In response to the Coronavirus disease-19 (COVID-19) pandemic, in-patient units in hospitals around the world have altered their patient care routines and Infection Prevention and Control (IPC) practices. Our interdisciplinary team of applied Human Factors (HF), ethnography, and IPC experts assisted one Unit, normally serving general surgical and orthopedic patients, as it rapidly converted to deliver COVID-19-specific care. This paper describes the conversion experience of the Unit, and outlines broader lessons for other acute care teams faced with similar issues.We deployed walkthroughs, simulations, and ethnography to identify important safety gaps in care delivery processes on the Unit. These interventions were undertaken using interdisciplinary theories of implementation that combined systems-level HF perspectives, ethnographic approaches, and individual-level IPC perspectives. Timely recommendations were developed and delivered to Unit staff for feedback and implementation.We describe three interventions on the Unit: 1) the de-cluttering and re-organization of personal protective equipment (PPE); 2) the reconfiguring of designated ‘dirty’ tray tables and supplies; and 3) the redesign of handling pathways for ‘dirty’ linens and laundry. Each of these interventions was implemented to varying degrees, but all contributed to discussions of safety and IPC implementation that extended beyond the Unit and into the operations of the broader hospital.Leveraging our team’s interdisciplinary expertise and blended approaches to implementation, the interventions assisted in the Unit’s rapid conversion towards providing COVID-19-specific care. The deployment and implementation of the interventions highlight the potential of collaboration between HF, ethnography, and IPC experts to support frontline healthcare delivery under pandemic conditions in an effort to minimize nosocomial transmission potential in the acute healthcare setting. The global spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and its clinical manifestation as Coronavirus Disease 2019 (COVID-19), has resulted in immense upheaval and strain across healthcare systems  have forAn emerging body of literature illustrates how individual hospitals and units redesigned their overall operations during the first wave of the pandemic –14. In tWe focus on three specific interventions to illustrate the collaborative potential inherent in combining the expertise and implementation theories of applied Human Factors (HF), ethnographic, and Infection Prevention and Control (IPC) professionals. The three interventions were developed by our interdisciplinary team working with Unit management and staff. The specific composition, as well as the broader theoretical foundations and deployment of the HF, ethnography, and IPC team have been described elsewhere . Here weUnit 64 is situated within the Foothills Medical Centre (FMC), the largest hospital in the province of Alberta, Canada. Like all hospitals in the province, FMC falls under the jurisdiction of Alberta Health Services (AHS). Formed in 2008 through the amalgamation of nine regional health entities to create a centralized health system, AHS is the sole health authority in the province of Alberta and is publicly-funded. It functions as the operational arm of the Ministry of Health , and is responsible for delivering care in a spectrum of facilities that is predominated by acute care hospitals, but includes public health centres, mental health clinics, and continuing care sites.Unit 64 is a 40-bed hospital unit  that normally serves FMC’s general surgical and orthopedic inpatients. It is located in the hospital’s newer (2010) McCaig Tower. On 23 March 2020, 18 days after Alberta reported its first presumptive case of COVID-19, Unit 64 was designated by FMC administration as the hospital’s primary treatment destination for COVID-19 patients, a change which was to occur within 24 hours. As a result, 23 existing patients were transferred off the Unit or discharged between 13h00 and 22h00, and by the end of the day, Unit 64 began receiving COVID-19 patients. The rapidity of this conversion from surgical and orthopedic care delivery to a COVID-19-focused Unit delivering medical care to respiratory patients required significant changes to routines and protocols for nursing, housekeeping, and healthcare aides, as well as porters and medical staff.Our team of applied HF and ethnography researchers initiated contact with Unit 64 on 3 April 2020. The HF and ethnography team was composed of two HF experts , and two ethnography experts: a medical anthropologist (RF), and a medical sociologist (ML). Our contact with the Unit was made through the FMC’s IPC leadership (JC), who had previously engaged with hospital administration to assist in converting the Unit for COVID-19 care. Our initial mandate was to support Unit 64 and work in concert with IPC to provide discrete recommendations to improve the layout, placement, and use of Personal Protective Equipment (PPE) and other safety supports. Throughout subsequent consultative sessions, our interdisciplinary team continued to engage with Unit 64 managers, the Clinical Nurse Educator, nursing staff, housekeepers and housekeeping managers on the Unit.The collaboration between Unit leadership, IPC staff, and the HF and ethnography team members continued through June, July, and August 2020, even after surgical and orthopedic services resumed alongside COVID-19-specific care. This ongoing work aided Unit 64 staff to revert to caring for post-operative patients, while continuing to enact the COVID-19 care practices and routines that had become their ‘new normal’.For this study, our HF and ethnography team members used cognitive walkthroughs , rapid tData collection involved direct observations of spatial configuration, the placement of supplies, staff protocols, and tasks and interactions. Data collection focused on identifying systemic factors on the unit, including IPC issues related to work routines and staff tasks. Each walkthrough lasted approximately 45 minutes, including the team’s observation period, followed by real-time feedback and discussion of the observed issues with Unit leadership and staff. Seven walkthroughs were conducted between April and August 2020, for a total of nearly 7 hours. Ethnographic observations (n = 7) were conducted as a follow-up to each of the walkthroughs. This included direct on-site ‘shadowing’ sessions, using an exploratory approach where observations were combined with on-the-spot, unstructured interviews with Unit staff. These ethnographic ‘shadowing’ sessions aimed to validate the observations from the walkthroughs, and to focus on how our team’s recommended changes were, or were not, implemented on the Unit.Data collection and analysis were done concurrently. Analysis of information from the walkthroughs involved the discussion and categorization of observations and key areas of intervention between our team  and Unit leadership . Emerging themes were drawn from ethnographic observations and interviews (RF) and used to structure and update the recommendations provided to the Unit. Data collection, processing and analysis from both the walkthroughs and ethnographic observations were discussed regularly between our HF and ethnography teams, as well as Unit leadership.Our recommendations emerged from a blending of implementation theories, which are assumptions and rationales about system features and human actions that are required to promote the translation of objectives into effective program and service delivery ,20. Our Similarly, our applied ethnographic researchers were focused on social and institutional contexts as key systems-level factors shaping the implementation of recommendations. We worked first as credible outsiders and became trusted ‘alongsiders’ ,23, ableFinally, our IPC professionals combined attention to systems-level factors with individual-level theories of implementation. By blending this perspective, our team did not entirely abandon the ‘person centric’ approach to evaluation , but maiThe following sections describe three interventions that we have selected as particularly illustrative of our team’s contributions to Unit 64’s conversion. The first section focuses on an initial intervention to declutter and improve PPE organization and layout on the Unit; the second focuses on the promotion of improved hygienic practices for tray tables that were used to house supplies outside patients’ rooms; and the third examines co-designed efforts to streamline processes for managing dirty linens with Unit management, IPC, and housekeeping staff.Our team followed the Standards for Reporting Qualitative Research (SRQR)  to reporEthics approval for the full study was granted by the University of Calgary’s Conjoint Health Research Ethics Board (CHREB) on 11 March 2020 (REB20-0371).We first deployed our ethnographer who took observations of the floor layout and staff practices. Our HF team members then organized an initial walkthrough of the Unit, which was shortly followed by a second walkthrough with the Manager, Clinical Nurse Educator and the ethnographer.During the initial walkthrough, our HF experts made safety-critical observations about the placement of PPE for donning and doffing. The hallways were cluttered with PPE supplies, with clean gowns kept in bundles on chairs in charting areas . AdditioBased on these observations, the interdisciplinary team discussed with IPC and met with Unit leadership to provide safety recommendations and co-designed solutions. Our initial recommendations and solutions were immediately presented by the Manager to the attending unit staff in a physically-distanced huddle at the Nursing Station.The following recommendations were shared with the Manager and Clinical Nurse Educator:Ensure separation of clean PPE from doffing spaces and contaminated items. Consolidate and simplify the PPE stations by positioning one donning cart between two single patient rooms.Provide additional doffing garbage and ‘dirty’ linen hampers inside individual rooms to minimize clinicians walking while wearing contaminated PPE to reach these bins. Ensure these bins are located to match the expected orientation  for the clinician as he/she exits a patient’s room to doff remaining contaminated PPE , clearly mark each tray table with diagonal hatch patterns to indicate the entire space of the designated dirty tray tables are to be considered contaminated.Standardizing the placement of the pink basins, hand sanitizer pumps, and Cavi-wipes™ on each tray table, to remind staff to first doff, then hand sanitize, and lastly clean equipment.Moving the tray tables and all items close to the doorways to reduce the convenience of the surface for item storage and discourage staff from temporarily placing clean items on the designated dirty trays.