The use of clinical practice guidelines envisages augmenting quality and best practice in clinical outcomes. Generic guidelines that are not adapted for local use often fail to produce these outcomes. Adaptation is a systematic and rigorous process that should maintain the quality and validity of the guideline, while making it more usable by the targeted users. Diverse skills are required for the task of adaptation. Although adapting a guideline is not a guarantee that it will be implemented, adaptation may improve acceptance and adherence to its recommendations.We describe the process used to adapt clinical guidelines for diabetic retinopathy in Kenya, using validated tools and manuals. A technical working group consisting of volunteers provided leadership.The process was intensive and required more time than anticipated. Flexibility in the process and concurrent health system activities contributed to the success of the adaptation. The outputs from the adaptation include the guidelines in different formats, point of care instruments, as well as tools for training, monitoring, quality assurance and patient education.Guideline adaptation is applicable and feasible at the national level in Kenya. However, it is labor- and time -intensive. It presents a valuable opportunity to develop several additional outputs that are useful at the point of care.The online version of this article (10.1186/s13012-018-0773-2) contains supplementary material, which is available to authorized users. The first definition of clinical practice guidelines (CPG), hereafter referred to as “guidelines,” was provided by the Institute of Medicine (IOM) in the USA in 1990: “systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific circumstances” . GuideliGuideline adaptation is potentially an efficient alternative to de novo guideline development, particularly in resource-constrained contexts . AdaptinThe Institute of Medicine  has descThis paper describes the process involved in adapting the diabetic retinopathy (DR) guidelines for Kenya, in order to assist others undertaking a similar endeavor.The STEPwise survey  for riskEffective and quality service delivery in relation to DR in Kenya is required within the existing health system –10. CurrClinical guidelines offer recommendations to improve service delivery, advocate for resources, leverage existing resources, and improve outcomes. Implementing evidence-based practice guidelines for DR is thus vital to address the gaps and prevent blindness from DR. International guidelines for this purpose exist, but there are no published local guidelines. This guideline adaptation aimed to address this lack of national guidelines. We envisaged providing a user-friendly guideline that describes appropriate care based on the best available scientific evidence.We relied on adaptation instead of de novo development of the guideline in order to avoid duplication of effort, to use the available resources cost-effectively, and to facilitate customization of the guidelines prepared for other income and health system settings to reflect local context.The process of standardizing clinical practice recommendations for DR in Kenya began over a decade ago. Several guideline documents have been produced although none has been formally published as a national guideline. Our reflection was that opportunity costs, turnover of experts involved in the process, and other contextual factors might have slowed down further development of the guidelines. The methodology discussed here is that followed over the last 2 years leading to the production of the published guideline. However, we expect that a similar process was undertaken in the previous period.ADAPTE framework, although some of the tasks were synchronized and we often had to return to previously completed steps. The ADAPTE process is a well-known framework for guideline adaptation, which consists of 3 phases and 24 steps. Seven core principles underpin this framework, and the TWG adopted them for this adaptation [The adaptation process has been systematic, consultative, and guided by a technical working group (TWG). Several widely used toolkits and guidelines provided a point of entry –20. We faptation . Figure The identification of the need for the DR guidelines by stakeholders prompted the Ophthalmic Services Unit to constitute a steering team of five members. This team prepared terms of reference and a list of potential members for the TWG. At the first few meetings of the TWG, we discussed the following: the need for the guidelines, the feasibility of guideline development, the required expertise, funding, work plan, outputs, and role definition of the members. In subsequent meetings, the topic and clinical questions were defined.We identified the methodological resources, the clinical guidelines, and the evidence for effectiveness of various DR interventions through a literature search on various databases including Cochrane Library, ELDIS, Embase, Global Health, and PubMed. We also searched the websites of agencies that develop these resources. The search strategy  Standards for Medical Care in Diabetes , InternaAGREE II  instrument to assess the quality of the clinical guidelines. This instrument consists of 23 items grouped into six domains: (a) scope and purpose, (b) stakeholder involvement, (c) rigor of development, (d) clarity and presentation, (e) applicability, and (f) editorial independence.We utilized the The following additional guidelines were also reviewed, so as to identify any potential conflict in recommendations for care of diabetes and other comorbidities: Kenya national guidelines for management of diabetes , Kenya nDraft guidelines were prepared by the TWG and circulated via email to all members for review. Three drafts were circulated, with the final draft also being circulated to external reviewers to assess content validity, clarity, and applicability. The TWG evaluated the final draft guidelines for the quality requirements of the AGREE II instrument prior to release. A consensus stakeholders meeting approved the final draft.Pilot testing was conducted in different health care settings in purposively selected counties that differed in characteristics that may influence applicability. We collected feedback on the usability through interviews, reports, and observation. Dissemination of guidelines was done through county coordinators, conferences, training institutions, professional associations, social media, and distribution of print material.Table The TWG’s first task was to define the scope. The main options were to include only DR or diabetic eye disease as a whole. The consensus was to limit the scope to DR because of its unique natural history and public health implications. The overall objective of the guideline is to reduce the proportion of PLWD who go blind due to diabetic retinopathy in Kenya through interventions for prevention, early detection, and effective treatment of DR. The adaptation process aimed to reduce inappropriate variation in screening and treatment, to provide a rational guide for referral, and to use the diabetes care and eye care resources efficiently to meet these goals. The recommendations needed to be germane to the social context, the patient pathway, and the referral systems in addition to being capable of integration into the routine workflow. The Population, Intervention, Professions, Outcomes and Health care system (PIPOH) summary Table  defined The Ophthalmic Services Unit at the Ministry of Health convened a steering group of five members. They drafted the terms of reference for a task-oriented TWG, which were to (1) determine the scope and focus of the required guidelines, (2) appraise the evidence and recommendations in existing DR guidelines, (3) develop the national guideline, and (4) craft messages to be used at the point of care, to influence practice.The steering group identified 25 potential members of the TWG, based on the criteria of diverse expertise, experience, representation of multiple stakeholder groups, and commitment to the process, all aimed at increasing both internal and external validity of the guidelines. These members received personal invitations to participate. An average of 15 were active members of the TWG at any given time, but the others remained involved on the periphery and received frequent reminders to participate remotely. Participation was through attending meetings, email and telephone correspondence, face-to-face consultations, availing resource documents, reviewing drafts, providing evidence, and informal consultations. This proactive integrative and flexible approach was designed to ensure ownership, external validity, and the involvement of end users of the guideline.The TWG members were all volunteers with other clinical, educational, administrative, and policy roles related to DM and DR in public, private, or faith-based health facilities, academia, ministry of health, and professional organizations. Participation on a volunteer basis inferred limitation of availability, though additionally, it implied indirect institutional participation of the employer. They had diverse expertise including clinical, public health, research, epidemiology, literature search, systematic reviews, and health systems. Differences in opinion were encountered in the deliberation of some recommendations, particularly regarding the role of different cadres in making DR treatment decisions and delivering treatment. This was resolved through varied strategies: expressing judgements about values and risks, making reference to regulation, reviewing the evidence for role specification, and adapting the role definition prescribed by the source guidelines and informal consensus techniques.We did not employ a research assistant, because the team had skills in literature review, recent systematic reviews on interventions for DR were available and the existing guidelines were current. The team did not have a health economist and did not conduct an economic appraisal. As the guidelines were in English, we did not require expertise in foreign languages.The TWG considered it is important to include patients’ values and perspectives in the guidelines. A patient group was invited and PLWD who are clinicians were included, but despite our efforts, we did not succeed in having patients directly participate in the adaptation. We also aspired to have the participation of large groups of PLWD in a way that adequately represents the diversity of perspectives of PLWD from different geographical locations, social strata, and stages of disease. Since we do not have a comprehensive database of PLWD in the country, this was not feasible.We obtained high quality and current international guidelines. We examined the methods and the quality of the evidence used to formulate the recommendations for interventions for DR. We also considered the implications for resources and health service delivery in Kenya. Further, we searched for any recent evidence from systematic reviews and for relevant domestic research. In the absence of this, and judging the recommendations current and evidence-based, we incorporated them in our guidelines. The draft guidelines were subsequently reviewed by external multidisciplinary reviewers and pilot-tested in various health facilities. The guideline will be updated in 5 years to incorporate any new evidence that will have emerged.checklist [We used the Conference for Guideline Standardization (COGS) hecklist  as a guiIn writing the guidelines, we avoided vague, nonspecific, or