Background: Healthcare services, in many countries, are increasingly being provided by cadres not trained as physicians, and these substitute health workers are referred to as mid-level health providers (MLHPs). The objective of this study was to rapidly synthesise evidence on the effectiveness of MLHPs involved in the delivery of healthcare, with a perspective on low- and middle-income countries.Methods: The review team performed an overview of systematic reviews assessing various outcomes for participants receiving care from MLHPs. The team evaluated systematic reviews for methodological quality and certainty of the evidence. Also, the review team consulted relevant stakeholders in India.Results: The final report included sevensystematic reviews, with six assessed as moderate to high methodological quality. Mortality outcomes concerning pregnancy and childbirth care services showed no significant differences in care provided by MLHPs when compared with doctors. Pregnancy care provided by midwives was found to improve the quality of care slightly. The risk of failure or incomplete abortion for surgical abortion procedures provided by MLHPs was twice when compared to the procedures provided by doctors. Moderate to high certainty evidence showed that initiation and maintenance of antiretroviral therapy for HIV-infected patients by a nurse or clinical officer slightly reduced mortality. High certainty evidence showed that chronic disease management by non-medical prescribers reduced some important physiological measures compared to medical prescribing by doctors.Conclusions: To date, this is the first rapid overview of the evidence on MLHPs. Low-quality evidence suggests that MLHPs might be suitable to deliver quality pregnancy care. Moderate and high-quality evidence from trials suggests that MLHPs are helpful for chronic disease management and initiation and maintenance of antiretroviral therapy in people with HIV/AIDS. However, the roles and subsequent training and regulation of MLHPs might be different for different care domains. Mid-level health providers (MLHPs) are currently being used in high- and low-income countries to assist doctors and specialists or render services independently, particularly in resource-poor settings, to make up for the scarcity of health professionals. Countries with poor economies and weak healthcare infrastructure have inadequate human resources for health. There is a growing movement for countries to strengthen and initiate the use of MLHWs to increase access to services. However, MLHPs have been used for many years in Africa and Asia. Their role has been progressively expanding and receiving attention, particularly in low- and middle-income countries (LMICs), as a strategy to overcome health workforce challenges and improve access to essential health services.There is a growing momentum worldwide to improve access to healthcare and provide efficient and cost-effective primary healthcare (PHC)Ayushman Bharat (AB) program. Primarily, the program has an insurance component  and the development of Health and Wellness Centres (HWCs) as strategies to advance on the path to universal health coverage.A cornerstone of India’s current health systems reform efforts is the flagship. One key pillar of rolling out the AB-HWC component is implementing a new health cadre trained and accredited for a set of skills/competencies related to PHC and public health. Further, one of this programme’s aims is the transformation of existing sub-health centres and PHCs to HWCs, with teams led by MLHPs.Ayushman Bharat’s HWC sub-strategy, the comprehensive primary healthcare (CPHC), conceives MLHPs as a key focal point for service organisation and delivery, performing a range of screening, diagnostic and clinical functions and improve health systems at the frontline. The program conceptualises 12 different packages for the CPHC reforms. The need to meet the time-sensitive demands and the availability of fewer resources necessitated a RES. We thus synthesised evidence related to the effectiveness of MLHPs in the PHC context of LMICs.The National Health Systems Resource Centre (NHSRC), the technical support agency of the National Health Mission, is responsible for developing the curriculum for MLHPs. We received a request from the NHSRC for a rapid review of evidence on the effectiveness of MLHPs in the PHC context of low- and middle-income countries (LMICs) to understand the role MLHPs can play in different packages. We host a rapid evidence synthesis (RES) platform, which provides RES products in various formats to public agencies. RES or rapid review is an emerging form of evidence synthesis that is increasingly being promoted by the WHO and employed by governments to inform decision makingAyushman Bharat. The 12 CPHC packages are: pregnancy and childbirth; neonatal and infant health services; childhood and adolescent health services; family planning, contraceptive services and other reproductive care services; communicable diseases (prevention and management); non-communicable diseases; elderly and palliative care; oral healthcare; ophthalmic and ear, nose and throat (ENT) care; mental health and emergency medical services.We conducted a rapid overview of systematic reviews (SRs) of evidence on the effectiveness of MLHPs within a span of about eight weeks and in all domains corresponding to the CPHC package in. However, MLHPs in various countries have been variously referred to as substitute health workers, auxiliaries, non-physician clinicians, and include cadres such as clinical officers, medical assistants, physician assistants, nurse practitioners, and surgical technicians. Institutions and researchers worldwide use alternate or less well-specified definitions, and therefore MLHP as defined in the SRs was considered for this review. Therefore, we used broad criteria for the rapid overview wherein we accepted the definition of MLHPs as defined by the SR authors. The overview of SRs is an appropriate study design for our research because we intended to summarise the evidence for multiple conditions in different disease/condition domains for the same type of intervention and on similar health systems, clinical and public health outcomes.The World Health Organization (WHO), defined MLHP as “a health provider who is trained, authorised and regulated to work autonomously, receives pre-service training at a higher education institution for at least 2–3 years and whose scope of practice includes (but is not restricted to) being able to diagnose, manage and treat illness, disease, and impairments , prescribe medicines, as well as engage in preventive and promotive care”Participants. The RES considered SRs assessing outcomes for participants receiving care from MLHPs in LMICs, including India.Intervention and comparators. SRs that compared service delivery provided by MLHPs with doctors or other types of MLHPs were included. The MLHPs included were midwives, nurses, auxiliary nurses, nurse assistants, non‐physician clinicians, and surgical technicians.Outcomes. The following outcomes were considered for inclusion based on the initial discussions with the requester: healthcare and clinical outcomes ; access to care; and quality of care (including patient or client satisfaction with care).Study design. SRs including studies of any quantitative study design, irrespective of whether they have or have not conducted meta-analyses and irrespective of whether they have or have not used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess the certainty of evidence were included. Qualitative SRs were not considered.Context. The review considered SRs with a focus on and including studies from LMICs. SRs that included studies conducted in both HICs and LMICs were considered for inclusion, with no pre-specified criteria for the percentage of studies included from LMICs.Stakeholder engagement. As part of the RES process, the review team and NHSRC jointly convened a policy dialogue to consult with relevant stakeholders on an interim draft of the MLHP policy brief. The final draft of the policy brief incorporated feedback from the consultation. The stakeholders included key stakeholders, including policymakers, health system managers and researchers.Extended data).Given time constraints, the search was limited to published and indexed articles, and those published in the English language. The following databases were searched (from database inception up until March 2019): Cochrane Database of Systematic Reviews; Medline (PubMed); EMBASE; Health Systems Evidence; and CINAHL. An additional search was conducted from April 2019 to April 2020 to update the review findings for recency and relevancy. Search strategies (for both the periods) are provided separately for each database  independently extracted all relevant outcome data, with random verification of 20% of the included studies by another author (SB).The lead reviewer (SM) independently screened the titles and abstracts of studies for inclusion, following which full-text examination of eligible studies was conducted for potential inclusion. A second reviewer (SB) randomly verified the results of the study selection process during both the screening stages. For each domain of interest, where multiple SRs were available, only one SR was included based on its comprehensiveness, recency, and quality. Each SR was independently assessed for methodological quality by using established standardised criteria (A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 checklist). The GRADE of evidence was synthesised with respect to a PHC setting and in an LMIC context to make the product locally relevant.The GRADE approach was used to assess the certainty of the evidence using a transparent framework for developing and presenting the summary of findings tablesAs part of the RES process, the RES team and NHSRC jointly convened a policy dialogue to engage and consult with relevant stakeholders to present an interim draft of the MLHP policy brief. The stakeholders included policy makers (key stakeholders from government agencies and collaborators), health system managers, and researchers from more than eight states in India.The search for evidence identified 5171 studies , with some quasi-experimental study designs and observational studies. Key characteristics of the included SRs are provided in the was used to assess the methodological quality of SRs included in the report. The checklist is a 16-item questionnaire. The critical appraisal results of the included SRs are provided in theExtended data file. Six out of seven SRs were of moderate to high methodological quality and well reported. Almost all the SRs did not refer toa priori protocol and publication bias was not assessed. One SR by Chaudharyet al. was of poor quality, as assessed by the checklist.The AMSTAR-2 checklistKey findings. The key findings from the included SRs have been