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BACKGROUNDThe inclusion of adolescents in TB drug trials is essential for the development of safe, child-friendly regimens for the prevention and treatment of TB. TB Trials Consortium Study 31/AIDS Clinical Trials Group A5349 (S31/A5349) enrolled adolescents as young as 12 years old. We assessed investigator and coordinator described facilitators and barriers to adolescent recruitment, enrollment, and retention.METHODSInterviews were conducted with six investigators from sites that enrolled adolescent participants and six investigators from non-enrolling sites. Additionally, two focus groups were conducted with study coordinators from enrolling sites and two focus groups with non-enrolling sites. Discussions were transcribed, analyzed, summarized, and summaries were reviewed by Community Research Advisors Group members and research group representatives for content validity.RESULTSInvestigators and coordinators attributed the successful enrollment of adolescents to the establishment and cultivation of external partnerships, flexibility to accommodate adolescents' schedules, staff engagement, recruitment from multiple locations, dedicated recruitment staff working onsite to access potential participants, creation of youth-friendly environments, and effective communications. Non-enrolling sites were mainly hindered by regulations. Suggestions for improvement in future trials focused on study planning and site preparations.CONCLUSIONProactive partnerships and collaboration with institutions serving adolescents helped identify and reduce barriers to their inclusion in this trial..

BACKGROUND: The value, speed of completion and robustness of the evidence generated by TB treatment trials could be improved by implementing standards for best practice.METHODS: A global panel of experts participated in a Delphi process, using a 7-point Likert scale to score and revise draft standards until consensus was reached.RESULTS: Eleven standards were defined: Standard 1, high quality data on TB regimens are essential to inform clinical and programmatic management; Standard 2, the research questions addressed by TB trials should be relevant to affected communities, who should be included in all trial stages; Standard 3, trials should make every effort to be as inclusive as possible; Standard 4, the most efficient trial designs should be considered to improve the evidence base as quickly and cost effectively as possible, without compromising quality; Standard 5, trial governance should be in line with accepted good clinical practice; Standard 6, trials should investigate and report strategies that promote optimal engagement in care; Standard 7, where possible, TB trials should include pharmacokinetic and pharmacodynamic components; Standard 8, outcomes should include frequency of disease recurrence and post-treatment sequelae; Standard 9, TB trials should aim to harmonise key outcomes and data structures across studies; Standard 10, TB trials should include biobanking; Standard 11, treatment trials should invest in capacity strengthening of local trial and TB programme staff.CONCLUSION: These standards should improve the efficiency and effectiveness of evidence generation, as well as the translation of research into policy and practice.

Anna Kurniati,1 Ferry Efendi,2,3 Ismawiningsih Ismawiningsih,1 Nila Mulyani,1 Zakaria Zakaria,1 Retno Ambarwati,1 Hutomo Tuhu Prasetyo,1 Endro Muljandari,1 Irni Damayanti,1 Arif Yustian Maulana Noor,4 Lisa McKenna,3 Iin Nurlinawati5 1Directorate of Health Workforce Deployment, Directorate General of Health Workforce, Ministry of Health, Jakarta, Indonesia; 2Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 3School of Nursing and Midwifery, La Trobe University, Melbourne, Australia; 4Agriculture Socio-Economic Department, Faculty of Agriculture, Brawijaya University, Malang, Indonesia; 5Badan Riset Inovasi Nasional, Jakarta, IndonesiaCorrespondence: Ferry Efendi, Faculty of Nursing, Universitas Airlangga, Campus C Mulyorejo, Surabaya, East Java, 60115, Indonesia, Tel +62 31 591 3754, Email ferry-e@fkp.unair.ac.idIntroduction: Retaining doctors and dentists in remote areas of Indonesia remains a national priority of the Indonesian government. The purpose of this study was to analyze the interventions for retention of doctors and dentists in remote areas using the discrete choice experiment (DCE) approach.Materials and Methods: A DCE was conducted to investigate preferences of doctors and dentists for retention in remote areas. This research was conducted in 78 primary healthcare settings across 15 provinces in Indonesia. The conditional logit model was used to explore stated preferences for each attribute.Results: The total number of respondents was 158, including 113 doctors and 45 dentists. In general, doctors placed the highest preference on getting priority for government scholarships to facilitate retention in remote areas (OR=5.65, p< 0.001). Specifically, dentists preferred security guarantees from local government (OR = 4.87, p< 0.001). Both groups valued having an official residence (OR=3.6, p< 0.001) as a factor for retention in remote areas.Conclusion: Scholarship, security guarantees, housing facilities, and medical facilities were the most considered factors for retaining doctors and dentists in a remote area. This study confirms the importance of a combination of interventions in maintaining doctors and dentists in remote areas. Policy options in the form of non-financial and financial intervention packages can be combined to improve their retention.Keywords: preferences, health systems, health workers, rural area, health workforces, DCE

