Caledonian Stadium, the main mass temporary shelter for homeless people in the City of Tshwane, was created as a local response to the imperatives of the novel coronavirus disease (COVID-19) National State of Disaster lockdown in South Africa. This is a case study of the coordinated emergency healthcare response provided by the University of Pretoria’s Department of Family Medicine between 24 March and 6 April 2020.This study uses a narrative approach to restory situated, transient, partial and provisional knowledge. Analysis is based on documented data and iteratively triangulated interviews on the operational experiences of selected healthcare first responders directly involved in the shelter.The impending lockdown generated intense interactions by UP-DFM to prepare for the provision of COVID-19 and essential generalist primary with partners involved in the Community Oriented Substance Use Programme (COSUP). With approximately 2000 people at the shelter at its peak, the numbers exceeded expectations. Throughout, while government officials tried to secure bedding, food and toilets, the shelter was poorly equipped and without onsite management. The COSUP clinical team prioritised opioid substitution therapy using methadone and COVID-19 screening over generalist healthcare to manage withdrawal and contain tension and anxiety. COSUP and its partners helped the city plan and implement the safe re-sheltering of all Caledonian residents.The Caledonian shelter is an account of organisational resilience in the face of homelessness and substance use emergencies triggered by lockdown. Through community-oriented, bottom-up self-organisation, a clinically led team navigated a response to the immediate needs of people who are homeless and/or use drugs that evolved into a more sustainable intervention. Key lessons learnt were the importance of communicating with people directly affected by emergencies, the value of using methadone to reduce harms during emergencies and the imperative of including OST in essential primary healthcare. COVID-19, as a novel, infectious disease, puts healthcare systems and healthcare service providers’ front and centre of preparing and responding to the pandemic. However, and notwithstanding the primacy of medical science and clinical care, public health management by definition requires interdisciplinary, intersectoral and interagency cooperation [On 23 March 2020, the president of South Africa announced a 21-day national lockdown   characteOf particular note regarding lockdown is Regulation Section 11D . It simuIn the 3 days before lockdown, while media attention focused on the frantic scramble for essential supplies by people with available income , the annParticipation in COVID-19 Family Medicine daily meetings draws on the existing multidisciplinary, multisectoral core of expertise of faculty and staff as well as not for profit and municipal, district and national government personnel. All participants are involved in healthcare research, education and service delivery at the university as well as in district and municipal facilities and projects. Collectively they combine years of clinical experience and expertise in providing generalist integrated community-oriented primary care . They alDuring the first COVID-19 daily meetings (23–26 March 2020) the team identified seven priorities for action  the lead clinician  who was responsible for Caledonian shelter clinical service delivery, health screening and opioid substitution therapy (OST) prescription; (2) a clinical associate  who supported OST screening and daily dosing; and (3) the COSUP stakeholder liaison officer who engaged with key government, university and third sector organisations before and during the lockdown.In the 3 days between the announcement of the lockdown and its implementation, COSUP and UP-DFM engaged in a series of meetings to plan a response to the lockdown. Internal meetings focused on identifying and working out how to render essential COSUP services. Meetings with partners focused on getting an understanding of the city’s departmental responsibilities and plans and, especially, the expectations of social development, the lead agency responsible for sheltering the homeless. Particular concern was raised about meeting needs and ensuring humanitarian treatment of vulnerable populations during the disaster .On the evening before the lockdown (26 March 2020), small groups of people started arriving at the Caledonian Stadium. They had heard that “corona” was coming and that they would have to be off the streets by the next day. They said they had been advised to come to the shelter by city and other community workers. They came of their own volition, because they were scared and did not want to get sick. They also did not want to be locked up or sent “home” by the police , 14.The stadium, a long neglected, city-owned facility without electricity and connected sewerage , was barWhile some people continued to drift in throughout the night, by the morning (27 March 2020) they were arriving in significant numbers. Many walked from shelters, parks and derelict building “homeless hotspots” around town. On that first day of the lockdown, the South African Police ServiceTents were being set up and, although the bedding was ordered by city officials, no mattresses and only about 240 blankets arrived. No one took charge of ensuring that the shelter was organised to address COVID-19 public health requirements, manage resident intake or inform people about what to expect and do. The scale of the influx of people was completely unanticipated .As the day progressed, people with opioid dependence became increasingly agitated as they struggled to deal with withdrawal , 16. To Early on Saturday morning (28 March 2020), a small COSUP clinical team created a make shift service point outside the stadium. With the help of the municipal police, people who were withdrawing or in need of medical care came forward. For each person, the clinical team did a health intake and general substance use screening, followed by a consultation. Clients with a history of opioid use and clinical signs of withdrawal  were given low initiation doses of methadone (20–30 mg) without baseline urinalysis. They wrote scripts, fetched medicines and administered directly observed treatment for those in need of methadone. Equipped with surgical masks, gloves and hand wash, they worked “on the fly” through a seemingly never-ending queue of people crushing up against the gazebo . MunicipAfter considerable effort on the part of the Tshwane Homelessness Forum , the citOn the 29th of March, the stadium remained unmanaged. The numbers of people fluctuated, with an ebb and flow of people around meal time and COSUP clinical services. There was considerable overcrowding; people were not assigned places to sleep; there were no visible handwashing facilities; and the few toilets that were there were not being adequately serviced. Also, there was no place to separate anyone with respiratory symptoms, including those with TB .After a family medicine operational review of COSUP sites , the CalA number of Caledonian residents voluntarily assisted with patient flow, releasing people in groups of 10 and arranging chairs for them to wait to see a doctor or receive their supervised methadone dose. Together with city community development workers, they also supported physical distancing and handwashing at the stations .Although the start of services was delayed until municipal police arrived to maintain crowd control, the COSUP stadium clinical team was able to get through the queue by the end of the afternoon. By obtaining methadone in sufficient quantities to meet demand, they were able to significantly reduce the time spent going back and forth to the pharmacy to fill scripts. Also, the use of measuring cups made dosing easier and quicker .In response to the SAPS Joint Operations Command directive that all homeless people were to be in shelters and that they would assist by supporting the process of shelter creation, COSUP and the Tshwane Homeless Forum advised on the size and composition of other temporary shelters, finalised protocols on intake and screening and mobilised partner organisations  to provide additional clinical support , 22.On Monday, 30 March, media reports of dire conditions and disgruntlement at the shelter , led to The Caledonian clinical team continued to provide OST services outside the main gates and were able to meet the daily demand for methadone, even though many people were coming into the stadium from outside and several were trying to double dose. On site, with assistance from a Tshwane Homelessness Forum pastor to attend to people’s welfare needs, the COSUP team became the de facto face of care. The team, however, was still too small and lacked the space and resources to attend to people’s other physical and mental health needs. They were unable to provide a full harm reduction package of care. Harmless, the organisation with the largest needle and syringe service in the city was asked to hold off as municipal and national police were actively confiscating needles and the city regarded the concurrent provision of needle and syringe services and OST as a form of mixed messaging. There also were no social development personnel to assist with basic social services and family contacting , 21.COSUP and other Homelessness Task Team members spent the day working with partners to identify alternative COVID-19 shelters. Although many public, private, faith-based and non-governmental organisations wanted to assist, few were able to comply with the public and personal health stringencies of COVID-19. Two immediately available sites were identified, and the team worked through the