Evidence-based Model Research Articles

Evidence-based flood resilience models for bridges

Bridges are critical transport link that are frequently impacted by flooding. Despite substantial research on the risk of bridges to floods, there is a knowledge gap regarding restoration modelling, as there are very few available in the literature and most of them rely on expert elicitation. This paper provides the first restoration models that are based on documented cases and real data. The restoration of a portfolio of bridges that were damaged or collapsed during the 2015 Cumbrian floods in the UK was analysed. The purpose of this exercise was to develop a methodology that can be replicated to other case studies for facilitating resilience modelling for bridges affected by floods. Published restoration and recovery modelling techniques were used to establish a repeatable way of analysing a large portfolio of bridges in one model, offering valuable insights into the specific challenges and strategic considerations essential for effective post-flood recovery. This approach evaluates the serviceability levels during the restoration process and identifies key factors influencing restoration outcomes, underscoring the need for evidence-based restoration models to enhance infrastructure resilience against future flood events.

Evidence-Based Implementation Support: Considering Motivation and Capacity Within the Ecosystem of Training and Technical Assistance.

This invited commentary reflects on Wandersman and Scheier's (2024) call for a more evidence-based model of training and technical assistance (i.e. TTA or implementation support). Their clarion call prompts us to consider what steps need to be taken to refine and scale a solution that genuinely enhances the effectiveness of TTA through a re-imagined model of implementation support. We highlight eight priorities to re-imagine a more effective and efficient model of TTA that reflects best practice and simultaneously contributes to continuous, collective evidence-building. The eight priorities include: (1) an ecosystem of TTA connecting TTA research and practice; (2) TTA capacity building; (3) health equity, and equitable partnerships; (4) trust and relationships; (5) TTA evaluation; (6) continuous quality improvement; (7) implementation support mechanisms; and (8) cost-effective solutions. We advocate for an international, cross-disciplinary, applied agenda aimed at establishing a robust empirical foundation for TTA to foster a culture of continuous quality improvement and knowledge generation across government agencies and philanthropies that fund TTA Centers. We describe a potential scenario for how funders can initiate and support evidence-based TTA.

Cost-effectiveness analysis of proactive home visits compared with site-based community health worker care on antenatal care outcomes in Mali: a cluster-randomised trial

IntroductionDespite recommendations from the WHO, antenatal care (ANC) coverage remains low in many low-income and middle-income countries (LMICs). Community health workers (CHWs) can play an important role in expanding ANC...

Implementation cost analysis of collaborative care for perinatal mental health in community health centers.

Although costs are of key importance to clinic leadership when considering adoption of new programs, few studies examine real-world resource needs associated with implementing complex interventions for chronic conditions in primary care. This analysis sought to identify the costs necessary to implement the evidence-based collaborative care model (CoCM), an integrated behavioral health program for common mental disorders in primary care. Ten federally qualified health centers (FQHCs) adopted CoCM as part of a larger national randomized trial evaluating implementation strategies for CoCM when adapted for perinatal mental health. The Cost of Implementing New Strategies (COINS) tool was used to assess implementation costs associated with activities completed by sites as they progressed through the implementation process. National wage norms were used to calculate cost estimates for staff time. On average, clinics spent $40,778 (SD=$30,611) on implementation, with clinics ranging widely from $4,502 to $103,156. Three out of 10 participating clinics achieved competency in the intervention during the 2-year implementation period. Costs among competent clinics ranged from $20,944 to $65,415 (mean=$41,788). Clinics that did not achieve competency were more varied, with both the lowest and highest resource use. Significant staff effort was required to complete all implementation stages; clinical staff and program champions showed greatest effort. Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites who did not achieve competence. Additional work is needed to identify optimal site resource investment related to implementation success for CoCM. ClinicalTrials.gov.NCT02976025. Registered on November 23, 2016.

