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Objective: Poor mental health represents a large proportion of disease burden faced by young Australians, which has been further exacerbated by the Covid-19 pandemic and the reluctance of this population to seek support. Surf therapy is a novel form of intervention targeting mental health. The objective of this study was to interrogate programme theory within surf therapy, as delivered by the Waves of Wellness Foundation (WOW) in Australia., Methods and Measures: The study utilised grounded theory to understand or develop theoretical mediators for WOW surf therapy based on interviews exploring the experiences of previous intervention participants ( n  = 16; mean age = 18.4 years, SD  = 2.8, range 14-24). Data were analysed through constant comparative analysis., Results: Five categories emerged from participant data as foundational to WOW programme theory: (a) Safe Space, (b) Social Support, (c) Sensory Grounding, (d) Mastery and (e) Respite. These categories have novel theoretical and practical implications for both surf therapy and wider clinical practice, especially around concepts such as delivering 'mental health by stealth' and fostering longer term 'mental health maintenance' for participants., Conclusion: The study developed an initial WOW programme theory, highlighting the importance of foundational therapeutic structures beyond simply going surfing.

Background: Commissioning for health services has been implemented as one approach to improve the quality and access to healthcare for First Nations, regional and remote populations. This review systematically scoped the literature for studies that described or evaluated the governance, funding, implementation and outcomes from health service commissioning targeting these groups in Canada, Australia, Aotearoa/New Zealand and the United States (CANZUS nations)., Methods: Seventeen databases were searched for relevant peer reviewed and grey literature studies published in English from 2010 to 2023. Grounded theory methods were used to identify the enablers and strategies or processes that support commissioning and any challenges to implementation., Results: Overall, 29 Peer reviewed and 18 grey literature studies remained after screening. The studies reported enabling conditions for effective commissioning including operating models that were responsive to beneficiary needs, workforce and technical capability, flexibility and duration of contracts, adequate funding, and achievable health outcomes and indicators. Supporting strategies focussed on multi-actor collaboration, relationship building, and service innovation. Reported impacts included improved access to care, and self-determination and wellbeing for First Nations populations. Challenges related to inflexible funding, high transaction costs, overcompliance, and poor relationships. Most studies were process evaluations or descriptions of the application of commissioning to various health areas, with comparatively limited assessment of the impacts across the health system, or on health status., Conclusion: Findings suggests that a relational model drives success in commissioning for health and wellbeing services for First Nations, regional and remote populations. The relational model presented in this review is supported by the following attributes: responsive, resourced, collaborative, equitable, innovative and self-determined: and when applied by multiple actors in the commissioning process can address the complex health and wellbeing needs of end users., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval was provided by: Central Queensland University, approval number Human Research Ethics Committee (ID: 0000023943) and; Queensland Health, Far North Queensland Human Research Ethics Committee (HREC/2023/QCH/97970 (Jun ver 2) – 1723). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Issue Addressed: University students are at risk of poor health behaviours which negatively affect mental health and wellbeing. Informing the implementation of appropriate strategies to support Australian university students' health and wellbeing, requires quality evidence. This study aimed to identify research priorities for improving health behaviours to optimise mental health of Australian university students., Methods: A twin-panel Delphi method comprising 32 experts across two panels (Panel 1: n = 24, Panel 2; n = 8), with three rounds of data collection, was utilised. In round one panellists identified up to five research priorities. Identified priorities were grouped into themes and in Round 2 panellists ranked their panels priorities using a 4-point Likert scale (1 irrelevant, 2 peripheral, 3 important, 4 essential), and in Round 3 they ranked the importance of the priorities identified by the other panel., Results: Panel 1 identified 35 research priorities in Round 1, and Panel 2 identified 11. Priorities were ranked based on the mean score, with strong, between-panel agreement in the rankings for Panel 1's priorities. (r s  = .68, p < .001) but not Panel 2 (r s  = .32, p = .34). A list of 25 priorities was retained., Conclusions: Priorities were derived from experts and provided a further call to action for research targeting suicide prevention, social determinants, co-design, behaviour change, and the effectiveness and accessibility of services. SO WHAT?: With further input from students, universities and other stakeholders, these research priorities can guide research to optimise health behaviours and mental health of Australian university students., (© 2025 Australian Health Promotion Association.)

Background: Online grocery shopping is a growing source of food purchases in many countries. We investigated the effect of nudging consumers towards purchases of lower sodium products using a web browser extension., Methods: This trial was conducted among individuals with hypertension who shopped for their groceries online in Australia. From July 2021 to June 2023, participants were randomised to use the SaltSwitch Online Grocery Shopping web browser extension or continue their usual grocery shopping for 12 weeks. The SaltSwitch extension modified a retailer's online shopping interface to suggest similar but lower sodium alternative products to those initially selected. The primary outcome was the difference in mean sodium density (mg sodium per 1000 kcal of energy) of packaged food purchases between the intervention and control groups., Results: We randomised 185 participants of average age 56.0 (SD 11.0) years. Most were women (64%), White (89%), had BMI > 25 kg/m 2 (91%), and were taking anti-hypertensive medication (83%). Demographic and medical characteristics were similar across the randomised groups. 182 (98%) completed the trial. Over the 12-week intervention, the sodium density of groceries purchased by the intervention group compared to the control group was 204 mg/1000 kcal lower (95%CI, -352 to -56) (P = 0.01). The reduction in sodium density of purchases was apparent in weeks 1-4 and sustained through the end of the trial. 86% of participants in the intervention group made at least one switch to a lower sodium product. There were no detectable effects on blood pressure, spot urine sodium concentration, or other secondary outcomes across the 12-week study period., Conclusions: Online shopping platforms provide a novel opportunity to support purchases of lower sodium foods. While the reductions in sodium density of purchases were moderate in size, population health benefits could nonetheless be large if they were sustained over time and at scale, with large and growing numbers of online grocery shoppers and a high prevalence of elevated blood pressure amongst adults., Trial Registration: ACTRN12621000642886., Competing Interests: Declarations. Ethics approval and consent to participate: The trial received ethics approval from the University of New South Wales Human Research Ethics Committee (HC200970). Consent for publication: Not applicable. Competing interests: JHYW is a member of the Editorial Board of International Journal of Behavioral Nutrition and Physical Activity. JHYW was not involved in the journal’s peer review process of, or decisions related to, this manuscript. In the last 3 years, JHYW has received grant support from New South Wales (NSW) Health, Ian Potter Foundation, Hort Innovation, and Future Food System Cooperative Research Centre, as well as travel support by AusVeg, all outside of the present work. In the last 3 years, MDH has received travel support from the World Heart Federation. MDH has planned patents for combination therapy for the treatment of heart failure. AJC and CNM were academic partners on a healthy supermarket intervention trial that includes Australian local government and supermarket retail (IGA) collaborators, with funding from the Australian National Health and Medical Research Council (NHMRC), the Victorian Health Promotion Foundation (VicHealth) and Deakin University. The George Institute for Global Health has a patent, license, and has received investment funding with intent to commercialize fixed-dose combination therapy for hypertension through its social enterprise business, George Medicines. The George Institute has also previously received funding from Australian supermarket retailers to independently assess and provide advice on improving the healthiness of private label (home brand) product ranges. BN is supported by an Australian NHMRC fellowship. AES is supported by a NHMRC Investigator Grant (APP2017504), has received funding from the MRFF and NSW Health, and has also received speaker honoraria or sat on Advisory Boards for Servier, Medtronic, Sanofi, AstraZeneca, Omron, Aktiia, Skylabs, and Abbott. CA has received research funding from NHMRC, MRFF and NSW Health and has also received honoraria or sat on Advisory Boards for Novo Nordisk, Amgen and Astra Zeneca., (© 2024. The Author(s).)

Background: Diagnostic imaging is commonly used in the management of low back pain (LBP), with approximately one-quarter of those who present to primary care referred for imaging. Current estimates of imaging frequency commonly exclude older adults; however, pathology detected with imaging (e.g., osteoporosis, cancer) may occur more frequently in older populations. The aims of this study were to: (i) determine the frequency and forms of diagnostic imaging use in older adults presenting for chiropractic care for LBP in Australia; (ii) describe participant characteristics associated with imaging use; and (iii) describe the types of radiographic findings., Methods: Data were collected from the BAck Complaints in Elders: Chiropractic-Australia (BACE: C-A) study, a 12-month, prospective cohort study of adults aged ≥ 55 years with a new episode of LBP. Self-reported frequency of imaging use (baseline, 2 and 6 weeks, 3, 6, 9, and 12 months) was reported descriptively by imaging modality. Imaging reports were obtained, and imaging findings were independently extracted and categorised. Baseline characteristics were assessed for differences in those who received imaging compared to those who did not. Proportions of imaging use and imaging findings were presented descriptively with 95% confidence intervals., Results: The BACE: C-A cohort comprised 217 participants of whom 60.8% reported receiving diagnostic imaging for their current episode of LBP. X-ray was performed most (44.7%), followed by computed tomography (CT) (30.8%). Participants receiving imaging reported higher low back disability, more healthcare use for LBP, more frequent leg pain, more suspected serious pathology, and stronger beliefs that imaging was important. Degenerative changes were the most common imaging finding (96.6%). Pathology of possible clinical significance, including compression fracture or suspected osteoporosis, was present in 15.5% of participants., Conclusion: Three out of five older adults with LBP who sought chiropractic care received imaging over one-year. Participants receiving imaging tended to have more complex presentations (e.g., more disability, suspected underlying pathology) or stronger beliefs that imaging was necessary for the management of LBP. Degenerative changes were the most common imaging finding. Pathology of potential clinical relevance was present on approximately 15% of imaging reports received. No conditions requiring immediate medical attention were reported., Competing Interests: Declarations. Ethics approval and consent to participate: Ethics approval was provided by Macquarie University, Approval No.: 5201954609164. All participants provided consent before entering the study. Consent for publication: Not applicable. Competing interests: SDF is Co-Editor-in-Chief of Chiropractic & Manual Therapies. The editorial management system automatically blinded him from the submitted manuscript, and he had no part in the editorial or peer-review process of this manuscript. KD is guest editor of the Chiropractic & Manual Therapies special collection, Manual therapies for older adults during the Decade of Healthy Ageing. The editorial management system automatically blinded her from the submitted manuscript, and she had no part in the editorial or peer-review process of this manuscript., (© 2024. The Author(s).)

