Cranberry is a fruit originally from New England and currently growing throughout the east and northeast parts of the USA and Canada. The supplementation of cranberry extracts as nutraceuticals showed to contribute to the prevention of urinary tract infections, and most likely it may help to prevent cardiovascular and gastroenteric diseases, as highlighted by several clinical trials. However, aiming to validate the efficacy and safety of clinical applications as long-term randomized clinical trials (RCTs), further investigations of the mechanisms of action are required. In addition, a real challenge for next years is the standardization of cranberry’s polyphenolic fractions. In this context, the optimization of the extraction process and downstream processing represent a key point for a reliable active principle for the formulation of a food supplement. For this reason, new non-conventional extraction methods have been developed to improve the quality of the extracts and reduce the overall costs. The aim of this survey is to describe both technologies and processes for highly active cranberry extracts as well as the effects observed in clinical studies and the respective tolerability notes. Vaccinum macrocarpon (Ait. Ericaceae) called “large cranberry”, “North American cranberry” “bearberry”, or simply “cranberry” is a fruit originally from New England and currently grows throughout the east and northeast parts of the USA and Canada. The USA produces 436.691 tons/year of cranberries equal to 58% of the world’s total cranberry production, with $3.5 billion estimated in economic activity [V. macrocarpon juice to treat urinary tract infections (UTIs) and wounds has been reported in different manuals of phytotherapy. According to subsequently observational and interventional studies in humans, consumption of cranberry demonstrated to be associated with beneficial effects firstly in UTIs prevention, but also in other conditions [Helicobacter pylori infection of susceptible people [activity ,3. Howevactivity . In factnditions ,8. Durine people .After a description of the main bioactive components of cranberry, this review will describe the state of the art of the main extraction and purification methods of cranberry, discussing the advantages and limitations of these strategies. Clinical applications that have arisen from RCTs are also discussed. Finally, future perspectives for cranberry extracts will be presented.Vaccinum macrocarpon’, ‘extraction techniques’, and ‘clinical trial’. The eligible papers must be published in English. Randomized clinical trials have been preferred and included wherever possible, although in some minor conditions both open-label and animal studies were considered due to the lack of controlled studies. The work is characterized by a first general introduction and a description of the phytochemical composition of cranberry, followed by a description of the technologies and processes for highly active cranberry extracts, the effects observed in clinical studies, and the respective tolerability notes. The Declaration of Interest forms related to real or potential sources of conflicts of interest were compiled by the drafting and review groups.The literature search has been performed using the most relevant databases recognized for medical scientific literature, including PubMed, MEDLINE , the Cochrane Register of Controlled Trials  with access to Scopus, EMBASE, and ClinicalTrials.gov. The terms used for the electronic search strategy were ‘cranberry’, ‘proanthocyanidins’, ‘urinary tract infections’, ‘V. macrocarpon phytochemical composition is complex and includes many polyphenols like A-type procyanidins (PACs), anthocyanins, benzoic acid, but also terpenes like ursolic acid (UA). The amounts of different classes of phytochemicals in cranberry fresh fruit, dried fruit, juice, and sauce are synthesized in Escherichia coli adhesion to uroepithelial cells [Vaccinum vitis-idaea L.) [al cells . Moreovedaea L.) . The antdaea L.) . Anthocydaea L.) .p-hydroxybenzoic, o-hydroxybenzoic, and 2,4-dihydroxybenzoic acids. As concerns the hydroxycinnamic acids, cranberries contain p-coumaric, caffeic, ferulic, and sinapic acids [Phenolic acids are not specific components; indeed, it is present in many other plant food and berries. In cranberries, phenolic acids are mainly represented by hydroxybenzoic and hydroxycinnamic acids while ellagic acid and ellagitannins have not been detected. The hydroxybenzoic acids are the most abundant and benzoic acid is more prevalent than ic acids .cis- and trans-3-O-p-hydroxycinnamoyl ursolic acid. On the other hand, in a study focused on cranberry juice fractions tested through a bacterial adherence assay, two coumaroyl iridoid glycosides and a depside have been identified [Cranberry fruits also contain phytochemicals not included in the polyphenols class such as triterpenoids compounds like ursolic, oleanolic, and betulinic acids. Among them, the most abundant is the ursolic acid which is present also in the peels of several fruits and which has anti-inflammatory recognized properties  but cranentified .V. macrocarpon is probably the richest species for flavonols and the most abundant flavonols, in cranberries are represented by the glycosylated form of quercetin, myricetin, and a small amount of kaempferol. In particular, quercetin 3-galactoside represents the predominant flavanol, even if other glycosides are present in traces [Among berries and plant food, n traces .The exact amount of each bioactive compound in cranberry depends on the variety of American cranberry which is analysed and from the exact phase of the plant life. In general, PACs and flavonols have been found high in the earliest stage and decrease during the growth of the fruits. The decrease of PACs is more rapid than the decline of flavanols. Anthocyanins production starts when cranberry fruit has finished its growth and continues during ripening .All the phytochemicals are present in the cranberry fresh fruits but often cranberries are consumed in processed forms to obtain juice, sauce or dried fruits, and these processes could affect the content of bioactive compounds . AnthocySeveral types of cranberry products have been tested in pre-clinical and clinical trials even if data regarding the comparison of the relative composition of the extracts and the bioactivity for different products is still few or lacking .American cranberry is rarely consumed as fresh fruit, due to the sour, astringent flavour of the berry . For thiThe most common use of cranberry is the production of juice, which causes an increase in food industry waste, well known as pomace (berry press residues) that contain berry skin and seeds . In a coDepending on the nature of the chemical and physical extraction processes and the sequence of processing steps adopted, it is possible to obtain several cranberry extracts with different bioactive components . Whole bCranberry juice is extracted by pressing or decanting from frozen berries which have been cut and macerated and include the separation of solid and liquid fruit components, followed by centrifugation and filtering, in order to remove the suspended solid particulates . The freAfter the separation of solid and liquid fruit components, the juice is particularly rich in water-soluble molecules including several flavonoids and organic acids  as well as sugars , while the pomace is composed mainly of cranberry skins and seeds is rich in proteins, insoluble polymers, and polyphenols adhered within the physical structures of such residues . The extIn general, the liquid achieved from the juice production undergoes the process of pasteurization with the use of heat to facilitate the long-term storage. The concentration of juice exploits the mechanism of reverse osmosis or counter current chromatography, obtaining the cranberry juice concentrate also known as cranberry syrup with a remarkably high concentration of solute (50 Brix) . ConcentCranberry juice can be treated with proprietary methods to remove sugars, especially for nutraceuticals preparations, in order to reduce the caloric content of juice and avoid any problems with gluco-intolerant patients ,35.Fresh berries can also be processed to obtain dried cranberries, canned cranberry sauce, and other foods with added cranberry materials. Sweetened dried cranberries prepared from the frozen, cut berries are instead used in food industries .However, during the drying process, there is a partial loss of nutritional value as a consequence of exposure of cranberry fruits to high temperatures and air for a long time. In this regard, during the extrusion process, characterized by the exposition of cranberries at high-temperature for a short-time, in order to reduce the moisture and then prolong the shelf-life, a significant loss of total anthocyanins have been observed .For this reason, and in addition to reducing energy expenditures, new unconventional technologies and pre-treatment have been developed . The stuAn interesting technique to reduce deteriorating reactions and increase the shelf life is represented by the food coating, which is characterized by the application of edible layers on the surface of cranberries. In this regard, Lozano-Navarro et al.  reportedAn interesting product from cranberry pomace or enriched juice (from the whole berries) is the hull extract powder, which can be used both for food and nutraceutical applications. Starting from the pomace or the whole berries cut, after pressing and filtering, the enriched juice is treated with additional enzymes and heat beyond those typically used for juice production. After that, the resulting enriched juice extract is typically spray-dried to obtain the hull extract powder .The composition of cranberry extracts is extremely variable, depending on several factors, such as the treatments with different enzymes, temperature and time conditions, and the concentration and drying steps that affect the qualitative-quantitative composition of the final extracts . ConsideHowever, the great variability of bioactive molecules present in the extracts could influence the results of cranberry effects administered in clinical practice. In addition, even if a major part of the clinical studies has investigated the effects of cranberry as a nutraceutical, marketed in the form of dry extracts (some of these titrated and standardized in phenolic compounds) in different dosage forms , the lack of information which describe the methods used to obtain the extracts make impossible to predict the difference of bioactive compounds which may be present in the final product ,44.A consolidated method to extract polyphenols from cranberry pomace provides the use of petrochemical-based solvents, including methanol, acetone, ethyl acetate, and chloroform. In particular, methanol/hydrochloric acid and acetonitrile/trifluoroacetic acid/water are the most employed mixtures; nevertheless, this technique requires extensive time, and the solvent residue is toxic and then represents a limit for the extract’s application, since these are non-GRAS  solvents . TherefoThere is evidence that many procyanidins are not able to be extracted by conventional methods and they remain in the cranberry pomace, thus, some authors suggest using alkaline hydrolysis to improve the extraction of procyanidins