categorised based on the various healthcare domains of interest in the CPHC package. The quality of evidence for the main outcomes is summarised using the GRADE approach and ‘Summary of Findings’ tables. The Summary of Findings tables aid in recording results, outcomes, and outcome risks in a structured synthesis format.MLHPs for care in pregnancy and childbirth. An SR compared the effectiveness of care provided by MLHPs, particularly midwives and auxiliary nurse midwives with doctors providing care in a team with midwives. The review included patients receiving pregnancy and childbirth services including antenatal care. The majority of the studies were conducted in tertiary care settings and developed countries. Most of the evidence was assessed as low certainty. It was found that the use of intrapartum analgesia and episiotomies were less likely with care provided by midwives when compared with that provided by doctors working along with midwives. Also, no significant difference in rates for performing caesarean section, postpartum haemorrhage, and preterm births were reported.No significant difference in the likelihood of an incomplete abortion was reported between groups of patients treated by auxiliary nurse midwives compared to those cared for by doctors. However, the likelihood of a complication during or an adverse event after manual vacuum aspiration was significantly greater with care provided by auxiliary nurse midwives. There was very low certainty evidence to suggest that pregnancy care provided by clinical officers reduced the likelihood of early neonatal death or postoperative maternal health outcomes, such as fever and wound infections.MLHPs for neonatal and infant health care services. The effectiveness of midwives/nurses delivering care for neonatal and infant healthcare services was compared with that provided by doctors or obstetricians in a team with midwives in a SR. The population included patients receiving neonatal and infant health services. The majority of the studies were conducted in tertiary care settings and developed countries. The certainty of the evidence was assessed as low quality. The review results showed that there was no significant difference between the groups in foetal or neonatal death rates. None of the studies included in the review reported on clinical outcomes, and outcomes related to quality of care and access to care.MLHPs for family planning, contraceptive and other reproductive health care services. Another SR by Barnardet al. evaluated the safety and effectiveness of surgical and medical abortion procedures administered by MLHPs compared to doctors. The review included various MLHPs who included nurses, midwives, doctor assistants, and physician assistants delivering care for patients requesting abortion procedures, either surgical or medical. The majority of the studies were conducted in PHC settings and LMICs. Much of the evidence was of low or very low quality. The review found that the evidence for surgical abortion procedures provided by MLHPs was lacking. Further, evidence from cohort studies suggested that there was an increase in the risk of failure or incomplete abortion for surgical abortion procedures when provided by MLHPs. However, no statistically significant differences in complications alone, immediate complications or delayed complications were reported when surgical abortion was provided by MLHPs. Concerning medical abortion procedures, the review results suggested MLHPs could safely and effectively carry out these procedures. No significant differences were reported for abortion failure or incomplete abortion. None of the studies included in the SR examined other outcomes of interest such as mortality, quality of care, and access to care.MLHPs for communicable diseases. Two SRs examined the effectiveness of the delivery of antiretroviral therapy (ART) provided by MLHPs in HIV-infected patients. The reviews included studies mainly conducted in primary healthcare settings and LMICs. The studies included in the reviews compared ART provided by nurses or clinical officers with doctors. The certainty of the evidence varied for different outcomes, from high to very low quality. However, the evidence for various outcomes was based on relatively few studies. The review reported that there was no significant difference in mortality, with lower rates of losses to follow up at 12 months. Further, no difference in death or number of patients lost to follow up at 12 months was reported when doctors initiated therapy and nurses provided follow-up. The reviews suggested that shifting tasks from doctors to MLHPs may help in potentially reducing costs of ART provision, without compromising on the quality of care and patient outcomes.MLHPs for non-communicable diseases. Two reviews compared the effectiveness of care provided by non-physician health workers (NPHWs) for patients with non-communicable diseases in primary and secondary healthcare settings. The NPHWs included nurses, pharmacists, allied health professionals, and physician assistants. The care provided by NPHWs was compared to that provided by doctors for various physiological measure outcomes, health-related quality of life, and access to care. The evidence assessed was of moderate to high quality. The findings from the two reviews suggested that care provided by NPHWs with varying but high degrees of autonomy and with support was comparable to that provided by doctors for various relevant outcomes. Care prescription by NPHWs significantly improved outcomes such as systolic blood pressure, glycated haemoglobin and low-density lipoprotein levels. Also, the care provided by NPHWs improved health-related quality of life . However, the mental health-related quality of life was reduced with the care provided by NPHWs compared to that provided by doctors. There was a lack of conclusive evidence on outcomes related to access to care.MLHPs for mental health. One SR compared the effectiveness of delivery of care provided by non-specialist health workers (NSHWs) to that provided by mental health specialists in women with perinatal depression. The NSHWs included midwives, nurses, and community health workers. The studies included in the review were conducted in primary health settings and LMICs. The review found that the NSHWs could effectively deliver psychological interventions for perinatal depression in low-resource settings, particularly where specialist services are both scarce and expensive. The review did not examine other relevant outcomes such as mortality, quality of care, and access to care. The review lacked proper reporting and hence it was not possible to assess the certainty of evidence by GRADE. The SR included nine RCTs involving a total of 14,555 participants.MLHPs for other packages of care. This RES did not identify any SRs that assessed the role of MLHPs in the provision of following health services.MLHPs for childhood and adolescent health servicesMLHPs for ophthalmic and ENT conditionsMLHPs for elderly and palliative healthcareMLHPs for emergency medical services. We contextualised the certainty using the GRADE approach. We found that there is some evidence that MLHP-led care may be appropriate in patients for management of various outcomes in different healthcare domains of interest such as maternal and child health, neonatal and infant health, and communicable and non-communicable disease management when compared to a physician or doctor-led care. Still, the certainty of the evidence for this was mostly low or moderate (barring a few exceptions). As such, while MLHPs can be considered as an alternative to medical professionals for some domains, the certainty of evidence implies the need for building an evidence base and careful evaluation of programs.In this rapid overview of SRs, we examined the evidence on the effectiveness of care provided by MLHPs in LMICs for various healthcare domains of India’s CPHC package, indicated that shifting tasks or sharing them with MLHPs could lead to increased service provision and improved patient outcomes in the provision of emergency obstetric care and family planning services. Studies from India and Nepal suggest that MLHPs found task-shifting of medical abortion provision to mid-level providers to be acceptable, and women were happy with the service provided. Moderate and high-quality evidence from trials suggests that MLHPs are helpful for chronic disease management and initiation and maintenance of ART in people with HIV/AIDS. As reported in a review that focussed on sub-Saharan Africa, task-shifting from physicians to nurses and midwives is a viable and cost-effective option for the management of HIV-AIDS.Low-quality evidence suggests that MLHPs might be suitable to deliver quality pregnancy care. In their review. However, similar to our review, previous reviews were limited by the quality of included studies.Other studies that investigated the effects of MLHPs support our review findings. We did not find any synthesised evidence in the form of SRs for childhood and adolescent health services, ophthalmic and ENT conditions, elderly and palliative health care, or emergency medical services. There is a need for conducting well-designed primary studies on these domains to inform future plans for rolling out of MLHPs to improve the delivery of health services in LMICs. The shortage and unbalanced distribution of the health workforce is a significant obstacle in achieving better health outcomes for maternal and child health, neonatal and infant health, and communicable and non-communicable disease management in LMICsJudging relevance to low-income countries is sometimes tricky, and we are aware that evidence from high-income countries is not directly generalisable to low-income countries. We based our judgments on assessing the likelihood that MLHP-lead care considered in the review address a problem that would be feasible and would be of interest to decision-makers in LMICs, regardless of where the included studies took place. While we looked at global evidence, the use of GRADE enabled us to contextualise evidence to India. A detailed examination of contextual factors specific to the Indian context would have provided extensive contextualised evidence; however, exploration of specific contextual factors was not the focus of this overview. We utilised a robust, transparent and comprehensive search strategy to identify all relevant SRs. We used a standardised checklist for methodological quality assessment of included SRs. Having a wide scope covering multiple CPHC domains enabled the identification of knowledge gaps that could inform relevant stakeholders at the national and state levels.As part of the RES process, we presented the interim policy brief to engage with key stakeholders to ensure that the product was robust, relevant, and valuable to the target audience. The stakeholders deliberated on the policy