Background: This study aimed to explore perceived work stress and its association with burnout, compassion fatigue, and compassion satisfaction and the mediating effect of psychological flexibility on these relationships., Method: Two hundred and fifty-one disability support workers across Australia reported on work stress, psychological flexibility, burnout, compassion fatigue, and compassion satisfaction through an online anonymous survey., Results: Perceived work stress was found to have a significant relationship with burnout, compassion fatigue, and compassion satisfaction. Psychological flexibility had a significant mediating effect on all three relationships., Conclusion: These results highlight the role that psychological flexibility has in response to work stress and the development of burnout, compassion fatigue, and compassion satisfaction in disability support workers.

Managing LBP via clinical practice guidelines in healthcare settings is recommended, yet burgeoning evidence suggests adherence is suboptimal in emergency department settings. Whether adherence differs between public and private settings is unknown. A retrospective audit of two Australian emergency departments matched 86 private patients to 86 public patients by age ( ± 5 years), sex (male/female) and LBP duration (first time/history of LBP). Patient charts were reviewed according to the Australian clinical guidelines for the management of LBP. Guidelines were considered individually and via a collective guideline adherence score (GAS). Management GAS was lower in private patients compared to public patients (d [95 %CI]: -0.67 [-0.98, -0.36], P < 0.001). Public patients were more likely to have documentation of guideline-based advice (OR [95 %CI]: 4.4 [2.4, 8.4], P < 0.001) and less likely to be sent for imaging (OR [95 %CI]: 5.0 [2.6, 9.4], P < 0.001). Private patients were more likely to have documented screening for psychosocial risk factors (OR [95 %CI]: 21.8 [9.1, 52.1], P < 0.001) and more likely to receive guideline-based medication prescriptions at patient discharge (OR [95 %CI]: 2.2 [1.2, 4.2], P = 0.013). Differences exist in public and private hospital emergency department guideline adherence. Exploring barriers and facilitators underpinning these differences will assist in guiding future implementation science approaches., Competing Interests: Declaration of Competing Interest The authors declare no conflicts., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Trace elements in game meats remain a point of concern for both the public and policymakers alike due to the human health implications if levels present are above guideline limits. This study aimed to: (1) determine trace element concentrations (As, Cd, Hg, Pb Cr, Cu, Se, Zn) in edible portions (breast meat and liver) of the four most frequently hunted duck Anatidae species inhabiting wetlands in Victoria, Australia, to identify the risk to human health from consumption; (2) investigate landscape-scale variables that may influence the detected concentrations and; (3) review the studies available (n = 41) in duck liver and muscle tissues from the 1970s to 2024, to contextualise the detected concentrations found on a global scale. Our study shows that ducks in Victoria had trace element concentrations below tolerable daily intake (TDI) guidelines for human health with one exception: notably high Hg in a filter-feeding specialist, the Pink-eared duck (Malacorhynchus membranaceus). Yet, the only trace element concentrations that were influenced by proximity to populated centres, were As and Zn. Compared to international reports, Pb concentrations in livers and muscle of Victorian waterfowl were lower, however, Pink-eared ducks had higher Hg than other duck (Anas spp.) species. Review of the worldwide data indicate that Pb concentrations in liver tissues from all Anas species have declined from the 1970s to 2024. This is the first study to identify this trend at a global scale. International movements towards Pb-shot bans, along with phasing out of Pb in gasoline and paint are the most likely cause of declining concentrations in tissues of wild waterfowl. These findings strongly underscore the importance of legislative efforts to limit trace elements entering the environment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Dragon fruit, which is native to northern South America and Mexico, has become a significant crop in tropical and subtropical regions worldwide, including Vietnam, China, and Australia. The fruit ( Hylocereus spp.) is rich in various bioactive phytochemical compounds, including phenolic acids, flavonoids, and pigments such as betalains and anthocyanins, which contribute to its antioxidant, anti-inflammatory, and anti-microbial properties. This comprehensive review introduces the origin, classification, and global production of dragon fruit, with a particular focus on its bioactive phytochemicals and therapeutic potential. Additionally, it critically evaluates the current industry standards for fresh dragon fruit production across key producing countries. While these standards primarily focus on quality, classification, and grading criteria, they lack focus on parameters related to the fruit's bioactive content. The absence of established quality standards for fresh produce in the Australian dragon fruit industry presents a unique opportunity to develop guidelines that align with both international benchmarks and the therapeutic potential of the fruit. By addressing this gap, this review can potentially help Australia to position its dragon fruit industry to achieve greater consistency, competitiveness, and consumer appeal. As the demand for functional foods continues to rise, aligning Australian production practices with global standards becomes critical to meeting domestic market expectations. This review provides a comprehensive understanding of dragon fruit's nutritional and therapeutic significance and highlights its potential role in establishing a robust standard for the Australian dragon fruit industry. A review of global industry standards reveled that Australian standard could incorporate classifications of dragon fruits, including external factors like appearance, size, and defect tolerance. Future research is needed to prioritize understanding of the impact of cultivation practices and environmental factors on the bioactive composition of dragon fruit, enabling the development of best practices for growers. Additionally, further studies are needed to evaluate the therapeutic effects of these bioactive properties through clinical trials, particularly their potential in preventing chronic diseases. The advancement of analytical methods for quantifying bioactive compounds will provide deeper insights into their health benefits and support the establishment of bioactive-oriented industry standards. Moreover, investigations of post-harvest handling and processing techniques could optimize the preservation of these valuable compounds, enhancing dragon fruit's role as a functional food.

Objectives: The objective of this study is to examine the hospitalisation profile for respiratory diseases in Australia between 1998 and 2019., Design: An ecological study., Setting: A population study that involved all private and public hospitalisations for respiratory diseases in Australia from 1998 to 2019. Data were gathered from the National Hospital Morbidity Database., Participants: All patients who were hospitalised at all private and public hospitalisations for respiratory diseases in Australia., Primary Outcome Measure: Hospitalisation rates related to respiratory diseases., Results: A total of 8 090 021 hospital admission episodes for diseases of the respiratory system were recorded in Australia between 1998 and 2019. Hospital admission rates increased by 12.4%, from 1766.45 (95% CI 1760.50 to 1772.41) in 1998 to 1985.86 (95% CI 1980.43 to 1991.28) in 2019 per 100 000 persons, p<0.05. Patients who were admitted for an overnight stay made up 82.2% of the total admissions. Females showed a greater increase in hospital admission rates (18.4%) compared with males (7.0%). The age group 15-59 years accounted for 31.0% of the total admissions. The most frequent respiratory system hospital admissions were for chronic lower respiratory diseases; these accounted for 27.8% of all admissions., Conclusion: Hospital admissions due to diseases of the respiratory system increased significantly in the last two decades in Australia. Male gender and younger age groups were more likely to be hospitalised for respiratory diseases. Strong public health measures are crucial to raising awareness about diseases of the respiratory system and their implications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: Australian general practices are highly involved with accreditation programs; however, there is evidence to suggest variability in their levels of performance. The aim of the current study was to determine the association with between several metrics of preparation with accreditation performance outcomes., Method: Several metrics were synthesised that measured preparation time to general practice accreditation. Performance outcomes were: (1) conformity to 124 indicators of the standards; (2) time to remediate indicator non-conformities; and (3) level of assistance required., Results: A greater number of months between registration with the accrediting agency and practice accreditation expiry date was associated with higher indicator conformity at the site visit (OR=1.04, P=0.001), as well as less time (β=-0.02, P=0.002) and less assistance (β=-0.66, P=0.02) to remediate non-conformant indicators post site visit., Discussion: Adequate preparation time for several components within the accreditation framework for general practices were associated with small-to-moderate improvements in key performance outcomes.

Background and Objectives: Chronic breathlessness is a frequent diagnostic challenge in primary care. Our aim is to evaluate the feasibility of a stepwise breathlessness diagnostic algorithm for primary care., Method: This mixed-methods study included: (1) a general practitioner (GP) nominal group technique study; (2) focus groups on GPs' views on the algorithm; and (3) analysis of algorithm alignment against patterns of diagnostic referrals and diagnoses of breathlessness presentations (2014-19) from the MedicineInsight primary care electronic health record (EHR) dataset of 1,961,264 patients (405 general practice sites)., Results: All the tests in our algorithm, except for echocardiography, were ranked in the top 10 tests used by most GPs for patients presenting with chronic breathlessness. Themes from the focus group include similarity with current practice and test accessibility. Analysis of EHR diagnostic referrals revealed that all tests in the algorithm are regularly utilised and covered the major tests needed for breathlessness diagnoses recorded., Discussion: The results of the three studies support the acceptability and feasibility of the clinical algorithm in primary care.