—used to hold ‘dirty’ stethoscopes, eye protection, and other reusable small pieces of equipment—closest to the doorway entry. The basins were followed by hand sanitizer dispensers (10 cm long x 6 cm wide), then by Cavi-wipe™ dispensers (15 cm diameter). Simply by repositioning the supplies on the tray tables closer to the doorway and reducing unoccupied space to only a few centimetres (~5 cm), these tray tables became much less convenient places for clean items to be temporarily placed or stored. In addition, the order of item placement reflected their order of use, reinforcing proper adherence to doffing protocols. This recommendation was implemented immediately after being shared.Although Unit 64 leadership was willing to accept both these recommendations, IPC team members raised concerns over tape and/or labels being a hindrance for full environmental cleaning. As a result, our team focused on standardizing the placement of the supplies on the ‘designated dirty’ tray tables (79 cm long x 43 cm wide x 84 cm high) to discourage their use for clean supply storage. This placement positioned the pink basins (20 cm long x 23 cm wide)Although standardizing the placement of the supplies housed on the designated dirty tray tables helped hinder their use as temporary storage, clinical staff began to place patient meal trays on top of the waste bins beneath the designated dirty tray tables, as our team discovered on subsequent Unit walkthroughs . This fiBecause of additional concerns about potential contamination events involving dirty linens and laundry, another follow-up visit ensued three months after the Unit was designated for COVID-19 inpatient care. Discussions with IPC and Unit staff revealed that there was no AHS guidance available for the management of dirty linens and laundry. As a result, Unit 64 leadership and some of the staff  had developed improvised solutions to take bags containing dirty linens and laundry from patients’ rooms to be disposed of down the laundry chute. The chute served the entire wing of the hospital and was thus often locked due to active use by other floors/units.Alongside Unit leadership, HF, ethnography, and IPC team members co-designed solutions to minimize potential staff contamination. We conducted a staff-guided walkthrough, which had us follow and map the journey of dirty linens on the Unit: from a patient’s bedside to an empty linen bag inside the patient’s Isolation Room, down the hall to the Dirty Utility Room and then finally to the Laundry Chute Room. This Laundry Chute Room was located off the Unit, in a small non-clinical wing, where Unit leadership had quickly responded to the reports of staff contamination by installing a PPE doffing station . From thOur initial walkthrough was followed up with a subsequent simulation that involved HF, ethnography, IPC, Unit leadership, housekeeping management and housekeeping staff. We initially gathered these stakeholders to reinforce and demonstrate the dirty linen recommendations co-designed during the walkthroughs with IPC and Unit leadership. We also determined how many dirty linens would fill a laundry bag to 50% capacity. This was measured to discourage overfilling of the laundry bags and lower the risk of viral aerosolization, if the contents of the bags were compressed before being tied shut.During this simulation, we quickly discovered that housekeepers had a pre-existing routine to handle linens on the Unit that differed from the routine used by other Unit staff, such as nurses and HCAs. As such, we also used the simulation as an opportunity to address these differences in task performance, better understand the needs of housekeeping staff, and align the formal process and procedures to ensure that these changes could be adopted by housekeeping staff in different areas of the hospital immediately.During our initial walkthrough and subsequent co-design huddle, our HF and ethnography team members recognized a key assumption made by IPC and unit staff–that the outside surfaces of the laundry bags were clean–was not aligned with the actual situation on the Unit. In almost all cases, the dirty laundry bags were overflowing, with contaminated sheets and gowns draped over the sides . This obRecommendations delivered to the unit. Following our initial walkthrough, our HF and ethnography team members recommended:Dedicating one of the Unit’s two Dirty Utility Rooms for each half of the Unit, as temporary storage of dirty linen bags.Preventing overfilling dirty linen bags (beyond 50% capacity) before replacing them.Wearing full Contact and Droplet Precautions PPE  when bagging and transporting linens from patients’ rooms to Dirty Utility Rooms, or from Dirty Utility Rooms to the Laundry Chute Room.Preparing clean linen carts before they are required and at the end of each shift, to have an adequate supply ready for replacement in patients’ rooms.During and following the simulation with housekeeping, our team recommended:Placing a second linen bag/frame in each patient’s room to reduce the likelihood of overfilling bags past 50% capacity.Doffing dirty PPE prior to exiting patient room. Re-donning clean contact/droplet PPE to transport dirty linen bags from patient room to the dirty utility room or Laundry Chute Room. Doffing dirty PPE after placing bag(s) in the utility room or down the chute.Using a permanent marker during adaptation period to show the 50% capacity of empty laundry bags, to assist with visual recognition of appropriate fill levels and to minimize overfilling.Using the doffing station in the Laundry Chute Room to minimize the frequency of having staff walk through the Unit’s hallways while wearing contaminated PPE.Shortly following the simulation, the Unit resumed providing post-operative services as well as COVID-19 care. Unit leadership thus decided to designate one Dirty Utility Room for dirty laundry from the surgical part of the Unit, and one Dirty Utility Room for the COVID-19 section of the Unit. Unit leadership also decided that they would not use the permanent markers for laundry bag capacity, as this increased complexity and workload for staff, as well as to not double-bag linen. In addition, Unit leadership also chose to maintain the use of a single dirty laundry cart in each patient’s room. It was assumed that having a second bag would not discourage staff from overfilling bags with linens. Housekeeping management conducted a staff training session on the Unit the morning after the simulation, to ensure that all the housekeeping staff knew about the new protocols.Encouraging staff adherence to minimize overfilling laundry bags has required continued education and a new protocol involving scheduled emptying of all linen bags at shift changes. In addition, having a doffing station in the Laundry Chute Room was found to be critical to improving the overall processes involved in handling dirty laundry.The repurposing of hospital in-patient units for COVID-19 care has been studied in a range of settings –14. The IPC professionals are accustomed to sharing responsibility with Public Health, Occupational Health and Safety, and frontline facility staff in managing not just pandemics, but lesser outbreaks in hospitals.Extending this standard model of interdisciplinary work, a growing body of literature highlights the synergy and collaborative potential between IPC and HF experts ,29–33. TEthnographers generally use concepts from sociology and anthropology to describe their work. Ethnography has been established as a key methodology for understanding the context and culture where organizational changes, including healthcare QI interventions, occur . As withWorking in concert with IPC individual-level or ‘person-centered’ reminders and education, HF contributed structure and process standardization, as well as simplification recommendations, while ethnography provided real-time ‘alongsider’ feedback on the uptake of those recommendations. Our team and Unit 64 staff identified the following elements as most relevant to the success of our contributions: the urgency of the pandemic-induced operational changes to the hospital; the quality and contextual relevance of our recommendations; our status as credible outsiders, with the validity of HF and ethnography expertise strongly supported by IPC leadership; our ongoing efforts to shift from being credible outsiders to trusted collaborators ,23; as wDue to the clinical urgency introduced by the pandemic, the cognitive walkthroughs, task analyses, and ethnographic observations were necessarily conducted in ‘real-time’. There was no opportunity to conduct more formalized data collection, or use other methodologies (e.g., use of the Safety Risk Assessment Tool . This clIn the case of our initial intervention to de-clutter PPE, we successfully introduced lasting changes to improve safety. In the case of our intervention to optimize the storage of equipment outside patients’ rooms, we produced recommendations that collaboratively and with compromise were able to balance contextual needs with implementation hurdles and adapt our recommendations accordingly. In the case of our intervention to redesign the management of dirty linens, our team was able to identify gaps between the assumptions that were made as IPC guidelines were developed and the actual practices and working conditions of Unit staff and housekeepers. In each of these examples, our team combined IPC reminders and education with HF systems-focused redesign to achieve process standardization and simplification . Our intWe have provided three examples of specific interventions aimed at the rapid conversion of a general medical unit for COVID-19-based care. These interventions relied on our team’s interdisciplinary triangulation of IPC, HF, and ethnography. This collaborative approach helped us provide recommendations for safety-focused structure and process improvements, which were co-designed alongside Unit leadership and staff. The combination of collaborative engagement and expertise that our team brought to the work bolstered mutual findings and discoveries, and supported frontline healthcare delivery during the COVID-19 pandemic in Alberta.