Abstract High blood pressure is an important risk factor for cardiovascular disease and disease progression in chronic kidney disease (CKD). Evidence on the effects of home blood pressure monitoring (HBPM) is limited. This review aimed to determine the effect of HBPM on systolic (SBP) and diastolic blood pressure (DBP) in patients with CKD. We searched medical literature databases for eligible studies presenting pre‐ and post‐data for interventions utilizing HBPM. Study quality was assessed using the NHLBI tools for quality assessment. Heterogeneity prohibited a meta‐analysis so estimates of effects were calculated along a sign test to examine the probability of observing the given pattern of positive effect direction. Eighteen studies were included (n = 1187 participants, mean age 56.7 [± 7.7] years). In 15 studies, HBPM was conducted within the context of additional high‐level tailored support. Overall, the quality of n = 7/18 studies was rated as “good”; n = 6/18 were “fair,” and n = 5/18 were rated as “poor.” Interventions utilizing HBPM had a significant effect on SBP, with 14/16 studies favoring the intervention (88% [95% CI: 62%–98%], P = .002). Favorable effects were also seen on DBP (73% [95% CI: 45%–92%], P = .059). HBPM had a favorable effect on blood pressure goal attainment (86% [95% CI: 42%–100%], P = .062). HBPM in patients with CKD as part of a multicomponent intervention may lead to clinically significant reductions in blood pressure; however, research is needed to support the validity of this claim due to the high heterogeneity across the studies included.

Abstract A tubular bone bead dating to ~ 12,940 BP was recovered from a hearth-centered activity area at the La Prele Mammoth site in Converse County, Wyoming, USA. This is the oldest known bead from the Western Hemisphere. To determine the taxonomic origin of the bead, we extracted collagen for zooarchaeology by mass spectrometry (ZooMS). We also used micro-CT scanning for morphological analysis to determine likely skeletal elements used for its production. We conclude that the bead was made from a metapodial or proximal phalanx of a hare (Lepus sp.). This find represents the first secure evidence for the use of hares during the Clovis period. While the use of hare bone for the manufacture of beads was a common practice in western North America during the Holocene, its origins can now be traced back to at least the terminal Pleistocene.

Background: Increasing COVID-19 vaccine intention in college students is essential to mitigate serious illness and transmission to higher risk populations. We currently do not have an adequate understanding of college students' perceptions and likelihoods of getting vaccinated against COVID-19. Purpose: To quantitatively examine the demographic and psychosocial factors that predict college students' intent of COVID-19 vaccination. Methods: Undergraduate students were recruited through general education courses at a public western US university to complete an online survey measuring their perceptions, experiences, and behaviors regarding COVID-19. Two binary logistic regression models ascertained the influence of predictor variables on college students' vaccination intention. Results: Participants (n = 241) were between ages 18 and 24, with a majority identifying as female (74.7%). The final binary logistic regression indicated that perceived susceptibility (Exp (B) = [1.167], p = 0.002, 95% CI (1.059, 1.286)) significantly predicted likelihood of obtaining a COVID-19 vaccine. Discussion: University-based interventions focusing on college students should address perceived susceptibility regarding vaccination to promote uptake in this population. Translation to Health Education Practice: Our study emphasizes opportunities for health educators in college settings to implement programming and communication campaigns focusing on perceived susceptibility to better mitigate the COVID-19 pandemic.

