Patients with low health literacy experience difficulty in understanding their medications leading to worse health outcomes. Pharmacists need to use formal assessment tools to be able to identify these patients, so they can better tailor their patient education. The objective of the study was to characterize hospital pharmacists understanding of health literacy and their use of screening and counselling strategies before and after completion of an educational module and to identify barriers that hospital pharmacists perceive to exist that prevent them from using health literacy tools.Pharmacists in three health authorities were administered a pre-survey and then given access to an online 11 min educational video. The post-survey was distributed 1 month later. Descriptive statistics were used to quantify survey responses with comparisons made between pre and post responses. The main outcome measure was pharmacists’ understanding of health literacy and their current practice related to health literacy.There were 131 respondents for the pre-survey and 39 for the post-survey. In the pre-module survey, 84% of pharmacists felt they understood what health literacy was, but only 53% currently assessed patients for their health literacy status and 40% were aware of what strategies to use in low health literacy patients. Lack of time (74%) was the biggest barrier in assessing patients’ health literacy. In the post-module survey, 87% felt they understood what health literacy was and 64% incorporated health literacy status evaluation into their clinical practice. The educational module was helpful to the clinical practice of 74% of respondents.As health literacy can affect a patient’s ability to adhere to their medications it is important for pharmacists to assess this in their patients. While pharmacists self-reported a high degree of understanding of health literacy, they are not regularly assessing their patients’ health literacy status and are unaware of what strategies to use for low literacy patients. While literacy refers to an individual’s ability to read and write, the World Health Organization (WHO) defines health literacy to be “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health” . AccordiWhile these demographic characteristics have been reported, past literature has shown us that it is difficult to accurately identify patients with low health literacy without using standardized assessment methods . In a crCurrently, the most common and widespread screening tools for health literacy are the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Test of Functional Health Literacy in Adults (TOFHLA) , 11. TheGiven the variety of the assessment tools available, pharmacists could benefit from learning at least one of these assessment tools in order to more effectively identify patients with low health literacy. Unfortunately, uptake amongst community pharmacists has been low. Studies conducted in community pharmacies have shown that only 7 % of pharmacies reported that they attempted to identify patients with health literacy needs . If healPharmacists can utilize different strategies to tailor patient education for individuals with low health literacy. Communication techniques and patient counselling strategies exist to help support the learning of patients with inadequate health literacy , 30–33. Pharmacists in three health authorities  were recruited to participate in the study. Ethics approval was obtained from the University of British Columbia (UBC) Clinical Research Ethics Board. All participants gave their informed consent.A pre and post survey was developed and was based on a comprehensive search of the literature , 34. TheThe educational module itself was an 11-min educational video titled “Reading Into the Health Literacy of Our Patients”. The investigators created it for the purpose of the study and its content was based on an extensive review of the literature , 35, 36.The initial pre-module survey was distributed via group e-mail lists to pharmacists within each of the three health authorities. A reminder e-mail was sent 1 week later. After completion of the initial survey, participants were asked for permission for the study investigators to contact them 1 month later with the post-module survey. The survey was estimated to take approximately 5 min to complete. All of the survey invitations and reminders contained consent information. Consent was implied by responding to the survey. Responses to the survey as a whole and to the individual survey questions was entirely voluntary.Pharmacists were included in the study if they were involved in any direct patient care activities. Questions were embedded into the start of the survey to screen for this inclusion criteria. An incentive of a draw for one of four $25 coffee gift cards was offered to all potential participants. Funding for the study was from the unrestricted research start-up grant of the primary investigator (KD).Data analysis consisted of simple descriptive statistics which included total counts, percentages, averages, and standard deviations. Comparisons of responses before and after completion of the educational module was planned. Qualitative analysis of open-ended responses was also done.One hundred and thirty-one pharmacists completed the pre-survey and thirty-nine completed the post-survey. Table Prior to completing the educational module, 84% of the participants felt they understood health literacy with 53% currently assessing patients for health literacy in their practice Table . The mosOf the 38 pharmacists that completed the post-survey, 74% felt that completing the educational module on health literacy was helpful to their clinical practice Table .Table 4Comparisons between pre and post module survey responses to the questions regarding whether participants understand what health literacy is and if they currently assess patients for their health literacy status were not statistically significantly different.Open-ended responses were also incorporated into the survey design. Qualitative analysis of these responses with categorization of themes found that many of these responses would fit into an existing response. For example, an open-ended response to the pre-survey question of counselling strategies used for patients with health literacy was “Highlighting and writing information in simpler words on teaching sheets.” Which would fit into the existing option of “Ensuring that printed materials area easy to read for patients”.Our study assessed the pharmacists baseline knowledge of health literacy; their use of health literacy assessment tools and counselling strategies; and whether an educational video intervention had an impact on their practice. In addition, barriers to the implementation of health literacy patient assessment and counselling strategies that prevent pharmacists from integrating these interventions into their clinical practice were also identified. While pharmacists self-reported a high rate of understanding of health literacy, just over half of the study population indicated that they currently assessed patients for health literacy and only 41% were aware of what strategies to use with most relying on just subjective patient observation.Interestingly while survey respondents were not aware of the strategies to use, 63% indicated they use specific strategies when counselling patients with low health literacy. The majority of the study population seemed to use strategies such as presenting essential information first, asking patients to demonstrate what has been taught and encouraging the presence of a family member. While these strategies have been shown to improve patient comprehension, other standardized communication techniques such as the Indian Health Service Model, the Teach-back method, and the Ask-Me-3 method have been shown to better promote understanding in patients with inadequate health literacy , 31, 33.Time continues to be a barrier for using an assessment tool to screen for patient’s health literacy and in deters pharmacists from using the available counselling strategies as found again in our study. While time constraints are consistently reported as a barrier Welch et al. evaluated the implementation of the Newest Vital Sign (NVS) instrument in a primary care clinic and found that it took 30 s to hand out the forms and instruct patients on how to fill them out . It tookSince the response rate for the post-survey was considerably lower than the pre-survey, we were not able to assess whether the educational intervention had an impact on practice. Other studies that have looked at factors that influence the adoption and implementation of health literacy tools in community pharmacy settings have identified a number of barriers that prevent implementation. Factors preventing uptake include limited support from leadership, higher prioritization of other activities, lack of qualified staff and complexity of the tool being used . The secThere were many limitations of this study. We did not prospectively assess pharmacists understanding of health literacy; we asked them to self-report if they felt that they had an understanding. The poor response rate for the post-survey limits our ability to determine if the educational intervention had any impact on the pharmacists’ practice. While we educated the pharmacists on what tools were available we did not provide any detailed training on how to use the tools. In addition, our educational intervention was limited to a short video.Our study did highlight a need for organized educational interventions to pharmacists on health literacy. Pharmacists may self-report a good understanding of health literacy, but they do not regularly assess their patients’ health literacy status and are unaware of what strategies should be used for low literacy patients. From our survey, pharmacists indicated that they would prefer engaging in interactive small group meetings with colleagues or utilizing computerized decision support. Future research should explore which tools are most appropriate for pharmacists to use and how best to implement a practice change.