from the treated residues through the breaking of their bonds .v/v) aqueous ethanol  and stabilizing the extracted compounds via complexation with soy protein isolate [A new method proposed by Roopchand and colleagues consists of the extraction of polyphenols from cranberry pomace with 50% , and as cystitis and urethritis when it affects the lower urinary tract (bladder or urethra). It is also generally divided into sporadic uncomplicated and complicated infections . Complicithelium ,64.E. coli to the uroepithelial cell receptors, attenuate the uropathogen reservoir in the gastrointestinal tract and suppress the inflammatory cascade. In this regard, A-type proanthocyanidins contain an additional ether interflavan bond between C2 →O →C7 if compared with B-type proanthocyanidins, which probably do not exert any effect on UTIs prevention  at risk of UTIs showed that cranberry reduced the risk of UTIs by 26% , suggesting the possible effect of this nutraceutical in preventing uncomplicated UTI recurrence in healthy people [p < 0.0001) [The meta-analysis by Fu et al., including 7 RCTs conducted on healthy women ( 0.0001) . However 0.0001) ,82,83,84 0.0001) ,82,83.E. coli and thus, the risk of UTIs incidence [Cranberry proanthocyanidins and their metabolites also act by reducing the intestine reservoir of potential uropathogenic bacteria. In particular, cranberry flavonoids might decrease the intestinal colonization of opportunistic extra-intestinal ncidence . At the ncidence . For exancidence . TherefoLactobacillus spp.) has been proposed to be effective for the management of recurrent UTIs [Lactobacillus spp. seem to improve the production of biosurfactants, bacteriocins, lactic acid, and hydrogen peroxide and to inhibit the intestinal adherence of uropathogenic bacteria [Finally, the combination of cranberry with some probiotic strains -1β, IL-6 , bacteri content .n =10) using the faecal microbiome test, an improvement of Firmicutes/Bacteroidetes ratio as well as of the count of Akkermansia has been observed after the nutraceutical assumption [A-type proanthocyanidins and their metabolites also interacted positively with the intestinal microbiota composition, preventing microbial dysbiosis. As demonstrated by Bekiares and colleagues, who investigated the impact of dried cranberries (42 g/day) consumption on human gut microbiota  or placebo for 90 days. At the end of the study, 14 of the 97 subjects (14.43%) in the cranberry juice treatment group had negative results for the 13C-urea breath test (vs. 5 of the 92 in the placebo group) (p < 0.05) [H. pylori infection rate by 20% as compared with low dosages of proanthocyanidins (p < 0.05) [In the last 15 years, cranberry supplementation was investigated to improve the success of eradication of c cancer . In fact. pylori . In a pr < 0.05) . Consump < 0.05) .Seyyedmajidi and colleagues, which included 200 patients with H. pylori infection and peptic ulcer disease, in treatment with the triple therapy , the addition of cranberry to triple therapy for H. pylori had a higher rate of eradication if compared with the conventional therapy alone (up to 89% and significant) [H. pylori infection and treated for the first week with the triple therapy  were randomized to receive 250 mL of either cranberry juice  or placebo  twice daily and only cranberry juice or placebo for the next two weeks. At the end of the treatments, analysis by gender revealed that the eradication rate was higher in the cranberry arm for female subjects. However, no significant differences were observed in male subjects [In the study by ificant) . In anotsubjects .H. pylori, they were randomly divided into four groups: cranberry juice/Lactobacillus johnsonii La1 (CB/La1), placebo juice/La1 (La1), cranberry juice/heat-killed La1 (CB), and placebo juice/heat-killed La1 (control). Cranberry juice (200 mL) and La1 product (80 mL) were given daily for 3 weeks. At the end of the study, H. pylori eradication rates significantly differed in the four groups: 1.5% in the control group compared with 14.9%, 16.9%, and 22.9% in the La1, CB, and CB/La1 groups, respectively (p < 0.01) [H. pylori eradication [In a multicentric RCT including 295 asymptomatic children (6–16 years of age) who tested positive for  < 0.01) . Finallydication .P. gingivalis biofilm, and thus to be useful also for oral health. PACs act through three main mechanisms of action: the inhibition of bacterial and host-derived proteolytic enzymes, the regulation of host inflammatory response, and osteoclast differentiation and activity [Bodet and colleagues suggested that cranberry extract has the potential to reduce the proliferation of P. gingivalis, T. forsythia, and T. denticola in periodontal pockets or its protienase mediated destructive processes occurring in periodontitis, reducing the inflammatory cytokine response of macrophages induced by the LPS fraction of Gram- [Aggregatibacter actinomycetocomitans [S. mutans), acting as an oral anti-adhesive nutraceutical and inhibiting the extracellular polysaccaride synthesis that promotes the sucrose dependent adhesion of oral bacteria [Yamanaka et al. [Durate et al. [Weiss et al. [S. mutans. The research groups concluded by highlighting the possible preventive action of cranberry polyphenols in the development of dental plaque.Cranberry PACs were demonstrated to prevent the formation of activity . The stuof Gram- ,109. In comitans . The supbacteria ,112. Sima et al. , Durate e et al. , and Weis et al.  who examH. pylori eradication represents one of the most interesting research points of the coming years, in order to prevent oral health and both gastro-intestinal and extra-intestinal diseases. However, longer RCTs are still lacking and urgent to better understand the role of bioactive molecules of cranberry in oral and gut microbiome modulation and the future perspectives for this nutraceutical beyond the UTIs prevention.The impact of cranberry supplementation on oral health, gut microbiota, and Cardiovascular diseases (CVDs) are the leading cause of mortality and disability in developed countries . The impp < 0.05 for all) compared with the placebo. Cranberry also reduced serum insulin and increased HDL cholesterol compared with the placebo (p < 0.05) [24 Chinese people with type 2 diabetes and treated with 160 mg/day of anthocyanins from bilberries and blackcurrants showed a reduction in fasting plasma glucose and HOMA-IR . Similar < 0.05) .p = 0.02). In addition, an improvement in levels of triglycerides  and nitrates  was also observed. However, cranberry beverage consumption showed no impact on insulin sensitivity [p < 0.05 compared with placebo; insulin: p < 0.001 compared with baseline for active group and p = 0.020 compared with baseline with placebo) [However, data on insulin improvement after cranberry treatments are still contrasting, as highlighted in a study that investigated the effects of cranberry juice in subjects with coronary artery disease  . In a RCsitivity . Anotherplacebo) .Cranberry supplementation has no lipid-lowering properties as demonstrated by several RCTs, even if anthocyanins have been reported to improve LDL cholesterol in dyslipidemic people through the inhibition of cholesterol ester transfer protein . Data onIn conclusion, to date, data regarding the supplementation of cranberry on glycemia and insulinemia is still contrasting and needs further investigations also to understand the glucoregolation mechanism of actions. Cranberry seems not able to exert significant lipid-lowering activities even if it may contribute to reducing lipid peroxidation, oxidative stress, and inflammation.H. pylori eradication in addition to the conventional treatments. In this regard, despite that it represents one of the most interesting research points of the coming years, longer RCTs are urgent to better understand the role of bioactive molecules of cranberry in oral and gut microbiome modulation before recommending it in clinical practice [Today, the first indication for cranberry prescription regards the prevention of UTIs, which are responsible for 7 million doctor visits, 1 million emergency room visits, and 100,000 hospitalizations each year (only in the USA), with an estimated economic burden of $1.6 billion . In thispractice . Similarpractice .An important limitation that concerns cranberry supplementation is the generally high dropout rates which can exceed 30% especially for sugar-free juices  . In thisWang et al. and Mannino et al. emphasized the urgency of standardized product quality control and labelling for cranberry dietary supplements manufacture and marketing, reporting some cases of adulteration by other botanical extracts, non-uniformity between the test of dosage forms and the contents of PACs, and the low quality of extracts [Another important limit in cranberry supplementation regards the high costs to obtain titrated (in PACs) and standardized extracts. The above-mentioned conventional techniques do not allow the production of inexpensive quality extracts and thus low-cost strategies to prevent UTIs and other diseases . In the extracts ,136.The problem of cheap but poor-quality cranberry extracts is a serious, underestimated, and potentially dangerous problem for consumer health, not only for the absence of PACs or for the low-quality un-titrated extracts, but above all for the presence of contaminants. A Chinese study that used the gas chromatography-triple quadrupole tandem mass spectrometry demonstrated a possible contamination with pesticide residues of cranberry plant extracts . HoweverKlavins et al. demonstrated the great potential of unconventional techniques such as ultrasound or microwave-assisted extraction associated with hydroalcoholic solvents, being potentially fast to use and ensuring good yields [An important challenge for the next years is also to develop a food-compatible method for the extraction of cranberry phytochemicals and thus produce qualitatively effective and safe extracts. The study by d yields . NeverthThe ideal extraction technique for cranberry PACs should enable a low energy consumption using water as a solvent, resulting in high yields, little capital investment, and easy integration into current processing lines. However, none of the unconventional techniques described in the literature really satisfy all of these points. In fact, although the unconventional techniques, such as ultrasound or microwave-assisted extraction have been shown to improve the extraction efficiency, their cost remains high if compared to classical methods, and new solutions to reduce these constraints are, at this moment, still lacking or unpracticable.Cranberry extracts supplementation as a functional food and nutraceutical, could constitute an adjuvant for the prevention of urinary tract infections, and probably may exert benefits in the prevention of cardiovascular and gastroenteric diseases. Aiming to validate the efficacy and safety of clinical applications as long-term RCTs, further investigations of the mechanisms of action are required. The quality of cranberry’s polyphenolic fractions start from the raw material, then extraction processing and formulation and represents a key point for a good food supplement. New non-conventional extraction methods are welcome to improve the quality of the extracts and reduce the overall costs.


