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Introduction Building and implementing a robust evidence-base which is informed by high quality research is the challenge facing contemporary healthcare professions. In doing so, it can be valuable for healthcare professions to establish a strategic research agenda in order to enhance the professions public health priorities within healthcare and assist in the allocation of limited research resources. Whilst formal chiropractic research agendas have been established in North America and Europe, no comprehensive, inter-organisational chiropractic research agenda has been formulated within the Australian context. A critical precursor to inform the development of any such Australian chiropractic research agenda, is the identification of the priorities held by practising chiropractors, chiropractic academics, educators, researchers, and postgraduate HDR students, along with an appraisal of the current research capacity and output of the Australian chiropractic profession. Objectives Design a questionnaire to; a) identify and rank the research priorities of a national sample of practising chiropractors, chiropractic academics, educators, researchers, and postgraduate HDR students, and; b) examine the current research capacity and output of the Australian chiropractic profession. Methods A survey instrument design was developed via an iterative process that initially built upon an extensive search of the chiropractic research priority literature from which items were aggregated and distilled. Senior and experienced members of the profession were then consulted to identify other items that should be considered for inclusion. Results The finalised cross-sectional questionnaire is a self-administered, multi-dimensional instrument comprising 5 main research categories. In addition, the questionnaire also includes items such as research funding, support for existing research agendas, and suggestions for future research. The questionnaire also explores research output, research barriers, research time allocation, perspectives on engagement, interdisciplinary collaboration and secured research funding. Analysis Quantitative data will be descriptively analysed whilst qualitative data will be analysed and reported along standard qualitative study protocols. Conclusion The Australian chiropractic profession needs to maximise ambitious, collaborative, creative research performed at best practice standards and then accelerate the implementation of useful findings that emerge. By ensuring the voices of all sectors of the profession are heard in the formulation of an Australian Chiropractic Research Agenda, the findings from our study will provide important insights into future research directions for the Australian chiropractic profession.

Background Impaired sleep is a common complaint among patients undergoing major surgery and may be a contributing factor in postoperative pain. The provision of eye masks to patients after cardiac surgery may reduce postoperative pain through improvements in sleep quality. Objective To examine the effect of nocturnal eye masks on postoperative pain and sleep quality in cardiac surgical patients. Methods In this randomized controlled trial, 70 adult patients who had undergone cardiac surgery requiring immediate postoperative care in the intensive care unit were randomly assigned to sleep with or without nocturnal eye masks for the first 3 nights in the unit. A visual analog scale was used to assess pain intensity, and the Arabic version of the Richards-Campbell Sleep Questionnaire was used to assess subjective sleep quality. Results A total of 66 patients completed the trial. A statistically significant difference was found between groups in mean total Richards-Campbell Sleep Questionnaire score over the 3-day study period (P = .001), with the intervention group reporting better sleep quality. A statistically significant difference was also found between groups in mean pain score on days 1, 2, and 3 (P < .001), with the intervention group having less pain. Conclusion Nocturnal eye masks are a simple, low-risk, low-cost intervention that may contribute to reductions in perceived pain in cardiac surgery patients.

© 2019 The Author(s). Background: Osteopaths are an integral member of the health care team, playing a pivotal role in the provision of care for patients with musculoskeletal disorders. Osteopaths, like other health care providers, are under increasing pressure to deliver evidence-based health care and to improve patient outcomes. However, the extent to which osteopaths engage in evidence-based practice (EBP), particularly in Australia, is not well understood. This study therefore set out to investigate the attitudes, skills and use of EBP, and perceived barriers and enablers of EBP uptake, among osteopaths practicing in Australia. Methods: National cross-sectional survey of Australian registered osteopaths. Eligible participants were invited by email and other digital media recruitment strategies to complete the online Evidence-Based Practice Attitude and Utilisation Survey (EBASE). Results: A total of 332 osteopaths completed the survey. The demographic characteristics of respondents were generally consistent with the characteristics of the Australian osteopathy workforce. The respondents were mostly favourable of EBP, with the majority agreeing or strongly agreeing that EBP assists in making decisions about patient care (86.7%) and improves the quality of patient care (75.6%). While most respondents (88.3%) had some training in EBP, most reported a moderate level of perceived skill in EBP. The majority of respondents engaged infrequently (0-5 times) in EBP activities within the last month, and most indicated that a very small or small proportion of their clinical practice was based on clinical research evidence. Leading barriers to the uptake of EBP were lack of time and lack of clinical evidence in osteopathy. Key enablers of EBP uptake were access to the internet and online databases at work, and access to full-text articles and EBP education materials. Conclusions: Osteopaths participating in the survey were largely supportive of evidence-based practice, yet engaged infrequently in EBP activities. An important next step in this research is to identify suitable strategies that effectively improve EBP uptake in osteopathy, and perchance, improve patient outcomes.

Purpose: Accessibility and availability of health care services/providers is an increasing concern for many regional communities, particularly regional South Australia. Assessing the level of health service/provider utilization within a region (ie, expressed demand) can be useful in determining health care need and health service/workforce demand. Methods: The regional South Australia health (RESONATE) survey aimed to determine the expressed demand for health care services and the health workforce in a regional South Australian population. The study was open to adults living in regional South Australia and was promoted using a comprehensive multimodal recruitment campaign. Data were collected between April 2017 and March 2018 using the consumer utilization, expectations and experiences of healthcare instrument. Findings: A total of 3,926 adults completed the questionnaire. Participants reported using 47 different health care providers in the previous 12 months. Whilst almost all (92.9%) participants had seen a general practitioner in the past 12 months, yoga instructors, chiropractors, pharmacists, and physiotherapists were visited most frequently. Proportionally fewer participants in more remote locations received conventional services/treatments, though a significantly greater proportion of those in more remote locations had received complementary medicine services/treatments (relative to inner regional areas). Conclusions: Findings of the RESONATE survey point to a high level of expressed demand for conventional and complementary health care services among study participants, possibly higher than that reported in the general population. Examining the extent to which the health needs of this and other regional populations are met should be the focus of further research to better inform future health workforce/services planning Refereed/Peer-reviewed

Background: The public health relevance of true vitamin D deficiency is undisputed, although controversy remains regarding optimal vitamin D status. Few contemporary cross-ethnic studies have investigated the prevalence and determinants of very low 25-hydroxyvitamin D [25(OH)D] concentrations. Methods: We conducted cross-ethnic analyses on the prevalence and determinants of vitamin D deficiency (25(OH)D ≤ 25 nmol/L) using data from 440,581 UK Biobank participants, of which 415,903 identified as White European, 7880 Asian, 7602 Black African, 1383 Chinese, and 6473 of mixed ancestry. Determinants of vitamin D deficiency were examined by logistic regression. Results: The prevalence of vitamin D deficiency was highest among participants of Asian ancestry (57.2% in winter/spring and 50.8% in summer/autumn) followed by those of Black African ancestry (38.5% and 30.8%, respectively), mixed (36.5%, 22.5%), Chinese (33.1%, 20.7%) and White European ancestry (17.5%, 5.9%). Participants with higher socioeconomic deprivation were more likely to have 25(OH)D deficiency compared to less deprived participants (P =

Regional South Australia has some of the highest rates of psychological distress, chronic disease and multimorbidity of any Australian State or Territory. Yet, the healthcare needs of this population are still not completely understood. To better understand the healthcare needs of regional South Australians, we invited adults living in the region to complete the 44‐item consumer utilisation, expectations and experiences of healthcare instrument (CONVERSATIONS), online or in hard‐copy. The survey was conducted between April 2017 and March 2018. A multi‐modal recruitment campaign was utilised to promote the survey. We examined associations between study outcomes and remoteness area, and drew comparisons between our findings and other surveys reporting pertinent outcomes in the urban SA population. The questionnaire was completed by 3,926 adults (52.5% females; 37.6% aged 60 + years). Among the 264 distinct health conditions reported by participants, the most prevalent were hypertension (31.6%), depression (25.7%), anxiety (23.5%) and hypercholesterolaemia (22.9%). The lifetime prevalence of these conditions among participants exceeded rates reported in urban SA. The largest regional‐urban health disparities were observed for eczema/dermatitis, skin cancer, other cancer types and cataracts, where prevalence rates were 2075%, 400%, 373% and 324% higher, respectively, than that reported in urban SA. Participants also reported higher levels of multimorbidity (37.7% higher) relative to urban South Australians. By contrast, participants appeared to be exposed to fewer lifestyle risk behaviours (e.g. smoking, alcohol, inadequate fruit or vegetable intake) than their urban counterparts. In summary, there was a high level of healthcare need, and considerable health disparity among participants when compared with urban settings (particularly for skin and eye conditions). These findings highlight the need for a more targeted approach to delivering health services and health promotion activities in regional areas. Refereed/Peer-reviewed