Today, evidence-based nursing practice strives to improve health care, ensure adherence to treatment, improve health outcomes, and guarantee patient safety. The main scientific documents that nurses should consult, to obtain the best possible evidence, are systematic reviews and meta-analyses. However, this type of scientific document has a major issue if it uses retracted articles that could directly affect the consistency of the results shown in the reviews. The aim of this commentary is to present the current issue represented by the use of retracted articles in meta-analyses of systematic reviews and how researchers could detect them, through the use of different instruments, avoiding them, and providing a reliable SR or meta-analysis that could be useful for day-to-day clinical and research activities. The practice of nursing requires a continuous process of decision-making and problem-solving regarding health and care procedures provided to individuals, groups, and communities in healthcare facilities. Responsible decision making and problem solving requires knowing which solution is the most appropriate, most effective, and safest for the patient. Therefore, to ensure the best possible care, the knowledge of nursing staff must always be up to date. Often, we find the argument “it has always been done this way” in some healthcare facilities, assuming that it is not necessary to change procedures that have operated reasonably well over a long time. This statement has greatly impaired the need for updating the effectiveness and safety of care provided in hospitals or other healthcare facilities.The evidence-based practice (EBP) in general, and evidence-based nursing (EBN) particularly, is a core competency for nurses these days because it guides healthcare decisions that ensure patient safety ,2. UnderThe EBP is supported by three main cornerstones: (i) the best available scientific evidence, (ii) awareness of clinical experience , and (iii) the experience of patients  . TherefoTo implement and conduct EBP, the five-step model defined in the Declaration of Sicily, describing the essential steps for conducting adequate clinical practice based on the best scientific evidence, needs to be considered . This fiThe EBP, as we know, is the integration of the best research trials with clinical experience, but the integration of these research trials into practice takes time and it is necessary to provide an easy way for nurses and other clinical researchers (who are mainly affected by a large workload) to access the trials. Indeed, systematic reviews are the best way to identify, analyze, and summarize the findings of all relevant individual studies on a health or social issue, making the available evidence more accessible to nurses and other health researchers and facilitating the search for the most appropriate solution to a clinical or even social problem .However, developing an SR involves covering the full range of available scientific methods for synthesizing information, and knowing how to apply them carefully and rigorously to produce higher quality reviews that are assessed and used by decision makers related to healthcare procedures.There is an issue that seriously affects the quality of SR, making them poorly performed, by even conducting a misleading meta-analysis, and therefore seriously affecting the quality of one of the main decision-making tools useful for nurses and other clinical researchers. These concerns refer to the use of retracted articles, articles that have been removed from the scientific literature for a number of reasons, such as (i) compromised peer review process, (ii) duplication of publication, (iii) duplication of images, (iv) lack of ethical approval, (v) plagiarism, (vi) undisclosed conflict of interest, among others .The use of retracted articles that had been previously retracted to develop an SR or meta-analysis, significantly affects the quality and consistency of the results shown in the reviews  and, theToday, thousands of newly published life science studies are being released continuously. PubMed, for example, currently handles more than 30 million records of biomedical literature alone from MEDLINE, life science journals, and online books . TherefoTherefore, nurses and other health science researchers need tools to access the best scientific evidence in the life science literature . Systematic reviews and meta-analyses are the reference standard for synthesizing evidence in healthcare given their methodological rigorousness. Systematic reviews are developed on the basis of a protocol that describes the foundations, hypotheses, and planned methods of the review  and metaNevertheless, health professionals and health science researchers should be aware of a potential risk when searching for the best possible scientific evidence in the scientific literature: select and even use retracted articles in their systematic reviews and meta-analyses.This commentary’s major objective is to support researchers by providing some instruments focused on the detection of retracted articles to develop, or even recognize, a reliable SR or meta-analysis that may be useful for day-to-day clinical and research activities.For authors, there is no clear guidance on how to prevent the selection of a retracted article in their systematic review process, which could later be included in a meta-analysis . Therefo(i)Alert services: nurses and other health researchers can use PubChase, which is linked to RetractionWatch, the largest online database of retracted articles and reasons for retraction.(ii)Database: an example of this option is PubMed, which offers biomedical researchers an important tool for detecting retracted articles in the scientific literature.(iii)In relation to the use of a reference manager, Zotero© is a clear example of a reference manager that warns researchers when a retracted article has been selected. Zotero© is also linked to RetractionWatch .Some tools that could be used when researchers decide to examine the references used in the examinations  are:(i)AFurthermore, recently a new method to detect retracted papers that combine two possibilities described above, using a database to track retracted articles combined with a reference manager, has been published. This new way is called SCRUTATIOm  and it cSCRUTATIOm is a fast, reproducible, and reliable five-step solution for detecting retracted articles, which could be an essential screening tool for nurses who seek to check the consistency of results and conclusions arising from both meta-analyses and systematic reviews. A good and accurate literature review is a key element of systematic reviews, meta-analyses and research studies and always needs to be based on high quality original studies and logically never retracted. SCRUTATIOm is fast, reproducible, and enables the possibility to communicate the potential presence of flaws to the scientific community through a post-publication or post-peer review process.We consider it essential to enhance EBN education, as well as training in the procedures for locating and selecting the most relevant scientific manuscripts. This requires filtering and identifying the articles retracted to avoid compromising the nursing body of knowledge. Use and access to the best possible scientific evidence is the safest way to improve decision-making , being u


Background: Non-alcoholic fatty liver disease (NAFLD) is associated with dyslipidemia and increased cardiovascular disease risk. Dietary choices may produce profound effects on blood lipids. Thus, the purpose of this study was to investigate which foods modify blood lipids in NAFLD.Methods: Systematic review of published systematic reviews and randomized controlled trials (RCTs). Searches were performed in PubMed, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from inception through March 2020. Studies in populations with NAFLD, which provided data on foods or dietary patterns and blood lipids were included, but not weight loss diets, supplements, nor individual nutrients. The strength of evidence was evaluated using The Grading of Recommendations Assessment, Development, and Evaluation (GRADE).Results: No relevant systematic reviews were identified. Eleven RCTs were included in the qualitative synthesis. Two RCTs were included in meta-analyses, regarding the comparison between Mediterranean and Low-fat diets, in which there were no clear effects on either high-density lipoprotein cholesterol or triglycerides, with Low evidence. From single RCTs, there was Moderate evidence for reduced triglycerides by a healthy dietary pattern, compared with usual care; and for reduced total cholesterol by a probiotic yogurt, enriched with Lactobacillus acidophilus La5 and Bifidobacterium lactis Bb12, compared with conventional yogurt. For all other comparisons, the evidence was considered as Low or Very low.Conclusion: Few studies were identified which reported effects of foods on blood lipids in subjects with NAFLD. The possible beneficial effect of probiotics warrants further study. PROSPERO identifier: CRD42020178927. Non-alcoholic fatty liver disease (NAFLD) is a prevalent and emerging public health concern, closely associated with obesity, metabolic syndrome, insulin resistance, and type 2 diabetes . Individwww.crd.york.ac.uk/PROSPERO, identifier CRD42018089661. No ethics approval was required.A systematic search for systematic reviews and RCTs was performed, in PubMed, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from inception through March 2020. The PICO and full search strategy are provided in n analyzed overall and per group, % male, age in years (mean ± SD and/or range), intervention/daily dose (mean ± SD and/or range), control/daily dose (mean ± SD and/or range), effects on lipids , duration, country, and funding. Risk of bias in RCTs was assessed by two authors using the SBU Risk of Bias tool for intervention studies (version 6 May 2020). The quality of evidence was evaluated using The Grading of Recommendations Assessment, Development, and Evaluation (GRADE), by pre-determined criteria for risk of bias, inconsistency, indirectness, imprecision, publication bias, large effects, dose response relationships, and opposing bias. For instance, evidence was downgraded (-1) for inconsistency if results were not replicated, as consistent results of low heterogeneity are impossible to attain from a single RCT. In indeterminate cases, discussions were extended among all authors and overall judgments were employed.Two reviewers screened abstracts and in cases of disagreement, the paper was included for full-text review. From RCTs that fulfilled inclusion criteria, data was extracted by at least two researchers using standardized forms including: author, year, study type , population (NAFLD/other), 2>50%) unexplained heterogeneity, random effects models were preferred. If mean changes from baseline and their standard deviations were unavailable and impossible