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Scoping reviewers often face challenges in the extraction, analysis, and presentation of scoping review results. Using best-practice examples and drawing on the expertise of the JBI Scoping Review Methodology Group and an editor of a journal that publishes scoping reviews, this paper expands on existing JBI scoping review guidance. The aim of this article is to clarify the process of extracting data from different sources of evidence; discuss what data should be extracted (and what should not); outline how to analyze extracted data, including an explanation of basic qualitative content analysis; and offer suggestions for the presentation of results in scoping reviews. Refereed/Peer-reviewed

The objective of this scoping review is to identify evidence synthesis types and previously proposed classification systems, typologies, or taxonomies that have guided evidence synthesis.Evidence synthesis is a constantly evolving field. There is now a plethora of evidence synthesis approaches used across many different disciplines. Historically, there have been numerous attempts to organize the types and methods of evidence synthesis in the form of classification systems, typologies, or taxonomies. This scoping review will seek to identify all the available classification systems, typologies, or taxonomies; how they were developed; their characteristics; and the types of evidence syntheses included within them.This scoping review will include discussion papers, commentaries, books, editorials, manuals, handbooks, and guidance from major organizations that describe multiple approaches to evidence synthesis in any discipline.The Evidence Synthesis Taxonomy Initiative will support this scoping review. The search strategy will aim to locate both published and unpublished documents utilizing a three-step search strategy. An exploratory search of MEDLINE (Ovid) has identified keywords and MeSH terms. A second search of MEDLINE (Ovid), Embase (Elsevier), CINAHL with Full Text (EBSCO), ERIC (EBSCO), Scopus (Elsevier), Compendex (Elsevier), and JSTOR will be conducted. Relevant evidence synthesis organizations will be searched. Identified documents will be independently screened, selected, and extracted by two researchers, and the data will be presented in tables and summarized descriptively.OSF https://osf.io/qwc27.

OBJECTIVE The objective of this review is to evaluate the accuracy of different imaging modalities in detecting extracapsular spread (ECS) of cervical lymph node metastases in human papillomavirus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). INTRODUCTION Extracapsular spread of lymph node metastases is associated with poor prognosis, and its detection in head and neck cancer is crucial for treatment planning. Commonly used imaging modalities to detect ECS in OPSCC include computed tomography, magnetic resonance imaging, positron emission tomography, and ultrasonography. Currently there is no gold standard imaging modality to detect ECS in OPSCC. INCLUSION CRITERIA This review will consider published studies examining the diagnostic accuracy (including sensitivity and specificity) of an imaging modality used to detect ECS in HPV+ OPSCC. Participants will have a diagnosis of HPV+ OPSCC and suspected diagnosis of ECS of cervical lymph node metastases. The index test will be different imaging modalities used to detect ECS, and the reference test will be histopathology. Currently there is no gold standard imaging modality to detect ECS in OPSCC. METHODS A three-step search strategy will be undertaken to identify relevant studies in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus. A standardized critical appraisal tool (QUADAS-2) will be used to assess the methodological quality of the studies. The main outcomes will be sensitivity and specificity measures reported with 95% confidence intervals. Meta-analysis will be conducted using a bivariate model approach after pooling the studies according to imaging modality. Meta-regression will be used to explore heterogeneity. Meta-regression and subgroup analyses will be used to compare studies and imaging modalities. The results will be presented using either paired forest plots, summary receiver operator characteristic curves, or a narrative synthesis. A GRADE Summary of Findings will be provided. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42021250626.

A systematic review involves the identification, evaluation, and synthesis of the best-available evidence to provide an answer to a specific question. The "best-available evidence" is, in many cases, a peer-reviewed scientific article published in an academic journal that details the conduct and results of a scientific study. Any potential threat to the validity of these individual studies (and hence the resultant synthesis) must be evaluated and critiqued.In science, the number of predatory journals continue to rise. Studies published in predatory journals may be of lower quality and more likely to be impacted by fraud and error compared to studies published in traditional journals. This poses a threat to the validity of systematic reviews that include these studies and, therefore, the translation of evidence into guidance for policy and practice. Despite the challenges predatory journals present to systematic reviewers, there is currently little guidance regarding how they should be managed.In 2020, a subgroup of the JBI Scientific Committee was formed to investigate this issue. In this overview paper, we introduce predatory journals to systematic reviewers, outline the problems they present and their potential impact on systematic reviews, and provide some alternative strategies for consideration of studies from predatory journals in systematic reviews. Options for systematic reviewers could include excluding all studies from suspected predatory journals, applying additional strategies to forensically examine the results of studies published in suspected predatory journals, setting stringent search limits, and applying analytical techniques (such as subgroup or sensitivity analyses) to investigate the impact of suspected predatory journals in a synthesis.

Objective To synthesize and integrate the best available evidence on the experiences and effectiveness of occupational therapy interventions delivered in the acute setting. Introduction Occupational therapy is a client-centered health profession promoting health and well-being through occupation. In acute hospital settings, occupational therapy interventions are provided to patients to maximize function, prevent readmission, and promote safe discharge. Recent studies have demonstrated that occupational therapy has modified its practice in acute settings, including providing advocacy, team facilitation, and rapid clinical reasoning. This review will investigate not only the effectiveness of occupational therapy interventions, but also the experiences of patients, caregivers, and clinicians in the acute setting. Inclusion criteria This review will consider qualitative, quantitative, and mixed methods studies on the experiences and effectiveness of occupational therapy interventions delivered in acute settings. For the qualitative component, the experiences of patients and caregivers receiving any occupational therapy intervention, and clinicians directly or indirectly involved in delivering occupational therapy interventions, will be investigated. For the quantitative component, occupational therapy interventions will be compared with non-occupational therapy interventions, no intervention, wait-list, or other inactive or active (usual care) control interventions; patient outcomes will include impairment, activities of daily living, psychological outcomes, and quality of life, while health system outcomes will include health care utilization and patient flow. Methods The databases to be searched will include CINAHL, Cochrane Controlled Trials Register, MEDLINE (Ovid), OT Seeker, PsycINFO (Ovid), and Scopus. Study selection, critical appraisal, data extraction, and data synthesis and integration will be undertaken following the JBI segregated approach to mixed methods systematic reviews. Systematic review registration number PROSPERO CRD42020206363.

