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Purpose Domestic and family violence is a major public health issue impacting one in three women worldwide. The implications of such violence are considerable. Transcendental Meditation® (TM) represents a promising treatment option for women impacted by domestic violence given its demonstrable effects on mental and trauma-related symptoms. This study set out to compare the effectiveness of TM to group support, on quality of life, perceived stress and mood in female survivors of domestic violence. Methods This 16-week pilot randomised controlled trial recruited women from metropolitan Adelaide, who survived any type of domestic violence in their lifetime. Outcomes included health-related quality of life, severity of depression, anxiety and perceived stress, symptoms of post-traumatic stress disorder, and subjective experience. Data were analysed by intention-to-treat using linear mixed-effects models. Results Forty-two women were randomly assigned to the TM (n = 21) and support (n = 21) groups. Adjusting for random effects, TM was shown to be significantly more effective than support at improving Australian Quality of Life (AQoL-8D) utility scores (p = .011), and Depression Anxiety and Stress Scale (DASS-21) severity scores for depression (p = .029), anxiety (p = .017) and stress (p = .021) over the 16 weeks. There was no statistically significant time-group interaction effect for PTSD Checklist for DSM-5 (PCL-5) total symptom severity scores. Conclusions TM is shown to have promising effects on quality of life, perceived stress and mood among women exposed to domestic violence, suggesting that it may represent an effective alternative to group support. Trial Registration ACTRN12620000467932 (09/04/2020).

Background: Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age‐inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long‐term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega‐3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. Objectives: To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. Search methods: We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. Selection criteria: We included randomised and quasi‐randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. Data collection and analysis: We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow‐up; and cost. We used GRADE to assess the certainty of evidence for each outcome. Main results: We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross‐over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega‐3 PUFA, six used a combined omega‐3/omega‐6 supplement, and two used an omega‐6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co‐intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega‐3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega‐3 PUFA plus atomoxetine to atomoxetine; omega‐3 PUFA plus physical training to physical training; and an omega‐3 or omega‐6 supplement plus methylphenidate to methylphenidate; and two trials compared omega‐3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months.Although we found low‐certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high‐certainty evidence that PUFA had no effect on parent‐rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) −0.08, 95% CI −0.24 to 0.07; 16 studies, 1166 participants). There was also high‐certainty evidence that parent‐rated inattention (medium‐term: SMD −0.01, 95% CI −0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium‐term: SMD 0.09, 95% CI −0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo.There was moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate‐certainty evidence that medium‐term loss to follow‐up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). Authors' conclusions: Although we found low‐certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high‐certainty evidence that PUFA had no effect on total parent‐rated ADHD symptoms. There was also high‐certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups.We found moderate‐certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate‐certainty evidence that follow‐up was similar between groups.It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow‐up times. Refereed/Peer-reviewed

Refereed/Peer-reviewed Background: Current evidence favors a multidisciplinary biopsychosocial approach to the management of chronic non-specific low back pain (CLBP). However, it is unclear whether such an approach is facilitated by current clinical guidelines. This rapid review set out to examine the extent to which clinical guideline recommendations for managing CLBP address domains of the biopsychosocial approach. Methods: MEDLINE, EMBASE, CINAHL, and the gray literature were searched for any clinical guidelines targeting the management of CLBP, published within the last 6 years. Title/abstract and full-text screening were undertaken by two reviewers using the accelerated approach. Data extraction and critical appraisal were completed by two reviewers, independently. Extracted data were synthesized in narrative form. Results: Fifteen guidelines met the review inclusion criteria. One-half of the guidelines were considered to be of medium quality. All guidelines provided management recommendations addressing the biological domain of the biopsychosocial approach; 13 (87%) guidelines reported recommendations addressing the psychological domain, and 8 (53%) guidelines presented recommendations addressing the social domain. Only 53% (8/15) of guidelines reported recommendations addressing all three domains of the biopsychosocial approach. Guideline recommendations both across and within the biopsychosocial domains were varied and inconsistent. Conclusions: The CLBP clinical guidelines included in this review provided detailed guidance on the biological domain, yet limited attention and detail were afforded to the psychological and social domains. Several recommendations are presented on how to improve the quality of future CLBP guidelines, and to help foster the provision of a biopsychosocial approach to CLBP management.

Evidence-based practice (EBP) is a framework aimed at facilitating the delivery of best practice care. Despite documented benefits, many health professionals have expressed concerns about EBP. Naturopathic medicine has been cited as being in opposition to EBP; however, this is not supported by the evidence. In a recent cross-sectional Canadian survey of naturopathic doctors, respondents self-reported a moderate to high use of EBP and use of a range of sources of evidence to guide clinical decisions. Evidence-based practice skill was reported to be moderately high, and attitudes were predominantly positive. These findings are consistent with other research undertaken on the topic which has identified a shift towards embracing EBP. Canadian naturopathic doctors have indicated a high level of interest in improving their EBP skills, and we present an upcoming opportunity for skill development.

Background Supporting a child’s healthy development is determined, in part, by a parent’s ability to seek, access, interpret and effectively utilize health information. This aspect of parenting draws on a set of skills referred to as health literacy. Objective To assess the level of health literacy among parents/carers in a regional South Australian community. Methods Parents/carers of primary school-aged children, residing in Whyalla, South Australia, were invited to complete the 13-item All Aspects of Health Literacy Survey. Results 155 parents/carers completed the survey (79% mothers). Most participants were English-speaking (97%), employed (62%) and had 2–3 children (62%), with 52% completing tertiary education. Median total health literacy scores were mostly in the moderate-high range (median 27, IQR 26,27), as were critical health literacy scores (median 7, IQR 6,8). Higher scores were reported for functional health literacy (median 8, IQR 7,9), communicative health literacy (median 9, IQR 8,9) and empowerment health literacy (median 4, IQR 3,5). Conclusions Our findings reveal modest levels of health literacy among a sample of parents/carers of primary school-aged children in a regional South Australian community. Further work is needed to understand the differential effect of parental health literacy on child health outcomes, and the types of strategies that may mitigate the impact of these barriers on a child’s healthy development.