brief and provided feedback on the usefulness, relevance, format, and GRADE use. Following deliberations with the stakeholders, we made several changes to the policy brief regarding the use of standardised definitions, the use of more plain language statements, and contextualising evidence to the Indian setting. The inclusion of SRs provided more high-level insight into synthesised evidence around MLHPs. We did not update the reviews, and as such, we acknowledge the limitation of evidence from recently published primary studies.We found several gaps in current research on MLHPs. Evidence from SRs of randomised controlled trials is important. Still, this approach may not be the most appropriate, as they are unlikely to yield data to inform such a complex intervention. Primary research on outcomes related to access to care and quality of care is required. Future studies may consider addressing the implementation aspects as part of the existing healthcare system and the cost-effectiveness in LMICs. There is a lack of empirical studies in primary healthcare settings in LMICs.. Another study conducted in Chhattisgarh reported that physicians and nonphysician clinicians performed similarly in patient satisfaction, trust, and perceived quality. In Assam, a three-year rural health practitioner course was developed and implemented to select, train and deploy Rural Health Practitioners  in sub-centres, which showed significant improvements in the number and the range of services delivered.There is limited evidence on strategies and facilitators for implementing universal healthcare policies and the provision of equitable healthcare through MLHPs in India. A study in Chhattisgarh that assessed the clinical competence of non-physician clinicians and physicians in the delivery of primary healthcare services found comparable levels of competencyIn conclusion, and based on our findings, utilisation of MLHPs for care provision for certain healthcare domains may be applicable, relevant, and feasible in LMICs, including in India. MLHPs such as nurse practitioners, physician assistants, and community health officers will be required for primary care to fill the gaps in access and quality in health services. However, the roles and subsequent training and regulation of MLHPs might be different for several CPHC packages. There is a need for embedded research and robust evaluations in the future.All data underlying the results are available as part of the article and no additional source data are required.https://doi.org/10.6084/m9.figshare.12401525.v2Figshare: Extended data.docx.This project contains the following extended data:- Appendix 1: Search strategies (since database inception up until March 2019)- Appendix 2: Updated search strategies (April 2019 to April 2020)- Appendix 3: Key characteristics of the included SRs- Appendix 4: Critical appraisal results of included systematic reviews assessed using the AMSTAR-2 checklistCreative Commons Attribution 4.0 International license (CC-BY 4.0).Data are available under the terms of the The revisions are appropriate.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?PartlyAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?PartlyReviewer Expertise:Public health, epidemiologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Abstract . Results: no results are presented on the evaluation of the quality of the evidence. Conclusion: The conclusion does not emphasize that the evidence is of low or moderate quality on the usefulness of MLHPs in primary healthcare, and this should be mentioned).  Introduction:  The need for a rapid evidence synthesis for the study topic is not explicitly justified. I believe that the word "gratis" in the last paragraph is not suitable. The introduction is focused on India. This topic is suitable for LMIC. Hence, I recommend focusing the narrative of the manuscript on LMIC.     Methods: Specify stakeholder participation. The methodology describes that a single reviewer performed the screening process (specify the reason for this). Results: Specify characteristics of the documents included in the analysis. There are tables that could be merged (table 2 to 6) to reduce the number of appendices since the last ones include data that should be presented in the manuscript body. Discussion: A very brief discussion of the results obtained on the usefulness of MLHPs in primary care was carried out. Authors should discuss and compare the results of the SRs evaluated with the available literature in the study topic.  In the document, at times the discussion of the results is oriented to a context of low- and middle-income countries and at other times to the context of India. It would be helpful for authors to target their paper to LMIC with an emphasis on India at the discretion of the authors.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?PartlyAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?PartlyReviewer Expertise:Public health, epidemiologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Dear Guido,  Thank you for taking out time to review the paper and for your valuable comments. We will revise and upload a new version of the article based on your feedback. Thanks again. Regards Sandeep Abstract (Introduction: Provide only necessary information to inform the context of the study.Thank you for your comments. We have revised the abstract incorporating the necessary changes (page 2). Introduction: Methods: There is insufficient information about the study methods . Results: no results are presented on the evaluation of the quality of the evidence. Conclusion: The conclusion does not emphasize that the evidence is of low or moderate quality on the usefulness of MLHPs in primary healthcare, and this should be mentioned).We have now provided a statement to justify the conduct of a rapid evidence synthesis on the study topic. We have deleted the word “gratis” in the last paragraph. (page 3) We included some information relevant to LMICs to reflect the context and the nature of the findings of this review. Methods: The need for a rapid evidence synthesis for the study topic is not explicitly justified. I believe that the word "gratis" in the last paragraph is not suitable. The introduction is focused on India. This topic is suitable for LMIC. Hence, I recommend focusing the narrative of the manuscript on LMIC. We included relevant information on stakeholder participation (page 4). Thank you for an excellent point on single reviewer screening. We used a single reviewer approach for study screening and selection based on the requirements of the review and resources available at the time. At the time, we considered this as a reasonable approach, as it involved using a single experienced reviewer (SM) for screening with a random verification of a subset of screening records by another experienced reviewer (SB). Results: Specify stakeholder participation. The methodology describes that a single reviewer performed the screening process (specify the reason for this).Thank you. We briefly described the key characteristics of the documents under each domain of interest. We note your point about merging tables, but they have been kept separate for each domain of interest to avoid long tables and avoid confusion. We included tables related to essential characteristics of the SRs and the AMSTAR-2 checklist in the extended data file to limit the number of tables in the manuscript body. However, we did try to merge the tables, but the format appeared inappropriate. Discussion: Specify characteristics of the documents included in the analysis. There are tables that could be merged (table 2 to 6) to reduce the number of appendices since the last ones include data that should be presented in the manuscript body. A very brief discussion of the results obtained on the usefulness of MLHPs in primary care was carried out. Authors should discuss and compare the results of the SRs evaluated with the available literature in the study topic.Thank you for your valuable comments on the discussion section. We have revised the discussion section in light of the feedback. In the document, at times the discussion of the results is oriented to a context of low- and middle-income countries and at other times to the context of India. It would be helpful for authors to target their paper to LMIC with an emphasis on India at the discretion of the authors. Thank you for providing me opportunity to review this piece of work.  Considering the lack of qualified doctors in some of the resource limited settings like India, mid-levels health providers can be an alternative. I must appreciate authors for this work and presenting the findings in a comprehensive manner.  included 50% studies from HICs, Weeks et al., 2016 included 42 of 46 studies conducted in HICs, similarly, Lassi et al., 2013 included studies majorly conducted in HICs). Hence, it would be good if the authors make it clear in the inclusion criteria > context- what percent of included studies within SRs should have been conducted in LMICs. Or explicitly state, the evidence from HICs were eligible considering the statement reported in Discussion section, “While we looked at global evidence….”. Secondly, in the result section it was reported,“All SRs, except one11 included studies that were mostly conducted in LMICs”. However, SR by Weeks et al., 2016 also included studies majorly conducted in HICs.The focus of the rapid overview of systematic review was on LMICs, however some of the SRs included studies conducted in high income countries . Hence, it would be good if the authors make it clear in the inclusion criteria > context- what percent of included studies within SRs should have been conducted in LMICs. Or explicitly state, the evidence from HICs were eligible considering the statement reported in Discussion section, “While we looked at global evidence….”.   We have deleted the statement. Secondly, in the result section it was reported, “All SRs, except one11 included studies that were mostly conducted in LMICs”. However, SR by Weeks et al., 2016 also included studies majorly conducted in HICs.  In the Discussion section it was reported, "While we looked at global evidence, the use of GRADE enabled us to contextualise evidence to India." Although GRADE help in certainty of evidence, it is worthwhile to consider the contextual factors while contextualising the evidence to India, which I understand was not the focus of this overview of systematic review. We added relevant information to provide more clarity (page 22)Thank you for pointing out the error. We checked the main text and the extended data file and fixed the referencing numbering errors that were seen in a couple of places. Reference numbering in the extended file and the main text do not match, kindly make necessary edits. E.g., Barnard et al., 2015 is reference number 13 in main text while in supplementary file it is 11.