to calculate, end-of-study means and standard deviations were used. Cross-over studies were included together with parallel studies, with modified weights, calculated from available data. In cases where the variances of mean differences were unavailable, a conservative correlation R = 0.5 was imputed and standard deviations adjusted accordingly. Mg/dL was converted to mmol/L by multiplication with 0.02586 for cholesterol and 0.01129 for triglycerides. Data is presented as mean±SD. P-values > 0.05 were considered as non-significant (NS).Results from included RCTs were included in meta-analyses, when considered appropriate, using ReviewManager 5.3 software. The Cochrane Handbook  was adheSix systematic reviews and 26 RCTs were evaluated in full text. No systematic reviews and 11 RCTs (12 publications) fulfilled inclusion criteria . The chaP = 0.04) and triglycerides . There was a tendency toward reduced LDL cholesterol , but no clear effect for HDL cholesterol . The quality of evidence for the effect on triglycerides was considered as Moderate, upgraded for large effects, whereas all other comparisons were further downgraded to Very low evidence, due to high imprecision.In the RCT by Arab et al. , there wFrom the RCTs by Properzi et al.  and RyanP < 0.05). We did not perform evidence gradings for these outcomes, as they were not clearly pre-specified.In the RCT by Bozzetto et al. , 13, theIn the RCT by Campos et al. , triglycP = 0.096) and LDL cholesterol , and in triglycerides (from 1.57 ± 0.97 to 1.36 ± 0.51 vs. from 1.41 ± 0.56 to 1.50 ± 0.57 mmol/L P = 0.16), in the kamut vs. modern wheat group. There was no clear effect on HDL cholesterol . The evidence was considered as Very low for all outcomes.In the RCT by Dinu et al. , there wThe RCT by Nigam et al.  had threP = 0.03) and a reduction in triglycerides  in the enriched vs. regular olive oil group. No clear differences were seen for total  or LDL cholesterol . The evidence was considered as Very low for all outcomes.In the RCT by Sofi et al. , there wP = 0.09), LDL , or HDL cholesterol , or on triglycerides . Some data on variances were estimated because of implausible data in table. The evidence was considered as Very low for all outcomes.In the RCT by Khavasi et al. , there wP-values N/A for mean differences in change). No clear effect was observed for HDL cholesterol (from 1.23 ± 0.28 to 1.27 ± 0.32 vs. from 1.24 ± 0.25 to 1.31 ± 0.25 mmol/L). The evidence was Moderate for total cholesterol (upgraded for large effects) and Low for all other outcomes.In the RCT by Nabavi et al. , there wIn the RCT by Bakhshimoghaddam et al. , there wLactobacillus acidophilus La5 and Bifidobacterium lactis Bb12, decreases total cholesterol, compared with conventional yogurt, and with Low evidence, reduces LDL cholesterol and triglycerides. Also with Low evidence, a synbiotic yogurt containing Bifidobacterium animalis and inulin reduces total and LDL cholesterol, and triglycerides. Finally, with Low evidence, a Mediterranean dietary pattern (high in unsaturated fatty acids) reduces total cholesterol (but not other lipoproteins) compared with a Low-fat dietary pattern. For all other comparisons, the evidence quality was considered as Very low for all effects, or lack thereof.In this systematic review of the effects of foods on blood lipids in individuals with NAFLD, no systematic reviews and only 11 RCTs fulfilled the inclusion criteria. No foods or dietary patterns modifies blood lipids with High quality evidence in NAFLD. With Moderate evidence, a Healthy dietary pattern reduces fasting triglycerides, compared with standard care. Also with Moderate evidence, a probiotic yogurt, enriched with The limited number of studies discovered was somewhat surprising, given the prevalence and clinical significance of NAFLD. One plausible reason may be that, in most studies on diet and CVD risk factors, liver fat content is not easily attainable and thus overlooked. Also, many patients with NAFLD go undiagnosed, as it usually presents with little symptoms. The effect of dietary fat type  on plasma lipoproteins is diminished in individuals with obesity compared with normal body weight . ConsideB. animalis) on liver fat content and liver fibrosis in NAFLD was published during the writing of this manuscript  may provide beneficial effects on plasma lipoproteins. Also, we did not search gray literature or contact authors for additional information, and only studies published in English were included. Thus, we cannot rule out that additional relevant studies may exist. In addition, the present study could not confidently determine effect sizes or required daily doses for the included foods, because of the scarce data available.The results from the included RCTs are mostly in line with current guidelines for the treatment of dyslipidemia or prevention of CVD , 44 in oThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The study was conceptualized by DI. AR and FR performed screening. AR, FR, and DI performed data extraction. Risk of bias was assessed by FR and DI. Data analysis and grading of the evidence was performed by DI, with support from AR and FR. The paper was written by AR, FR, and DI. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Decision-makers in crisis zones are faced with the challenge of having to make health-related decisions under limited time and resource constraints and in light of the many factors that can influence their decisions, of which research evidence is just one. To address a key gap in the research literature about how best to support the use of research evidence in such situations, we conducted a critical interpretive synthesis approach to develop a conceptual framework that outlines the strategies that leverage the facilitators and address the barriers to evidence use in crisis zones.We systematically reviewed both empirical and non-empirical literature and used an interpretive analytic approach to synthesise the results and develop the conceptual framework. We used a ‘compass’ question to create a detailed search strategy and conducted electronic searches in CINAHL, EMBASE, MEDLINE, SSCI and Web of Science. A second reviewer was assigned to a representative sample of articles. We purposively sampled additional papers to fill in conceptual gaps.We identified 21 eligible papers to be analysed and purposively sampled an additional 6 to fill conceptual gaps. The synthesis resulted in a conceptual framework that focuses on evidence use in crisis zones examined through the lens of four systems – political, health, international humanitarian aid and health research. Within each of the four systems, the framework identifies the most actionable strategies that leverage the facilitators and address the barriers to evidence use.This study presents a new conceptual framework that outlines strategies that leverage the facilitators and address the barriers to evidence use in crisis zones within different systems. This study expands on the literature pertaining to evidence-informed decision-making. The pressure to demonstrate that responses to crises are grounded in research evidence has been growing over recent years –3. WhileDecision-making is complex, both because it is context dependent and because it is often influenced by the need to act quickly in sometimes less than ideal situations with relatively little access to information. Recognising this complexity, evidence-informed decision-making has been described as an approach that aims to ensure that decisions are influenced by the best available research evidence, while acknowledging the other factors that influence it . These oCrises are no longer contained in one geographical location but rather transcend borders and they can affect mass populations and disrupt health systems. There are several defining characteristics of a crisis situation. First, events that led up to a crisis situation are often unexpected. Second, the crisis event creates uncertainty with what the future holds under this new unexpected event. Third, the crisis event is seen as a threat to the important goals of security and sustainability of a normal structure. Recent humanitarian crises – be it the Ebola epidemic or the Syrian refugee crisis – have placed considerable stress on health systems that are not fully equipped to deal with such crises. For all these reasons, it is important that we start to think how we can build effective humanitarian systems that are able to respond to crises. What makes decision-making in crisis situations unique is the high levels of stress, often in intense and sometimes dangerous situations. Research evidence can help decision-makers respond in a timely manner in such situations.One area to consider when seeking to strengthen the use of research evidence in crisis zones is what strategies can be used to support evidence-informed decision-making. Up until now, the thinking about the strategies has been mostly confined to the research system, with an emphasis on making evidence more available and accessible to decision-makers and less on formalised processes for facilitating its use , 18, 19.We used a critical interpretive synthesis (CIS) to develop the theoretical framework and answer our compass question – what are the strategies that leverage the facilitators and address the barriers to evidence use in crisis zones in LMICs? CIS, developed by Dixon-Woods et al. , uses maThe literature search was carried out in phases and guided by our compass question and included available research literature that aims, through empirical or non-empirical approaches, to contribute to generalisable knowledge Fig. . InitialFor inclusion, the documents had to provide examples of strategies, facilitators and/or barriers to evidence use in crisis zones in LMICs. For the purpose of article selection, we defined research evidence as the output of research that has been conducted in a systematic way and reported in a transparent manner. Our definition of research evidence includes evidence described in both empirical papers  and conceptual papers . It also includes both primary studies and secondary research (e.g. systematic reviews and other forms of evidence synthesis). We distinguish such research evidence from other types of information, including data, tacit knowledge or ordinary knowledge , and staWe excluded the following types of articles: (1) focused on translating clinical research into practice; (2) focused on translating health knowledge to citizens ; (3) focused on information systems that deal with raw data and not research evidence; and (4) deemed to be fatally flawed .We assessed the relevance of included studies in the synthesis. For the purposes of this interpretive review, we applied a low threshold of relevance to maximise the inclusion and contribution of a wide variety of papers that address the objectives of this synthesis . We did A second reviewer (KM) was assigned to a representative sample of articles to ensure