Background: The rapid proliferation of medical apps has transformed the health care landscape by giving patients and health care providers unprecedented access to personalized health information and services. However, concerns regarding the effectiveness and safety of medical apps have raised questions regarding the efficacy of randomized controlled trials (RCTs) in the evaluation of such apps and as a requirement for their regulation as mobile medical devices., Objective: This study aims to address this issue by investigating alternative methods, apart from RCTs, for evaluating and regulating medical apps., Methods: Using a qualitative approach, a focus group study with 46 international and multidisciplinary public health experts was conducted at the 17th World Congress on Public Health in May 2023 in Rome, Italy. The group was split into 3 subgroups to gather in-depth insights into alternative approaches for evaluating and regulating medical apps. We conducted a policy analysis on the current regulation of medical apps as mobile medical devices for the 4 most represented countries in the workshop: Italy, Germany, Canada, and Australia. We developed a logic model that combines the evaluation and regulation domains on the basis of these findings., Results: The focus group discussions explored the strengths and limitations of the current evaluation and regulation methods and identified potential alternatives that could enhance the quality and safety of medical apps. Although RCTs were only explicitly mentioned in the German regulatory system as one of many options, an analysis of chosen evaluation methods for German apps on prescription pointed toward a "scientific reflex" where RCTs are always the chosen evaluation method. However, this method has substantial limitations when used to evaluate digital interventions such as medical apps. Comparable results were observed during the focus group discussions, where participants expressed similar experiences with their own evaluation approaches. In addition, the participants highlighted numerous alternatives to RCTs. These alternatives can be used at different points during the life cycle of a digital intervention to assess its efficacy and potential harm to users., Conclusions: It is crucial to recognize that unlike analog tools, digital interventions constantly evolve, posing challenges to inflexible evaluation methods such as RCTs. Potential risks include high dropout rates, decreased adherence, and nonsignificant results. However, existing regulations do not explicitly advocate for other evaluation methodologies. Our research highlighted the necessity of overcoming the gap between regulatory demands to demonstrate safety and efficacy of medical apps and evolving scientific practices, ensuring that digital health innovation is evaluated and regulated in a way that considers the unique characteristics of mobile medical devices., (©Laura Maaß, Robert Hrynyschyn, Martin Lange, Alexandra Löwe, Kathrin Burdenski, Kaley Butten, Sebastian Vorberg, Mariam Hachem, Aldo Gorga, Vittorio Grieco, Vincenzo Restivo, Giuseppe Vella, Marlien Varnfield, Felix Holl. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 30.09.2024.)

High dietary salt intake is a known risk factor for hypertension. However, Australians continue to consume excessive amounts of salt. The purpose of this study was to identify barriers, enablers and strategies to reduce salt in a sample of Australian adults with hypertension. This was a qualitative study. Participants were asked a set of open-ended questions during focus groups conducted between October 2020 and April 2021. Sessions were recorded and transcribed. Using an inductive approach, the transcript data from the focus groups were thematically analysed. This involved checking accuracy, becoming familiar with the data, coding responses based on questions, identifying themes through common patterns and validating themes by grouping similar questions that represented the data and study aim effectively. Thirty-one adults (55 % females) with high blood pressure participated in the focus group discussions. Participants demonstrated good knowledge of high blood pressure risk factors but lacked an understanding of recommended salt intake levels and sources of hidden salt. Challenges in reducing salt intake included the limited availability of low-salt commercial foods. Participants suggested improved food labelling and the use of technology-based interventions to promote healthier choices. Findings highlight the need for behavioural interventions, policy reforms and collaborations between the government, food industries and health organisations to address high salt intake in the population.

Objective: To examine the impact of breathlessness on quality of life, health care use, productivity loss, and economic costs in Australia., Study Design: National internet-based survey of Australian adults drawn from a web-based survey panel (National Breathlessness Survey)., Participants, Setting: Australian adults (18 years or older), nationally representative by age group, gender, state of residence, and postcode-based socio-economic status (Index of Relative Socioeconomic Disadvantage quintile), 13-30 October 2019., Main Outcome Measures: Quality of life assessed with the EQ-5D 5-level version (EQ-5D-5L) and visual analogue scale (EQ-VAS), health care use, productivity loss, and societal cost, each by severity of breathlessness (modified Medical Research Council [mMRC] dyspnoea scale; mMRC grade 1: mild breathlessness; mMRC grades 2-4: clinically important breathlessness)., Results: Of 10 072 adults who completed the survey, mild breathlessness was reported by 3044 respondents (30.2%), and clinically important breathlessness by 961 (9.5%). The mean EQ-VAS score was 74.8 points (95% confidence interval [CI], 74.3-75.3 points) and the mean EQ-5D-5L score 0.846 (95% CI, 0.841-0.850) for respondents with mMRC grade 0 breathlessness; for each measure, the mean value declined with increasing severity of breathlessness (trends: each P < 0.001). Respondents with clinically important breathlessness were more likely than those with mild breathlessness to report non-urgent general practitioner visits, urgent general practitioner visits, and specialist visits (exception: mMRC scores of 4) during the preceding year. Among the 2839 respondents of working age, the likelihood of being employed declined with increasing breathlessness severity (mMRC grades 4 v 1: adjusted odds ratio, 0.34; 95% CI, 0.22-0.53). Adjusted mean annual societal cost per person was $1413 (95% CI, $1326-1501) for respondents with mMRC grade 1 breathlessness, $2065 (95% CI, $1766-2365) at mMRC grade 2, $1795 (95% CI, $1371-2218) at mMRC grade 3, and $2075 (95% CI, $1389-2762) at mMRC grade 4., Conclusion: Breathlessness imposes major burdens on individuals, the health care system, and the economy., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objective: Although evidence of the global effectiveness and usability of mobile health (mHealth) apps as non-drug interventions is growing, older adults often demonstrate low adoption rates of these apps. This study aims to identify the perspectives of older adults on introducing and adopting mHealth apps in Australia and Germany., Materials and Methods: We conducted two online cross-sectional surveys to examine factors from contextual, technological and personal perspectives that influence older adults in mHealth app adoption. Using descriptive statistics, chi-square tests and exploratory factor analysis, we identified the differences and similarities between respondents' perspectives across two countries., Results: A total of 290 respondents (149, Australia; 141, Germany) completed the survey. Older adults' ability to use a mHealth app, the user-friendliness of the app, their positive self-efficacy regarding their health and resource availability for using mHealth apps were related to intended adoption. Differences between Germany and Australia were found in issues concerned with data sharing and empowerment by the doctor, while similarities were related to trust in the doctor and their treatment approaches., Discussion and Conclusion: This study highlights participants' perspectives and attitudes towards mHealth app use, unmet needs and barriers, and the facilitating influences in the two countries. These insights can be used to inform the development and implementation of mHealth apps and to construct tailored strategies to increase the adoption rates of mHealth apps among older adults and to maximise their potential benefits., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Symptomatic HIV-associated neurocognitive disorder (HAND) is a complication of HIV (cognitive impairment, difficulties with everyday functioning). If detected early, interventions assist with optimizing care, avoiding rapid decline and enhancing coping. There remains inconsistency surrounding screening/diagnosis information within Australian healthcare professionals and community settings. A scoping review of academic literature, government policies and non-government organisations (NGOs) was conducted to map existing screening/diagnosis information using the guidelines of Joanna Briggs Institute. A literature search of EBSCOhost and Medline (dates: 2015-2021), the Australian government NGO web domains, Google and unpublished academic works was conducted (July 2021) and updated (December 2022) to identify Australian items (past 5 years). Seventeen items met the inclusion criteria. No government guidelines were identified. Various HIV-related organisations proposed different diagnostic guidelines. Most HAND research originated in Sydney. The most accessible information was from Dementia Australia, with some inaccuracies noted. There is scant Australian research/information on HAND screening/diagnosis. HAND translational research and screening/diagnosis standards are urgently needed to inform best practices. The Australian context is used to discuss international implications regarding higher-income countries with similar patterns/healthcare.

The relationship between heart rate variability (HRV) and training load in team-sport is unknown. We therefore assessed relations between completed training-load in the previous 1-, 3- and 7-days and waking HRV in professional Australian Rules Football. Linear-mixed models analysed changes in HRV, considering training load from the previous 1-, 3- and 7-days. Total Distance (TD), distance >14.4 km ‧ h-1 (HSR) and >24.9 km ‧ h-1 (Sprint-Distance), duration >85% max heart rate and Rating of Perceived Exertion were included as independent variables. Sub-group analysis of season-phase and years of professional experience was also conducted. Increased three-day Sprint-Distance reduced HRV in the first 8-weeks of pre-season (-13.1 ms, p = 0.03) and across the data collection period (-3.75 ms, p = 0.01). In first-year players, higher previous-day (-63.3 ms, p=0.04) and seven-day TD (-38.2 ms, p = 0.02) reduced HRV, whilst higher seven-day HSR increased HRV (34.5 ms, p = 0.01). In players with five-to-seven years of professional experience, higher three-day (-14.4 ms, p = 0.02) and seven-day TD (-15.7 ms, p = 0.01) reduced HRV, while higher three-day HSR increased HRV (12.5 ms, p = 0.04). In players with greater than eight years of professional experience, higher previous-day Sprint-Distance reduced HRV (-13.1 ms, p < 0.008). Completed training load across the previous 7-days influences HRV, but the relation between variables is complex and influenced by professional experience and season-phase.