This review aimed to identify and describe evidence published in the past 3 years from trials of psychosocial support programs for children and adolescents affected by natural disasters.Previous reviews have indicated these programs are beneficial overall. Positive impacts were documented in school-based programs conducted by trained teachers and paraprofessionals with stronger effects achieved by more qualified professionals.The review found supporting evidence for positive impacts of post-disaster psychosocial programs. However, the strength of evidence is limited due to heterogeneity in interventions and evaluations. The stepped care model was found to be useful in differentiating between programs and level of available evidence. Hobfoll’s five essential elements of mass trauma intervention provide an additional means of guiding program content and assessments, particularly for universal programs. Identified gaps in evidence included groups likely to be at most risk: preschool children, ethnically diverse groups, those with disability, and social disadvantage. There were promising indications of program benefits for groups with repeated exposure to natural disasters. It is well established that there is an increased risk of mental health problems for both adults and children in the aftermath of a mass trauma event such as a natural disaster , 2, arisThere has been increasing recognition of the need for appropriate disaster recovery support programs for children and adolescents over the past two decades. These programs can be difficult to operationalise in the upheaval of a post-disaster environment. Given the increasing risk of disasters occurring with more frequency, severity and complexity due to climate change, it is imperative to monitor emerging evidence about which programs are likely to provide the most effective support and which program delivery modes are likely to be feasible and appropriate in post-trauma settings.The Australian and International Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder recommend a stepped care approach to post-disaster psychosocial recovery for both children and adults . In the Level 1 in the stepped care approach, identified as universal care, promotes recovery by offering support, education and advice on self-care strategies such as calming techniques and social connectedness. Psychological First Aid (PFA), based on five essential elements of immediate and mid-term mass trauma intervention identified by Hobfoll et al. —namely sLevel 2 specifies both “selective” and/or “indicated” interventions that are targeted at those exhibiting continued signs of distress or sub-clinical signs of a mental health disorder in the months following the disaster. These early intervention programs usually offer some skills training in adaptive coping aimed at building resilience and reducing the risk of developing a posttraumatic mental health disorder. An example of a level 2 intervention developed by an international panel of trauma experts for use with children, adolescents and adults is Skills for Psychological Recovery (SPR) . AnotherLevel 3 interventions are high-intensity, evidence-based psychological therapies aimed at treating diagnosed posttraumatic mental health disorders and must be delivered by specialist mental health professionals. Interventions with the strongest evidence base are Trauma-Focused Cognitive Behavioural Therapies and can be transdiagnostic in nature or targeting a specific disorder.While the stepped care approach is widely endorsed by trauma specialists and treatment guidelines internationally, the evidence supporting its effectiveness has been slow to develop, particularly regarding level 1 and 2 and child-focussed interventions. However, recent meta-reviews have identified a range of post-disaster psychological and psychosocial interventions for children and adolescents that demonstrate those receiving interventions fared better than those in control or waitlist groups –16. The The challenges associated with conducting clinical trials and evaluating the effectiveness of interventions in post-disaster environments are well-known, with multiple factors contributing to the complexity, not least of which is the heterogeneity of program models offered and a lack of identified consistent outcomes and goals , 19. ShuThe goal of this scoping review is to identify any emerging psychosocial interventions and/or new evidence regarding existing disaster recovery programs for children and adolescents that would help inform best practice. The review employs the stepped care model as a structure for differentiating the intervention studies and the presentation of findings.This review was conducted using a scoping review approach informed by Arksey and O’Malley . This apThe final search was conducted on 18 May 2021 across the following databases: Cochrane Library, EMBASE, Family & Society Studies Worldwide, Global Health, Medline, PILOTS , PsycINFO, Scopus, SocINDEX, and Web of Science and article reference lists. In keeping with the journal focus, the review scope was studies published in the last 3 years.Inclusion criteria are articles that (a) are peer-reviewed primary research or reviews of primary research, (b) are published in English, (c) are published between 1 January 2018 and 18 May 2021, (d) assess interventions implemented in the aftermath of a naturalStudy details Level of intervention in the stepped care modelElements of interventions .Alignment of intervention with one or more of the five essential elements of recovery—i.e. safety, calming, connectedness, efficacy and hope.Discrepancies in study selection and data extraction were resolved in collaboration with other members of the research team (LG and JN). The final step was to collate, summarize and synthesize the extracted information, based on the following guiding questions:When and where were the interventions implemented?What type of interventions were delivered?How did the interventions align with the five essential elements of disaster recovery?How were the interventions delivered?Who received the interventions?What intervention evaluation study designs were used?What were the outcomes and impact of the interventions?The review data were categorised according to the stepped care model and the literature on the key elements of interventions for disaster-affected communities. Two team members (KM and LT) developed the evidence table with six test articles. They then independently extracted information from all included articles based on the following categories:A total of 18 studies were identified, including 13 primary research articles and 5 literature reviews  were delivered in groups [Six interventions corresponded to level 1 in the stepped care model –35, 37, n groups •, 37 andn groups , 32, 38.n groups , 29•, psn groups •, 32, 38n groups •, 30, 34n groups •, 32, 38n groups , 37, gron groups , philoson groups , engaginn groups , and EMDn groups •. Most in groups . In two n groups  or indivn groups •.Figure N = 9), followed by calm (N = 8), connectedness (N = 5), efficacy (N = 4) and hope (N = 3). All the interventions that addressed connectedness [From this perspective, most interventions served to promote a sense of safety  were delivered to groups of children [All the interventions identified in this review worked directly with children to support their mental health and almost all of them  with slightly less defined as level 2 (N = 4) or level 3 (N = 3). This may manifest a shift towards mental health promotion through community-based interventions, consistent with evidence showing that, after disasters, most children will show signs of resilience, and a few will develop more severe symptoms that require more specialized treatment [Presenting the review findings within a stepped care framework in which universal interventions were allocated to level 1, targeted interventions to level 2 and treatment interventions to level 3, provided a useful means of differentiating the evidence. More of the recent studies of mental health interventions for children after disasters corresponded to level 1 interventions (reatment . While treatment . Study lreatment •• concluAll the interventions were assessed in terms of their outcomes and impacts, and most included some sort of control or comparison group. The overall findings show positive program impacts on the mental health and wellbeing of the children and adolescent participants, consistent with previous reviews , 15, 17.The evidence on the negative impact of disasters on mental health shows that these effects can be long-lasting , 3. MoreThe COVID-19 pandemic is reshaping mental health interventions for children after disasters, with new advances in use of digital technology to teach children and developing telehealth interventions. This was reflected in this review which identified four interventions conducted online during the COVID-19 pandemic. An additional equity consideration for these interventions is the level of access that families have to digital devices and internet connection and provides an example of how local considerations can be important in shaping psychosocial interventions and evaluation of impacts. The importance of stakeholder input into disaster preparedness and recovery initiatives is enshrined in the Sendai Framework for Disaster Risk Reduction . While sThis scoping review contributes to the growing understanding of the contribution of psychosocial programs to child and adolescent recovery following exposure to natural disasters. Most importantly, it shows that positive impacts are being achieved across a range of programs, delivery modes and settings. Further studies are needed to confirm the findings because there are still a number of limitations to the evidence, not surprisingly given the complexity of post-trauma mental health needs and the disrupted context of post-disaster environments. Structuring the evidence according to a stepped care model provides a useful means of aligning the available evidence with recommended approaches. Similarly, Hobfoll et al.’s  nominate


The Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist was used to assess the reporting quality of 2009–2019 clinical practice guidelines (CPGs) regarding gout and hyperuricemia, aimed to improve the reporting quality of future guidelines.We searched PubMed, the Chinese Biomedical Literature database, the Wanfang Database, and the China National Knowledge Infrastructure from January 2009 to June 2019 for guidelines regarding gout and hyperuricemia. We also searched the websites of guideline development organizations ). Furthermore, supplementary guidelines reported in included articles were systematically searched, as well as Google Scholar.Seventeen guidelines were included, of which one was in Chinese and 16 were in English. The mean reporting rate of the 35 items specified was 14.9 (42.5%); only five CPGs (29.4%) had a reporting rate >50%. Of the 35 items, three were very frequently reported. The reporting proportion of the seven domains  were 64.7%, 36.8%, 50.6%, 42.9%, 8.82%, 33.8%, and 31.4%, respectively.The reporting quality of the present guidelines for gout and hyperuricemia is relatively poor. We suggest that the RIGHT reporting checklist should be used by CPG developers to ensure higher reporting quality of future guidelines.The online version contains supplementary material available at 10.1186/s13643-021-01645-1. Gout is a group of heterogeneous diseases caused by long-term disturbance of purine metabolism, which results in a high serum uric acid concentration. The prevalence of gout is >1% in most developed countries, and with the recent improvement in living standards, the prevalence of gout is likely to increase . FurtherWith recent advances in pharmaceutical therapies, auxiliary diagnostic methods, and novel treatment approaches, a number of clinical practice guidelines (CPGs) have been developed to standardize the diagnosis and treatment of gout –9. On thAGREE II  assesseshttps://osf.io/z4evs/), and search strategy is listed in Supplementary file Table: We searched PubMed, the Chinese Biomedical Literature database (CBM), the Wanfang Database, and the China National Knowledge Infrastructure (CNKI) from January 2009 to June 2019 for the relevant guidelines. We also searched the websites of the organizations responsible for guideline development: the Guidelines International Network (GIN), the National Institute for Health and Clinical Excellence (NICE), the American College of Rheumatology (ACR), and the European League Against Rheumatism (EULAR). Furthermore, supplementary guidelines reported in the included articles were systematically searched, and we also searched Google Scholar for additional material , 9, 16; “P” gout and/or hyperuricemia; “I” any intervention; “C” any comparator or comparison, no “key” CPG content is of interest; “A” 2009 to 2019, English or Chinese; “R” no recommendation is of interest [(1) Old versions of guidelines, if an updated version was available; (2) interpretations and translations of guidelines; (3) repeatedly published guidelines; and (4) guideline for which full text was still not available after contacting authors.Two researchers (Zhen Liu and Can Wang) searched the database; all retrieved studies were screened using EndNote X8. After eliminating duplicates, the titles and abstracts were first screened according to the inclusion criteria, and the reasons for exclusion were recorded. Next, full text of the literature that met the inclusion criteria were screened again and determined whether the retrieved guidelines met the study criteria. Then, independent screening and cross-checking of the guidelines were carried out. Differences between reviewers were resolved through discussion or consultation with a third party (Yaolong Chen and his team).The RIGHT tool  supplem was usedA total of 765 records were identified through database searching. Four other records were identified via the guideline development organization websites and Google Scholar. Of these, 17 guidelines that met the criteria were analyzed , of which four were developed by EULAR (23.5%); six originated from the USA (35.3%), of which three were developed by ACR (17.6%); and three (17.6%) by universities . The remaining two (11.8%) were developed by the Evidence, Expertise, and Exchange initiative. The features of each are summarized (Table The mean reporting rate of the 35 items was 14.9 42.5%), and it ranged from nine (25.7%) to 22 (62.9%) for the 17 CPGs , #12 (describe the approach used to assess the certainty of the body of evidence), and #13c (indicate the strength of the recommendations and the certainty of the supporting evidence), which were reported in 16 (94.1%) guidelines. These were followed by #13a , which was reported in 15 (88.2%) CPGs. Items #8b (describe the setting(s) for which the guideline is intended, such as primary care, low- and middle-income countries, or inpatient facilities) and #17  were reported in none of the CPGs  were 64.7%, 36.8%, 50.6%, 42.9%, 8.82%, 33.8%, and 31.4%, respectively.According to the geographical regions of the sponsors or participants, nine CPGs were participated in or initiated by European countries, and 6 CPGs originated from American countries. Firstly, the mean number of reporting items of the 9 CPGs developed by European countries was 15.2, and only 3 CPGs had a compliance rate of >50% (33.3%); four of these 9 CPGs were EULAR-generated; the mean number of reporting items in these 4 CPGs was 15.8. Secondly, as for the six CPGs developed in the USA, the mean number of reporting item was 14.8. Two of these 6 CPGs were prepared by the ACR, with a mean number of reporting items of 16.5, and two were published on NGC , reported only nine items. Twenty-two items were reported in the American College of Physicians (ACP) CPG, which was the guideline with the largest number of reporting items among the 17 included in the analysis.Eight CPGs were published between 2009 and 2014, which had a mean of 13.9 reporting items, and only one (12.5%) guideline had a compliance rate of more than 50%. Between 2015 and 2019, a total of nine CPGs were published, with a mean of 15.8 items being reported, but only four (44.4%) had a compliance rate of >50%.With regard to the basic information, most of the CPGs could be judged by their title (82.4%), and the contact information for at least one author could be found (82.4%). The classification of the guidelines could be easily discerned in 76.5% of the CPGs, and a summary was presented in 70.5%. However, only 29.4% of the CPGs reported a publication date. Forty-one-point-two percent of the CPGs defined new terms and gave corresponding acronyms.The 17 CPGs did not comprehensively describe the background. More than half reported the epidemiology of gout (52.9%). Six (35.3%) CPGs reported the overall objectives of the guidelines and the specific objectives they were designed to achieve. Most of the guidelines described the main target population (76.5%), but only 17.6% described the subgroups that should be considered. Fewer than half (47.1%) of the guidelines described the key users and other potential users of the guidelines, and none described the specific target environment. Six (35.3%) CPGs listed all the contributors and their roles, and six (35.3%) gave the titles and affiliations of all the participants in their development, but only four (23.5%) contained both sets of information.Seven (41.2%) of the CPGs described the key findings on which the recommendations were based, but only two described the selection and classification of outcomes, and only one reported both. Sixteen (94.1%) guidelines described whether the systematic reviews on which the guidelines were based had been recently completed, but only two (11.8%) presented references, described how they were retrieved and evaluated, and stated whether they had been updated. Only one CPG did not describe the method of evaluation and grading of the quality of evidence.Most of the CPGs  provided clear, accurate, and enforceable recommendations. Sixteen (94.1%) CPGs described the strength of the recommendation and the quality of the evidence supporting it, but only four provided recommendations for subgroups. Four CPGs took into account the preferences and values of the target group, two (11.8%) took into account cost and resource utilization, and two (11.8%) took into account fairness, feasibility, and acceptability, when creating their recommendations. Most of the CPGs  described the decision-making process and the methods used by the working group that created the guideline.Only three (17.6%) CPGs described whether they had been sent for review or not, and none described the level of supervision involved.More than half of the CPGs  described the sources of funding at each stage of their development, but only one described the role of the sponsor in the different stages of guideline formulation, as well as in the dissemination and implementation of the recommendations. Similarly, most of the CPGs  described the types of conflict of interest associated, but only two (11.8%) described the evaluation and management of these conflicts of interest and how users of the guidelines could obtain this information.Eleven (64.7%) CPGs described where the guidelines, corresponding attachments, and other related documents could be obtained. However, only three (17.6%) articles described the differences between current practice and that recommended by research evidence, and/or provided recommendations for future research. In addition, only two CPGs described all the limitations associated with the formulation of the guidelines and their possible impact on the effectiveness of the recommendations.The quality of CPGs about gout and hyperuricemia were assessed before with AGREE II , whereasAmong the seven sections of the RIGHT tool, the reporting rate of basic information was the highest (64.7%), followed by evidence (50.6%), but the reporting rate of the other sections was <50%. The most poorly reported section was the declaration and management of funds and interests, with only 8.8% of CPGs reporting these items. This suggests that the guideline creators are generally good at including basic information, but that review and quality assurance are easily ignored.Most of the CPGs were written by European and American organizations, and the overall completeness of the guidelines was slightly better in Europe than that in the USA. However, the scores for the CPGs written by the ACR and ACP, which are influential guideline-writing organizations in the USA, were higher than those for EULAR-generated