Ferry Efendi,1,2 Gading Ekapuja Aurizki,1,2 Ilmiawan Auwalin,3 Lisa McKenna4 1Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 2Community, Family and Gerontological Nursing Research Group, Universitas Airlangga, Surabaya, Indonesia; 3Faculty of Economics and Business, Universitas Airlangga, Surabaya, Indonesia; 4School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, AustraliaCorrespondence: Ferry Efendi, Faculty of Nursing, Universitas Airlangga, Campus C Mulyorejo, Surabaya, East Java, 60115, Indonesia, Tel +62 31 591 3754, Email ferry-e@fkp.unair.ac.idIntroduction: Nursing workforce is a pivotal element in tackling the COVID-19 pandemic. However, this has not been comprehensively discussed, particularly in Indonesia. This study aimed to explore stakeholders’ perspectives on Indonesian nursing workforce recruitment and management during the COVID-19 pandemic.Methods: This study employed a qualitative design with an exploratory descriptive approach. Stakeholders who recruited and managed nursing resources in Indonesia were involved. In-depth interviews and focus group discussions with stakeholders representing eight different institutions were undertaken. Data were analysed using thematic analysis. Eight key stakeholders were interviewed.Results: Three themes emerged, namely uncertain recruitment system, nursing labour market situation, and workforce management dynamics. COVID-19 caused reduced workforce capacity and increased demands for health professionals, especially nurses.Conclusion: Uncertainty and volatility happened at the recruitment and management of nursing human resources during the pandemic. Stakeholders were not convinced of overall quality of local nurses recruited to care for COVID-19 patients given workforce was dominated by new graduates and nurses without specialistic qualifications. Employers gave new staff more training to ease their deployment to COVID-19 units to make up for the nurses’ lack of expertise and experience.Keywords: adaptive management, COVID-19, health worker, labour market, pandemic, personnel management

Abdullah Mohammed Alobaid,1,2 Abdulmajeed Mobrad,3 Cameron Gosling,2 Lisa McKenna,4 Brett Williams2 1Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 2Department of Paramedicine, Faculty of Medicine, Nursing and Health Sciences Monash University, Melbourne, Victoria, Australia; 3Department of Emergency Medical Services, Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 4La Trobe University, School of Nursing and Midwifery, Melbourne, Victoria, AustraliaCorrespondence: Abdullah Mohammed AlobaidPrince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia, Tel +966533336396, Email a.alobaid33@gmail.comIntroduction: Although emergency medical services (EMS) stakeholders acknowledge the need for both male and female paramedics in the EMS field, the Saudi EMS system is currently only staffed by male paramedics and emergency medical technicians (EMTs) working in EMS organisations.Aim: To understand and explore the Saudi Arabian community’s perceptions on engaging Saudi female paramedics in the EMS workforce.Material and Methods: This was a cross-sectional survey design using convenience sampling of the public in Riyadh city by self-administered English and Arabic language questionnaires. Questionnaire validity was assessed by face and content validity.Results: Of the 3603 surveys distributed, 3132 were returned (87% completion response rate). Most respondents were aged between 18 and 29 years (n = 1308, 41%), and the sex distribution was (n = 1646, 52.6%) male and (n = 1486, 47.4%) female. Overall, 77% (n = 2412) of the respondents supported the need for female paramedics in Saudi Arabian ambulance services, and 74.8% (n = 2343) preferred that female paramedics treated female patients.Conclusion: This is the first public study to explore Saudi public perceptions about female paramedics in EMS in the Riyadh region, Saudi Arabia. The Saudi public is supportive of female paramedics being employed as paramedics in the country. Moreover, significant differences in perceptions were evidenced in the sex groups over any other factors.Keywords: emergency medical services, female, paramedic, public perception, Saudi Arabia