night to set them up as shelters .On the 31st of March, the COSUP clinical team was instructed by the city to deliver services inside the stadium to prevent "walk-ins" off the street accessing OST. The clinical team felt unsafe to set up stations inside, as over the previous days they had observed municipal police personnel to be insufficiently trained to deal with crowds . The metThe planned staggered re-sheltering of people at the Caledonian and other congested shelters also began that day. The first group of 431 men and women who were not receiving OST were bussed to two new shelters. The remainder were re-sheltered in batches over the next 6 days at newly created, smaller facilities  shelters in the city. Over and above providing OST to manage withdrawal, clinical care returned to an integrated community-oriented primary care approach to address acute and chronic conditions including infections, injuries, TB, HIV and mental health as well as the potential threat of COVID-19 in the homeless and substance-using populations . HoweverThe Caledonian Stadium emergency shelter is the outcome of an emergent emergency . ArisingThis account tells a story of bottom-up self-organisation. Amid a chaotic and rapidly evolving environment, a network of organisations and actors coalesced to respond to the emergency through an effort to provide shelter, food and healthcare.Among the many differences in focus and priorities, the needs of people with opioid dependence took centre stage. In part, this was because of the imperative of managing the unpleasant physical, mental and social side effects of withdrawal from opioids, including elevated temperature, increased respiratory rate, anxiety, nausea and diarrhoea, tachycardia, hypertension, sweating, tearing, runny nose and bone and muscle pain. Given many similarities with COVID-19 symptoms, it was important to ensure that withdrawal was not confused with or masked novel coronavirus infection. There also was a need to prevent the risk of fatal overdose, given the known loss of opioid tolerance even after a relative short period of abstinence .Many lockdown responders were opposed to COSUP’s harm reduction approach to substance use and the need for OST. They had no grasp of the scale and physical effects of opioid dependence nor were they able to propose any practical options for the hundreds of people struggling with withdrawal inside and outside the stadium. In contrast, by providing methadone, COSUP’s clinical interventions reduced volatility and tension at the shelters and prevented fatal overdoses among clients across the city. The provision of methadone also served as a way into harm reduction, even though the emergency nature of the situation made it impossible to provide several essential harm reduction components, follow standard OST protocols or provide integrated HIV, TB, viral hepatitis or other chronic disease detection, treatment adherence and support.Rendering a focused heathcare service alongside safely re-sheltering people in the midst of the lockdown required the deliberate nurturing of established relationships and the mobilisation of cooperation and collaborative practices among key organisations and individuals. Through a steady flow of communication, a diverse network of actors and skills were mobilised to respond to problems as they arose.However, the critical issue of communication with the people living in the shelter was overlooked entirely. This added to the levels of anxiety and uncertainty among shelter residents, since they were not informed about the work being done, the challenges being faced or the plans being made. Also, even though several individuals came forward of their own volition to help, the population itself was insufficiently informed about or mobilised to protect their health and the health of others.More generally, by demonstrating an effective response to street homelessness and substance use disorder under exceptional conditions, the Caledonian stadium experience made evident to policy makers and practitioners the possibility and necessity of providing shelter and healthcare services to homeless people and people who use drugs in “normal” times. As a consequence, a combined comprehensive approach to deliver services to these populations is being planned for long-term implementation by the city, the university and the relevant partner organisations.The Caledonian Stadium story also talks to the portentous challenges of public and individual health in the COVID-19 pandemic. COSUP and other partners repeatedly warned of the inadequacy of the setup, layout and provision of essential utilities to ensure basic public health. Although there were no instances of COVID-19 among residents or healthcare providers, this was due mainly to chance and the stage of the epidemic in the city during lockdown. Had the epidemic been more advanced, the fact of the matter is that the creation of a poorly managed, inadequately prepared mass shelter would have been the perfect petri dish to culture the pandemic in the city. Equally, had the Department of Family Medicine and its partners not been able to surmount the multitude of bureaucratic, policy and personal belief barriers to providing methadone to manage withdrawal and prevent heroin overdose, the emergent emergency could have become a socially explosive, personal disaster for thousands of vulnerable city residents.This account of the first 2 weeks of work has several limitations. By definition, it is partial both in terms of perspective and in time. The voices of other responders as well as the people coming in and outside the shelter would enrich the narrative. The story, too is still unfolding as the lockdown and the pandemic are far from over. Lastly, in the immediacy of the response data inevitably are partial and in places inconsistent, but the experience, threads and lessons override these gaps.The story of the Caledonian shelter is an account of organisational resilience in the face of a dual emergency around shelter and substance use that was triggered by the lockdown on 27 March 2020. Over 2 weeks, the Department of Family Medicine, through COSUP, navigated a clinically led, bottom-up, collaborative response to address the immediate needs of people who are homeless and may or may not use drugs in the City of Tshwane. Time, resources and urgency all combined to compress services in the emergency warp, until things were more stabilised. Through this response to contain the disruptive potential of an emergent emergency, a better, more sustainable COVID-19 intervention evolved. The key lessons learnt were the importance of communicating with people directly affected by emergencies, the value of using methadone to reduce harms during emergencies and the imperative of including OST in essential primary healthcare.Homelessness and harmful substance use interventions require a harm reduction approach that is bottom-up, inclusive, collaborative and multisectoral.OST and related harm reduction services need to be enabled and applied.It is critical to foreground communication with people directly affected by emergencies as well as those responding to them.Best practice clinical therapy in opioid dependence, including in emergencies, needs to enable and apply OST and related harm reduction services.The provision of essential comprehensive mental and physical healthcare for vulnerable populations during and beyond the COVID-19 pandemic is an imperative.


The Syrian crisis, which started in 2011, has had a profound impact on the entire region. Jordan, with its limited resources, now has the second highest ratio of refugees to inhabitants in the world . The actual number of Syrians in Jordan is hotly contested: more than 630,776 refugees registered in November 2015 compared with 1,265,514 reported by the national census conducted at the same time. Although the numbers are slowly but steadily increasing, the number of patients with cancer who were registered by the Jordan Cancer Registry peaked in 2013 at 510 patients reported and subsequently slumped downward, which coincided with changes in funding as a result of the increasing strains on the Ministry of Health. Older individuals, women, and patients with advanced diseases were less likely to be registered. These findings overlap with data obtained from the authors’ own center registry. Using age- and sex-specific population-based incidence rates, we estimated that 869 Syrians are diagnosed with cancer in Jordan annually. Using diagnosis-specific cost records of the King Hussein Cancer Foundation, we estimated that the cost of their treatments is 15.6 million Jordan dinars (US$22.1 million). Fatima and her family thought they had overcome the most difficult hardships imaginable after they abandoned their home in Syria and fled to Jordan in 2013 to seek asylum and leave behind the suffering and woes of war. Their family outside Syria were scattered among different countries, and they knew nothing about the fate of the home they left behind. Despite such tribulations, the days ahead concealed a more difficult ordeal, as Fatima's belly began to swell. She had lost appetite and her weight dropped markedly, among other harrowing symptoms. The cause of this newfound distress was later found and diagnosed as ovarian cancer. The diagnosis came as an unbearable shock for Fatima's parents. She was only 12 years old, and they had no financial means to cover her costly treatment. A glimpse of hope appeared when the King Hussein Cancer Center (KHCC) agreed to assist with Fatima's case and allocated donations from the Goodwill Fund to cover her treatment. The doctors reassured the parents that Fatima had a chance for survival, because she was among the lucky Syrian patients with