Pretreatment determination of extranodal extension (ENE) has significant clinical implications in human papillomavirus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). Unfortunately there is no gold-standard imaging modality for radiological assessment of ENE in HPV+ OPSCC, leading to subjective assessments and complex decision making concerning ENE. A systematic review of diagnostic test accuracy was therefore undertaken, with five databases systemically searched to evaluate the diagnostic performance of an imaging modality for detection of ENE in HPV+ OPSCC. A meta-analysis was conducted on four CT studies using a random-effects model. While a narrative synthesis was provided for the studies using PET/CT and "CT and MRI." Out of 1772 hits, six studies were included in the review. Meta-analysis on four CT studies showed CT had an overall sensitivity of 77% and specificity of 60%. PET/CT had a sensitivity of 37.5% and specificity of 97%. "CT and MRI" had a sensitivity of 62% and specificity of 78%. Further diagnostic studies involving CT, PET/CT and MRI are ultimately required.

OBJECTIVE This systematic review aimed to identify and explore the barriers to and facilitators of learning and preparedness for clinical practice among undergraduate paramedicine students, graduate/intern paramedics, and their preceptors. INTRODUCTION The educational landscape for paramedicine has evolved considerably since the introduction of the first paramedicine bachelor degree. A need to identify the contemporary barriers to and facilitators of learning within the context of early career training in paramedicine education is needed. INCLUSION CRITERIA Participants were undergraduate paramedicine students, graduate/intern paramedics, newly qualified UK paramedics and their preceptors within Australia, the United Kingdom, and New Zealand. Published and unpublished studies utilizing qualitative research designs were considered. Studies published in English since 1994 were considered for inclusion. METHODS Five bibliographic databases (PubMed, CINAHL, ERIC, Embase, and ProQuest Dissertations and Theses) were searched in 2018. A search of websites relevant to paramedic learning and a hand search of paramedicine journals were also undertaken in 2019.All studies identified from the search were examined against the inclusion criteria. Papers selected for inclusion were assessed by two independent reviewers for methodological quality prior to inclusion in the review.Qualitative research findings were extracted and pooled. Findings were assembled and categorized based on similarity in meaning. These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings. The final synthesized findings were graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis. RESULTS Twenty-six studies were included in the review. Eleven studies used semi-structured interviews, five used open-ended interviews, and 10 used focus groups. The total sample size was 564 participants. Sixteen studies focused on undergraduate paramedicine students, four involved paramedic preceptors, two focused on paramedic educators at paramedicine universities, and four included undergraduate paramedicine students and their preceptors. A total of 295 findings were extracted and grouped into 28 categories, which were grouped into five synthesized findings: the role of mentoring/preceptorship, opportunities to develop emotional intelligence and communication skills, the role of non-traditional placements/experiences, the role of non-traditional classroom teaching methods, and preparedness for practice. CONCLUSIONS A variety of education models exist with associated barriers and facilitators that impact on paramedicine students, graduate paramedics, and preceptors. The findings emphasize the importance of the preceptor to student learning and the need to develop students' skills/capacity to manage the emotional side of paramedic practice. Paramedicine students and paramedic graduates were found to be underprepared to effectively communicate with patients, families, and other professionals. Most of these barriers could be mitigated by use of non-traditional placements/experiences and non-traditional teaching methods. The introduction of a paramedic facilitator model was shown to have considerable benefits, suggesting that the introduction of a national model similar to other allied health models may be beneficial. The findings indicate a need for more effective communication between the education sector and industry with regard to the challenges in paramedicine education and which models best facilitate learning, development, and preparedness for clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019119336.

Objective\ud Mixed methods systematic reviews (MMSR) combine quantitative and qualitative evidence within a single review. Since the revision of the JBI Methodology for MMSRs in 2020, there has been an increasing number of reviews published that claim to follow this approach. A preliminary examination of these indicated that authors frequently deviated from the methodology. This paper outlines five common ‘pitfalls’ associated with undertaking MMSR and provides direction for future reviewers attempting MMSR.\ud \ud Methods\ud Forward citation tracking identified 17 reviews published since the revision of the JBI mixed methods methodological guidance. Methods used in these reviews were then examined against the JBI methodology to identify deviations.\ud \ud Results\ud The issues identified related to the rationale for choosing the methodological approach; incorrect synthesis and integration approach chosen to answer the review question/s posed; the exclusion of primary mixed methods studies in the review; the lack of detail regarding the process of data transformation and a lack of ‘mixing’ of the quantitative and qualitative components.\ud \ud Conclusion\ud This exercise was undertaken to assist systematic reviewers considering conducting a MMSR as well as MMSR users to identify potential areas where authors tend to deviate from the methodological approach. Based on these findings a series of recommendations are provided.

OBJECTIVE The objective of this review update is to determine the best strategies for assisted bathing or showering of older people with dementia. INTRODUCTION Bathing is a high-risk activity that can worsen agitated behavior in people with dementia, becoming a source of stress or burden for nurses and caregivers. Since a review was originally published in 2013, new studies have been conducted reporting on various interventions related to assisted bathing and showering. INCLUSION CRITERIA The review will consider people older than 60 years with dementia, their families, nurses, and formal caregivers. The quantitative component will consider studies that examine interventions aiming to reduce agitated behaviors during assisted bathing. The qualitative component will include studies reporting on experiences of assisted bathing of older people with dementia. METHODS This review update will follow the JBI mixed methods review approach. Published and unpublished studies will be identified from searches of the major international databases and relevant databases for gray literature. Two independent reviewers will carry out screening, critical appraisal, and data extraction. The extracted data will include details about the study characteristics, quantitative results, and qualitative findings relevant to the review. Where possible, quantitative data will be statistically pooled. Qualitative results will be synthesized using the meta-aggregation approach developed by JBI. Finally, the findings from both quantitative and qualitative components will be organized into a line of argument to produce an overall configured analysis. Where configuration is not possible, the findings will be presented in narrative form. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020208048.