Aortic dissection occurs when a weakened portion of the intima tears, and a separation of layers propagates along the aortic wall to form a false lumen filled with active blood flow or intramural thrombus. The unpredictable nature of aortic dissection formation and need for immediate intervention leaves limited serial human image data to study the formation and morphological changes that follow dissection. We used volumetric ultrasound examination, histology, and scanning electron microscopy (SEM) to examine intramural thrombi at well-defined timepoints after dissection occurs in apolipoprotein E-deficient mice infused with angiotensin II (n = 71). Stratification of red blood cell (RBC) morphologies (biconcave, intermediate biconcave, intermediate polyhedrocyte, and polyhedrocyte) in the thrombi with scanning electron microscopy (n = 5) was used to determine degree of thrombus deposition/contraction. Very few biconcave RBCs (1.2 ± 0.6%) were in the thrombi, and greater amounts of intermediate biconcave RBCs (25.8 ± 6.7%) were located in the descending thoracic portion of the dissection while more polyhedrocytes (14.6 ± 5.1%) and fibrin (42.3 ± 4.5%; P < .05) were found in the distal suprarenal aorta. Thrombus deposition likely plays some role in patient outcomes, and this multimodality technique can help investigate thrombus deposition and characteristics in experimental animal models and human tissue samples.

Abstract Predators can strongly influence disease transmission and evolution, particularly when they prey selectively on infected hosts. Although selective predation has been observed in numerous systems, why predators select infected prey remains poorly understood. Here, we use a mathematical model of predator vision to test a long‐standing hypothesis about the mechanistic basis of selective predation in a Daphnia–microparasite system, which serves as a model for the ecology and evolution of infectious diseases. Bluegill sunfish feed selectively on Daphnia infected by a variety of parasites, particularly in water uncolored by dissolved organic carbon. The leading hypothesis for selective predation in this system is that infection‐induced changes in the transparency of Daphnia render them more visible to bluegill. Rigorously evaluating this hypothesis requires that we quantify the effect of infection on the visibility of prey from the predator's perspective, rather than our own. Using a model of the bluegill visual system, we show that three common parasites, Metschnikowia bicuspidata, Pasteuria ramosa, and Spirobacillus cienkowskii, decrease the transparency of Daphnia, rendering infected Daphnia darker against a background of bright downwelling light. As a result of this increased brightness contrast, bluegill can see infected Daphnia at greater distances than uninfected Daphnia—between 19% and 33% further, depending on the parasite. Pasteuria and Spirobacillus also increase the chromatic contrast of Daphnia. These findings lend support to the hypothesis that selective predation by fish on infected Daphnia could result from the effects of infection on Daphnia's visibility. However, contrary to expectations, the visibility of Daphnia was not strongly impacted by water color in our model. Our work demonstrates that models of animal visual systems can be useful in understanding ecological interactions that impact disease transmission.