Brief overview Collectively the evidence obtained from across five clinical studies involving 936 adults indicate that mono-herbal preparations of Sambucus nigra L. berry (S.nigra), when taken within 48 hours of the onset of acute respiratory viral infection, may reduce the duration and severity of common cold and influenza symptoms in adults. There is currently no evidence to support the use of S.nigra berry for the treatment or prevention of COVID-19. Given the body of evidence from preclinical studies demonstrating the antiviral effects of S.nigra berry, alongside the results from clinical studies involving influenza viral infections included in this review, pre-clinical research exploring the potential effects of S.nigra berry on COVID-19 are encouraged. Verdict The evidence included in this review is mostly derived from clinical studies involving adult participants and examining short-term use of commercial formulations of S.nigra berry for up to 16 days. Findings from included studies suggest that mono-herbal preparations of S.nigra berry (in extract or lozenge formulation) may reduce influenza-type symptoms, including fever, headache, nasal congestion and nasal mucous discharge in adults, when taken within the first 48 hours of symptom onset. Within 2–4 days of S.nigra treatment, most adult participants experienced significant symptom reduction, by an average of 50%. Evidence regarding the effectiveness of S.nigra berry on the symptom of cough, and need for/use of medicines (including antibiotics) to treat acute respiratory infections, is currently unclear and inconsistent. Adverse events were rare with no serious events reported. Adverse events, reported in two studies, were more common in comparators than in treatments. There is currently no reliable or sufficient scientific evidence to support the use of S.nigra in pregnant or lactating women.

Background Evidence-based practice (EBP) is integral to the provision of ethical, safe and high-quality health care. While osteopathy is an established and registered health profession in many countries, it is a developing, unregistered health profession in Sweden. This study explored the perceptions, skills, use, barriers and enablers of EBP among Swedish osteopaths. Methods Osteopath members of the Swedish Osteopathic Association were invited by email to participate in an anonymous online survey - a Swedish-translated and pilot-tested version of the Evidence-Based Practice Attitude and Utilisation Survey. Data collection was conducted between January and March 2019. Results Thirty-one per cent (78/249) of invited osteopaths responded to the survey. Respondents were largely supportive of EBP and most agreed or strongly agreed that EBP assisted clinical decision-making (84.7%), improved quality of patient care (83.3%), and was necessary in the practice of osteopathy (80.8%). Respondents typically reported moderate to moderate-high levels of EBP skills, whereas their level of engagement in EBP activities was variable and infrequent. The main reported barrier for EBP uptake was lack of clinical evidence in osteopathy. Workplace access to the internet and free online databases, and the ability to download full-text journal articles, were considered very useful enablers of EBP. Conclusions The responding Swedish osteopaths appeared largely supportive of EBP, reported moderate to moderate-high levels of EBP skills but participated infrequently in EBP activities. Studies of interventions aimed at enhancing the skills and clinical use of EBP in osteopathy are warranted.

Objectives Osteoarthritis is a prevalent condition with a high level of disease burden. Some dietary regimens used in traditional medicine systems show promise as a treatment for osteoarthritis. The aim of this study was to assess the effect of a Persian food on the symptoms of osteoarthritis. Design A pilot non-randomised open-labeled clinical study Methods Patients with a diagnosis of osteoarthritis received 500 g chickpea broth (Nokhodāb) daily for the first five days, followed by the same amount per week for the next three weeks. The knee injury and osteoarthritis outcome score questionnaire and short-form World Health Organisation quality of life questionnaire were administered at baseline, day five and day thirty. The safety profile of the intervention was also assessed. Results Consumption of Nokhodāb was associated with improvements in pain, with a statistically significant decline in pain scores detected after 30 days (p = 0.005). Significant improvements in three of five quality of life domain scores were also reported at the same time point (p = 0.04). Conclusions The findings of this pilot study reveal a promising effect of Nokhodāb on pain and quality of life in patients with osteoarthritis. More definitive controlled trials are now needed to verify these findings.

Introduction Building and implementing a robust evidence-base which is informed by high quality research is the challenge facing contemporary healthcare professions. In doing so, it can be valuable for healthcare professions to establish a strategic research agenda in order to enhance the professions public health priorities within healthcare and assist in the allocation of limited research resources. Whilst formal chiropractic research agendas have been established in North America and Europe, no comprehensive, inter-organisational chiropractic research agenda has been formulated within the Australian context. A critical precursor to inform the development of any such Australian chiropractic research agenda, is the identification of the priorities held by practising chiropractors, chiropractic academics, educators, researchers, and postgraduate HDR students, along with an appraisal of the current research capacity and output of the Australian chiropractic profession. Objectives Design a questionnaire to; a) identify and rank the research priorities of a national sample of practising chiropractors, chiropractic academics, educators, researchers, and postgraduate HDR students, and; b) examine the current research capacity and output of the Australian chiropractic profession. Methods A survey instrument design was developed via an iterative process that initially built upon an extensive search of the chiropractic research priority literature from which items were aggregated and distilled. Senior and experienced members of the profession were then consulted to identify other items that should be considered for inclusion. Results The finalised cross-sectional questionnaire is a self-administered, multi-dimensional instrument comprising 5 main research categories. In addition, the questionnaire also includes items such as research funding, support for existing research agendas, and suggestions for future research. The questionnaire also explores research output, research barriers, research time allocation, perspectives on engagement, interdisciplinary collaboration and secured research funding. Analysis Quantitative data will be descriptively analysed whilst qualitative data will be analysed and reported along standard qualitative study protocols. Conclusion The Australian chiropractic profession needs to maximise ambitious, collaborative, creative research performed at best practice standards and then accelerate the implementation of useful findings that emerge. By ensuring the voices of all sectors of the profession are heard in the formulation of an Australian Chiropractic Research Agenda, the findings from our study will provide important insights into future research directions for the Australian chiropractic profession.