cancer who were treated at KHCC. However, it is disheartening to admit that the same is not the case for many refugee patients with cancer who go untreated because of lack of funding, among other reasons.1 With limited resources, and because the blindsiding nature of the conflict led the entire region to find themselves unprepared for a crisis of such a scale, surrounding countries were faced with an unprecedented set of problems. Despite its struggling economy, scarce water resources, and increasing security threats, Jordan has become host to the second highest number of refugees  in the world. The number of refugees in Jordan is contested: Although the United Nations High Commissioner for Refugees (UNHCR) had registered 630,776 Syrians as of November 2015,2 the Jordan National Census, conducted at the same time, reported 1,265,514 Syrians in the country. The gap between the two numbers is alarming, but the discrepancy could reflect that some Syrians had moved to Jordan before the crisis because of many varied factors, including political asylum, marriage, work, and poverty. In addition, many Syrian refugees who moved to Jordan after the crisis elected to avoid registration through the UNHCR and used relatives in Jordan to provide them with basic needs and financial support.The Syrian crisis, which began in 2011, has had a profound effect on the Middle Eastern region.3 It is important to point out that many refugees suffer from neuropsychiatric disorders and depression, which are considered NCDs.5 Poor access to medications and advanced health care are among the challenges that face refugees with NCDs in Jordan,6 and, although the public sector contributes significantly to the care of refugees with illness, out-of-pocket payments are commonly needed to receive proper care or medications.7 Traditionally, the focus among refugee populations had been on infectious diseases and malnutrition. Therefore, one problem that went largely unaddressed in the aftermath of the Syrian crisis was that many refugees and displaced people had cancer, which requires extensive resources for treatment, including financial support and medical facilities.It is notable that more than half of Syrian refugee households in Jordan reported at least one family member with a noncommunicable disease (NCD) and that a significant minority of these families did not receive any care because of financial reasons.8 Conversely, and similar to comparable situations, under-reporting of cancer is also expected, because refugees may have difficulty integrating into the public health systems of their host country.9 Patients with advanced disease who may need palliative care are more likely to have funding refused.10 These patients may be over-represented in refugee groups because of late diagnoses and may be missed in national registries because they die without proper diagnoses or treatments.Cancer can be over-represented in refugees, as families with cancer are more likely to migrate out of hostile regions to seek medical care, a pattern which was previously reported during the Iraqi crisis.11 we estimated that 869 Syrians in Jordan had cancer . The numbers decreased significantly in 2014 (n = 353) and 2015 (n = 331). In a comparison of the numbers of these last 2 years to those of 2013 (the year with the highest number of registered patients), there were fewer women with cancer (50% v 53%), fewer adult patients (92% v 95%), and fewer patients with late-stage diagnoses (25% v 35%). Conversely, the types of cancer diagnosed were similar through the years; breast cancer, colorectal cancer, lymphomas and leukemia, brain cancer, and lung cancer topped the list.Using data obtained from the Jordan National Census and age-specific cancer incidence among Syrians approximated by Globocan,12The difference in patient numbers across the years for which data are available is alarming and implies heavy amounts of under-reporting. The number of Syrian refugees who reside in Jordan has increased markedly since 2013, and the number of Syrian patients with cancer should have increased in parallel, comparable to the increase in the number of registered patients with cancer in the Kingdom. It is possible that women, older individuals with cancer, and those with advanced diseases are less likely to have access to medical care and hence are less likely to be reported in the collected data. Although international agencies and volunteer organizations provide various kinds of needed medical support, the expenses of treating refugee patients with cancer many times are not covered, because the cancers are designated as too poor of a prognosis and/or too financially costly to treat.12 Moreover, the UNHCR is facing serious limitations to support these patients and provide them with the treatment they need, because funding for humanitarian emergencies has been limited since the beginning of the Syrian crisis. Because of the limited resources and the overwhelming needs, the UNHCR selectively funds expensive treatments according to the decision of the UNHCR Exceptional Care Committee, which relies on several criteria to select the cases that most deserve to receive health care coverage. One such criteria is the aforementioned need of a disease prognosis.10The Government of Jordan had allowed Syrians registered with UNHCR to access health care services free of charge in Ministry of Health’s primary health care centers and hospitals as of March 5, 2012. However, in November 2014 this policy was withdrawn because of immense strains on the health care system, and Syrian refugees became required to pay the noninsured Jordanian rate when they used all types of health services provided by the Ministry of Health. This is a subsidized rate that is used for Jordanians who do not have government health insurance and is approximately 35% to 60% of what non-Jordanians  are paying. Though the noninsured Jordanian rate is normally affordable for nonvulnerable individuals, this change caused considerable hardship for many refugees and limited their access to health care, including cancer care provisions.12 and which can overwhelm the health care system of any country with limited resources.KHCC is a leading comprehensive cancer center in the region and is the only hospital dedicated entirely to cancer care in Jordan. KHCC provides cancer treatment to more than 4,000 new patients with cancer and 110,000 outpatients every year. During the period of 2011 to 2018, 356 Syrian patients have been treated at KHCC, and their treatment was covered by the King Hussein Cancer Foundation (KHCF) Goodwill Fund. The KHCF is an independent, nongovernmental, not-for-profit institution founded in 1997 by a Royal Decree to combat cancer in Jordan and the Middle East region. KHCF is the largest community-based organization in Jordan dedicated to combating cancer. KHCF work focuses on fundraising and development, global advocacy, public awareness about early detection and prevention, cancer coverage, and patient support. The cost of treating these 356 Syrian patients totaled 8,071,973 JOD . Using the cost of treatment per cancer type as provided by KHCF records and the expected number of patients with cancer diagnosed in 2017, we estimate that the annual cost of treating Syrian refugees is approximately 15,676,752 JOD . The Goodwill Fund of the KHCF covered the treatment of almost two thirds of these patients. The percentage of pediatric patients was higher among Syrian patients (29%) than Jordanian patients (11%). This is properly caused by selection bias, because children with cancer were more likely to receive medical attention and funding. Women represented 46% of Syrian patients versus 54% of Jordanian patients. Notably, 20% of Syrian patients with breast cancer presented with distant metastasis compared with only 16% among Jordanians seen during the same period. This may support earlier reports that cancers reach a more advanced stage at the time of diagnosis among refugee patients with cancerWars and conflicts can cause major delay in the diagnosis and treatment of displaced patients with cancer. In Jordan, cancer care for refugees is considered suboptimal because of limited financial coverage and access to care. Awareness and education for the prevention, screening, and early detection of cancer are also sorely lacking for refugee populations. Health care system capacities must be improved to absorb increasing demands, and financial support is crucial to cover the cost of treatment. The humanitarian community needs to consider the health care system of the country as a whole and not only for refugees to ensure harmony between the host community and refugees. Innovative and sustainable financing, such as social security and health insurance schemes, must be secured to ensure continuous coverage. Humanitarian responses should be coordinated with development organizations and donors, such as the World Bank, with an integrated approach that accounts for existing development plans and funds for the country and the added burden of a large refugee influx. A recommendation for patients to be treated according to resource-stratified guidelines rather than to receive suboptimal or no treatment could improve the sustainability of health care provisions and care for displaced patients with cancer. Financial coverage provided by the KHCF Goodwill Fund is helping treat some of the refugee Syrian patients with cancer; however, other nongovernmental and international relief organizations could play an important role in the support of refugees and displaced patients, and the international community is called upon to allocate more financial resources so at to alleviate the aching pain that these already suffering individuals are experiencing.