Purpose: The dearth of accessible and appropriate conventional health care services in regional areas may drive many people to seek care provided by complementary medicine (CM) practitioners. Understanding the drivers of CM service use in this population may help inform future health services planning.This study set out to examine the determinants of CM service utilization in a regional South Australian population.Methods: Adults residing in regional South Australia between April 2017 and March 2018 were invited to complete the 44-item consumer utilization, expectations, and experiences of health care instrument. The questionnaire was available in print and online, and was promoted using a multimodal recruitment campaign. Independent predictors of CM service use were determined using multivariate logistic regression.Findings: Completing the questionnaire were 3,926 adults (56.7% aged 50+years; 52.5% females). Forty-seven percent of participants reported using a CM service within the last 12 months. Univariate analyses revealed a statistically significant association between 13 factors and CM service use. When these factors were forced into a multivariate logistic regression model, the number of predictors of CM service utilization was reduced to 10, which included 6 predisposing factors, 3 enabling factors, and 1 personal health practice. This model was able to explain 23.1% (Nagelkerke R2 = 0.231) of the variation in CM service use in this sample.Conclusions: A high level of CM service use was reported among participants living in regional South Australia. The findings highlight the degree to which the appropriateness of health services impacts health-seeking behavior in regional communities. Refereed/Peer-reviewed

Objective: To identify communication patterns of Registered Nurses regarding patients’ use of complementary therapies. Methods: A cross-sectional online survey conducted in 2017 recruited Australian Registered Nurses working in any area of nursing. Results: Responses of 614 Registered Nurses were analysed. Patient-initiated discussion of complementary therapies were common for 77% of nurses; nurse-initiated discussions were perceived by 73% (sometimes/almost always/always). Nurses’ personal use of complementary therapies predicted discussion with patients and education-based, oncology, or aged care/rehabilitation nurses were most likely to initiate dialogue. Many (55%) did not ‘recommend’ a particular therapy, although 12% ‘almost always/always’ did so. Four out of five nurses (84%) documented patients’ use and communicated with medical/nursing colleagues about this use. Conversely, 61% ‘never’ or ‘almost never’ communicated with a complementary therapy practitioner. Conclusion: Nurses working in Australia often discuss complementary therapies, however they rarely specifically recommend their use. Their workplace environment and clinical context influenced nurses’ willingness to communicate about complementary therapy use. Practice implications evidence: suggests the need for policy development to promote communication between mainstream healthcare providers and complementary therapy practitioners to support the delivery of safe, high quality patient care. Refereed/Peer-reviewed

Objective: To develop a policy, practice, education and research agenda for evidence-based practice (EBP) in traditional and complementary medicine (T & CM). Methods: The study was a secondary analysis of qualitative data, using the method of roundtable discussion. The sample comprised seventeen experts in EBP and T & CM. The discussion was audio-recorded, and the transcript analysed using thematic analysis. Results: Four central themes emerged from the data; understanding evidence and EBP, drivers of change, interpersonal interaction, and moving forward. Captured within these themes were fifteen sub-themes. These themes/sub-themes translated into three broad calls to action: (1) defining terminology, (2) defining the EBP approach, and (3) fostering social movement. These calls to action formed the framework of the agenda. Conclusions: This analysis presents a potential framework for an agenda to improve EBP implementation in T & CM. The fundamental elements of this action plan seek clarification, leadership and unification on the issue of EBP in T & CM. Refereed/Peer-reviewed

Background Clinical guidelines recommend non-pharmacological interventions as the first line of treatment for agitation in dementia. One intervention that shows some promise as a treatment for agitation is essential oils. The objective of this study was to provide preliminary evidence of the effectiveness and feasibility of using topically-administered, individualized essential oil preparations for the alleviation of agitation in persons with dementia. Methods We conducted a 10-week pragmatic, cluster-randomized, placebo-controlled, pilot feasibility trial to compare the effectiveness of topically-administered, individualized essential oil preparations to control (placebo) preparations. Outcomes included frequency and severity of agitation, quality of life, frequency of antipsychotic medication use and physical restraint, incidence of adverse events, and trial feasibility. Participants with dementia and clinically significant agitation were recruited from five residential aged-care facilities across regional South Australia. Results Thirty-eight participants were randomized from five sites. Accounting for random effects, we found statistically significant differences between the intervention and control groups in Pittsburgh Agitation Scale (PAS) aberrant vocalization sub score, Cohen Mansfield Agitation Inventory (CMAI) verbally agitated sub score and CMAI total score at week 4, but not at weeks 8 (post-intervention) or 10 (follow-up). No significant time-group interactions were observed for other PAS/CMAI scores or sub scores, quality of life - Alzheimer's disease total score, or frequency of physical restraint or as-needed antipsychotic medication. No adverse events were reported in any group. Conclusions The study findings highlight some promising effects of topically-administered, individualized essential oil preparations for agitation in dementia, and indicate that a large multi-center, cluster-randomized controlled trial of this treatment is feasible. Trial registration Australian New Zealand Clinical Trial Registry [ACTRN12617001159347].

Aims and objectives: To compare the effectiveness of clinical pathway-directed care to usual care on hospitalisation-related outcomes in patients with severe traumatic brain injury (STBI). Background: Severe traumatic brain injury is a major cause of disability and mortality in young adults. Clinical pathways endeavour to bring evidence and clinical practice closer together to foster the delivery of best practice and to improve patient outcomes. Design: Quasi-experimental study. Methods: The study was conducted in a trauma intensive care unit of a large teaching hospital in Egypt. Patients aged 18-60 years with a diagnosis of STBI, a Glasgow Coma Scale score between 3-8 and a nonpenetrating head injury were consecutively assigned to 15 days of care. The outcomes assessed were complications related to hospitalisation, clinical variances, length of intensive care unit (ICU) stay, ICU readmission rate and patient/family satisfaction. Results: Sixty participants completed the study (30 in each arm). Apart from age, there were no significant differences between groups in baseline characteristics. The clinical pathway group demonstrated statistically significantly fewer cases of hospitalisation-related complications on day 15, and a significantly shorter length of ICU stay, lower ICU readmission rate and a high level of patient/family satisfaction when compared with the usual care group. The effect of the intervention on fever, pressure ulceration, hyperglycaemia and readmission to the ICU was no longer statistically significant after controlling for age. Conclusions: The findings of the current study suggest that the implementation of a clinical pathway for patients with severe TBI may be helpful in improving the patient experience as well as some hospitalisation-related outcomes. Relevance to clinical practice: The provision of clinical pathway-directed care in a trauma ICU may offer benefits to the patient, family and institution beyond that provided by usual care. Refereed/Peer-reviewed

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Background Relapse prevention is an important objective in the management of serious mental illness (SMI). While community mental health nurses (CMHN) might be well-placed to support people with SMI in averting relapse, no systematic reviews have examined this association. Aim To review the evidence from studies reporting an association between CMHN exposure and hospitalisation of persons living with SMI (a proxy for relapse). Methods Searches were undertaken in ten bibliographic databases and two clinical trial registries. We included studies of patients with SMI, where CMHN was the exposure, and the outcome was relapse (i.e. readmission to a psychiatric inpatient facility). Quality assessment of included studies was completed using two risk-of-bias measures. Results Two studies met the inclusion criteria. Studies were rated as being of low-moderate methodological quality. There was insufficient evidence to conclude that community mental health nursing reduced the risk of admission to psychiatric inpatient facilities. Conclusions The review found no evidence that CMHN was associated with higher or lower odds of admission to psychiatric inpatient facilities among patients with SMI. The findings of the review point to a need for further research to investigate the impact of CMHN exposure and relapse in people with SMI. Systematic review registration PROSPERO CRD42017058694