OBJECTIVE The objective of this review is to evaluate measurement properties of instruments used to measure fatigue in clinicians within hospital settings. INTRODUCTION Research has shown that clinician fatigue leads to accidents and mistakes, and puts patient safety at risk. The problem of managing fatigue in clinicians may need a more complex approach than only restricting work hours. It may be helpful to include a measure of fatigue in the workplace so that fatigue may be quantified, predicted, and correlated to performance. INCLUSION CRITERIA Articles will include clinicians working in hospitals, and will evaluate and present measurement properties of the instruments used to measure fatigue. The studies of interest include validation studies, quantitative research, and instrument development reports. METHODS Databases to be searched include PubMed, Scopus, Web of Science, Cochrane Library, Embase, PsycINFO, CINAHL, EThOS (Electronic Thesis Online Service), ProQuest Dissertations and Theses: Global, and will be limited to publications in English. There will be no date limits. Articles will be screened and those meeting the inclusion criteria will be retained and assessed for methodological quality by two independent appraisers. Data will be presented using a narrative synthesis and tables presenting the measurement properties of each instrument and ancillary data. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020186226.

Objective The objective of the proposed systematic review is to determine the barriers and enablers (or facilitators) to the implementation of pressure injury prevention among adults receiving care in the hospital setting. Introduction Hospital-acquired pressure injuries are preventable; however, they remain an ongoing safety and quality health care concern in many countries. There are various evidence-based preventative interventions for pressure injuries, but their implementation in clinical practice is limited. An understanding of the different factors that support (enablers or facilitators) and inhibit (barriers) the implementation of these interventions from different perspectives is important, so that targeted strategies can be incorporated into implementation plans. Inclusion criteria This review will include quantitative, qualitative, and mixed methods studies that investigate barriers and/or enablers in relation to hospital-acquired pressure injury prevention in hospitalized adults. Only English publications will be considered, with no publication date restrictions. Methods The systematic review will be conducted in accordance with the JBI methodology for mixed methods systematic review. Published studies will be searched in PubMed, CINAHL, Embase, PsycINFO and Scopus. Gray literature will also be considered. Critical appraisal and data extraction will be performed using standardized tools, followed by data transformation. Data synthesis will follow the convergent integrated approach.

Evidence synthesis is critical in evidence-based healthcare and is a core program of JBI. JBI evidence synthesis is characterised by a pluralistic view of what constitutes evidence and is underpinned by a pragmatic ethos to facilitate the use of evidence to inform practice and policy. This second paper in this series provides a descriptive overview of the JBI evidence synthesis toolkit with reference to resources for 11 different types of reviews. Unique methodologies such as qualitative syntheses, mixed methods reviews, and scoping reviews are highlighted. Key features include standardised and collaborative processes for development of methodologies and a broad range of tailored resources to facilitate the conduct of a JBI evidence synthesis, including appraisal and data extraction tools, software to support the conduct of a systematic review and an intensive systematic review training program. JBI is one of the leading international protagonists for evidence synthesis, providing those who want to answer health-related questions with a toolkit of resources to synthesize the evidence.

BACKGROUND Across healthcare there are acknowledged gaps in the translation of evidence into clinical practice. Undertaking a structured implementation program may assist clinicians to achieve this in their clinical practice setting. AIMS/METHODS The current study descriptively evaluates and analyzes the impact of JBI's (formerly known as the Joanna Briggs Institute) Evidence-based Clinical Fellowship program, since its inception in 2005. RESULTS Since its inception the JBI Evidence-based Clinical Fellowship Program has trained over 560 Clinical Fellows. The program consists of two 1-week intensive training workshops at JBI, collaborating with a JBI Research Fellow facilitator, with each participant then conducting a workplace evidence implementation project over the intervening 6 months in their own clinical setting. A 'train-the-trainer' program was established to provide accredited trainers to run the program through established JBI Collaborating Entities. CONCLUSION Implementation of research evidence into the clinical setting is challenging for health professionals. A pragmatic approach adopted through the JBI Evidence-based Clinical Fellowship Program ensures that the Clinical Fellow remains central as the program leader, but has direction and support from their team of various stakeholders, and ongoing collaboration with a JBI facilitator. This ensures increased capacity for engagement and ongoing sustainability of future implementation programs.

Objective The objective of this paper is to outline the updated methodological approach for conducting a JBI mixed methods systematic review with a focus on data synthesis, specifically, methods related to how data are combined and the overall integration of the quantitative and qualitative evidence. Introduction Mixed methods systematic reviews provide a more complete basis for complex decision-making than that currently offered by single method reviews, thereby maximizing their usefulness to clinical and policy decision-makers. Although mixed methods systematic reviews are gaining traction, guidance regarding the methodology of combining quantitative and qualitative data is limited. In 2014, the JBI Mixed Methods Review Methodology Group developed guidance for mixed methods systematic reviews; however, since the introduction of this guidance, there have been significant developments in mixed methods synthesis. As such, the methodology group recognized the need to revise the guidance to align it with the current state of knowledge on evidence synthesis methodology. Methods Between 2015 and 2019, the JBI Mixed Methods Review Methodology Group undertook an extensive review of the literature, held annual face-to-face meetings (which were supplemented by teleconferences and regular email correspondence), sought advice from experts in the field, and presented at scientific conferences. This process led to the development of guidance in the form of a chapter in the JBI Manual for Evidence Synthesis, the official guidance for conducting JBI systematic reviews. In 2019, the guidance was ratified by the JBI International Scientific Committee. Results The updated JBI methodological guidance for conducting a mixed methods systematic review recommends that reviewers take a convergent approach to synthesis and integration whereby the specific method utilized is dependent on the nature/type of questions that are posed in the systematic review. The JBI guidance is primarily based on Hong et al. and Sandelowski's typology on mixed methods systematic reviews. If the review question can be addressed by both quantitative and qualitative research designs, the convergent integrated approach should be followed, which involves data transformation and allows reviewers to combine quantitative and qualitative data. If the focus of the review is on different aspects or dimensions of a particular phenomenon of interest, the convergent segregated approach is undertaken, which involves independent synthesis of quantitative and qualitative data leading to the generation of quantitative and qualitative evidence, which are then integrated together. Conclusions The updated guidance on JBI mixed methods systematic reviews provides foundational work to a rapidly evolving methodology and aligns with other seminal work undertaken in the field of mixed methods synthesis. Limitations to the current guidance are acknowledged, and a series of methodological projects identified by the JBI Mixed Methods Review Methodology Group to further refine the methodology are proposed. Mixed methods reviews offer an innovative framework for generating unique insights related to the complexities associated with health care quality and safety.

