published in international peer-reviewed medical journals and presented in conferences.Trial registration numberChiCTR2000034382.

IntroductionRecent studies have pointed to the substantial role of private health sector delivery of maternal and newborn health (MNH) care in low-/middle-income countries (LMICs). While this role has been partly documented, an evidence synthesis is missing. To analyse opportunities and challenges of private sector delivery of MNH care as they pertain to the new World Health Organization (WHO) strategy on engaging the private health service delivery sector through governance in mixed health systems, a more granular understanding of the private health sector’s role and extent in MNH delivery is imperative. We developed a scoping review protocol to map and conceptualise interventions that were explicitly designed and implemented by formal private health sector providers to deliver MNH care in mixed health systems.Methods and analysisThis protocol details our intended methodological and analytical approach following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Seven databases (Cumulative Index to Nursing and Allied Health, Excerpta Medica Database, International Bibliography of the Social Sciences, PubMed, ScienceDirect, Web of Science, WHO Institutional Repository for Information Sharing) and two websites will be searched for studies published between 1 January 2002 and 1 June 2021. For inclusion, quantitative and/or qualitative studies in LMICs must report at least one of the following outcomes: maternal morbidity or mortality; newborn morbidity or mortality; experience of care; use of formal private sector care during pregnancy, childbirth, and postpartum; and stillbirth. Analyses will synthesise the evidence base and gaps on private sector MNH service delivery interventions for each of the six governance behaviours.Ethics and disseminationEthical approval is not required. Findings will be used to develop a menu of private sector interventions for MNH care by governance behaviour. This study will be disseminated through a peer-reviewed publication, working groups, webinars and partners.

IntroductionThe development of innovative invasive procedures and devices are essential to improving outcomes in healthcare. However, how these are introduced into practice has not been studied in detail. The Lotus study will follow a wide range of ‘case studies’ of new procedures and/or devices being introduced into NHS trusts to explore what information is communicated to patients, how procedures are modified over time and how outcomes are selected and reported.Methods and analysisThis qualitative study will use ethnographic approaches to investigate how new invasive procedures and/or devices are introduced. Consultations in which the innovation is discussed will be audio-recorded to understand information provision practice. To understand if and how procedures evolve, they will be video recorded and non-participant observations will be conducted. Post-operative interviews will be conducted with the innovating team and patients who are eligible for the intervention. Audio-recordings will be audio-recorded, transcribed verbatim and analysed thematically using constant comparison techniques. Video-recordings will be reviewed to deconstruct procedures into key components and document how the procedure evolves. Comparisons will be made between the different data sources.Ethics and disseminationThe study protocol has Health Research Authority (HRA) and Health and Care Research Wales approval (Ref 18/SW/0277). Results will be disseminated at appropriate conferences and will be published in peer-reviewed journals. The findings of this study will provide a better understanding of how innovative invasive procedures and/or devices are introduced into practice.

ObjectivesThe COVID-19 pandemic has changed the way people are accessing healthcare. The aim of this study was to examine the impact of COVID-19 on emergency department (ED) attendance for frequent attenders and to explore potential reasons for changes in attendance.DesignThis convergent parallel mixed methods study comprised two parts.SettingAn interrupted time-series analysis evaluated changes in ED presentation rates; interviews investigated reasons for changes for frequent ED users in a culturally and linguistically diverse setting.ParticipantsA total of 4868 patients were included in the time series. A subgroup of 200 patients were interviewed, mean age 66 years (range 23–99).ResultsInterrupted time-series analysis from 4868 eligible participants showed an instantaneous decrease in weekly ED presentations by 36% (pConclusionsThis study demonstrated reduced ED use by a vulnerable population of previously frequent attenders. COVID-19 has resulted in some fear and avoidance of hospitals, but has also offered new opportunity for alternative care through telehealth.