WHO Traditional Medicine Strategy 2014-23 recommended evidence-based healthcare (EBHC) education for traditional and complementary medicine (T&CM) professionals, including Chinese medicine practitioners (CMPs). We evaluated the impact of a customized educational workshop on Hong Kong CMPs’ knowledge, attitude and practice of EBHC. Two validated instruments, Evidence-based Practice Questionnaire (EPQ) and Evidence-based Practice Inventory (EPI), were used to assess the impact of EBHC education. Paired t-tests were used to compare scores before and after the workshop. Multiple linear regression was performed to explore the associations between changes in EPQ/EPI scores and CMPs’ characteristics. CMPs who completed the workshop (n = 59) demonstrated significant improvements in the attitude (p = 0.013) and knowledge domains of the EPQ (p = 0.005). Significant improvements were also observed in the attitude, perceived behavioural control, decision making, and intention and behaviour domains of the EPI. CMPs who had never received prior EBHC training showed a larger magnitude of improvement in the EPI attitude (p = 0.032), decision making (p = 0.015), and intention and behaviour (p = 0.015) domains post-workshop. Our findings suggest that tailored workshop is effective in strengthening knowledge and in improving attitudes towards EBHC. Future RCTs should be conducted to affirm our findings. Future initiatives may consider incorporating this education approach into CMP curricula, as well as facilitating implementation of EBHC in routine Chinese medicine practice. Refereed/Peer-reviewed

Background: The past few decades have witnessed a surge in consumer, clinician and academic interest in the field of integrative health care (IHC). Yet, there is still uncertainty regarding the effectiveness of IHC for complex, long-term health conditions. Objective: To assess the effectiveness of IHC for the management of any chronic health condition. Methods: Seven databases and four clinical trial registries were searched from inception through to May 2018 for comparative/controlled clinical trials investigating the effectiveness of IHC for any chronic disease, and assessing any outcome. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool. Results: The search yielded 6,926 results. Eight studies met the inclusion criteria. All studies had at least three design features that carried an uncertain/high risk of bias. Differences in physiological, psychological and functional outcomes, and quality of life between patients receiving IHC and patients receiving conventional/usual care were varied and inconsistent. Changes in patient satisfaction with care were inconclusive. No studies reported the effectiveness of IHC on workforce- or administration-related parameters. Evidence from one trial suggested IHC may be more cost-effective than conventional care. Conclusions: The findings indicate some promising effects for the use of IHC to manage chronic disease. However, the uncertain/high-risk of bias across multiple domains, diverse and inconsistent findings, and heterogeneity of outcome measures and study populations prevents firm conclusions from being reached. Along with conducting further well-designed, long-term studies in this field, there is a need to ensure interventions closely align with the definition/principles of IHC. Refereed/Peer-reviewed

The Australian government has recently announced major reforms to the private health insurance (PHI) system. Amongst the changes are the removal of government-subsidised PHI rebates for consultations with most unregistered complementary medicine practitioners, including naturopathy. However, there are several doubts about these reforms, as this commentary explains, which primarily relate to (1) the basis of the decision, and (2) the consequences of the proposed changes. In terms of the former, an insufficient clinical evidence base was claimed to be the main driver of this decision. However, the evidence informing this decision had several limitations, and in the case of naturopathy, was somewhat contradictory. The absence of enforceable standards (from statutory registration) was another factor contributing to the decision; yet, for naturopathy, this has largely been the product of government inaction, rather than a lack of action from the profession. In terms of the downstream effects of these reforms, these could be considerable, including mass membership withdrawal from ancillary (extras) cover and cost-shifting to the public health sector; potentially leading to a rise in PHI premiums, increased demand for general practice services, and a rise in the number of avoidable hospitalisations. The proposed changes also deviate from international standards and declarations, and contravene key performance indicators of a quality health care system. In light of these concerns, the commentary calls for an immediate rethink of the intended PHI reforms, at least for naturopathy Refereed/Peer-reviewed

BackgroundMindfulness-based stress reduction/cognitive therapy are frequently used for pain-related conditions, but their effects on headache remain uncertain. This review aimed to assess the efficacy and safety of mindfulness-based stress reduction/cognitive therapy in reducing the symptoms of chronic headache.Data sources and study selectionMEDLINE/PubMed, Scopus, CENTRAL, and PsychINFO were searched to 16 June 2017. Randomized controlled trials comparing mindfulness-based stress reduction/cognitive therapy with usual care or active comparators for migraine and/or tension-type headache, which assessed headache frequency, duration or intensity as a primary outcome, were eligible for inclusion. Risk of bias was assessed using the Cochrane Tool.ResultsFive randomized controlled trials (two on tension-type headache; one on migraine; two with mixed samples) with a total of 185 participants were included. Compared to usual care, mindfulness-based stress reduction/cognitive therapy did not improve headache frequency (three randomized controlled trials; standardized mean difference = 0.00; 95% confidence interval = −0.33,0.32) or headache duration (three randomized controlled trials; standardized mean difference = −0.08; 95% confidence interval = −1.03,0.87). Similarly, no significant difference between groups was found for pain intensity (five randomized controlled trials; standardized mean difference = −0.78; 95% confidence interval = −1.72,0.16).ConclusionsDue to the low number, small scale and often high or unclear risk of bias of included randomized controlled trials, the results are imprecise; this may be consistent with either an important or negligible effect. Therefore, more rigorous trials with larger sample sizes are needed.

To examine the attitudes and utilization of evidence-based practice by chiropractors. Methods: Utilizing a descriptive survey implemented as an online questionnaire, we examined chiropractors perception, skills, and level of training, their engagement in, the bathers and facilitators to, and possible interventions to evidence-based practice. Results: A total of 162 of 500 chiropractors completed the survey, providing a response rate of 32.4%. The majority of respondents were 30-39 years old, female, and worked in solo practice. A high proportion agreed/strongly agreed that evidence-based practice was necessary in the practice of chiropractic. Most respondents considered themselves to have above-average skills in locating professional literature, identifying answerable clinical questions, and identifying knowledge gaps in practice. However, many indicated receiving either no training or minimal education for conducting clinical research and systematic reviews and meta-analyses Most respondents had read or reviewed one to five professional articles and/or clinical research reports pertinent to their practice in the preceding month. Identified minor to moderate bathers to evidence-based practice were lack of time and lack of clinical evidence. Activities "very useful" in participating in evidence-based practice were access to free online databases and the ability to download full-text journal articles. Conclusions: The responders of our survey embraced and considered themselves skillful in evidence-based practice. They utilized a number of resources to practice in such a manner and were not deterred by identified barriers. We support continued research in this field. Refereed/Peer-reviewed

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Background Relapse in individuals with severe mental illness (SMI) is a frequent occurrence and can add considerably to the burden of disease. As such, relapse prevention is an essential therapeutic outcome for people with SMI. Mental health nurses (MHNs) are well placed to support individuals with SMI and to prevent relapse; notwithstanding, there has been no synthesis of the evidence to date to determine whether MHNs prevent relapse in this population. Methods Electronic databases will be systemically searched for observational studies and clinical trials that report the association between mental health nursing and the hospitalisation of persons living with an SMI. The search will be supplemented by reference checking and a search of the grey literature. The primary outcome of interest will be hospital admission rate. Screening of articles, data extraction and critical appraisal will be undertaken by two reviewers, independently, with a third reviewer consulted should disagreement occur between reviewers. The quality of studies will be assessed using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool and the Cochrane Collaboration risk of bias tool. Depending on the number of studies and level of heterogeneity, the evidence may be synthesised using meta-analysis or narrative synthesis. Discussion This review will explore for the first time the clinical potential of mental health nursing in preventing relapse in persons with SMI. The findings of this review will serve to inform future research and education in this area. The evidence may also help inform future policy, including decisions regarding future mental health workforce development and planning. Systematic review registration PROSPERO CRD42017058694 .