The objective of this review was to synthesize the best available evidence on the effectiveness and harms of pharmacological interventions for the treatment of delirium in adult patients in the intensive care unit (ICU) after cardiac surgery.Patients who undergo cardiac surgery are at high risk of delirium (incidence: 50-90%). Delirium has deleterious effects, increasing the risk of death and adversely affecting recovery. Clinical interventional trials have been conducted to prevent and treat postoperative delirium pharmacologically including antipsychotics and sedatives. These trials have provided some evidence about efficacy and influenced clinical decision making. However, much reporting is incomplete and provides biased assessments of efficacy; benefits are emphasized while harms are inadequately reported.Participants were ≥ 16 years, any sex or ethnicity, who were treated postoperatively in a cardiothoracic ICU following cardiac surgery and were identified as having delirium. Any pharmacological intervention for the treatment of delirium was included, regardless of drug classification, dosage, intensity or frequency of administration. Outcomes of interest of this review were: mortality, duration and severity of delirium, use of physical restraints, quality of life, family members' satisfaction with delirium management, duration/severity of the aggressive episode, associated falls, severity of accidental self-harm, pharmacological harms, harms related to over-sedation, ICU length of stay, hospital length of stay (post ICU), total hospital length of stay, need for additional intervention medication and need for rescue medication. Randomized controlled trials were considered first and in their absence, non-randomized controlled trials and quasi-experimental would have been considered, followed by analytical observational studies.A search was conducted in PubMed, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, Epistemonikos, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, Clinical Trials in New Zealand, and ProQuest Dissertations and Theses to locate both published and unpublished studies. There was no date limit for the search. A hand search for primary studies published between January 1, 2012 and November 17, 2018 in relevant journals was also conducted. Only studies published in English were considered for inclusion. Two reviewers independently assessed the methodological quality using standardized critical appraisal instruments from JBI and McMaster University. Quantitative data were extracted using the standardized JBI data extraction tool. A meta-analysis was not performed, as there was too much clinical and methodological heterogeneity in the included studies. Results have been presented in a narrative form. Standard GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) evidence assessment of outcomes has been reported.Three RCTs investigating morphine versus haloperidol (n = 53), ondansetron versus haloperidol (n = 72), and dexmedetomidine versus midazolam (n = 80) were included. Due to heterogeneity and incomplete reporting, a meta-analysis was not feasible. Overall, the methodological quality of these studies was found to be low. Additionally, this review found reporting of harms to be inadequate and superficial for all three studies and did not meet the required standards for harms reporting, as defined by the CONSORT statement extension for harms.It was not possible to draw any valid conclusions regarding the effectiveness of morphine vs haloperidol, ondansetron vs haloperidol or dexmedetomidine vs midazolam in treating delirium after cardiac surgery. This is due to the low number of studies, the poor methodological quality in conducting and reporting and the heterogeneity between the studies.

Introduction: Approaches to the synthesis of qualitative research have existed for more than 20 years and have evolved significantly during that time. One common approach is meta-aggregation, as advocated by JBI. There is now a considerable number of published reviews that claim to follow the JBI approach to meta-aggregation. This methodological review sought to determine the extent to which a selection of these reviews follow the available guidance, with a view to establishing compliance and identifying potential areas for improvement. Methods: The JBI Database of Systematic Reviews and Implementation Reports (JBISRIR) was searched from 2015 to 2017 to identify all qualitative systematic reviews following the JBI approach. Citations were screened by two independent reviewers, and data extraction was conducted independently by at least two reviewers. Eligible reviews were then assessed against the JBI methodological guidance and ENTREQ statement to determine compliance. Results: From the search, 33 health care–related reviews that met the inclusion criteria were identified. Several areas were identified where reviewers consistently made errors or did not clearly report their findings, including study screening and selection issues (particularly how this was done and by whom), transparent rationale for study exclusion, who performed data extraction and how, processes for developing synthesized findings, and the development and presentation of recommendations. Conclusion: Although qualitative synthesis has come a long way, there are still some areas for improvement in conduct and reporting. This has implications for those who develop guidance and provide education to systematic reviewers. Refereed/Peer-reviewed

Introduction Systematic reviews provide a rigorous synthesis of the best available evidence regarding a certain question. Where high-quality evidence is lacking, systematic reviewers may choose to rely on case series studies to provide information in relation to their question. However, to date there has been limited guidance on how to incorporate case series studies within systematic reviews assessing the effectiveness of an intervention, particularly with reference to assessing the methodological quality or risk of bias of these studies. Methods An international working group was formed to review the methodological literature regarding case series as a form of evidence for inclusion in systematic reviews. The group then developed a critical appraisal tool based on the epidemiological literature relating to bias within these studies. This was then piloted, reviewed and approved by the international Scientific Committee of JBI. Results The JBI critical appraisal tool for case series studies includes 10 questions addressing the internal validity and risk of bias of case series designs, particularly confounding, selection and information bias, in addition to the importance of clear reporting. Conclusion In certain situations, case series designs may represent the best available evidence to inform clinical practice. The JBI critical appraisal tool for case series offers systematic reviewers an approved method to assess the methodological quality of these studies.

The objective of this review is to synthesize and integrate the best available evidence on the impact of canine-assisted interventions on the health and well-being of older people residing in long-term care.Canine-assisted interventions are commonly used as an adjunct therapy to enhance health and well-being, and are often implemented in long-term care facilities. The number of studies undertaken in this area has increased substantially over the previous five years; therefore, an update of two previous systematic reviews is warranted.This review will consider older people who reside in long-term care facilities and who receive canine-assisted interventions. For the quantitative component, canine-assisted interventions will be compared to usual care, alternative therapeutic interventions, or no interventions, and outcomes will be grouped under the following headings: biological, psychological, and social. For the qualitative component, the experiences of older people receiving canine-assisted interventions, as well as the views of people directly or indirectly involved in delivering canine-assisted interventions, will be explored. Quantitative, qualitative, and mixed methods studies published from 2009 to the present will be considered.A search of 10 bibliographic databases and other resources for published and unpublished English language studies will be undertaken. Study selection, critical appraisal, data extraction, and data synthesis will be undertaken by two independent reviewers following the segregated JBI approach to mixed methods reviews.PROSPERO CRD42020161235.