ObjectivesThe aim of this study was to explore the relationship between functional disability and depressive symptoms, focusing on whether an interaction exists between functional disability, demographic characteristics and depressive symptoms among older adults in rural China.DesignA cross-sectional study using multistage, stratified random sampling.SettingData from 18 villages in Anhui Province of China between January to July 2018.Participants3491 Chinese participants aged 60 and over.Primary and secondary outcome measuresThe 30-item Geriatric Depression Scale and WHO Disability Assessment Schedule 2.0 were used to evaluate depressive symptoms and functional disability, respectively. Data were analysed using SPSS statistics V.25.0 program with χ2test, Mann-Whitney U test, binary logistic regression analysis and classification and regression tree (CART) model.ResultsThe prevalence of depressive symptoms in 3336 interviewed older people was 52.94%. After adjustment, subjects who had problems in mobility domain (adjusted OR (AOR) 1.842, 95% CI 1.503 to 2.258), getting along domain (AOR 1.616, 95% CI 1.299 to 2.010), life activities domain (AOR 1.683, 95% CI 1.370 to 2.066) and participation domain (AOR 3.499, 95% CI 2.385 to 4.987) had an increased depressive symptoms risk. However, cognition domain (AOR 0.785, 95% CI 0.647 to 0.953) negatively correlated with depressive symptoms. Additionally, the CART model showed that those who had problems in mobility domain, getting along domain and were unemployed, the possibility of having depressive symptoms was the highest.ConclusionsMore attention should be paid to unemployed older adults, and those with problems in participation, life activities, getting along and mobility and no problems in cognition to maintain a good psychological state.

ObjectivesThe Texas Christian University Organisational Readiness for Change Scale (TCU-ORC) assesses factors influencing adoption of evidence-based practices. It has not been validated in low-income and middle-income countries (LMIC). This study assessed its psychometric properties in a South African setting with the aim of adapting it into a shorter measure.MethodsThis study was conducted in 24 South African primary healthcare clinics in the Western Cape Province. The TCU-ORC and two other measures, the Organisational Readiness to Change Assessment (ORCA) and the Checklist for Assessing Readiness for Implementation (CARI) were administered. The questionnaire was readministered after 2 weeks to obtain data on test–retest reliability. Three hundred and ninety-five surveys were completed: 281 participants completed the first survey, and 118 recompleted the assessments.ResultsWe used exploratory factor analysis (EFA) to identify latent dimensions represented in the data. Cronbach’s alpha for each subscale was assessed and we examined the extent to which the subscales and total scale scores for the first and retest surveys correlated. Convergent validity was assessed by the correlation coefficient between the TCU-ORC, ORCA and CARI total scale scores. EFA resulted in a three-factor solution. The three subscales proposed are Clinic Organisational Climate (8 items), Motivational Readiness for Change (13 items) and Individual Change Efficacy (5 items) (26 items total). Cronbach’s alpha for each subscale was >0.80. The overall shortened scale had a test–retest correlation of r=0.80, p=39, p<0.05) and strong correlation with the original scale (r=0.79, pConclusionsThis study presents the first psychometric data on the TCU-ORC from an LMIC. The proposed shortened tool may be more feasible for use in LMICs.Trial registration numberResults stage. Project MIND trial. Pan-African Clinical Trials Registry. PACTR201610001825405.

ObjectiveThis study aimed to explore pharmacists’ perceptions on drug shortages and its impingement on the Pakistani healthcare system, in particular on patient care.DesignOnline questionnaire survey.Setting and participantsHospital pharmacists from five out of seven regions of Pakistan were approached; including the federal territory (Islamabad) and four provinces (Khyber Pakhtunkhwa, Balochistan, Punjab and Sindh).Primary and secondary outcome measuresPrevalence and type of shortages were identified along with strategies to reduce its effect on patient care.MethodA validated questionnaire was distributed through various online platforms to 800 registered hospital pharmacists. A convenience sampling technique was used to obtain information on drug shortages, the reporting system for shortages, the impact on patients and policy solutions for managing drug shortages.ResultsOut of 800 hospital pharmacists, 708 completed the questionnaire (response rate: 88.5%). Of these hospital pharmacists, 47% came from hospitals of Punjab, 26% from Khyber Pakhtunkhwa, 13% from Sindh, 11% from Balochistan and 4% from Islamabad; 72% and 28% worked in tertiary and secondary hospitals, respectively. The majority (32%) interacted with shortages daily. The top three drug categories reported in shortage were oncology drugs (54%), cardiovascular drugs (53%) and antimicrobials (42%). 58% of the respondents have seen care delayed as a negative consequence of shortages. ‘Creating new communication system’ (65%) and ‘readjust budget plans’ (41%) were the two most frequently indicated recommendations for shortages management at hospital, while ‘circulars or alerts from the regulatory authority’ (60%) and ‘time to time directives from local health statuaries’ (48%) were two most widely suggested policy solutions.ConclusionDrug shortage is a serious concern in Pakistani hospitals, experienced on a daily basis endangering patients’ health. Enhanced communication is required, connecting the key stakeholders. Health policies should be reviewed; adequate funds should be allocated to the health sector preventing future shortages.

IntroductionMusculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people’s risk of poor outcome.Methods and analysisMulticentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration.Ethics and disseminationEthics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media.Trial registration numberACTRN12619000871145.

IntroductionSeveral studies explored a relationship between religiousness and the utilisation of cancer screenings, as religious people may obtain an increased social network or could have certain personality traits that enhance screening use. To the best of our knowledge, there is no systematic review that sums up the evidence gained from research on that relationship. Thus, our review aims to appraise the findings of observational studies regarding that relationship. Its findings may be useful in addressing specific target groups to increase ineffectively the low cancer screening rates.Methods and analysisEmploying a predefined search algorithm, three online databases (CINAHL, PsycInfo and PubMed) will be searched. In addition, the bibliographies of the studies included in our review will be searched through manually and independently by two reviewers. We are looking for observational studies (both cross-sectional and longitudinal) which examine the association between religion and cancer screening utilisation. However, studies regarding specific samples (as ethnic minorities or religious sects) will be excluded. We expect that the studies examine various dimensions of religion, such as religious attendance or religious intensity. We will extract data that describe methodology, sample characteristics and the findings concerning our object of investigation. Moreover, a quality assessment will be performed. Two reviewers will independently select the studies, extract the data and assess the studies’ quality. Disagreements will be dissolved by discussion or by inclusion of a third party. The findings will be presented narratively in text and tables. If possible, a meta-analysis will be carried out.Ethics and disseminationAs no primary data are collected, the approval from an ethics committee is not required. Our review will be published in a peer-reviewed, scientific journal.PROSPERO registration numberCRD42021229222.

ObjectivesUsing nationally representative surveys, the study’s aims were to: (1) evaluate healthcare facilities’ readiness to provide diabetes mellitus (DM) services and (2) identify the factors that affect DM service readiness.Data sourceData from Service Provision Assessment surveys conducted in three low-resource South Asian (SA) countries: Afghanistan, Bangladesh and Nepal, were used in this study.DesignCross-sectional nationally representative surveyParticipantsA total of 117, 317 and 397 public and private health facilities in Afghanistan, Bangladesh and Nepal, respectively were analysed.Primary outcomeA total of 12 items/indicators were used to measure a health facility’s readiness to provide DM services across four domains.ResultsFor DM management, about 39.3%, 58.4% and 58.2% of health facilities in Afghanistan, Bangladesh and Nepal centred around 7–8, 3–6 and 4–6 items. Only 12.8%, 5.0% and 4.8% of healthcare facilities in Afghanistan, Bangladesh and Nepal reported having at least % (9/12) of the necessary items for DM management, and no one reported having all 12 important items for DM management. According to the negative binomial regression models, the factors associated with higher readiness scores vary among the three countries analysed. Regression models also showed that increases in the number of DM care providers and facility types are similar factors linked to increased readiness scores in all three countries.ConclusionsIn order to increase a health facility’s readiness to offer DM care, country-specific factors must be addressed in addition to common factors found in all three countries. Further research is required to determine the cause of country-level differences in tracer item availability in order to develop targeted and effective country-specific strategies to improve care quality in the SA region.