Objective: In 2023, Australian government emergency medical services (EMS) responded to over 4 million consumers, of which over 56% were not classified as an 'emergency', at the cost of AU$5.5 billion. We explored the viewpoints of politicians, policymakers, clinicians and consumers on how these non-emergency requests should be managed., Design: A realist framework was adopted; a multidisciplinary team (including paramedicine, medicine and nursing) was formed; data were collected via semistructured focus groups or interviews, and thematic analysis was performed., Setting and Participants: 56 participants were selected purposefully and via open advertisement: national and state parliamentarians (n=3); government heads of healthcare disciplines (n=3); government policymakers (n=5); industry policymakers in emergency medicine, general practice and paramedicine (n=6); EMS chief executive officers, medical directors and managers (n=7); academics (n=8), frontline clinicians in medicine, nursing and paramedicine (n=8); and consumers (n=16)., Results: Three themes emerged: first, the reality of the EMS workload (theme titled 'facing reality'); second, perceptions of what direction policy should take to manage this ('no silver bullet') and finally, what the future role of EMS in society should be ('finding the right space'). Participants provided 16 policy suggestions, of which 10 were widely supported: increasing public health literacy, removing the Medical Priority Dispatch System, supporting multidisciplinary teams, increasing 24-hour virtual emergency departments, revising undergraduate paramedic university education to reflect the reality of the contemporary role, increasing use of management plans for frequent consumers, better paramedic integration with the healthcare system, empowering callers by providing estimated wait times, reducing ineffective media campaigns to 'save EMS for emergencies' and EMS moving away from hospital referrals and towards community care., Conclusions: There is a need to establish consensus on the role of EMS within society and, particularly, on whether the scope should continue expanding beyond emergency care. This research reports 16 possible ideas, each of which may warrant consideration, and maps them onto the standard patient journey., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Integration of exercise into standard oncology care requires a highly skilled workforce of exercise professionals; however, competency requirements have not kept pace with advancements in the field. Therefore, the aim of this study was to obtain consensus on core competencies required for an exercise professional to be qualified to work with adults undergoing active cancer treatment., Materials and Methods: A three-round modified electronic Delphi process was used. In Round 1, an international group of 64 exercise oncology stakeholders (i.e., exercise oncology professionals (n = 29), clinical referrers (n = 21), and people with lived experience (n = 14)) responded to open-ended prompts eliciting perspectives regarding competencies needed for an exercise oncology professional to work with adults receiving active cancer treatment. Subsequently, only exercise oncology professionals participated, ranking the importance of competencies. In Round 2, professionals received summary feedback, ranked new competencies generated from open-ended responses, and reranked competencies not reaching consensus. In the final round, professionals finalized consensus ranking and rated frequency and mastery level for each., Results: Consensus was reached on 103 core competencies required for exercise professionals to be qualified to deliver care to adults undergoing active cancer treatment. The core competencies represent 10 content areas and reflect the needs of clinical referrers and people with lived experience of receiving cancer treatment., Conclusions: The core competencies identified reflect significant advancements in the field of exercise oncology. Results will underpin the development of education, certification, and employment requirements for exercise oncology professionals, providing a critical step toward achieving routine integration of exercise into standard oncology care., (© 2024 The Author(s). Cancer Medicine published by John Wiley & Sons Ltd.)

Background & Aim: Echocardiography education involves the teaching and assessment of multiple competencies to ensure work-ready graduates. To connect these competency standards to professional practice, it is important that the industry expectation around specific entrustable professional activities (EPAs) is determined. In Australia, echocardiography examinations are eligible for Medicare reimbursement when performed by sonographers listed on the Australian Sonographers Accreditation Registry (ASAR), either as an Accredited Medical Sonographer or as an Accredited Student Sonographer. A key criterion for acceptance onto the registry is the completion of, or active enrolment in, an accredited cardiac sonography course. Eligible courses apply for accreditation and are assessed by ASAR against their Standards for Accreditation of Sonographer Courses. This study sought to investigate the existing cardiac EPAs and provide insights into the industry's expectations for graduate cardiac sonographers in Australia., Methods: Using an anonymous online survey tool, an invitation to participate was circulated via professional sonography groups and social media platforms. Accredited Medical Sonographers, Accredited Student Sonographers or interested stakeholders (academic, employer, medical specialist) working in Australia or New Zealand were invited to complete the survey. Survey questions were structured around the existing EPAs and knowledge items described in published sonography competency documents. Participants were asked if each individual EPA should be considered appropriate at the threshold of graduation, or at a higher level following a period of working in the profession., Results: There were 211 cardiac sonographers who completed the survey. The majority of respondents (148 of 211, 72.2%) indicated that the current EPAs should be updated. At 80% agreement, the following EPAs were considered essential for the graduate: left ventricular structure and function, right ventricular structure and function, atrial size, valvular disease, systemic hypertension, cardiomyopathies, diseases of the aorta, coronary artery disease, pulmonic hypertension, and basic congenital heart disease. This list is more extensive than the current ASAR-endorsed EPAs, and the findings in this research will guide the revision of current ASAR-endorsed EPAs for graduate-level cardiac sonography., Conclusions: The results of this study show Accredited Medical Sonographers completing a cardiac sonography course in Australia should be entrusted to perform a wide range of examinations however, greater alignment between educational providers, ASAR and industry is still required., Competing Interests: Conflicts of Interest There are no conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

The present study examined distinctions between child (n = 30) and adult (n = 212) sexual homicide offenders (SHOs) in Australia and New Zealand, contributing to the limited international research on the subject. Data, primarily sourced from judges' sentencing comments on AustLII and New Zealand Legal Information Institute, revealed significant differences. Child SHOs displayed elevated rates of pedophilia, sexual deviance, and adverse childhood experiences, including sexual abuse. They were more likely to be married, cohabitate, and target familial victims. Their crimes were more often committed during daylight and outdoors, involving tactics such as victim conning, restraints, strangulation, and hiding victim's bodies. No significant group differences emerged regarding offenders' psychopathy or sexual sadism scores. Results were interpreted in line with child SHOs' deviant sexual preferences and the routine activity theory. The study, as the first investigating child sexual homicides in Australia and New Zealand, sets the foundation for an evidence-based approach to policy and practice., (© 2024 The Author(s). Behavioral Sciences & The Law published by John Wiley & Sons Ltd.)

Despite the phase-out of lead-based products, lead contamination can still present a contemporary risk to public health. In situations where elevated blood lead cannot be attributed to common sources, detailed environmental investigation is needed to identify more elusive sources and manage harmful exposure pathways. We apply a forensics approach to assess common and elusive sources of lead in the home environment of two individuals with fluctuating blood lead levels in Sydney, Australia. Using multiple analytical lines of evidence (portable X-Ray Fluorescence spectrometry (pXRF), inductively coupled-plasma mass spectrometry (ICP-MS), lead isotopic compositional analysis (PbIC) and haematological assessment) a pewter pepper grinder containing lead (>6000 mg/kg; 70% bioavailable) was identified as a potential source. After removing the pepper grinder from the home, the couple's blood lead decreased to below the Australian intervention level of 5 μg/dL within a year (Person A: from 12.5 μg/dL in August 2020 to 4.4 μg/dL in March 2022; and Person B: 15.4 μg/dL in August 2020 to 2.1 μg/dL in July 2021). This case study demonstrates how environmental science investigations can play a crucial role in supporting people to take evidence-based action to improve their health., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Research for this study was supported via an Australian Government Citizen Science Grant, CSG55984 to M.P. Taylor ‘Citizen insights to the composition and risks of home dust’ (the DustSafe project)., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Despite the well-known benefits of physical activity, physical inactivity is presently a global health pandemic. Allied healthcare providers, such as chiropractors, knowingly recognise the importance of physical activity and are prepared to routinely discuss and/or counsel patients on this topic; however, little is known about Australian chiropractors in the physical activity setting. Our aim was to explore and identify factors associated with physical activity promotion among Australian chiropractors, including their knowledge of the physical activity and sedentary behaviour guidelines and their own levels of physical activity., Methods: From February to May 2021, a convenience sample of Australian chiropractors completed an online survey. Items assessed by Likert scale included: physical activity promotion frequency, with the type, quantity, barriers, perceptions, and feasibility. We asked questions about their familiarity with, and knowledge of, Australian Physical Activity and Sedentary Behaviour Guidelines, chiropractors' own physical activity, and whether the chiropractors met activity guidelines. Survey responses were descriptively reported. Univariable logistic regression models explored factors explaining frequent physical activity promotion., Results: Of 217 respondents, 64% reported that they frequently (≥ 70%) recommended a more physically active lifestyle. Only 15% often performed pre-exercise screening, 73% frequently prescribed resistance exercise, 19% reported time as the most frequent barrier, while 37% reported being not at all familiar with the guidelines. Univariable logistic regression models found male chiropractors were more likely to promote physical activity, [odds ratio (OR) = 2.33; 95% confidence interval (CI): 1.32-4.12)], while chiropractors who frequently treat children 0-3 years (OR = 0.5; 95% CI: 0.28-0.87), children 4-18 years (OR = 0.42; 95% CI: 0.21-0.86), and pregnant women (OR = 0.5; 95% CI: 0.26-0.94) were less likely. Chiropractors were more likely to promote physical activity if they were familiar with the activity guidelines (OR = 2.9; 95% CI: 1.32-6.41), were confident promoting (OR = 11.6; 95% CI: 1.37-98.71) and prescribing physical activity programs (OR = 4.5; 95% CI: 2.03-9.99)., Conclusion: Most chiropractors confidently and regularly integrate physical activity into practice. Yet, despite acknowledging its importance, one third of chiropractors reported poor knowledge of the Physical Activity and Sedentary Behaviour Guidelines. Identifying barriers to the awareness, and implementation of physical activity guidelines should be further explored within chiropractic clinical settings., (© 2024. The Author(s).)