Background and objectives: Available evidence shows a low uptake of HIV services among men in Rwanda. HIV self-testing (HIVST), a new intervention, may have the potential to improve the uptake of HIV testing services among men. The current study aims to adapt a health education program (HEP) for improving the uptake of HIVST among men in Rwanda. Materials and Methods: We propose a mixed method study, which will be conducted in four phases. In Phase 1, we will conduct a scoping review to map the available evidence on health education programs for men in low- and middle-income countries (LMICs). In Phase 2, we will conduct interviews with stakeholders in the Rwanda HIV response and healthcare providers to determine their perspectives on implementation of HIVST in Rwanda. In Phase 3, a cross-sectional survey will be used to assess HIVST awareness and acceptability among men in Rwanda. Guided by findings from Phases 1, 2, and 3, we will employ the nominal group technique to develop and optimize the HEP for improving the uptake of HIVST among men in Rwanda. In Phase 4, we will use a pragmatic pilot randomized controlled trial to assess the preliminary impact of the HEP for men in Rwanda and assess the feasibility of a later, larger study. We will employ the Stata version 16 statistical package and NVivo version 12 for the analysis of quantitative and qualitative data, respectively. We anticipate that the findings of this study will inform implementers and policy makers to guide strategies on the implementation of HIVST in Rwanda and ultimately accomplish goals set forth in the Rwanda 2019–2024 Fourth Health Sector Strategic Plan on scaling up the number of men who know their HIV status. Conclusion: It is anticipated that this study will proffer solutions and strategies that are applicable not only in Rwanda but also in similar settings of LMICs.  In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched the 90-90-90 targets for 2020 that call for 90% of people with HIV to be diagnosed, 90% of the diagnosed to access ART, and 90% of the treated to be virally suppressed . HoweverThe first documented AIDS cases in Rwanda were in 1983 . Rwanda Epidemic control of HIV infection depends on the success of the strategies to prevent new infections and increase the treatment availability and uptake for currently infected individuals ,12. For Historically, health education programs (HEPs) have been shown to play an important role in not only the provision of knowledge to individuals concerning their health but also building skills and changing attitudes regarding health issues . Given tThis study has been ethically reviewed and approved by four institutional review boards: The Rwanda National Ethics Committee , the University Teaching Hospital of Kigali Ethics Committee , Rwanda Military Hospital Institutional Review Board  and the University of KwaZulu Natal Biomedical Research Ethics Committee . All participants will sign a consent form  prior to participation in the study.https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=8310.Pan African Clinical Trial Registry, PACTR201908758321490), Registered 8 August 2019, Guided by the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT), we propose a multi-phase mixed method study. In Phase 1, we will conduct a scoping review to map available evidence on HEPs for men in LMICs. We chose to use the scoping methodology, a useful approach for determining the need for, and value of, a full systematic review. In Phase 2, we will conduct interviews with stakeholders in the Rwanda HIV response and healthcare providers to determine their perspectives on the implementation of HIVST in Rwanda. In Phase 3, a cross-sectional survey will be used to assess HIVST awareness among men in Rwanda.Guided by findings from Phases 1, 2, and 3, we will employ the nominal group technique  to co-crTwo models will guide this study. The Consolidated Framework for Implementation Research (CFIR)  and the This study will be guided by the theory of change (ToC) . The theKigali City Province is the capital city of Rwanda. There are three districts, namely Gasabo, Kicukiro, and Nyarugenge, 35 sectors, 161 cells, and 1183 villages in Kigali . The popObjective 1: To conduct a scoping review on HEPs for men’s engagement in health services in LMICs.Design: The scoping review protocol has been developed a priori and has been published elsewhere . The scoData Source: Eligible studies will be selected guided by an inclusion and exclusion criteria. Analysis: We will use NVivo version 12 to extract relevant outcomes and thematic analysis of the studies.Outcome Measures: A narrative report of evidence on HEPs for men’s engagement in health services in LMICs. Objective 2: To determine key stakeholders’ perceptions on the implementation of HIVST in Rwanda.Design: A qualitative study design will be employed . We willData Source: Data will be gathered through in depth-interviews.Analysis: Thematic content analysis will be based on the naturalistic paradigm  followinOutcome measures: A narrative report of key stakeholder and health care providers perspectives on the implementation of HIVST in Rwanda. Perspectives will be assessed using the intervention characteristics domains of the CFIR .n = 384 participants.Design: A cross-sectional study will be employed. One health facility will be selected in each district. Due to the nature of the study design, and assuming that the population is >10,000 and that there is an unknown level of awareness of HIVST among men in Rwanda, the overall sample size will be deduced using the formula below:For HIVST acceptability, assuming the acceptability rate of 94% reported in Kenya , the calData collection will be conducted using a self-administered semi-structured questionnaire . The queData Source: A semi-structured questionnaire will be employed.Analysis: Quantitative variables will be summarized by means and standard deviation. Qualitative variables will be summarized using frequency distribution. We will use the student t-test or the chi-square test to determine study variables associated with age awareness and the acceptability of HIVST. Univariate binary logistic regression analysis will be carried out to obtain preliminary insight into the unconditional association of each independent variable and dependent variables (awareness and acceptability). Multiple logistic regression will be employed to determine explanatory variables associated with awareness or acceptability status while adjusting for other study variables. All statistical tests will be concluded at a 5% level of significance employing Stata version 16 statistical package.Outcome measures: We will assess two outcome measures: awareness and acceptability. Awareness will be considered as a yes response to the question “Do you know what HIVST is?”. Acceptability will be assessed by the question “As of 20 February 2017, it is recommended by the MOH to use HIVST kits as an additional strategy to reach out to people who are not yet tested, and there are plans for a national roll-out. Do you agree with this recommendation?”Design: Using the nominal group technique, purposive sampling will be done to recruit group participants. Individuals will be selected based on the researcher’s assessment that they will contribute to the adaptation of the HEP. A maximum of eight people is anticipated. Two staff from the HIV/AIDS and STIs Diseases Division of the Rwanda Biomedical Center at the national level, one representative each of a public and private health facility HIV department working in health promotion, and four representatives of the target population (men), purposively selected by the researcher. The principal investigator (first author) will serve as the convener and facilitator for the group. Guided by findings from the scoping review, by a qualitative study on the perspectives of key stakeholders, and by a cross-sectional survey on awareness and acceptability among men, information will be gathered by asking panel members to respond to questions posed by the moderator, and then by asking participants to prioritize the ideas or suggestions of each group member. The process is expected to prevent the domination of the discussion by a single person, encourage all group members to participate, and result in a set of prioritized strategies or recommendations that represent the group’s preferences for the HEP. Steps to be followed include introductions and explanations, a silent generation of ideas, sharing ideas, group discussion, voting, and ranking . The incThe principal investigator’s institution will send invitation letters to two purposively selected staff from the HIV/AIDS and STIs Diseases Division of the Rwanda Biomedical Center at the national level and one representative each of a public and private health facility HIV department working in health promotion. We will consult sector and cell leaders to enroll four representatives of the target population (men).For this objective, we will enroll personnel employed by HIV/AIDS and STIs Diseases Division at the Rwanda Biomedical Center at the national level, or personnel employed by a public and private hospital and responsible for HIV services and health promotion as subject matter experts. Men over the age of 18 residing in Nyarugenge will be eligible as representatives of the target population.Data Source: Data will be obtained from the transcripts.Analysis: We will audiotape and transcribe the nominal group meeting. We will group related ideas to form themes. The themes will be ranked and prioritized. The ranking score will be between one and five, one being the least severe and five being the most severe barrier to the uptake of current HTSs. Thereafter, stakeholders will discuss key messages to include in the HEP to address each barrier. The panel members will receive a summary of the formulated HEP for validation.Outcome: An adapted and optimized HEP tailored implementation strategy, likely to be effective for improving the uptake of HIVST among men in Rwanda, will be designed.Objective 5: HIVST was officially introduced on World AIDS Day in 2017 in Rwanda . Since tDesign: The pilot RCT protocol is registered with the Pan African Clinical Trial Registry (Registration: PACTR201908758321490). We will conduct a two-arm pilot RCT. Participants will be randomized to the HEP arm or the control arm. In the control group, routine health education will be administered. In the intervention group, the adapted HEP will be administered in addition to routine health education. Data collection will be through interviewer-administered questionnaire captured onto mobile tablet devices using pre-programmed study software Open Data Kit.is an adult man 18 years and older;does not know his HIV status;is visiting the study-selected health facility during the enrollment periodis willing to be followed up three months post-enrollment.Recruitment strategy: The University Teaching Hospital of Kigali (CHUK) will be purposively selected to pilot the implementation of the HEP intervention. CHUK is the largest hospital located in the district of Nyarugenge, Kigali. It is also the largest referral hospital in the country with a capacity of 519 beds. In 2017, the hospital recorded 140,559 patients with an average of 11,713 per month [Intervention: The intervention will be presented at the end of Phase 3 of the study. It will be a male-tailored HEP aimed at improving the uptake of HIVST among men. This will be delivered through face to face personal communication with the use of information education communication materials. We anticipate the HEP to address general information on HIV, transmission, prevention, HIVST, anti-retroviral therapy, and care in a manner that is tailored to men.Randomization procedure: Simple randomization using a randomization table created by a computer software program will be employed.Blinding: For the purposes of this study, there will be no masking. Data Source: We will employ an interviewer-administered questionnaire to collect data.Analysis: Proportions will be calculated for the uptake of HIVST for both control and intervention groups. KAP scores will be calculated by determining the average score for each individual for each category of KAPs that will be assessed. Tables and graphs will be used where appropriate to present results. Quantitative variables will be summarized by means and standard deviation (SD). Qualitative variables will be summarized using frequency distribution. The student t-test or analysis of variance (ANOVA) will be used to compare if there are differences in KAP scores between different categories of the factor variables. Linear regression will be utilized to determine the association between KAP scores and quantitative factor variables. Multiple logistic regression will be used to determine the association between the uptake of HIVST and the use of HEP whilst adjusting for other study variables. All statistical tests will be concluded at a 5% level of significance. All statistical analysis will be carried in the Stata version 16 statistical package.Primary outcome(s): The feasibility of a larger RCT trial will be assessed by recruitment and the uptake of HIVST Uptake of HIVST will be measured as self-reported use of a HIVST kit at follow-up interview. Secondary outcome(s): Secondary outcome variables will include HIV diagnosis among participants, linkage to care for men who tested positive for HIV, a repeat test from men who tested negative for HIV, and HIV status disclosure to sexual partner(s) post-HIVST.The study will be conducted in accordance with the Helsinki Declaration . EthicalThe aim of this study is to adapt an HEP for improving the uptake of HIVST by men in Rwanda. To the best of our knowledge, this study is the first of its kind in Rwanda. Given the reported low uptake of HTSs among men in Rwanda, and in Sub-Saharan Africa in general, implementing an effective HEP to improve the uptake of HIVST, a new intervention with reported acceptability among men, may help bridge this gap. The pragmatic approach is designed to provide results that are directly applicable to normal practice.Several studies have called for the need for the implementation of policies that advocate for men’s health ,50,51. TConsistent with the nature of pragmatic trials, we aim to influence policy by providing stakeholders with results that are applicable to routine practice. We intend to disseminate findings of the study through reports, publications in peer-reviewed journals, research meetings, and conference presentations.Due to constraints of time and resources, as this study is for a doctoral degree with limited findings, a pilot RCT will be used to assess the preliminary effects of the HEP. A pilot study is not a hypothesis testing study. However, a pilot study is a requisite initial step, and results can inform feasibility and identify modifications needed in the design of a larger ensuing hypothesis-testing study. In this study, the feasibility of recruitment, intervention implementation, and retention will be examined. Secondly, due to the nature of the HIVST being conducted privately, study outcomes will be based on self-reported data. Finally, the HIVST uptake is only as important as the number of individuals actively linked to care and treatment services. The proposed study will not actively follow up on participants for linkage to care and treatment services. However, sufficient information on linkage to care post-HIVST will be provided on both enrollment and follow-up visits.