Background Impaired sleep is a common complaint among patients undergoing major surgery and may be a contributing factor in postoperative pain. The provision of eye masks to patients after cardiac surgery may reduce postoperative pain through improvements in sleep quality. Objective To examine the effect of nocturnal eye masks on postoperative pain and sleep quality in cardiac surgical patients. Methods In this randomized controlled trial, 70 adult patients who had undergone cardiac surgery requiring immediate postoperative care in the intensive care unit were randomly assigned to sleep with or without nocturnal eye masks for the first 3 nights in the unit. A visual analog scale was used to assess pain intensity, and the Arabic version of the Richards-Campbell Sleep Questionnaire was used to assess subjective sleep quality. Results A total of 66 patients completed the trial. A statistically significant difference was found between groups in mean total Richards-Campbell Sleep Questionnaire score over the 3-day study period (P = .001), with the intervention group reporting better sleep quality. A statistically significant difference was also found between groups in mean pain score on days 1, 2, and 3 (P < .001), with the intervention group having less pain. Conclusion Nocturnal eye masks are a simple, low-risk, low-cost intervention that may contribute to reductions in perceived pain in cardiac surgery patients.

Background: This study set out to determine the prevalence and possible risk factors of headache and/or migraine in U.S. children, as well as the prevalence of complementary medicine use in this population. Methods: This is a secondary analysis of data from the 2017 U.S. National Health Interview Survey. Sociodemographic and clinical characteristics were compared between individuals with and without headaches. A backward stepwise procedure with a logistic regression statistic was used to test for potential predictors. Results: Six percent of children reported headaches and/or migraine within the past 12 months. Headaches were predicted by older age, female sex, non-Hispanic white ethnicity, and living in the southern United States. Inability to afford balanced meals and feeling sad or depressed in the past 6 months were also associated with higher odds of headache. A total of 19.2% of children with headaches reported using mind-body medicine, compared with 12.2% of children without headaches. Most frequently used therapy was yoga (57.2%), followed by spiritual meditation (31.1%) and mindfulness meditation (24.0%). The prevalence of visits to a complementary medicine practitioner or healer was 12.5%. Most frequently seen practitioners were chiropractors (62.1%), followed by naturopaths (21.2%), homeopaths (14.1%), and traditional healers (2.5%). Conclusions: The common use of complementary medicine among children suffering from headaches is worth noting. Understanding the motivation for using complementary medicine, as well as the choice of different forms of such therapy, may shed further light on the health-seeking behavior of this population.

OBJECTIVE: The purpose of this study was to explore the research priorities of Australian practicing chiropractors and academics across a set of research domains to determine the agreement or disagreement based on these domains. METHODS: We conducted a pilot-tested online survey focusing on the following 5 principal research domains: basic science, conditions (disorders chiropractors may encounter), patient subgroups, clinical interventions, and practice and public health/health services. Responses were sought regarding support for funding research scholarships, practice-based research networks, scientific conferences/symposia, journals, and existing research agendas. Data were collected (February 19 to May 24, 2019) from a sample of chiropractic academics (n1 = 33) representing 4 Australian programs and practicing chiropractors (n2 = 340). Collected data were ranked and analyzed to determine agreement across domains and items. RESULTS: There was agreement between the 2 groups across the majority (>90%) of domain items. The closest agreement and highest rankings were achieved for the "clinical interventions and practice" and "conditions" domains. Disagreement was observed within specific domain items, such as patient subgroups (infants), and for 1 intervention (chiropractic-specific techniques). Disagreement also occurred outside of the main domains, including research agenda support and funding. CONCLUSIONS: There was overall agreement between practicing chiropractors and academics across most research area domain items, which should help facilitate consensus-led development of any potential Australian Chiropractic research agenda. Disagreements across specific domain items, such as population subgroups, interventions, and funding require further investigation.

usc Background and purpose: The current body of research examining the effectiveness of reflexology in patients with cancer have predominantly focused on managing physical symptoms and treatment side effects. This review aimed to synthesise evidence from randomised controlled trials (RCTs) examining the effectiveness of reflexology on mental health outcomes in people with cancer. Methods: RCTs published in English and measuring stress, anxiety, depression or quality of life (QoL) were included. Eligible RCTs were identified through search of MEDLINE, Embase, Emcare, PsycINFO, Scopus, the Cochrane Library, OTseeker, PEDro (18 June 2021) and Google and Google Scholar (21 June 2021). The Critical Appraisal Skills Programme Randomised Controlled Trials Checklist was used to assess risk of bias. Meta-analysis and narrative synthesis were undertaken. The certainty of evidence was assessed by using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Results: Fifteen RCTs (1356 adult participants) were included. Evidence for stress and anxiety (primary outcomes), as well as depression and QoL (secondary outcomes), were mixed and conflicting. The certainty of the evidence was low to very low. Conclusion: An unequivocal recommendation supporting reflexology cannot be made. Greater utilisation of well-established reporting guidelines, together with increased investment in well-designed, high-quality clinical research are required. Refereed/Peer-reviewed