Objective The objective of the scoping review is to map the range of methodologies used to undertake evidence synthesis aimed at determining barriers and enablers in health care. Introduction The number of evidence synthesis studies focusing on identifying factors that support/facilitate (act as "enablers") or impede (act as "barriers") implementation of best practice in health care has significantly increased as researchers and clinicians strive to understand the evidence-practice gap. There is currently no consensus on the evidence synthesis approach for such topics, with the methods for analyzing or synthesizing results from barrier and enabler studies varying across existing evidence reviews. Inclusion criteria This scoping review will consider various evidence synthesis approaches that identify barriers and enablers in health care. The review will only consider evidence synthesis approaches that describe their methods (e.g. systematic reviews or scoping reviews rather than literature reviews). Barriers and enablers could be at different levels of the health system, including consumers of care, health practitioners, health organization, policy makers, and the community. The scoping review will focus on the methodological aspects or processes related to the review of primary studies on barriers and/or enablers. Methods The proposed scoping review will be conducted in accordance with JBI methodology for scoping reviews. Studies will be searched in PubMed (NLM), Embase (Elsevier), CINAHL (EBSCOhost), PsycINFO (Ovid), Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, and EPPI-Centre Systematic Reviews. Data extraction will be undertaken using a purpose-built data extraction form. A narrative summary will accompany the tabulated data/figures, with a view to proposing recommendations related to the methodology for undertaking evidence synthesis of barrier and enabler studies.

Objectives: The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach is accepted methodology to assess the certainty of the evidence included in systematic reviews and clinical practice guidelines. The GRADE approach is endorsed globally, in Australia, the National Health and Medical Research Council advocated for the use of the GRADE approach in 2011. The purpose of this methodological review was to assess how GRADE has been adopted for Australian practice guidelines. Study Design and Setting: This methodological review searched of the National Health and Medical Research Council Clinical Practice Guidelines Portal from 2011 to 2018, in an effort to retrieve all practice guidelines available via this medium. Results: 240 guidelines were retrieved authored by 51 different organizations. 15 guidelines followed GRADE methodology. Application of GRADE methods varied between guidelines, some misreported and altered aspects of the GRADE process. Guidelines that closely adhered to the guidance from the GRADE Working Group scored higher in domain 3 (rigor of development) of the Appraisal of Guidelines for Research and Evaluation II tool, indicating a positive linear relationship between GRADE adherence and rigor of development scores. Conclusion: The results of our project suggest that the use of GRADE in Australian guidelines is increasing, however, strategies to increase uptake and reporting within the guideline community need to be explored. Refereed/Peer-reviewed

OBJECTIVE:To synthesize and integrate the best available evidence on the experiences and effectiveness of canine-assisted interventions (CAIs) on the health and well-being of older people residing in long-term care. INTRODUCTION:Canine-assisted interventions (CAIs) are commonly used as an adjunct therapy to enhance health and well-being and are often implemented in long-term care facilities. The number of studies undertaken in this area has increased substantially over the last five years; therefore, an update of two previous systematic reviews is warranted. INCLUSION CRITERIA:This review will consider older people who reside in long-term care facilities and who receive CAIs. For the quantitative component, CAIs will be compared to usual care, alternative therapeutic interventions or no interventions, and outcomes will be grouped under the following headings: biological, psychological and social. For the qualitative component, the experiences of older people receiving CAIs, as well as the views of people directly or indirectly involved in delivering CAIs, will be explored. Quantitative, qualitative and mixed methods studies published from 2009 to the present will be considered. METHODS:A search of 10 bibliographic databases and other various resources for published and unpublished English language studies will be undertaken. Study selection, critical appraisal, data extraction and data synthesis will be undertaken following the segregated JBI approach to mixed methods reviews.

Background: Scoping reviews are a relatively new approach to evidence synthesis and currently there exists little guidance regarding the decision to choose between a systematic review or scoping review approach when synthesising evidence. The purpose of this article is to clearly describe the differences in indications between scoping reviews and systematic reviews and to provide guidance for when a scoping review is (and is not) appropriate. Results: Researchers may conduct scoping reviews instead of systematic reviews where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct. While useful in their own right, scoping reviews may also be helpful precursors to systematic reviews and can be used to confirm the relevance of inclusion criteria and potential questions. Conclusions: Scoping reviews are a useful tool in the ever increasing arsenal of evidence synthesis approaches. Although conducted for different purposes compared to systematic reviews, scoping reviews still require rigorous and transparent methods in their conduct to ensure that the results are trustworthy. Our hope is that with clear guidance available regarding whether to conduct a scoping review or a systematic review, there will be less scoping reviews being performed for inappropriate indications better served by a systematic review, and vice-versa usc Refereed/Peer-reviewed

Objectives This project aimed to identify and promote evidence-based practice in the management of cancer related fatigue (CRF) in the oncology unit of Nanfang Hospital, affiliated with the Southern Medical University in People's Republic of China. Introduction Cancer-related fatigue is one of the most common symptoms in patients with cancer and significantly affects their functioning and quality of life. However, it is often inadequately addressed and evidence-based practices are not always followed. Methods The Joanna Briggs Institute (JBI) has a validated audit and feedback tool to assist with best practice implementation audits. The JBI Practical Application of Clinical Evidence System (PACES) was used in this project. A three-phase project was undertaken: i) a pre-implementation audit of current practice against evidence-based audit criteria, ii) identification of barriers and implementation of strategies to improve practice using the JBI Getting Research into Practice (GRiP) tool and iii) a post-implementation audit. Results The baseline audit results identified non-compliance to best practice in all areas of CRF. Strategies to improve practice involved relevant education for nurses, establishment of a CRF management routine and related documentation systems and displaying and distributing educational materials for the patients. Improved compliance was shown across all audit criteria in post-evaluation. Conclusions The implementation of institution specific evidence-based resources demonstrated immediate improvement in CRF management and practice. Continuous effort is required to maintain changes and further improve practice. Future projects should focus on measuring the impact of changed practice on patient outcomes.