Eating disorders are complex to manage, and there is limited guidance around the depth and breadth of knowledge, skills and experience required by treatment providers. The Australia & New Zealand Academy for Eating Disorders (ANZAED) convened an expert group of eating disorder researchers and clinicians to define the clinical practice and training standards recommended for mental health professionals and dietitians providing treatment for individuals with an eating disorder. General principles and clinical practice standards were first developed, after which separate mental health professional and dietitian standards were drafted and collated by the appropriate members of the expert group. The subsequent review process included four stages of consultation and document revision: (1) expert reviewers; (2) a face-to-face consultation workshop attended by approximately 100 health professionals working within the sector; (3) an extensive open access online consultation process; and (4) consultation with key professional and consumer/carer stakeholder organisations.The resulting paper outlines and describes the following eight eating disorder treatment principles: (1) early intervention is essential; (2) co-ordination of services is fundamental to all service models; (3) services must be evidence-based; (4) involvement of significant others in service provision is highly desirable; (5) a personalised treatment approach is required for all patients; (6) education and/or psychoeducation is included in all interventions; (7) multidisciplinary care is required and (8) a skilled workforce is necessary. Seven general clinical practice standards are also discussed, including: (1) diagnosis and assessment; (2) the multidisciplinary care team; (3) a positive therapeutic alliance; (4) knowledge of evidence-based treatment; (5) knowledge of levels of care; (6) relapse prevention; and (7) professional responsibility.These principles and standards provide guidance to professional training programs and service providers on the development of knowledge required as a foundation on which to build competent practice in the eating disorder field. Implementing these standards aims to bring treatment closer to best practice, and consequently improve treatment outcomes, reduce financial cost to patients and services and improve patient quality of life. Mental health professional includes many types of health professionals working in mental health care, including psychologists, social workers, mental health nurses, occupational therapists and counsellors.Little research exists around the practitioner knowledge and skill required for the treatment of eating disorders. To ensure best practice, patient safety and optimal patient outcomes in eating disorder management, health professionals need to demonstrate adequate knowledge through specialised training and experience. The Australia & New Zealand Academy for Eating Disorders (ANZAED) convened an expert group of eating disorder researchers and clinicians to define the clinical practice and training standards recommended for mental health professionals and dietitians providing treatment for individuals with an eating disorder. There was a four-stage review and consultation process including:  expert rEating disorders are severe, complex and often debilitating mental health conditions, characterised by a severe and persistent disturbance in eating behaviour. Affecting approximately 16% of adults  and chilTo date, tertiary health education programs have provided limited training in eating disorders, and graduates enter the workforce with inadequate skills needed to work in this field. The National Agenda for Eating Disorders in Australia identified that 97% of clinicians had received no or insufficient training in eating disorders to enable them to provide treatment with confidence . The NatThese principles and standards are a project of the Australia & New Zealand Academy for Eating Disorders (ANZAED), the peak body for eating disorder professionals involved in research, prevention, treatment and advocacy in Australia and New Zealand. ANZAED fosters professional development and networking in the eating disorder field and provides leadership within the eating disorder sector. This project represents the work of the co-authors, a core expert group of clinicians and researchers, and incorporates sector-wide public consultation and feedback. The current paper aims to provide guidance on the important treatment principles and minimum general clinical practice and training standards for mental health and dietetic professionals who provide treatment to individuals with an eating disorder.ANZAED established two expert working groups – the mental health professional and dietitian groups – with representatives from around Australia and New Zealand. The groups included both clinicians and academics each with greater than ten years’ experience within the field of eating disorders. The mental health group included nine professionals with backgrounds including psychology, social work and occupational therapy, and eight dietitians made up the other group.n = 100). Following this, online consultation from the broader public was sought, with feedback received from international expert advisors, professional bodies (various disciplines) and consumer and carer groups with comments reviewed and integrated by the working groups. The final version was also reviewed by the NEDC Steering Committee and again by ANZAED’s Executive Committee. Consensus on all papers was reached through discussion by the authors and there was no identified conflict of interest. The resulting eight principles and seven general clinical practice standards are detailed below. The mental health-specific  and Pacific peoples) and people from culturally and linguistically diverse backgrounds. It is important that clinicians adopt a strengths-focused approach, supporting recovery and/or quality of life, tailored to meet individual decision-making capacity and needs as they develop over the course of the illness.aluation  collaboraluation , but alsaluation . Service6.Education and/or psychoeducation is included in all interventions. Communication and information for those with an eating disorder, as well as families and significant others involved in supporting the person, is important, particularly given the degree of misinformation widely available about ‘healthy’ eating, weight and the medical impact of disordered eating. Education and/or psychoeducation should also include the rationale for evidence-based treatment strategies, including an initial focus on restoring nutritional health.7.Multidisciplinary care is required. Eating disorders co-occur with a range of serious physical and psychological issues. Clinicians need to understand and ensure that a medical practitioner  is actively involved in patient care to provide regular medical monitoring and linked with other treating professionals, which may include psychiatrists, psychologists, dietitians, social workers, occupational therapists, mental health nurses and eating disorder-trained peer support workers. The clinician should be aware of and have access to tertiary-level eating disorder services, specialised private practices or professionals with relevant expertise for consultation, supervision, guidance and referral, if required.8.A skilled workforce is necessary. Evidence suggests that clinician expertise in eating disorders produces better outcomes. For example, in child and adolescent anorexia nervosa, specialised outpatient eating disorder teams have been associated with faster recovery, higher patient satisfaction, lower costs, lower rates of inpatient admission and better case identification and access compared to care by generalist services [services , 33. It services .Patient journeys across the developmental spectrum of eating disorders are varying and complex, involving many different trajectories, from brief illnesses to recurring, but different eating disorders  each migDiagnosis and assessment. Clinicians should be aware of and have a working knowledge of the current diagnostic criteria for eating disorders [isorders , and cli2.Multidisciplinary care team (MDT). Treatment of eating disorders should be multidisciplinary, including a medical practitioner, mental health professional and a dietitian if accessible. Respective roles across the MDT should be clearly documented and understood, and a designated clinical lead identified. Processes of communication within the MDT need to be clearly outlined. All clinicians must practice within the scope of their profession and know when to refer to another clinician with focused eating disorder skills. However, all clinicians will need to have an interdisciplinary working knowledge of medical, mental health, nutritional and psychiatric aspects of eating disorders, as indicated below:To provide effective management of the physical and psychiatric complexities of eating disorders as well as clinical safety, minimum understanding, knowledge and skills are essential for health professionals practicing in the space. It is recommended that all clinicians involved in the assessment, diagnosis, management and treatment of patients with an eating disorder follow the below practice standards.Medical: All clinicians should understand the significant physical risks associated with eating disorder behaviour, including the risk of death, and be aware of the parameters of physical stability, as outlined in the Royal Australian and New Zealand College of Psychiatry clinical practice guidelines for the treatment of eating disorders . There iMental Health: All clinicians should understand core psychological principles including behaviour change, behavioural experiments, core counselling micro-skills, modifying cognitions, managing affect and addressing underlying issues that may maintain the behavioural aspects of the eating disorder. Referral to a mental health professional is recommended for most patients to provide psychological support and evidence-based psychological interventions.Nutritional: All clinicians should have a knowledge of nutritional issues relevant to eating disorders . It is important that clinicians are aware of the services that are not available in the local area, and to know where the closest available alternative treatment service is located. Treatment options may include involuntary treatment and the use of a community treatment order. Clinicians should be aware of local guidelines for moving between levels of care. Constant assessment of patient status and progress is needed to inform changes in the level of care. Wherever possible these changes should be made collaboratively with the patient. It should be recognised that psychotherapy with a severely malnourished patient (noting this can present across the weight spectrum) is unlikely to be effective in achieving behavioural change [l change .6.Relapse prevention. Every individual treated for an eating disorder requires a relapse management plan with monitoring for at least 12 months post-treatment [reatment . An asse7.Professional responsibility. Clinicians should be aware of and maintain important professional practices such as clinical supervision, professional development and practices to manage their own wellbeing. Clinical supervision and ongoing professional development aim to upskill clinicians, support reflective practice, aid the provision of high-quality treatment and recognise the intensity and personal impact of treating complex mental health issues. For mental health professionals and dietitians treating patients with an eating disorder, a significant component of these professional practices should be eating disorder-specific, incorporating the implementation of non-negotiables to establish boundaries around treatment. Clinicians should also be aware of their own attitudes toward body shape, weight, food and eating to avoid transmission of unhelpful messages or practices during therapy. It is expected that a clinician experiencing their own mental health difficulties while providing eating disorder treatment would seek appropriate support and modify their work as needed to maintain their own and their patients’ wellbeing.Psychiatric: All clinicians should have an awareness of common co-occurring psychiatric presentations, and the ability to assess and respond to a risk of harm to self, and suicidal ideation. An assessment by a psychiatrist, preferably one experienced in eating disorders, is recommended where risk is identified, a complex formulation and treatment plan is required and/or when medication is required to support complexity and co-occurring diagnoses.Effective treatment of eating disorders typically requires a well-coordinated and skilled clinical management team across different disciplines  with a dClinicians who assess and treat individuals with an eating disorder should be competent to do so . Further


Elder abuse is a complex, multifaceted problem that can devastate the lives of older adults, and overwhelm medical, legal, and social service providers. To address this problem, the Elder Abuse Multidisciplinary Team (MDT) is an oft-utilized intervention that brings individuals from various professional disciplines together to address elder abuse. With the passage of the Elder Justice Act of 2010, the Federal Government included budgetary provisions in support of a particularly promising model of MDT: The Elder Abuse Forensic Center (EAFC). Although the EAFC model has been implemented at four sites in California with promising outcomes, the specific structures, processes, and practices that currently define this model have not been validated with rigorous research of other MDTs in the United States. In this study, we surveyed 81 elder abuse MDT key informants across the country, using instruments guided by the most current EAFC model . We then used Latent Class Analysis (LCA) to group these teams based on EAFC model characteristics. We hypothesized that elder abuse MDTs would fall on a spectrum: those that were identical or nearly identical to the EAFC model, those that had some EAFC qualities, and those that were not identical. Results of the LCA supported our hypothesis and revealed three types of elder abuse MDTs: EAFCs (n=26), Semi-EAFCs (n=24), and Non-EAFCs (n=31). Policy makers, advocates, and professionals seeking to form new teams or support existing teams can draw on these findings to make decisions about MDT creation and sustainability.