ObjectiveTo determine if the choice of methodological elements affects the results in continuity of care studies.DesignThis is a retrospective cohort study. The association between continuity of care and clinical outcome was investigated using the Continuity of Care Index. The association was explored in 12 scenarios based on four definitions of the relative timing of continuity and outcome measurements in three populations (threePs × fourTs).SettingNational Health Insurance claims from all primary and secondary care facilities in South Korea between 2007 and 2015.ParticipantsParticipants were patients diagnosed with dyslipidaemia, made ≥2 ambulatory visits and were newly prescribed with ≥1 antihyperlipidaemic agent at an ambulatory setting in 2008. Three study populations were defined based on the number of ambulatory visits: 10 084 patients in population 1 (P1), 8454 in population 2 (P2) and 4754 in population 3 (P3).Main outcome measureHospitalisation related to one of the four atherosclerotic cardiovascular diseases, including myocardial infarction, stable or unstable angina, ischaemic stroke and transient ischaemic attack.ResultsConcurrent measure of continuity and outcome (T1) showed a significantly higher risk of hospitalisation (adjusted HRs: 2.73–3.07, pConclusionsThe study design in continuity of care studies should be planned carefully because the results are sensitive to the temporal relationship between continuity and outcome and the population selection criteria.

IntroductionThe impacts of violence have a significant effect on health and well-being, particularly for women and children. Violence within families is widely recognised as a complex problem constituted by constantly interacting and evolving social, economic, health and cultural elements. Calls for integrated services have arisen from growing understanding about the implications of this complexity, which suggest family violence and solutions to it are generated endogenously from the reflexive nonlinear interactions of system agents. Despite these calls for integration, services designed to support families impacted by violence and the systems that design and fund them are often responsive only to one part of the problem and might not pay attention to agent interactions and their adaptive reflexivity. This paper outlines a scoping protocol to explore how integrated approaches to family violence are conceptualised in current literature, with innovative use of a complexity theory lens.MethodOur scoping review protocol follows the framework outlined by Arksey and O’Malley and refined by Levac. It searches 6 databases, 3 journals and 10 websites using keywords to capture the notion of integration and a complex adaptive system, namely the participant (system agents), concept (system agent interaction) and the context (family violence). Selection criteria require the articles to be written in English, have full-text article available, and were published after 2010. Items selected also need to be evidence based showing interaction between system agents. Applying complexity theory, sensitises us to the reflexive patterns of interaction between system elements and routine ways of interacting.Ethics and disseminationThe nature of this review means that ethics approval is not required. Findings will be disseminated via academic publications, conferences and discussions with policy decision-makers. The findings will be used to develop a plan for stakeholder consultation to share and validate learnings and inform future research.

ObjectiveLittle is known about clinicians’ decision-making about decreasing active surveillance (AS) testing/converting patients to watchful waiting (WW), nor are there any guidelines. The objective of this study was to identify factors that clinicians consider when decreasing AS testing/converting to WW for men with prostate cancer.DesignExploratory qualitative study.SettingAll participants practiced in various institutions in the USA.ParticipantsEligible clinicians had to provide clinical care for patients with prostate cancer in the USA and speak English. Clinicians could be either urologists or radiation oncologists. Of the 24 clinicians, 83% were urologists representing 11 states, 92% were men and 62% were white.MethodsThis qualitative study used data from semi-structured interviews. Purposive sampling was used to ensure geographical variation in the USA. Data collection continued until thematic saturation was achieved. Framework analysis guided coding and identification of themes. Two researchers coded all transcripts independently, met to discuss and reached consensus.ResultsInterviews with clinicians demonstrated that testing or monitoring for AS or transitioning to WW is happening in practice, whether intentionally or unintentionally. Decisions to decrease AS were personalised and tailored to patients’ health status. Life expectancy was the dominant factor that influenced decision, but clinicians were generally hesitant to specify an age when they would decrease AS or transition to WW. Fear that poor adherence could lead to missed progression and concerns about the medico-legal issue of not doing enough were cited as barriers to decreasing AS.ConclusionsThese findings suggest that in certain situations, AS frequency is reduced or transitioned to WW, yet decisions appear to be inconsistent and there are no significant barriers. These findings could inform further areas to explore when drafting recommendations that consider patients’ values and preferences when making decisions about decreasing AS/converting to WW.