Aims: Understanding how gambling harm is distributed is essential to inform effective harm reduction measures. This first national Australian study of gambling harm-to-self examined the extent, distribution, risk factors, and health related quality of life (HRQoL) impacts of this harm., Methods: A Random Digit Dialling sample of 15,000 Australian adults was weighted to key population variables. Key measures included the Gambling Harms Scale-10 (GHS-10), PGSI, SF-6D, gambling behaviours, and demographics. Analyses included ordinal logistic regression., Results: Amongst gamblers, 14.7% reported harm on the GHS-10, including 1.9% reporting high-level harm. While high-level harm occurred mainly in the problem gambling group (77.3%), other PGSI groups accounted for most of the more prevalent low (98.5%) and moderate (87.2%) harms reported. Proximal predictors of greater harm were use of online gambling and more frequent gambling on electronic gaming machines (EGMs), race betting sports betting, poker, skin gambling, scratchies, and loot box purchasing. Distal predictors were being younger, male, single, Aboriginal or Torres Strait Islander, and speaking a non-English language at home. At the population level, the greatest aggregate HRQoL impacts were amongst lower-risk gamblers, confirming the results of other studies regarding the 'prevention paradox'., Conclusions: The distribution of harm across gambler risk groups indicates the need for preventive measures, not just interventions for problem gambling. Reducing harm requires modifying product features that amplify their risk, especially for EGMs, race betting and sports betting that are both inherently risky and widely used. Gambling harm exacerbates health disparities for disadvantaged and vulnerable groups, requiring targeted resources and support.

Background: Gambling abstinence when underage lowers the risk of harmful gambling in later life. However, little research has examined why many young people refrain from gambling, even though this knowledge can inform protective strategies and lower risk factors to reduce underage gambling and subsequent harm. This study draws on the lived experience of adolescent non-gamblers to explore how social determinants while growing up have shaped their reasons and choices to not gamble., Methods: Fourteen Australian non-gamblers, aged 12-17 years, participated in an in-depth individual interview (4 girls, 3 boys) or online community (4 girls, 3 boys). Questions in each condition differed, but both explored participants' gambling-related experiences while growing up, including exposure, attitudes and behaviours of parents and peers, advertising, simulated gambling and motivations for not gambling. The analysis used adaptive grounded theory methods., Results: The grounded theory model identifies several reasons for not gambling, including not being interested, being below the legal gambling age, discouragement from parent and peers, concern about gambling addiction and harm, not wanting to risk money on a low chance of winning, and moral objections. These reasons were underpinned by several social determinants, including individual, parental, peer and environmental factors that can interact to deter young people from underage gambling. Key protective factors were parental role modelling and guidance, friendship groups who avoided gambling, critical thinking, rational gambling beliefs, financial literacy and having other hobbies and interests., Conclusions: Choices to not gamble emanated from multiple layers of influence, implying that multi-layered interventions, aligned with a public health response, are needed to deter underage gambling. At the environmental level, better age-gating for monetary and simulated gambling, countering cultural pressures, and less exposure to promotional gambling messages, may assist young people to resist these influences. Interventions that support parents to provide appropriate role modelling and guidance for their children are also important. Youth education could include cautionary tales from people with lived experience of gambling harm, and education to increase young people's financial literacy, ability to recognise marketing tactics, awareness of the risks and harms of gambling, and how to resist peer and other normalising gambling influences., (© 2024. The Author(s).)

Bioaccessibility and relative bioavailability of As, Cd, Pb and Sb was investigated in 30 legacy gold mining wastes (calcine sands, grey battery sands, tailings) from Victorian goldfields (Australia). Pseudo-total As concentration in 29 samples was 1.45-148-fold higher than the residential soil guidance value (100 mg/kg) while Cd and Pb concentrations in calcine sands were up to 2.4-fold and 30.1-fold higher than the corresponding guidance value (Cd: 20 mg/kg and Pb: 300 mg/kg). Five calcine sands exhibited elevated Sb (31.9-5983 mg/kg), although an Australian soil guidance value is currently unavailable. Arsenic bioaccessibility (n = 30) and relative bioavailability (RBA; n = 8) ranged from 6.10-77.6% and 10.3-52.9% respectively. Samples containing > 50% arsenopyrite/scorodite showed low As bioaccessibility (<20.0%) and RBA (<15.0%). Co-contaminant RBA was assessed in 4 calcine sands; Pb RBA ranged from 73.7-119% with high Pb RBA associated with organic and mineral sorbed Pb and, lower Pb RBA observed in samples containing plumbojarosite. In contrast, Cd RBA ranged from 55.0-67.0%, while Sb RBA was < 5%. This study highlights the importance of using multiple lines of evidence during exposure assessment and provides valuable baseline data for co-contaminants associated with legacy gold mining activities., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare that generative artificial intelligence (AI) and AI-assisted technologies were not used in the writing process or any other process during the preparation of this manuscript., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To describe the occurrence of pneumonia in individuals with acute spinal cord injury (SCI) and identify its key predictors., Design: Multi-centric, longitudinal cohort study., Setting: 10 specialized SCI rehabilitation units in Europe and Australia., Participants: Eligible were 902 men and women with acute SCI, aged 18 years or older, with cervical or thoracic lesions and not dependent on 24-hour mechanical ventilation; 503 participated in the study (N=503)., Interventions: Not applicable., Main Outcome Measures: We assessed demographics and lesion related parameters at study entry, and any pneumonia events throughout inpatient rehabilitation. Respiratory function, decubitus, and urinary tract infections were assessed at 1, 3, and 6 months post injury as well as at discharge from inpatient rehabilitation. Time to event (pneumonia) analyses were done using the Kaplan-Meier method, and potential predictors for pneumonia were analyzed with multivariable survival models., Results: Five hundred three patients with SCI were included, with 70 experiencing at least 1 pneumonia event. 11 participants experienced 2 or more events during inpatient rehabilitation. Most events occurred very early after injury, with a median of 6 days. Pneumonia risk was associated with tetraplegia (hazard ratio [HR]=1.78; 95% confidence interval [CI] 1.00-3.17) and traumatic etiology (HR=3.75; 95% CI 1.30-10.8) American Spinal Injury Impairment Scale (AIS) A (HR=5.30; 95% CI 2.28-12.31), B (HR=4.38; 95% CI 1.77-10.83), or C (HR=4.09; 95% CI 1.71-9.81) lesions. For every 10 cmH 2 O increase in inspiratory muscle strength, pneumonia risk was reduced by 13% (HR=0.87; 95% CI 0.78-0.97)., Conclusion: Pneumonia is a major complication after SCI with the highest incidence very early after injury. Individuals with traumatic or AIS A, B, or C tetraplegia are at highest risk for pneumonia., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The 'PenCS Flu Topbar' app was deployed in Central Queensland (CQ), Australia, medical practices through a pilot programme in March 2021., Methods: We evaluated the app's user experience and examined whether the introduction of 'PenCS Flu Topbar' in medical practices could improve the coverage of NIP-funded influenza vaccinations. We conducted a mixed-method study including a qualitative analysis of in-depth interviews with key end-users and a quantitative analysis of influenza vaccine administrative data., Results: 'PenCS Flu Topbar' app users reported positive experiences identifying patients eligible for NIP-funded seasonal influenza vaccination. A total of 3606 NIP-funded influenza vaccinations was administered in the eight intervention practices, 14% higher than the eight control practices. NIP-funded vaccination coverage within practices was significantly higher in the intervention practices (31.2%) than in the control practices (27.3%) (absolute difference: 3.9%; 95% CI: 2.9%-5.0%; p < 0.001). The coverage was substantially higher in Aboriginal and Torres Strait Islander people aged more than 6 months, pregnant women and children aged 6 months to less than 5 years for the practices where the app was introduced when compared to control practices: incidence rate ratio (IRR) 2.4 (95% CI: 1.8-3.2), IRR 2.7 (95% CI: 1.8-4.2) and IRR 2.3 (1.8-2.9) times higher, respectively., Conclusions: Our evaluation indicated that the 'PenCS Flu Topbar' app is useful for identifying the patients eligible for NIP-funded influenza vaccination and is likely to increase NIP-funded influenza vaccine coverage in the eligible populations. Future impact evaluation including a greater number of practices and a wider geographical area is essential., (© 2024 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Household food waste is increasingly recognised as a global wicked problem for its greenhouse gas emissions, economic damage, and resource loss. Although targeted in the UN's Sustainable Development Goals, countries can only respond according to their capacity. For Australia, national policy has put the pressure on states and territories to divert food waste away from landfill into a nascent circular economy. For councils, this increasingly means implementing a FOGO (Food Organics/Garden Organics) kerbside collection. Despite funding and infrastructure development, many are resisting. Framed by the tenets of policy diffusion, this paper presents the results of a nationwide exploratory survey aimed at identifying how and why council-based waste services staff resist, emulate or lead FOGO implementation. By assessing participants current kerbside systems and their attitudes towards household food waste management, the survey found costs, contamination, and capacity and were key concerns. However, responses to these varied considerably despite similarities of situation, often relating more to collaborative attitudes across waste services, council, and councillors. This paper recognises that a conducive environment for change is urgently needed for Australia to achieve organics diversion targets and shift household food towards a circular economy. It provides a starting point for further research into the complex and nuanced dynamics between council waste services and FOGO implementations, from external drivers and council paradigms to individual attitudes and perceptions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Issue Addressed: Interventions targeting health care professionals' behaviours are assumed to support them in learning how to give behavioural advice to patients, but such assumptions are rarely examined. This study investigated whether key assumptions were held regarding the design and delivery of physical activity interventions among health care professionals in applied health care settings. This study was part of the 'Physical Activity Tailored intervention in Hospital Staff' randomised controlled trial of three variants of a web-based intervention., Methods: We used data-prompted interviews to explore whether the interventions were delivered and operated as intended in health care professionals working in four hospitals in Western Australia (N = 25). Data were analysed using codebook thematic analysis., Results: Five themes were constructed: (1) health care professionals' perceived role in changing patients' health behaviours; (2) work-related barriers to physical activity intervention adherence; (3) health care professionals' use of behaviour change techniques; (4) contamination between groups; and (5) perceptions of intervention tailoring., Conclusions: The intervention was not experienced by participants, nor did they implement the intervention guidance, in the way we expected. For example, not all health care professionals felt responsible for providing behaviour change advice, time and shift constraints were key barriers to intervention participation, and contamination effects were difficult to avoid. SO WHAT?: Our study challenges assumptions about how health care professionals respond to behaviour change advice and possible knock-on benefits for patients. Applying our learnings may improve the implementation of health promotion interventions in health care settings., (© 2023 The Authors. Health Promotion Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of Australian Health Promotion Association.)