CPGs. This shows that there are differences in reporting quality of the CPGs written by different organizations in different geographical regions. With regard to the relationship between publication date and score, the compilation of guidelines has greatly improved in recent years. The guideline writers have aimed to correct the deficits of the previous CPGs with regard to the practical applications of the guidelines, but the emergence of guideline-based systematic reviews in recent years have also made them consider writing their guidelines in accordance with certain norms.Most of the CPGs had a high reporting rate for basic information, but there were still some in which the year of publication was not clear and there was ambiguity in the definitions of acronyms. These issues are very important for researchers and practitioners who wish to know how up-to-date guidelines are, and it is necessary to interpret vague terms and acronyms for more accurate understanding of the guidelines.In the background of the CPGs, the writers usually described the main target groups for the guidelines and discussed the epidemiology of the problems described. However, the other items were frequently not well reported. For example, the inclusion of 8a (the main users of the guide should be described) and 8b (the specific environment for which the guide should be described) demonstrate that the application of the guidelines will vary for different users and different environments. For example, for low- and middle-income people, it is necessary to consider the economic benefits . TherefoAbout half of the items in the evidence section were reported, and items 10b (the methodology for the selection and classification of outcomes should be described) and 11b  had low reporting rates. Items 10b and 11b can greatly help researchers and practitioners to understand the evidence and assess the accuracy of the guidelines. Furthermore, they are important for peer review because they permit shortcomings in the CPGs to be found and remedied. Items 10b and 11b can also be supplemented as new evidence accumulates over time.Most of the guidelines did not make recommendations for subgroups, suggesting that the writers did not regard subgroups as important. Most writers did not consider items 14a , 14b (whether to consider cost and resource utilization), or 14c , or they once considered these issues but did not included them in the CPGs. This means that healthcare professionals cannot easily adapt the CPGs according to different clinical situations.Items in this section were described in only a small number of CPGs, such that the reporting rate was the lowest for all the sections. Some of the guidelines may have been independently reviewed and quality-controlled, but the absence of such information is likely to make guide users and peer reviewers doubt the quality of the guidelines.The RIGHT checklist showed that the quality of the published CPGs was low with regard to this aspect, suggesting that the writers did not pay enough attention to it. A lack of information of this section may lead to the inference that the recommendations of these CPGs could have been influenced by multiple interested parties, which would lower the credibility of the guidelines, especially with regard to specific treatment recommendations.Most of the CPGs failed to differentiate evidence obtained from practice and research or to provide recommendations for future research (or both). They also failed to describe the limitations in the formulation of the CPGs and the possible impact of these limitations on the effectiveness of the recommendations. Such content could have provided a reference for guide users to appropriately use the recommendations and provided guidance for future updates and other researches.This is the first study using the RIGHT tool to evaluate the reporting quality of CPGs in the field of gout and hyperuricemia. In addition, the methods of systematic retrieval, screening, and evaluation were adopted, and the quality of the outcome measurements was strictly controlled.First, only CPGs written in Chinese and English were included; this might cause language bias. Second, only CPGs published in journals and online regarding gout and hyperuricemia were included; CPGs published in the form of books or government documents were not analyzed.In conclusion, most of the current CPGs in the field of gout and hyperuricemia had relatively low scores, when evaluated by using the RIGHT checklist. CPGs with poor reporting quality might mislead users and lead to wrong diagnosis and/or treatment, resulting in a waste of medical resources and/or delay of the disease. We suggest organizations that participate in reporting of CPGs regarding gout and hyperuricemia to use RIGHT tool, so as to improve standardization of reporting, making the reporting clear, complete, and transparent.Additional file 1.


ClinicalTrials.gov databases) was conducted to identify existing and in-progress research published on the topic of first aid for burn injuries. Seven guidelines were identified from the Australia/New Zealand region, and 11 international guidelines were identified from the United States of America and Europe. All Australian and New Zealand guidelines recommended a cooling duration of 20 minutes and made some mention of when to refer a burn for medical evaluation, while international guidelines saw cooling duration variation, a number of guidelines failed to mention referral criteria. The review of published systematic reviews and clinical trials revealed a lack of new evidence in the last six years. Our rapid review identified key variation between first aid guidelines for burns that would benefit from the development of an international consensus on management. We identified no new significant evidence that would alter guideline recommendations and did not identify any upcoming reviews or clinical trials on this subject.We conducted a rapid review of current international and Australian/New Zealand guidelines on first aid for burns to identify any critical variation and any recent major changes in the literature that would warrant a significant change to current recommendations. A search was conducted to identify Australian/New Zealand and international first aid guidelines for burn care using guideline databases, and we compared key recommendations from each guideline relating to burns first aid. A literature search of relevant databases (Medline, Embase, Cochrane Database of Systematic Reviews, PROSPERO international register of systematic reviews, and  The World Health Organization (WHO) defines burns as “an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or chemicals” . Burns aThe management of burns is complex and multifaceted; however, high-quality burns care starts with first aid immediately after injury . First aFirst aid guidelines provide an important reference for bystanders, first aid providers, and medical professionals to guide them in the effective provision of safe, effective, and timely first aid care. In Australia and New Zealand, the Australian and New Zealand Committee on Resuscitation (ANZCOR) provides first aid guidelines to guide care throughout the region. However, there are also a range of other reputable sources offering their own burns first aid guidelines which may be accessed by those seeking information. As such, it is imperative that there is minimal variation between national and international guidelines to reduce confusion and to ensure that recommendations are supported by best available evidence. With the ANZCOR first aid guidelines for burns last updated in 2016, this study aimed to conduct a rapid review of current first aid guidelines to identify any critical variation as well as identify any recent major changes in the literature that would warrant a significant change to current recommendations.Rapid reviews are a form of evidence synthesis well-suited to answering focused research questions or assessing the current knowledge base surrounding a policy or practice. As they are conducted in a short period of time, they employ a simplified review process to produce information in a timely manner ,23. The Guideline searchIn order to identify major international and Australian/New Zealand guidelines, we searched known guideline databases, including the Australian National Health and Medical Research Council guidelines, Canadian Medical Association Infobase of Clinical Practice Guidelines, National Institute for Clinical Excellence, New Zealand Guidelines Group, ILCOR’s affiliated member databases, the WHO, and the Scottish Intercollegiate Guidelines Network. This was followed by an internet search using Google to identify other prominent first aid guidelines for burns.Only guidelines written in English that primarily covered the first aid management of burns were included. Guidelines that covered advanced burns management within a specialist setting  were excluded, as they do not fall within the realm of first aid as defined by ILCOR. For guidelines that included both first aid and more specialized management, only recommendations that could reasonably be provided in a first aid setting with minimal specialist equipment or training were included in our guideline comparison. If multiple versions of a guideline were identified from the same source, the most recent iteration was selected, ensuring the inclusion of any evidence-based updates. For each identified guideline, the key recommendations were extracted and assessed.New evidence searchWe conducted a literature search to identify any systematic reviews or meta-analyses published in the last decade on the topic of burns first aid. A search was conducted of the Medline, Embase, and Cochrane Database of Systematic Reviews electronic database using the search strategy provided in Tables Search for systematic reviews and clinical trials currently underwayClinicalTrials.gov databases was conducted [A search of both the PROSPERO and onducted ,25. The Data extractionA standardized data extraction table was developed including the following variables: safety, initial approach, cooling of heat/flame injuries, dressings/coverings, when to refer for medical treatment, additional management, chemical burns, electrical burns, and radiation burns. Data were extracted separately for