Background Mental health disorders are a global health concern. In Australia, numerous national reports have found that the current mental healthcare system does not adequately meet the needs of Australians with mental illness. Consequently, a greater understanding of how people with a mental health disorder are using the broader healthcare system is needed. The aim of this paper is to explore conventional and complementary health care use and expenditure among Australian adults reporting a mental health disorder diagnosis. Methods A cross-sectional online survey of 2,019 Australian adults examined socio-demographic characteristics, complementary and conventional health care use and the health status of participants. Results 32 % (n = 641) of the total sample (N = 2019) reported a mental health disorder in the previous 3 years. Of these, 96 % reported consulting a general practitioner, 90.6 % reported using prescription medicines, 42.4 % consulted a complementary medicine practitioner, 56.9 % used a complementary medicine product and 23 % used a complementary medicine practice. The estimated 12-month out-of-pocket health care expenditure among Australians with a mental health disorder was AUD$ 4,568,267,421 (US$ 3,398,293,672) for conventional health care practitioners and medicines, and AUD$ 1,183,752,486 (US$ 880,729,891) for complementary medicine practitioners, products and practices. Older people (50–59 and 60 and over) were less likely to consult a CM practitioner (OR = 0.538, 95% CI [0.373, 0.775]; OR = 0.398, 95% CI [0.273, 0.581] respectively) or a psychologist/counsellor (OR = 0.394, 95% CI [0.243, 0.639]; OR = 0.267, 95% CI [0.160, 0.447] respectively). People either looking for work or not in the workforce were less likely to visit a CM practitioner (OR = 0.298, 95% CI [0.194, 0.458]; OR = 0.476, 95% CI [0.353, 0.642], respectively). Conclusions A substantial proportion of Australian adults living with a mental health disorder pay for both complementary and conventional health care directly out-of-pocket. This finding suggests improved coordination of healthcare services is needed for individuals living with a mental health disorder. Research examining the redesign of primary health care provision should also consider whether complementary medicine practitioners and/or integrative health care service delivery models could play a role in addressing risks associated with complementary medicine use and the unmet needs of people living with a mental health disorder.

BackgroundWhile evidence-based practice (EBP) is widely accepted across healthcare professions, research investigating its implementation in manual therapy professions such as osteopathy is limited. The primary aim of this study was to investigate Italian osteopaths’ attitudes, skills, and use of EBP. A secondary purpose was to understand the obstacles and enablers to EBP adoption in the Italian osteopathic context.MethodsA cross-sectional national survey was conducted (April to June 2020) among a sample of Italian osteopaths. Eligible participants were invited to complete the Italian-translated Evidence-Based practice Attitude and Utilization Survey (EBASE) anonymously online using various recruitment strategies, including email and social media campaigns. In addition to the three EBASE sub-scores (attitudes, skills and use), the demographic characteristics of the sample were considered.ResultsA total of 473 osteopaths responded to the survey. The sample appeared to represent the Italian osteopathic profession. The majority of participants had a favorable attitude toward EBP. Eighty-eight percent of respondents agreed that EBP was necessary for osteopathy practice and that scientific literature and research findings were beneficial to their clinical scenario (95%). Perceived skill levels in EBP were rated as moderate, with the lowest scores for items relating to clinical research and systematic review conduct. Apart from reading/reviewing scientific literature and using online search engines to locate relevant research papers, participant engagement in all other EBP-related activities was generally low. Clinical practice was perceived to be based on a very small proportion of clinical research evidence. The primary obstacles to EBP implementation were a dearth of clinical evidence in osteopathy, and poor skills in applying research findings. The primary enablers of EBP adoption were access to full-text articles, internet connectivity at work, and access to online databases.ConclusionsItalian osteopaths were largely supportive of evidence-based practice but lacked basic skills in EBP and rarely engaged in EBP activities. The updating of osteopathic training curriculum and professional formal regulation in Italy could provide a suitable framework to improve EBP skills and use.

Background While controversy remains regarding optimal vitamin D status, the public health relevance of true vitamin D deficiency is undisputed. There are few contemporary cross-ethnic studies investigating the prevalence and determinants of very low 25-hydroxyvitamin D [25(OH)D] concentrations. Methods We used data from 440,581 UK Biobank participants, of which 415,903 identified as white European, 7,880 Asian, 7,602 black African, 1,383 Chinese, and 6,473 of mixed ancestry. 25(OH)D concentrations were measured by DiaSorin Liaison XL and deficiency defined as ≤ 25 nmol/L 25(OH)D. Results The prevalence of 25(OH)D deficiency was highest among participants of Asian ancestry (57.2% in winter/spring and 50.8% in summer/autumn; followed by black African [38.47%/30.78%], mixed ancestry [36.53%/22.48%], Chinese [33.12%/20.68%] and white European [17.45%/5.90%], P Conclusions Vitamin D deficiency remains an issue throughout the UK, particularly in lower socioeconomic areas and the UK Asian population, half of whom have vitamin D deficiency across seasons. Key messages The prevalence of 25(OH)D deficiency in the UK is alarming, with certain ethnic and socioeconomic groups considered particularly vulnerable.

ObjectivesNaturopathy is a traditional medicine system informed by codified philosophies and principles, and an emphasis on non-pharmacologic therapeutic interventions. While naturopathy is practiced by approximately 75 000 to 100 000 naturopathic practitioners in at least 98 countries, little is known about the international prevalence of history of consultation with a naturopathic practitioner. This study reports a systematic review and meta-analysis of studies describing the global prevalence of history of consultation with a naturopathic practitioner by the general population.SettingThe included literature was identified through a systematic search of eight databases between September and October 2019, as well as the grey literature.ParticipantsStudies were included if they reported the prevalence rate of consultations with a naturopathic practitioner by the general populationInterventionsSurvey items needed to report consultations with a naturopathic practitioner as defined in the country where data was collected, and not combine naturopathic consultations with other health services or only report consulations for illness populations.Primary and secondary outcome measuresPrimary measures used for the analysis was consultations in the previous 12-months. Other prevalence timeframes were reported as secondary measures.MethodsMeta-analysis of prevalence data was conducted using random effects models based on individual countries and World Health Organisation (WHO) world regions.ResultsThe literature search identified eight manuscripts summarizing 13 studies reporting prevalence for inclusion in the review. All included studies had a low risk of bias. Meta-analysis of the included studies by world region found the 12-month prevalence of history of naturopathy consultations ranged from 1% in the Region of the Americas to 6% in the European and Western Pacific Regions.ConclusionsThere are up to 6-fold differences in the prevalence of naturopathy consults over 12-months between and within world regions, which may be driven by a range of policy, legislative and social factors.Strengths andLimitations of this studyNaturopathy is one of the most commonly used traditional and complementary medicines in the Western world and this is the first systematic review and meta-analysis reporting the prevalence of consutations with a naturopathic practitioner.This study includes only includes data published after 2010 to ensure the results are contemporary, however this may have excluded some studies in countries with older data.The results are limited by the poor availability of data reporting consultations with a naturopathic practitioner, including in countries where a large number of naturopathic practitioners are known to provide care.