ObjectiveThis study investigates the frequency of sexual harassment among female nurses in the Greek health system and the nurses’ reluctance to report their experiences.DesignCross-sectional study.SettingGreece.Participants1264 female nurses of working age across different settings responded to the Sexual Experiences Questionnaire (SEQ) web-based format between October 2020 and February 2021. The period investigated by the SEQ was the participant’s entire professional life. The final sample consisted of 1217 nurses with valid data on the frequency of sexually harassing behaviours (gender harassment, unwanted sexual attention, sexual coercion) and the reasons for not reporting sexual harassment.Main outcome measuresThe frequency of sexual harassment was measured in a 5-point Likert Scale (1: very often, 2: often, 3: occasionally, 4: rarely, 5: never), the decision to report/not report sexual harassment was measured in a yes/no format and the impact of sexual harassment on the physical, mental and job-related performance was measured in a 5-point Likert Scale (1: very positively, 2: positively, 3: moderately, 4: negatively, 5: very negatively).Results70% of the nurses have experienced sexual harassment at least once in their working lives, while the most frequent type is gender harassment. Male doctors are the most common perpetrators. T-tests and analysis of variance showed that private and younger nurses were more likely to experience sexual harassment while divorced nurses with 1–5 years of experience dealt with sexually coercive behaviours more frequently. 30% did not report sexual harassment because of the fear of negative consequences and beliefs that no action will be taken against the perpetrator. Multiple regression analyses showed that unwanted sexual attention and sexual coercion explain the victim’s physical and job-related adverse outcomes. Cronbach’s α was 0.939.ConclusionsThe results show that sexual harassment rates are high in the Greek health system, while many victims do not report their experiences to the authorities. This emphasises the need to implement drastic measures on behalf of the National Health Service (NHS) policy makers towards helping victims speak up without the fear of negative consequences. Nurse managers are called to implement effective policies against sexual harassment.

IntroductionEven in advanced economies with universal healthcare coverage (UHC), a social gradient in healthcare utilisation has been reported. Many individual, community and healthcare system factors have been considered that may be associated with the variation in healthcare utilisation between socioeconomic groups. Nevertheless, relatively little is known about the complex interaction and relative contribution of these factors to socioeconomic differences in healthcare utilisation. In order to improve understanding of why utilisation patterns differ by socioeconomic status (SES), the proposed systematic review will explore the main mechanisms that have been examined in quantitative research.Methods and analysisThe systematic review will follow the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and will be conducted in Embase, PubMed, Scopus, Web of Science, Econlit and PsycInfo. Articles examining factors associated with the differences in primary and specialised healthcare utilisation between socioeconomic groups in Organisation for Economic Co-operation and Development (OECD) countries with UHC will be included. Further restrictions concern specifications of outcome measures, factors of interest, study design, population, language and type of publication. Data will be numerically summarised, narratively synthesised and thematically discussed. The factors will be categorised according to existing frameworks for barriers to healthcare access.Ethics and disseminationNo primary data will be collected. No ethics approval is required. We intend to publish a scientific article in an international peer-reviewed journal.

ObjectivesPatients in German ambulatory care frequently report patient safety problems (PSP). It is unclear whether patients report PSP back to their general practitioner (GP) or specialist in charge. This study reports on how patients respond to experienced PSP.DesignRetrospective cross-sectional study.SettingComputer-assisted telephone interviews (CATI) with randomly recruited citizens aged ≥40 years in Germany.Participants10 037 citizens ≥40 years. About 52% of the interviewees were female, 38% were between 60 and 79 years old and about 47% reported that they were chronically ill. A total of 2589 PSPs was reported.Primary and secondary measures/ResultsAccording to the respondents (n=1422, 77%, 95% CI: 74.7 to 79.1), 72% (95% CI: 70.2 to 73.7) of PSP were reported back to the GP in charge or to another GP/specialist. Further reactions were taken by 65% (95% CI: 62.5 to 67.5) of the interviewees: around 63% (95% CI: 62.5 to 66.2) of the reported PSP led to a loss of faith in the physician or to complaints. χ2 and binary logistic regression analyses show significant associations between the (a) reporting and (b) reaction behaviour and determinants like ‘medical treatment area’ ((a) χ2=17.13, p=0.009/(b) χ2=97.58, p=0.000), ‘PSP with/without harm’ ((a) χ2=111.84, p=0.000/(b) χ2=265.39, p=0.000) and sociodemographic characteristics when respondents are aged between 40 and 59 years ((a) OR 2.57/(b) OR 2.60) or have chronic illnesses ((a) OR 2.16/(b) OR 2.14).ConclusionThe data suggest that PSPs are frequently reported back to the GP or specialist in charge and have a significant serious impact on the physician–patient relationship. Much could be learnt from the patient reporting and reacting behaviour to prevent PSPs in ambulatory care.