The NIH-funded Research Centers in Minority Institutions (RCMI) program is currently funding 18 academic institutions to strengthen the research environment and contribution to health disparities research. The purpose of this multiphase mixed-methods study was to establish a uniform evaluation framework for demonstrating the collective success of this research consortium. Methods included discussions of aims and logic models at the RCMI Evaluators’ Workshop, a literature review to inform an evaluation conceptual framework, and a case study survey to obtain evaluation-related information and metrics. Ten RCMIs participated in the workshop and 14 submitted responses to the survey. The resultant RCMI Evaluation Conceptual Model presents a practical ongoing approach to document RCMIs’ impacts on health disparities. Survey results identified 37 common metrics under four primary categories. Evaluation challenges were issues related to limited human resources, data collection, decision-making, defining metrics, cost-sharing, and revenue-generation. There is a need for further collaborative efforts across RCMI sites to engage program leadership and community stakeholders in addressing the identified evaluation challenges and measurement. Program leadership should be engaged to apply the Evaluation Conceptual Framework and common metrics to allow for valid inter-institutional comparisons and consortium-wide evaluations. Stakeholders could ensure evaluation metrics are used to facilitate community impacts. The National Institutes of Health (NIH) has various types of grants to support research- related programs and funds over 1200 research centers at $41.7 billion USD annually . IdeallyThe links between scientific research, practice, and impact to community and society can be complex. This is especially true for research centers, which are funded to be multifaceted. These centers often involve a variety of investigators from different backgrounds and training to collaborate on research projects that are aligned with the goals of the academic research center ,6 and thEvaluation that focuses on research projects’ outcomes and impacts can often take years after funding to establish the value of the research center conducting the research project, while neglecting to demonstrate other key accomplishments of the funded activities. Given the complexity of what (and how) research efforts are translated to the community, funders should acknowledge the approaches that allow evaluation of earlier phases of research and research centers’ program activities. A focus on a variety of process measures is critical for demonstrating the broad range of impact of research centers ,6. The fThe Research Centers in Minority Institutions (RCMI) program was initiated in 1985 by the NIH to strengthen the research environment and participation of minority serving institutions and increase resources for health disparities research. The program is a U54 award mechanism administered by the NIH National Institute on Minority Health and Health Disparities (NIMHD) and provides support to specialized research centers that have historically trained and awarded doctorate degrees in health professions and health-related sciences to individuals from underrepresented, underserved, and minority populations. The 18 currently active RCMI sites, which are funded under three Requests for Applications , are listed in The RCMI programs’ national goals are to: (1) enhance institutional research capacity within the areas of basic biomedical, behavioral and/or clinical research; (2) enable all levels of investigators to become more successful in obtaining competitive extramural support, especially from NIH, particularly on diseases that disproportionately affect minority and other health disparity populations; (3) foster environments conducive to career enhancement with a special emphasis on development of new and early career investigators; (4) enhance the quality of all scientific inquiry and promote research on minority health and health disparities; and (5) establish sustainable relationships with community-based organizations that will partner with the RCMI site.As academic research centers sponsored by NIH, the overall RCMI program addresses common goals of other research support mechanisms while having unique objectives for each RCMI outlined in goal (4) and goal (5) mentioned above. Community participation in decision-making processes is essential to ensure the proper tailoring of research toward the respective communities . TherefoThe RCMIs vary in purpose, core components, size, and infrastructure, but all are required to evaluate the impact of the center. According to NIMHD , the proSince 2007, the RCMIs have worked collaboratively to centralize their tools and applications to improve evaluation tracking . An evalEvaluation involves applying methodical approaches that are valid and reliable, and arriving at findings that can influence program services and outcomes . The evaEvaluating programs aimed at addressing health disparities provides attention to specific elements such as population characteristics and the role of social determinants of health . AccordiTo address the need for a uniform evaluation framework, we designed this multiphase mixed-methods collaborative study to (a) develop an RCMI evaluation conceptual framework; (b) identify a comprehensive set of shared metrics; and (c) discuss challenges and best practices for evaluating the RCMI programs. Applying this framework across the RCMI consortium will facilitate demonstrating the short- and long-term success of the collective efforts of the awarded RCMIs and allow for valid comparisons in identifying effective interventions. For the purpose of this paper, the terms “framework” and “model” are used interchangeably throughout the manuscript.Information to develop an evaluation conceptual model to frame and identify common metrics, best practices, and challenges was obtained using a multiphase mixed-methods approach: an in-depth discussion at a workshop for RCMI evaluators, synthesis of logic model metrics to identify common metrics, iterative discussions about a proposed conceptual framework and a common metrics survey questionnaire administered to RCMIs. All RCMIs’ evaluators and/or other key individuals were invited to participate in data collection activities: the workshop, iterative discussions, and the common metrics survey.The evaluation experts from each of the RCMI were invited to participate in a discussion workshop of RCMI evaluation methods, indicators, and metrics at the RCMI 2019 National Conference, Collaborative Solutions to Improve Minority Health and Reduce Health Disparities, held December 14 and 15, in Bethesda, Maryland. The RCMI conference hosts emailed invitations directly to RCMI evaluators. Initially, the RCMI conference hosts included this “by invitation only” session for RCMI evaluators and/or designees as part of the conference registration process. Later the workshop was open to any conference attendees.The purpose of the workshop was to elucidate RCMIs evaluation challenges and successes and to establish a comprehensive evaluation framework that includes how community engagement may contribute to reduction in health disparities. The workshop was facilitated by two representatives of the RCMI Translational Research Network (A.S. and T.H.) and two RCMI evaluators (K.L. and L.R.). At the workshop, the participants discussed a comprehensive evaluation framework that establishes standards and priorities for a synergistic consortium while considering the unique needs of the individual RCMIs. The evaluators were asked to prepare materials  in advance of the workshop as a tool to engage in meaningful discussion. Each evaluator in attendance shared this information in individual presentations and made the information available to the entire group via a shared “cloud based” folder.After the workshop, a report summarizing key points was disseminated to participants to guide subsequent discussions for the evaluators working group (EWG) and develop the RCMI evaluation framework. The RCMI evaluators were invited to participate in two meetings to identify next steps for developing the framework. Collaborating via bimonthly videoconferences, the EWG synthesized data from workshop presentation slides and other materials prepared by each participating RCMI that included program logic models and existing evaluation frameworks. The EWG also conducted a literature review of existing evaluation frameworks and conceptual models to inform the development of the proposed evaluation model ,25. Furtn = 10); eight sites shared a logic model. The metrics were methodically selected from logic models and classified as primary targets, secondary targets, outcomes, and impact metrics. Metrics were also examined based on their recurrence in the logic models. Less common metrics were included in the model with an asterisk. Next, the EWG reviewed the metrics and excluded those that were deemed irrelevant based on general consensus.To develop a metrics table that was common across sites, the EWG requested a copy of logic models from participating evaluators (n = 18) were invited via email to complete the online survey with reminders. Six key metrics associated with primary evaluation targets were selected. The survey contained eight questions about how each of the metrics are conceptualized and measured. The final instrument consisted of 62 questions, including a section (12 questions) related to the RCMI site information. For the purpose of this paper the EWG focused on finding answers to the following key questions:How was the metric operationalized?What are the primary approaches and methods for data collection?Does the RCMI use primary or secondary data?What is the periodicity for data collection?The EWG developed a survey questionnaire based on the key metrics identified in previous phases to outline definitions, approaches, and data collection practices used among current RCMI evaluators. Evaluators of currently funded RCMIs  representing 10 RCMIs attended the facilitated workshop. The discussion explored in-depth, the programs’ various metrics and measures, the challenges of evaluating the multi-faceted programs, and the resources utilized and needed to collect and manage the data to address key performance measures.Evaluation best practices and challenges shared during the RCMI Evaluator’s Workshop included a focus on the importance of (1) continuous RCMI team/institutional engagement, (2) establishing a multidisciplinary evaluation team, and (3) extracting multiple data sources to obtain baseline data for ongoing annual benchmarking and systematic data collection. The challenges in conducting RCMI evaluations involved barriers in being able to conduct the evaluations and limited evaluation guidance comprised of (1) RCMI cost-sharing, (2) revenue generation through charge-back plans to collect fees from researchers funded by other grants who use RCMI-funded facilities/equipment, (3) data collection, access to the data and infrastructure, (4) decision making , (5) disaster/crisis management , (6) having full time employees and staffing (FTEs), and (7) how to evaluate the broader community impact of the RCMI program. The RCMIs shared that they were diligent in their efforts to incorporate technologies to streamline data collection and improve monitoring. To improve evaluation tracking, the RCMI’s use online platforms  that track scholarly activities and use diverse data management tools including Research Electronic Data Capture , Profiles Networking  and eagle-I .The iterative process of the in-depth discussions among the EWG and review of the literature resulted in the RCMI Evaluation Conceptual Model and the identification of key evaluation metrics and extrapolated measures . The modThe model reflects how the RCMI programs share a common vision that aligns with that of the NIMHD. The RCMI programs individually and collectively aim to reduce health disparities among minority and other underserved populations through collaborative, interdisciplinary, transdisciplinary, and community engaged research. Community impacts contribute to national efforts to reduce health disparities through collaborative translational research.The RCMI evaluation teams are the curators of the site metrics and direct the evaluation of the program performance, coordinate and harmonize data collection, and enable the integration of relevant components for favorable program amendment . The evaKey metrics are performance measures critical in determining the effectiveness and efficiency of the program toward achieving its mission . Univershttps://reporter.nih.gov/) or Altmetric , and customizable applications such as Profiles Networking , along with quantitative  and qualitative data collection analysis tools facilitate a thorough and efficient evaluation process [Tools and technologies contribute to the collaborative process of the RCMI programs. The management of evaluation data requires the use of widely accepted applications and those designed for specific site needs. The evaluation process relies on data curation tools and analytical approaches to document the integration of the various program components and core facilities (cores). Widely accepted tools such as the NIH RePORTER  number of grant submissions, (2) number of grant awards, (3) number of peer-reviewed publications, and (4) number of presentations or symposia given (conference/symposia or community-based).Second, increasing scientific collaborations is a broad primary target for measuring the growth of the RCMI research infrastructures. Secondary targets