A qualitative exploration of knowledge attainment, safety practices and accessibility barriers to chest binding

ABSTRACT Objectives Chest binding is a common gender-affirming practice that transmasculine individuals can engage in for a range of reasons, including masculinising their physical appearance, which can facilitate gender euphoria, or alleviate gender dysphoria. In this study, we explored chest-binding experiences with a focus on knowledge attainment, understandings of safety and accessibility factors for those interested in binding. Method The study involved 15 semi-structured qualitative interviews with transmasculine people in Australia (aged 20–37 years) who have past or current chest binding experiences. These were analysed using thematic analysis. Results Data analysis resulted in the generation of four themes: 1) Online and social communities influence understandings of binding practices; (2) Learning about safety in binding is often self-directed; (3) Difficulties of navigating the application of safe binding within daily life, and (4) Common accessibility barriers to binding can be mitigated by trans communities. Conclusion The evidence in this study showed that chest-binding knowledge is acquired in diverse ways, and knowledge around safety and accessibility is not always readily available or easy to locate. However, participants unequivocally expressed that the practices are a crucial form of affirming care. Future research should continue to focus on creating strong, evidence-based affirming healthcare models for transmasculine Australians.

Improving Black Maternal Health: Early Implementation Findings from California's Black Infant Health Program.

This paper reviews the scientific basis and reports initial implementation results of California's Black Infant Health Program, a statewide group-based program with complementary one-on-one life planning to improve maternal and infant health among Black mothers and birthing persons. Descriptive analyses were conducted at the participant and group session level using program evaluation data from the initial three years of program implementation to examine participation rates, rates of service delivery, and participants perceptions of the program. From 2015 to 2018, 3332 Black birthing persons received group and/or life planning and 386 10-session prenatal group series were initiated with an average of 5.9 participants per series. Most sessions delivered all required activities (86.1%) and met requirements for providing food (84.5%), transportation support (72.2%), and childcare (55.4%). More than 90% of responding participants agreed or strongly agreed that BIH helped them manage stress (94.5%), set (97.4%) and achieve (92.9%) goals, and build stronger social connections (94.5%). The program was developed in response to evolving scientific knowledge regarding racism as the root cause of health disparities for Black birthing people. Focusing on six interwoven strategies for improving maternal and infant health outcomes, the program is supported by current scientific knowledge and can be feasibly implemented at a level consistent with similar evidence-based models.

Literacy Promotion: An Essential Component of Primary Care Pediatric Practice: Technical Report.

Early literacy promotion in pediatric primary care supports parents and caregivers in reading with their children from birth, offering counseling in interactive, developmentally appropriate strategies and providing developmentally and culturally appropriate and appealing children's books. This technical report reviews the evidence that reading with young children supports language, cognitive, and social-emotional development. Promoting early literacy in pediatric primary care offers a strengths-based strategy to support families in creating positive childhood experiences, which strengthen early relational health. An increasing body of evidence, reviewed in this report, shows that clinic-based literacy promotion, provided with fidelity to an evidence-based model, has benefits for children, for parents and caregivers, and for pediatric physicians and advanced care providers as well. Reading with young children supports early brain development and the neural "reading network," and improves school readiness. High-quality literacy promotion is especially essential for children who face disparities and inequities because of social factors, systemic racism, and socioeconomic risk. All families benefit from high-quality and diverse books and from developmentally appropriate guidance supporting interactions around books and stories. Thus, literacy promotion can be a universal primary prevention strategy to strengthen families and support healthy development. Partnerships at community, local, and state levels offer opportunities for integration with other programs, services, and platforms. Literacy promotion in primary care pediatric practice, recognized by the American Academy of Pediatrics as an essential component since 2014, has become increasingly common. There are successful models for public funding at federal, state, county, and municipal levels, but sustainable funding, including payment to pediatric physicians and advanced care providers, remains a need so that the benefits of pediatric early literacy promotion and the joys of books and shared reading can truly be offered on a population level.

Predicting Smoking Cessation Stages: An Insight from the Transtheoretical Model Using a Cross-Sectional Approach Among Adults in Saudi Arabia.