This study aimed to investigate the predictors of maternal parenting self-efficacy when the children concerned are in the early years of life.A descriptive-analytical research study was carried out among 213 women who were in the early months of the postpartum period and attending healthcare facilities in Irbid, Jordan. The State Anxiety Inventory (SAI) and the Maternal Parenting Self-Efficacy (PMP S-E) tool were used to collect the data.A significant correlation was found between the scores in self-efficacy and the quality of marriage relations , family income , employment , education , and living with extended family .The findings of this study show that MPSE is significantly associated with various predictors. These predictors are the mother’s education, income, whether she lives with extended family, her quality of marriage, and her employment. Maternal anxiety was found not to be a predictor for MPSE and this may explain other factors such as social support and living with extended family.It is essential for nurses to understand maternal parenting self-efficacy, therefore, including the concept of maternal parenting self-efficacy in nursing curricula can help raise awareness of this important concept. Understanding maternal parenting self-efficacy is necessary for nurses to evaluate the mothers’ parenting self-efficacy. Maternal parenting self-efficacy (MPSE) is one of the critical elements of maternal transformation as a woman moves into parenthood. A mother’s self-efficacy as a parent not only affects her own mental health, it also influences the psychological development of her infant , 2.The pThus, to enable a seamless transition into parenting, it is essential to be aware of the factors that affect MPSE in order to facilitate the planning and delivery of comprehensive care to disadvantaged mothers. According to Bandura, MPSE refers to the perceptions that mothers have regarding their ability to accomplish particular duties in caring for newborns . MothersAccording to Yap, Nasir, Tan, and Lau, the level of MPSE is dependent on various factors, such as individual assets, society, and the environmental context . The facA review of eight quantitative studies on MPSE concluded that MPSE has a positive relationship with multiparty support, the support of society, parenting, and contentment in marriage, while it has a negative association with maternal stress and state of anxiety . Leahy-WNevertheless, irrespective of the apparent relationship between self-efficacy, social assistance, and postnatal stress, scant research has been conducted to investigate these interlinked elements in mothers during the early postpartum period . The limA descriptive cross-sectional approach was utilized in this research. This strategy seemed appropriate for achieving the research objectives since the aim of the study was to examine and define the association between all the factors of interest at a specific time without altering the associations between variables.The study was conducted in public tertiary health facilities in Irbid City in Jordan with an annual delivery of services to 30,000 mothers. Convenience sampling was employed to select suitable participants during the hospital discharge procedure. Convenience sample was achieved by visiting tertiary health centers in Irbid city and determine mothers that met inclusion criteria and invited them to participated.This type of sampling is especially beneficial when seeking to recruit subjects within a short duration of time, which is particularly relevant for the topic under study. The inclusion criteria for selecting the women were as follows: (a) age more than 18 years old, (b) mother to a child aged less than 3 years old, and (c) ability to read and write in Arabic. The exclusion criteria were designed to omit mothers who (a) were cognitively disabled according to their medical records, and (b) had suffered extreme intra-partum, ante-partum, or postnatal maternal difficulties, since these problems may impact the mother’s self-efficacy in negative ways. This is an indication that only women without any ante-natal complications were enrolled in the study.The estimation of the sample size relied on the use of a correlation assessment. This assessment suggested that in order to determine the association of MPSE with social assistance and other demographic factors, a minimum sample size of 200 was required. This figure was based on the need to have an effect of 0.25, and 80% power at a level of significance of .05 (two-sided). More than 250 were approached to participate in the study, but some of them did not participate for personal reasons. 220 surveys were returned, but seven were excluded since they were missing more than 20% of the data. A total of 213 women participated in the study.The instrument for this study consisted of three parts: a demographic questionnaire, the State Anxiety Inventory (SAI), and the Maternal Parenting Self-Efficacy (PMP S-E) tool. The researcher developed a questionnaire to obtain background information about the sample, such as age, gender, marital status, education level of the mother, living area , and the number of family members. See The SAI  was usedThe PMP S-E tool  was usedThe ethical endorsement to carry out this research was granted by the Ethical Committee of the Jordan University of Science and Technology (JUST) and the Institutional Review Board (IRB) of the Ministry of Health. The subjects were given information concerning the objectives of the study by the researcher, details of its benefits, the freedom to choose to participate, and the privilege of freely withdrawing from the survey. In addition, the subjects were given an assurance that their data would be confidential and that only the researcher could access the information.Data was only collected after the IRB of the Ministry of Health and the Ethical Committed of the JUST had given approval for the study to proceed. The mothers at the facilities who agreed to participate were interviewed to determine whether they met the criteria for inclusion. If they satisfied the criteria, they were asked to sign a consent form confirming that they wished to participate before they were issued with a folder. The folder contained an introduction letter, two consent forms (one for the researcher and one for the subject), a self-sealing envelope, and a survey form. The researcher gathered data from the subjects from the facilities. Every subject at the facilities was given approximately 20 minutes to finish the survey. This was in line with a pilot study that was conducted on a sample with a diverse range of education from which it was concluded that the survey instrument would take from 15 to 20 minutes to complete. The researcher’s assistants were present during the completion of the survey in order to respond to questions, and give clarifications.The descriptive statistics were analyzed using SPSS first according to mean, frequency, and distribution. Any discrepant or unusual data was identified and dealt with before this analysis. Surveys with more than 20% of the data missing were excluded from the study. A table format was used to display the descriptive information on the attributes and socio-demographics of the participating mothers. All the statistical procedures were subjected to an assumption trial. Normality was investigated for all the continuous-level data. The assumption trial for the multiple regression analysis was done to determine the predictors of MPSE. The significance level was determined to p≥ .05. The covariates factors were mother age, mother education, mother assistance, mother employment, mother experience with children, place of living, marital relation, family income, infant age, infant gender.n = 168) had completed a bachelor’s degree or higher. Over half were unemployed . The mean monthly income of the family was 887.2 Jordanian dinars. The age of the infant and toddlers ranged between 3 and 30 months, with a mean age of 17 months with just over half the infants and toddlers female  and the rest male . See The age of the mothers ranged between 19 and 37, with a mean age of 30.2 years. The majority of the mothers . This means that maternal anxiety does not predict MPSE and does not have any impact. See F = 2.930, P = 0.01) that indicated that MPSE was associated with the following factors: quality of marriage relations , as a higher quality of marriage meant an increased MPSE score, family income  as the increasing of income also caused an increase in the MPSE score. Employment is another factor that impacted MPSE and showed that working mothers did not exhibit more MPSE toward infants and toddlers . Education is another factor that impacted the MPSE score  and this means educated mothers exhibit more MPSE toward their infants and toddlers than uneducated mothers, and living with extended family  enhance the mother ability to exhibit greater MPSE. Hence, these factors were found to be key predictors of MPSE. The results of the multivariate regression analysis are shown in detail in Multiple regression analysis revealed a significant pattern (This study aims to investigate the relationship between maternal anxiety and the predictors of maternal parental self-efficacy when the children concerned are in the early years of life. Based on the outcomes of this study, it seems that environmental factors, including family factors, could have an impact on MPSE.Similar to previous studies by Ngai et al. and Salonen et al, our study found that maternal anxiety did not predict self-efficacy. However, there is a need for a longitudinal study to gauge the association between MPSE and maternal anxiety at different times during the postnatal period , 14. HowOur results showed that Jordanian mothers appreciate being in contact with their infant and toddlers, irrespective of the time taken to understand the needs of their infant and toddlers through the infant and toddlers’ expressions of temperament. In addition, Jordanian mothers with experience in caring for infants and toddlers before they had their own child and those living in a large family had an elevated level of MPSE. The above outcomes are in agreement with the results reported by Gharaibeh and Halman, who proposed that maternal background may work