commonly utilized as indicators of research growth within an RCMI are evaluating both the number and types of research partners and community partners. Scientific collaborations are often measured as process metrics, such as networking events or outcome metrics, such as the number of grant collaborators.An increasingly important component of the RCMI program is community engagement, as new and renewed RCMIs funded since 2016 are required to include a Community Engagement Core. Measures related to this concept include (1) number of memoranda of understanding (MOUs) signed, (2) expansion of community advisory boards, and (3) academic-community grants submitted.The third primary target area for evaluating RCMI programs, fostering professional growth, focuses on the training, professional development, and support of early career investigators (ECIs), particularly those who are from historically underrepresented groups in academia . Comprehensive evaluation that entails both results on process and outcomes of various professional development efforts is important in the context of how RCMIs foster career development of RCMI-funded early investigators.The fourth primary target area for RCMI evaluation, expanding research resources includes metrics that evaluate the growth in physical infrastructure, intellectual resources, and hiring faculty needed to conduct and expand health disparities and minority health research. Metrics in this category include the number of training seminars/workshops  and/or biostatistics consultations for RCMI-affiliated faculty or early-career investigators. Other metrics in this area frequently include the tabulation of increases in physical research space, acquisition of technology or software, and developing or expanding data repository capacity. Finally, the number of researchers hired as a result of RCMI recruitment efforts is often documented as a direct measure of expansion of the RCMIs’ resources.n = 10) for scientific productivity (publications) and fostering professional growth (mentoring) metrics to 11.1% (n = 2) for the health disparity  metric  metric . Select The EWG compiled the case study results to discuss the breadth of approaches used to measure and operationalize the same metrics across centers. The case study survey results are summarized in The metric, number of peer-reviewed publications, was selected from the measures for scientific productivity (primary target). As presented in A measure of scientific collaboration examined was the number of research partners . Eight oprofessional growth of underrepresented investigators, a secondary target , results are not reported.The number of external health disparity focused grants submitted by RCMI-funded pilot project investigators was the metric selected to measure health disparities. Given the very low response rate  develop an RCMI conceptual evaluation framework; (2) identify and examine shared evaluation metrics; and (3) identify and discuss challenges and best practices for evaluating the RCMI programs. The multiphase study resulted in establishing a uniform evaluation framework and specific metrics that can be used to demonstrate short and long-term success of the individual RCMIs and the collective RCMI consortium.The RCMI Evaluation Conceptual Model  illustraPrevious examinations of research center evaluation metrics noted that in addition to those commonly used for academic research centers, expanded indicators are needed to sufficiently address the complexity of research initiatives such as the RCMI . To thatComprehensive metrics were identified for each of the primary and secondary evaluation targets. For each of the four primary target areas—scientific productivity, scientific collaborations, professional growth, and research resources—a key metric was selected for further examination to obtain greater detail on how these outcomes are measured and collected across RCMIs. Although all respondents reported utilizing both primary and secondary sources to measure scientific productivity, significant variability in secondary data sources was noted across RCMI programs. Since most of the secondary sources for publication data are open-source, the sponsor NIMHD could consider establishing standard metrics and practices of data abstraction about peer-reviewed publications among the tools available: Scopus, Google Scholar, Web of Science, PubMed, or PubCrawler.Increases in scientific collaborations have been shown to benefit research productivity  and may Fostering professional growth through quality mentoring of early career and underrepresented investigators was operationalized as the perceived quality and satisfaction of professional growth activities, mentorship benefit or impact, trainee needs, and promotion and tenure. Although the field has made some progress in this area ,30, an oCommunity engagement  was operationalized as community members involved in the RCMI activities and decision making, formal community partnerships in proposals, and partners associated with research studies supported by RCMI-related/affiliated activities. Data sources for this metric varied widely, including surveys, interviews, tracking systems, administrative records, needs assessments, progress reports, and focus groups. In order to support a robust national evaluation of the RCMI program by the NIMHD, Centers could benefit from sharing specific tools and instruments for evaluating community engagement and reviewing them to find common questions. A review of community engagement metrics from similarly complex initiatives  and otheMetrics and methods for data collection were not established for health disparities  due to the low response on this outcome. In the RCMI context, reducing health disparities is a key dimension of the evaluation targets, not a stand-alone metric. Several examples to evaluate this outcome include grant proposals submitted with health disparity topics through the Investigator Development Core or an increase in underrepresented investigators at the RCMI institution who are conducting health disparities research. Additional metrics identified to evaluate health disparities as a target area would inform the RCMI impact and value added of this unique but necessary feature of RCMIs. At a minimum, a common understanding (shared vision) is needed among RCMI leadership, evaluators, and community stakeholders as to the interpretation of (what is meant by) this metric. Moreover, an agreement on operational definitions of key collective impacts for RCMI aligned with NIMHD’s mission such as “health disparity” and “health disparities research” as well as related concepts, such as “health inequities” and “social determinants of health”, would provide a shared vision across programs.A well-defined evaluation approach is critical to RCMI program success. An inclusive pragmatic conceptual framework is an evaluation best practice that enables continuous program improvement strategies and supports the centers in meeting goals at their respective institutional level. The RCMI Evaluation Conceptual Model provides a structure to facilitate the close monitoring and careful documentation of RCMI program activities and initiatives to better understand the value-added of this program for individual programs and across RCMI programs . MoreoveOne of the primary NIMHD RCMI program goals is to foster early stage investigators’ careers, particularly those who focus on health disparity and minority health research. The key metrics identified from this effort should be applied to document productivity and outcomes associated with investigators and early-career faculty who are funded by the RCMI. The RCMI’s Investigator Development Core includes a pilot project program to provide research funding to investigators and foster early research careers. Process metrics are critical to document career advancement of early career investigators and can be used in continuous process improvement. These may include the number and types of workshops attended or feedback via mock reviews. Outcome metrics should include grant submissions/awards and publications among early career investigators funded by their RCMI, including the RCMI Pilot Project programs.Long-term metrics for documenting the success of the pilot project program should focus on documenting the impact of the RCMI in fostering investigator career progression to becoming an independent researcher, demonstrated by converting pilot or early career funding into efforts to secure research funding on NIH Research Program Project Grants (R01 mechanism) or equivalent grants. Evaluation of how the RCMIs foster investigators’ careers should rely on secondary data sources, whenever possible, to reduce respondent burden. However, the inclusion of primary data sources for selected key metrics ensures investigators’ involvement in the evaluation process and provides a means of demonstrating their individual success. This way, RCMI researchers can serve as “champions” of ongoing evaluation data collection.Community engagement is a distinctive value-added component of the RCMI programs. As such, evaluation of community engagement is fundamental to supporting the broader goals of RCMI efforts. Assessment of engagement with communities may be measured in various ways, due to the complexity of capturing these activities accurately—i.e., community-specific activities, with little guidance on metrics. However, evaluations should go beyond the current commonly used process metrics . Attempts should be made to document the direction of engagement (community-initiated or investigator-initiated) as well as the level of involvement of communities in all stages of the research process . In caseA culture of evaluation, continuous dissemination of findings to the academic and lay communities, and opportunities for leveraging program and consortium-driven data for program decision making must be created to foster consistent and responsive evaluation tracking. Existing research infrastructure programs, such as NIH’s IDeA Networks of Biomedical Research Excellence  and the The EWG’s multiphase mixed-methods approach operationalized and validated the disparate evaluation activities across RCMIs, resulted in an RCMI Evaluation Conceptual Model, and identified metrics and best practices while depicting the diversity of RCMI communities. Meaningful, successful evaluation and tracking are continual processes that facilitate the documentation of impact and should be championed across the institutions . RCMIs sAn overall limitation is that not all RCMI evaluators or other key personnel participated in this process, as participation in this effort was voluntary and optional . Additionally, time constraints and competing demands may not have allowed for survey respondents  to consult with their RCMI stakeholders, or respond at all. Having a longer timeline to allow for RCMI evaluators to complete the survey, especially amidst the COVID-19 pandemic, would have been ideal. Furthermore, we did not obtain responses to some survey questions that originally were not phrased as a question. Including pilot testing of our survey items may have caught our inconsistent format of asking for information. Finally, this was not an anonymous survey, and since a Google document was used for collecting information, respondents could see each other’s entries. These limitations might have impacted the accuracy and reliability of responses. The EWG acknowledges that the evaluation metrics presented here may need to be better defined and further refined; however, this was beyond the scope of this manuscript. A working group specifically to critically examine each metric is recommended.The process and approach for evaluating the progress of the individual RCMIs and a program-wide evaluation are described in this manuscript, providing original guidance that should be prioritized for RCMI evaluations. Our effort to identify an RCMI evaluation conceptual model, metrics and measures, and best practices and challenges resulted in the development of an integrative pragmatic framework for collecting common critical data points and operationalizing measures and data collection approaches.Challenges and best practices of evaluating programs are varied and many. The RCMIs are positioned in communities that appreciate a mutually-beneficial research process in an effort to effectively change behaviors and policies that address health disparities in traditionally disenfranchised communities ,37. A syFindings address existing gaps about evaluation approaches for defining metrics and collecting critical data that demonstrate the aggregated impact of the RCMI consortium. This unique and vigorous collaboration of RCMI evaluators and the RCMI Translational Research Network coordinators established key metrics and measures for RCMIs. Collaborative and coordinated data collection, management, analysis, and reporting guided by the RCMI Evaluation Conceptual Model will support each Center in fostering health disparities research, and allow the centers to leverage their collective strength as a consortium to address health disparities. The availability of a guiding evaluation framework and identification of metrics may facilitate more rigorous evaluation approaches and improve the ability of RCMIs to demonstrate the collective impact of their health disparities research programs. Furthermore, obtaining relevant, robust evaluation results will also aid the funding agency, NIMHD, in demonstrating the added value of the RCMI program in achieving the agency’s mission. Ultimately, the impacts of the RCMIs  will benefit marginalized communities and increase the likelihood of health equity.