Smoking is a detrimental health behavior that can be addressed by designing stage-matched interventions with evidence-based behavioral change models such as the transtheoretical model (TTM). This study applied the TTM to predict smoking cessation stages among adults in Saudi Arabia. This social media-based cross-sectional study in Saudi Arabia used a convenient sample of 491 adult smokers (men and women). A digital questionnaire containing basic and smoking-related data and smoking scales (stages of change, cessation readiness, decisional balance, and self-efficacy) was used for data collection. The data were collected from 1 July to 30 October 2023 and were investigated using an ordinal regression analysis. The results illustrate that among the studied smokers, cigarette smoking was the prevalent method of smoking, especially among men (71.7%) compared to women (27.8%). Regarding stages of smoking, the pre-contemplation (35.8%) and contemplation (30.1%) stages were the highest, where men were more represented in both stages (37.9% and 40.8%, respectively). In comparison, women represented a higher percentage in the action (23.9%) and maintenance (21.1%) stages. The ordinal regression showed that increasing age (adjusted odds ratio; AOR = 1.045, p = 0.044), high quitting readiness (AOR = 1.134, p < 0.001), self-efficacy (AOR = 1.965, p = 0.028), decisional balance (AOR = 1.870, p < 0.001), and absence of psychological problems (AOR = 2.047, p < 0.001) increased the likelihood of being at higher smoking cessation stages. However, increased smoking duration (AOR = 0.756, p = 0.010), male gender (AOR = 0.340, p < 0.001), not working (AOR = 0.364, p = 0.013), adequate income (AOR = 0.535, p = 0.032), no chronic diseases (AOR = 0.430, p < 0.001), regular smoking (AOR = 0.052, p < 0.001), high smoking dependency (AOR = 0.775, p = 0.038), and hookah smoking (AOR = 0.032, p < 0.001) decreased the likelihood of being at higher smoking cessation stages. Cigarette smoking is a prevalent problem among Saudi adults, especially men, with the highest percentage of these being at lower smoking cessation stages. Thus, this study recommends the development of stage-matched interventions to facilitate the move towards higher smoking cessation stages through efforts by, and collaboration between, community sectors to face this rising issue.

An ontology-based agriculture decision-support system with an evidence-based explanation model

Effective management of plant diseases and pests requires knowledge that covers multiple domains. At the same time, retrieving the relevant information in a timely manner is always challenging, due to the unstructured nature of agricultural data. Over the years, efforts have been made to develop an ontology-based Decision-Support System (DSS) to facilitate the diagnosis and control of plant diseases. Some major issues with these systems are that: (1) they do not adopt the full extent of the ontological constructs to represent domain entities, which, in turn, reduces reasoning capabilities and prevents systems from being more intelligent, (2) they do not adequately provide the desired level of knowledge to support complex decisions, which requires many factors to be considered, (3) they do not adequately explain or provide evidence to demonstrate the validity of the system's outputs. To address these limitations, we present a novel system termed Agriculture Ontology Based Decision Support System (AgrODSS), which aims to assist in plant disease and pest identification and control. AgrODSS architecture consists of two semantic-based models. First, we developed Plant Diseases and Pests Ontology (PDP-O) to capture, model, and represent diseases and pest knowledge in a machine-understandable format. Second, we designed and developed an Evidence-Based Explanation Model (EBEM) that points to related evidence from the literature to demonstrate the validity of the system outputs. We demonstrate the effectiveness of AgrODSS by executing various queries via AgrODSS SPARQL Endpoint and obtaining valuable information to support decision-making. Finally, we evaluated AgrODSS practically with domain experts (including entomologists and pathologists) and it produced similar answers to those given by the experts, with an overall accuracy of 80.66%. These results demonstrate AgrODSS's ability to assist agricultural stakeholders in making proper disease or pest diagnoses and choosing the appropriate control methods.

Human Communication Elements of the Continuity of Midwife Carer Newsletter: A Descriptive Case Report.