The Joanna Briggs Institute Model of evidence-based healthcare (EBHC) states that the main phases of EBHC include evidence synthesis, transfer, and implementation. There has been some confusion regarding the term 'evidence transfer', with this term previously being considered by many as synonymous with knowledge or evidence translation. The aim of this paper is to discuss a proposed definition of evidence transfer and the pivotal role it plays as part of the EBHC process. 'Evidence transfer' can be thought of simply as getting the message (evidence) across and at its core it is all about information delivery. We specifically define evidence transfer as a process that helps communicate or convey the results of research or evidence, or brings evidence to the forefront. It is focused on ensuring people are aware of, have access to and understand evidence.

Osteosarcoma mostly occurs during the period of rapid bone growth in children and adolescents as high-grade osteosarcomas. Current treatment recommended for high-grade non-metastatic and metastatic and/or relapsed osteosarcoma involves neoadjuvant multiagent conventional chemotherapy, followed by surgical resection of macroscopically detected tumor and postoperative adjuvant chemotherapy. However, residual micrometastatic deposits that develop following surgery have shown resistance to postoperative/adjuvant chemotherapy. Therefore, there is a critical need for more effective and innovative therapeutic approaches such as immune stimulatory agents. The most extensively studied immune stimulatory agent in the treatment of osteosarcoma is mifamurtide. The aim of this systematic review was to identify and synthesize the evidence on the effectiveness of mifamurtide in addition to standard chemotherapy on survival outcomes.To present the best available evidence on the treatment of high-grade non-metastatic and metastatic osteosarcoma with mifamurtide in addition to standard chemotherapy.All populations of patients regardless of age, gender or ethnicity with high-grade, resectable, non-metastatic and metastatic osteosarcoma based on histological diagnosis.This review focused on intravenous infusion of either of the pharmaceutical formulations of mifamurtide (MTP-PE or L-MTP-PE) in addition to standard chemotherapy, and the comparator was chemotherapy alone.This review considered any experimental study design including randomized controlled trials, non-randomized trials and quasi-experimental studies.The primary outcomes of interest were event-free survival, overall survival and recurrence of osteosarcoma. Secondary outcomes that were considered included health-related quality of life and any mifamurtide-related adverse events.A search for published and unpublished literature in English was undertaken (seven published literature databases, four unpublished literature databases, and three government agency and organizational websites were searched). Studies published between 1990 to June 2016 were considered. A three-step strategy was developed using MeSH terminology and keywords to ensure that all relevant studies were included related to this review.The methodological quality of included studies was assessed by two reviewers, who appraised each study independently, using a standardized Joanna Briggs Institute (JBI) critical appraisal tool.Data was extracted from the studies that were identified as meeting the criteria for methodological quality using the standard JBI data extraction tool.Due to the heterogeneity of populations and interventions in available studies, meta-analysis was not possible and results are presented in narrative form.Three papers outlining two studies involving 802 patients evaluated the effectiveness of mifamurtide in addition of chemotherapy. Results indicated no significant difference in event-free survival between the addition of mifamurtide to standard chemotherapy regimen and chemotherapy alone, both in non-metastatic and metastatic osteosarcoma patients. There was a significant difference in progression-free survival favoring the addition of mifamurtide in pulmonary metastatic and/or relapsed osteosarcoma. There was no significant difference in overall survival between the addition of mifamurtide and chemotherapy alone in metastatic osteosarcoma; however there was a significant difference favoring the addition of mifamurtide in non-metastatic osteosarcoma patients. The addition of mifamurtide resulted in a significant difference in survival after relapse in pulmonary metastatic and/or relapsed osteosarcoma patients. Both studies reported on mifamurtide-related adverse events - the first was reported as toxicity which included haematological, hepatic, renal, gastrointestinal disorders, cardiac, rhythm and nervous system disorders, ear disorders and others (infection, fever; and performance status) in metastatic osteosarcoma patients. Results were similar across all combined treatment regimens. Although no statistical analysis was undertaken, the figures suggest there were no significant differences between the treatment regimens. In the other study, mifamurtide-related adverse events were reported as clinical toxic effects of mifamurtide in relapsed osteosarcoma, which included chills, fever and headache for the initial dose of mifamurtide, while for the subsequent doses of mifamurtide all patients reported toxicity as delayed fatigue.The available evidence on the effectiveness of mifamurtide in addition to a standard chemotherapy regimen for the treatment of high-grade osteosarcoma is limited and therefore no definitive conclusions can be made.

Objective The objective of this systematic review is to explore the experiences of caregivers and healthcare workers regarding the management of pneumonia in children younger than five years in low-and lower middle-income countries. Introduction Pneumonia is a major cause of mortality among children younger than five years. A large percentage of these deaths occur in low-and lower-middle income countries. These deaths can be averted if the disease is recognized early and prompt medical care is sought. The ability of caregivers to detect early symptoms of pneumonia and seek prompt medical care is critical. The ability of healthcare workers to correctly diagnose and initiate early and effective treatment is also key to preventing pneumonia-related deaths. Inclusion criteria This systematic review will consider qualitative studies that explored the experiences of caregivers and healthcare workers regarding the management of pneumonia in children younger than five years in low- and lower middle-income countries. The term "caregivers" primarily refers to family members, whereas the term "healthcare workers" can include nurses, doctors, community and lay healthcare workers. Only studies published in English will be included, with no date restrictions. Methods The systematic review will use the JBI systematic review approach for qualitative studies, with meta-aggregation as the method of synthesis. The search for published studies will be undertaken in PubMed, Embase, Scopus and CINAHL. Gray literature will also be considered. Critical appraisal and data extraction will be conducted using the appropriate JBI tools. Following synthesis, recommendations for clinical practice and areas for future research will be identified.