Aim To describe the prevalence of health care utilisation and out-of-pocket expenditure associated with the management of diabetes among Australian women aged 45 years and older. Design Cross-sectional survey design. Methods The questionnaire was administered to 392 women (a cohort of the 45 and Up Study) reporting a diagnosis of diabetes between August and November 2016. It asked about the use of conventional medicine, complementary medicine (CM) and self-prescribed treatments for diabetes and associated out-of-pocket spending. Results Most women (88.3%; n = 346) consulted at least one health care practitioner in the previous 12 months for their diabetes; 84.6% (n = 332) consulted a doctor, 44.4% (n = 174) consulted an allied health practitioner, and 20.4% (n = 80) consulted a CM practitioner. On average, the combined annual out-of-pocket health care expenditure was AU$492.6 per woman, which extrapolated to approximately AU$252 million per annum. Of this total figure, approximately AU$70 million was spent on CM per annum. Conclusions Women with diabetes use a diverse range of health services and incur significant out-of-pocket expense to manage their health. The degree to which the health care services women received were coordinated, or addressed their needs and preferences, warrants further exploration. Limitations of this study include the use of self-report and inability to generalise findings to other populations.

Background Over the past few decades, the popularity of complementary and alternative medicine (CAM) has grown considerably and along with it, scrutiny regarding its evidence base. While this is to be expected, and is in line with other health disciplines, research in CAM is confronted by numerous obstacles. This scoping review aims to identify and report the strategies implemented to address barriers to the conduct and application of research in CAM. Methods The scoping review was undertaken using the Arksey and O’Malley framework. The search was conducted using MEDLINE, EMBASE, EMCARE, ERIC, Scopus, Web of Science, The Cochrane Library, JBI and the grey literature. Two reviewers independently screened the records, following which data extraction was completed for the included studies. Descriptive synthesis was used to summarise the data. Results Of the 7945 records identified, 15 studies met the inclusion criteria. Using the oBSTACLES instrument as a framework, the included studies reported diverse strategies to address barriers to the conduct and application of research in CAM. All included studies reported the use of educational strategies and collaborative initiatives with CAM stakeholders, including targeted funding, to address a range of barriers. Conclusions While the importance of addressing barriers to the conduct and application of research in CAM has been recognised, to date, much of the focus has been limited to initiatives originating from a handful of jurisdictions, for a small group of CAM disciplines, and addressing few barriers. Myriad barriers continue to persist, which will require concerted effort and collaboration across a range of CAM stakeholders and across multiple sectors. Further research can contribute to the evidence base on how best to address these barriers to promote the conduct and application of research in CAM.

Background Acute respiratory tract infection (ARTI) is one of the most prevalent types of infection among children and a common reason for hospital admission. Although parents frequently consult complementary and alternative medicine (CAM) practitioners to assist with the management of childhood ARTI, little is known about the treatments that CAM practitioners recommend and why. The aim of this research was to understand what CAM practitioners typically prescribe for the management of childhood ARTI and how practitioners formulate decisions regarding the management of this condition. Method The research was guided by a qualitative descriptive framework. CAM practitioners across Greater Melbourne (Victoria, Australia) who had treated children aged 0-12 years with ARTI in the past 12 months were eligible to participate. Data were captured using semi-structured interviews, which were audio-recorded and transcribed verbatim. Multiple strategies to improve trustworthiness were implemented (e.g., triangulation of data). Data were analysed using inductive content analysis. Results Twenty-four CAM practitioners from ten different disciplines participated in the interviews. Most participants were female (75%), and more than half (54%) were practicing naturopaths. The treatments most commonly recommended were lifestyle modification (95%), nutrition/diet-based treatments (91%), and vitamin/mineral supplementation (87%). Practitioners' decision-making process was underpinned by four key concepts namely: the approach to management, individualisation, do no harm, and collaborative practice. Individualisation and the safety of the child are cornerstones of treatment in the practitioner's decision-making process. Conclusion This research sheds light on commonly used CAM interventions, many of which build on easily accessible and readily available treatments (such as soups) and are aligned with mainstream recommendations (such as rest). Practitioners' decision-making process too aligns well with mainstream health care where the focus is on safety and informed by a biopsychosocial-cultural approach.

Background The use of complementary and alternative medicine (CAM) is increasing globally, in both adults and children. A common condition where CAM is used in children is acute respiratory tract infection (ARTI). However, limited information exists regarding specific CAM modalities used in children, and the factors that influence a parent's decision to use CAM for ARTI in children. This research aimed to address this knowledge gap. Method This research used a qualitative descriptive approach. Parents residing in Greater Melbourne, Australia, who had children aged from 0-12 years, and had used CAM for treating ARTI in their children in the last 12 months, were eligible to participate. Parents' perspectives were captured using individual semi-structured interviews, which were then transcribed verbatim. Data were analysed using content analysis. Results Twenty-four families were interviewed. Several strategies to improve trustworthiness were implemented. Three themes underpinning the parents' decision to use CAM emerged from the data: safety, internal drivers and external drivers. Parents used a breadth of different treatments, predominantly food as medicine, followed by aromatherapy and other CAM remedies typically found in the kitchen, to manage ARTI in their children. Parents often used both CAM practitioners and mainstream medicine to manage ARTI in their children. While mainstream medicine was typically used to rule out any sinister pathology, CAM was often used as a frontline treatment option, with food as medicine (e.g. soups) dominating. This was due in part to concerns regarding the negative aspects of pharmaceutical use. Parents utilised a diverse range of information sources to inform their decision-making, including friends, families and the internet; traditional sources of research evidence were generally not used. Conclusion Child safety was a major factor influencing a primary carer's decision to utilise CAM for ARTI. The safety and effectiveness of remedies utilised by parents now warrants further investigation.