Background: The Continuity of Midwife Care (CMC) model is an evidence-based care model that positively influences the health and well-being of women, their families, and midwives. Although effective communication strategies have not been determined, online resources are known to reach a wider audience and make CMC research more visible. The All-you-need-to-know-about-continuity-of-carer newsletter, distributed by the authors, is a strategy to communicate valuable and credible CMC content from knowledge producers to users. Purpose: To explore the newsletter's functional elements and the connection between it as a communication strategy and the individuals interacting with it and to present a case demonstration of a newsletter example. Methods: A descriptive case report with a theory-driven approach using 10 elements of human communication theories. Conclusions: The following elements of human communication contribute to understanding the functioning of the newsletter: Grounded Theoretical Theory, the Practical-Action Theory and goal-oriented communication (communication theory), the Syntactic Theory of Visual Communication and the rhetorical tradition of communication (tradition of communication), Elaboration Likelihood and the socio-cultural model of communication (communicator), implied compliance-gaining, parole, semiosis, narrative paradigm and rhetoric logic (message), social organisation communication, co-cultural communication and invitational rhetoric (conversation), the orientation and exploratory affective exchange stages of social exchange (relationship), Structuration Theory (group), the Theory of Bureaucracy (organisation), the Cultivation Theory (media), and the Diffusion of Innovation and Ethnography of Communication (culture and society). Implications: The newsletter succeeds in managing CMC information and reaching an interested audience. Further evaluation is required to explore if or how the newsletter affects information use.

What Supports Do Incarcerated Mothers and Their Families Need? The Views of Incarcerated Mothers and Service Providers

Maternal incarceration causes complex and diverse outcomes, affecting the mother, her family, and her community. Despite this, there are few evidence-based models of support. This paper aims to identify participant’s perspectives in developing a model of support by identifying needs, preferred services, and current barriers. Incarcerated mothers (n = 75) and service providers (n = 24) in Queensland, Australia contributed through workshops. Participants identified three support areas: (i) children’s wellbeing and mother-child relationships; (ii) while mothers are incarcerated; and (iii) when mothers return to the community. Mothers prioritized relational and self-development goals whereas service providers prioritized material needs and service delivery methods. Barriers reflected mothers’ multifaceted needs and the complex service delivery area. Preferred programs incorporated individualized, multi-modal, long-term, culturally-informed, and trauma-informed care, while system-level barriers included administrative burdens and navigating complex systems. Overall, models of support must incorporate optimal program-level and system-level characteristics to improve the outcomes of mothers and their children.

Australian community and inpatient general public sector mental health services between 2017-18 and 2021-22: Relative stasis in bed capacity, increasing outpatient demand, and stunted expenditure.

To descriptively analyse Australian public sector General Mental Health Services (GMHS) expenditure, ambulatory, and inpatient services, including key performance indicators (KPIs) in comparison with other subspeciality mental health services (MHS). We descriptively analysed data published by the Australian Institute of Health and Welfare (AIHW), including inpatient, ambulatory services, expenditure, and KPIs. From 2017-18 to 2021-22, per capita expenditure for Australian GMHS (18-64) rose by an average annual inflation-adjusted change of 2%. Overall bed numbers remained static, with non-acute beds declining, and commensurate expansion of acute beds. Community GMHS had high outpatient utilisation, with high rates of schizophrenia, schizoaffective disorder, and bipolar affective disorders as primary diagnoses in mid-life. From 2017-18 to 2021-22, GMHS inpatient and ambulatory episodes had decreasing rates of significant improvement and increasing rates of significant deterioration. Although GMHS has the highest overall population and service utilisation, there has been static bed availability and relatively small increases in expenditure which are occurring concurrently with worsening clinical outcomes. Evidence-based modelling of GMHS and outcomes is required to inform future service improvement.

Commentary: Strengthening System Readiness for Health Interventions: Lessons for Implementing Interventions and Implementation Support in Low-And Middle-Income Countries.