ambiguous terms and phrases. We aimed to produce a user-friendly guideline in which the precise recommendations are easily identifiable and clear, and the formatting is appropriate.We recognized the facilitators and barriers to the application of this guideline in the Kenyan health system. To overcome the barriers, the guideline provides tools to facilitate its implementation at the point of use. These include workshop slides for training guideline implementers. Flexible 1- day training programs have been executed at implementing health facilities, conferences and training institutions, in conjunction with guidelines dissemination. The potential resource implications  and resultant work burden of applying the recommendations were considered. A monitoring and evaluation plan has also been included to assess adherence to recommendations and the outcomes of the implementation.We required data on the costs of DR services in Kenya, but we did not undertake this as the Division of Non-Communicable Diseases had recently undertaken costing for diabetes services, including DR services. We lacked a costing model for guideline adaptation at the start of the exercise, but in our experience, the largest cost of the adaptation process was the production, pilot-testing, dissemination, and implementation of the print outputs. This may be reduced with progressive enhancement of digital literacy of the users and increased utilization of the electronic resources.The basic logistic needs of the adaptation process (administrative and meeting costs), as well as the implementation costs, were funded by The Fred Hollows Foundation. The funders did not influence the content of the guideline. There was a 100% consensus on the desired outcome of the guidelines, which is prevention of blindness from DR. Members and funders did not have any conflict of interest with respect to this outcome.Unlike the reference guidelines, the Kenyan guideline is designed for use by both diabetes and eye care clinicians, as well as other stakeholders in eye care. The population of interest is all PLWD aged 12 years and over, without any exceptions. The guideline attempts to take care of various complexities of service delivery. The role of different cadres in the screening, diagnosis, and treatment of DR is highlighted. Noting the variability in access to required equipment and skills, a referral mechanism has been determined through mapping of the services available in different facilities in the country. We found it practical to constantly relate the guideline to the patient pathway. Additional specifications have been made on linking diabetes care and eye care services, clinical governance for the services, and using the health information management systems (HIMS) to monitor the effect of implementation of the guidelines.electronic version, and an executive summary of the recommendations. The guideline has a national coverage and applies to persons with any type of diabetes.' (ii) quality assurance guidelines; (iii) mapping of DR services in the country; (iv) posters and leaflets for patients; (v) posters and checklists for clinicians; (vi) workshop slides for training health workers; and (vii) monitoring and evaluation tool. These outputs are to be used at the point of care by diabetes and eye care clinicians, as well as by administrators and policy makers. They were chosen because they were perceived to increase convenience of users and to intensify user adoption of the guidelines. They are in English, but they can be translated. An executive summary of the guidelines is published in a separate paper [This process has led to several outputs: (i) the national guidelines in various formats—print copies, te paper .Feedback from pilot-testing indicated that the guideline is useful in various clinical and geographic settings in the country. It served an educational role for clinicians and reduced missed opportunities for screening and referral. The demand for the print outputs continued after pilot-testing. The point-of-use outputs were reported to boost user satisfaction because they contained simplified key messages for different users. During prospective collection of feedback, the lack of a tool to guide integration of diabetes and eye care services has been identified as a gap, and its development is being considered.The process of DR guideline development in Kenya has taken several iterative episodes. This trajectory may reflect the intensive work that guideline adaptation entails, as well as the capacity building that has resulted over that process. This experience is not unique to this initiative; long timelines have been reported in other guideline initiatives in the same context . ContextWe did not experience a shorter time scale for adaptation compared to the 2–3 year period suggested for de novo development or shorter timelines for adaptation . This coThe diverse expert skills and commitment of our multidisciplinary TWG are a recognizable success factor for our initiative. This is pertinent for both the internal and external validity  of the guidelines , 17. As The integrative participation method, which allowed both in-person participation and remote participation of the working group, helped to mitigate this constraint. This may have provided impetus to the process and achievement of the outcome. The enabling factor was that both electronic communication and face-to-face meetings were feasible, allowing for flexible engagement.Involving patients in the process of guideline development is recommended , 29, becWe found that the guideline adaptation had the pattern of back and forth interlinked steps. We did not follow the ADAPTE steps sequentially as a stringently linear progressive and prescriptive tool. Further, even with the use of methodological tools, we found that there is need to maintain focus so that the process is not staggered. Clarity of the scope and significance to the patient pathway helped to maintain focus and continuity. Focus helped to avoid attrition, considering that universal completion of guideline development is not the norm .Similar to de novo development, adaptation requires a review of the evidence and explicit use of valid evidence . It woulAdaptation itself has cost implications, and although we did not have a large dedicated budget for the process, we found it important to have a budget for the variable costs. In the absence of funding for fixed costs, we cannot provide an estimate of the funding required. Such estimates would help to calculate the cost-effectiveness of the process, considering the opportunity costs, and comparison with the cost of de novo development. The interventions described in the guidelines are clinically effective, but we need to investigate whether these interventions and the process of guideline development are also cost-effective in our setting. At present, we assume that guidelines augment the efficiency of DR services and optimize value for every shilling invested in the health system. In order to balance cost and accessibility of services, the guidelines promote the use of existing resources while aspiring to progressively mobilize the range of resources that are recommended.National guidelines for various conditions may contain conflicting recommendations, which can be confusing for clinicians. This is especially the case for PLWD, as they often have comorbidities. We avoided such discrepancies by reviewing the other diabetes-related guidelines, and we recommend this as an important step in adaptation.The output from the adaptation process is a guideline that is different from the generic guidelines (or source guidelines) and contains additional information that will be useful for the target user. An additional benefit is the production of additional tools for use at the point of care. This shows that the role of guideline adaptation is not limited to endorsing generic recommendations.This initiative has coincided with other DR activities, such as the initial steps towards implementing regular retinal screening for PLWD attending diabetes services. This may have contributed to its success, and we can further leverage on this to market the guidelines. Given that countries in the African region, particularly the Eastern, Central, and Sothern African region may face similar needs to develop guidelines, a network or collaboration of sharing and learning may be an efficient approach to develop them.Guideline adaptation is a structured investment -intensive process that is feasible at the country level. Rigor and focus are important in this process. The ADAPTE process and AGREE II instrument are valuable tools for this process, though it would be helpful for the generic guidelines to have an adaptation template for other contexts.Multiple informational, technological, economic, social, and professional variables influence the effectiveness of guideline adaptation. Beyond the utility of this process in producing the outputs we required, it could also be useful to inform the development of other guidelines in similar contexts. Our experience has helped to provide insights on the use of the adaptation methodology in the African context. We have also identified guideline development as a potential area for collaboration.Involvement of the end user of the guidelines  in this adaptation process aims to increase adherence to the guidelines. We expect that DR services that were not routinely available to PLWD in Kenya will now become accessible as a response to the guidelines.Availability of a national guideline is a necessary but not sufficient impetus to standardize patient care. The extent to which the prevention of blindness from DR is realized will depend on the effectiveness of guideline dissemination and implementation, in tandem with other interventions.An economic analysis is required to determine whether guideline adaptation is cost-effective. Research evidence is also required to determine the effective methods of involving patients, such as DR patients, in the adaptation process. In addition, the effectiveness of the guidelines in reducing DR blindness will need evaluation.Additional file 1:Search strategy for “Adapting Clinical Practice Guidelines for Diabetic Retinopathy in Kenya” (PDF 568 kb)