ObjectivesWhile CT scanning plays a significant role in healthcare, its increasing use has raised concerns about inappropriate use. This study investigated factors driving the changing use of CT among people admitted to tertiary hospitals in Western Australia (WA).Design and settingA repeated cross-sectional study of CT use in WA in 2003–2005 and 2013–2015 using linked administrative heath data at the individual patient level.ParticipantsA total of 2 375 787 tertiary hospital admissions of people aged 18 years or older.Main outcome measureRate of CT scanning per 1000 hospital admissions.MethodsA multivariable decomposition model was used to quantify the contribution of changes in patient characteristics and changes in the probability of having a CT over the study period.ResultsThe rate of CT scanning increased by 112 CT scans per 1000 admissions over the study period. Changes in the distribution of the observed patient characteristics were accounted for 62.7% of the growth in CT use. However, among unplanned admissions, changes in the distribution of patient characteristics only explained 17% of the growth in CT use, the remainder being explained by changes in the probability of having a CT scan. While the relative probability of having a CT scan generally increased over time across most observed characteristics, it reduced in young adults (−2.8%), people living in the rural/remote areas (−0.8%) and people transferred from secondary hospitals (−0.8%).ConclusionsOur study highlights potential improvements in practice towards reducing medical radiation exposure in certain high risk population. Since changes in the relative probability of having a CT scan (representing changes in scope) rather than changes in the distribution of the patient characteristics (representing changes in need) explained a major proportion of the growth in CT use, this warrants more in-depth investigations in clinical practices to better inform health policies promoting appropriate use of diagnostic imaging tests.

ObjectivesThe current study aimed to evaluate the status quo of perceived job demands and resources respectively among Chinese doctors, to examine the mediating role of work–family conflicts in the relationship between perceived job demands and various indicators of well-being, and to test the mediating role of psychological attachment in the relationship between perceived job resources and thriving at work among Chinese doctors.DesignA cross-sectional online survey study.SettingOnline questionnaires were administered across 30 provinces.ParticipantsA total of 2617 doctors provided sufficiently complete responses to be used in the study.ResultsPerceived job demands (M=3.843, SD=0.791) of participants were positively associated with work–family conflicts (B=0.454, pB=−0.065, pB=−0.261, pM=2.474, SD=0.740) among Chinese doctors were positively associated with psychological attachment (B=0.988, pB=0.582, pConclusionDoctors in China with high-level job demands tended to exhibit increased work–family conflicts, which in turn threatened their job and life satisfaction. On the contrary, doctors with greater job resources were more likely to thrive at work by increasing their degree of psychological attachment. The current study suggested that Chinese health policymakers and hospital administrators should provide a work environment with a dynamic equilibrium between doctors’ job demands and resources.

IntroductionThe well-being and health of healthcare personnel is becoming increasingly important in the delivery of high-quality healthcare. The recent developments in technology have provided new opportunities for the objective detection of a wide variety of real-world properties and movement. However, technologies that are used to monitor health, well-being and movement among healthcare personnel have not been fully synthesised. The overall aim of this scoping review is to examine what type of sensor technology is available to monitor the health, well-being and movement of healthcare personnel in healthcare settings. More specifically, we want to explore what types of sensor technology applications, for what purposes and how they have been used to monitor health, well-being and movement among healthcare personnel in different workplace settings.Methods and analysisThis scoping review protocol will follow Arksey and O’Malley’s methodology, complemented by the approach of the Joanna Briggs Institute to scoping reviews and guidance for conducting systematic scoping reviews. Peer-reviewed literature will be identified using a search strategy developed by a librarian, and a wide range of electronic datasets of medical, computer and information systems disciplines will be used. Eligibility of the articles will be determined using a two-stage screening process consisting of (1) a title and abstract scan, and (2) a full-text review. Extracted data will be thematically analysed and validated by an expert of sensor technology and a group of nurses as stakeholders. Descriptive statistics will be calculated when necessary.Ethics and disseminationThe results obtained from the review will inform what technology has been used, how it has been used in healthcare settings and what types of technology might still be needed for future innovations. Findings of the scoping review will be published in a peer-reviewed journal.RegistrationThis review was submitted in Open Science Framework on 12 December 2020.