Study Design: Anonymous online survey OBJECTIVES: To investigate the priorities, needs and willingness to adopt nerve stimulation devices for managing neurogenic bladder and bowel function in people with spinal cord injury (SCI) living in Australia., Setting: Online survey of people living with SCI in Australia., Methods: This anonymous online survey used Qualtrics and was advertised via standard communication channels, such as advocacy groups representing the SCI community in Australia, social media, attending SCI sporting events and by word-of-mouth., Results: Responses from 62 individuals (32% female, 68% male) were included. Bladder emptying through urethra without catheter was the highest priority for bladder function. Reducing time required for bowel routines and constipation were the top priorities regarding bowel function. The highest concern for internal/implanted devices was the 4% chance of device surgical removal, while wearing wires under the clothes was the main concern for external devices. 53% of respondents were willing to trial an implanted nerve stimulation device, while 70% would trial an external device to improve and gain independence in bladder and bowel function., Conclusion: The findings of this study highlighted the potential role in which nerve stimulation can have in addressing bladder and bowel dysfunction in people with SCI, and have also identified that there was a need for Australian physiotherapists to evaluate their role in bladder and bowel dysfunction. Results from this study can help guide further research in nerve stimulation devices for bladder and bowel dysfunction in people with SCI., Sponsorship: n/a., (© 2024. The Author(s).)

Understanding groundwater contamination from legacy landfills, including fate and transport of Per- and polyfluoroalkyl substances (PFAS), is a critical challenge for sustainable urban renewal. We analysed groundwater within and surrounding legacy landfills at Fishermans Bend for PFAS and complementary hydrochemical indicators. Sampling in 2017 revealed extensive PFAS contamination from the landfills. We re-examined concentrations after a 3-year period, to assess natural source attenuation and evolution of the contaminant plumes. Total PFAS (∑ 38 PFAS) ranged from 88 to 973 ng/L, with relatively high concentrations (mean = 500 ng/L, n = 4) in samples directly within the waste mass of a large legacy municipal and industrial landfill (Port Melbourne Tip). Two samples on the boundary of a former construction and demolition waste landfill also had elevated PFAS concentrations (∑ 38 PFAS = 232 and 761.5 ng/L). Down-gradient of the landfills, groundwater showed reductions in total PFAS, though still maintained considerable loads (∑PFAS = 107.5-207.5 ng/L). Long-chained PFAS showed greatest reductions relative to chloride concentrations down-gradient of the landfills, consistent with sorption as the predominant removal mechanism. The dominant mass fractions detected were similar in 2017 and 2020 (median: PFOS > PFHxS > PFHxA > PFOA); comprising the widely known, persistent 'legacy' PFAS. Re-sampled bores returned similar concentrations of these PFAS in 2017 and 2020 (median %RPDs of 0.0, 9.3 and 15.4, for PFOS, PFOA, and PFHxS, respectively). However, there were marked increases in concentrations of certain PFAS in three bores - including a previously un-impacted background site. The results show limited attenuation of legacy landfill PFAS contamination in groundwater over a 3-year period., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose of Review: Climate change poses a serious threat to human health and well-being. Australia is not immune to the public health impacts and continues to be underprepared, putting the population health at risk. However, there is a dearth in knowledge about how the Australian public health system will address the impacts of climate change., Recent Findings: This integrative review synthesises tools, frameworks, and guidance material suitable for climate change adaptation from a preventive public health perspective. The literature search was conducted in electronic databases MEDLINE, PubMed, CINAHL, and Web of Science. Of 4507 articles identified, 19 articles met the inclusion criteria that focused on operational methods in public health and excluded the clinical context and reactive disaster response approaches. This review revealed that Australia is ill-prepared to manage climate change adverse health impacts due to ineffective adaptation strategies. The review highlights that Australia urgently requires effective adaptation strategies such as undertaking a National Adaptation Plan process and an improved understanding in managing complex health risks. Taking this action will strengthen the public health system and build health resilience especially for vulnerable populations. These findings will help understand and develop of the necessary adaptive strategies in Australia., (© 2023. The Author(s).)

Objective: This study examined how social associations from a person's social network may be associated with their own alcohol consumption., Method: Alcohol consumption behavior was examined among the social networks of 784 survey respondents (54% female, M age = 35.3 years), using egocentric social network analysis. Participants (egos) were recruited via a panel aggregator and completed an online survey about the frequency of their alcohol consumption and that of the 20 most influential people in their lives (alters). The survey also explored who these alters were (family, friends, work colleagues) and the interrelationships among these alters., Results: Egos who consumed alcohol, or consumed alcohol more frequently, were surrounded by more alters who also drank alcohol and felt closer (had stronger ties) to these alters. These relationships remained statistically significant when controlling for demographic and other variables. The social networks of those who consumed alcohol more frequently were more densely intertwined., Conclusions: Alcohol may serve to initiate social connections and be a "social glue" that reinforces relationships. These strong social associations present a potential barrier to individuals who wish to reduce their alcohol consumption because they have few close social connections who do not drink alcohol (or who do so infrequently), and their highly interconnected social networks make it difficult to socialize only with those who do not drink frequently. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Black-box deep learning (DL) models trained for the early detection of Alzheimer's Disease (AD) often lack systematic model interpretation. This work computes the activated brain regions during DL and compares those with classical Machine Learning (ML) explanations. The architectures used for DL were 3D DenseNets, EfficientNets, and Squeeze-and-Excitation (SE) networks. The classical models include Random Forests (RFs), Support Vector Machines (SVMs), eXtreme Gradient Boosting (XGBoost), Light Gradient Boosting (LightGBM), Decision Trees (DTs), and Logistic Regression (LR). For explanations, SHapley Additive exPlanations (SHAP) values, Local Interpretable Model-agnostic Explanations (LIME), Gradient-weighted Class Activation Mapping (GradCAM), GradCAM++ and permutation-based feature importance were implemented. During interpretation, correlated features were consolidated into aspects. All models were trained on the Alzheimer's Disease Neuroimaging Initiative (ADNI) dataset. The validation includes internal and external validation on the Australian Imaging and Lifestyle flagship study of Ageing (AIBL) and the Open Access Series of Imaging Studies (OASIS). DL and ML models reached similar classification performances. Regarding the brain regions, both types focus on different regions. The ML models focus on the inferior and middle temporal gyri, and the hippocampus, and amygdala regions previously associated with AD. The DL models focus on a wider range of regions including the optical chiasm, the entorhinal cortices, the left and right vessels, and the 4th ventricle which were partially associated with AD. One explanation for the differences is the input features (textures vs. volumes). Both types show reasonable similarity to a ground truth Voxel-Based Morphometry (VBM) analysis. Slightly higher similarities were measured for ML models., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background and Aims: COVID-19 lockdowns limited access to gambling but simultaneously elevated psychosocial stressors. This study assessed the relative effects of these changes on gambling risk status during and after the Australian COVID-19 lockdown from late-March to late-May 2020., Methods: The study administered three surveys to people who had gambled within the past year at T1. Wave 1 asked about before (T1, N = 2,125) and during lockdown (T2, N = 2,125). Subsequent surveys focused on one year (T3; N = 649) and two years after lockdown (T4, N = 458). The dependent variable was changes in reporting any problem gambling symptoms (PGSI 0 vs 1+). Bivariate analyses and multinomial logistic regression tested for significant associations with: demographics, psychosocial stressors (perceived stress, psychological distress, loneliness, health anxiety about COVID, financial hardship, stressful life events), gambling participation and gambling frequency., Results: Gambling participation and at-risk gambling decreased between T1 and T2, increased at T3, with little further change at T4. When gambling availability was curtailed, decreased gambling frequency on EGMs, casino games, sports betting or race betting, and lower psychosocial stress, were associated with transitions from at-risk to non-problem gambling. When gambling availability resumed, increased EGM gambling frequency, decreased online gambling frequency, and higher psychosocial stress were associated with transitions from non-problem to at-risk gambling., Discussion and Conclusions: Gambling availability appears a stronger influence on gambling problems, at the population level, than psychosocial risk factors. Reducing the supply of high-risk gambling products, particularly EGMs, is likely to reduce gambling harm.