Objective: The objective of the review was to identify, critically appraise and synthesize the best available qualitative evidence to understand the lived experiences of parents and carers caring for a child aged 0–18 years with asthma in any setting and managing their condition. Introduction: Asthma affects around 14% of children and despite the availability of effective therapies, asthma control is suboptimal and hospitalization rates remain high. Mothers predominantly manage their child’s asthma and experience stress and exhaustion due to complex treatments and balancing work and family life. This review provides an understanding of the barriers parents and carers face in managing their child’s asthma and highlights the needs of families throughout their asthma journey. Inclusion criteria: The review considered qualitative studies examining the experiences of parents and carer scaring for a child with asthma, wheeze or bronchiolitis and managing their condition. Research designs included, but were not limited to, phenomenology, grounded theory, ethnography, and action and feminist research. Methods: A comprehensive search using PubMed, CINAHL, Embase, PsycINFO, Web of Science and ProQuest for published and unpublished studies was undertaken in June 2017 and December 2017. Studies published in English from 1972 to 2017 were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used Results: Seventy-seven qualitative studies were included in this review, including grounded theory, phenomenology and ethnography methodologies. From these 77 studies, 1655 participants from a variety of cultural backgrounds and socio-economic status groups were represented. The methodological quality of included articles was sound and participants’ voices were strong. A total of 1161 findings (966 unequivocal and 195 credible) were extracted and grouped into 41 categories, based on similarity in meaning. From the 41 categories, seven synthesized statements were produced: i) Negotiating the meaning of having a child with asthma, ii) Impact on family life, iii) The process of getting a diagnosis and learning about asthma, iv) Relationships with healthcare professionals and the emergency department experience, v) Medication beliefs, concerns and management strategies, vi) With time,parents and carers become more comfortable managing their child’s asthma, vii) The need for support Conclusions: This review highlights the difficulties parents and carers face when caring for a child with asthma and managing their child’s condition. Attaining a definitive diagnosis of asthma can be challenging, and parents and carers express uncertainty and fear due to continuing symptoms and repeated hospitalizations. Healthcare professionals should ensure that a clear diagnostic strategy and treatment plan are communicated so parents and carers have an understanding of the pathway to receiving an actual diagnosis. Comprehensive asthma education is essential at the onset of asthma symptoms, with accurate, easy to understand and culturally relevant information. Supportive relationships, with healthcare professionals taking a partnership approach, ensuring adequate time, continuity of care, regular follow-up, and addressing the psychosocial and cultural needs and concerns of parents and carers, are recommended. Support groups and training for education staff is imperative to ensure they can support parents and carers, provide asthma friendly environments and respond appropriately in an asthma emergency Refereed/Peer-reviewed

usc AIM: Systematic reviews play an important role in ensuring trustworthy recommendations in healthcare. However, systematic reviews can be laborious to undertake and as such software has been developed to assist in the conduct and reporting of systematic reviews. The Joanna Briggs Institute and its collaborating centres consist of thousands of researchers, academics and clinicians across the globe conducting systematic reviews of various types. To support them in their work, modern software and online tools are required. Our aim was to develop a software program to support systematic reviewers across the globe. Methods:A working party was formed with extensive consultation with members of the Joanna Briggs Collaboration focusing on ideal features of a software program to support systematic reviews. The new systematic review software was built using an agile methodology and designed to be a modern web application. Results:The new systematic review software, the Joanna Briggs Institute System for the Unified Management,Assessment and Review of Information (JBI SUMARI), was successfully developed through an iterative process of development, feedback, testing and review. The software is now available (https://www.jbisumari.org/) and supports the entire systematic review process for different types of systematic reviews. Conclusions:An agile software development approach combined with wide consultation and user testing can facilitate systematic review software design and development. This new software can support systematic reviews and guideline developers to create systematic reviews for a diverse range of questions. Refereed/Peer-reviewed

REVIEW QUESTION/OBJECTIVE The objectives of this review are to identify and present definitions of fatigue and theoretical, conceptual and mechanistic models of fatigue, and to identify the commonly used instruments that measure fatigue in humans and the settings in which they are used.Specifically, the review questions are.

Research question/objective: The purpose of this methodological review is to determine whether and to what extent GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology has been and is currently being used in Australian clinical practice guidelines. Refereed/Peer-reviewed

Background: The cornerstone of evidence-based health care is the systematic review of international evidence. Systematic reviews follow a rigorous, standardized approach in their conduct and reporting, and as such, education and training are essential prior to commencement. Aims: This study reports on the evolution of the Joanna Briggs Institute Comprehensive Systematic Review Training Program (JBICSRTP) as an exemplar approach for teaching systematic review methods. Results: The Joanna Briggs Institute (JBI) is an international research and development center at the University of Adelaide, South Australia. Its mission is to promote and facilitate evidence-based best practice globally, largely through the provision of education and training. JBI was one of the first to consider all forms of evidence in systematic reviews, and as such, implementation of standardized training was essential. Since 1999, JBI has offered a systematic review training program. The JBICSRTP is now delivered face to face over 5 days, with an optional online component; the content aligns to that proposed in the Sicily statement. Over the last 3 years, JBI and its Collaboration have trained over 3,300 people from over 30 countries. A ”train-the-trainer” (TtT) style program was established to cope with demand, and to date, hundreds of trainers have been licensed across the globe to deliver the JBICSRTP. Linking Evidence to Action: Providing standardized training materials, ensuring open and ongoing communication, and adopting a TtT style program while still allowing for local adaptability are strategies that have led to the establishment of a highly skilled global training network and ensured the success and longevity of the JBICSRTP. usc Refereed/Peer-reviewed

Trachoma is an infectious disease caused by the bacterium Chlamydia trachomatis. Infection with C. trachomatis produces characteristic changes to the inner surface of the eyelids, resulting in sequela that when left untreated, leads to vision impairment and blindness. Repeated trachoma infections can cause severe scarring of the inside of the eyelid and can cause the eyelashes to scratch the cornea (trichiasis). The objective of this overview was to synthesize the evidence from Cochrane systematic reviews regarding the treatment of trachoma, and to provide a brief and user-friendly front end for health professionals, researchers and policy makers. Face washing plus topical tetracycline eye ointment gave no additional protective benefit against active trachoma when compared with topical tetracycline eye ointment alone. Nor was any benefit conferred in the presence of severe trachoma. Primary health-care education was found to be effective in reducing the odds of active trachoma. Evidence of benefit from insecticide spray or provision of latrines away from living areas was inconclusive for active trachoma. Surgical interventions that involve full-thickness incision with tarsal rotation are more effective than alternate surgical procedures.