intercoder reliability at two stages of article selection (e.g. titles and abstracts and full-text documents). Given that this is a mixed method synthesis, a Cohen’s Kappa statistic measuring inter-rater agreement was performed with the intent of spurring reflection about the inclusion and exclusion criteria for this study rather than being overly focused on the quantitative estimate . As a reSimilar to a grounded theory approach, additional articles were purposively sampled from the broader literature providing insight into strategies to support evidence use in other settings but that are equally relevant to crisis zones . The addn = 27) were read in full and any specific information in the results and discussion sections of the included papers that shed light into the topic area were considered as data. The overarching guide used when developing categories for data synthesis was that the category contributed to answering our compass question. Concepts that were repeated in papers that do not provide a new insight into the topic area were excluded as the focus was on uncovering new insights into the strategies to support evidence use, and the facilitators of and barriers to evidence use in crisis zones.All included papers  the strategies that can be employed to integrate the use of evidence more systematically into decision-making as well as 2) the facilitators and barriers that influence evidence use in decision-making in crisis zones, both individually and in relation to each other  and rapid operational research is needed. However, strategies are needed to support the use of the vast pool of high quality and locally applicable research evidence. For example, an organisation has collected such evidence in a freely available online resource (e.g. Evidence Aid).The focus in the broader literature has been on emphasising the importance of research evidence, even as it acknowledges that research evidence is only one input into the decision-making processes –81. ThisThe broader literature contains many strategies to support evidence-informed decision-making in other settings that are equally relevant to crisis zones , 83–85. The strengths of the study included the use of a critical interpretive synthesis methodology that harnessed both a rigorous traditional systematic review methodology with the benefits of an interpretive approach . Additionally, a second reviewer was involved in the two phases of article selection and in the inclusion phase and a Cohen’s Kappa statistic was completed, with a result that indicated excellent inter-rater agreement and spurred reflection about the appropriate inclusion and exclusion of articles. Finally, the synthesis identified the strategies to support evidence use and the facilitators of and barriers to evidence use, within different systems, that can serve as a point of departure for researchers undertaking empirical work that focuses on one or more specific systems.Within humanitarian aid research, this study is the first to explicitly focus on the four interconnected systems – political, health, international humanitarian aid and health research. Research to date has tended to take a broader, non-system-specific approach to examining evidence use in crisis zones. This makes it challenging to identify which system the strategies to support evidence use are best handled by and, within a system, which actor is best suited to implement the strategies. The systems level analysis explored in this study contributes to alleviating this challenge by focusing on each system specifically and the actors that can exert influence on supporting evidence use within them.Despite the merits of our approach, a limitation of the study was that, at times, it was difficult to know from the literature which system the strategies to support evidence use in crisis zones are best handled by and, within a system, whether the strategies are focused on policy-makers, health-system leaders, humanitarian aid decision-makers or research producers. In addition, literature stemming from highly insecure contexts was less available as often researchers have difficulty conducting research in such settings. We addressed these limitations by drawing on existing knowledge translation literature to inform our interpretation of those who would be best positioned to support evidence use, and by suggesting strategies that can be applicable in highly insecure contexts (e.g. rapid evidence service).In addition, despite our best efforts to examine evidence use in crisis zones, we were unable to make assertions on how context influences the application of strategies to support evidence use in crisis zones in different systems. For example, it is considerably easier to convene a stakeholder dialogue to inform policy options within a relatively stable county (i.e. for Syrian refugees in Lebanon), rather than attempting to convene dialogue in the midst of war zones, outbreaks or natural disasters. However, the findings presented in this study serve as a foundation for research that aims to explore the impact of context on strategic outcomes related to evidence use.The results of our study may enable different actors in crisis zones to reflect on how they can utilise their professional position to support the use of evidence in decision-making, both in the system within their sphere of at least potential control and in the other systems that may be within their sphere of influence. For example, policy-makers in the political system can engage researchers in the health research system to help facilitate a stakeholder dialogue. We recognise that asking these actors to adopt or adapt established strategies and develop new ones that address all the barriers and leverage all of the facilitators is a big challenge to undertake. Our hope is that our framework and strategies serve as the starting point for incremental change to occur over time with the goal of getting closer to addressing the evidence needs of decision-makers in crisis zones.Future studies could apply our theoretical framework in purposively sampled crises, examining specific facilitators of and barriers to research evidence use in decision-making as well as which strategies, if any, are used to leverage the facilitators or address barriers. This would be beneficial in drawing lessons from the framework’s application and in identifying gaps in the framework that need to be addressed. Additionally, future studies could apply the strategies in one or more of the four involved systems to examine whether and how they increase the prospects for evidence use in crisis zones. This could potentially better inform the design of future strategies to support the use of research evidence in such situations and contribute further to our understanding of what types of influence each strategy could be expected to have if successfully implemented in different systems and for different types of crises.During a humanitarian response, decision-makers tend to rely on their professional judgement to make decisions as their main goal is the provision of support to people affected by the crisis in often unpredictable situations. Part of the challenge in getting decision-makers to account for research evidence alongside their professional judgement is their uncertainty of whether the existing research evidence can be applied to their unique setting. What is currently missing from the theory is specific strategies to support evidence use in crisis zones that leverage the facilitators and address the barriers to evidence use within different systems . This study offers a new conceptual framework that addresses this gap by identifying and helping to explain the strategies that can be employed to integrate the use of evidence more systematically in crisis zones.Additional file 1: Table S1. Initial database search strategy.


NICE Evidence Standards Framework for DHTs. This provides guidance for evaluating the effectiveness and economic value of DHTs in health care settings in the United Kingdom.There is a growing role of digital health technologies (DHTs) in the management of chronic health conditions, specifically type 2 diabetes. It is increasingly important that health technologies meet the evidence standards for health care settings. In 2019, the National Institute for Health and Care Excellence (NICE) published the NICE Evidence Standards Framework for DHTs.The aim of this study is to assess whether scientific articles on DHTs for the self-management of type 2 diabetes mellitus report the evidence suggested for implementation in clinical practice, as described in the We performed a scoping review of published articles and searched 5 databases to identify systematic reviews and primary studies of mobile device–delivered DHTs that provide self-management support for adults with type 2 diabetes mellitus. The evidence reported within articles was assessed against standards described in the NICE framework.best practice standards, 3 met minimum standards only, and 23 technologies did not meet minimum standards.The database search yielded 715 systematic reviews, of which, 45 were relevant and together included 59 eligible primary studies. Within these, there were 39 unique technologies. Using the NICE framework, 13 technologies met On the assessment of peer-reviewed publications, over half of the identified DHTs did not appear to meet the minimum evidence standards recommended by the NICE framework. The most common reasons for studies of DHTs not meeting these evidence standards included the absence of a comparator group, no previous justification of sample size, no measurable improvement in condition-related outcomes, and a lack of statistical data analysis. This report provides information that will enable researchers and digital health developers to address these limitations when designing, delivering, and reporting digital health technology research in the future. Digital technologies are now integral to the delivery of health care and feature in policies for the future of national  and globMany DHTs are intended to support chronic disease management, where self-management and preventative medicine are key components of effective care. Approximately 500 million people use mobile device apps to manage their health . With anhost country. Therefore, the NICE Evidence Framework may be used to guide assessment of and make comparisons between scientific literature regarding a variety of DHTs developed and applied internationally.There are several existing guidelines on evaluating the use of DHTs, including guidelines by policy makers such as the WHO, the United States’ Federal Drug Association, and National Health Service England -11 as webest practice and minimum standards. Stakeholders are encouraged to assess the evidence against these standards, which include, for example, whether the study measures important outcomes for users, whether the intervention works independently of health care professionals’ input, and