Acupuncture is widely used worldwide, and systematic reviews on acupuncture are increasingly being published. Although acupuncture systematic reviews share several essential elements with other systematic reviews, some essential information for the application of acupuncture is not covered by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Considering this, we aimed to develop an extension of the PRISMA statement for acupuncture systematic reviews.We used the PRISMA statement as a starting point, and conducted this study referring to the development strategy recommended by the EQUATOR network. The initial items were collected through a wide survey among evidence users and a review of relevant studies. We conducted a three-round Delphi survey and one-day face-to-face meeting to select items and formulate the checklist. After the consensus meeting, we drafted the manuscript (including the checklist) and sent it to our advisory experts for comments, following which the checklist was refined and circulated to a group of acupuncture systematic review authors for pilot test. We also selected a sample of acupuncture systematic reviews published in 2017 to test the checklist.A checklist of five new sub-items (including sub items) and six modified items was formulated, involving content related to title, rationale, eligibility criteria, literature search, data extraction, and study characteristics. We clarified the rationales of the items and provided examples for each item for additional guidance.The PRISMA for Acupuncture checklist is developed for improving the reporting of systematic reviews of acupuncture interventions.http://www.equator-network.org/library/reporting-guidelines-under-development/#91).We have registered the study on the EQUATOR network (The online version of this article (10.1186/s12906-019-2624-3) contains supplementary material, which is available to authorized users. Having been applied for thousands of years for prevention, treatment and rehabilitation for various diseases, acupuncture is currently used in more than 140 countries worldwide . With a The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) has been developed and is used by academic institutions and journals worldwide to promote the reporting quality of systematic reviews and meta-analyses , 7. ExteThe aim of the PRISMA for Acupuncture checklist is to optimize reporting of systematic reviews focusing on acupuncture interventions for specific conditions. The main group of target users of PRISMA for Acupuncture are authors of systematic reviews on acupuncture, journal editors, peer reviewers and methodologists. We hope this checklist is a useful and practical tool for these audiences and will improve reporting and usability of systematic reviews on acupuncture.The PRISMA for Acupuncture working group registered the project on the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network . We usedAfter establishing the PRISMA for Acupuncture working group, we conducted a review of systematic reviews for acupuncture  and a suBased on the results from the first step, we selected the potential items for reporting in acupuncture systematic reviews. The initial items focused mainly on details of the acupuncture intervention. We also considered items relevant to other aspects of systematic reviews on acupuncture, such as sources for literature search and selection of studies. We then assembled a multidisciplinary group of experts based on their specialties and experience, and balanced the numbers of clinicians, researchers and healthcare providers when forming the panel. We invited 32 experts, of whom 29 agreed to participate, including senior acupuncture practitioners, methodologists of reporting guidelines and systematic reviews, epidemiologists, journal editors and statisticians.We conducted a three-round Delphi process from October 2015 to July 2016, aiming to achieve consensus on essential items that should be included in the PRISMA for Acupuncture checklist and to identify items that required discussion at the face-to-face meeting. All 29 participants responded during the three rounds of the Delphi survey. In the Delphi survey, participants were asked to score each item using a 5-point Likert scale ranging from “of no importance” to “very important” . In the Ni represents the number of respondents who gave the score. We consulted with the leading authors as well as the statistician in the Reporting Items for practice Guidelines in HealThcare (RIGHT) working group and used the same scale and formula from the RIGHT statement, where both the consensus level and the weight of responses were considered. Ni means the number of experts who chose specific “i” in the Likert scale (1 to 5), and items with a score greater than or equal to 75% were included [After each round, the score was calculated with the below formula, where included . An anonAfter the Delphi process, we created a draft checklist with the included items. Ten experts, including acupuncture practitioners, methodologists, reporting guideline developers, journal editors and a statistician, attended a one-day face-to-face meeting in Lanzhou, China, on 12th October 2016. During the meeting, the results of the Delphi process were presented, followed by a discussion and refinement of each item. The participants then voted about the inclusion of each proposed item and decided the precise wording. We present only the aggregated results to maintain the anonymity of the participants. At the end of the meeting, the ten experts reviewed the checklist again to confirm that their comments were appropriately understood and considered.The checklist was then developed in accordance with the EQUATOR template and presented in line with the PRISMA checklist.After the face-to-face meeting, we circulated the manuscript to advisory experts for additional comments. During consultations, the wording and presentation of the checklist and manuscript were further revised. Following this, the checklist was pilot tested.To identify practical challenges with any of the items, members of the PRISMA for Acupuncture working group applied the checklist to investigate the reporting condition of a sample of acupuncture systematic reviews published in 2017. In addition, we also conducted an online survey to corresponding authors of systematic reviews on acupuncture to obtain further comments on the utility and clarity of the checklist. Feedback from all pilot tests were used to refine the wording and presentation of the final checklist.Two items that scored greater than 75% were included after the first round. The experts gave their feedback for revising the remaining items. No additional items were suggested by the panel.For the remaining items, we combined or split some items into sub-items, and revised the wording according to feedback from the first round. A total of 15 items were surveyed in the second round, and the results showed a high consensus on twelve items with no more major changes. While the remaining three items were modified according to comments and entered into the third round.By analyzing the feedback from the third round of the Delphi process, one item was added from the third round of the Delphi process.Based on the results of the collection of initial items, we included seven items for the first round of the Delphi process. The Delphi results were as follows Fig. :Two itemThe results of the 3-round Delphi process are shown in Additional file Experts attending the face-to-face meeting discussed each item to improve their practicability and accuracy and approved all the 15 items included in the Delphi stage. The two items excluded in the Delphi survey were confirmed for removal.The advisory experts reviewed the checklist and manuscript, provided comments about the wording of items, as well as if the item should be considered as new, or as an elaboration of an existing PRISMA item to enhance the relevance, as done in other extensions of PRISMA . At the Data abstraction domain was moved to the Study characteristics domain, and several minor modifications were made to improve the wording of the items. Finally, a checklist of five new items (marked with‡) and six modified items (marked with*) was formulated  of acupuncture systematic reviews from the US, Australia, Taiwan, and Mainland China replied and commented on the checklist  and report characteristics  used as criteria for eligibility, giving rationale.‡Describe the diagnostic criteria of the target condition in Western medicine.6a.1Diagnostic criteria are important to define a disease, and thus to clarify the population of interest. As there may be different diagnostic criteria for one condition, and the diagnostic criteria may change over time, this may result in different inclusion criteria of the participants. For example, a systematic review on acupuncture for hypertension used a blood pressure above 140/90 as inclusion criteria, which is the threshold for high blood pressure according to the editions of the American Heart Association guidelines published during the past 14 years . But in ‡If applicable, describe the diagnostic criteria in terms of traditional medicine, such as traditional Chinese medicine.6a.2Acupuncture is a type of traditional medicine, and therefore research in acupuncture sometimes uses diagnostic criteria and syndrome classification in terms of traditional medicine, which often differ from those in Western medicine. This information is however often omitted in the final report. Authors should report the diagnostic criteria according to traditional medicine when using these classifications to include patients.‡Describe the types of acupuncture to be included, such as traditional acupuncture, electroacupuncture, or fire acupuncture.6bThe types of acupuncture interventions are diverse, including traditional acupuncture , electroacupuncture, ear acupuncture, scalp acupuncture, wrist-ankle acupuncture, and others . The eff‡If applicable, report measures for therapeutic effects using the terminology of either traditional medicine (e.g. syndrome score for syndrome remission) or Western medicine .6cMeasures for therapeutic effects in both traditional medicine  and WestInformation sources7* Describe all sources of information  in the search, and report the date of the last search. If applicable, report the databases or complementary search methods for acupuncture or traditional medicine.Many databases focusing specifically on acupuncture or traditional medicine have become increasingly mature, and they can provide a considerable amount of information for Traditional Chinese Medicine (TCM), Korean medicine and Japanese traditional medicine . AdditioLiterature searches8* Present full electronic search strategy for at least one commonly used database (e.g. MEDLINE), including any limits used, such that it could be repeated. If applicable, include the full search strategy for at least a Western and a traditional medicine database for each systematic review where both were used.http://acutrials.ocom.edu).The search strategy is an indispensable part of a systematic review. Currently, there are only few studies on how to search literature on acupuncture in specific TCM databases. The authors of the systematic reviews should develop search strategies that are rigorous and repeatable and provide a clear description for at least one commonly used database (like MEDLINE) and, when applicable, one acupuncture- or traditional medicine-tailored source, like the Allied and Complementary Medicine Database (AMED) and AcuTrials®  and any assumptions and simplifications made; describe data items about details of the acupuncture interventions and controls (e.g. sham acupuncture) referring to TIDieR when applicable.In acupuncture, the effect is associated with several details of intervention, such as the type of needle and angle and depth of inserting, number of needles, duration of treatment, and acupoints, which vary between diseases , 38. In Study characteristics (one extended item)18* For each study, present characteristics that were extracted  and provide the citations of the included studies. Summarize details of the acupuncture intervention for each study in a table referring to TIDieRThis information corresponds to the item on data extraction, and should be presented with corresponding results referring to TIDieR items. If the information is insufficiently reported and cannot be obtained by contacting authors of the included studies, then authors should describe this information as “not reported” in their review.18a‡Describe details to refer to typical sensations associated with needling after acupuncture reported in the included studies."De-qi" refers to the sensations typically associated with needling including soreness, numbness, heaviness, distension and aching at the insert position when the