Pediatric associations have been urged not to interact with and not to accept support from commercial providers of breast milk substitutes (BMSs), based on the assumption that such interaction would lead to diminished promotion and support of breastfeeding. The leadership of seven European pediatric learned societies reviewed the issue and share their position and policy conclusions here. We consider breastfeeding as the best way of infant feeding and strongly encourage its active promotion, protection, and support. We support the World Health Organization (WHO) Code of Marketing of BMSs. Infant formula and follow-on formula for older infants should not be advertised to families or the public, to avoid undermining breastfeeding. With consistently restricted marketing of BMSs, families need counseling on infant feeding choices by well-informed pediatricians. Current and trustworthy information is shared through congresses and other medical education directed and supervised by independent pediatric organizations or public bodies. Financial support from commercial organizations for congresses, educational, and scientific activities of pediatric organizations is an acceptable option if scientific, ethical, societal, and legal standards are followed; any influence of commercial organizations on the program is excluded, and transparency is ensured. Public–private research collaborations for improving and evaluating pharmaceuticals, vaccines, medical devices, dietetic products, and other products and services for children are actively encouraged, provided they are guided by the goal of enhancing child health and are performed following established high standards. We support increasing investment of public funding for research aiming at promoting child health, as well as for medical education. The glohildren” . The texGuidance on Ending the Inappropriate Promotion of Foods for Infants and Young Children. Implementation Manual” in 2017 , in either liquid or powdered form, that are specifically marketed for feeding infants and young children up to the age of 3 years (including follow-up formula and growing-up milks).” It further states, “Companies that market foods for infants and young children should not create conflicts of interest in health facilities or throughout health systems.” Listed examples of actions considered inappropriate include, i.e., provision of free or reduced-price products considered BMSs through health workers or health facilities; donation of equipment, services, or gifts to health facilities, or HCPs; and sponsoring meetings of HCPs and scientific meetings. The background text proposes that the reputation and credibility of HCPs and their associations would be damaged if funding is accepted “by a company that makes a profit on goods that are not in the best interest of maternal and child health”  published the “ in 2017 . This gu health” , and it The conclusions presented here are based on extensive professional experience, a nonsystematic review of current literature, and detailed discussions within and among the participating societies, and they present a consensus position on concepts and policy.We enthusiastically encourage effective protection, promotion, and support of breastfeeding. This requires active engagement of pediatricians and their collaborative action with multiple stakeholders in numerous areas such as policy and planning, parental leave, and other support of families, information, education and communication, training of HCPs and others, monitoring, and research . ImpropeThe WHO guidance document also suggested to ban all marketing for complementary foods and for formulas for young children . The WHOImplementation of effective restrictions of the marketing of infant and follow-on formula to families and the public makes it essential that families can obtain evidence-based counseling on infant feeding choices from well-informed pediatricians and other HCPs. Therefore, pediatricians and other HCPs need access to evidence-based information on current scientific knowledge, as well as information on available products. Trusted information providers are learned pediatric societies and professional organizations, and governmental bodies. They share information with pediatricians and other HCPs through congresses, different forms of continuing medical education (CME), and other information channels. The essential role of pediatric professional organizations in providing guidance for the work of HCPs was again evident during the Covid-19 pandemic . MedicalWe strongly disagree with the recently published position of the European pharmaceutical industry association taking the view that commercial enterprises should independently be organizing medical education activities . We mainCode of Conduct for HCPs and Scientific Organizations” adopted by the Biomedical Alliance in Europe and the “Code for Interactions With Companies of the American Council of Medical Specialty Societies” provide examples for possible guiding principles that should be followed , Prolacta Bioscience, and Semper AB, one consultation fee from Danone Nutricia, and research grants to Umeå University from Baxter AB and Prolacta Bioscience. DD received research and educational grants from Chiesi Pharmaceuticals spa, ABBVIE Inc., Radiometer Ltd., served as consultant and lecturer for Airway Therapeutics, Chiesi Pharmaceuticals spa, ABBVIE Inc., Medtronic Inc., and MASIMO Inc., and has served on advisory boards for Chiesi Pharmaceuticals spa and ABBVIE Inc. He received travel grants and research technical assistance from Vyaire Inc., Osypka Medical los, and Sonoscanner Ltd. MJ has received conference travel reimbursements from Prolacta Bioscience. SK received lecture fees or research support assigned to the hospital from Abbott, AbbVie, Abela Pharma, Fresenius, Mead Johnson, Nestle, Nutricia, Oktal Pharma, and Shire. BK tends to be biased toward breastfeeding as member of the National Breastfeeding Committee, chair of the Nutrition Committee, German Paediatric Society, and President, Int Soc Research in Human Milk and Lactation. LMU—University of Munich and its employee BK received support for scientific and educational activities from the European Commission, H2020 Programmes DYNAHEALTH—633595 und Lifecycle—733206, the European Research Council Advanced Grant META-GROWTH ERC-2012-AdG—no. 322605, the Erasmus Plus Programmes Early Nutrition eAcademy Southeast Asia—573651-EPP-1-2016-1-DE-EPPKA2-CBHE-JP and Capacity Building to Improve Early Nutrition and Health in South Africa—598488-EPP-1-2018-1-DE-EPPKA2-CBHE-JP, the EU Interreg Programme Focus in CD-CE111 and the European Joint Programming Initiative Project NutriPROGRAM, the German Ministry of Education and Research, Berlin (Grant No. 01 GI 0825), the German Research Council (Ko912/12-1 and INST 409/224-1 FUGG), and from healthcare and nutrition companies, predominantly as part of publically funded research projects supported by the European Commission or German government. MS received lecture fees and travel reimbursements from Nutricia and Nestle. LT served as a scientific consultant for SHIRE Pharmaceuticals Group and the National French Haute Authorité de Santé. PT has received research grants from Chiesi Pharmaceuticals spa and bioMérieux Inc., and has been serving as consultant for Sedana Inc., Baxter Acute Therapies Inc., and Bristol Myers Squib Inc. JT received honoraria for advisory work from MSD Vaccines and travel reimbursements to scientific conferences from Takeda (formerly Shire) and GSK vaccines. None of the authors declares a conflict of interest as defined by the US National Academy of Medicine, with no circumstances involving the risk that the professional judgment or acts of primary interest may be unduly influenced by a secondary interest. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Mediterranean Journal of Rheumatology (MJR) has recently achieved a major milestone for any “young” scholarly journal: it has been accepted for indexing by PubMed and archiving by PubMed Central (PMC). This is a major achievement that could not have been realized without the dedicated effort, hard work and support of our editorial team, reviewers, authors, and, of course, the vision and continuing support of the Greek Rheumatology Society and Professional Association of Rheumatologists. Journal editorial strategies require regular updates in view of the fast-changing global publishing trends, quality of journal submissions, and readership preferences. To successfully compete with numerous publication outlets in the field and better serve professional communities, journal editors should prioritize the quality and integrity of published contents that influence research, education, and practice. In the era of digitization and Open Access, registering journals with freely accessible scholarly platforms and permanently archiving on reliable repositories are becoming prerequisites of responsible and impactful publishing.1The 2 There are concerns that authors in developing countries and those lacking research funds are disadvantaged by Plan S and cut out of quality gold open-access journals.3 The latter, however, is largely compensated by the availability of platinum open-access journals, such as the MJR, where publishing and archiving charges are covered by professional societies, easing the authors’ and readers’ financial burden.4In the field of biomedicine, PMC archiving is a major step towards global visibility and influence for journals and their contributors. Launched in 2000 by the US National Institutes of Health’s National Library of Medicine (NIH/NLM), PMC has become the most prestigious free repository of biomedical and life sciences journals that employ various open-access models. PMC as a reliable and freely accessible scholarly hub is gaining momentum in view of Plan S that will be enacted in 2021 to mandate immediate and free access to all publicly funded research.https://www.ncbi.nlm.nih.gov/pmc/), which are selected after thorough scientific and technical evaluations. Being accepted for archiving is a mark of academic recognition and a credit, both requiring continuing efforts to fulfil the accepted obligations towards the global scholarly community. Journal editors and publishers should be aware that not all PMC-archived journals retain their status over time due to failing scientific standards. PMC articles are retrievable along with MEDLINE-indexed and NIH-funded items through the same PubMed platform that is arguably the main search point for the absolute majority of biomedical researchers, practitioners, and authors. The functionality of the PubMed platform allows recommending it for systematic syntheses of biomedical literature.5Currently, PMC archives more than 2,200 fully participating journals  copyrights and distribution licenses, assigning Digital Object Identifiers (DOI), formatting by Journal Article Tag Suite (JATS) eXtensible Markup Language (XML), and other essential adjustments for optimal open access can be supportive towards PMC archiving. Publishing articles in well-edited English is yet another requirement, which is particularly important for journals from non-Anglophone countries. Investing in substantive editing services may open up the PMC gates for a large number of such journals. Finally, validating article references and requesting relevant updates are also useful tactics given the fact that the PMC platform facilitates easy navigation to cross-linked references from PMC and MEDLINE-indexed articles.To get archived and maintain their status, biomedical journals should regularly revise and upgrade their author instructions and publication ethics statements.10 Open-access journals with social media accounts are especially advantageous in that they can improve their immediate societal implications and build up on activities of their followers by regularly disseminating posts with open links to their articles.11 Journal editors concerned with post-publication promotion can benefit from PMC archiving by guiding their contributors how to actively share comments with open links and expand their social media networks.12Although PMC tracks citations, related metrics do not play a role for archiving. The citation tracking merely eases the online navigation within the PMC platform. At the same time, PMC archiving widens prospects of boosting article and journal traditional (citation) and alternative metrics. PubMed and PMC platforms are equipped with plug-ins for post-publication promotion through social media channels, such as Twitter and Facebook. Publicly available tweets and Facebook mentions expand the openness and implications of scholarly communications.Importantly, the appearance of PMC articles on the PubMed platform reveals cross-links to semantically similar items, which may help the authors widen their collaboration prospects and guide the journal editors over the overlapping topics and redundancies.https://www.ncbi.nlm.nih.gov/nlmcatalog/?term=journalspmcjournalspmc). Of these, 16 are in the field of rheumatology . The list includes flagship gold open-access periodicals of the American and European rheumatology associations – ACR Open Rheumatology and RMD Open. The rest of the archived journals also predominantly employ a gold open access model, publishing articles with research funding and open-access fees. Only a few journals in the field, supported by regional societies, afford platinum open access – MJR has also achieved this with the continuing support of the Greek Rheumatology Society. These journals can be primarily targeted by researchers who lack research funds and archiving fees; the researchers can benefit from making their research and reviews discoverable and permanently archived.Currently, the number of PMC journals listed by the NLM catalogue stands at 2,823 (13Although PMC archiving is a major milestone for all successful rheumatology and allied journals, there remains a lot of work to do for journals, such as ours, that are still not indexed by major bibliographic databases, such as MEDLINE, Scopus and Science Citation Index Expanded. Merely opening access and archiving cannot secure journal quality and citability. As journal editors, we will continue to strive to get endorsements and supply of quality articles from related professional societies, to constantly improve the quality, transparency, and crediting of the peer review, and try and expand the geography of our authorship, so that we can claim that we deserve ‘whitelisting’ by concerned academic and research evaluation institutions.


Homelessness is a growing concern as it affects a large number of people worldwide. Individuals and families experiencing homelessness are vulnerable in terms of health and underutilise health services. Despite being a global problem, not much is known about the range and breath of literature exploring health problems and health care service utilisation among homeless adults in Africa.To identify the nature and scope of existing evidence on physical and mental health, and health service utilisation among homeless adults in Africa. The review aimed to examine how research is conducted, identify gaps, guide future research, and make recommendations for development and implementation of policies and practices.A search of articles and reports involving six databases: Scopus, MEDLINE, CINAHL, PubMed, African Journal Online, and Google Scholar was conducted from June 2018 to February 2019. Studies published between 1980 and 2019 that examined the health problems and health service utilisation among homeless adults in Africa were considered. Manual search in reference lists and grey literature was also done to add reports. Data was extracted manually using a charting developed. A descriptive analysis and narrative synthesis were performed.Of 761 records found, 14 satisfied the pre-determined inclusion and exclusion criteria. Three themes emerged from the studies: Physical health problems, mental health problems; and healthcare services utilisation. Of the 14 included studies, nine studied and reported physical health problems such as sexually transmitted infections, injuries and disabilities, respiratory and cardiac diseases. Five studies explored mental health problems such as psychotic disorders, mood disorders, self-harm and suicidal behaviour. Only five studies investigated utilisation of different types of health care services among homeless people.Evidence shows that homeless adults suffered from a range of physical and mental health problems, and underutilisation of health care services. However, there is lack of information on the complex interrelationship between homelessness and health, as well as differences in prevalence of health problems among the various sub-groups of homeless. There is also lack of information regarding utilisation other important healthcare services such as mental health services, alcohol and drugs services, and accident and emergency service, and future researches should address that. Also, attention should be given to intervention models for complex and effective physical and psychiatric care as well as social support to address the homeless people’s health vulnerabilities. Homelessness affects a growing number of people worldwide, and presents a complex challenge for policymakers and service providers. Various United Nations estimates show that between 100 to 150 million people experience different forms of homelessness worldwide . This isAfrican countries generally have a housing challenge manifested in high housing deficits, higher prices, growing slums, overcrowding, and homelessness particularly in urban areas . AlthougIn some parts of Africa, civil conflicts, political unrest, and activities of terrorist groups are destroying lives and homes, displacing people, and rendering millions of people homeless . The actHomelessness is associated with a lot of problems and the consequences of homelessness for the affected individuals and communities are damaging. Homeless people experience poor health, suffer from a range of physical and mental problems related to their sleeping conditions and the environment in which they live. Substance abuse, violence, and malnourishment are overrepresented in the homeless population , 11. Wit, and registered patients are sometimes required to pay [Health systems in most African countries are generally weak, and many have not attained equitable and sustainable access to well-functioning health systems . Health d to pay , 32. Govd to pay .Although health issues are an important focus for homelessness research and a substantial body of literature exploring health and health service usage among homeless people exists, little is known about the situation in Africa. In order to identify the nature and scope of existing evidence, identify gaps, guide future research, and recommend policies and interventions for implementation, a scoping review which is suitable for gathering information from many different sources was conducted. The review was guided by the overarching research question: What is the scope and nature of literature exploring the health problems and health care utilisation among homeless people in Africa? The specific objective of this review was to explore and summarise existing research on the physical and mental health illnesses experienced by homeless adults, and their health care service utilisation in Africa.A scoping review was conducted from June 2018 to February 2019 according to the guidelines in the Joanna Briggs Institute’s Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist .The population of interest in the review was the homeless adults 18 years and above. To be considered homeless, a person must meet one of the following criteria: (1) be rough sleeping, roofless, or in places not designed for shelter; (2) unstably residing in slums, shacks, and squats; (3) residing in a homeless shelter, crisis and emergency accommodations temporarily, and (5) be admitted into drug rehabilitation, psychiatric facilities or religious healing centres with immediate preceding homeless episode and/or no place of residence when discharged . The defA search for articles was conducted on six electronic databases: Scopus, MEDLINE, CINAHL (EBSCO), PubMed, African Journal Online (AJOL), and Google Scholar. The search involved three steps: (a) initial search in MEDLINE to confirm search terms; (b) use of keywords and MeSH terms to search for articles across all databases (abstract and title search only); and (c) manual search of reference lists of included articles. A complete search strategy for Medline is provided in supplementary Table The search terms and keywords are shown in Table Must be conducted in AfricaMust focus on homeless adults (described under the section on study population).Must focus on physical or mental healthMust be published in the English language from 1980 to 2019All citations were uploaded into the Covidence online systematic review programme, which was used for the study selection. The selection of studies was undertaken in three phases of screening: (a) removing duplicates, (b) screening titles and abstract, and (c) screening full text articles. At each phase, the articles were compared against a pre-determined set of inclusion and exclusion criteria. To be included, a study:Not conducted in AfricaWrong population (not homeless adults)Not focused on health, andNot published in the English Language from 1980 to 2019All excluded papers were pointed out along with reasons, as follows:A data charting form was developed and used to manually capture data relevant to the review objective. The form had the following sections: (a) author(s)/publication year, (b) geographical location, (c) study design, (d) study population, (e) sample size and (f) summary of key findings. Data charting was