In low- and middle-income countries (LMICs), barriers such as low system readiness, contextual mismatches, and resource limitations impede effective implementation of evidence-based interventions. This commentary offers insights into overcoming these challenges with a case study of the PRISM project, designed to reduce behavioral and psychological symptoms of dementia in older adults living in Thailand. The case highlights how combining two evidence-based models - the Reducing Disability in Alzheimer's Disease clinical intervention and the Getting To Outcomes implementation science process enhances program success. Using interviews with stakeholders across various health system levels, we identify factors critical to successful program implementation: (1) integrating interventions into policy frameworks, (2) empowering local implementers, (3) fostering collaborative learning, and (4) adapting interventions to local contexts. The case demonstrates that building system readiness through local engagement and ownership is central to scaling up health programs in LMICs. This commentary's contribution lies in its emphasis on the role of implementation science as a vehicle for translating research into practice. It presents a practical, adaptive model for embedding interventions into routine health systems, thereby offering a pathway for successfully scaling up evidence-based programs in LMICs. Such findings provide lessons for overcoming barriers to implementation in resource-limited environments.

Establishment of Evidence-Based Nursing Indices for Dysphagia After Anterior Cervical Spine Surgery.

To select and obtain relevant evidence for the management of dysphagia after anterior cervical spine surgery both domestically and internationally, clinical quality evaluation indicators were developed based on evidence-based nursing practices, and obstacles and promoting factors in evidence-based nursing practices were analysed. This research was aimed to provide a basis for evidence-based nursing practices to promote standardized management of dysphagia after anterior cervical surgery. Dysphagia is the most common complication following anterior cervical surgery, but there is a lack of standard protocols and guidelines to direct clinical practice. Mixed methods were employed for the translational research to support evidence-based practice. This study was based on the JBI evidence-based health care model. According to the '6S Evidence Resource Pyramid Model', we searched from top to bottom. This study is guided by the knowledge to action (KTA) evidence-based practice model. Utilizing a comprehensive evidence-based approach and following the 6S evidence resource pyramid model, relevant evidence on the management of swallowing disorders after cervical anterior surgery was selected from both domestic and international sources. Based on the best available evidence, the Delphi expert consultation method was used to establish a management plan for swallowing disorders post-cervical anterior surgery. Semi-structured interviews were then conducted to identify barriers to clinical implementation, and clinical quality evaluation indicators, as well as promoting factors, were subsequently developed. Based on the 31 best evidence points, 12 evaluation indicators were developed. The baseline results of these indicators reveal that, apart from evaluation indicator 8, which has a compliance rate of 72.2%, the compliance rates for most of the other indicators are relatively low. Based on the results of the clinical quality review, the following main obstacles were analysed: negative behaviours and attributes, lack of professional knowledge, and lack of standardized management. Effective management of swallowing disorders after cervical spine surgery is crucial for enhancing treatment outcomes, reducing complications, shortening hospital stays and improving patient quality of life. This study identified the best evidence for managing dysphagia post-anterior cervical surgery and developed corresponding solutions. The next step involves applying these measures in clinical practice to improve patient prognosis and elevate the quality of care.

Co-designing the INHSU Prisons Hepatitis C Advocacy Toolkit using the Advocacy Strategy Framework

BackgroundThe World Health Organization (WHO) has established targets to eliminate the hepatitis C virus (HCV) by 2030. Prisons are a key focus of elimination efforts, however, access to HCV services in prisons remains low globally. With the aim of increasing advocacy efforts to help address this gap, the International Network on Health and Hepatitis in Substance Users (INHSU) Prisons, developed a Prisons Hepatitis C Advocacy Toolkit. MethodsToolkit development involved a co-design process to ensure advocacy resources met end-user needs. A scoping study was conducted, involving a web-based survey and in-depth interviews, to understand advocacy resource needs of key stakeholders from countries of different socio-economic strata. Data were analysed, and suggested advocacy resources were mapped onto the Advocacy Strategy Framework with the audiences resources are targetting and the changes they aim to influence. Advocacy resources were co-developed and validated by interview participants before incorporation into the web-based platform. ResultsSurvey responses (n = 181) and interview data (n = 25) highlighted several barriers to enhancing HCV services in prisons globally, and an understanding that advocacy efforts are needed to bring about this change. Advocacy resources were suggested for influencing three key audiences: policymakers/funders, implementers, and community. Thereafter, a suite of 20 de novo tools were co-developed with key stakeholders including case studies of evidence-based models of HCV care, policy briefs, HCV infographics, and fact sheets about how to leverage funding and build advocacy campaigns. Findings underscore the importance of capitalising on the knowledge and expertise of potential end-users, to ensure Toolkit resources are context-specific and match their needs. ConclusionThe Toolkit holds promise for progressing the WHO elimination goals by increasing advocacy efforts for enhanced prison HCV services globally. The co-design of Toolkit resources with potential end-users has increased its potential accessibility, acceptability, and inclusivity for a globally diverse audience.