For questions on purchase habits, a lower number of respondents reported eating in a restaurant, eating takeaway meals, having lunch away from home, or buying pastries, cakes or crisps. For questions on preparation habits, an greater number of respondents reported that they usually avoided eating fried food and tried to keep their overall sugar intake down, but fewer respondents said they tried to have low-fat desserts. For questions on consumption habits, a lower number of respondents reported that they usually ate a dessert or pudding if one were available and a larger number said they made sure to eat at least one serving of vegetables or salad a day and at least three servings of fruit most days. Based on the obtained results, it may be stated that although there was an increase in the AFHC scores during the pandemic, a similar share of respondents showed improved or worsened food habits, and a similar share changed their food habits from healthy to unhealthy and from unhealthy to healthy. At the same time, a majority of changes were associated with purchase habits, which were probably forced by lockdowns and the resultant restrictions in eating out or grocery shopping.The COVID-19 pandemic is known to influence the dietary habits of adults, but results for adolescents in studies are ambiguous. The present work aimed to analyze the differences in the scores of the Adolescents’ Food Habits Checklist (AFHC) before and during the pandemic in the Polish Adolescents’ COVID-19 Experience (PLACE-19) Study population. The PLACE-19 Study was conducted during the pandemic among a population of 2448 students recruited from secondary schools in all regions of Poland using a random quota sampling. The participants were required to complete an AFHC consisting of 23 items pertaining to food purchase, preparation, and consumption habits. Current habits (during the pandemic) and previous habits were assessed and scored separately. The total ( In December 2019, a novel coronavirus, named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), emerged in Hubei Province, China, causing the respiratory disease COVID-19  and annoA widespread COVID-19 outbreak caused adverse mental health consequences, including stress, anxiety, and depression among the affected populations . It is wMoreover, diet and the resultant nutritional status of individuals have a substantial effect on the immune system and may influence susceptibility to disease . In partAnother issue influencing the dietary habits of people is limited access to daily grocery shopping due to lockdowns, which may decrease the eating of fresh food  and increase the consumption of processed food . Last buA recent study by Sidor & Rzymski , conductTaking into account the contradictory results shown by the studies on dietary habits of adolescents, the present study aimed to analyze the differences in the scores on the Adolescents’ Food Habits Checklist (AFHC) scores before and during the pandemic in the Polish Adolescents’ COVID-19 Experience (PLACE-19) Study.The study was conducted at the Institute of Human Nutrition Sciences, Warsaw University of Life Sciences (WULS-SGGW) in accordance with the guidelines laid down in the Declaration of Helsinki. All procedures involving human subjects received the approval of the Ethics Committee of the Institute of Human Nutrition Sciences of the Warsaw University of Life Sciences, as presented previously .This study was carried out in a population-based sample of Polish secondary school students within the second phase of the national PLACE-19 Study. The adolescents who participated in the study were aged 15–20, which is a typical range for Polish secondary school students, for whom the Net Enrolment Rate (NER) is 89.38% . The firDuring the study period, in accordance with the decision of the Polish Ministry of Education, made on 12 March 2020 , educatiTo obtain a national sample of adolescents from all six regions of Poland (defined by geography and socioeconomic condition), a stratified sampling of secondary schools was used: (1) a random selection of five counties from each of the 16 voivodeships (provinces) of Poland for 80 counties in total, and (2) a random selection of secondary schools: ten from each of the 80 counties for 800 schools in total during the first phase. In the case of voivodeships for which a low response rate was observed after 10 days of data collection during this stage, an identical sampling procedure was conducted involving: (1) a random selection of counties  and (2) a random selection of secondary schools within the counties (10 secondary schools from each of the 40 counties) for a total of 400 schools during the second phase. A total of 1200 secondary schools were randomly selected and invited to participate in the study. The first phase (carried out in April 2020) assessed hand washing and personal protective behavior) and the schools that participated were excluded from the second phase. If necessary, the local boards of education were involved in procedural issues. The headmaster of each randomly selected secondary school received an invitation for the school to take part in the study and was informed about its aim and scope. As participation was voluntary, the headmaster forwarded the invitation to the students. Those who were willing to take part were required to provide written informed consent, as well as the consent of their parents or legal guardians. The inclusion criteria for students included the following: being a student from a randomly chosen school, 15–20 years of age, and providing informed consent. As soon as consent was obtained, the students received an electronic link to the questionnaire. The dedicated questionnaire was anonymous and did not collect any data that could identify the respondent. It also did not have any questions concerning personal or sensitive data except for age and the secondary school the student attended to verify the inclusion criteria. Because some of the headmasters who received the invitation did not report if they were interested in participating in the study, a reminder was sent after 1 week of the first stage and after 1 week of the second stage. Before the students completed the questionnaire, they were informed that the received link to the survey was dedicated only to them and could not be passed on to any other student because they constitute a specific study group and were chosen exclusively to take part in the study. After the students completed the questionnaire, the answers were verified for the presence of missing or unreliable data, and the respondents who provided such data were excluded from the analysis . The questionnaire used in the study to collect information about dietary habits during the COVID-19 pandemic was AFHC, which was developed by Johnson et al.  and valiThe participants were asked about their dietary habits before and during the pandemic. As remote learning had been implemented for all students in Poland, according to the decision of the Polish Ministry of National Education , the stuAs there was no Polish version of AFHC available before the study, it was translated into Polish based on the WHO recommendations . TranslaThe applied AFHC consists of questions concerning issues associated with purchasing, preparing, and consuming certain types of food, both healthy and unhealthy. The highest possible score was 23 points, as described by Johnson et al. . AdditioU test with a rank-biserial correlation (due to nonparametric distribution).The internal reliability of the data was assessed using the Cronbach’s alpha coefficient  which waThe Confirmatory Factor Analysis (CFA) was performed for internal reliability assessment. The Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR) were calculated. A similar approach was applied in the previously published paper with following cutoff criteria: CFI ≥ 0.90, RMSEA ≤ 0.06 (good fit), and SRMR ≤ 0.08 . The CFAThe Cronbach’s alpha coefficient for dietary habit scores within the PLACE-19 Study population before and during the pandemic were calculated on the basis of the AFHC for purchase, preparation, consumption and total habits and are presented in p ≤ 0.05 was attributed to statistically significant differences. The statistical analysis was conducted using Statistica 13.3 .The value of p < 0.001) but the number of respondents who rarely ate takeaway meals increased . At the same time, for having lunch away from home, the number of both respondents choosing or not choosing a low-fat option decreased, while the number of those not having lunch away from home increased . However, for buying crisps and having a dessert or pudding in a restaurant, the number of respondents who reported choosing a low-fat crisps brand or the healthiest dessert or pudding did not change; only the number of those who declared not doing it decreased, whereas the number of respondents who declared not buying crisps  or not eating in a restaurant increased .The food purchase dietary habits assessed on the basis of the AFHC by Johnson et al.  within tp < 0.001) as did the number of respondents trying to keep their overall sugar intake down . At the same time, regarding dessert at home, the number of respondents not trying to have something low in fat decreased , as they either started to try to have something low in fat, or avoided having desserts at home at all.The food preparation dietary habits assessed on the basis of the AFHC by Johnson et al.  within tp = 0.009). At the same time, the number of respondents making sure to eat at least one serving of vegetables or salad a day increased  as did the number of respondents eating at least three servings of fruit most days .The food consumption dietary habits assessed on the basis of the AFHC by Johnson et al.  within tp = 0.001), purchase score (p < 0.001) and consumption score (p = 0.014) were observed.The dietary habits scores calculated on the basis of the AFHC by Johnson et al.  for purcChanges in dietary habit scores for the purchase, preparation, consumption of food, as well as total habits in the categories of healthy, neutral and unhealthy habits  or fear of infection, were not influenced by a conscious decision to improve the diet, but by the lack of possibility of following the same diet as before. As a result, even if the respondents declared that they would follow a healthier diet even after the pandemic, as in the study by Hunter , we do nThe present study also revealed some relevant findings about specific purchase habits: the number of respondents