done by authors in duplicate. The following were charted from the included studies: documented chronic and acute physical health problems; documented chronic and acute mental health problems; health seeking behaviour including frequencies and types of healthcare service utilised.A thematic analysis of the results from the studies was conducted. The process of data analysis identified three main themes concerning health problems and health service usage: physical health, mental health, and healthcare service usage. Studies have been grouped according to these three themes. Finally, a narrative synthesis and interpretation of the data was undertaken.Out of the 761 records identified, the full texts of 24 articles were screened for inclusion, and 14 records satisfied the inclusion criteria  Physical health problems; (2) Mental health problems; and 3) Underutilisation of health care services. All records associated with various themes, and related sub-themes are summarised in Table  UnderutiOverwhelmingly, studies found various physical health problems among homeless adults in African countries. The nine studies that measured physical health reported a range of illnesses. One study specifically looked at smear positive pulmonary tuberculosis , and twoRespiratory illnesses were reported in six studies conducted in South Africa , 38, EthPrevalence of cardiovascular diseases was presented in two studies in Nigeria  and TuniPhysical disabilities and injuries were presented in four studies based on street sample , 37, 39.In addition to the physical health problems mentioned above, HIV was presented in six studies including four in South Africa , 38, 44 Apart from the above-mentioned categories of health problems reported in included studies, other health problems such as stomach diseases among street and shelter residents were reorted , 38. SkiFive studies explored and reported a range of mental health problems across four sub-Saharan African countries , 41–43. Four studies measured psychosis , 42, 43;Depression and psychological stress were reported in three studies , 41, 42.Bipolar and mood disorders were assessed in two studies, one among street dwellers and shelter residents  and one Only one study reported on self-harm and suicidal behaviour among a sample of street dwellers . The stuThe homeless adults’ health service utilisation was explored in five studies , 38, 45.Four studies explored homeless people’s utilisation of hospital and clinic services , 37, 38.Only two studies elaborated on the use of complementary service among both street dwellers and shelter people; one was quantitative  and the One study specifically investigated the prevalence of utilisation of contraceptives among female adult street dwellers in Ethiopia . The stuThis review is the first to explore the literature relating to the critical issues of health and health service utilisation among homeless adults in Africa. The review identified studies with different settings, focus, and design, and there was a heterogeneity of study samples and methods employed to assess both physical and mental illnesses, and health service utilisation. Studies’ findings converge to indicate that homeless adults in African countries have high burdens of physical and mental ill-health and underutilise health care services.A key theme in this review is that studies explored and reported a range of chronic and acute physical health problems among homeless people, including HIV, respiratory diseases, physical disabilities and injuries, cardiac diseases, and skin diseases. Studies in African countries commonly focused on HIV. This is possibly due to the high burden of the disease on the continent particularly in sub-Sahara African countries such as South Africa which has the highest prevalence of HIV in the world. Therefore, a greater number of HIV studies are funded and conducted both in the general population and among vulnerable populations including the homeless.Mental health problems were commonly reported to be quite high regardless of the focus of the studies. This high prevalence may be due to three factors. First, the rough living condition including stress, trauma, and victimisation could directly cause mental health problems. Second, the poor support available for mental health may have resulted in people with mental illnesses becoming homeless . Third, A key point of divergence among the studies was the many different definitions of homelessness. Many of the studies sampled rough sleepers, roofless individuals, and individuals in squats and shacks; and institutional homeless people were inconsistently included. Another problematic point of divergence among the studies was their varying methods to assess physical and mental health problems, from clinical examinations and standardized instruments to self-reports. The use of clinical examinations and standardized instruments tended to result in higher prevalence than self-reports.Although studies’ focus and measurement approaches differed, physical health and mental health were more commonly found among the rough sleepers compared to homeless shelter dwellers. Moreover, health problems among people in homeless shelters and crisis accommodations were likely underestimated because few studies sampled from shelters. This is so because unsheltered people including people residing in squats and shacks, and streets far outnumber shelter dwellers and people in emergency accommodations in Africa. Some African countries do not even have homeless shelters, and homelessness is basically defined to mean unsheltered people or people without roofs . Also, pThe review found low health service utilisation, but similar to findings in other aspects in this review the findings from various studies were not directly comparable. In order to explore this matter further in future research, we recommend three improvements. First, future studies of service utilisation need to ensure a balance representation of street dwellers and shelter dwellers. Second, the time frame used in asking service utilisation needs to be standardised, for example in the past 6 months, bearing in mind the risk of recall bias. Third, the use of mixed-methods research may offer benefit from the combination of in-depth insight from qualitative methods and the generalisability of quantitative methods.What emerges from the health service utilisation theme is the need to recognise and address the various barriers that limit homeless adults in their care seeking, including a number of socio-economic barriers . HealthcOne notable gap in the records identified is the lack of information regarding the complex interrelationship and direction of causality between homelessness and physical and mental health. Understanding the underlying interrelationships between homelessness and poor health might help in the design of preventive interventions and reduce co-occurrences. No study has also focused on the difference in prevalence of health problems among the sub-groups of homeless people, and what factors account for such differences. Better understanding of the differences in prevalence of health problems among the various sub-groups of homeless might help in the design of intervention models for complex health presentations and effective physical and psychiatric care as well as social support for this population.There is also lack of information regarding utilisation of some specific healthcare services which are important to the homeless population. Homeless people’s use of mental health services, alcohol and drugs services, and accident and emergency service have not been studied. Utilisation of sexual and reproductive health services, maternal health services, and traditional/spiritual health services has also not been studied. A rigorous evidence base on how homelessness affects access and use of various health services in Africa is needed, particularly in sub-Sahara Africa, which carries the greatest homelessness problem, disease burden, and poverty.The search for research articles in the electronic databases are not error free and the search of grey literature was not systematic. Included studies covered only six out of 54 African countries and no study performed a multi-country analyses. Caution is needed when making generalisations from the review findings to homeless adult populations across Africa. The scope and method of the included studies also differed. There were differences in the quantitative studies in terms of study population, sampling techniques, sample size, and measurement methods. Also, interpretation of the results of this review need to be considered with the knowledge that scoping reviews do not screen for quality of studies.The review considered only records reported in English published since 1980. Broadening the scope of the review in terms of languages would have yielded additional relevant results, such as results from Francophone countries.This scoping review demonstrates that homeless people suffer from a range of physical and mental health problems and underutilise health services due to numerous accessibility and socio-economic barriers. Intervention models for complex and effective healthcare services and support for the homeless population are needed to help improve their health and wellbeing. Hospitals and clinics can be a key platform to address the health and welling of homeless people and to address homelessness as a whole, if various barriers can be minimised and utilisation improved. Thus, hospitals and clinics can be used as an opportunity to engage with homeless people, and help provide needs beyond regular hospital care, such as food, clothing, and other social support. This should be done through collaboration between hospitals/clinics and community-based homeless programs run by governments and NGOs. This could be effective through by ensuring stigma-free approaches that combine healthcare and social assistance as part of a package for homeless patients. The review also identified that studies did not focus on the interrelationship between homelessness and poor health and healthcare service utilisation in Africa, hence further research is needed. Future studies should also focus on utilisation of specific healthcare services that are important to the homeless adult population using mixed methods to take advantage of the strength of both methods achieve full understanding. Such services include accident and emergency, inpatient or hospitalisation, mental health, alcohol and drugs, and traditional or spiritual services. This would provide a stronger knowledge on the health problems and extent of use of different types of healthcare services.Six out of the 14 included studies reported receiving funding or financial support , 44, 45.Additional file 1: Table S1. Sample Search Strategy-Medline. Table S2. Physical Health Problems. Table S3. Mental Health Problems. Table S4. Health service Utilisation.