Ferry Efendi,1 Lisa McKenna,2 Sonia Reisenhofer,2 Anna Kurniati,3 Eka Misbhahatul Marah Has1 1Department of Advanced Nursing Care, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 2School of Nursing and Midwifery, La Trobe University, Melbourne, Australia; 3Center of Planning and Management of Human Resources for Health, Ministry of Health of the Republic of Indonesia, Jakarta, IndonesiaCorrespondence: Ferry EfendiDepartment of Advanced Nursing Care, Faculty of Nursing, Universitas Airlangga, Jl. Mulyorejo Kampus C Unair, Surabaya, 60115, IndonesiaTel +62-315913257; +6281331533805Email ferry-e@fkp.unair.ac.idBackground: International migration of healthcare workers is a global phenomenon driven by growing demand in developed countries and expectations of healthcare workers from developing countries to have improved employment and lives. This migration has been understood to impact both the individuals and countries involved, with positive and negative consequences. However, little is known about returnees’ experiences that could be used to address challenges and optimize benefits. The aim of this review was to understand what is known about experiences of migrant health workers after returning to their home countries.Methods: A scoping review of primary research addressing experiences of migrant health workers upon their return to their homelands. A range of database were searched including Career and Technical Education Database via ProQuest, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education database via ProQuest, Excerpta Medica Care (EMCare) via Ovid, Education Resources Information Center (ERIC), Excerpta Medica database (EMBASE) via Ovid, MEDLINE and Scopus. A systematic process was performed guided by the work of Arksey and O’Malley. Eight databases were searched and 226 articles were retrieved. After screening articles and abstracts, 15 full-texts were assessed for eligibility, and finally seven studies were further analyzed and synthesized.Results: Five qualitative studies, one quantitative study and one mixed methods study met inclusion criteria. Five themes emerged: (1) reasons to return, (2) upskilling and deskilling, (3) impact on human, financial, and social capital, (4) challenges and opportunities in the home country, and (5) facilitation supports.Conclusion: Return migration is portrayed as a complex situation experienced by returnees. Structured policy and supports are required to help healthcare worker returnees prepare, and to adjust to life after their return. This study highlights the importance of comprehensive approach in return migration stage. Return migration policy should support healthcare worker returnees in their home country and facilitate utilization of their skills. Multi-stakeholder partnerships are vital to develop platforms for helping and facilitating returnees in the reintegration process at their home countries.Keywords: international migration, migrant worker, migration policy, nurse migration, return migration

Abdullah Mohammed ALobaid,1,2 Cameron McR Gosling,1 Eihab Khasawneh,1,3 Lisa McKenna,4 Brett Williams1 1Department of Paramedicine, Monash University, Melbourne, Victoria, Australia; 2Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 3Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan; 4La Trobe University, School of Nursing and Midwifery, Melbourne, Victoria, AustraliaCorrespondence: Abdullah Mohammed ALobaidDepartment of Community Emergency Health & Paramedic Practice, Monash University, Monash University-Peninsula Campus, McMahons Road, Frankston, Melbourne, Victoria, AustraliaTel +61 411112042Email a.alobaid33@gmail.comBackground: The number of women entering the medical and healthcare workforce globally has increased in the past several decades. Women have many roles and positions in healthcare organizations, hospitals and healthcare education settings. Although there has been an increase in the number of women, female workers continue to face many workplace challenges. This scoping review aimed to explore the challenges female healthcare professionals face in the workforce.Methods: A scoping review utilizing Arksey and O’Malley’s six-step framework was undertaken to identify and map available literature addressing challenges faced by female healthcare professionals in the workforce. The databases searched included Embase, EmCare, Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Business Source Complete (BSC). Additional searches were performed using Google Scholar, Trove and grey literature.Results: The initial search yielded 2455 publications (Medline n=369; EmCare n=276; Embase n=612; CINAHL n=1088; Business Source Complete n=109; mixed grey literature n=1). After removal of duplicates, 1782 citations remained. Abstract and title screening reduced the field to 36 publications, following which full-text reviews were conducted. Consensus was reached on 16 publications for final review. After analyzing the articles, three themes were identified: i) family responsibilities, ii) workplace environment and iii) stereotyping.Conclusion: Findings confirm that female healthcare professionals face circumstances that may affect their family lives, as well as factors relating to the workplace environment and stereotypes. Implementing strategies such as reduced work hours, flexible timing and part-time work can support women in the workplace, which then enhances and supports gender equality in healthcare organizations.Keywords: female, healthcare providers, family responsibilities, workplace, stereotype