who often bought pastries or cakes was lower during the pandemic than before. Similar results were also obtained for buying crisps, as there was a significant decrease in the number of respondents who declared buying crisps during COVID-19. Such dietary changes may be directly associated with a range of restrictions imposed by the Polish government, including restrictions on restaurants  and the However, the study also revealed some beneficial consumption habits that were not directly associated with pandemic restrictions, but might probably have resulted from a conscious decision to change diet. It was found that a lower number of respondents avoided eating fried food and a higher number tried to reduce sugar intake compared to the period before the pandemic. Additionally, respondents were less likely to eat a dessert or pudding, even if it were available. Such changes observed in the studied group of adolescents may have especially favorable effects, as they comply with the recommendations of the Food and Agriculture Organization of the United Nations (FAO) for maintaining a healthy diet, which emphasize the need to reduce the intake of fat, sugar, and salt . BecauseMoreover, the present study showed that adolescents were more likely to eat at least one serving of vegetables or salad a day and at least three servings of fruit most days. These results are consistent with those obtained in the study by López-Bueno et al. , which pOn the other hand, some authors stated that the COVID-19 period promoted negative changes in eating habits in the studied populations ,21,59. TOne of the strengths of the present study is that it was conducted in a large homogenous sample of adolescents recruited from all regions of Poland. In addition, it was conducted during a specific period of the pandemic, and provided valuable information regarding changes to dietary behavior, which had not been studied. Moreover, the study not only indicated the frequency of specific kinds of behavior but also made possible an assessment of the changes at the population level, revealing a similar share of beneficial dietary habits during the pandemic as in the period before.The study also has some limitations that must be indicated. The use of AFHC to assess dietary habits is the first because the information obtained is based on self-reporting. A retrospective analysis was carried out simultaneously, but it was associated with recall bias. Furthermore, some of the changes in the assessed dietary behaviors reported by the respondents may not have been conscious choices but imposed by the general situation in Poland, including the lockdown and remote education. Taking into account the above limitations of the study, the necessary areas that should be focused on in further studies should be indicated. The pandemic is still influencing the lifestyle of populations, so there is a need for prospective studies of dietary habits. In the initial phase of the pandemic, when the situation was unpredictable, only retrospective studies were possible, but now it is possible to observe changes in the whole population and relate them to the current epidemiologic situation. Therefore, such studies should be conducted in various countries and the potential differences among populations observed. Last but not least, the studies should consider the influencing factors to indicate the determinants of dietary habit changes during the pandemic. Although an increase in AFHC scores was observed in the studied group during the COVID-19 pandemic, the study revealed that a similar share of respondents adopted improved and worsened food habits, and a similar share changed their food habits from healthy to unhealthy and from unhealthy to healthy. At the same time, a majority of changes were associated with purchasing habits, which were probably forced by the lockdown and resultant restrictions in eating out or grocery shopping. Taking these into account, it may be concluded that healthy food habits should be promoted among adolescents, especially during the pandemic, as some positive changes observed in this period may have been caused by existing limitations, and afterwards previous unhealthy habits may be revived or sustained.


Introduction: Physical handling (PH) of patients is an essential component of nursing care. It is an intervention that is troublesome for patients and strenuous for general nurses and other nursing staff. Handling techniques and mechanical aids for PH have improved through the years; however, they are not routinely used in nursing practice. Aim: The aim of this research was to determine (1) the level of awareness of PH issues within the management of South Bohemian hospitals, (2) how management perceives, organizes and implements PH protocols, and (3) how PH protocols are applied in everyday nursing practice. Method and Research Sample: Two qualitative methods were used: a semi-structured interview and observation. The participants were management representatives of South Bohemian hospitals in Czech Republic. Fifty nurses were observed during PH at the same hospitals. Results: The study found that PH was not monitored, nor was it provided systematically. In spite of this, no serious drawbacks were found; nonetheless, many areas were identified where the quality of PH could be improved. For example, awareness of PH issues by management, educational programs teaching new handling techniques, and provision of state-of-the-art PH aids. Several issues related to PH were found to be related to staff shortages, which remains a major problem. Conclusion: This issue needs more attention; it should be addressed by both those doing nursing research as well as those engaged in everyday nursing practice. Both will require the assistance of hospital staff and management. Physical handling (PH) of patients during nursing care is a basic skill required of all nursing staff and has developed through the centuries. Many present-day research studies have started looking at this topic, e.g., Lee et al. . These aTo ensure greater patient comfort and to reduce the physical demand on nursing staff, a number of modern PH aids and devices have been developed . In ordeThe top management of five hospitals in the Czech Republic’s South Bohemia region participated in a qualitative research investigation implemented using semi-structured interviews. These hospitals are our faculty’s active collaborators in several researches. There is an effort to raise the quality of care on the faculty as on the hospital’s side. These hospitals are also our clinical placements for students’ clinical practice. Answers were recorded in prepared record sheets, and then analyzed using the paper and pencil method, to code and categorize transcribed text. During preparation of the research drafts, we created five categories for investigation on the bases of literature study: (1) documents; (2) form and system of quality and safety; (3) dealing with complaints and management; (4) perception and organization of physical handling by the management and education; (5) safety, risk and management. We also used hidden observers in the above-mentioned hospitals to confirm results. In the pilot phase, 5 observations from each department were required from each hospital. The following departments were observed: the internal medicine department, the surgical department, the anesthesiology-intensive care department, and the subsequent care department. We received 50 observation sheets back to analyze. Only physical handling interventions (PHI) performed by nurses were used as a selection criterion. The following PHI were monitored: (1) sitting up in bed, (2) sitting on the side of bed with legs dangling, (3) repositioning in bed, (4) changing bed linen, (5) hygiene done in the bed, (6) lying down from a sitting position, (7) transfer from bed to chair/wheelchair and back, (8) hygiene from bed to bath, (9) standing up from a wheelchair, (10) standing up from the bed. During observations, observers specified the number of PH interventions, which could consist of multiple interventions, e.g., hygiene in the bed (5 times) and changing bed linen (4 times). The observers were unit nurses addressed by head nurses out of each individual hospital. They had been instructed about the observation sheet and how to use the observation scale. Observers worked together with shift nurses and monitored one nurse during provision of one FM. The observation sheet used to record PH interventions was developed based on theoretical knowledge and the study of literature resources. It included the most common nursing interventions associated with PH, the level of patient self-sufficiency, risk of patient injury, use of aids, comfort, and the degree of communication and cooperation with the patient. There was patient expression of possible pain, discomfort and fear observed and recorded. Nurses were also monitored during PH interventions, i.e., preparation of the environment and the patient for physical handling, use of good body mechanics by the nurse, utilization of efficient physical handling techniques to prevent musculoskeletal injuries to the nurses, and whether the nurse used effective communication to ensure the security and safety of patients during the PH intervention. For each item of observation, the two evaluation systems were used—either pass-fail or a three-stage score . Observations were done by nurses working in the specific departments, which included both staff nurses, charge nurses, and/or nurse managers. Due to the current shortage of nurses, many of the nurses in the above-mentioned positions also regularly participated in nursing care. To respect the anonymity of individual hospitals, we do not specify the results in relation to particular hospitals.All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of University of South Bohemia.Ensuring care is defined in ,20,21,22If we wanted to monitor the quality and safety of care, it was necessary to define it and to develop a standard by which staff would be guided and motivated by management to comply8]. Compliance with the above-mentioned rules is monitored by the management, both visually and through documentation, using checks and audits . FitzpatThe hospitals addressed did not have to deal with patient complaints about physical handling very often: “Complaints are rare and usually unjustified. It concerns especially excessively obese patients when there are problems with handling, adjustment, position changes and transfer where it is necessary to exert