needle is inserted into acupoints of a certain depth during needling . SeekingIn addition to present the checklist, we also provided examples for each item from existing acupuncture systematic reviews and meta-analyses in Additional file With the aim to optimize reporting of systematic reviews focusing on acupuncture interventions for specific conditions, the PRISMA for Acupuncture checklist can be used for systematic reviews studying specific acupuncture, as well as a large category of interventions that include acupuncture, such as non-pharmacological interventions. The PRISMA for Acupuncture are developed for authors of systematic reviews on acupuncture, journal editors, peer reviewers and methodologists. Besides reporting, PRISMA for Acupuncture can also be used to evaluate the current condition of reporting, and to help journals identify acupuncture systematic reviews of higher quality. PRISMA for Acupuncture can also assist with the early design and development of protocols of acupuncture systematic reviews as other reporting guidelines do .As with other extension of reporting guidelines, the PRISMA for Acupuncture checklist should be used together with the original PRISMA checklist, because some items in PRISMA are universally applicable for systematic reviews for different interventions. Referring to both, where relevant, and other PRISMA guidance (e.g. PRISMA for Protocols  can effehttp://prisma-statement.org/), and the working group welcomes and collects comments and feedback from those in research or practice in order to revise PRISMA for Acupuncture and keep it up to date. We will also monitor the application and evaluate the effect of PRISMA for Acupuncture continuously, and when necessary, update it according to users’ feedback and the latest evidence.The implementation of PRISMA for Acupuncture requires continuous promotion of its use. We will continue to share the PRISMA for Acupuncture by presenting our results of international conferences and seminars, and contacting journals for endorsement. This reporting guideline will be published in both Chinese and English to promote its spread and increase its applicability, and additional translations are also encouraged as necessary, which will hopefully improve the accessibility. All the documents will be available on the PRISMA website Additional file 2:Results of the pilot test of the PRISMA for Acupuncture checklist. (DOCX 27 kb)Additional file 3:Examples of reporting items in systematic reviews for Acupuncture. (DOCX 278 kb)


Due to the rapid installation of a massive number of fixed and mobile sensors, monitoring machines are intentionally or unintentionally involved in the production of a large amount of geospatial data. Environmental sensors and related software applications are rapidly altering human lifestyles and even impacting ecological and human health. However, there are rarely specific geospatial sensor web (GSW) applications for certain ecological public health questions. In this paper, we propose an ontology-driven approach for integrating intelligence to manage human and ecological health risks in the GSW. We design a Human and Ecological health Risks Ontology (HERO) based on a semantic sensor network ontology template. We also illustrate a web-based prototype, the Human and Ecological Health Risk Management System (HaEHMS), which helps health experts and decision makers to estimate human and ecological health risks. We demonstrate this intelligent system through a case study of automatic prediction of air quality and related health risk. Ecological public health promotes the concept that health depends on successful co-existence of the natural world and social relationships . This coSensors are deployed all over the world, ranging from high level remote sensing to low level camera videoing, from earth observation to smart home monitoring, from advanced industry 4.0 to daily healthcare . HoweverTraditional platforms of sensor networks  is indispensable . Data miIn order to solve “intelligent” tasks at low, middle and high levels of the sensor architecture, soft sensors  and compThere are several typical GSW prototypes that semantically handle sensor networks. GeoCENS  consistsHowever, there is a lack of cloud computing architecture to support big-data analytics. Knowledge-based systems are proposed as the solution for big-data analytics, including the application of automatic mode mapping to handle data-oriented heterogeneity, as well as semantic reasoning and ontology extraction that are used for innovative processing. A semantic link network was developed as a base system named Knowle , to orgaIn short, sensor information is associated with geospatial elements . At present, there is a lack of unified manipulation and specification representation for geospatial sensing and computing in the big-data and cloud computing environments. There are few means to share ecological public health resources in the heterogeneous geographic space. The distribution and share of the resources are usually closely coupled with particular locations, applications, or apparatuses used. Therefore, adding intelligent semantics to IoT and deep-learning to sensor management becomes an overwhelming trend . New enhOur initiative expands the OGC SWE by providing a standard set of common message models and service interface specifications for integrating network-connected sensors and sensor systems. The components in the Sensor Web Management Framework are illustrated in The OGC Observations and Measurements (O&M) standard is used to encode and archive real-time observation results and values by sensors. OGC Sensor Model Language (SensorML) contains the Extensive Makeup Language (XML) schema and standard models for describing sensor systems and procedures. It also offers a list of the information that is needed to discover the sensors, the procedure of low level observations, and the process attributes. OGC SWE Common Data Model Encoding delimits the low level data models, which are used for exchanging referred data between nodes. The models are applied to construct, encode, and transmit data sets by self-description and semantic possibility. OGC SWE Service Model Implementation defines the type of data and interfaces that are common to services. The OGC Sensor Observation Service (SOS) and Sensor Alert Service (SAS) are web service interfaces that can be used to request, filter, and retrieve observations and sensor system messages. The OGC Sensor Planning Service (SPS) is applied to request client-driven gains and observations. The OGC Web Notification Service (WNS) is applied to the asynchronous delivery of information or early warnings of the SAS and SPS network services and other parts of the service work process. The Programmable Underwater Connector with Knowledge (PUCK) defines an agreement for the apparatus RS232 and web connections. PUCK transducers are installed and configured to solve the problem by defining an apparatus protocol to automatically store metadata and other information from the instrument itself. The SWMF also follows a Service Oriented Architecture (SOA) approach. A registry maintains a list of available sensors and queries using a group of web-based services. The Catalog Service contains dictionaries of phenomena, units of measure, sensor types and applications. This criterion of the SWMF includes formats for interfaces, agreements, and encodings so as to apply sensor data and services.It is hard to interconnect sensor webs and to realize efficient resource sharing and reuse because of their heterogeneity. As sensor networks become more and more common, the requirements of administering and inquiring the sensor web need to be aided by both standards and machine reasons. When massive numbers of sensors and amounts of data appear, it is very difficult for users to find the sensor and its related resources through the network. Even though the data is found, users cannot easily comprehend the acquired messages. Although the SWMF in Ontologies and some other semantic technologies can become pivotal sensor web technologies, because they enhance the interoperability and integration of semantics, and because they promote the OGC standard to involve reasoning, classification and other types of assurance and automation. It is important to establish the core concepts and relationships of the sensor ontologies to describe the sensor knowledge. To solve this problem, the OGC SWE sensor ontologies frame could be organized into six core concepts: the systems, components, sensors, observations, process model and the process. It has been used as a general purpose method to conceptually describe or simulate the information that is executed in web resources that use various sorts of sentence structure markup and data serialization pattern. The abstract data matrix requires a specific syntax for representation and transmission, whereas the Resource Description Framework (RDF) has been given the XML syntax. Therefore, it carries on the advantages related to XML. Based on the kernel conception and the relations with the sensor ontologies, the RDF encoding is shown in part in The HERO includes Sensor,  Observation, and Phenomenon ontology components. The Observation can be described with the HealthRisk component to draw a picture of human and ecological health risks from the views of ambient air, surface water environment, soil environment, environmental noise, ecology, and biological environment, etc. The measured Phenomenon objects could be any natural element or event.2-NOx, SO2, CO, O3, and PM10/PM2.5 are described in the category of the Sensor component. The measurement capability of the Sensor is linked with the FeatureOfInterest of the Observation. The Location and Time components use the standard GEO W3C Ontology (http://www.w3.org/2003/01/geo/), that is, a simple RDF encoding for the WGS84 latitude and longitude values, and the OWL (Web Ontology Language)-time ontology as the templates. The geospatial and temporal ontology and the Observation Value component are connected with the Observation to describe the computational abilities. The Process component grants the capability of the heterogeneous sensors to compose chained sensing.Take ambient air observation as an example; the analyzers for NO-NOThe intelligent agent for the geospatial and temporal processes will be shown in the Government planners around the world must develop more efficient environmental information management systems to control human and ecological health risks, such as monitoring and evaluating the water quality of lakes, the soil structure of farmlands, the urban air quality of cities, and other environmental matters that are vital to people’s livelihoods, and also announcing the observation data to the public at a regular fixed period . In addition to the governmental agency, universities, research institutes, polluters, and citizens with green awareness are also able to acquire the environmental data by using their own standalone systems or citizen applications. In order to analyze the observations’ impacts on the ecosystems and human health, manage the human and ecological health risks, and deal with relevant decision-making issues, a web-based HaEHMS integrating the existing monitoring data, models, and processes was developed based on the SWMF and HERO.In addition to SWMF standardized interfaces and HERO virtual pervasive elements, HaEHMS consists of the following main subsystems:(1) Environmental Sensing Subsystem2.5 concentrations), civil findings , and their transmission from regional and national backbone platforms. In situ apparatuses consist of transducers and other numerators of the monitoring Web that lie in and keep in touch with the phenomena where they are surveying. The main objective is to establish, operate, and to maintain a continuous time-series monitoring platform that is capable of tracking physical, chemical, and biological features. Another objective is to link this observatory with models, to better describe ecosystem changes and health risks, in order to provide current condition, short-term forecast, long-term projections, and trends analysis. Particularly, customer terminal equipment with citizen science applications can provide sustainable environmental sensing.This is the observation and monitoring of subsystems that are supplying remotely sensed observations , in situ measurements  Environmental Information DatabasesThe databases are used for information technology infrastructure and shared standards, protocols that are able to deliver real-time, delayed-patterns, and historical data for physical, chemical, and biological observations, and model-generated outputs. The sustainable environmental sensing data could be stored in databases. In particular, crowdsourcing information can be always treated as dynamic and remote sustainable environmental sensing information.