Australian/New Zealand guidelines and international guidelines. Author M.M. extracted all data, and author L.M.T. verified the extracted data.ResultsGuideline ComparisonA total of 18 guidelines were identified that met the selection criteria for first aid guidelines covering burns. Seven guidelines were identified in the Australia/New Zealand region from ANZCOR , the VicSafetyWhen considering safety while administering first aid, only seven of 18 guidelines made comment on general safety principles such as ensuring bystander and responder safety when treating burns patients ,29,40,41Initial ApproachFourteen of 18 guidelines provided some guidance on the initial approach to managing a patient with a burn injury, in particular the management of a patient engulfed in flames. Ten guidelines recommended the use of the “stop, drop, and roll” method of extinguishing a patient currently on fire ,36,38-40Cooling of Heat/Flame InjuriesWith regard to cooling, there was general consensus among all guidelines on active cooling of the burn injury. The majority of guidelines n = 11), including all of the Australia/New Zealand guidelines, recommended exposing burn injuries to cool running water for at least 20 minutes 1, includ,36,39,40Dressings and CoveringsA majority of guidelines recommended the removal of burned, wet, or contaminated clothing from the patient -32,35-40When to Refer to Medical TreatmentSignificant variation between guidelines existed on when a burn should be referred for medical evaluation, and some guidelines provided no referral criteria. Some guidelines suggested that any burn greater than a certain total body surface area should be referred for medical assessment in both adults and children -29,37,40Additional ManagementOne guideline from Australia and New Zealand advised rescuers to check the patient’s airway and how adequately they could breathe , while tChemical, Electrical, and Radiation BurnsEight guidelines made mention of first aid for chemical burns ,36,40,41Eight guidelines made mention of first aid for electrical burns ,36,40,41New EvidenceThe literature search yielded 57 results from OVID Medline, 220 results from Embase, and 23 results from the Cochrane Database of Systematic Reviews. After removing duplicate studies, three studies met the inclusion criteria; all were systematic reviews -47. One Systematic Reviews and Clinical Trials Currently UnderwayClinicalTrials.gov did not yield any relevant results for upcoming studies involving burns first aid care.The search of the PROSPERO database yielded two systematic reviews currently underway. One aimed to review all aspects of prehospital management of severe burns; however, the authors have not provided enough detail to assess the usefulness of their study to first aid . The othDiscussionOur results indicate that there is key variation between guidelines on first aid for burn injuries. While there is a general consensus among guidelines on the use of cool running water for cooling of burns, there is still some variation in the duration of cooling recommended by some guidelines. This variation could be explained by the differing evidence available at the date these guidelines were last updated as well as the lack of or low level of evidence supporting some treatments. Due to the crucial nature of early and effective cooling in the management of burn wounds, consistency needs to be promoted across first aid guidelines to ensure that wound cooling recommendations are in line with the best available evidence.The most recent ILCOR evidence review on cooling burns was conducted in 2015 and resulted in a broad treatment recommendation that first aid providers actively cool thermal burns  . This reDressings/wound coverings were another area in the guidelines where variation existed. There were three main recommendations made across each of the guidelines: dry dressings, a clean cloth or sheet, and plastic cling film . However, most guidelines only recommended one or two of these options, with only one guideline recommending all three as potential dressing options. This is an area where consistency across guidelines should be encouraged in order to provide as many dressing options as possible across different first aid settings.An area where significant variation existed among guidelines was advice as to when to seek medical evaluation for burns. While there was a general consensus across guidelines that burns to special areas of the body  should be seen by a burn specialist, there was less consistency among guidelines on other factors  that would warrant referral to a medical practitioner. Some guidelines appeared to take a very cautious approach to their referral criteria by suggesting that any concerning or severe burns should be seen by a medical practitioner. However, in this case, many failed to define what made a burn concerning or serious. Other guidelines appeared to have stricter referral criteria that would preclude a number of burn injuries that would usually necessitate medical evaluation and intervention. It is worth noting that many bystanders and first responders may not be able to accurately differentiate between a superficial, partial-thickness, and full-thickness burn. Similarly, many may not know what constitutes a “large” or “significant” burn, which highlights a need for clarification within these guidelines. This variation between guidelines highlights a need for a more consistent evidence-based international referral criteria standard to be developed. Given that a number of guidelines investigated in this report are from member organizations of ILCOR, it is important to recognize that a concerted effort has been made to standardize the first aid for burns by ILCOR. However, there is significant variation in areas not covered by the Continuous Evidence Evaluation and CoSTR publications, namely methods of determining burn area and which burns need further medical care. While these could be considered teaching points, the international variation suggests the need for further guidance on these points.Other key areas where guideline variability existed include general safety principles and the initial approach to a burning patient. While both are simple concepts, two-thirds of guidelines mentioned the importance of ensuring first responder and bystander safety when treating a burns patient. Similarly, only two-thirds of guidelines mentioned the “stop, drop, and roll” method of extinguishing an actively burning patient, and only two guidelines mentioned extinguishing flames with a non-flammable liquid such as water. While these interventions are usually assumed to be “common sense,” guidelines should be encouraged to make mention of them in order to provide a holistic approach to the management of a patient with burns. This is especially pertinent as there is a body of evidence showing that the general public has a limited understanding of burns first aid, and therefore every effort should be made to improve this.There were a number of areas where a general consensus existed among the guidelines. This included avoiding ice as a cooling method, as well as avoiding salves, creams, and other home remedies as cooling methods. There was also consensus among the guidelines that included the management of chemical and electrical burns. While there was a general consensus among guidelines that contaminated clothing and jewelry should be removed from the patient, some confusion still remains about whether garments should be removed before or after cooling and whether molten/adherent clothing should be left in place or removed. Further clarity on this point needs to be achieved.There was some variation between the Australian/New Zealand guidelines and the international guidelines. All of the Australian/New Zealand guidelines recommended 20 minutes of cooling, and all made recommendations about when to refer a burn for medical evaluation in some form. Many of the international guidelines had variation in cooling duration, and many did not make any mention of when to refer a burn for medical evaluation.ClinicalTrials.gov yielded only two potential studies that met our inclusion criteria, which was of marginal quality. This suggests that there is a lack of recent and high-quality systematic reviews or meta-analyses in this area and that further research into first aid management of burns should be conducted. However, the search of PROSPERO did reveal additional systematic reviews outside our inclusion criteria that were either underway or complete (but not published). While there are potential barriers to developing high-level evidence in the prehospital setting, given the critical nature of those first stages of burn management, further research should be conducted to guide future guideline recommendations.The literature review we conducted did not provide any additional evidence to support or refute current recommendations for prehospital management of burns. Our search of PROSPERO and LimitationsIt is important to acknowledge the potential limitations of our review. While every effort has been made to identify suitable guidelines for inclusion in our study, there is potential for some guidelines to have been overlooked. Additionally, while we aimed to conduct a methodological search for systematic reviews and meta-analyses, due to the nature of a rapid review, the search was not systematic in its approach, and thus it is possible that we have missed suitable studies published during our search period that warrant discussion. Finally, it should be acknowledged that some guidelines in our review may currently be under review or shortly due for an update. This may alter the variability between them and other guidelines; however, our rapid review suggests that there is unlikely to be any significant change to the treatments we evaluated.Our rapid review identified key variation between first aid guidelines for burns that would benefit from the development of an international consensus on management. There was variation between the Australian/New Zealand guidelines and international guidelines concerning cooling duration and criteria for when to refer for medical evaluation. We identified no new significant evidence that would alter guideline recommendations and did not identify any upcoming reviews or clinical trials on this subject.