greater force. The situation is even worse when the patient does not cooperate or refuses to change position.” Some hospitals reported no problems with complaints: “We have not had such experiences. We did not register any complaints like that”. The complaints and concerns from staff are also infrequent. “We have not solved any official complaint of a staff member about the difficult physical handling of a patient so far.” However, if there were complaints, then “the complaints of the staff about difficulties and overloading during the physical handling of patients are often resolved by the department of subsequent care or by the internal, surgical, and neurological departments”. The statement that “a number of staff members who worked, for example, in a retirement home before their employment here in our health care facility regard the physical load during patient handling to be more easily managed” was found to be noteworthy. Based on the information from the hospitals involved, the reason for complaints is the “lack of auxiliary staff  and lack of lifting equipment and aids”. The management solves potential objections “verbally and by reporting them to the personnel department, objections are dealt with by middle management and handed over to hospital management”. Similar obstacles were reported by Constantin et al. . The numWorking conditions for the implementation of PH are characterized by education, suitable space, specific aids, and equipment ,39,40. WTo maintain or improve quality and safety, it is necessary to regularly monitor these parameters. This is done by using audits with subsequent remedial activities—education , the innA comparison of results from the two research techniques used in the investigation revealed that the attitudes of both the nurses and HM, relative to the performance of PHI, are identical. In our investigation, we tried to determine which nursing interventions require PH of patients. Out of nine suggested nursing interventions, PH was most often observed during the making of beds and changing bed linen, and during hygiene in bed. It was interesting that the observers did not record PH during patient positioning, in spite of the fact that HM repeatedly mentioned positioning records relative to documentation. We noted that many patients had restricted independence and therefore required in-bed hygiene care. We assume that as part of bed care for patients—lying patients—it is necessary to include these patients in the positioning schedule. Of 50 monitored patients, 25 were dependent on the nurse and 12 patients were unable to participate in the PHI at all; this included 8 patients who were unconscious. The observers evaluated the care provided by nurses as comfortable; PH caused pain in 15 out of 50 cases. Is it possible to consider such care as careful, even if it was believed by the observers to be careful on the basis of the observed elements? On the basis of the observation of nurses during the PH of patients, we can conclude that the nurses followed the basic rules of PH necessary for the safety of the patient and their own safety. These rules can be found, for example, in the documents “Moving and Handling” by Royal College of Nursing  as well When comparing our results with research studies and other evidence, we can assume that the views of nurses and management regarding PH in nursing practice are comparable. We can say that there is not a big difference. However, the PH is not specified in detail in the documentation. The form and system of quality and safety concerning FH is not systematically organized. There is not much attention given to patient and nurse complaints. The perception and organization of physical handling by management is not clear when we consider unequal attitude towards PH. We found that the quality of care could be increased by utilization of a larger range of aids for PH, and more training focused specifically on PH. There was room for improvement relative to documentation, which should be specifically focused on covering the whole spectrum of possible handling issues, e.g., regarding body weight, the patient’s state of health and ability involved in the lack of homogeneity and consistency in the rules, methods, and documentation associated with PHI. Obtained results cannot be generalized, but they describe specific actual situations of observed samples in the Czech Republic. In conclusion, this issue needs more attention; it should be addressed by both those doing nursing research as well as those engaged in everyday nursing practice. Both will require the assistance of hospital staff and management. The top management of five hospitals in the Czech Republic’s South Bohemia region who are participants of the project are expecting the results to improve the quality of care and to prevent the risks related with PH.We are aware of limitations. We take into account that the results could be influenced by the fact that the observations were made both by unit nurses and in some cases, by charge nurses and nurse managers who assisted with routine nursing care in their departments due to staffing shortages.


The identification and announcement of the COVID-19 pandemic has been a global issue. Disaster preparedness for internal and external threats is inherent within health care environments and requires agile thinking and swift remediation. Nosocomial infection is a risk for recipients of care, especially in hospital settings, which has implications for workforce planning. The aim of this case study was to examine the community response to the internal disaster of the first nosocomial COVID-19 outbreak within an Australian rural health care environment. A critical discourse analysis method was adopted to generate and analyse data collected from three different media platforms during a six-week period. Four main themes were distilled: actions and intent, loss, well-being and recognising choice, and community action. Phase two of the study interrogated these themes to expose the power positioning of speakers and their relationships to the audiences. Strengthening communication with local communities within health care environments must be a priority in any future rural workforce disaster preparedness planning. Maintenance of trust with health service provision and delivery in rural communities is imperative. The inclusion of a robust communication plan within any risk management strategy that meets the needs of the local users of health services is mandatory. The identification and subsequent announcement of the Coronavirus Disease 2019 (associated with the virus SARS-CoV-2), hereafter known as COVID-19, as a pandemic has been a global issue ,4,5,6,7.In Australia, the advent of COVID-19 resulted in additional funding to support remote digital health service delivery. Access to adequate healthcare was provided to the population whilst reducing the amount of physical contact required and thereby limiting the risk for transmission of COVID-19. In rural areas, remote digital service delivery was impeded by Internet access issues ; howeverA COVID-19 outbreak was declared on 3 April 2020 at the North West Regional Hospital (NWRH), a 160-bed facility, on the island state of Tasmania. For this rural community, the sudden escalation of COVID-19 cases sparked the temporary closure of two health facilities and quarantine of all staff and their household members . The perThe outbreak at the NWRH occurred on Day 18 of the declared global public health emergency, which was also soon after the implementation of Tasmania’s COVID-19 health response. Three cases of COVID-19 in health care workers were reported between 3 and 4 April 2020, and a further eleven cases were reported over the next three days, resulting in police assistance in contact tracing [National guidelines regarding the definition of close contact between individuals changed on 9 April 2020 to 15 min cumulative face to face, rather than continuous contact, which required additional contact tracing to be undertaken. Further escalation to Level 4 of the COVID-19 plan occurred, and at this point, all staff were required to self-isolate for a period of fourteen days. On 10 April 2020, ten more cases relating to the outbreak were reported. Households of quarantining hospital staff and all discharged patients, since 27 March 2020, were required to isolate for a period of fourteen days. On 11 April 2020, the State Senior Executive, including the Premier of Tasmania, confirmed the decision to close the NWRH precincts based on the safety and sustainably of service delivery . During Online health information has increasingly become available to populations worldwide ,16. IndiThe aim of this research was to analyse the first nosocomial outbreak of COVID-19 in Australia, which occurred within a rural health care environment on the island of Tasmania, Australia. As a result of this outbreak, there are implications for preparing rural workforces for future internal disasters. For this research, the nosocomial outbreak is reported as a case study . CriticaA case study methodology can be employed when a detailed understanding of an issue (the impact of COVID-19) that occurs in a real-life context is the focus of research . This caSelect the discourse;Locate and prepare data sources;Explore the background of each text;Code texts and identify overarching themes;Analyse the external relations in the texts (interdiscursivity);Analyse the internal relations in the texts;Interpret the data .Mullet  providesTwo phases of analysis were undertaken to expose overt and covert discourses within the texts examined. The first phase’s findings were framed and evolved from the CDA of original data, which were collected over a six-week period. Two researchers analysed this data by finding commonalities and differences within the data sets, which resulted in four key themes: Action and Intent, Loss, Wellbeing and Recognising Choice, and Community Action. These themes are linked to community experience, government and community actions, and the information portrayed through various media platforms. Within each of these categories, there is a strong sense of the need to recognise the voices who were speaking and how the chosen audience perceived the information delivered. In the second phase of analysis, data were interrogated by the researchers to expose who was speaking and why, and the power positioning of speakers along with their relationships to the audiences listening. The results are presented within each of these phases.Advocate