as precursors of self-efficacy. In the context of Arabic culture , these oThe findings of this study also showed that mothers with experience of caring for an infant and toddler before motherhood by living with extended family, being an aunt, and participating in childcare had a lot of confidence in their ability to take on caregiving responsibilities. Those who had watched others care for infants and toddlers or had received guidance, assistance, and words of encouragement perceived that they had high levels of self-efficacy. These outcomes are consistent with the results of Farkas and Valdés and Abuhammad et al, who stressed the significance of assistance in promoting self-efficacy and courage in caring for infants and toddlers , 22.According to Leahy-Warren and McCarthy , maternaAs for the impact of age, in contrast with previous Jordanian  and inteIt is essential for nurses to understand MPSE. Therefore, including the concept of maternal parenting self-efficacy in nursing curricula can help raise awareness of this important concept. Understanding maternal parenting self-efficacy is necessary for nurses to evaluate the mothers’ parenting self-efficacy. Certain anticipatory guidance and related interventions can be explored as required. Nurses can offer education to the mothers regarding parenting maternal self-efficacy, which will enable them to care for their children properly. For example, the nurses should teach mothers that parenting self-efficacy is modifiable. It is possible that maternal parenting self-efficacy and parenting practices may mutually influence each other over time.The findings of this study show that MPSE is significantly associated with various predictors. These predictors are the mother’s education, income, if she lives with extended family, her quality of marriage, and her employment. Maternal anxiety was found not to be a predictor for MPSE and this may explain other factors such as social support and living with extended family. Nurses may therefore wish to consider evaluating women who show a possible risk of low MPSE and assist them via training, assistance, and interventions to boost their parental self-efficacy. However, it should be noted that the theoretical technique applied in this study needs to be replicated in order to bolster these findings empirically. In addition, more studies on the impact of socio-demographic variables and other factors on MPSE are required to provide support to the outcomes of this study and deeper insight into this phenomenon.


The use of telemedicine has greatly increased, largely derived from the COVID-19 pandemic, which has created the need for a guide aimed towards the adequate management of a modality of health care: the video consultation. A Delphi study composed of three rounds was conducted with 16 experts in holding video consultations and managing non-technical skills from different specialties and nationalities to conceive a consensus on the criteria needed for properly managing video consultations by healthcare professionals. The consensus criteria were defined by three dimensions  and their corresponding items. Excellent consensus data was obtained; therefore, use is recommended by any healthcare professional who is going to utilize a video consultation, in order to manage it effectively. The pandemic caused by the novel coronavirus disease 2019 (COVID-19) is a threat to global health [There is no doubt that the COVID-19 pandemic and its rapid evolution has created quite a confounding situation , creatinIt should be pointed out that the World Health Organization  defines Video consultations have been used throughout the world ,24. AlthIt is therefore crucial to ensure the quality of health care through this modality. To achieve this, a set of requirements for video consultation assistance is required that deal with factors such as the ethical issues related to the protection of privacy and confidentiality, creating trust in patients, providing competent health care, ensuring continuity of care , at the To date, some approaches have recommended a range of strategies to hold an adequate video consultation, but these are related to quite specific clinical conditions and diseases, and not aimed at providing general health care for most clinical practice situations and patients through this modality. For instance, the following have been promoted: broad guidelines for ethical conduct related to key issues in telehealth/telemedicine , an examAdditionally, previous telecare experiences, such as the use of telephone calls, have demonstrated that structured telephone assistance is effective, improving patients’ quality of life and reducing costs ,34. TakiAs the video consultation is a novel and innovative topic, the creation of a consensus on criteria for good practices in video consultation using the Delphi method is proposed, as it is an effective method for obtaining a consensus among experts in any given field of study ,36. MoreAccording to Mosadeghrad , includiAll questionnaires were sent electronically using the application Google Forms™ , whose use has increased over the years, demonstrating its effectiveness . MoreoveThree Delphi rounds were carried out during the study between 25 March and 9 June 2020. First round: The Delphi process traditionally starts with an open-ended questionnaire to collect specific information about a content area from experts [ experts . ConsequSecond round: A second self-administered questionnaire was electronically sent to participants to obtain their opinion about the items that should be included in the guideline, including a brief report of the panel’s most outstanding qualitative results. The response rate was 100% (n = 16). The experts scored this using a Likert scale ranging from 1  to 4  to assess the inclusion or not of the different items prepared, after analyzing the content of responses obtained in the first-round survey . In addition, an observations section was included, where experts could add indicators or proposals for change or inclusion of new items that they considered necessary to be evaluated in subsequent rounds.Third round: After the second-round survey, both quantitative and qualitative responses and observations were analyzed. The revised survey obtained was forwarded to experts with the same evaluation criteria , including feedback of both quantitative  and qualitative (more frequent observations) results obtained in the previous round [us round . Once agA content analysis of data obtained in the first round was performed by two different members of the research team who were experts in qualitative methodologies, by analyzing the eight open-ended questions raised in this round through a self-administered questionnaire. This content was performed according to the methodology proposed by Piñuel , which rHigh consensus: the median response was equal to or greater than 3 and at least 80% of the experts scored the element proposed with at least 3 points.Low consensus: the median response was equal to or greater than 3 and 70–79% of the experts scored the element proposed with at least 3 points.No consensus: the median response was less than 3 and less than 70% of the experts scored the element proposed with at least 3 points.Conversely, both quantitative and qualitative data were obtained in the second and third rounds. Regarding the quantitative data collected, as a 4-point Likert response scale was used, the criteria used to decide the consensus on the inclusion of each element proposed were as follows ,43: HighThe major statistics used in Delphi studies are measures of central tendency and level of dispersion in order to present information concerning the collective judgments of the respondents. Generally, the use of median and mode is favored ,43. WhenThe qualitative data collected in the observations section of the questionnaire distributed during the second and third rounds were also analyzed according to the content analysis methodology proposed by Piñuel . More spParticipation was voluntary and the process was anonymous and was carried out following the ethical principles for medical research of the international Declaration of Helsinki . This stA total of 16 national , Madrid (two), Murcia (three), Galicia (two), and Andalusia (three)) and international experts (Mexico (two) and Argentina (two)) on video consultations participated in the study. The mean age of the participants was 44.31 years (SD = 7.854) and most were women . The panel of experts was composed of five psychologists, eight nurses, and three general practitioners (three of these had been in turn patients attended by video consultation). Their average length of work experience was 19.86 years (SD = 9.979), and they had performed 53.43 video consultations on average (SD = 50.029).Availability of other alternative forms of communication in order to be able to contact the patient in case of problems with the video call .To plan the reason for the consultation , and searching for scientific evidence available to resolve any questions, if necessary.To start the conversation, refer to some temporospatial aspect to contextualize .Postpone video consultation if it is not possible at that time due to non-rectifiable connection problems that prevent effective communication, but in that case always agree on the date, time and type of the new interaction to provide continuity.In the case of performing a prior consultation and if it is necessary, summarize its significant aspects, established objectives, and their degree of compliance, as well as strengths and difficulties found during this consultation before presenting the action plan derived from the current video consultation.After performing the content analysis of the experts’ responses to the eight open-ended questions raised in the first round, responses were translated into the questionnaire distributed in the second round. In this second round, consensus on criteria proposed in this questionnaire was achieved, as more than 80% of the experts scored each element proposed with at least three points, obtaining a median response greater than 3.25. However, to increase the degree of consensus, a third round was carried out after refining several items according to the analysis of both quantitative and qualitative