Evidence-based medicine (EBM) is a core skillset for enhancing the quality and safety of patients’ care. Online EBM education could improve clinicians’ skills in EBM, particularly when it is conducted during vocational training. There are limited studies on the impact of online EBM training on clinical practice among general practitioner (GP) registrars . We aimed to describe and evaluate the acceptability, utility, satisfaction and applicability of the GP registrars experience with the online course. The course was developed by content-matter experts with educational designers to encompass effective teaching methods (e.g. it was interactive and used multiple teaching methods).Mixed-method data collection was conducted after individual registrars’ completion of the course. The course comprised six modules that aimed to increase knowledge of research methods and application of EBM skills to everyday practice. GP registrars who completed the online course during 2016–2020 were invited to complete an online survey about their experience and satisfaction with the course. Those who completed the course within the six months prior to data collection were invited to participate in semi-structured phone interviews about their experience with the course and the impact of the course on clinical practice. A thematic analysis approach was used to analyse the data from qualitative interviews.The data showed the registrars were generally positive towards the course and the concept of EBM. They stated that the course improved their confidence, knowledge, and skills and consequently impacted their practice. The students perceived the course increased their understanding of EBM with a Cohen’s d of 1.6. Registrars identified factors that influenced the impact of the course. Of those, some were GP-related including their perception of EBM, and being comfortable with what they already learnt; some were work-place related such as time, the influence of supervisors, access to resources; and one was related to patient preferences.This study showed that GP registrars who attended the online course reported that it improved their knowledge, confidence, skill and practice of EBM over the period of three months. The study highlights the supervisor’s role on GP registrars’ ability in translating the EBM skills learnt in to practice and suggests exploring the effect of EBM training for supervisors.The online version contains supplementary material available at 10.1186/s12909-021-02916-0. Evidence-based medicine (EBM) is the integration of best available clinical evidence with clinical expertise and patient values to inform a clinical decision . It is rDespite some evidence that GPs generally acknowledge the importance of EBM , it is nThere are a range of influences on the use of EBM in practice. Many of these factors are shared among GPs and GP registrars. Some of these barriers are at the GP-level, such as doubt about the applicability of the research evidence to practice , 10) or Medical education has a major role in preparing a workforce skilled in EBM, but its translation from learning to practice is challenging , 22. SpeInternet-based learning activities offer a range of advantages, such as ease of access from various settings and for a large audience . Online While online learning has potential benefits, it must engage and empower learners for the learnings to be applied in the real world. Boettcher’s review of pedagogical theory and research identified the following core principles for effective teaching : that teaching should be interactive, customised to learners’ background knowledge, deliver information in the form of organised chunks, and provide opportunities for learners to write, explain and analyse . EBM eduWhile there is abundant evidence for the efficacy of online learning, the teaching of EBM is a singular area. There is a good deal of theoretical understanding to be imparted, but also a complex application of that theory to practical use . There is a modest amount of evidence for online EBM courses , 32–35. What were the GP registrars’ experiences with the course (including how engaged were they with the course)?What were the impacts of the course on GP registrars’ attitudes, knowledge, skills and clinical practice?What factors influenced the impact of the course on the GP registrars’ clinical practice?This research explored GP registrars’ experience with an online interactive training course that aimed to increase knowledge of research methods by GP registrars and, ultimately, may be able to produce practitioners who can use evidence in practice. The findings of this study not only can be used for the improvement of the current training course but also for informing future similar course development by identifying its efficacy, strengths and limitations. The study’s research questions were:The evaluation was a one-group design (post-test only) conducted after completion of the course, using a triangulation mixed methods design.n = 1142) were invited to fill in an online survey via a link within the course.Participants were GP registrars who completed the online course. GP registrars are required to complete the course by the end of term two of the training. GP registrars who completed the course during Nov 2016-Feb 2020  were invited to participate in semi-structured interviews. Registrars were invited to express interest in being interviewed for the study via:Sampling was purposive, based on potential participants’ characteristics of medical training  and GP training pathway .2).An online education course (“the course”) was designed and built for GP registrars to complete as a compulsory component of their vocational specialist training. This was commissioned by GP Synergy Ltd., the government-funded vocational GP regional training organisation in New South Wales and the Australian Capital Territory, Australia. The reason for developing the course was that GP Synergy needed a scalable method of teaching GP registrars  spread over the whole of New South Wales and the Australian Capital Territory  and an interactive software developer (Smart Sparrow Pty Ltd) to ensure modules were educationally sound.identify links between research and practiceapply the research findings to examples from practicedescribe the principles of research designparticipate in research.The course was designed to provide a grounding in research , epidemiology and critical evaluation and how evidence from these sources is incorporated into clinical practice: that is, the course sought to present the knowledge required to practice as an evidence- based practitioner. The overarching aim of the course was “to have registrars using evidence and practising EBM in their everyday practice” . It compThe modules included text with visual learning methods such as graphs and images, video lectures, links to publicly accessible video resources, interactive exercises (e.g. multiple choice), clinical scenarios and further reading. To relate the course content to GP registrars’ daily practice, clinical scenarios were included in the lessons. Each module was expected to take about an hour to complete, not counting additional reading. The online survey asked participants to indicate the degree to which they agreed with 11 statements that described their experience with the course using a 6-point rating scale; rate their understanding of the topic before the course and after completing the course on a scale from 0 to 10; and answer two open-ended questions: 1) what they liked most about the course and 2) what they would like to see changed. Participants self-completed the online survey via the link provided in the course.Experience with the courseImpact of the course on clinical practice.The semi-structured interview schedule Table  containeTwo sessions: If the Registrar had completed the course less than one month before recruitment, the first interview was restricted to section one of the interview schedule. A second interview to complete section two of the interview schedule was conducted three months later.One session: If the Registrar had completed the course at least three months before recruitment both sections of the interview schedule were completed in the one interview.Interviews were conducted by telephone in one or two sessions, depending on the course completion time:The timing was designed to allow participants the opportunity to apply the knowledge and skills gained during the course before answering the questions in section two about how the course influenced clinical practice.The interviews were conducted via telephone by a trained Research Officer [HR-A] who had not been involved in the course development. The average times to complete the interviews were 23 min (first interviews) and 19 min (second interviews).d. Data analysis was performed using SPSS (version 23). The answers to open-ended questions were coded and summarised. These were then discussed between authors  and grouped into broader categories and sub-categories based on their similarities and differences.Descriptive statistics were used to present quantitative data from the online survey. The difference between the self-report level of understating of the topic before and after the course was tested using paired t-test and the effect size compared using Cohen’s Data collection and analysis were concurrent and iterative for interviews. The interviews were transcribed verbatim and coded using the software program NVivo (Version 12 Pro). A thematic analysis approach was used  to analyTo ensure trustworthiness, an audit trail of all the steps and decisions made during the research process were recorded . The resWhen data analyses were completed, qualitative and quantitative findings were synthesised to answer the study questions. Codes were reviewed for patterns, and they were further revised and developed into themes to answer the research questions. The final themes are presented in Fig. Of 1142 GP registrars who invited to take part in the online survey, 391 (34%) completed the survey between Nov 2016-Feb 2020. Twelve GP registrars completed interviews. Details of the recruitment process and data collection are provided in Fig. The interview sample comprised nine women, five men; two registrars enrolled in the rural pathway, and only one registrar who had completed medical training overseas. The interviewees enrolled in the course during the second or last year of their three-year  program. Participants stated that they spent an average of nine hours to complete the whole course.Results are presented to answer each research question.Registrars’ responses to 11 questions on satisfaction with the course are presented in Fig. Data from the online survey and the interviews indicated that participants’ course experience was generally positive. As illustrated in Table The responses to online questions on registrar satisfaction were mostly in the upper half of the rating scale, suggesting general satisfaction Fig. . ConsistIn contrast to the positive responses to Q.6, the open-ended question about what participants would like changed (Table S2) identified that many participants had problems with technical issues, and some thought the interface could have been more user friendly.Data from the open-ended questions  suggested the course changed the participant’s clinical practice to better incorporate EBM.Most participants said they were only interested in the application of research into practice. Only a few participants said that they their interest in doing