the extent to which the intervention guides diagnosis, management, and treatment of a disease.The NICE framework classifies apps by function and stratifies them into tiers . The tier framework corresponds with the evidence level required to support use of the technology; requirements are cumulative, becoming increasingly rigorous from tier 1 to 3 and divided into To date, there has been no review exploring whether peer-reviewed scientific literature regarding DHTs meets these evidence requirements. We investigated this in the context of DHTs designed to support the self-management of type 2 diabetes, as it is the most common chronic condition targeted by self-management DHTs .The objectives of this review are (1) to systematically identify peer-reviewed publications on mobile device DHTs intended to support or encourage the self-management of type 2 diabetes mellitus (T2DM), (2) to use the NICE Evidence Standards Framework to allocate each DHT to the appropriate intervention tier based on their described technology and function, and (3) to examine the extent to which the evidence reported for the identified DHTs meets the NICE framework level of evidence required according to its tier.We performed a scoping review  to underA total of 5 databases  were searched for systematic reviews published between January 2000 and August 2019 that evaluated mobile device DHT interventions for T2DM. Our database choice and search strategy were developed through consultation with a medical information specialist to identify the most relevant sources for peer-reviewed medical and clinical research studies. An example search strategy is provided in Two reviewers (JF and LA) independently screened all citations for systematic reviews by title and abstract and excluded those that clearly did not meet the eligibility criteria. Decisions were then unblinded, and any conflicting decisions were arbitrated by a third reviewer (AF). Full-text articles for all included citations were then screened against the inclusion criteria by 2 reviewers (JF and LA). Reviews were eligible if they included primary studies evaluating mobile apps designed to support adults with the self-management of diabetes mellitus. Reviews were excluded if they included studies in which the study population included people with type 1 diabetes, an undifferentiated mix of people with type 1 diabetes or type 2 diabetes, gestational diabetes, childhood diabetes or prediabetes, or focused on diagnosing diabetes (due to our focus on assessing DHTs designed to support self-management). Reviews that focused exclusively on telemedicine or telehealth interventions were also excluded, owing to our focus on technologies that support self-management and therefore require some degree of functionality independent of a clinician.Relevant primary studies were then identified from eligible systematic reviews. The eligible reviews were equally divided between the 4 reviewers  who then screened the title and abstract of each primary study included in each review. When a primary study was excluded, the study was double screened by a second reviewer, and in the instance of any conflict, a third reviewer arbitrated (LA or AF). Primary studies included at this stage were then divided between the 4 reviewers who reviewed the full text of each study for eligibility. Furthermore, when a study was excluded, the study was double screened by a second reviewer, and any conflict was arbitrated by a third reviewer (LA or AF).Primary studies were eligible for inclusion if they met the following inclusion criteria:Population: adults with a diagnosis of T2DM.Intervention: a mobile device–delivered DHT designed to support the self-management of T2DM, which provides support independent of a clinician.evidence for effectiveness tables from the NICE framework [Data were extracted from the included primary studies by 4 reviewers . We designed a custom data extraction form using the We extracted the following items from primary studies: (1) DHT investigated, (2) year of study, (3) study nation, (4) study design, (5) study setting, (6) outcomes of interest, (7) study duration and follow-up period, (8) sample size, (9) recruitment setting, (10) comparator group, (11) improvement in outcome with intervention, (12) justification of sample size, (13) statistical methods, and (14) follow-up rate. For tier 3a studies, we also extracted the following item: (15) description of and reference to a behavior change technique. Where more than one article that investigated the same DHT intervention was identified, data were extracted separately for each article.Descriptions of each technology were extracted from the primary studies, and we assigned each app a tier according to the NICE framework, as described in minimum and best practice evidence requirements. Where a technology was reported in more than one primary study, we analyzed each primary study separately against the framework and selected the strongest supporting evidence for the technology reported across the primary studies.We used the NICE framework to evaluate each DHT against evidence levels, referring to evidence in the primary studies for each DHT, as described in We also compared the NICE evidence standards outcome for a DHT against the income status of the study nation (as defined by the World Bank ). This wTier 3a guidance requires evidence of a referenced behavioral change technique (BCT) in the development or use of a technology that encourages behavioral change. For the purposes of this review and evidence assessment, we took a pragmatic decision to exclude this requirement in our overall decision on whether a tier 3a technology met the evidence requirements, accounting for the fact that our search methods may not have identified all relevant development studies reporting on a technology’s design.data quality as the presence of “statistical considerations such as sample size and statistical testing.” A pragmatic decision was made that statistical testing of some degree was needed as the minimum evidence requirement for all studies. However, the framework accommodates observational and quasi-experimental study designs, where it is impractical to statistically justify the sample size. Therefore, when making an assessment of evidence for studies of these designs, a statistical justification of sample size was not needed to meet minimum standards .In addition, the framework defines The initial database search returned 715 citations. After removal of duplicates, 709 citations were screened by title and abstract. We identified 68 relevant systematic reviews for which we screened the full-text articles. Of these, 45 reviews were included .From these 45 reviews, we identified 145 relevant primary studies and screened their full-text articles. Of these, 61 primary studies met the inclusion criteria described above. We subsequently excluded 2 studies because there was insufficient information describing their technology to allocate a tier. The remaining 59 studies described 39 unique technologies and were included for data extraction .The characteristics of the 59 included studies are presented in All DHTs identified and included in this review were classified as tier 3 technologies. Descriptions of the technologies and their assigned subtiers are presented in preventative behavior change and self-manage. Of these 23 technologies, 6 were apps and 17 were SMS based. Of the tier 3a technologies, 12 were classified as preventative behavior change only, 3 were classified as self-manage only, and 8 had both 3a preventative behavior change and self-manage characteristics.Of the 39 technologies, 23 (59%) were assigned to tier 3a. Tier 3a describes DHTs used for preventing and managing diseases and is divided into treat, active monitoring, calculate, and diagnose. Of these 16 technologies, 13 were apps and 3 were SMS based. Of the tier 3b technologies, 7 were active monitoring only, 3 were treat and active monitoring, 1 was treat and calculate, 1 was active monitoring and calculate, and 4 had all 3 of the 3b treat, active monitoring, and calculate characteristics.We assigned 16 (41%) of the 39 technologies to tier 3b. Tier 3b describes technologies used as tools for treatment, diagnosis, and management decisions and is divided into best practice standards for the evidence level assigned, 3 technologies demonstrated minimum standards, and 25 did not report methods or findings that met minimum standards.The assessment of evidence level according to the assigned tier is presented in Table S1 ,45-51,77best practice standards, 3 met the minimum evidence standards, and 13 did not report methods or findings reaching minimum standards. Of the 13 technologies that did not provide evidence for minimum standards, there were several common reasons for falling short of the minimum standard. First, 7 technologies did not provide statistical justification of sample size where the study design was appropriate, with this being the only reason for not meeting minimum standards in all 7 technologies. Second, 6 technologies did not provide comparative data, with this being the only reason for not meeting the minimum standards in the 2 technologies. Finally, 3 technologies did not conduct any statistical testing on the data set.Of the 23 tier 3a technologies, 7 met the best practice standards. First, 2 technologies showed no improvement in condition-relevant outcomes, with this being the only reason for both technologies not meeting the best practice. Second, 1 technology’s comparator group did not represent usual care, with this being the only reason for not meeting the best practice.For the 3 tier 3a technologies that met the minimum evidence standards, there were 2 common reasons why these technologies did not meet the best practice standards, none met only minimum evidence standards, and 12 did not report methods or findings reaching minimum standards. Of the 12 technologies that did not provide evidence for minimum standards, there were several common reasons for falling short of the minimum standard. First, 3 technologies used a single-arm cohort study design that lacked a comparator group and failed to meet the requirement of design being quasi-experimental or higher, with inappropriate study design being the only reason for not meeting minimum standards in all 3 technologies. Second, 7 technologies had no statistical justification of sample size where the study design was appropriate, with this being the only reason for 5 of these technologies. Third, there were 2 technologies that did not conduct any statistical testing on the data set. Finally, 2 technologies had a follow-up period of less than 3 months, which is the accepted minimum clinically relevant follow-up period for type 2 diabetes.Of the 16 tier 3b technologies, 4 met minimum or best practice standards, compared with 3 out of 5 DHTs investigated in upper middle-income economies, 2 out of 3 DHTs investigated in low- and middle-income