© 2019 The Author(s). Background: Osteopaths are an integral member of the health care team, playing a pivotal role in the provision of care for patients with musculoskeletal disorders. Osteopaths, like other health care providers, are under increasing pressure to deliver evidence-based health care and to improve patient outcomes. However, the extent to which osteopaths engage in evidence-based practice (EBP), particularly in Australia, is not well understood. This study therefore set out to investigate the attitudes, skills and use of EBP, and perceived barriers and enablers of EBP uptake, among osteopaths practicing in Australia. Methods: National cross-sectional survey of Australian registered osteopaths. Eligible participants were invited by email and other digital media recruitment strategies to complete the online Evidence-Based Practice Attitude and Utilisation Survey (EBASE). Results: A total of 332 osteopaths completed the survey. The demographic characteristics of respondents were generally consistent with the characteristics of the Australian osteopathy workforce. The respondents were mostly favourable of EBP, with the majority agreeing or strongly agreeing that EBP assists in making decisions about patient care (86.7%) and improves the quality of patient care (75.6%). While most respondents (88.3%) had some training in EBP, most reported a moderate level of perceived skill in EBP. The majority of respondents engaged infrequently (0-5 times) in EBP activities within the last month, and most indicated that a very small or small proportion of their clinical practice was based on clinical research evidence. Leading barriers to the uptake of EBP were lack of time and lack of clinical evidence in osteopathy. Key enablers of EBP uptake were access to the internet and online databases at work, and access to full-text articles and EBP education materials. Conclusions: Osteopaths participating in the survey were largely supportive of evidence-based practice, yet engaged infrequently in EBP activities. An important next step in this research is to identify suitable strategies that effectively improve EBP uptake in osteopathy, and perchance, improve patient outcomes.

Objective: To explore the influence of nonmetropolitan clinical immersion placements (CIPs) on undergraduate chiropractic student experience, professional attributes, and practice destination. Methods: Students enrolled in an Australian undergraduate chiropractic program were invited to complete a service experience questionnaire and an open-ended reflective feedback form following a nonmetropolitan CIP (Part A). Online searches were performed to gather data on graduate practice location (Part B). Results: Sixty-four students participated in Part A. All agreed that the placement was educational and should be retained in the program. Students agreed that the placement enhanced respect for individuals and awareness of others in need, highlighted the importance of respect for all people, improved empathy for the disadvantaged, and provided an opportunity to improve communication skills. Most indicated that they were more likely to practice in a country setting as a result of their placement, with those participating in a country placement more likely to practice in nonmetropolitan regions after graduation. Conclusion: Many chiropractic programs around the world are adopting CIPs. This study is the 1st to investigate the possible influence of nonmetropolitan CIPs on the development of desirable attributes in Australian chiropractic students. It also discusses the potential influence of nonmetropolitan CIPs on future practice location decisions. These results support the utility of CIPs to help meet the educational objectives of chiropractic programs and possibly address the maldistribution of the chiropractic workforce in Australia.

Evidence suggests an integrative, biopsychosocial approach to managing chronic nonspecific low back pain (CLBP) may help address the complex, unmet healthcare needs of people living with CLBP. Notwithstanding, the translation of this approach into primary care settings has been largely overlooked. This study aimed to develop, and reach consensus on, a needs-based integrative service delivery model to provide best practice care for people living with CLBP in a primary care context.Methods: The study comprised four stages: (a) translate practice guidelines into competencies; (b) map competencies onto healthcare occupations; (c) align competencies/occupations to an integrative health care framework; and (d) operationalise the framework by defining a high-level clinical pathway. A modified nominal group technique, comprising seven experts from different disciplinary backgrounds, reviewed and provided feedback on the outputs of each stage of the study. Facilitated discussions were undertaken to reach consensus on each output.Results Practice guidelines were translated into ten competencies, which were mapped to 25 distinct occupations. The competencies/occupations aligned with all 22 elements of the integrative healthcare framework, which were used to develop a high-level, four-stage clinical pathway. Following minor amendments, the nominal group reached consensus on all outputs of the study. Conclusions:This research used a novel design to develop a needs-based integrative service delivery model to facilitate the translation of an integrative, biopsychosocial approach for CLBP management into primary care. The next step of this research will be to test the acceptability and feasibility of the model in a primary care setting. Refereed/Peer-reviewed

ObjectivesNaturopathy is a traditional medicine system informed by codified philosophies and principles, and an emphasis on non-pharmacologic therapeutic interventions. While naturopathy is practised by approximately 75 000–100 000 000 naturopathic practitioners in at least 98 countries, little is known about the international prevalence of history of consultation with a naturopathic practitioner. This study reports a systematic review and meta-analysis of studies describing the global prevalence of history of consultation with a naturopathic practitioner by the general population.SettingThe included literature was identified through a systematic search of eight databases between September and October 2019, as well as the grey literature.ParticipantsStudies were included if they reported the prevalence rate of consultations with a naturopathic practitioner by the general population.InterventionsSurvey items needed to report consultations with a naturopathic practitioner as defined in the country where data was collected, and not combine naturopathic consultations with other health services or only report consulations for illness populations.Primary and secondary outcome measuresPrimary measures used for the analysis was consultations in the previous 12 months. Other prevalence timeframes were reported as secondary measures.MethodsMeta-analysis of prevalence data was conducted using random effects models based on individual countries and WHO world regions.ResultsThe literature search identified eight manuscripts summarising 14 studies reporting prevalence for inclusion in the review. All included studies had a low risk of bias. Meta-analysis of the included studies by world region found the 12-month prevalence of history of naturopathy consultations ranged from 1% in the Region of the Americas to 6% in the European and Western Pacific Regions.ConclusionsThere are up to sixfold differences in the prevalence of naturopathy consults over 12 months between and within world regions, which may be driven by a range of policy, legislative and social factors.PROSPERO registration numberCRD42020145529.