or participating in research. Was influenced by taking the course.confident in understanding, interpreting and appraising research evidence after completing the course.I feel more confident, and I think that I would be able to if I needed to look through a study and make some comments [#08-female].However, they acknowledged that they might not be able to conduct research, or there is room for improvements.I probably feel about the same as I did before. I don’t know that I feel any more or less confident [#10-female].Participants mostly found themselves more n = 320, p<0.0001) which represents a very large effect size (d = 1.6). Similar findings found from the interview.It’s a good idea I think to have an understanding of research when we’re going out into clinical practice [#05-female].It [the course] makes me more aware to incorporate research into my practice [#07-male].In addition, participants acknowledged that the course, led them to start questioning practice where clinicians follow others’ experience/opinion without thinking critically.The way it’s [the course] influenced my management is just always being aware that just because it’s been done as usual practice doesn’t necessarily mean like it’s evidence-based and doesn’t mean that it’s necessarily proven to be effective [#01-male].One participant highlighted an improvement in her understanding of the importance of contextual and environmental factors, including patient preferences in applying evidence.It’s not just whether or not they’re sick, it’s also about how they approach health providers, … So, I just keep it in the back of my mind that we need to be aware of the other socioeconomic and environmental factors which a lot of that qualitative research helps us consider as well [#14-female].An increase in knowledge was identified in the interview and the online survey. Based on the survey findings, participants’ self-reported understanding of the topic substantially improved from the mean of 4.4 (out of 10) ± 0.1 (SD) before the course to 7.2 ± 0.1 after completing the course ; the work-place ; and patients (treatment expectation being different from evidence).positive attitudes towards EBM and acknowledged the value of EBM.Obviously, we have to practice evidence-based medicine, so in order to do so, we need to be able to understand and interpret and incorporate research into our practice [#07-male].Almost all participants reported they needed to seek information to inform their decisions on a daily basis. They reported that they tried to choose EBM resources that were recent and relevant to the Australian context and had confidence in the quality of the information.All of them [the guidelines that I use] are sort of peer-reviewed and accepted by the wider community as factually correct [#11_2-male].A few participants expressed a different opinion and described research evidence as neither relevant nor transferable into clinical practice.I think they’re [research evidence] just answering questions that are quite different from the questions that we get in general practice [#06-female].However, a few participants described an approach based upon trust in the credentials of the source of information:I do feel if it’s [a research findings] published in a reputable source, I tend to leave it without thinking too critically… I trust my supervisor and feel that they are quite competent [#05-female].A barrier that was described was, despite that the participants were willing to change, they felt more comfortable with what they have already learnt and get accustomed to, than using new evidence-based resources.Often you’re introduced to something like an UpToDate [a resource for supporting clinical decision] quite early, so you get good at searching and using it, that you know what sort of services are on it [#13_2-male].Most of the participants had Time was one of the main barriers identified for accessing and using research evidence in practice by almost all participants. The time-consuming nature of using research evidence was attributed to the way it was accessed, , the overwhelming amount of information identified by searches, and the time needed to critically appraise the findings.If I were to go through Cochrane and look up a whole bunch of different articles which would take a lot longer [#05-female].For almost all registrars, pre-appraised resources that are brief and ready to use, such as guidelines, were preferred over primary research evidence.I would tend to use resources that are incorporated study findings into a summary like eTG [online Therapeutic Guidelines], I don’t read the specific articles and therefore analyse the data’ [#5-female].Participants’ responses indicated that using research evidence might not be their priority; work and exams were specified as activities that they prioritised.Because I do have exams coming up I haven’t been able to do – look into research papers [#11_2-male].Participants reported that supervisors could be role models influencing GP registrars’ beliefs about evidence-based medicine by encouraging and guiding GP registrars to practice evidence-based medicine. Participants who said their supervisors encouraged them to use research evidence had a stronger belief than other participants about the applicability of research into practice.Well, I think evidence-based research should inform good clinical practice, and it should always be the starting point for good management… Well, my supervisors have mostly been very evidence-based as well, so I’ve actually just learnt a lot from how they appraise studies [#03-female].Some participants also indicated that some supervisors expect GP registrars to follow their advice and treatment approach without critically evaluating the relevance of the advice into the clinical situation.[one of my supervisors is a] real old-school doctor, right, so they are less likely to change or read the literature or – this is the way we’ve always done it, so that’s the way they’ll always do it. So that’s the way they want me to do it as well. Which may not be – it’s not dangerous, but it may not be an optimal solution [#11_2-male].Patient expectation for particular treatment options that were not supported by evidence was reported to be a barrier to practicing EBM.That’s mainly patient preference, so potentially they don’t want to go with the evidence-based therapy [#04-male].Figure Participants specified that they used the skills learnt in the course for interpreting evidence, investigating their clinical questions, and the course led them to have better communication with patients in their clinical practice. The factors that influenced the course’s impact were specified to be related to GP, work-place, and patient factors.d = 1.6).This study evaluated GP registrars’ experience with an online training course that aimed to increase their knowledge of research methods and the application of critical appraisal. The course was a compulsory component of their vocational specialist training developed by content and educational-design experts. The data showed the registrars were generally positive towards the course and the concept of EBM. They stated that the course improved their confidence, knowledge, and skills and consequently impacted how they practice. Particularly, participants specified that they used the skills learnt in the course for investigating their clinical questions, interpreting evidence, and communicating with patients in clinical practice. The self-reported improved understanding of the topic increased with a very large effect size  reviewed the evidence on motivation theories , action theories  for explaining the process of behaviour change. Twelve domains were identified, nine of which were relevant to our findings. Table In addition, relating the behaviour change wheel (BCW) framework  with ourThe current study suggests an engaging online course that is relevant to GP’s daily practice can be used as appropriate training for EBM among GP registrars. Supervisors could have a considerable impact on registers’ motivation and ability to translate EBM skills into practice by encouraging registrars and actively engaging in an equal, interactive discussion around EBM. Future studies might explore the addition of simultaneous supervisor training. In addition, future EBM learning courses might consider training registrars on how to respond to patients if their preferences are at odds with research evidence. Our findings were consistent with Mitchie’s nine domains suggested for behaviour change of health professionals. It suggests that online course may be effective if improves knowledge, skills/ability, confidence and beliefs about consequences. Some factors may act as barriers or enablers such as how GPs see themselves in their professional role, memory, routine, social influences or environmental context and resources.There are several limitations to this study that should be acknowledged. The study only provided data on learner perspectives after finishing the course. Objective measures of knowledge, attitudes and behaviours were not collected from a control group that received no training or training with different type of educational modality. Also, data were notcollected before the intervention to measure changes over time. Consequently, the study is vulnerable to social desirability (telling us what we want to hear) and recall biases.The online survey achieved a response rate of only 34%, which does bring issues of responder bias. This is, however, quite a reasonable response rate for a survey of GPs without incentives .The telephone interviews sample was homogeneous and lacking in a full spectrum of variation. In particular, only one student was trained overseas, and the experience of overseas-trained students could be different to those of locally trained students. Since the data collection ceased before the data saturaation, we might have missed some information. However, there was good saturation in most of the themes. Further, the study used triangulation to compare results from the survey and qualitative interviews and found them generally consistent.This study showed that an online interactive and multi-media training that aimed to enable GP registrars to use research evidence in their practice changed registrars’ knowledge, confidence, skill and behaviour of EBM. The findings of this study can assist future educational interventions to be effective. We conclude that an interactive and engaging online course with relevant practical scenarios can be effective in teaching EBM. Further, this study highlights the importance of the supervisor’s role in GP registrars’ ability in translating the EBM skills learnt in to practice. Thus, studies might want to explore how educating supervisors can facilitate their role in supporting registrars to practice EMB. Incorporating training on how registrars can engage with patients regarding evidence might also be considered in future EBM course developments. In addition, considering theoretical frameworks for developing interventions suggest that investigating the role of motivation, emotion and behavioural change techniques on practicing EBM might be beneficial.Additional file 1 Table S1 Topics, lessons and learning objectives of the six modules. Fig. S1 Examples of the course screens. Table S2 Response to an open-ended question on what participants liked most about the course (n = 160). Table S3 Responses to an open-ended question on what participants would like to see changed in the course (n = 98).