Background: Although global interest in integrative healthcare (IHC) has escalated over the past few decades, stakeholder perspectives and preferences in relation to IHC remain poorly understood. Our study aimed to address this knowledge gap by exploring Australian health consumer (HC) and healthcare provider (HCP) understanding, attitudes and preferences for an IHC service delivery model, and to translate these views into an operational framework for IHC. Method: The research used a cross-sectional study design. Eligible persons were informed of the study using a multi-modal recruitment approach. Adult HCs and HCPs from any medical, nursing, allied and traditional and complementary medicine discipline, who had internet access and resided in Australia, were eligible to complete the 55-item online questionnaire Results: Four hundred and nine participants completed the survey. HCs and HCPs shared a common understanding of, and positive attitude towards, IHC. When asked about the IHC service delivery model, participants advocated the provision of diverse healthcare and support services across multiple centres, to individuals mainly presenting with chronic/terminal conditions. The preference was for these services to be charged as fee-for-service, paid using a split payment system, and managed by a customised team of clinicians following triage by a non-medical staff member. These findings were subsequently translated into an operational framework for IHC. Conclusions: This is first known study to translate HC and HCP attitudes and preferences into an operational framework for IHC. A logical next step of this work will be to ascertain the feasibility of this model in primary care Refereed/Peer-reviewed

Background: To examine the prevalence of vegetarianism among yoga practitioners, and to explore differences and similarities between yoga practitioners who also use vegetarian diet and those who do not. Design and setting: Using cross-sectional data from the 2012 National Health Interview Survey (NHIS) (N = 34,525), weighted frequencies for 12-month prevalence of vegetarian diet use among yoga practitioners were analyzed. Logistic regression analyses were used to analyze sociodemographic and clinical predictors of vegetarian diet use. Results: A total of 1.7 million US yoga practitioners have used a vegetarian diet in the past 12 months (8.3%), compared to 2.7 million non-yoga practitioners (1.3%). Yoga practitioners who were aged between 30 and 64 years as compared to being 29 years or younger were more likely to have used a vegetarian diet in the past 12 months; while those being in a relationship (OR = 0.64), overweight (OR = 0.54), smoking (OR 0.64) or having private health insurance (OR = 0.59) were less likely. Vegetarian diet practitioners more often included meditation as part of their yoga practice and more often chose yoga because it had a holistic focus, and was perceived to treat the cause and not the symptoms of their health complaint. Conclusions: Yoga practitioners following a vegetarian diet seem to embrace yoga more as a lifestyle than as a therapy. Refereed/Peer-reviewed

© 2018 The Author(s). Background: Evidence-based practice (EBP) is a clinical decision-making framework that supports quality improvement in healthcare. While osteopaths are key providers of musculoskeletal healthcare, the extent to which osteopaths engage in EBP is unclear. Thus, the aim of this cross-sectional study was to investigate UK osteopaths' attitudes, skills and use of EBP, and perceived barriers and facilitators of EBP uptake. Methods: UK-registered osteopaths were invited to complete the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) online. Results: Of the 5200 registered osteopaths in the UK, 9.9% (517/5200) responded to the invitation, and 7.2% (375/5200) completed the EBASE (< 20% incomplete answers). The demographic characteristics of the survey sample were largely similar to those of the UK osteopathy workforce. The osteopaths reported overall positive attitudes towards EBP, with most agreeing that EBP improves the quality of patient care (69.3%) and is necessary for osteopathy practice (76.5%). The majority reported moderate-level skills in EBP, and most (80.8%) were interested in improving these skills. Participating osteopaths typically engaged in EBP activities 1-5 times over the last month. Barriers to EBP uptake included a lack of time and clinical evidence in osteopathy. Main facilitators of EBP included having access to online databases, internet at work, full-text articles, and EBP education materials. Conclusions: UK osteopaths were generally supportive of evidence-based practice, had moderate-level skills in EBP and engaged in EBP activities infrequently. The development of effective interventions that improve osteopaths' skills and the incorporation of EBP into clinical practice should be the focus of future research.

Background: Herbal medicine is among the most frequently used complementary medicines. This study aims to identify the socio-demographic and health-related predictors of herbal medicine utilisation among patients with chronic internal medicine conditions admitted to inpatient care. Methods: Patients referred to a German integrative medicine clinic were asked whether they had ever used herbal medicine for their primary medical diagnosis, and whether they experienced benefits or harm. Socio-demographic characteristics, health behaviour, medical diagnosis, health status, mental health, satisfaction with health, and health locus of control were determined as potential predictors of herbal medicine use. Results: Of 2105 respondents, 41.9% reported herbal medicine use for their primary medical complaint, with 57.4% of them reporting perceived benefits and no harm due to use. Herbal medicine use was positively associated with female gender, at least high school education, a diagnosis of fibromyalgia, lung disease or sub-threshold depression, high internal health locus of control and avoidance of fast food, and was negatively associated with spinal pain. High satisfaction with life and high internal health locus of control were positively associated with perceiving herbal medicine as helpful. Whilst, being a smoker and diagnosed with headaches or irritable bowel syndrome had a negative association with the use of herbal medicine. Conclusion: Herbal medicine utilisation among patients admitted to integrative inpatient care is common. While predictors of herbal medicine use appear to be in line with previous findings, there is a need for more in-depth examination of patients' motivations for the use of herbal medicine to further the understanding of their health behaviours and needs. Refereed/Peer-reviewed

© 2017 American Headache Society Background: Given the safety concerns regarding pharmacological agents, and the considerable impact of headache and migraine on the sufferer's quality of life, many people seek other treatment options beyond conventional medication and care to address their symptoms; this includes complementary and alternative medicine (CAM). Some CAM interventions have shown promising results in clinical trials of headache and migraine management. Nonetheless, there has been little research exploring the reasons for using CAM, and the types of CAM used, among this population. Objective: The study aimed to answer the following questions: (1) Which CAM modalities are used most frequently among migraine/headache sufferers? and (2) What are the self-reported reasons for CAM use among migraine/headache sufferers?. Methods: This secondary analysis of data from the 2012 U.S. NHIS (a national cross-sectional survey) examined the use of CAM among migraine/headache sufferers, including the main reasons related to CAM use. Data were weighted and analyzed using STATA 14.0. Results: The sample of 34,525 adults included 6558 (18.7%) headache/migraine sufferers. Of the headache/migraine sufferers, a substantial proportion (37.6%, n = 2427) used CAM for various conditions; however, CAM use specifically for headache/migraine was much less prevalent (3.3%, n = 216). Of those who used CAM for headache/migraine, about half used CAM in conjunction with prescription (47.8%, n = 100) or over-the-counter medication (55.1%, n = 113). As severity of headache/migraine increased so did the likelihood of using CAM (severe migraine odds ratio [OR] = 2.32; 95% confidence interval [CI]: 1.41, 3.82; both recurring headache/severe migraine OR = 3.36; 95% CI: 2.08, 5.43; when compared to those with recurring headache only). The most frequently used CAM modality among all headache/migraine sufferers (N = 6558) was manipulative therapy (22.0%, n = 1317), herbal supplementation (21.7%, n = 1389) and mind-body therapy (17.9%, n = 1100). The top 3 reasons for using CAM for headache were general wellness (28.7%, n = 60/209), improving overall health (26.8%, n = 56/209), and reducing stress (16.7%, n = 35/209). Conclusions: Although CAM is used by many sufferers of headache/migraine, the use of CAM specifically for the treatment of headache/migraine is relatively low in the United States. The study also assesses the key differences of CAM use among headache/migraine sufferers in NHIS 2012 compared with those in NHIS 2007, and identifies shortfalls in the evidence-base of several CAM modalities used by U.S. adults for headache/migraine. This information may assist health providers and consumers in making informed decisions about the safest and most appropriate approach to managing headache/migraine.