data collected (responses to each item proposed and experts’ observations) in the second round. More specifically, an item was removed  since it was redundant in relation to a previous item, and a total of five items were modified in this round :AvailabiOnce again, more than 80% of the experts scored each element proposed with at least three points in this third round, obtaining a median response greater than 3.25. It should be noted that only one expert provided an observation related to an error in the numbering of an item. Consequently, as a high consensus was achieved after this round, no more rounds were needed. Therefore, a series of criteria for good practice in video consultation management were obtained by the consensus of a panel of experts. These criteria were defined by three dimensions . These dimensions and their corresponding criteria are shown in Due to the COVID-19 pandemic, the need has arisen to promote telemedicine, and specifically, video consultation ,14,18. CSome specific aspects should be noted in both video consultation phases  and the context of the patient-healthcare professional relationship, as it is essential to establish an adequate encounter and interaction between them, generating a substantial impact on the participants’ experience . In thisIt should be noted that the high consensus obtained in our study was achieved following the recommended methodology criteria for reporting of Delphi studies ,43. In aAlthough it may seem controversial to create a standard for a unique and personalized act such as a video consultation, in this study an expert consensus was reached to achieve structured and detailed criteria for the steps and indications that are considered essential in this modality of health care. All of these recommendations are flexible and versatile enough for all healthcare professionals  to be able to adapt them to their particular conditions, helping to successfully manage a video consultation. However, it is highly recommended that all healthcare professionals, patients, and caregivers be trained and taught in this modality of healthcare before its real-life use in order to master this technology. In this sense, our guideline includes the availability of other alternative forms of communication in order to be able to contact the patient in case of problems with the video call. In addition, ethical issues related to this technology depend on the specific platform or video consultation software provided by the healthcare service, ensuring privacy and confidentiality. In this case, our guideline includes two elements related to ensuring an environment that is secure, private and confidential. Our study is not exempt from limitations, which are fundamentally related to the Spanish and Latin American origin of the experts selected and the sample size (n = 16 experts). Although there is no standard sample size for the Delphi method, some authors recommend that the sample should range between 20–50 experts , whereasA consensus on criteria for good practices in video consultations management was achieved with a panel of experts using a 3-round Delphi study. The resulting criteria were focused on both video consultation phases  and the context of the patient-healthcare professional relationship. The use of these video consultation criteria is recommended for all health professionals who are going to hold a video consultation. Pilot studies on the use of these criteria for good practice in video consultation management are recommended to analyze their operability, satisfaction, and quality.


The ongoing COVID-19 pandemic constitutes not only a danger for public health, but may also threaten civil liberties. Looking at the examples of recent events in Poland and Hungary, the authors argue that governments may misuse pandemic for their political advantage, thus endangering public health. Political decisions taken to stem the spread of pandemics should be limited and strictly proportionate to the situation. The recent pandemic of the novel coronavirus SARS-CoV-2 poses a profound challenge, not only to public health systems around the globe, but also reaches deeply into very basic values on which many countries are built. As the global number of COVID-19 infection increases, political commentators and scientists are raising important questions: What does the spread of pandemic mean for democracies? How can we ethically balance public health and civil liberties?The COVID-19 crisis presents an enormous spectrum of legal, ethical, and public health dilemmas. These range from allocation of scarce medical resources , intrusiThere is another view. An international mission of epidemiologists to China organized by the World Health Organization (WHO) stated in its report that the aggressive response imposed by the Chinese authoritarian regime led to containing the spread of the pandemic in that country . If dataGiven this situation, we highlight two important examples from Central Europe: Hungary and Poland. In Hungary, as of 7 September 2020, there were 8963 confirmed cases and 625 deaths caused by COVID-19. In Poland, the corresponding numbers are 71,126 and 2124, respectively . EpidemiPolitical systems in Hungary and Poland are organized within the framework of representative democratic republics. In both countries, the head of state is the president, but in Hungary the president holds a largely ceremonial position. The National Assembly in Hungary elects the president for a 5-year term. In Poland, the voters elect the president directly for a 5-year term, and the Polish president has wider prerogatives, although, considerably less broad than in those in presidential republics like the United States of America or France. The Polish president represents the state in foreign affairs, may nominate and appoint the prime minister and judges. Presidential powers also include the right to initiate legislation, to veto legislative acts, and, in certain instances, to dissolve the parliament.Executive powers in Hungary and Poland—the real political power—are exercised by the Council of Ministers (government) of each state. The head of the government is the prime minister, who together with other ministers manages the policy of the state, coordinates and controls the work of government administrative bodies, and ensures public order and the internal and external security of the state, including issues related to public health. Typically, the governments in both countries are formed by the representatives of parties, or coalition of parties, that won the respective parliamentary elections and have the majority in their national parliaments. Governments in both countries are accountable to their respective parliaments, that have the right to monitor the work of the government. If the government is not pursuing its responsibilities satisfactorily or exceeds its constitutional powers, the parliament may withdraw its support for the government, leading to dissolution of the government. Although opposition parties in parliaments do not have a direct influence on execution of the tasks of the government, they can exercise control by issuing particular questions for the ministers, or by initiating investigations of policies of the government. Certain policy measures in Hungary and Poland, such as declaring a state of emergency in the country, need to be approved by the parliament.Governments in both countries sought to limit the spread of COVID-19 through public health measures including compulsory quarantine, isolation, and social distancing along with special governmental emergency powers for managing the outbreak of the pandemic. Although most of these measures do not differ from means implemented by other democracies, independent observation bodies, such as the Hungarian Helsinki Committee or Amnesty International Hungary, expressed concerns that measures introduced during the pandemic may be abused for political gains . Due to On 30 March 2020, Hungary’s parliament passed regulations that gave the government a right to issue special decrees under emergency rule . While aIn Poland, parliament decided that a presidential election anticipated in 2020 should proceed on schedule despite the pandemic . Poland’The election took place in two rounds on 28 June and 12 July 2020. In the first round, out of 11 candidates, none received required majority of 50% of the votes. In the second round, in which only two candidates with highest results from the first turn participated, the incumbent Andrzej Duda narrowly defeated the opposition challenger, Rafał Trzaskowski. Representatives of the opposition contested the results as deeply flawed . Also, tIn addition, limitations to the right to free speech in Poland caused further concern among international observers, representatives of the Polish medical profession, and Polish independent private media. On 20 March 2020, the Polish Ministry of Health issued a letter in which it banned consultants and epidemiologists from expressing their views on the virus or on the reaction of public health services to the pandemic. Although the government asserted that the ban should prohibit the spread of false information, the medical community in Poland recognized the ban as a muzzle on independent opinions in the society and medical profession criticizing the state of Polish healthcare or the dangers of holding an election during the pandemic . Some doIn Hungary, since winning the election in 2010, the conservative-national Fidesz party of Viktor Orbán systematically dismantled a previously existing liberal system of checks and balances. Having gained its political power from popular support fueled by state-sponsored campaigns against migrants and non-governmental organizations, the government skewed the electoral process in its own favor, extended partisan control over state agencies, media and civil society, and developed a harshly anti-liberal ideology .In Poland, a similarly conservative-national Law and Justice (PiS) party staged during the last 5 years a massive attack on democratic institutions through subduing independent courts, including the Polish Constitutional Court. It also turned the state television networks into purveyors of governmental propaganda, re-politicizing the civil service, restricting