(3) Cloud ComputingData provisioning systems are used to capture messages from the material world, interact with heterogeneous equipment and observation circumstances, possess high-speed processing abilities, and save and administrate massive data. In order to deal with the big sustainable environmental sensing data and related models, our application was enabled by the Amazon EC2 cloud hosting environment for data services. The cloud service is intended for web and mobile application data processing with analysis algorithms. The semantic web annotates data with geospatial, temporal, and topic semantic metadata. Throughout the SWMF, it is crucial to add semantic annotation to current criterion languages to promote the significance of the sensor observations. The HERO enhances its implication through adding semantic notes to SWMF’s existing criterion language. These notes offer more significant characterization and improve access to the data, and they play the role of a connection mechanism to make up the disparity between the principally syntactical XML-based metadata criterions of the sensor network, and the RDF/OWL-based metadata criterions. The HaEHMS is assembled by semantic web technologies through adding semantic notes, and constructing ontologies for interoperability, analysis, and reasoning over the heterogeneous multimodal data. This section mainly discusses the agent components and it gives a case study of querying the Air Quality Index (AQI) levels around the individual from the shared the Keyhole Markup Language (KML) sensor files that are annotated with RDF serializations in the HaEHMS.The “agent components” in our study are the software programs that provided access to sensor data through web pages, and then trusted individuals could freely search, obtain, query and publish the data.Sensor knowledge was intended to have the characteristics of being open and free, and the semantic specification offers a powerful ability of sharing. Sharing is not restricted to standing up a SPARQL (the standardized query language for RDF) endpoint or to storing a static RDF document on the net server. In order to sustain the hybrid standards of KML, we developed the agent components, as shown in The extracting agent works like a web crawler. Since much sensor data are hidden in the heterogeneous geospatial sensor web, we must find ways to export the data. We are developing two extracting software agents for web mixtures that are applicable at distinct levels of the multi-layered plan, including the inclusion of remote RDF (or OWL) resources in XML using XLink, or in HTML/XHTML/KML using RDFa. The Extracting Agents are developed, based on the technology for processing XML/XHTML microformats as conventional RDF syntaxes, through having each point of file, directly or indirectly, to a transformation to an RDF figure. RDFa allows a single parser to work for data from any area, and they offer a direct relationship between the RDF data and the XHTML/HTML file construction.The RDF of the KML place mark is extracted by the agents, resulting in triples. The Table in The links in Consider the sensor locations that were included in Notions of space and time are intimately related to every sensor in the world, because every sensing event happens somewhere and some when. Almost every sensor network is concerned with the spatiotemporal aspect of data to some degree, though some deal only with the temporal plane. One of our goals is to develop appropriate RDF and OWL representations of spatiotemporal information from heterogeneous sensor networks. Any system that maintains information that can change must at some level deal with time; for instance, and many questions include some assumptions of location as well. For some sensor network applications, the connections to space and time are very obvious  tag tracking applications). However, different sorts of sensor network applications use space or time more implicitly; more so, to contextualize an answer to a related query. For example, for a query asking about whether someone should do their morning exercise outside today, the answer is not exclusively dependent on the spatiotemporal sensor data, but the information from the nearby air quality monitoring sites must be considered. Being able to bound queries into a particular spatiotemporal region can be very useful.This section presents the spatiotemporal development for the Query Agent. These challenges include not only abstract problems of information computing, but also practical concerns of program efficiency. A geospatial index in the agent, which is a special data structure, can be integrated into a Jena model, so as to make some of the most common types of spatial queries efficient.The SpatiotemporalQuery Agent uses RDF serializations  to answer spatiotemporal sensor information queries. As There are two main methods in the GeospatialIndex class. The addNodetoIndex method adds a sensor node, represented as a RDF resource, and defined with a latitude and longitude to the underlying geospatial index. The queryInMaxDistance method creates a bounding box based on the user-defined distance, and uses the geospatial index to return all sensor nodes within the box.The GeospatialGraph class wraps an existing Jena Graph object, and it has two methods of significance. The addTripletoGraph method inspects its parameter to determine whether it is a statement that describes a latitude or longitude value. If it is, the GeospatialGraph calls the addNodetoIndex method on its GeospatialIndex object to register the value. The getGeospatialSubgraph method is used to pose the geospatial queries of the model. Calling that method with latitude, longitude, and distance values, returns another Graph object containing only statements about the sensor locations within the specified region. This class addresses the challenge that a statement expresses only a single datum, but the spatial index requires both latitude and longitude values before a point can be indexed. Since the existence of one statement is independent of all others, it is possible that there could be a set of statements with an incompletely defined point, or of only a latitude or longitude. A final confirmation of all of the returned candidates is used to populate a list of sensor nodes that are ultimately returned to the calling code.The agent, however, is not specifically limited to enhancing Jena for spatial data. A similar approach is used to incorporate a temporal index by using the TimeTripleIndex class and the TimeGraph class, allowing for queries that are bounded in transaction time.Ontology components in the agent store the HERO Location and Time ontologies, which are designed according to the standard GEO W3C Ontology and the OWL-time Ontology, thus making it easier to share and interchange spatiotemporal information.2-NOx analyzer, the SO2 analyzer, etc. Some citizen science applications are also implemented through websites and smart phones.The monitoring functions of the sensors in the Hubei Province Monitoring Stations in China are classified as ambient air monitoring, surface water environment monitoring, soil environment monitoring, environmental noise monitoring, and ecology & biological environment monitoring. The air monitoring sensors work with instruments such as the NO-NO2, NO2, PM10, CO, O3, and PM2.5 hour values. The AQI of the sites, the primary pollutants, the levels of health concern, health implications, and cautionary statements are also published through official websites, APIs, and cellphone applications. The data are updated on an hourly frequency. AQI equals the maximum value of the IAQIs. IAQI is the individual Air Quality Index, which can be calculated, as Automatic air monitoring sites were deployed in 17 cities in Hubei Province for daily air quality assessment. Real-time data are published to public via web services, including SO2, NO2, PM10, CO, O3, and PM2.5, we may know the “potential” air quality that AQI watched. The results and health suggestions will be published to the public automatically through official websites and smartphone APIs (see We developed a prototype of the Semantic Sensor Observation Service (S-SOS) to add annotations to assist with obtaining health implications from air phenomena sensing. Semantically annotated air quality data are collected from the automatic monitoring sites in Hubei province, which is related to Location ontology, OWL-Time ontology, as well as HERO see . The rulAPIs see .2.5) concentrations through the rdf:resource, http://sensorml.com/ont/swe/property. Since the ontology is initialized, services can be applied to manufacture reasonable ratiocination on the existing facts, and to derive new knowledge, and additional knowledge can be extracted by applying rule-based reasoning. Snippet C describes the specification of time, in order to illustrate that the PM2.5 concentrations are observed every hour. Snippet D is programmed as a rule-based reasoning example, based on an air quality model named WRF-EMEP (http://hubei-aq.info). Our reasoning proxy needs to figure out the AQI level automatically for the daily announcement. The pollutant concentrations can be converted to the IAQIs, of which AQI equals the maximum value. When the AQI is less or more than a certain threshold, the reasoning proxy deduces the new ontological assertion of the AQI level, which can guide health implications and cautionary statements. Through this method, referred websites or smart phone apps can forecast the risks to the nearby people in time.The ontology of a ground-sensing ambient air monitoring system is modeled for the case study. For evaluation purpose, we invited five health experts in Wuhan City, Hubei Province, to conduct field assessments. We sent them the health-related events and information near their locations for manual verification of the health events collected by the sensor networks. As a comparison, the S-SOS agent in the HaEHMS is using the sensor observation data to verify the same health events, determining whether to prolong outdoor excises in certain locations.With the traditional approach, we usually obtain the observation data of the pollutants from certain monitoring sites