Objectives: To explore the challenges regarding evidence and complementary medicine in Australia and identify potential future directions to develop leadership, action and debate.Design: Facilitated discussion among a roundtable of experts to identify and consider the relevant issues and potential actions. Methods: Purposive sampling of 17 expert stakeholders with a variety of experience in the traditional and complementary medicine (T&CM) arena. Thematic analysis of the half-day discussion transcript resulted in a framework for a broad agenda to support the development of appropriate evidence for T&CM. Results: Five key areas (with sub-themes) were identified, forming the backbone of an agenda-setting framework: focus areas; strategies; actions and outputs; barriers; and drivers of change. ‘Focus areas’ encapsulated the main themes and informed all key areas, these were: consumer perspectives and needs; hierarchies of evidence; safety of products, practitioners and practices; modernisation ofT &CM; regulation and policy; and evidence-based practice. Two recurring themes informed the framework at multiple levels: the complexity and varied understanding of what is ‘appropriate evidence’ for T&CM; and putting consumers at the centre – to ensure that their needs and safety are prioritised. Lack of resources for undertaking T&CM research necessitates the need to bring together information from multiple sources so that ‘totalities of evidence’ can be assessed to increase the T&CM evidence-base. Doing so requires reassessment of the relative value of traditional forms ofevidence and challenges current linear evidence hierarchies that prioritise clinical trials as the ‘gold standard’. Conclusions: This Australian agenda-setting framework for strengthening T&CM evidence requires an interdisciplinary leadership group (including consumer, clinician, academic and industry representatives) to build consensus, foster collaboration, and generate and disseminate information. Prioritising the perspectives and needs of consumers should be a primary focus in taking the ‘strengthening evidence forT&CM’ agenda forward. Refereed/Peer-reviewed

Background The contemporary evidence-based practice model acknowledges the importance of patient preferences and clinician experience when applying evidence within a clinical setting. Knowledge mobilisation (KM) acknowledges the complexities of knowledge translation by recognising and respecting diversity in types of knowledge and how such diversity can influence health care and health care choices. While there has been considerable discussion on KM in health care, it has received little attention in the field of naturopathy. Despite naturopathy’s widespread international use, it is unclear how naturopathic practitioners (NPs) use and share knowledge and information in clinical practice. This study examines the mobilisation of knowledge amongst NPs internationally. Methods Online, international, cross-sectional survey of a self-selected sample of NPs from any country, that were either currently in clinical practice or had been in practice within the previous 12 months. The survey was administered in five languages (English, French, Portuguese, Spanish, German). Descriptive statistics were prepared for all survey items. Results The survey was completed by 478 NPs who reported using an average of seven (median = 7, SD = 2.6) information sources to inform patient care. NPs also drew on knowledge gained through patients sharing their perspectives of living with their health condition (Always/Most of the time: 89.3%). They mostly sought knowledge about how a treatment might benefit a patient, as well as knowledge about treatment safety and a better understanding of a patient’s health condition. NPs frequently reported sharing knowledge developed through consideration of the patient’s unique needs (83.3%), and primarily shared knowledge by producing information for the public (72.6%) and for patients (72.2%). Conclusions Based on these findings, it may be argued that NPs practice knowledge mobilisation; employing multiple forms and sources of knowledge, and mobilising knowledge to - as well as from - others. Due to their active engagement in patient and community education, NPs also may be considered knowledge brokers. In the context of the growing understanding of the complexities of knowledge translation and mobilisation in contemporary health care – and particularly within the context of implementation science – this study provides novel insights into an under-researched element of health services accessed by the community.

BackgroundInequalities in the availability of maternity health services in rural Australia have been documented, but not the impact on aeromedical retrievals. This study aims to examine the prevalence of pregnancy-related aeromedical retrievals, the most common conditions (overall and in specific age groups), and their distribution according to operation area and demographic characteristics.MethodsCross-sectional study using administrative data from the Royal Flying Doctors Service (RFDS) including all pregnant women aged 15–49 years retrieved by the RFDS between 2015 and 2019. All pregnancy-related aeromedical retrievals were classified according to the International Classification of Diseases, Tenth Revision (ICD-10, chapter XV). The distribution of pregnancy-related conditions was presented overall and stratified by age group (i.e. ResultsA total of 4653 pregnancy-related retrievals were identified (mean age 27.8 ± 6.1 years), representing 3.1% of all RFDS transfers between 2015 and 18 and 3.5% in 2018–19 (p-value 0.01). The highest proportion of pregnancy-related retrievals (4.8%) occurred in Western operation. There was an apparent increase in pregnancy-related retrievals in South Australia and the Northern Territory (Central Operation) in 2018–19. Preterm labour/delivery was responsible for 36.4% of all retrievals (40.7% among women aged 15–19 years) and premature rupture of membranes for 14.9% (19.4% among women aged 35–49 years). Inter-hospital transfers represented 87.9% of all retrievals, with most patients relocated from rural and remote regions to urban hospitals; most retrievals occurred during the day, with a median distance of 300 km. Adolescents and Aboriginal and Torres Strait Islander were overrepresented in the sample (four and eight times higher than their metropolitan counterparts, respectively).ConclusionsThe proportion of pregnancy-related aeromedical retrievals varies geographically across Australia. Overall, one-third of retrievals were related to preterm/delivery complications, especially among adolescents. Most retrievals performed by the RFDS are susceptible to public health strategies aimed at improving antenatal care and preventing unintended pregnancies among adolescents and Aboriginal and Torres Strait Islander women. Greater capacity to manage pregnancy conditions in rural hospitals could reduce the requirement for aeromedical inter-hospital transfers.