Background: The use of ginger as a topical intervention is widely advocated in the popular media. However, there has been no attempt to date to synthesize the evidence for topically administered ginger. Objective: To systematically review and synthesize the best available evidence of effectiveness for topical ginger in any condition. Data Sources: CAM on PubMed, CINAHL, Google Scholar, MEDLINE, National Library of Australia, The Cochrane Library, TRIP, pertinent texts, and bibliographies of relevant papers. Study Selection: Data sources were systematically searched for studies investigating the clinical effectiveness of topical ginger, in any form and for any condition, regardless of study design. Studies were limited to those published between 1980 and 2010, and published in English, Mandarin, Cantonese, or Taiwanese. Data Extraction: Data were extracted by two authors, independently, using standardized templates. Data Synthesis: Four studies met the inclusion criteria, including three randomized controlled trials and one non-randomized controlled trial. All studies differed in terms of study population, outcome measures, comparative interventions, and dose and form of ginger used, and thus, were not amenable to meta-analysis. Findings from all trials favored usage of ginger for most outcomes. However, the small sample sizes and inadequate methodological reporting indicate a high risk of bias and the need for caution when interpreting these results. Conclusions: Few studies have investigated the effectiveness of topically administered ginger for any condition. Until the findings of these studies are corroborated by more robust research, and the safety of ginger is adequately established, clinicians should remain cautious about using topical ginger in clinical practice. Refereed/Peer-reviewed

Background Evidence-based practice (EBP) has been the focus of increasing attention in the teaching and delivery of both complementary and conventional healthcare. Western herbal medicine (WHM) is a system of complementary healthcare rooted in tradition. How WHM practitioners perceive, are prepared for, and use EBP, has to date been largely ignored. We therefore examined the use, opinion, skills, and training in EBP, and barriers and facilitators of EBP uptake, among herbal practitioners in the United States (US). Methods The study utilized a cross-sectional, descriptive survey design. A sample of US clinical herbalists was invited to complete a validated online questionnaire, the Evidence-Based practice Attitude and utilization SurvEy (EBASE). Results Seventy-four US herbal practitioners completed the survey (response rate=35 %). Participants demonstrated a generally positive attitude toward EBP (median attitude subscore 31 [possible range=8–40]), a moderate to high level of self-assessed skill in EBP (median skill subscore 46 [13–65]) and a moderate level of EBP uptake (median use subscore 12 [0–24]). Apart from a lack of clinical evidence in herbal medicine, there were few perceived barriers to EBP uptake among herbal practitioners. Access to the Internet, online databases and full-text journal articles were considered most useful in facilitating the uptake of EBP in WHM practice. Conclusions Respondents’ attitudes, skill level, and uptake of EBP were generally consistent with other complementary and alternative medicine providers. Educational initiatives, including those focused on the appraisal and application of evidence, may help to optimize the use of EBP among WHM practitioners.

Background: The popularity of Complementary and alternative medicine (CAM) has grown considerably over the past few decades. This has been accompanied by increasing public pressure for CAM to be evidence-based. Notwithstanding, the conduct and application of research in CAM faces a number of obstacles. No systematic review has mapped these barriers to date. Therefore, this systematic literature review aimed to explore, identify and map the barriers to the conduct and application of research in CAM. Methods: Systematic searching of MEDLINE, Embase, AMED, CINAHL, The Cochrane library, Google scholar and Google was conducted between February and June 2016 for pertinent publications. Pearling (secondary searching) of retrieved publications was also undertaken. Literature published only in English were included; however, no year limit was placed for searching. Two critical appraisal tools were used to critically appraise descriptive studies and opinion publications. Results: A total of 21 eligible publications were included in this review; this comprised of eight primary research articles and thirteen opinion publications. A critical appraisal process found two categories of good quality publications while recognising their limitations in terms of descriptive and opinion publications. The synthesised data from the selected publications about the barriers to the conduct and application of research within CAM were captured within two broad components, namely capacity and culture. Capacity encompassed elements such as access, competency, bias, incentives and time. Encompassed within culture were elements relating to the values and complex system of CAM. Conclusions: Multiple barriers exist for the conduct and application of research in CAM. Given the growing popularity of these therapies, it is essential that the evidence base underpinning CAM also continues to expand. Without overt recognition of these barriers, enabling strategies cannot be applied. By addressing these barriers, CAM professions will be able to develop a critical mass and a well-coordinated research effort to assist the integration of evidence - based practice in CAM. Refereed/Peer-reviewed

Context Research plays an important role in advancing health and healthcare. However, much research evidence is not reflected in contemporary complementary and alternative medicine (CAM) practice. Understanding and addressing the reasons for this research–practice gap may have positive implications for quality of care. Objective To shed light on the gap between research and CAM practice. Design Descriptive cross-sectional, mixed-method study. Sample and Setting A total of 126 senior CAM academics across Australasia, Europe, UK, and North America. Outcome Measures Participants completed a 30-item online survey and a semi-structured interview; both of which explored the research–practice gap in CAM. Results A total of 43 (34%) academics completed the survey, with 29 (67%) respondents undergoing an interview. There was general agreement among respondents that CAM research should be informed by practice, and practice informed by research; however, most agreed that this did not reflect the current situation. Translational issues were perceived to be the primary reason for the research–practice gap in CAM. Suggested strategies for closing the gap focussed mostly around improving CAM student/practitioner education and training, and researcher–practitioner engagement and collaboration. Conclusions Study findings point toward the presence of a research–practice gap in CAM, with several factors likely to be instrumental in sustaining this gap. Attention now needs to focus on understanding the views of CAM clinicians on this issue. Insights gained from this research will help inform the development of a multi-modal strategy that will effectively target the barriers to change in order to bring CAM research and practice closer together.

Background Osteoarthritis (OA) is a degenerative joint disease, which is associated with increased pain and disability, and a simultaneous decline in the quality of life of sufferers. While there is no cure for OA, there are numerous treatments that aim to reduce sufferers' symptoms and disability, and improve their quality of life. Medications, which have long been integral interventions for the management of OA, have recently been found to cause harm in some patients. Simultaneously, the increasing recognition of complementary and alternative therapies as part of mainstream health care, has seen many sufferers of OA use these therapies. Ginger has been commonly prescribed by herbalists for sufferers of OA due to its anti-inflammatory and circulatory stimulant effects. However, to date there has been no systematic review of the literature to evaluate the clinical effectiveness of Ginger for OA. Objective The objective of this systematic review was to evaluate the safety and effectiveness of Ginger in adults with OA. Data sources A comprehensive search was undertaken on 18 electronic databases from their inception to January 2007, including AARP Ageline, AMED, AMI, BioMed central gateway, CAM on PubMed, CENTRAL, CINAHL, Cochrane library, Current controlled trials, Current contents connect, DARE, Dissertations Abstract International, EMBASE, Health Source Nursing/Academic edition, International Pharmaceutical Abstract, MEDLINE, Natural medicines comprehensive database and TRIP. Review methods Randomised controlled trials or clinical controlled trials were sought, which evaluated the effectiveness of mono-preparations of ginger in adults with OA of the knee or hip. Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments. Data extraction was via the Joanna Briggs Institute standard data extraction form for evidence of effectiveness. Results Five randomised controlled trials were identified from the search, of which three met the inclusion criteria. The methodological quality of the included studies was good. However, given that studies were clinically and methodologically heterogeneous, meta-analysis could not be conducted. Instead, evidence was summarised in narrative form. For changes in pain severity, studies comparing ginger extract (n = 110) to placebo (n = 111) reported mixed findings in support of the use of Ginger. Studies comparing ginger to an active control found participants who received Ibuprofen (n = 96) had a greater change in median pain intensity compared with participants who received Ginger (n = 110), and while findings were statistically significant for only one of the two studies, the results had limited clinical significance. Similarly, while two placebo-controlled studies reported differences between ginger (n = 70) and placebo (n = 71) for changes in disability and functional capacity, the difference was statistically and clinically significant for only one study. In one study comparing ginger to an active control, participants receiving Ibuprofen (n = 56) reported a statistically significant improvement in disability and functional capacity over time when compared with participants receiving Ginger (n = 56). In terms of safety, Ginger was well tolerated when compared with Ibuprofen, with infrequent reports of mild, and predominantly gastrointestinal, adverse effects. Conclusion Current evidence is weak for the use of Ginger in adults with OA of the knee and/or hip. Much of this can be attributed to significant heterogeneity between studies. Improvements in research design, instrumentation and ginger dosage, which more closely reflect current clinical practice, may help to demonstrate the safe and effective use of Ginger in OA sufferers.