that is nearest to the event location, and assess the AQI result of that location.With the proposed methodology, as described in In this example, the observation describes the AQI value of Wuhan city where the average of the high and low values in May is 93. If the observation has an AQI value of 23, it is annotated with a consistency score of 0.2473 (=23/93).The evaluation was done in two stages:(1) AQI calculation and inference through the HaEHMS: As described in (2) Manual verification by the health experts in field: Results of the case record were sent to the experts. The experts manually collected the same set of information as collected by the sensors installed at this site and compared the outcomes of two different sets of information:The accuracy is the ratio of the number of identical results  over the total number of cases (the sensor observation records). The sensor system collected information is very close to the manual observation by the field experts see .We found differences in some columns. After a joint review by the researchers, it was found that the reasons were related to weather conditions. The fluctuation of weather conditions was an important interference factor, which caused the differences. However, for the cases without the weather condition interference, the inference outcomes of the HaEHMS and the experts were identical.As the sensor web has developed rapidly, people have begun to realize that there exists a lack of uniform operations for resource reallocation, resource sharing and standard representation for sensor data. A sensor data management structure should be developed to address the problem of a lack of mutual operability between sensor data. The OGC SWE norms make all kinds of sensors and sensor data attainable, searchable and workable for creators through the internet by clarifying service connectors that allow for the mutual and functional use of sensor data.The contribution of this study focuses on the ontology-driven approach for integrating intelligence to manage human and ecological health risks in the GSW. Firstly, we proposed the SWMF on the basis of the SWE services, to conceal the heterogeneity of its bottom sensor networks, and to facilitate the communication between its corresponding particulars and all equipment parts. Thus, the SWMF makes application developments under its framework an easier job. The sustainable environmental sensing in this paper not only utilizes observation data from the natural environment, but also citizen science data from crowdsourcing applications. Environmental computing can also be interfaced with the SWMF. Encoding sensor and sensor networks illustrations and monitoring data with semantic web languages allows for more meaningful expression, superior visits, and the official analysis of sensor resources. Moreover, the HERO ontology that we designed based on the SSNO template, is not just for sustainable environmental sensing, but also provides a robust means of describing the processes including the methodology. Then, we developed a software agent for pervasive sustainable environmental sensing and computing through using HERO models. The S-SOS agent could offer various kinds of observation data, and more often, daily routine environmental monitoring data from different sites. The ontology reasoning in the S-SOS agent also plays the intent modeling role in deriving the data. Finally, we developed the HaEMHS, which is also an application and prototype based on the SWMF to integrate the existing monitoring data, models and processes in the context of environmental risk monitoring. In our prototype implementation, we used the Amazon cloud service architecture to solve the problem brought about by the complex calculation of big-data and models. The steps of automatically reasoning the air quality forecast are also illustrated.In short, this work makes a vital step towards the creation of an exoteric, broad, mutually operable, and smart sensor web for public environmental supervising. Our future work will focus on: (1) the reliability of the result of the data processing and analysis over a multi-layer sensor web; (2) the integration of an architecture with an emergency response, which contains video on mobile devices running operating systems; and (3) addressing management issues, such as how to involve policy-makers, ‘stakeholders’, and other end-users, which are vital to the standard of corresponding decision-making matters and the evolution of useful interactive sustainable instruments.


The multicultural nature of a higher academic institution comprising students from different backgrounds can either negatively or positively influence student behaviour. Students might engage in high-risk practices, which in turn can make them vulnerable to HIV infection. Higher academic institutions are then tasked with finding strategies that can help to reduce this risk and vulnerability to HIV and/or AIDS. However, there are many issues and barriers, both from the institution and students, which can impede the success of any communication strategy. The University of the Free State’s main campus was selected for this study. A sample of 402 students from a total of 17 591 undergraduate students participated in the study. A structured questionnaire was randomly distributed to the undergraduate students. The sample was compiled across all faculties, as well as on campus and off campus. A transact walk on campus with an observation checklist was also used for triangulation purposes. The observation checklist helped to collect data on the visibility of male and female condoms in toilet facilities, and HIV and/or AIDS information on noticeboards, bins, stationery, billboards, etc. The main finding indicated that students were not knowledgeable about HIV and/or AIDS campaigns rolled out on campus. To support this, the observational transact walk results indicated that there were no visible campaigns on campus. Also, problems with existing communication and organisational barriers were found not only with the students but also with the implementation office. This study recommends that the university needs to engage with the students by identifying the root cause of their vulnerability. The university should explore and make use of all the available resources for a successful intervention, thereby building students’ resilience in preventing HIV infection. Several scholars have found that there is a general misconception regarding the risk of HIV and/or AIDS transmission , UNAIDS and World Health Organization (WHO)  argue thMany students engage in high-risk practices, which render them vulnerable to HIV , has three campuses all located in the Free State province of South Africa. The Main and South campuses are both in the city of Bloemfontein in the Mangaung Metropolitan Municipality, while the QwaQwa campus is located in the Thabo Mofutsanyane District Municipality. The UFS is a multicultural institution that hosts approximately 33 000 students on its three campuses. At the time of this study, about 28 186 students were studying at the main campus, 874 at the South campus and 4260 at the QwaQwa campus  for HIV and/or AIDS, sexually transmitted infections (STIs) and tuberculosis (TB) was to address social and structural barriers that increased the vulnerability to HIV, STI and TB prevention, care and impacts ROSA . CommuniNarrowing the policy discussion to higher academic institutions, studies conducted between 2008 and 2009 show that many higher institutions of learning in South Africa are affected by HIV and/or AIDS HEAIDS . As a reMost higher education institutions within the Southern African Development Community (SADC) occupied a unique position to shape, debate and create actions and policies on HIV and/or AIDS. These institutions realise that in the absence of a cure, education is the best social response to the epidemic. Notably, other institutions of higher learning are not exempt from the fight against the spread of HIV and/or AIDS infection. Universities in Kenya, such as the Daystar University, host Voluntary Counselling and Testing (VCT) services for both students and employees. They believe that strategies like these are a milestone towards stigma reduction , the Jes Foord Breakfast, the Word-A-Thorn Crossword Competition, the Transformers Re-union at World AIDS Day, the Candlelight Memorial on World AIDS Day and the New Start Male Circumcision Campaign.In 2001, a study described the HIV and/or AIDS plan of the UFS as socially responsible, because it supported condom distribution, counselling at a campus clinic and the consideration of education and changes to the curriculum , Attitude (A) and Practices (P) survey by distributing a questionnaire. The qualitative component entailed a transact walk and, more specifically, observations using a checklist. The study was conveniently carried out on the UFS main campus since it houses the office of Health and Wellness. A multistage sampling approach was adopted for sampling purposes. The target population consisted of undergraduate students enrolled at the UFS and who, at the time of the study, totalled 17 591. This group consisted of students aged between 18 and 25 years. This age group was chosen because it is one of the most vulnerable age groups for contracting or being affected by HIV and/or AIDS. The final stage involved a non-random sampling (convenience) approach, which was based on the distribution of questionnaires at key points. The size of the sample was 402 and because of the non-probability design of the sample, the findings could not be extrapolated to the rest of the student population at the UFS.For the transact walk, 21 residences were visited, of which 10 were female and 11 were male residences. A total of 24 Lecture halls, 30 historical buildings, 14 sports facilities, 15 recreational halls and some toilets in these facilities were visited. Other facilities or campus amenities such as notice-boards, bins, parking lots, billboards, UFS-branded vehicles, students’ clothing and stationery were also observed.The questionnaire had five categories that were measured with a 5-point Likert scale, ‘yes’ or ‘no’ answers and open-ended questions. The five categories consisted of demographics and background questions, HIV and/or AIDS knowledge and awareness, HIV and/or AIDS stigma-related or attitude questions, HIV and/or AIDS behavioural practice, and social support questions. The students participated voluntarily and no personal questions about their HIV status were asked. The questionnaire was distributed over the course of a week and on different days at various busy points at the university. Places of distribution included the university’s entrance gates, taxi rank, student centre, faculty building entrances, on-campus residence entrances and lecturer hall entrances. Before handing out the questionnaire, the students were asked if they were undergraduates and upon confirmation a questionnaire was handed out to them. The observation checklist had five observation variables, which were visible HIV and/or AIDS billboards or information boards; HIV and/or AIDS-branded vehicles; the presence of HIV and/or AIDS flyers at building reception desks or any accessible information dispenser; the wearing of promotional materials related to HIV and/or AIDS such as T-shirts, caps and student backpacks; and the availability of male or female condoms in both male and female toilet facilities. The transact walk was carried out over 2 months and, if observed, the items were ticked off from the