Background Although evidence-based practice (EBP) is largely supported across healthcare professions, its implementation in manual therapy professions such as osteopathy remains limited and debated. There is currently little knowledge of how Spanish osteopaths relate to EBP. Objectives The main aim of this study was to investigate the attitudes, skills and use of EBP among Spanish osteopaths. A secondary aim was to identify barriers and facilitators for the adoption of EBP in the Spanish osteopathic context. Methods National cross-sectional survey of Spanish osteopaths registered and non-registered to an osteopathic association in Spain. Eligible participants were invited by a range of recruitment strategies including email and social media campaigns to complete the Spanish-translated Evidence-Based practice Attitude and utilization Survey (EBASE) anonymously online. Results A total of 567 osteopaths completed the survey which represents an approximate response rate of 9%. Participant’s attitudes toward EBP were largely positive. Most respondents agreed or strongly agreed that EBP was necessary in the practice of osteopathy (89.6%) and that professional literature and research findings were useful to their day-to-day practice (88.9%). Levels of perceived skill in EBP were reported as low to moderate with lowest levels for items related to ‘research conduct’. Except reading/reviewing professional literature and using online search engines to find practice-related literature, participant engagement in all other EBP-related activities was generally infrequent. The perceived proportion of clinical practice that was based on clinical research evidence was reported to be very small. Main barriers to EBP uptake included a lack of clinical evidence in osteopathy and insufficient skills for applying research findings. Main facilitators of EBP uptake included access to full-text articles, internet at the workplace and online databases. Conclusions Spanish osteopaths were largely supportive of evidence-based practice, had low to moderate skills in EBP and engaged in EBP activities infrequently. Formal regulation of the profession in Spain and the inclusion of osteopathic programs into the university sector would potentially improve EBP skills and use.

Background There has been little attempt to date to narrow the education-practice gap in naturopathic medicine. A framework that brings naturopathic medicine education and practice closer together could help codify the knowledge of naturopathic medicine by providing simultaneous guidance on curriculum development and clinical decision-making in the discipline. Objective To develop, refine and validate the Advancing Naturopathic Education and Practice (ADVANCER) framework. Methods Published literature and pertinent government, professional association and institutional websites were scoped to identify key constructs for the ADVANCER framework. The constructs were grouped into ten domains, with each domain defined and translated into teaching and clinical practice outcomes. A two-round e-Delphi method, comprising international experts in naturopathic medicine education, was used to refine and validate the framework definitions and outcomes. Results Sixteen academics, from five different countries, participated in the Delphi study. In round one, nine of the ten domains of the ADVANCER framework were rated as either very important or extremely important by 81.2% of participants. Only 68.8% of participants rated the tenth domain as either very important or extremely important. Participant feedback on each domain were pooled and reviewed, and where suggested changes were recommended by more than one participant, respective definitions and outcomes of each domain were amended. In round two, at least 90% of participants rated each domain of the amended ADVANCER framework as either very important or extremely important, meaning consensus to retain these domains, definitions and outcomes had been reached. Conclusions The study findings indicate that the ADVANCER framework is conceptually sound and potentially applicable to diverse institutions and countries. An important next step of this research is to establish whether implementation of the ADVANCER framework within naturopathic medicine education and practice is feasible, effective and sustainable.

Objective: This study aims to describe the prevalence of health care utilization (including conventional medicine, self-care and complementary medicine treatments) for the management of asthma by women aged 45 years and over and their associated out-of-pocket expenditure.Methods: A self-reported mail survey of 375 Australian women, a cohort of the national 45 and Up Study, reporting a clinical diagnosis of asthma. The women were asked about their use of health care resources including conventional medicine, complementary medicine,and self-prescribed treatments for asthma and their associated out-of-pocket spending. Spearman’s correlation coefficient, student’s t-test and chi-square test were used as appropriate. Population level costs were created by extrapolating the costs reported by participants by available national prevalence data.Results: Survey respondents (N ¼ 375; response rate, 46.9%) were, on average, 67.0 years old (min 53, max 91). The majority (69.1%; n ¼ 259) consulted at least one health care practitioner in the previous 12 months for their asthma. Most of the participants (n ¼ 247; 65.9%)reported using at least one prescription medication for asthma in the previous 12 months.The total out-of-pocket expenditure on asthma treatment for Australian women aged 50 years and over is estimated to be AU$159 million per annum. Conclusions: The breadth of conventional and complementary medicine health care services reported in this study, as well as the range of treatments that patients self-prescribe,highlights the challenges of coordinating care for individuals living with asthma. Refereed/Peer-reviewed

Refereed/Peer-reviewed Introduction: Despite the growing international popularity and use of complementary and alternative medicine (CAM), the uptake of evidence-based practice (EBP) in CAM has been slow. This cross-sectional survey aimed to further our understanding of the factors impacting EBP uptake in CAM. Methods: The 32-item oBSTACLES instrument was administered online using the SurveyMonkeyTM platform. The survey evaluated barriers to both the conduct and application of research among CAM practitioners and researchers, from multiple CAM disciplines across Australia and New Zealand. Participants were recruited via practice-based research networks, professional associations, CAM educational institutions, CAM research centres, pertinent product manufacturers and social media platforms. Data were analysed using descriptive statistics. Results: Six hundred and eighty-two CAM stakeholders responded to the survey. Barrier items were divided into two interlinked constructs, “capacity” and “culture”. Capacity related to issues regarding access, competency, bias, incentives, and time, whereas culture related to values and complex systems. Under capacity, the greatest proportion of participants (>70%) agreed that access was a barrier to the conduct and application of research, including lack of funding, institutional support, research training and collaborations. In terms of culture, the majority of participants (>60%) agreed that values were a barrier to research conduct and application, including limited undergraduate research opportunities and diverse views of evidence. Conclusion: Findings from this research suggest a multitude of barriers negatively impact the conduct and application of research in CAM. Insights gained from this research will be instrumental in developing actionable strategies aimed at mitigating the impact of these barriers to improve research engagement in CAM.