free speech, and weakening the independence of the electoral commission . The govFor these actions both governments have been criticized by European institutions, such as the European Commission and the European Parliament. The European Commission and the European Parliament warned against breaching the European Union’s founding values and in December 2017 (for Poland) and September 2018 (for Hungary) initiated a process that may lead to sanctions against both countries [For 10 years in Hungary and 5 years in Poland, the ruling political parties systematically have eroded the democratic foundations of the political systems.ountries .These two examples highlight an ongoing concern among political commentators and scientists around the world: how far can governments go in using pandemic for their political advantage? , 30 ContThe right to vote is fundamental for any democratic system. It should not, however, take precedence over the protection of voters’ health. Numerous experts in Poland and around the world are concerned that holding elections during a pandemic can be dangerous for public health, especially if there are no scientific data showing it is safe to do so . Public The right to free speech is essential and should not be limited in a democratic system, especially in such an extraordinary situation as presented by the COVID-19 pandemic of 2020. An important foundation for trust is the structure of government—with checks and balances for limiting certain actions by government and for assuring that individuals may freely express their opinions. The role of free media is indisputable; it should not be limited by any democratic government. Prohibiting medical professionals from criticizing actions of hospitals or taking part in public discussion contradicts their human rights and the very core of professional medical ethics. In Poland, as in many other countries, the Code of Medical Ethics specifies the obligation of every physician to draw the attention of the public, authorities, and every patient to the importance of protecting human health. In pursuit of any patient’s wellbeing, a doctor should not succumb to social pressure or administrative requirements. Denying medical professionals the right to freely express their opinions, even if dictated by fear of misinformation, erodes fundamental democratic values.Misusing public health for political objectives may be dangerous, not only for the health and lives of people but also for the political systems under which we live. Success in limiting the spread of infections depends on voluntary compliance of citizens to rigorous epidemiologic rules, not on compulsion. Voluntary compliance is only possible with widespread mobilization in a society based on trust that governmental actions are indeed aimed at containing danger. If people endure severe restrictions of their liberties for several weeks—then see them removed for political reasons, they will lose confidence in future measures. If governments use the pandemic to excuse seizing or consolidating political power, they will squander popular confidence and lose legitimacy for combatting the pandemic. Efforts of medical professionals should not be mishandled for political gain. Frontline doctors, nurses, and medical staff daily risk their lives and health to help patients. Abusing their dedication to containing the disease is highly immoral. Political decisions to stem the spread of pandemics should be limited and strictly proportionate to the situation at the time.Not only Hungary or Poland should be under a special scrutiny. Several important political events will take place around the world, among them, a presidential election in the USA. Some political leaders have called for their countries to reopen as soon as possible, fearing that a declining economy would decrease their chances to win an election. Such decisions should not be based on political strategy, but on scientific data. It should be the moral obligation of politicians, medical professionals, and also of the public to guarantee that the COVID-19 pandemic of 2020 is not misused for political goals.


Case Presentation. The 15-year-old male patient was referred to our hospital for an OCD in the medial femoral condyle of the left knee. He had a history of an OCD in his right elbow, and his father had a history of surgically treated OCDs in both knees. One year and five months after, surgery was performed to the lesion in his left medial femoral condyle, a new OCD lesion occurred in the femoral trochlea of the same knee, which was again treated surgically. Five months after the second surgery, the patient returned with pain in the right knee, and an OCD on the right femoral trochlea was detected by an MRI scan. This lesion remained stable without any further restriction in physical activities for 17 months until detachment occurred and was again treated surgically.  Osteochondritis dissecans (OCD) rarely occurs in multiple joints. Furthermore, the existence of left-right asymmetric OCDs in different joints of the contralateral side of the body and lesions occurring with a temporal difference is rare. Here, we report a rare case with multiple OCDs sequentially detected in various joints.  In cases with history and a family history of multiple OCDs, in particular, with a short stature, an MRI scan should be performed for the symptomatic joint to detect and treat the lesion before progression. Osteochondritis dissecans (OCD) is a disorder that affects the subchondral bone and potentially leads to detachment of cartilage and bone fragment with progression . It is kSome cases with bilateral knee OCDs have been reported , 6, but A 15-year-old boy was referred to our department after the failure of a conservative treatment to an OCD lesion in his left knee. He presented at his orthopedic practitioner three months before referral to our department, complaining of pain in his left knee during sports activity such as baseball. At the initial visit, his height was 150 cm, which was below the -2 standard deviation (SD) cutoff (approximately -2.8 SD) of Japanese average of the same age, with a body mass index of 22. He had a history of OCD in the right elbow at the age of 11. The patient's father also had short stature  and had a history of OCDs in both knees, which was surgically treated after maturity. There was no other family history of OCD. There was no swelling or tenderness of the knee joint, and no abnormalities in the range of motion or joint laxity and stability were detected on physical examination. The boy did not have any pain during normal daily activities, including PE. An OCD of the medial femoral condyle (MFC) was detected by radiograph and classified as stage III, according to Brückl  Figure . The lesSince the patient was asymptomatic at the time he was referred to our department, he was treated conservatively for another three months but did not show any improvement in radiographic finding. Thus, we decided to perform surgical treatment. The operative treatment consisted of an initial arthroscopy. The lesion was identified since there was cleavage in the rim of the lesion by probing , and theThe postoperative course was successful until one year and four months after surgery when he fell and hit the left anterior knee. The radiograph taken immediately after this injury showed no abnormal findings. Since the patient started to feel pain on running, and since an event of locking of the knee joint occurred, we performed another radiographic examination one month after the injury but were unable to detect any abnormal findings, and the patient was conservatively treated. Four months after the injury, the knee became more frequently locked, and knee pain on flexion and swelling of the knee joint became evident, and another radiographic examination was performed. A defect in the lateral facet of the femoral trochlea that had been normal on the previous MRI before this event was detected by radiography, and the lesion was confirmed by MRI scan. The lesion was diagnosed as OCD in the femoral trochlea , and no kissing lesion was confirmed on the patella . The ostOne month after returning to sports (5 months after fragment fixation surgery), the patient returned to the office complaining of pain in his contralateral knee during sports activities without any obvious history of injury. Radiography and MRI scan were performed for his right knee, and an OCD lesion of Brückl's classification stage II and Nelson's classification stage I OCD in the lateral facet of the trochlea was identified . The lesIn the presented case, we experienced multiple OCDs occurring in various joints (4 lesions in the three joints), with the temporal difference in occurrence. We failed to detect one of the lesions in the early phase of the disease before detachment from the base and were required to perform surgery to treat the lesion.In terms of the epidemiology of OCDs, bilateral lesions have been reported to be present in 7.3-29%  of OCDs Considering the timing of diagnosis of multiple OCDs according to the literature, there were 26 cases of multiple OCDs that mentioned the time point of diagnosis of each lesion. In most cases, multiple lesions were identified at the same time, and there were only 6 cases, which was diagnosed one after the other. It was reported that, in 40% of bilateral OCD cases, the incidentally diagnosed contralateral lesion was asymptomatic . In otheSeveral theories have been suggested for the etiology of OCDs, including ischemia of subchondral bone, trauma, repetitive microtrauma, genetic factor, metabolic disease, and inflammatory disease –4. HowevThere are a couple of limitations in the present paper. First, the lesion at the trochlea of the left knee might not be the OCD but traumatic osteochondral lesion. There were no abnormal findings on the patella on MRI, and lack of kissing lesion in the patella might support our diagnosis as an OCD. Second, an MRI exam of the right knee was performed only once before we detected the OCD in the right trochlea. Thus, we could not tell when the lesion developed.In conclusion, in cases with history of OCD and a family history of multiple OCDs, in particular, with a short stature, an MRI scan should be performed for the symptomatic joint , 31 to d