checklist in accordance with the area visited.The data were analysed by means of descriptive statistics . The difference in means was used to analyse the descriptive characteristics. The observation checklists were captured in an Excel sheet according to the five observation themes. Some of the qualitative data from the observations were triangulated with the quantitative data from the questionnaire to ensure a higher accuracy of the data.The questionnaire was submitted for ethical clearance and also checked by the HIV and/or AIDS Unit for approval and confidentiality.From the total population that participated, 57% were females and 43% were males. A large group of respondents (79.19%) resided off campus; that is, either with parents, a partner, in a flat or in a student commune . The majority of the students were residing off campus; because it was more affordable than on-campus accommodation and free from the campus residences’ regulations and restrictions. There was a possibility that the degree of freedom that the undergraduate students enjoyed, whether they reside either on or off campus, might have contributed to their vulnerability to HIV infection.A study by Van Wyk et al. , carriedThe 402 respondents were asked if they were aware of nine campaigns which the HIV and/or AIDS Unit had claimed to have implemented throughout the year. Of these, 52 respondents indicated that they were aware of the STI and Condom Week, 47 were aware of the First Things First Campaign, 31 were aware of the Jes Foord Breakfast, 25 were aware of the Word-A-Thorn Crossword Competition, 46 were aware of the Transformers Re-union at World AIDS Day, 40 were aware of the Blue Light Campaign celebrated during World AIDS Day, 85 were aware of the Candlelight Memorial on World AIDS Day, 80 were aware of the New Start Male Circumcision Campaign and 149 were aware of the VCHTC.Respondents who experienced the campaigns in a positive light mentioned that the campaigns were helpful in reducing and preventing infection. Further benefits of the campaigns as mentioned by 13% of the respondents were that they were taught to live with the virus, and that voluntary counselling helped students know their status as well as encouraged them to use condoms through the STI and Condom Week campaign. Few respondents (5%) indicated that they were encouraged to use social support services, like church, and to manage their studies. However, there were some negative perceptions about the strategies as well. Two-thirds (66%) of the respondents mentioned that the HIV and Wellness Unit was not doing its job, because of a lack of campaign visibility. Students who witnessed these campaigns said that they were not informative enough. Some respondents (45%) felt uncomfortable attending public HIV and/or AIDS activities. The students preferred the activities to be more private and confidential, with some urging that professionals instead of students be used for counselling. Most respondents (78%) felt that the campaigns needed to be advertised along with frequent condom distribution. Most respondents (89%) suggested that the campaigns should cover the early symptoms of HIV infection in order for them to seek help in time.These findings addressed the research objective relating to factors that increased students’ vulnerability as well as the possible communication barriers that hampered the successful implementation of HIV and/or AIDS campaigns. These results clearly indicated the existence of misconceptions among the undergraduate student population when it comes to HIV and/or AIDS. Even more disturbing was the fact that 4% of the respondents did not perceive multiple sex partners to be a high-risk behavioural practice and possible mode of HIV infection. Sexual intercourse with multiple partners has been identified by  was bursaries; however, bursaries are not easily accessible. Approximately two-thirds (62%) of the students’ expenditure per month was between R100.00 and R1500.00, which was not enough to sustain a student’s complete needs. A lack of sufficient income can expose students to social vulnerabilities, such as forcing them into sexual relations that might make them vulnerable to HIV and/or AIDS infection UNICEF . Thus, tThe respondents were asked if they agreed or disagreed with whether it was possible to reduce the chance of contracting HIV by (1) using a condom, (2) having one sexual partner, (3) getting circumcised and (4) abstaining from sexual intercourse. In response, 95% of the respondents agreed that using a condom would reduce HIV infection. Most respondents (83%) agreed that having no more than one uninfected sexual partner at a time could serve as a prevention strategy. With regard to clinical male circumcision, 79% said HIV infection could indeed be reduced in this way. Lastly, as far as abstaining from sexual activities was concerned, 88% of respondents were of the opinion that abstinence could reduce the risk of HIV. These findings point to relatively high levels of ignorance and a lack of knowledge among the respondents. At least 80% of the 171 male participants agreed with male circumcision as compared to their female counterparts (77% of 231), which was an indication that male students were taking control of their health and reducing their risk of infection . A lack The majority of both male (94%) and female (96%) respondents agreed with the use of condoms at all times as a preventative strategy . HoweverAccording to Churcher :2, peoplThese results suggested the presence of vicarious stigma, meaning that people perceived HIV to be an illness of immorality  indicated that, if they were to fall sick while on campus, they would easily find someone to help them with their studies. About 64% of the respondents indicated that there was someone they could turn to for advice regarding their health care or treatment. Lastly, a high proportion (76%) indicated that when they need suggestions on dealing with personal problems, there was someone available to assist.Respondents were asked to indicate their social support needs. About 10% indicated that provision should be made for young PLWHA, in the event that they missed lectures or exams. About 23% indicated that they wanted a better understanding and protocol around the disclosure of their HIV and/or AIDS status on campus. Education regarding all forms of stigma and discrimination on campus was the biggest need among 31% of the students. About 19% indicated that the role of the HIV and/or AIDS Unit should be strengthened in university communications. Lastly, 17% of the students indicated that various networks aimed at supporting young PLWHA on campus need to be established and be very active.The respondents also indicated their preferred method of communication. The UFS has a rich platform of communication channels which include a private radio station called ‘Kovsies FM’, a newspaper called ‘Irawa’, four billboards situated at the entrances to the university and which are also visible to the public, a Twitter account, a Facebook page and magazines. About 25% of the respondents preferred social media as a platform of communication on HIV and/or AIDS. Moreover, according to a research carried out on all UFS campuses by the Centre for Teaching and Learning , almost The 2-week transect walks yielded no visible signs of any HIV and/or AIDS campaigns. The four billboards erected at the main entrances to the campus carried messages which welcomed everyone who stepped onto the campus. However, these billboards carried no messages about the university’s HIV and/or AIDS policy. HIV and/or AIDS risk reduction or prevention resources like condoms were non-existent at convenient places. There was the possibility that there were no campaigns running at the time of the transact walk, but at least past campaigns should have been visible with old posters on noticeboards and condoms should have been available at toilet facilities throughout the year. This lack of visibility of HIV and/or AIDS communication campaigns on campus indicated organisational and marketing barriers.The university needs to formulate a communication strategy in collaboration with the Student Representative Council that ‘speaks the language’ of students to make use of students’ social media platforms so as to repackage the message in order to appeal to the culture and social dynamics.Through regular focus group discussions with the students, the university needs to find the most efficient channels that can avoid a top-down approach.A university is an institution with many resources that can be explored and used to communicate a message of HIV and/or AIDS prevention and mitigation. As such, an academic institution is a good foundation for building resilience to HIV and/or AIDS infection through education and awareness. The following recommendations pertaining to the study on the UFS campus serve to illustrate this point.The Health and Wellness Unit should extend their programmes beyond the campus and work hand in hand with off-campus residence owners, since 79.19% of the respondents in this study lived off campus.HIV and/or AIDS education should be compulsory for all students in their first year of study, either as a UFS 101 subject or as part of one of the compulsory subjects. This should be encouraged by all the faculty deans and incorporated into the agenda of faculty board meetings.Social media has become very popular not only among students but also among various organisations. Social media is an affordable and abundant resource; hence, the higher academic institutions should make use of it to educate students about HIV and/or AIDS prevention and coping mechanisms.For any successful HIV and/or AIDS communication strategy, the root cause of HIV infection, barriers to the successful implementation of HIV and/or AIDS programmes and students’ social support needs must be identified.The HIV and/or AIDS Wellness Unit on campus should partner with non-governmental organisations and governmental organisations working with HIV and/or AIDS for contributions and participation in mitigating and preventing HIV and/or AIDS among students.The study findings indicate that there are some strategic gaps in the HIV and/or AIDS prevention and mitigation interventions at the UFS. Various contributing factors serve as barriers to the success of HIV and/or AIDS campaigns at the university. These barriers manifested from the students’ perceptions about the risks of the virus, knowledge about the virus and strategies to protect themselves. The barriers also materialised from the UFS HIV and/or AIDS Unit’s weak risk reduction strategies. Financial investment into the survival of the unit needs to be visible to the recipients. In addition, it is not only about the development of an HIV and/or AIDS campaign but also about backing it up with needed resources and implementing it with an effective and integrated communication package. Possible weaknesses with HIV and/or AIDS campaigns, such as a lack of targeting, timing, monitoring and evaluation, fatiguing messages and the possibility of boring and uncreative campaigns, need to be identified. Furthermore, disregarding detailed vulnerability assessments for possible socio-economic problems that might lead to exposure to HIV and/or AIDS can affect the development and implementation of HIV and/or AIDS campaigns. Issues that affect the success of HIV and/or AIDS campaigns such as stigma, a weakness in the programme, a lack of social support, distorted perceptions and poor knowledge should be identified and addressed.