Alzheimer’s disease (AD), the most common age-related neurodegenerative disease, is associated with various forms of cognitive and functional impairment that worsen with disease progression. AD is typically characterized as a protein misfolding disease, in which abnormal plaques form due to accumulation of tau and β-amyloid (Aβ) proteins. An assortment of proteins is responsible for the processing and trafficking of Aβ, including sortilin-related receptor 1 (SORL1). Recently, a genome-wide association study of microRNA-related variants found that a single nucleotide polymorphism (SNP) rs2291418 within premature microRNA-1229 (pre-miRNA-1229) is significantly associated with AD. Moreover, the levels of the mature miRNA-1229-3p, which has been shown to regulate the SORL1 translation, are increased in the rs2291418 pre-miRNA-1229 variant. In this study we used various biophysical techniques to show that pre-miRNA-1229 forms a G-quadruplex secondary structure that coexists in equilibrium with the canonical hairpin structure, potentially controlling the production of the mature miR-1229-3p, and furthermore, that the AD-associated SNP rs2291418 pre-miR-1229 changes the equilibrium between these structures. Thus, the G-quadruplex structure we identified within pre-miRNA-1229 could potentially act as a novel therapeutic target in AD.

Brett Williams,1 Ted Brown,2 Malcolm Boyle,1 Lisa McKenna,3 Claire Palermo,4 Jamie Etherington1 1Department of Community Emergency Health and Paramedic Practice, 2Department of Occupational Therapy, 3School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University–Peninsula Campus, Frankston, 4Department of Nutrition and Dietetics, Faculty of Medicine, Nursing and Health Sciences, Monash University–Berwick Campus, Berwick, Vic, Australia Purpose: This research examines the extent and nature of empathy among emergency health (paramedic), nursing, and midwifery students at one Australian university and investigates the longitudinal changes in empathy levels across the course of study. Methods: First-, second-, and third-year students at Monash University completed the Jefferson Scale of Empathy–Health Professional (JSE-HP) in 2008, 2009, and 2010, and the resulting mean empathy scores were analyzed by course, year of course, year of study, age, and sex. Results: Midwifery students were found to have higher empathy levels than nursing and emergency health students. Second- and third-year students scored higher than their counterparts in the first year. Empathy levels dipped in 2009 and rose in 2010. Students aged 26–30 years and 31–35 years recorded higher scores than their younger colleagues, and female students were found to be more empathic than their male counterparts. Conclusion: The finding that empathy levels are relatively stable over the term of study contributes to the understanding of how empathy evolves over the course of study and offers insights into the importance of incorporating and promoting empathy in health care curricula. Keywords: empathy, nursing, paramedics, midwifery, undergraduates

Brett Williams,1 Ted Brown,2 Lisa McKenna,3 Malcolm J Boyle,1 Claire Palermo,4 Debra Nestel,5 Richard Brightwell,6 Louise McCall,7 Verity Russo11Department of Community Emergency Health and Paramedic Practice, 2Department of Occupational Therapy, 3School of Nursing and Midwifery, 4Department of Nutrition and Dietetics, 5School of Rural Medicine, Monash University, Melbourne, VIC, 6School of Medical Sciences, Edith Cowan University, Perth, WA, 7Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, AustraliaBackground: Empathy is paramount in the health care setting, optimizing communication and rapport with patients. Recent empirical evidence suggests that empathy is associated with improved clinical outcomes. Therefore, given the importance of empathy in the health care setting, gaining a better understanding of students' attitudes and self-reported empathy is important. The objective of this study was to examine self-reported empathy levels of students enrolled in different health disciplines from two large Australian universities.Materials and methods: A total of 1,111 students from two different universities enrolled in eight different health professions were administered the Jefferson Scale of Physician Empathy – Health Profession Students version, a 20-item 7-point Likert scale questionnaire to evaluate self-reported empathy levels.Results: A total of 1,111 students participated in this study. The majority of participants were from Monash University (n=771), with 340 students from Edith Cowan University. No statistically significant differences were found between universities: Monash University (mean 110.1, standard deviation [SD] 11.8); Edith Cowan University (mean 109.2, SD 13.3, P=0.306). The mean female empathy score (mean 110.8, SD 11.7) was significantly higher than the mean male score (mean 105.3, SD 13.5; P