newspaper is the regional newspaper of Northwest Tasmania. It is currently owned by Antony Catalino of Domain publishing and the Thorney Investment Group, which have a 50% share each [Examiner and Mercury newspapers are owned by News Corporation. The Mercury newspaper serves the community of Southern Tasmania, while the Examiner is the preferred newspaper in the north of the State of Tasmania.The are each . Domain Social media platform Instagram was purchased by Facebook in 2012 by the current chief executive officer, Mark Zuckerburg. Instagram places community guidelines on its users that encourage an “authentic and safe place for inspiration and expression” . Due to Alphabet Inc is the parent company of Google and is owned by five major shareholders. The shareholders are the two co-founders, Vanguard Group Inc, BlackRock Inc and T Rowe Price Associates Inc. The newspapers are curated by journalists retrieving information from other journalists and fashioning it for their community readership. Direct messages from citizens or grassroots groups are less curated, although they are subject to “cleaning” via third party companies with agendas and biases of their own. Search engines are also curated, depending on the user’s previous searches .The theme of actions and intent arose primarily from the discourse analysed in print media. Open and axial coding of key headlines related to COVID-19 identified repetitive forms of punitive messaging in COVID-19-related media headlines. Frequent terms associated with the theme of actions and intent were observed in the following headlines: authority, fines, investigation, police, prisoners, mayors, handcuffs, consequence, crisis, ground zero, fight, bad luck, gloves are off, lucky to be alive, crises and lockdown extensions. Although at times the use of the terms and references outlined were framed otherwise, the use of the key terms can be perceived as and allude to the power differentials in social structure, the degree of control of action by local authorities and organisation, influencing the cognition and actions of the public. The analysis of each point of data collection reflected punitive messages and was associated with status, power and control-laden relationships with authority/authorities. This messaging influenced the provision of lockdown law(s) and the consumer readership within the general public. A sense of increased surveillance and suspicion of community members activities and reprimand for those who chose to be defiant and offend were noted at the beginning of the six-week point of data collection. Local newspaper headlines such as “helicopters to police compliance with COVID-19 restrictions in Tasmania” provides an explicit example of this surveillance . Rule anThe shifting of the narrative was also noted to draw associations with stigmatising lifestyle behaviours and the notion of criminality with direct references to the additional COVID-19-related penalties for speeding drivers, drug users and party goers. Thought-provoking punitive headlines further emphasised risks associated with lockdown extensions as well as questioning of health workforce integrity with local newspapers, indicating that over “60 staff were stood down as coronavirus outbreak investigation continues” . This poAn emphasis of this CDA was placed on the concept of loss. The sense of loss identified throughout the discourse was strongly linked to the rights of civilians and the loss of trust in essential services as a focal point within local print media and via Internet search engines such as Google. Messaging from these platforms hinted at the use of restrictions being placed on individuals due to COVID-19 as a violation of civil, sociocultural and political rights. Loss of trust within the Tasmanian health care system and health care workers employed was emphasised within the data. With the enforcement of quarantine for approximately 1300 staff and Level 4 of the COVID-19 plan in place, the discourse portrayed a sense of loss of identity and purpose for health care workers within the region. Newspaper headlines insinuated that health care staff were stood down due to poor behaviours, rather than as a necessary step to reduce further nosocomial infections within the hospital and community . These hWithin the discourse, the loss of freedoms that individuals within rural communities experienced during periods of hard lockdown was identified through the closure of businesses and education systems. The loss of individual rights was evident in the use of harsh punitive penalties described in theme one, including lengthened periods of restrictions and the use of population surveillance. Headlines such as “Gloves are off in Coronavirus fight”  describeIt was identified throughout the data collection period that information delivered via social media platforms such as Instagram had a strong sense of encouraging the mental and physical wellbeing of their followers through changed ways of living and optimism. Individuals posting on their own accounts and those posting on behalf of local businesses and sporting organisations provided their audiences with information on self-care practices that met social distancing guidelines. Alternative wellbeing practices that could be undertaken throughout their period of isolation were also suggested. These posts and images captured activities such as cooking, arts, reading, exploring nature in our own backyards and spending time with friends and family. This messaging allowed for the appreciation of activities or objects that were made available to individuals in a time when a waver in their beliefs and hope was indicated. These posts also provided individuals with different adaptations with respect to how they could remain connected by undertaking self-care practices in social isolation when physical contact was not permitted. Discourse data showed different means of adapting technology for maintaining social connections and individuals’ livelihood such as Apple FaceTime to speak with family and friends, live streaming of concerts and shows, and the use of Zoom videoconferencing platform. Posts from sporting and fitness organisations included inspiring images of community members maintaining a level of fitness by undertaking their normal gym workouts from the comfort of their homes. Such material extended a sense of motivation and appreciation for the mental and physical health that they were able to maintain during a time when Stage 3 restrictions were imposed. Within the discourse, it was recognised that providing individuals with an opportunity to spark reflection on past events led to aspirations for their future. The audiences of these followers provided support in the making of decisions as a response to recognising the need for change in how they chose to live moving forward following the global pandemic.Key data representative of community action was centred around the collective experiences of COVID-19-related precautions and practices in response to public health advice. This response was observed across all forms of media during the period of data collection, aligning with the peak of local community transmission. Frequently observed terms and phrases related to this theme featured in headlines, Internet search engines and hashtags. These communications included references to social and physical distancing, isolation, quarantine, staying at home and restrictions. A strong sense of continuing community spirit was a particularly sustained feature of the Instagram platform. Data collection via the Instagram platform was obtained by searching regions and locations to capture local data. A cluster of posts with a strong sense of sharing experiences of COVID-19-related practices, reinforcing standards and quality of such practices and support for self and others in this community action was observed. This theme took shape in a variety of pictorial postings aligning with key terms such as text memes, digital impressions reinforcing physical distancing of 1.5 m, handwashing and mask-wearing and the adoption of individual self-care activities. For health care workers, the sense of community was evident through local citizens coming together online to celebrate and praise the efforts of staff in other regional hospitals for their work during the period of Stage 4 COVID-19 restrictions. While their praise of health care workers in one region was recognised, fear was instilled amongst the health care workforce and community within the Northwest region secondary to Internet searches of local government information . StatemeSocial connectivity during the time of physical distancing was a repetitive nuance in the discourse framing on the Instagram platform, as was the vigilance pertaining to mental health implications for self and others in the face of a collective experience of the loss of liberty and freedom. This sentiment was expressed by posting well-being reminders and strategies along with a critical consciousness of checking in with others, elders and loved ones. Expressed concern for inclusivity with those who may be perceived as having the greatest risk concerning the influence of COVID-19-related social isolation, rather than the COVID-19 virus itself, was observed with reference to the communities of lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) individuals. The notion of gratitude for health and safety of self and others and reflecting on previous times of full expression of individual and collective freedom was portrayed. Holidaying in the past and plans for when the future normativity returns were specifically observed, along with forms of explicit goal-setting, past events of collective nature and posts targeted at motivating others also contributed to a sense of community action in the time of a pandemic. The Instagram platform, more so than the other forms of media analysed, offered valuable insight into perspectives and experiences of the general public. Posts from smaller-scale local businesses of rural communities offered clarity about the day-to-day realities of living in social isolation. The new challenges imposed by the pandemic for already geographically isolated communities within the island state were often superseded by community actions of resilience. Examples of community resilience were observed in the sharing of practical, pragmatic innovations in day-to-day living, eating, exercise, working and communication. Resilience in the adaption to the processes of the employed, working from home, was observed