Development of a Sexological Ontology.

This study aimed to show what role biomedical engineering can play in sexual health. A new concept of sexological ontology, an essential tool for building evidence-based models of sexual health, is proposed. This ontology should be based on properly validated mathematical models of sexual reactions identified using reliable measurements of physiological signals. This paper presents a review of the recommended measurement methods. Moreover, a general human sexual reaction model based on dynamic systems built at different levels of time × space × detail is presented, and the actual used modeling approaches are reviewed, referring to the introduced model. Lastly, examples of devices and computer programs designed for sexual therapy are described, indicating the need for legal regulation of their manufacturing, similar to that for other medical devices.

A prediction model of PTSD in the Israeli population in the aftermath of october 7th, 2023, terrorist attack and the Israel–Hamas war

BackgroundOn October 7th, 2023, a mass terror attack was launched by Hamas militants, which was followed by the Israel-Hamas war. These events constitute a nationwide trauma with major ramifications for public mental health. This article presents an evidence-based model for the prediction of the prevalence of posttraumatic stress disorder (PTSD) related to the terrorist attack and the war.Main body: The creation of the model consisted of several steps. Firstly, the Israeli population was divided into six groups based on the intensity, context, and type of traumatic exposure (direct exposure to terror, close proximity to terror, soldiers in combat and support units, intense exposure to rocket attacks, moderate exposure to rocket attacks, and indirectly affected communities), and the population size of each group was assessed using official national databases. Secondly, an estimation of the expected prevalence of PTSD in each of the exposure groups was based on a review of the relevant literature. A random-effects meta-analysis of the prevalence rates was conducted separately per each exposure group. Finally, the predicted number of PTSD causalities in the population was calculated by multiplying the group size and the PTSD prevalence estimation. Based on population size and estimated PTSD prevalence within each exposure category, the model predicts that approximately 5.3% (N = 519,923) of the Israeli population (95% confidence interval, 1.64–9%), may develop PTSD as a result of the terrorist attack and the war.ConclusionsThe predicted number of individuals with PTSD following mass trauma is expected to be considerable. The presented model can assist policymakers, clinicians, and researchers in preparing and devising adequate interventions for the mental health needs of large populations. Moreover, this model can be applied in other instances of mass-trauma exposure.

How do industry and other actors undermine tobacco control policies post-adoption? A scoping review

Abstract Background Over recent decades, many countries have strengthened their tobacco control policies. To be effective, full implementation is needed. Tobacco industry interference is widely recognised as a key barrier to tobacco control progress and evidence-based models like the policy dystopia model (PDM) list industry strategies, focusing on those avoiding and undermining policy adoption. While prior research highlighted industry activities post-adoption, these have not been captured systematically. This review aimed to map the efforts of industry, front groups and other actors to undermine the implementation of policies, including marketing, packaging, smokefree and flavour measures. Methods We searched six literature databases, relevant bibliographies and grey literature, and consulted experts. We included articles describing one or more attempts to undermine adopted policies, including marketing, packaging, smokefree and flavour. The PDM served as starting point for coding; additional strategies were identified inductively. Strategies were charted against aims and policies. Results Several aims and strategies were identified which were similar across policies. Following policy adoption efforts to 1) overturn and 2) weaken measures, and 3) delay implementation continued. Legal strategies were utilised and there were attempts to influence stakeholders. In addition, tobacco industry and other actors sought to 4) undermine policy effectiveness by creating confusion, circumventing policies, and noncompliance, and 5) use implementation as an opportunity to enhance industry reputation. Conclusions Interference from tobacco industry and other actors threatens effective tobacco control policy implementation. The public health community must continue to monitor, expose and counter industry conduct after policy adoption. More research is needed to enhance our understanding of how industry interferes in policy implementation, and how this can be pre-empted and countered. Key messages • The interference from tobacco industry and other actors following policy adoption threatens effective tobacco control, and needs to be monitored, exposed and countered by the public health community. • Policymakers and civil servants need to be wary of efforts to undermine tobacco control policies and act to ensure effective policy implementation.