The burden on those caring for a person with dementia is substantial. Although quality research assists in addressing the needs of these caregivers, recruiting caregivers into clinical studies is often problematic. This investigation explores the difficulties and successes in recruiting dementia caregivers into community-based clinical research by reporting the findings of a mixed-method substudy of a multicenter randomized controlled trial involving 40 community-dwelling dementia caregivers living in Adelaide, South Australia. Data for the substudy were derived from standardized trial monitoring documentation and structured telephone interviews. From a total of 16 distinct methods used across a 12-month recruitment campaign, the most cost-effective strategy was the distribution of flyers through a single study site. This approach generated the greatest number of enrollments of all methods used, achieving a 67% recruitment yield. The least cost-effective strategy, with a 0% recruitment yield, was the publication of a newspaper advertisement. Themes that emerged from the interviews pointed toward 5 key facilitators and 3 barriers to future trial recruitment. This study has generated new insights into the effective recruitment of dementia caregivers into clinical trials. We anticipate that these lessons learnt will assist in shaping the recruitment strategies of future studies of dementia caregivers. Refereed/Peer-reviewed

Objectives: To determine whether acupuncture use, sociodemographic characteristics, and existing health conditions differ between acupuncture-preferred consumers (i.e., those who deem acupuncture to be one of the three most important complementary and alternative medicine [CAM] modalities used) and non-acupuncture-preferred consumers who used acupuncture in the past 12 months Methods: This is a secondary analysis of the National Health Interview Survey Sample Adult File and Adult Alternative Medicine datasets collected by the Centers for Disease Control and Prevention during 2012. The sample was drawn from the noninstitutionalized civilian population of the United States. The datasets yielded 34,525 respondents aged 18 years and older. Measures included in the analysis were acupuncture use in the past 12 months, sociodemographic characteristics, and existing health conditions. Analyses were performed by using Stata software, version 9.0 (Stata Corp., College Station, TX). Results: Of the 10,158 adults who responded to the question regarding the "three most important" CAM modalities used, 572 (5.6%) had used acupuncture in the past 12 months. Of these, 456 (79.7%) chose acupuncture as one of the top three CAM modalities most important to their health. Acupuncture-preferred consumers reported significantly more visits to acupuncturists (7.46 versus 3.99 visits; p < 0.001), as well as higher out-of-pocket costs ($342.8 versus $246.4; p < 0.001), compared with non-acupuncture-preferred consumers. The logistic regression model revealed that with every additional CAM modality used, the likelihood of deeming acupuncture as one of the three CAM modalities most important to one's health decreased by 39% (odds ratio, 0.61; 95% confidence interval, 0.52-0.71; p < 0.001). Health conditions were not statistically significant predictors. Conclusions: A consumer's preference for acupuncture appeared not to be driven by health conditions but rather was related to sociodemographic factors. This suggests that health education regarding acupuncture may need to be tailored to certain consumer groups, such as those residing in the South, and could provide more information on the comparative effectiveness of acupuncture for various health conditions. Refereed/Peer-reviewed

Background: Health consumers are increasingly using the Internet to access information about health care, to self-diagnose, and to purchase medication. The use of the Internet to purchase herbal products is of particular interest because of the high level of consumer expenditure on herbal medicines, and the misperception by some consumers that herbal products are natural, and thus absent of any contraindications, drug interactions and adverse effects. It is possible that consumers may purchase herbal medicines via the Internet without consulting health professionals and therefore, use these medicines in an unsafe manner. Design: Cross-sectional survey of 54 selected websites, including online pharmacies, online health food stores and manufacturers of herbal medicines. Main outcome measure A modified version of the DISCERN instrument was used to assess the quality of websites. Objectives: To examine the quality of e-commerce websites that sell herbal products; specifically, websites where St. John's wort (Hypericum perforatum) can be purchased. Design Cross-sectional survey of 54 selected websites, including online pharmacies, online health food stores and manufacturers of herbal medicines. Main outcome measure A modified version of the DISCERN instrument was used to assess the quality of websites. Results: The majority of websites rated poorly with a concerning lack of information about the interaction between hypericum and warfarin, anti-depressants and oral contraceptives. Most sites also failed to provide sufficient information about the contraindications and adverse effects of hypericum treatment. Conclusions The results of this study strongly support the need for improved consumer education about herbal medicine, as well as the application of more stringent standards to websites that sell medications. Refereed/Peer-reviewed

Aims and Objectives: To measure the impact of an undergraduate research education program on the attitude, skill and uptake of evidence-based practice among undergraduate student nurses. Background: The contribution of evidence-based practice to clinical decision-making, quality of care and patient outcomes is well-documented. One approach to improving evidence-based practice uptake in clinical practice is through the provision of undergraduate research education; notwithstanding, the impact of research training on nursing practice is poorly established. Design: Descriptive longitudinal survey. Methods: Three hundred and fifty four third-year nursing students enrolled in a Bachelor of Nursing program of a large Australian University were invited. Pre- (Phase 1) and post-completion (Phase 2) of a 16-week research education program, participants were asked to complete the Evidence-Based Practice Attitude and Utilization Survey; an 82-item online questionnaire measuring attitudes, skills and use of evidence-based practice, and barriers and facilitators of evidence-based practice uptake. Results: The survey was completed by 84 (24%) participants in Phase 1 and 33 (39% of Phase 1) participants in Phase 2. Program exposure resulted in a significant improvement in median skill and use subscores, but not median attitude subscore. Participants perceived inadequate skills in the interpretation, appraisal and application of research findings to clinical practice as being less of a barrier to evidence-based practice uptake posteducation, and access to online critical appraisal tools as being significantly more useful in facilitating evidence-based practice uptake posteducation. Conclusions: The findings suggest that undergraduate research education may have a significant effect on nursing students' research skills and use of evidence-based practice, and minimise barriers to evidence-based practice uptake posteducation. Relevance to clinical practice: Undergraduate research education may play an important role in improving student nurse uptake of evidence-based practice; whether these changes can be sustained when transitioning from student nurse to registered nurse is a question for further research. Refereed/Peer-reviewed

We examined the National Health Interview Survey (NHIS) 2012 to explore how US adult consumers of CAM differ by gender in terms of their sociodemographic characteristics, current health conditions, and perceived benefits of CAM. All individuals who completed the adults core interviews (N= 34,525) were included. CAM use, major sociodemographic variables, perceived benefits of using CAM, and top ten reported health conditions for which CAM was used were selected and analyzed by Stata. Findings revealed that 29.6% (n= 10,181) reported having used at least one form of CAM in the previous 12 months. Compared to male CAM users, female CAM users were more likely to have a bachelor degree, to be divorced/separated or widowed, and less likely to earn $75,000 or more. Back pain/problem was the most common problem reported by both male and female CAM users (32.2% and 22.6%, resp.). A higher proportion of female CAM users reported using CAM for perceived benefits such as general wellness or general disease prevention. This paper provides foundation information regarding gender differences in CAM use and is a platform for further in-depth examination into how and why males and females differ in their reasons for CAM use.