Objective Health-related apps on mobile devices (mHealth apps) have become an effective self-management tool and treatment support for patients. There is limited research, however, on how older people (50 and over) perceive the opportunity of using mHealth apps. Our aim was to investigate the perceptions of older people in Australia regarding the opportunity of using prescribed or doctor-recommended mHealth apps and provide insights which can enhance their uptake of mHealth. Methods This was a qualitative study using semi-structured interviews involving 21 participants aged 51-82 years. Qualitative thematic analysis was used to categorise the factors that influence the adoption of mHealth apps by older adults. Results We show that beyond the prominent influencing factors from technology adoption research (such as performance and effort expectancy, social influence and facilitating conditions), health-specific factors such as a trusting doctor-patient relationship and strong health self-efficacy positively influence the intended adoption of mHealth apps among older adults. In addition, the IT security and accurate interpretation of participants' input in an mHealth app can present barriers to mHealth app adoption. Conclusion Our analyses provide additional insights complementing existing technology adoption research. Their successful adoption and utilisation require further empirical evidence on its effectiveness along with attention to the voices of those who are meant to use them. To address potential barriers, improve the quality and security of mHealth apps, and thus achieve greater patient safety, the involvement of consumers, regulators and health professionals is necessary.

Objective: This scoping review aims to provide an overview of how theories were used in the development or evaluation of social prescribing (SP) intervention studies., Background: SP describes a patient pathway where general practitioners (GPs) connect patients with community activities through referrals to link workers. This review seeks to understand the explanations provided for the outcomes and implementation process of SP., Inclusion Criteria: Studies using a defined theory to develop or evaluate a specific SP intervention in primary care and the community sector., Methods: This scoping review was conducted in accordance with JBI methodology. The following databases were searched on 8 th of July 2022: PubMed, ASSIA, Cochrane, Cinahl, PsycINFO, Social Care Online, Sociological Abstracts, Scopus, and Web of Science. The search only considered English language texts. Additional literature was identified by searching relevant web pages and by contacting experts. The selection of sources and the data extraction was done by two reviewers independently., Results: The search resulted in 4240 reports, of which 18 were included in the scoping review. Of these, 16 were conducted in the UK, one in Canada and one in Australia. The majority of reports employed a qualitative approach (11/18). Three were study protocols. 11 distinct theories were applied to explain outcomes (4 theories), differences in outcomes (3 theories), and the implementation of the intervention (4 theories). In terms of practical application, the identified theories were predominantly used to explain and understand qualitative findings. Only one theory was used to define variables for hypothesis testing. All theories were used for the evaluation and none for the development of SP., Conclusion: The theories influenced which outcomes the evaluation assessed, which causal pathway was expected to generate these outcomes, and which methodological approaches were used. All three groups of theories that were identified focus on relevant aspects of SP: fostering positive patient/community outcomes, addressing inequalities by considering the context of someone's individual circumstances, and successfully implementing SP by collaboratively working across professions and institutional boundaries. Additional insight is required regarding the optimal use of theories in practical applications., (© 2024. The Author(s).)

Germany became the first country to accept certain mobile health (mHealth) apps for prescription with costs covered by statutory health insurance. Yet, this option has only been used to a limited extent. To develop an international comparison, this study investigates GPs' perceptions of mHealth apps with a medical purpose in Germany and Australia. We conducted semi-structured interviews to examine their perspective on introducing and using mHealth apps and their awareness of their impact on patient adherence, empowerment, and health literacy. The results show that prescribing mHealth apps in general practice seems feasible in Australia and doctors are highly receptive to it.

Background and Aims: Smartphone, computer and land-based betting platforms each have distinctive features. This study examined 1) preferred features of sports betting platforms amongst young adults and 2) whether feature preferences vary with gambling severity., Methods: The study surveyed 616 Australians aged 18-29 years who bet at-least monthly on sports, esports and/or daily fantasy sports. Participants provided a simple rating of the importance of 24 features of betting platforms and then completed a discrete choice experiment to indicate their preferences amongst different groups of features., Results: Smartphones were the only platform providing all preferred features. The most important feature was ability to bet instantly 24/7 from any location, followed by electronic financial transactions. Less important features were ability to access betting information online and to bet with multiple operators. Social and privacy features, and access to promotions, did not significantly predict platform choice. The experiment found no significant differences in preferred features by gambling severity group or by gender. The non-experimental descriptive data, however, indicated that participants in the moderate risk/problem gambling categories placed significantly more importance on privacy, ability to place in-play bets, bet with cash, bet with a credit card, see frequent promotions, and bet with multiple operators., Discussion and Conclusions: Most features that bettors prefer can intensify betting. Curtailment of betting promotions, in-play betting, and credit card betting are measures that can assist higher-risk gamblers without unduly affecting other gamblers. Consumer protection tools, including mandatory pre-commitment, need strengthening to help counter the unique risks of smartphone betting.

Objective: This study applied the theory of reasoned goal pursuit (TRGP) in predicting physical activity among Australian undergraduate students, providing the first empirical test of the model. Methods: The research comprised an elicitation study ( N  = 25; M Age = 25.76, SD Age = 11.33, 20 female, 5 male) to identify readily accessible procurement and approval goal beliefs and behavioural, normative, and control beliefs; and, a two-wave prospective online survey study ( N  = 109; M Age = 21.88, SD Age = 7.04, 63 female, 46 male) to test the tenets of the TRGP in relation to meeting World Health Organization physical activity guidelines during the COVID-19 pandemic among first year university students. Results: A linear PLS-SEM model displayed good fit-to-data, predicting 38%, 74%, and 48% of the variance in motivation, intention, and physical activity, respectively. The model supported the majority of hypothesised pattern of effects among theory constructs; in particular, the proposition that beliefs corresponding to procurement and approval goals would be more consequential to people's motivation and, thus, their intentions and behaviour, than other behavioural and normative beliefs, respectively. Conclusions: Results lend support for the TRGP and sets the agenda for future research to systematically test the proposed direct, indirect, and moderation effects for different health behaviours, populations, and contexts., Supplemental data for this article is available online at https://doi.org/10.1080/08870446.2022.2026946 .

Background: Health-related mobile applications (apps) have the potential to improve health knowledge and promote healthy behaviours during pregnancy. Pregnancy apps are popular and extensively used by consumers., Objective: This study investigates the usage patterns, decision-making criteria and concerns regarding the quality and credibility of health-related information within pregnancy mobile applications. The aim of this study is to understand consumer perspectives to potentially contribute to guidelines for apps containing health-related information., Design: A cross-sectional study, utilising an online questionnaire for data collection., Methods: The study surveyed pregnant women in Australia who were recruited via online platforms, including social media and paid Facebook ads. Participants completed a 29-item questionnaire assessing their use of pregnancy apps, sources of health information and perceptions of app quality and safety, with data collected and analysed using the Qualtrics platform and SPSS Statistics., Results: The survey was survey completed by 427 current-or-recently pregnant individuals, aged 18 or over and located in Australia. Overall, 62.3% were currently pregnant and 37.7% were recently pregnant, within 6 months. Medical practitioners were the primary source of pregnancy-related health information, and pregnancy apps were the third most common source. Pregnancy apps were considered to be a trustworthy source of information by 63.8% of respondents and the majority used apps during pregnancy (94.2%). Of those who used pregnancy apps ( n  = 325), information being safe and trustworthy was their top priority when selecting an app. However, 35.5% ( n  = 115) had encountered information in an app they felt was unsafe or conflicted with previous knowledge or advice. Only 4.6% ( n  = 15) were aware that health-related apps are not screened for accurate information/undergo quality assurance checks before being made available to download. If provided with a guide to evaluate app quality, 74.6% ( n  = 241) would utilise the tool., Conclusions: These findings highlight a need to promote the critical assessment of health information within pregnancy apps and to develop resources to support consumers in doing so.