economies, and 0 out of 1 DHTs investigated in low-income economies.We aimed to evaluate whether peer-reviewed literature investigating the use of mobile device DHTs for the self-management of T2DM met the required evidence level set out in the NICE Evidence Standards Framework for DHTs. The framework aims to ensure that new technologies introduced to clinical health care settings are effective and offer economic value. We identified 39 mobile device DHTs designed to support self-management of T2DM in the scientific literature; these were a mix of app-based and SMS-based technologies. We found that all technologies fell into tier 3a or tier 3b (the highest tiers) of the NICE framework, with tier 3 interventions targeting disease management and requiring the most rigorous evidence. When assessing a technology using the NICE Evidence Standards Framework, we assessed all primary studies supporting a DHT individually against the framework and selected the strongest supporting evidence for the technology reported across the primary studies.minimum or best evidence standards, with 23 not meeting the minimum requirements. The most common reasons for not meeting the NICE standards included a lack of an appropriate comparator group that reflected usual care, no statistical justification of sample size, a lack of measurable improvement in condition-related outcomes, and no statistical data analysis. Given the high proportion of RCTs among the identified studies , it was surprising that such a large number did not meet the minimum evidence standards due to these reasons. We found that the evidence framework could easily be applied to a variety of study nations and that studies from a range of economic settings were able to meet evidence standards for the DHT. From the results of this study, we suggest that the application of DHT evidence standards are globally relevant.For more than half of the technologies identified, the underpinning literature did not meet the evidence standards to demonstrate effectiveness, as recommended by the NICE framework for the technology’s tier. Of the 39 technologies identified, only 16 met healthy living and technology for disease management. The same technology that targeted diet and exercise could be considered tier 2 for people without diabetes as a healthy living app but tier 3 for those with T2DM as a disease management app. There are several terms used in the NICE framework that can be ambiguous in their application and may require greater clarity, including the phrases high quality data and clinically relevant follow-up period. The framework does not include guidance as to how either of these points should be assessed.We encountered several challenges in interpreting and using the NICE framework. First, we found that for diabetes, there was ambiguity in distinguishing technology for host country, rather than specifically in the United Kingdom, allowed the analysis and comparison of DHTs in an international context. We also noted that the UK-specific requirement may restrict UK policy makers, commissioners, and clinicians from adopting and implementing DHTs that have been rigorously evaluated in another health care setting and do not require substantial adaptation. This could be considered overly restrictive for DHTs that target self-management and may not need integration with a health care system.As the NICE Evidence Framework was designed in the United Kingdom, the standards reference the UK health care setting when assessing the development and effectiveness of a technology. We found that adaptation of the NICE framework to assess a DHT in its preventative behavior change due to explicit suggestions by the DHT to the patient for actions or behavior change) might be considered a low-risk technology, involving automatic SMS reminders to take medication when a patient’s pill box remains unopened. However, Health Coach App [self-management for symptoms, health or disease related data, or medication tracking over time) might be considered as having higher risk, tracking multiple health behaviors, holding sensitive data, and facilitating two-way messaging. Despite this difference in the level of risk, both technologies fall under the same tier and require the same standard of supporting evidence. The evidence framework also stipulates that any technology where there is automatic transfer of data (regardless of type) to a health care professional should be categorized as tier 3b rather than tier 3a under active monitoring, requiring more rigorous evidence for clinical input without any apparent additional risk. Therefore, tier levels may need to be adjusted to reflect clinical risk rather than function alone.Finally, we observed a potential mismatch between the level of risk associated with an intervention and the level of evidence required according to the intervention’s associated tier. For example, Real-Time Medication Monitoring ,38, whicoach App ,64, alsoAlthough this is a scoping review, we took a systematic approach to identify peer-reviewed articles, adding rigor to our methods. We included reviews of all study design types, including experimental, observational, and qualitative study designs. However, while we identified several experimental and observational studies, this approach may not have captured all developmental studies and recently published studies that are less likely to be included in systematic reviews. However, we would have expected developmental studies to be cited in subsequent experimental and observational clinical studies, and we hand-searched full-text articles for such studies. We adapted our evidence assessments where appropriate .We identified technologies that have been investigated and published in the scientific literature and did not review app catalogs or commercial publications for relevant technologies. We feel this approach was appropriate, as we did not have the resources to obtain and evaluate these sources and assess the extent to which they meet evidence standards, as described in the NICE framework. In addition, although the NICE framework was developed for DHTs used in a clinical setting, we did not differentiate between commercial and commissioned DHTs in this study. However, we encountered no challenges in applying the tier 3 evidence requirements to technologies scientifically evaluated either by clinical or commercial teams; indeed, the evidence framework could be used to design studies to evaluate the use of commercial apps within a clinical setting. Although we assessed the income status of the study nation to explore the applicability of the framework in a variety of health care settings, this did not take into account the scenario where a technology was developed in a high-income country but delivered in a low-income population ,51,63,64Due to potential ambiguity and subjectivity applying the NICE framework, we acknowledge that our interpretation will have affected decisions around classification and evidence evaluation and consequently the number of DHTs meeting evidence standards. We have highlighted that greater clarity of key terms in the framework would be valuable. We also acknowledge that the scope of our analysis was limited to the evidence requirements in the NICE framework, but other considerations for study quality  and intervention effect  are interesting and relevant in evaluating the effectiveness of DHTs.We identified several evidence-level criteria as described by NICE that studies of DHTs commonly failed to meet. This offers a useful resource for digital health researchers and developers who may use this information in designing and reporting DHT research in the future. This might aid in the translation of research into clinical care by ensuring that the required information is measured and reported. This in turn will enable commissioners, policy makers, and clinicians to readily assess whether a technology is suitable for implementation in the UK health care setting.Previous studies have identified a lack of evidence of an effect in apps for diabetes. Recently, Veazie et al  identifi. This may pose a major barrier to the translation of mHealth interventions into the UK health care setting. However, we have highlighted the most common areas in which DHT evaluations do not meet the standards set out by NICE, and this provides an opportunity for researchers and DHT developers to address these points when designing and reporting DHTs in the future. In addition, we identified the potential scope for development of the NICE framework so that the evidence tiers correlate more closely with the associated risk of an intervention. Above all, commissioners, clinicians, and patients need to have confidence in the safety of DHTs for these to be implemented into everyday chronic disease management, and increased risk should be underpinned by the most rigorous scientific research.This review evaluated a defined group of mobile-delivered DHTs designed for use by people with T2DM, using the NICE Evidence Standards Framework for DHTs. Over half of the identified DHTs did not meet the minimum evidence standards required for their intervention tier, as defined by the NICE Evidence Standards Framework


In New Orleans, Louisiana, 61% of advanced age patients have low health literacy, 50% report financial insecurity, and more than one-third have high hospital readmission rates and medical complexity scores. This population has been disproportionately impacted by the COVID-19 pandemic and the system-wide transition to remote, virtual visits. While COVID-19 has accelerated needs for impactful remote care and research, this has been impeded by low telehealth literacy and structural barriers, such as lack of internet and devices. There are major gaps in the literature regarding telemedicine services in geriatric and complex populations and efficacy rates are variable in these populations. There is currently no telehealth literacy screening tool designed for identifying patients with barriers requiring additional interventions to succeed, no uniform understanding of the factors affecting use or how to increase engagement, and telehealth models requiring fluent use of technology for older adults have been met with poor rates of completed visits and associated harm. Following a dedicated 358.5 hours to training 309 geriatric, complex patients in telemedicine using our pre-existing telehealth model, averaging 4.78 hours per patient, only 18.8% of these patients were subsequently able to connect to the provider virtually. Here we describe lessons learned and tools developed from the Ochsner MedVantage Network Innovation project, including the development of a telehealth literacy screening tool, the adaptation and provision of simplified, user-friendly tablets, and a randomized control trial to determine if increased accessibility to telehealth leads to improved healthcare outcomes, such as decreased hospital admissions and emergency department utilization.