Development of a systematic referral model to primary care health interventions for patients with atrial fibrillation. a delphi study

Abstract Background The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) recommend integrated care in AF, combining medical treatment with lifestyle modifications and psychosocial management in a multi-disciplinary set-up. Research show that patients with AF can benefit from lifestyle interventions and psychosocial management, like patient education. According to World Health Organization recommendations, these health interventions are moving from hospitals to primary healthcare settings. Therefore, patients with AF should be systematically referred to these interventions. Yet, an evidence-based referral model that can support this transition is lacking. Purpose The purpose is to develop a systematic referral model for primary care health interventions for patients with AF. Methods We used the Delphi-technique with three rounds of questionnaires (figure 1). International and national clinical experts in AF across disciplines and health sectors were invited to participate. In the first round, the expert panel evaluated items that could be part of a referral model on relevance, improvability and self-reporting. In the second round, the expert panel evaluated each item as either an inclusion or exclusion criteria, important knowledge to have, or not relevant. In the third round, the expert panel evaluated the items according to data source and outcome status. A final model was drawn based on items reaching consensus. The study was reported according to the guidance on conducting and reporting Delphi studies (CREDES). Results In total, 69 of 139 invited experts accepted to participate (50%). These were mostly academics or clinicians (90%), stemming from primary sector (16%), secondary sector (35%) and research (32%). Most were medical doctors (36%) and nurses (35%). However physiotherapist, psychologists, dieticians, and other disciplines along with six patients with AF were also represented. The expert panel (60% females) had a mean age of 50 years, and 65% were from Denmark. For the final referral model (figure 2), AF symptom burden and impaired health-related quality of life, anxiety and poor medicine compliance combined with a risk factor profile were the main inclusion criteria. Furthermore, it was important to know about the patients’ mental well-being, self-management abilities and comorbidities. Conclusion Consensus was reached for a generic referral model, which can be further adjusted in the appropriate clinical context. The model includes inclusion criteria which closely correlate with guidelines for AF management focusing on reducing the patients’ symptom and risk factor burden. The referral model is expected to increase the number of patients with AF referred to primary care health interventions, which could lead to better quality of life, fewer hospital admissions and lowered health care costs in AF.

Achievements and Challenges in the Development of a Nurse-Led Respectful Delivery Care Model Provided by Partners in Health in Rural Mexico.

The model of obstetric care predominant in Mexico in most public and private healthcare institutions is particularly focused on a physiological perspective of the female body that does not respond to women's need for emotional comfort and satisfaction. In the last decade, however, various initiatives that provide obstetric care centered on women's rights have emerged. To analyze the implementation of a model of humanized/respectful delivery care supervised by nursing and midwifery undergraduate interns in a birthing center in the state of Chiapas, in order to identify achievements and future challenges. We used information from secondary sources and carried out a descriptive analysis. Births attended at the birthing center increased in relation to all the births registered in the Angel Albino Corzo municipality between 2017 and 2022. Positive indicators of respectful care increased with the implemented model, while negative indicators decreased. Between 2016 and 2022, obstetric nurses attended more than 1500 births without maternal deaths and managed some emergency cases referred to specialized care. This case illustrates the potential of alternative models of obstetric care. Evidence-based, midwife- and nurse-led models of clinical obstetric care should be expanded in the Mexican healthcare system.