REVIEW QUESTION/OBJECTIVE The objective of this systematic review is to identify and synthesize the best available evidence on the experiences and expectations of being involved in a program that aims to return nurses and midwives, who have acquired a musculoskeletal disorder (MSD) in the workplace, to work.The specific review questions are.

Background Death after surgery is an acknowledged outcome reflecting the safety of a procedure. Death rates after surgery are not often routinely collected, therefore mortality rates can be difficult to quantify. Colorectal surgery is increasingly offered to older patients. The likelihood of postoperative adverse outcomes (including death) may impact decision-making at individual, institutional or health care system levels. Objectives The objective of this review was to provide an estimate of the prevalence of all-cause 30-day postoperative mortality for older patients in highly developed countries undergoing elective colorectal surgery. Inclusion criteria Types of participants This review considered studies and reports that included patients aged 65 years and over from highly developed countries undergoing elective colorectal surgical resection. Only studies from countries with a very high Human Development Index were included. Types of interventions Studies and reports including patients having colorectal resection with or without anastamosis were included. Types of studies This review considered experimental, analytical and descriptive epidemiological study designs, including randomized controlled trials, prospective and retrospective cohort studies, case series and cross sectional studies and reports. Only studies with a minimum sample size of 150 were included. Types of outcomes This review included studies and reports that included rates of 30-day all-cause postoperative mortality. Search strategy A three-step search strategy was used in order to find published and unpublished studies and reports in the English language from 1998 to 2013. Databases searched were PubMed, Embase, Scopus, Web of Science, CINAHL, The Cochrane Central Register of Controlled Trials and the website of The Cochrane Colorectal Cancer Group. A search of the grey literature was performed, and hand searching of all retrieved articles was undertaken to identify additional studies or reports. Methodological quality Studies or reports which met the inclusion criteria were critically appraised by two independent reviewers for methodological quality using the standardized Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Any disagreements between reviewers were resolved by a third reviewer. Data collection Data was extracted from the included studies or reports using a standardized data extraction tool. The tool included details of the study type, the dates covered by the interventions, the setting and model of care, the indication for, as well as the precise intervention(s), the population age range and level of comorbidity, the outcome measure of significance to the systematic review question, and whether the study or report included any qualitative assessment of the safety or acceptability of the surgical outcome. Data synthesis Outcomes for the population of interest were identified and outcome rates over time were analysed. Sub-group analysis was undertaken for mortality rates for age groups 70 years and over, 75 years and over, and 79 years and over. Outcomes were reported separately for countries and regions. Outcome data was reported separately according to the population studied (national-level data, and also data from academic and non-academic centres). Other comparisons examined separately included laparoscopic surgery and open surgery, cancer and non-cancer surgery, rectal and colonic surgery, surgery involving only specialist colorectal surgeons and surgery where non-specialist colorectal surgeons were involved, and surgery where “enhanced recovery” models of care were identified. Any qualitative assessment of the safety or acceptability of surgical outcome was reported. Results Twenty-four studies were included in the review. Studies were reported in a range of surgical, medical and educational publications. Twenty-three of the studies were observational. Explicit postoperative mortality rates were often difficult to identify, and data was obtained through direct author contact. Postoperative mortality rates reported and discovered ranged from 0.57-11.3%. The pooled 30-day postoperative mortality rate for all patients across all included studies was 5.34%. TRUNCATED AT 600 WORDS

Review question/objective The objective of this review is to provide an estimate of the prevalence of all-cause 30-day postoperative mortality for older patients in developed countries presenting for elective colorectal surgery. Inclusion criteria As this review will report on the prevalence of mortality as an adverse outcome of a surgical intervention, the format does not conform to the standard PICO/PIO question. Types of participants This review will consider studies that include patients aged 65 years and over from developed countries, presenting for elective colorectal surgical resection. For the purposes of this review, developed countries will include only counties with a very high Human Development Index 25 . Studies including patients from countries without a very high HDI will be excluded. Patients having colorectal resection with or without anastomosis (joining of the ends of resected bowel) will be included. Patients having exploratory or diverting procedures (for example, patients who at surgery are found to have widespread disease which is unsuitable for operation) will be excluded from this review. Types of outcomes This review will consider studies that include the following outcome measures: rates of 30-day all-cause postoperative mortality (that is, patients dying from any cause within the first 30 days after surgery).

Objective The objective of this systematic review is to determine the best available evidence regarding assisting bathing/showering of older adults with dementia in aged care facilities and community settings. Review questions: The quantitative component will aim to answer questions of effectiveness: - What is the most effective bathing/showering method in reducing agitated or aggressive behaviours in older adults with dementia in aged care facilities and community settings? - What are the most effective bathing/showering method and related educational/ supportive interventions in improving confidence and satisfaction level of nurses, care staff or family caregivers in assisting bathing/showering older adults with dementia? The qualitative component will aim to answer questions of meaningfulness, appropriateness and feasibility: - What are the bathing/showering experiences of older adults with dementia? - What are the experiences of nurses, care staff and family caregivers in assisting bathing/showering older adults with dementia? The textual component will aim to provide supplemental evidence to the quantitative and qualitative components. Participants: - Older adults with dementia (assessed using scales such as Mini Mental Scare Examination, Global Deterioration Scale) in aged care and home settings - Nurses and formal care staff - Family caregivers Intervention: phenomena of interest Assisting bathing/showering of older adults with dementia and related educational or supportive interventions for nurses, formal care staff and family caregivers Comparison (quantitative component) - Usual care Outcome measures The quantitative component: - Frequency and severity of aggressive or agitated behaviours measured by scales such as RAGE (Rating Scale for Aggressive Behaviour in Elderly) - Satisfaction rate by residents, family caregivers or nursing/formal care staff - Confidence rate of residents, family caregivers or nursing/formal care staff The qualitative component: - Subjective accounts of nurses/formal care staff or family caregivers in assisting bathing/showering older adults with dementia - Subjective accounts of nurses/formal care staff or family caregivers to have received educational or supportive interventions related to bathing/showering older adults with dementia - Subjective accounts of older adults with dementia in receiving assistance in bathing/showering - Subjective accounts of older adults with dementia in receiving interventions aiming to improve bathing/showering experiences/outcomes TRUNCATED AT 350 WORDS