Practising caring presence is recognised as an important nursing intervention indispensable to high-quality, patient-centred care. An awareness of the real world of professional nurses (PNs) practising caring presence will assist in expanding and supporting the existing literature on the same. A clear and rich description of what the concept of caring presence entails within the unique South African nursing context may guide nurses in the art of this nursing skill, enhance their professionalism and facilitate the formulation of recommendations on how to encourage nurses to implement the practice of caring presence within nursing.This study explored and described the lived experiences of PNs practising caring presence in a rural public hospital.The study setting was a 120-bed, level-two district hospital in the North West Province of South Africa.A descriptive phenomenological method, specifically Husserl’s approach, informed this study. Semi-structured interviews were conducted with a purposive sample of 10 PNs. Data were coded and analysed using Colaizzi’s seven-step method.Five themes emerged from the data analysis: professional caring presence, ethical caring presence, personal caring presence, healing caring presence and what caring presence is not.Professional nurses experience practising caring presence as professionally and personally fulfilling, as an expression of their passion for the profession, as a way of portraying ethical care, as a willingness to be personally present and as a healing experience that involves commitment and taking care of patients holistically. Unprofessional, unethical behaviour and depersonalisation of patients were indicated as uncaring behaviour. In applying these principles, the researcher aimed to stay as close as possible to the data in their richness and complexity  of the experience  and thereafter their views on the study findings were obtained via telephone calls. Minor revisions were integrated into the final description of the interviewee’s experience, but overall they agreed that the themes and sub-themes were a true reflection of their experiences.From the transcribed interviews, 319 significant statements were extracted, leading to the development of 319 formulated meanings, reflecting the lived experience of these PNs. Eleven theme clusters were formed, which were further merged into five emergent themes.During a training and information session, which was held in the boardroom at the hospital, the researcher conducted a PowerPoint presentation in which she shared with the mediators an introduction to the research activities, the purpose of the project, selection of the study population, as well as the methods and procedures by which data would be collected. Furthermore, she provided an explanation of the risks and benefits of the study, and confirmed the anonymity, voluntary participation and confidentiality of the participants. The mediators agreed to sign confidentiality agreements in order to protect the identity of the participants and to recruit the participants by sending an invitation to all participants meeting the inclusion criteria. The identified participants were given time (at least 24 h) to consider whether they wanted to participate. The voluntary consent was also confirmed prior to the audio-recorded, semi-structured interviews. Participants were ensured that they could withdraw from the study without any threats to their well-being at any time if they wished so.The researcher assured that the transcripts and records were coded and numbered, and all data were kept confidential. Consequently, there were no links or clues to the identity of the participants. The audio recordings were destroyed by deleting them from the audio recorders after the transcribing process.Trustworthiness was demonstrated in providing rigour and strength to the study in accordance with the principles of credibility, dependability, confirmability, transferability and authenticity  Health Research Ethics Committee (HREC), Potchefstroom Campus (Ethics number NWU-00331-16-A1). In addition, the North West Department of Health as well as the chief executive officer (CEO) of the rural public hospital granted permission to conduct the research. The researcher utilised the informed consent form provided by the HREC of the NWU, Potchefstroom Campus. This consent form clearly stipulates the ethical principles of voluntary participation, beneficence, respect for people and justice.passion is fundamental to the nursing profession, and the aspect of 100% dedication and commitment was emphasised. Therefore, they confronted the reality that a lack of self-awareness can result in a drop in professional care. Their experiences also included the practice of leading by example, showing integrity, enhancing professionalism and consequently portraying a caring attitude:In their experience of practising caring presence, participants felt that ‘Yes, without passion, I could not do it … Passion goes for everything … You do it hundred per cent (silence). Everything comes with passion.’ ‘…I said to her, no, no, no, I am not here for the paperwork, I am here for the patients, you see.’ ‘We must be role models to the younger nurses to show them that we really care for our patients.’ ‘The other thing, neh, is that you cannot nurse in a rural village, with a broken heart or with anger, it is so (silence) wrong.’ self-awareness is a dynamic transformative process of self, as well as a professional competency that facilitates and enhances the care experience ‘Then I have to advocate for them. I beg them to give them a chance.’ Ethical responsibility and moral sensitivity are particularly relevant to caring presence ‘It’s on a daily basis, neh, usually I am happy when I go home … I go home seeing a difference in the patients’ condition.’ walked an extra mile for that patients, because remember … I gave everything.’ ‘I feel I ‘I was actually giving my all for this patient. That is caring presence for me.’ These findings reflect Palmiery’s  statemen[A]s human beings, our presence is automatically care: it expresses the way in which we are, who we are, able to be, given our limits, and the context, both material and relational, in which we live. (p. 66)When a nurse is personally present, compassionate care becomes real, and this state is needed for those who intend to facilitate healing Welch :93. Nursholistic nursing approach. They shared dedication and willingness to render patient-centred care in order to establish a healing caring presence. Therefore, they revealed that caring presence is a conscious intention to focus on the total, holistic needs of patients:The participants regarded the practice of caring presence as an experience grounded in a ‘Yes, to see the patient with physical, spiritual and emotional needs. Not only a body, but a person with more needs. Like I say to help the patient to heal.’ ‘All patients, sister, do have physical, emotional and spiritual needs, OK? I take care of all the needs and am present for the patient holistically.’ ‘I also take care of the patient’s spiritual needs. It is important to listen and if he needs to pray, let him pray and support him.’ ‘In rural areas, we have many social-economic problems. We must guide and assist the patients accordingly. It is very important.’ ‘Before you come to work, you must focus to be present. You must talk to yourself, you know what, today I am going to work for my patient, I am going to treat that patient that need me, because I am a nurse.’ The nursing literature supports these experiences of the participants in similar ways, for example, the use of the self as an instrument of healing  needed with resuscitation. How are we able to cope?’ ‘What they are doing is, they sit with their phone (silence). It is WhatsApp (silence) or Facebook? Um (silence).’ ‘That the role-models also don’t care and that they are also on their phones … and they are also not there for their patients (silence). Even you can go for a lunch for 3 h (silence). Because the same manager goes for hours! And when she comes back, she just sits in the office. If you do this, they will follow you.’ ‘You must not call the patient by his diagnosis. You must say, Mr so and so and Mrs so and so. If you call them the laparotomy-patient, they don’t feel all-right. It is not fair to the patient.’ Bright  also fouHaving selected a descriptive phenomenological design for this study, the researcher was able to incorporate the participants’ beliefs, insights, thoughts, actions and multiple realities regarding the practice of caring presence into an exhaustive description of the essence of their lived experiences. Furthermore, the semi-structured interview technique enabled the researcher to draw rich descriptions from the participants about the phenomenon of interest. In addition, the research findings were confirmed when literature integration was applied.Through this research, the researcher gained insight into the description of specific and unique moments of this experience, thus making known the significance and transformative potential of caring presence in the nursing profession, for future use in the practice, education and research fields. Based on the findings, integrated with available literature, it could be concluded that the essence that represents the true nature of the phenomenon of practising caring presence in a rural public hospital shared by the participants regarding their lived experiences is:a] willingness and commitment to be professionally, personally and ethically present for and with patients in order to be a healing caring presence through rendering holistic, patient-centred nursing care.  receive negative reports and warnings.Research on the relationship between passion for the nursing profession and the practice of caring presence.Research on PNs’ lived experience of practising caring presence in the private healthcare sector in South Africa.The findings of this qualitative, descriptive and phenomenological study can be used to expand and support the existing literature regarding the practice of caring presence. Consequently, the rich information and insight gained from the lived experiences of the PNs in this study add to the nursing body of knowledge, specifically regarding the understanding of the concept of caring presence from a South African point of view.


Domestic violence and abuse is a violation of human rights which damages the health and wellbeing of victims, their families and their friends. There has been less research on the experiences and support needs of male victims than those of women. Historically research on men’s experiences has not focused on what constitutes effective, needs-led service provision. The aim of this paper was to conduct an integrated mixed methods synthesis of systematic review evidence on the topic of help-seeking by male victims of domestic violence and abuse.An integrated mixed methods synthesis approach was taken to enhance our understanding of the complex phenomenon of help seeking by, and service provision to male victims. This process also identifies gaps in the evidence. Using previously identified systematic review data; mixed methods data from four primary-level service evaluation studies, along with expert and patient consultation were used to develop research propositions. Primary-level qualitative interview and survey data from 12 studies of men experiences were mapped onto the propositions to support them.Fourteen propositions were composed. Seven propositions were supported or at least partly supported by the qualitative data. These supported propositions were used to make recommendations for policy and practice particularly concerning service preferences of male victims. The remaining seven propositions were not specifically supported by the qualitative data. These unsupported propositions were used to develop research recommendations concerning the need to further understand the potential blurred boundaries of victim–perpetrator, hybrid perpetrator-victim experiences, men who are/have been victims of childhood sexual abuse and determining the level of risk for men. They also highlight the need to produce better guidance for the response of the police & the criminal justice system. Finally, they highlight the need to produce the most appropriate service for men in terms of access, linkage, substance/alcohol abuse, mental health, sexuality, and race.Integrated mixed-methods synthesis of systematic review evidence is a relatively novel approach. This approach can lead to recommendations for policy and practice as well as highlighting gaps in the research agenda as shown in this example. Domestic violence and abuse (DVA) is a violation of human rights which damages the health and wellbeing of victims, their families and friends. There has been less research on the experiences and support needs of men experiencing DVA than those of women survivors . HistoriThis integrated mixed methods synthesis (IMMS) builds on the systematic review evidence of four unpublished primary-level mixed methods service evaluation studies and a published synthesis of 12 primary-level qualitative interview and survey studies . This IMThere is a risk that