Background: Digital interventions in health services often fail due to an underappreciation of the complexity of the implementation. This study develops an approach to address complexity through an evidenced-based, theory-driven education and implementation program for an Electronic Medical Record (EMR) digital enhancement for acute stroke care., Methods: An action research approach was used to design, develop, and execute the education and implementation program over several phases, with iterative changes over time. The study involved collaboration with multiple statewide and local key stakeholders and was conducted across two tertiary teaching hospitals and a regional hospital in Australia., Results: Insights were gained over five phases. Phase 1 involved a review of evidence that supported blended learning strategies for the education and training of staff end-users. In Phase 2, contextual assessment was conducted via observation of study sites, providing awareness of local context variability and insight into key implementation considerations. The Non-adoption, Abandonment, Scale-Up, Spread and Sustainability (NASSS) framework assisted in Phase 3 to identify and manage the key domains of complexity. Phase 4 involved the design of the program which included group-based training and an e-learning package, endorsed and evaluated by key leaders. Throughout implementation in Phase 5, further barriers were identified, and iterative changes were tailored to each context., Conclusions: The NASSS framework, combined with a multi-phased approach employing blended learning techniques, context evaluations, and iterative modifications, can serve as a model for generating theory-driven and evidence-based education strategies that adresss the complexity of the implementation process and context., (© 2023. Crown.)

Patient harm is a leading cause of global disease burden with considerable morbidity, mortality, and economic impacts for individuals, families, and wider society. Large bodies of evidence exist for strategies to improve safety and reduce harm. However, it is not clear which patient safety issues are being addressed globally, and which factors are the most (or least) important contributors to patient safety improvements. We aimed to explore the perspectives of international patient safety experts to identify: (1) the nature and range of patient safety issues being addressed, and (2) aspects of patient safety governance and systems that are perceived to provide value (or not) in improving patient outcomes. English-speaking Fellows and Experts of the International Society for Quality in Healthcare participated in a web-based survey and in-depth semistructured interview, discussing their experience in implementing interventions to improve patient safety. Data collection focused on understanding the elements of patient safety governance that influence outcomes. Demographic survey data were analysed descriptively. Qualitative data were coded, analysed thematically (inductive approach), and mapped deductively to the System-Theoretic Accident Model and Processes framework. Findings are presented as themes and a patient safety governance model. The study was approved by the University of South Australia Human Research Ethics Committee. Twenty-seven experts (59% female) participated. Most hailed from Africa (n = 6, 22%), Australasia, and the Middle East (n = 5, 19% each). The majority were employed in hospital settings (n = 23, 85%), and reported blended experience across healthcare improvement (89%), accreditation (76%), organizational operations (64%), and policy (60%). The number and range of patient safety issues within our sample varied widely with 14 topics being addressed. Thematically, 532 textual segments were grouped into 90 codes (n = 44 barriers, n = 46 facilitators) and used to identify and arrange key patient safety governance actors and factors as a 'system' within the System-Theoretic Accident Model and Processes framework. Four themes for improved patient safety governance were identified: (1) 'safety culture' in healthcare organizations, (2) 'policies and procedures' to investigate, implement, and demonstrate impact from patient safety initiatives, (3) 'supporting staff' to upskill and share learnings, and (4) 'patient engagement, experiences, and expectations'. For sustainable patient safety governance, experts highlighted the importance of safety culture in healthcare organizations, national patient safety policies and regulatory standards, continuing education for staff, and meaningful patient engagement approaches. Our proposed 'patient safety governance model' provides policymakers and researchers with a framework to develop data-driven patient safety policy., (© The Author(s) 2023. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Objectives: To report the 15-year incidence of driving cessation and its associated vision-related risk factors in an older Australian population-based cohort., Study Design: 15-year data from a sample of 2379 participants who indicated that they were driving at baseline from The Blue Mountains Eye Study was analysed. Questions about driving cessation was asked at all four visits and was recorded as a binary response (Yes/No). Clinical vision examinations were performed at each visit to determine presenting and best-corrected visual acuity and any incident eye diseases (Yes/No)., Main Outcome Measures: The cumulative 15-year incidence of driving cessation was calculated using interval-censored data progression-free survival analyses. Age- and sex-adjusted and multivariable-adjusted interval-censored Cox proportional hazard models were used to report the hazard ratios (HRs) for associations of baseline and incident vision status with driving cessation., Results: The 15-year cumulative incidence of driving cessation amongst the 2379 participants was 20.7 %, with women more likely to cease driving than men (p = 0.0005). Cataract (HR 1.98 (95 % confidence interval(Cl) 1.45-2.71)) and age-related macular degeneration (HR 1.85 (95%Cl 1.37-2.50)) were associated with increased risk of driving cessation whilst presenting and best-corrected visual acuity in the better eye were protective against cessation (presenting: HR 0.96 (95%Cl 0.95-0.98); best-corrected: HR 0.93 (95%Cl 0.91-0.95)) in age- and sex-adjusted models, with these factors remaining independently associated in the multivariable-adjusted models., Conclusion: Cumulative incidence of driving cessation increased with older age and was higher in females. Cataract and age-related macular degeneration were independently associated with cessation, whilst better visual acuity at baseline helped prolong driving., Competing Interests: Declaration of competing interest The authors declare that they have no competing interest., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Studies evaluating the economic burden of dermatological care in the transplant setting are currently not available in Australia., Aims: To evaluate the clinical and economic burden of benign and malignant skin lesions in renal transplant recipients in Central Queensland., Methods: A bottom-up approach was used to determine the clinical burden and direct costs from patient-level Medicare data obtained from Service Australia for skin lesions., Results: Seventy-six percent of the renal transplant population in Central Queensland participated in this study. The median age was 57.0 years (standard deviation ± 13.6) and the majority (61.8%) of participants were men. The mean duration after transplant surgery was 99.9 months (interquartile range, 73.2-126.6 months). During a 2-year follow-up, 22 (40%) patients were diagnosed with benign skin lesions, 21 (38%) with nonmelanoma skin carcinoma (NMSC) and one (2%) with melanoma. There was a total of 231 visits to clinicians for diagnostic and therapeutic skin procedures and the direct costs to Medicare was $48 806 Australian Dollars (AUD) or $30 427 US Dollars (USD). Approximately 86% of the total direct costs was spent for nonNMSC and mean direct costs for NMSC was $763 AUD (or $476 USD)., Conclusion: This Medicare data-based study provides further insight into the burgeoning clinical and economic burden of the care for benign and malignant skin lesions in the renal transplantation setting in Australia., (© 2023 The Authors. Internal Medicine Journal published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Physicians.)

Objectives: Compare two approaches to analyzing time series data-interrupted time series with segmented regression (ITS-SR) and Bayesian structural time series using the CausalImpact R package (BSTS-CI)-highlighting advantages, disadvantages, and implementation considerations., Study Design and Setting: We analyzed electronic health records using each approach to estimate the antibiotic prescribing reduction associated with an educational program delivered to Australian primary care physicians between 2012 and 2017. Two outcomes were considered: antibiotics for upper respiratory tract infections (URTIs) and antibiotics of specified formulations., Results: For URTI indication prescribing, average monthly prescriptions changes were estimated at -4,550; (95% confidence interval, -5,486 to -3,614) and -4,270; (95% credible interval, -5,934 to -2,626) for ITS-SR and BSTS-CI, respectively. Similarly for specified formulation prescribing, monthly average changes were estimated at -7,923; (95% confidence interval, -15,887 to 40) for ITS-SR and -20,269; (95% credible interval, -25,011 to -15,635) for BSTS-CI., Conclusion: Differing results between ITS-SR and BSTS-CI appear driven by divergent explanatory and outcome series trends. The BSTS-CI may be a suitable alternative to ITS-SR only if the explanatory series represent the secular trend of the outcome series before the intervention and are equally affected by exogenous or confounding factors. When appropriately applied, BSTS-CI provides an alternative to ITS with more readily interpretable Bayesian effect estimates., Competing Interests: Declaration of competing interest None of the authors have any conflicts to disclose., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Pregnancy-related low back and/or pelvic girdle pain is common, with a prevalence rate of up to 86% in pregnant women. Although 19.5% of Australian pregnant women visit a chiropractor for pelvic girdle pain, little is known about the experience of pregnant women who seek this care. The aim of this study was to describe and explore the experiences of Australian pregnant women who seek chiropractic care for their current pregnancy-related low back and/or pelvic girdle pain., Methods: A qualitative case study approach with purposive sampling from 27 chiropractic practices was used. A grounded theory approach was informed by a constructivist and interpretivist stance, which provided understanding and meaning to the pregnant women's experiences. Online unstructured interviews were recorded, transcribed, and anonymised. A thematic analysis was subsequently conducted on the primary data. Codes and major themes were developed with the use of critical self- reflection (memos), survey finding triangulation and respondent validation., Results: Sixteen potential respondents expressed interest in participating. After eligibility screening and data saturation, nine interviews were undertaken. Four key themes were identified: "Care drivers: what drives care seeking?", "Care barriers: what barriers are encountered?", "Chiropractic treatment: what does treatment consist of?" and "Response to care: what response was there to care?"., Conclusion: Four key themes: care drivers, care barriers, chiropractic treatment, and response to care support an emergent substantive-level theory in women's care seeking experiences for pregnancy-related back pain and chiropractic care. This theory is that chiropractic care for pregnant women experiencing low back pain and pelvic girdle pain may improve pain and function, while reducing pregnancy-related biopsychosocial concerns. The findings may inform antenatal health providers and the chiropractic profession about pregnant women's experience seeking chiropractic care as well as directing future research., (© 2023. Chiropractic and Osteopathic College of Australasia, European Academy of Chiropractic, The Royal College of Chiropractors, Nordic Institute of Chiropractic and Clinical Biomechanics and BioMed Central Ltd.)