Insomnia is a prevalent sleep disorder that can profoundly impact a person's health and wellbeing.Herbal medicine represents one of the most frequently used complementary and alternative treatments of insomnia. However, the safety and efficacy of herbal medicine for the treatment of this disorder is currently uncertain. In order to ascertain the evidence base for herbal medicine for insomnia, we systematically searched seventeen electronic databases and the reference lists of included studies for relevant randomised controlled trials (RCTs). Fourteen RCTs, involving a total of 1602 participants with insomnia, met the inclusion criteria. Four distinct orally administered herbal mono preparations were identified (i.e., valerian, chamomile, kava and wuling). There was no statistically significant difference between any herbal medicine and placebo, or any herbal medicine and active control, for any of the thirteen measures of clinical efficacy. As for safety, a similar or smaller number of adverse events per person were reported with kava, chamomile and wuling when compared with placebo. By contrast, a greater number of events per person were reported with valerian. While there is insufficient evidence to support the use of herbal medicine for insomnia, there is a clear need for further research in this area. Refereed/Peer-reviewed

© 2017 Society for Nutrition Education and Behavior Objective Examine the prevalence, patterns, and associated factors of using a vegetarian or vegan diet for health reasons in the US general population. Design Cross-sectional data from the 2012 National Health Interview Survey. Participants Nationally representative sample (N = 34,525). Variables Measured Prevalence of ever use and 12-month use of vegetarian or vegan diet for health reasons, patterns of use, and sociodemographic and health-related factor associated with use. Analysis Multiple logistic regression analysis. Results Prevalence of ever use and 12-month use was 4.0% (n = 1,367) and 1.9% (n = 648), respectively. Health vegetarians and vegans were more likely aged 30–65 years, female, not Hispanic, from the Western US region, at least high school educated, chronically ill, and physically active. They were less likely to be in a relationship, overweight or obese, or smoking, or to have public or private health insurance. Among health vegetarians and vegans, 6.3% consulted with a practitioner for special diets; 26.1% followed the diet because of a specific health problem, mainly high cholesterol, overweight, hypertension, and diabetes; and 59.4% disclosed the diet to their health care provider. Conclusions and Implications Less than 2% of participants reported using a vegetarian or vegan diet for health reasons within the past 12 months. Despite potential benefits of plant-based nutrition, more research is warranted on the actual use and its effects and safety.

Dementia is a prevalent neurodegenerative disorder affecting an estimated 24.3 million people across the globe. The burden on those caring for people with dementia is substantial, with widespread implications for the caregiver, the care recipient and the community. Relaxation techniques, such as Transcendental Meditation® (TM), have been shown to reduce stress and anxiety in healthy workers; similar benefits are anticipated in dementia caregivers. The objective of this study was to ascertain whether TM can improve psychological stress, quality of life, affect and cognitive performance in dementia caregivers. The study was conducted as a pilot prospective, multi-centre, community-based, randomised wait-list controlled trial. Community-dwelling caregivers of persons with diagnosed dementia were randomly assigned to a 12-week (14-hour) TM training program or wait-list control. Participants were assessed for quality of life, stress, affect, cognitive performance and adverse effects. The feasibility of the study was also evaluated. Seventeen caregivers were recruited and randomised. Improvements in WebNeuro response speed scores over time were significantly (p = 0.03) greater in the TM group relative to control. Changes between groups over time in all other primary and secondary outcome measures did not reach statistical significance. However, there was a trend toward greater improvement in WebNeuro stress, depression and negativity bias scores in the TM group. Adverse events were reported amongst 63 % of TM-treated subjects; however, events were generally transient, of mild-moderate intensity and only ‘possibly’ related to TM. Dementia caregivers exposed to TM demonstrated varying degrees of improvement in several measures of cognitive function, mood, quality of life and stress following exposure to TM. However, as the pilot study was underpowered, no firm conclusions can be made about the effectiveness of TM in this caregiver population. Findings from full-scale trials are now warranted. Australian New Zealand Clinical Trial Registry ACTRN12613000184774 (Registered 15th February 2013).

Caring for a person with dementia can be an unrelenting and burdensome task, one that is often detrimental to the caregiver's health, well-being, and functionality. The enduring stress and frustration of the caregiver role can also contribute to poorer outcomes for dementia sufferers. Building on growing clinical interest in the capacity for Transcendental Meditation(®) (TM; a relaxation technique) to reduce stress and anxiety in healthy workers, this study examines whether similar improvements could be experienced by dementia caregivers.The study objective was to ascertain whether a TM program can improve psychological stress, quality of life, affect, and cognitive performance of dementia caregivers.The study was a pilot prospective, single-center, randomized wait-list controlled trial with two parallel arms.Community-dwelling carers of persons with diagnosed dementia, residing in metropolitan Adelaide, South Australia, were included in this study.Participants will be randomly assigned to a 13-hour TM training program or wait-list control over 12 weeks.Primary outcomes include quality of life and stress. Secondary outcomes include affect, cognitive performance, cost-effectiveness, and study feasibility. Outcomes will be assessed at baseline, week 12 (postintervention), and week 24 (follow-up).Results are expected to be available early in 2014.This project responds to a need for robust evidence of the clinical and economic effectiveness of TM for the management of caregiver stress. If Transcendental Meditation is shown to be effective, it could indicate a simple, cost-effective, and easily implemented strategy to assist many of the growing numbers of caregivers to cope with the demanding and often difficult caregiver role.

Background: Despite the expressed demand for complementary and alternative medicine (CAM) services in developed countries, little is known about the CAM workforce in terms of supply and composition. Objective: To describe the CAM workforce across five developed countries to better inform health workforce and health services planning, and perchance, inform debate on future public health and primary care policy. Methods: Data from the Australian, New Zealand, Canadian, UK and US Censuses of population were interrogated for information pertaining to the size and characteristics of the CAM workforce. This was supplemented by other population-level workforce data where available. Results: The quality and availability of population-level data on the CAM workforce vary substantially across nations. Of the nine CAM disciplines explored, massage therapy consistently comprised the largest portion of the CAM workforce, followed closely by chiropractic. Disciplines in shortest supply were homoeopathy in Australia, traditional Chinese medicine in New Zealand, and naturopathy in the US. Across the broader CAM workforce, practitioners were typically female, aged ≥40 years, worked within a primary care setting, held a vocational or higher education level qualification, worked full-time, and earned

This is the protocol for a review. The objective of this systematic review will be to evaluate the safety and efficacy of topical herbal interventions for the prevention or treatment (or both) of gingivitis. Refereed/Peer-reviewed

Background Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age-inappropriate levels of inattention, hyperactivity and impulsivity, and is associated with long-term social, academic and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Children and adolescents with ADHD have been shown to have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega-3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. Objectives To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods We searched the following databases in August 2011: CENTRAL (The Cochrane Library 2011, Issue 2), MEDLINE (1948 to July Week 3, 2011), EMBASE (1980 to 2011 Week 29), PsycINFO (1806 to current), CINAHL (1937 to current), BIOSIS (1969 to 30 July 2011), Science Citation Index (1970 to 30 July 2011), Social Science Citation Index (1970 to 30 July 2011), Conference Proceedings Citation Index - Science (1990 to 30 July 2011), Conference Proceedings Citation Index - Social Science and Humanities (1990 to 30 July 2011), Cochrane Database of Systematic Reviews (2011, Issue 7), DARE (2011 Issue 2), Dissertation Abstracts (via Dissertation Express) and the metaRegister of Controlled Trials (mRCT). In addition, we searched the following repositories for theses on 2 August 2011: DART, NTLTD and TROVE. We also checked reference lists of relevant studies and reviews for additional references. Selection criteria Two review authors independently assessed the results of the database searches. We resolved any disagreements regarding the selection of studies through consensus or, if necessary, by consultation with a third member of the review team. Data collection and analysis Two members of the review team independently extracted details of participants and setting, interventions, methodology and outcome data. If differences were identified, we resolved them by consensus or referral to a third member of the team. We made all reasonable attempts to contact the authors where further clarification or missing data were needed. Main results We included 13 trials with 1011 participants in the review. After screening 366 references, we considered 23 relevant and obtained the full text for consideration. We excluded five papers and included 18 papers describing the 13 trials. Eight of the included trials had a parallel design: five compared an omega-3 PUFA supplement to placebo; two compared a combined omega-3 and omega-6 supplement to placebo, and one compared an omega-3 PUFA to a dietary supplement. Five of the included trials had a cross-over design: two compared combined omega-3/6 PUFA to placebo; two compared omega-6 PUFA with placebo; one compared omega-3 to omega-6 PUFA, and one compared omega-6 PUFA to dexamphetamine. Supplements were given for a period of between four and 16 weeks. There was a significantly higher likelihood of improvement in the group receiving omega-3/6 PUFA compared to placebo (two trials, 97 participants; risk ratio (RR) 2.19, 95% confidence interval (CI) 1.04 to 4.62). However, there were no statistically significant differences in parent-rated ADHD symptoms (five trials, 413 participants; standardised mean difference (SMD) -0.17, 95% CI -0.38 to 0.03); inattention (six trials, 469 participants; SMD -0.04, 95% CI -0.29 to 0.21) or hyperactivity/impulsivity (five trials, 416 participants; SMD -0.04, 95% CI -0.25 to 0.16) when all participants receiving PUFA supplements were compared to those receiving placebo. There were no statistically significant differences in teacher ratings of overall ADHD symptoms (four trials, 324 participants; SMD 0.05, 95% CI -0.18 to 0.27); inattention (three trials, 260 participants; SMD 0.26, 95% CI -0.22 to 0.74) or hyperactivity/impulsivity (three trials, 259 participants; SMD 0.10, 95% CI -0.16 to 0.35). There were also no differences between groups in behaviour, side effects or loss to follow-up. Overall, there were no other differences between groups for any other comparison. Authors' conclusions Overall, there is little evidence that PUFA supplementation provides any benefit for the symptoms of ADHD in children and adolescents. The majority of data showed no benefit of PUFA supplementation, although there were some limited data that did show an improvement with combined omega-3 and omega-6 supplementation. It is important that future research addresses current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, short follow-up times and other methodological weaknesses.