systematic reviews steer the direction of research away from questions for which we do not have enough data, or which have not been asked. In this sometimes contentious area of research on male victims’ experiences of DVA, there are a number of important questions which need to be asked, but which can be obscured by what is already known. This paper seeks to broaden the scope of the conversation in this field by engaging both with what is known and what is not yet adequately known using a relatively novel mixed methods approach.Help seeking by, and service provision to male victims of DVA. Definitions of relevant DVA terms can be found in Table We have previously conducted a systematic review of the relevant literature using standard methodology based on Cochrane principles . This syOur IMMS was based on the mixed methods approach to systematic review evidence initially proposed by Dixon-Woods and colleagues and further developed by Heyvaert, Hanees and Obghena , 8. DefiIn this synthesis we used a Narrative Summary approach facilitated by the development of propositions. Narrative Summary is often used in systematic reviews alongside systematic searching and appraisal techniques . NarratiDespite methodological guidance, in practice Narrative Summary is still largely an informal approach and as such, is subject to criticism of its lack of transparency . This isIn this IMMS, we composed propositions to explore service provision for male victims of DVA using the mixed methods primary-level evaluation study evidence identified in the systematic review and then looked to support these propositions with the evidence from the 12 primary-level qualitative interview and survey studies of men’s experiences.In practice, the above methodology was applied in individual and group work. Fig. .Fig. 1AThe systematic review evidence was presented as part of a DVA stakeholder group (REPROVIDE Programme) consensus process for discussion. For the stakeholder group we identified experts in the field through existing contacts within the research team and through contacts of the REPROVIDE executive advisory group . The groThe purpose of the consensus process was to explore and debate some controversial and difficult areas of practice. The meeting, which took place in September 2016, generated a constructive multi-professional debate around issues identified during the review process. The main outcome of the consensus process was to feed into the development of the General Practice-based training and advocacy support intervention for DVA as part of the REPROVIDE Programme . HoweverThe first author (AH) drafted some example propositions from the primary-level service evaluation study data and the process was discussed face to face with the rest of the authors using a previous published exemplar of IMMS to clarify the process . Each auThe primary-level qualitative interview and survey data and published synthesis was discussed by the authors as a group . The quaThese propositions were presented by the research team  to four members of the REPROVIDE male victim Patient and Public Involvement (PPI) group during a meeting in February 2017 to discuss their relevance and check that they reflected reality.Propositions with supporting qualitative evidence were used by the research team to formulate recommendations for policy and practice. Propositions without supporting qualitative evidence were used to discuss the gaps in the evidence for help seeking for male victims of DVA.systematic review ‘ A mixed method systematic review of interventions in all settings for male victims of Domestic Violence and Abuse’ identified four primary-level mixed methods evaluation studies [DVA [The previous  studies , 13–15. ies [DVA –27 the importance of a private, confidential space to talk in; 2) the importance of being believed and listened to; 3) that the professional is knowledgeable about DVA ; 4) not to avoid difficult conversations; to take disclosure seriously and not to use humour; 5) professionals should acknowledge sexuality and ethnicity; 6) to avoid assumptions about sexuality (particularly heteronormative assumptions) and 7) appropriate transparent signposting. The qualitative themes demonstrate the importance of a facilitative environment, sensible timing and effective communication skills in trust building and effective immediate response [The evidence gives a strong steer as to what men expect out of a professional service both in terms of practical requirements e.g. confidential space and emotional support..These propositions were not supported by the primary-level qualitative study evidence and an IMMS was not achieved, identifying gaps in the evidence. Some of the proposition topics were briefly mentioned in the qualitative papers but with no evidence available to use for an IMMSProposition 8:It is important that we use the most appropriate approach to the potential blurred boundaries of victim –perpetrator (to provide support and not to make the man feel like it is surveillance)McCarrick and colleagues interviewed men who were frustrated and distressed by the confusion over victim/perpetrator role by the criminal justice system but no practical recommendations on this issue were discussed .Proposition 9:There is a need to understand the appropriate approach to hybrid perpetrator-victim experiences.Proposition 10:There is a need to understand the appropriate approach to discussing the current experiences of men who are/have been victims of childhood sexual abuse.Proposition 11: There is a need to understand the most appropriate and adequate way of determining the level of risk a man is at (bearing in mind current risk tools are underdeveloped).Proposition 12:There is a need to know if it is possible to have a single service (point of access) to provide appropriate support and linkage to other services to male victims from all backgrounds.Proposition 13:For men with experience of substance/alcohol abuse or mental health problems we need to know how it is best to signpost to relevant services.McCarrick mentions that mental health issues and lack of confidence e.g. post-traumatic stress disorder may prevent men accessing services .Proposition 14:There is a need to understand how linkage/co-ordination between services supporting male victims can be maximised.There were no significant primary-level qualitative data to provide any specific support to this proposition although it was acknowledged as an important issue in a couple of the studies , 27. Two.  and discussed and modified by the other authors until consensus was reached. Fig. .Fig. 2RThis is the first IMMS of systematic review evidence on help seeking by and service provision to male victims of DVA. We have generated recommendations from our synthesis based on what men would ideally want from a service and high-light significant gaps in the evidence for service provision. Our work adds to the development of IMMS within health and social care research by promoting the use of this relatively novel methodology, defining terms and extending the methodology by using extensive stakeholder involvement.In this discussion, we firstly debate the service provision in light of the evidence of the needs and actual experience of service provision by male victims of DVA and secondly contextualise the gaps in the evidence identified and make recommendations on the future of research in these areas. We acknowledge that these two tasks are not mutually exclusive.Propositions 1-7 have informed policy and practice recommendations regarding initial contact and approach, referral and ongoing care of male victims of DVA by professionals. They also identify the wider issues of awareness of male victims of DVA both by professional services and the public alike. This indicates a role for primary prevention efforts and wider media awareness campaigns around men’s health.Society is becoming more aware of male victims of DVA, and research, practice and policy are progressing, However, there are still many obstacles, not in the least unrelenting financial pressure on the DVA service sector and now in 2020 we have the impact of the Covid-19 crisis .We need to promote an intersectional approach in existing front-line organisations as well as supporting the development of new male victim needs-led support schemes. Robust evidence of effectiveness of interventions and appropriate resources supporting the running of these organisations/schemes are critical.Seven of our 14 propositions were not addressed by our IMMS (P8—14) and thus are the basis of the research recommendations. In part, it is important to acknowledge the issues are extremely difficult to address. However, equally we are aware of practice and to a lesser extent research in progress with many of these issues.Propositions 7-10 deal with how professionals approach the challenging issue of getting an accurate picture of a man’s relationship and experience of DVA. Being aware of any childhood or previous abuse history and the initial contact of male victims with services.http://respect.uk.net/) have developed a toolkit and national standards for working with male victims of DVA [Whilst there is a lack of formal research internationally, services have been developed in the USA, Canada, some Scandinavian countries and the Antipodes. Respect, London UK  because of their perception that they can be treated as perpetrators, yet we know from both the female and male victim data that their perpetrators sometimes present as victims at various points , 31. WhiPropositions 11-14 ask about service provision for male victims of DVA from all backgrounds whether it is possible to have a single service/point of access, whether these services are linked, and proposition 12 specifically tackles substance/alcohol abuse and mental health support.In the UK, helplines set up for male victims of DVA are likely to cover wide geographical areas but refer to local services. Blanket local provision would be difficult to justify financially as it is known that relatively small numbers of men are known to access these services .In terms of the high prevalence of alcohol and drug problems in DVA situations, work in the UK focuses on female victims and ongoing work seeks to develop an integrated substance abuse/DVA approach to tackling these challenging issues , 35.Linkage and communication between DVA and related services are difficult as the needs of male victims are diverse, and different services have different approaches. However, as our research shows, and the activities of DVA organisations are evolving, awareness surrounding intersectionality and the multiple barriers to help seeking and disclosure by male victims of DVA is increasing. This in turn can contribute to not only to a more nuanced understanding of the experiences of male victims and the obstacles to support but can also lead to a more joined up approach.IMMS fed into the development of the IRIS+ integrated general practice-based training and advocacy support intervention program [The findings of this  program . IRIS +  program . IRIS+ iThis IMMS is based on data obtained from a robust systematic review and has been conducted by an experienced team both in terms of the evidence synthesis methodology and the topic area of DVA. This synthesis is also a component part of the REPROVIDE programme and gains from the expertise of that group . The IMMThe limitation of such an approach are that proposition development is a subjective process reliant on the expertise and objectivity of the proposers. This can be counteracted at least in part by transparency of process and involving a wide variety of stakeholders, as well as consulting with a PPI group. Ideally, we would have consulted the male victim PPI group early in the process during the development of the propositions as opposed asking for their confirmation and comments on them. We were however restricted by the timings and availability of these meetings. In future analysis, we would endeavour to involve all parties in the initial development of the propositions.Production of an IMMS, is relatively lengthy, requiring conduct of the systematic review and initial synthesis of at least part of the data before moving on to the more complex mixed methods analysis. Careful thought is needed to ensure that a mixed methods synthesis is justified within a project. Our synthesis was part of a large programme of work and we feel justified that its output has not only fed into intervention development but has also high-lighted important evidence gaps in the area of male victims of DVA that need to be addressed in future research. We are aware because of the length of this process there is new evidence which could be assimilated into this IMMS. Three multi-country studies by the same research team have been published in 2020 –39.. OneMixed methods synthesis of systematically reviewed evidence is an appropriate and useful research tool to further knowledge. Application of this approach to help- seeking by and service provision to male victims of DVA has informed recommendations for policy and practice as well as highlighting gaps in the research agenda.Additional file 1 Appendix 1. Themes and subthemes from qualitative synthesis.