as an expression of enthusiasm, pride and accomplishment, as well as taking recognition for exceeding expectations in the reform efforts taken. A shift in paradigm, productivity and responding to unmet community needs was acknowledged, as well as the point of community connectivity, with measures related to prompt re-design and extension of services such as digital media health service provision. New initiatives were credited to the performance of community organisations, smaller-scale businesses and sole operators. The data collection coincided with the community significance of Earth Day and Mother’s Day with evidence of discourse promoting a sense of community spirit and survivorship shaped by the refuge and gratitude the celebrations offered individuals but also offering businesses the opportunity to harness gains with material advertising.Data collected were interrogated to expose who was speaking and why, the power positioning of speakers, and their relationships to the audiences listening ,38. WithWithin online search engines such as Google, algorithms are used to direct “preferred” content to the searcher. Content is paid, sponsored or pushed; thus identifying “biased’ views is markedly increased. Trending can occur through targeted action by groups and individuals to serve their own purposes and to increase visibility. No media communication is without bias, and it depends on how overt/covert the editorial control is in the print media and the direction of the chief executive officers of the Internet social media and search engine companies. Within the media, the voice appears divided. On one hand, messaging reflected that of the national and local government, and on the other, the government appears “attacked”. The power base from which the media speak is both supportive and confrontational . There iSocial media presented a different lens of living through a global pandemic in rural Tasmania. Instagram is a platform for individual expression, and, similar to other forms of social media, enables individuals to follow others they are interested in through the context of sponsored and unsponsored posting activity. The social media platform of Instagram offered insight into the experiences of local community members directly impacted by the hard lockdown and public health measures. The information available to consumers within the realm of social media generally provided content that was underrepresented in other forms of media data sets. It reflected individual community members’ experiences including success and hardship in the context of wellbeing, COVID-19 restrictions and supporting one another, as well as the broader local community, local businesses, local arts sector, sports and recreation organisations and education. The Instagram authorship for this data collection tended to represent community members who had less official or authoritarian positions to gain influence in other forms of media. The platform enabled community members to position themselves as political activists by content contributions that supported the metacognitions of others during a global pandemic by asking questions, provoking action and providing critique of others and those instigated by local government and public health officials.During the period of data collection, there was the addition of content with a continued government presence superseding the platform sponsorship. This content was observed as a direct link to the government COVID-19 website visualised at the top of the consumer’s viewing feed. The hierarchical presence of this link provided a constant visual cue of current times and a direct access point to valid and reliable current public health information for platform consumers to access. Another unique aspect of the findings from the content from this media platform was the trending of local e-commerce that leveraged off local experiences during the time of COVID-19 using perspectives of local businesses and perceived consumer needs as a point of engagement. This media platform tended to be more supportive of consumer needs during the data collection period compared to other media platforms described while ensuring an authentic and safe place for inspiration and expression by its users. Due to restrictions on health care workers and the use of social media to express their feelings and thoughts as a member of a health care organisation, it was difficult to determine the influence on the workforce through a social media lens. However, praise for health care workers within the state was evident and the messaging to “stay home” was emphasised to keep health care workers and their patients safe during periods of the Level 3 and 4 COVID-19 plan.Media communication is part of everyday life for many Australians, and how they interact with it is based on the generation and the media form . A mediaThe Mercury—61,000; The Examiner—30,000; and The Advocate—20,000) [In relation to the media considered, print media such as local newspapers analysed showed a reach to 101,000 Tasmanians in a 12-month period  . For soc—20,000) . People —20,000) . Interne—20,000) . This is—20,000) . Of the —20,000) . While GFoucault  argued tHeadlines within print media are considered significant; moreover, Le  describeThe theme of Actions and Intent in the media was not unusual, with many forms of Western media using headlines that relate to punitive actions to entice their readership . DiscussThe COVID-19 outbreak in rural Tasmania is a unique case study, as it was the first nosocomial hospital outbreak of COVID-19 in Australia. The Tasmanian State Government Department of Health invested substantial resources in informing the whole community about what was occurring within the local area and how they should respond. This information was supported by the Australian government, which concurrently was distributing information across the country at a national level. A later independent review into the nosocomial hospital outbreak at the NWRH identified several challenges to this communication strategy, including the ability for people to source their own information and the frequent changes in guidelines, which undermined the trust of the community . AdditioPhase one and two of this CDA provide lessons for future workforce disaster planning. Internal disaster preparedness needs to include media communication strategies that suit local environments. Transparent actions by local government and affected health care organisations are essential for maintaining trust in health care workers and service provision by members of the community. Furthermore, a tailored strategy for each local community enables seeking out vulnerable groups such as the LGBTQI, elderly and disadvantaged youth to support them with appropriate messaging, prevent misinformation or myth generation and reduce anxiety or fear .The communication plan needs to lever a multichannel approach and consider local media nuances and evolving digital platforms. Whilst internal disaster requires swift mitigation, it is imperative that media communication is bi-directional between the staff of health care environments and the community. Feedback from the community will facilitate appropriate messaging. The delivery of consistent, cohesive messaging to the health care workforce and members of the community requires support from appropriate trusted personnel. Additionally, an internal communication plan is vital to ensure that the health care workforce is informed. The health care workforce is an integral component of risk management of an internal disaster, as they can be harnessed at an individual level to promote the dissemination of appropriate information, prevent misinformation and dispel myths through personal media channels when required or asked. Factors such as presenteeism need to be considered and support provided for the health care workforce in creating an environment that represents health care workers accurately . DisasteAs with any study, there are limitations to this study. The data collected occurred at fortnightly intervals over a six-week period from three different forms of media. While the period of data collection did not extend beyond the six-week period, it can be considered a strength of the study that the researchers collected and analysed data from three different forms of media during the disaster. While the generalisability of these findings is limited by its primary intention to provide information in a local context for the Tasmania health service and community, understandings from this study can inform other rural health care services within Australia and globally. As this was the first nosocomial outbreak of COVID-19 in Australia, this study highlights community influence as a key component of internal workforce disaster preparedness. Although Mullet’s  CDA framCollaboration of community and health care environments to reduce vulnerabilities that emerge during disasters remains vital. Using the method of CDA, this case study highlighted that the COVID-19 pandemic has demonstrated external threats as invoking internal disasters that can adversely affect the health and wellbeing of the health care workforce and the local community. This study found that government messaging that embraced a unidirectional and castigatory approach may have alienated members of the community, while traditional print media utilised its position of power to support the government, and also acted as a protagonist ensuring a delicate balance of meeting competing needs: government and the community. Social media conversely enabled community members to articulate their needs, ask questions, receive feedback, and garner support for causes they deemed important. Issues of importance identified by community members, however, were not necessarily aligned to those advocated by the government or the traditional print media.Due to the ease of accessibility, social media play a significant role in the daily lives of many Australians, while print media and Internet search engines provide curative and mixed messaging of important health information. Appropriate and salient messaging can avert negative community perceptions of action and intent or loss while also promoting positive community action and ensuring the community trust in health care services remains. While the threat of COVID-19 is currently remnant in a global sense, the influence that media communication places on rural communities and those working within health care services and delivery of care remains significant.