The health workforce is perceived to be in short supply in most developed and developing countries. There are concerns that this could result in reduced coverage of health services and the delivery of suboptimal care. Strategies to address the health workforce shortage have focussed predominantly on recruitment and training, with relatively little regard to the equally important issue of retention. One approach that may improve job satisfaction, opportunities for specialisation and the workload of health workers, and thus, improve retention and more importantly, patient outcomes, is role substitution. Many complementary and alternative medicine (CAM) practitioners appear to be well placed in terms of educational preparation to substitute (either horizontally or vertically) a number of roles traditionally performed by conventional health disciplines. As well as the potential benefits to the health workforce and the quality of patient care, role substitution could provide an important first step toward integrating CAM practitioners into mainstream health care settings Refereed/Peer-reviewed

Background The delivery of best practice care can markedly improve clinical outcomes in patients with chronic disease. While the provision of a skilled, multidisciplinary team is pivotal to the delivery of best practice care, the occupational or skill mix required to deliver this care is unclear; it is also uncertain whether such a team would have the capacity to adequately address the complex needs of the clinic population. This is the role of needs-based health workforce planning. The objective of this article is to describe the development of an evidence-informed, needs-based health workforce model to support the delivery of best-practice interdisciplinary chronic disease management in the primary and community care setting using diabetes as a case exemplar. Discussion Development of the workforce model was informed by a strategic review of the literature, critical appraisal of clinical practice guidelines, and a consensus elicitation technique using expert multidisciplinary clinical panels. Twenty-four distinct patient attributes that require unique clinical competencies for the management of diabetes in the primary care setting were identified. Patient attributes were grouped into four major themes and developed into a conceptual model: the Workforce Evidence-Based (WEB) planning model. The four levels of the WEB model are (1) promotion, prevention, and screening of the general or high-risk population; (2) type or stage of disease; (3) complications; and (4) threats to self-care capacity. Given the number of potential combinations of attributes, the model can account for literally millions of individual patient types, each with a distinct clinical team need, which can be used to estimate the total health workforce requirement. Summary The WEB model was developed in a way that is not only reflective of the diversity in the community and clinic populations but also parsimonious and clear to present and operationalize. A key feature of the model is the classification of subpopulations, which gives attention to the particular care needs of disadvantaged groups by incorporating threats to self-care capacity. The model can be used for clinical, health services, and health workforce planning.

Background: Over the past few decades the health professions have witnessed increasing pressure to shift from a culture of delivering care based on tradition and intuition, to a situation where decisions are guided and justified by the best available evidence. While there are concerns that many complementary and alternative medicine (CAM) practitioners may be cautious about embracing such an approach, no studies to date have effectively tested this assumption. Conclusions: While the small response rate limits the generalisability of these findings, the sample was considered representative of Australian CAM practitioners. What this study shows is that even though CAM practitioners may be supportive of EBP, education and training is needed to further improve clinician understanding and application of evidence-based practice. Design: Descriptive survey, using the evidence-based practice attitude and utilisation survey (EBASE). Main outcome measures: Practitioner skill, attitude, training and use of EBP. Objective: To identify the skills, attitude, training and use of evidence-based practice (EBP) amongst CAM practitioners. Results: Of the 351 questionnaires successfully dispatched, 126 were returned (36%). Most practitioners believed EBP was useful (92%) and necessary (73%) in CAM practice. While the majority of clinicians (>74%) reported participation in EBP activities, albeit infrequently, only a small to moderate proportion of decisions were based on evidence from clinical trials, with most practitioners relying on traditional knowledge, textbooks and clinical practice guidelines. Lack of available evidence, time, industry support and skills were perceived as barriers to EBP uptake. Subjects: Randomly selected nationwide sample of system-based, non-medically qualified CAM practitioners practicing in a clinical capacity within Australia. Refereed/Peer-reviewed

Journal of Clinical Nursing 17, 1728–1734Planning: a necessary step in clinical careAim. The aim of this paper is to highlight the significance of care planning and toencourage the integration of a consistent and systematic planning process intonursing practice.Background. Many factors contribute to the successful achievement of clinicaloutcomes, including patient–practitioner rapport, comprehensive client assessment,accurate differential diagnosis, evidence-based care and the objective evaluation ofclient progress. One element that is of equal importance to these aforementionedfactors is the planning of patient care. However, there are concerns that somepractitioners may not be adopting a planned approach to client care, possiblybecause of a lack of understanding, time, skill or interest in care planning.Method. This is a position paper on the planning of patient care.Results. The planning of patient care can be effectively implemented using a two-stage process. In brief, the first step involves the construction of a general goal,which is the overall, desired outcome of care. The expected outcome, or specificgoal, forms the second part of the planning process, which clearly directs clinicalcare by specifically indicating how and when an individual will achieve the generalgoal of treatment.Conclusion. This paper highlights the importance of care planning and that the useof a clear, systematic planning framework may help to deliver a more transparentand consistent approach to patient care, which may greatly improve patient healthand well-being by hastening the achievement of clinical outcomes.Relevance to clinical practice. The knowledge and strategies contained in this papercan be easily adopted by nurses and other clinicians to modify or build upon existingpractice. This knowledge may help foster a more client-centred, participative,individualised approach to care, which may lead to improvements in patient out-comes.Key words: care, goals, nurses, nursing, patient-care planning, patient-centred care

Background Diabetes mellitus is an increasingly prevalent metabolic disorder that is associated with substantial disease burden. Australia has an opportunity to improve ways of caring for the growing number of people with diabetes, but this may require changes to the way care is funded, organised and delivered. To inform how best to care for people with diabetes, and to identify the extent of change that is required to achieve this, the Diabetes Care Project (DCP) will evaluate the impact of two different, evidence-based models of care (compared to usual care) on clinical quality, patient and provider experience, and cost. Methods/Design The DCP uses a pragmatic, cluster randomised controlled trial design. Accredited general practices that are situated within any of the seven Australian Medicare Locals/Divisions of General Practice that have agreed to take part in the study were invited to participate. Consenting practices will be randomly assigned to one of three treatment groups for approximately 18 to 22 months: (a) control group (usual care); (b) Intervention 1 (which tests improvements that could be made within the current funding model, facilitated through the use of an online chronic disease management network); or (c) Intervention 2 (which includes the same components as Intervention 1, as well as altered funding to support voluntary patient registration with their practice, incentive payments and a care facilitator). Adult patients who attend the enrolled practices and have established (≥12 month’s duration) type 1 diabetes mellitus or newly diagnosed or established type 2 diabetes mellitus are invited to participate. Multiple outcomes will be studied, including changes in glycosylated haemoglobin (primary outcome), changes in other biochemical and clinical metrics, incidence of diabetes-related complications, quality of life, clinical depression, success of tailored care, patient and practitioner satisfaction, and budget sustainability. Discussion This project responds to a need for robust evidence of the clinical and economic effectiveness of coordinated care for the management of diabetes in the Australian primary care setting. The outcomes of the study will have implications not only for diabetes management, but also for the management of other chronic diseases, both in Australia and overseas. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12612000363886); World Health Organisation (U1111-1128-0481).