Advances in experimental psychology have led to a better understanding of unconscious, automatic processes that result in individuals relapsing into their substance-using habits. While some reviews have demonstrated the effectiveness of bias retraining of these unconscious biases, there have been other reviews that have highlighted that bias retraining is not always effective. Other studies have revealed there was no baseline biases among some participants. An examination of mobile bias retraining interventions has also revealed mixed results, with some reporting effectiveness and others null findings. A recent feasibility and acceptability study, done by the authors, revealed that 53% of participants have had no baseline biases and 21% of those with positive baseline biases did not have a positive change in magnitude following intervention.The aim of this paper was to explore potential variables  that could account for the negative baseline biases in the prior feasibility and acceptability study, and to discuss some of the factors that could account for the absence of baseline biases. We also explored potential reasons for why there was no reduction in the magnitude of attentional biases among individuals with baseline biases.Participants who were in the rehabilitation phase of their treatment were invited to participate. During the study they had to complete a set of baseline questionnaires, and on each day that they were on the ward they had to complete an attention bias assessment and modification task and rate their cravings using a visual analogue scale. Attention bias was deemed to be present if individuals had a positive score.In our study, 53% (16/30) of individuals did not present with baseline attentional biases, and among those with positive baseline biases a total of 21% (3/14) of participants did not have a reduction in the overall magnitude of attentional biases. Chi-square analyses undertaken to compare the demographic characteristics of participants with and without baseline biases did not reveal any significant findings. However, with respect to clinical characteristics, those who had positive baseline biases had experimented with more substances.Our study is one of the first to have explored negative findings in attention bias modification interventions for individuals with addictive disorders. We postulate that several factors could account for the absence of baseline biases and there being no changes following bias retraining. Future research ought to take into consideration these factors. Advances in experimental psychology over the years have led to a better understanding of unconscious, automatic processes  that resConventionally, attention bias modification interventions have been delivered in the laboratory, but advances in electronic and mobile health technologies have transformed the delivery of these interventions . Zhang eNegative findings are common in attention bias modification interventions. Negative findings are found in two contexts: at baseline assessment where there is an absence of biases, and when bias retraining fails to reduce the magnitude of attentional biases. Negative findings (the absence of effectiveness of bias modification) were highlighted in Heitman et al’s  review oIn our prior feasibility and acceptability study, there were at least 53% (16/30) of individuals who did not present with baseline biases, and of the participants with baseline biases, 21% (3/14) did not have a reduction of biases following bias intervention . Thus, tThe methods for this study have been previously published as a study protocol  and in ZThis study has been approved by the National Healthcare Group’s Domain Specific Research Board with the following reference number (2018/00316) on May 2, 2018.Patients were included in the study if they were aged between 21-65 years old, were diagnosed with a primary psychiatric disorder of alcohol, opioid, cannabis, stimulants, or polysubstance dependence, were diagnosed with polysubstance dependence, with alcohol, opioid, cannabis or stimulants as the main substance of use, were able to read and write in English, and were capable of using a smartphone or tablet device. Patients were excluded from the study if they had a known history of cognitive impairment or dementia, if they had a history of seizures or a prior history of withdrawal seizures, if they had a history of migraines triggered by flashing lights, and if they had any moderate to severe comorbid psychiatric disorders based on clinical assessment.Upon recruitment into the study, baseline demographic and clinical information were acquired from the participants, including: nationality, gender, marital status, race, religion, highest level of education, housing conditions, current substance use, previous treatment history, chronic diseases , and any current psychiatric medication use. Participants also completed the modified Addiction Severity Index (ASI)–Lite, the Severity of Drug Dependence Scale (SDS), and the Short Form (SF-12) questionnaires. The ASI-Lite collects information about the participants’ drug and alcohol use. All participants were asked about their alcohol and substance use in the last 30 days, in the last last month, and over their lifetime. The SDS questionnaire has 5 questions, all of which are focused on the psychological components of dependence. The SF-12 assessed the participants’ self-reported quality of life.Upon the completion of these questionnaires, participants were oriented on how they should use the application. On the first day of the intervention, participants were required to undertake an assessment task, then an intervention task, and then rest for 15 minutes before completing another assessment task. On the subsequent days of the intervention, participants were asked to complete an intervention task and then rest for 10 minutes before completing the assessment task. All participants were also asked to complete a visual-analogue craving scale before and upon the completion of each of the bias modification tasks. Participants were to undertake the tasks only if it was a weekday and were exempted from undertaking these tasks on weekends or public holidays.In the assessment task, participants were presented with a central fixation cross for 500 milliseconds. Following the disappearance of the fixation cross, they were presented with a set of images, with one image being a substance image and the other a neutral image. The images would then disappear, and a probe would replace the position of one of these images. Participants were instructed to indicate the position of the probe by pressing on buttons within the application as rapidly as they could. In the assessment task, the probe would replace the substance-related image and the neutral image equally. In the intervention task, the probe would always replace the neutral image for the successful retraining of the attentional processes., where T1 refers to the time for probes that replaced the neutral stimulus, n1 refers to the number of trials for probes that replaced the neutral stimulus, T0 refers to the time for probes that replaced the substance stimulus, and N0 refers to the number of trials for probes that replaced the substance stimulus. A chi-square test was conducted to compare the demographic characteristics of those with and without baseline attentional biases.Data collated was analyzed using SPSS Version 22 . Baseline demographic information of the subjects was summarized using descriptive statistics. The presence of attentional biases was determined based on the mean reaction times taken to respond to the position of the probes that replaced either the drug or neutral stimuli. The formula used for the computation of attentional biases was 40 participants were screened and invited to participate in the study, of which 10 declined, thus leaving 30 who participated. A total of 11 of these participants failed to complete all the planned interventions, 10 of whom elected for premature discharge from the ward and 1 who withdrew from the study following the initial intervention. It is evident from Among those with baseline attention biases, there was a general decrease in their attentional bias scores from baseline till the end of the intervention, except for three participants . The changes in attentional biases scores ranged from 12.0 to 409.5 milliseconds.Participants with and without baseline attentional biases were compared. 2) analysis to compare the categorical demographical variables amongst those with and without baseline attentional biases, we found no significant differences between the two groups with respect to nationality , gender , substances , race , education status , employment , accommodation/housing , psychiatric diagnoses  and physical diagnosis .Using chi-square  of individuals did not present with baseline attentional biases, and among those with positive baseline biases, 21% (3/14) of participants did not have a reduction in the overall magnitude of attentional biases. Chi-square analyses undertaken to compare the demographic characteristics of participants with and without baseline biases did not reveal any significant findings. However, with respect to clinical characteristics, those who had positive baseline biases had experimented with more substances. We postulate that there are four factors that could account for the absence of baseline biases: the period of abstinence, the images used in the mobile application, the stimulus timings, and the clinical characteristics of the participants. With regards to the lack of retraining effects, we theorize that this might be due to practice effects or to the novelty of the other neutral stimulus.The lack of baseline biases we observed may be due firstly to the fact that our participants had received treatment and had been abstinent for at least seven days prior to being recruited into the study. This period of abstinence might have affected their baseline attentional biases. In most of the published studies ,18, partSecondly, the nature of the images/stimuli used in our application may have contributed to a null finding at baseline assessment. The images used in the application may not be good representations of the substances participants were familiar with, and thus did not manage to capture their attention. This is in line with Field et al’s  report tThirdly, as highlighted by Sharpe , the expLastly, with regards to the absence of baseline biases, Dean et al’s  researchRegarding the negative findings among those with positive baseline attentional biases , we postulate that the absence of effects could be accounted for by practice effects. Thus, for some individuals, over the course of the intervention they have learnt to focus only on the position of the probe and not on the stimulus. There is also the possibility that the neutral stimulus might have appeared to be more novel and appealing to some individuals, which lead to an increased focus on the neutral stimulus and a resultant more rapid response in identifying probes that replace the neutral stimulus.Our study is one of the first to have explored negative findings in attention bias modification interventions for individuals with addictive disorders. We postulate that there could be several factors that could account for the absence of baseline biases and there being no changes following bias retraining. Future research ought to take into consideration these factors, and it is especially pertinent for clinical studies to evaluate for baseline bias prior to administration of bias retraining interventions.