A Mixed Methods Evaluation of The Paediatric Musculoskeletal Matters (PMM) Online Portfolio

A Mixed Methods Evaluation of The Paediatric Musculoskeletal Matters (PMM) Online Portfolio | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article A Mixed Methods Evaluation of The Paediatric Musculoskeletal Matters (PMM) Online Portfolio Nicola Smith, Helen E Foster, Sharmila Jandial This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-87044/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Jun, 2021 Read the published version in Pediatric Rheumatology → Version 1 posted 14 You are reading this latest preprint version Abstract Background Electronic resources (e-resources) have considerable potential to reach users around the world to promote awareness and knowledge about musculoskeletal conditions. The ‘PMM portfolio’ targets non-specialists in musculoskeletal medicine and comprises the Paediatric Musculoskeletal Matters (PMM) website, the paediatric Gait, Arms, Legs and Spine (pGALS) app and e-learning modules (ELM). Our aim was to evaluate the ‘PMM portfolio’ to gain insights about it’s impact on learning and clinical practice. Methods Mixed methods (e-resource analytics, online survey, interviews) with PMM and ELM registered users in addition to purposive sampling of users using UK and international contacts within paediatrics and paediatric rheumatology. Data was analysed using descriptive statistics and free-text comments using qualitative techniques. A Paired T-Test compared self-rated confidence before and after use of the e-resources. Results There has been wide international reach for all e-resources PMM website (662,827 hits, 262,476 users, 214 countries, data 31 st July 2020), pGALS app (12,670 downloads, 70 countries, data 31 st July 2020); ELM (150 users, 30 countries, data 30 th May 2019). There were 164 responses to the survey from 25 countries from a range of students, trainees and health care professionals. Most deemed the ‘PMM portfolio’ to be ‘useful or very useful’ for their learning (or when used to teach others) and reported significantly increased self-rated confidence in their clinical examination and reasoning skills following access to the e-resources (PMM website, p=<0.01; pGALS app, p=<0.01; ELM, p=<0.01). Easy, open access, clinical images, videos and cases were deemed the most valued features of the e-resources. The most popular PMM website pages related to clinical assessment. There was high uptake of the pGALS app and pGALS’ ELM especially from trainees and allied health professionals. Conclusions The ‘PMM portfolio’ has wide reach amongst a spectrum of our target users to raise awareness and improve knowledge and skills. Ongoing engagement with users will facilitate further iterations of the ‘PMM portfolio’ to remain relevant for the global context. PMM as a model of e-learning has increasing applicability with the ongoing Covid-19 pandemic and is an important way to expand global paediatric rheumatology. Pediatrics Rheumatology Clinical education E-learning E-resources pGALS Global health Access to care Evaluation Workforce capacity building Model of practice Global paediatric rheumatology Figures Figure 1 Background Musculoskeletal (MSK) presentations in children and young people (CYP) are common (reported prevalence of 1 in 8 ( 1 ) and a frequent cause of health care consultations increasing with age (6% of 7 year olds to 16% of 22 year olds in a cohort study from the UK) ( 2 ). Delay in diagnosis and access to specialist care is a priority to address amongst parents ( 3 ) and is often reported in conditions that present with MSK features ( 4 – 9 ) with adverse impact on clinical outcomes ( 4 , 5 , 10 ). The reasons for such delay are multifactorial ( 9 , 11 ); including complex care pathways involving community care and various hospital care specialties (usually general paediatrics or emergency care) ( 8 , 11 ) where self-rated lack of confidence in paediatric MSK clinical skills is reported ( 12 ). Clinicians working in the community play a crucial role to diagnose and instigate specialist referral ( 2 , 7 , 8 ). Family medicine practitioners are often the ‘gatekeepers’ to specialist services ( 13 ) and yet many training schemes do not include paediatrics ( 14 ), or MSK medicine ( 15 ) despite the learning needs being known ( 16 ). Other clinicians including nurses and allied health professionals (AHP) may encounter CYP in their clinical practice and there is need for more knowledge about MSK problems ( 17 , 18 ) With these challenges in mind our group developed a portfolio of e-resources (the ‘PMM portfolio’) to up skill and support all clinicians who play an integral role in the early recognition, diagnosis and initial care of CYP with MSK conditions. The target audiences therefore include a spectrum of clinical learners who are not ‘paediatric MSK experts’; ranging from students in medicine and nursing, trainees in family medicine and paediatrics, through to practitioners in general paediatrics, family medicine, nursing and allied health. The ‘PMM portfolio’ encompasses the Paediatric Musculoskeletal Matters (PMM) website (launched 2014), the paediatric Gait, Arms, Legs and Spine (pGALS) app (added 2015) and e-learning modules (ELM) (added 2017) to aid signposting through the website. The PMM website ( www.pmmonline.org ) is a free and open evidence based, peer reviewed e-resource with user engagement to inform content and website design functionality ( 19 ). PMM Nursing (2017) is a further version of PMM to address the needs of the wider nursing community ( 17 ). The PMM website includes an open anonymised online survey and since 2014, 84 responses from 19 countries (data not shown but available on request), has informed ‘PMM portfolio’ development with requests for more global content and signposting. ‘PMM International’ was hence developed and replaced the original PMM website in September 2018 following collaboration with paediatric rheumatologists in 11 countries (within Asia, Africa, Americas, Australasia and Europe) who developed additional content reflecting case mix and the health care in their country ( 20 ). New content focused on infections and infection-related disease with MSK features, or differential diagnoses of rheumatic disease with further cases and images to reflect ethnic diversity. All contributions were subject to editorial review to ensure consistency of language and compliance with our governance framework ( 19 , 20 ). Paediatric Gait, Arms, Legs and Spine (pGALS) ( 21 ) is a simple MSK examination schedule useful in clinical practice ( 22 – 28 ) and is widely taught ( 29 , 30 ). The free pGALS app (launched in 2015) was developed with medical students at Newcastle University UK to inform format and content with exam revision notes and links to PMM website key pages ( 31 , 32 ). Language translations of pGALS produced with our PMM International collaborators (to date 20 languages) and a version for telehealth (V-pGALS) are freely available on the pGALS app and PMM website ( http://www.pmmonline.org/doctor/approach-to-clinical-assessment/examination ). The PMM E-Learning Modules (ELM) aid navigation through the PMM website and were developed with our multi-professional team (including family medicine doctors, paediatricians, medical students) ( 30 , 32 ). At the time of our evaluation there were three e-modules ( https://cpd.ncl.ac.uk/courses ) i) pGALS and clinical examination skills for medical students ii) Assessment of childhood MSK presentations in family medicine iii) The paediatricians approach to a child with fever Aims This study focuses on evaluation of the ‘PMM portfolio’ to describe and understand reach and impact on learning and clinical practice. Furthermore the evaluation aimed to inform future development of the ‘PMM portfolio’ and strategy to optimise impact. Methods We adopted a mixed methods approach comprising e-resource analytics, an online survey (including self-rated confidence before and after access to the e-resources) and telephone interviews to explore themes raised by the survey. Google Analytics described access to PMM website (site hits, page hits, accessing countries) and resource analytics described pGALS App Store data (country and number of downloads) and ELM data (country, number of users, clinician role). An online survey using ©Survey Monkey (see additional file 1) was used to explore how the ‘PMM portfolio’ resources impact on learning and clinical practice. The survey included sections about each of the ‘PMM portfolio’ e-resources and respondents were asked to provide feedback on all the resources including those that they had not accessed. The survey was piloted and included Likert Scale questions ( on perceived usefulness and impact on confidence on MSK knowledge and skills ), free text options and open-ended questions to encourage comment. A random selection of PMM website registered users (n = 450) and all the users registered for the ELM at the time of survey recruitment (n = 142, July 2019) were invited to complete the online survey in addition to purposive sampling amongst user groups within the UK and through our PMM global partners. Selected 1–1 telephone interviews followed the online survey to explore the findings in more detail. Interview participants comprised medical students (n = 2), clinical lecturer paediatricians (n = 2) and family medicine doctors involved in teaching alongside their clinical practice (n = 2); 4/6 were from the UK. Utilising various recruitment sources was important to include a wide range of target audiences and to enable recruitment of users and non-users of the ‘PMM portfolio’. Written consent was obtained from interview participants and survey respondents consented to participation through an online response. All participant information was anonymised. Interviews were audio-recorded and transcripts anonymised before data analysis. E-resource analytic and survey data was analysed using descriptive statistics, with free-text comments and interview transcripts analysed following standard procedures for qualitative analysis, including open and focused coding, constant comparison and deviant case analysis ( 33 ). Reflexivity was maintained throughout the analysis and writing, by recording, discussing and challenging established assumptions. A Paired T Test (©Minitab) compared self-rated confidence scores (Range: 1 not very confident – 5 very confident) before and after use of the e-resources. The study had ethical approval from Newcastle University, UK. Results Resource Analytics The PMM website has had 662,827 hits and 262,476 users across 214 countries (data 31st July 2020 - see Fig. 1 and Table 1 ). Usage has continued to grow since launch (2014) and furthermore following evolution to PMM International (September 2018). Most PMM users are from the US and UK although the total number of countries accessing PMM has increased over time (see additional file 2). Table 1 Top 50 Countries Accessing PMM Website Country Number of Users Country Number of Users 1. US 79,928 26. Spain 962 2. UK 65,417 27. Italy 890 3. Australia 15,487 28. France 865 4. India 13,895 29. Taiwan 804 5. Canada 10,796 30. Sri Lanka 793 6. Malaysia 5,788 31. Colombia 788 7. Ireland 4,825 32. Mexico 780 8. New Zealand 3,840 33. Japan 779 9. Saudi Arabia 3,534 34. China 749 10. Philippines 3,050 35. Israel 749 11. South Africa 2,836 36. Bangladesh 738 12. Pakistan 2,343 37. Sweden 725 13. Indonesia 2,187 38. Greece 608 14. Singapore 2,163 39. Portugal 581 15. Thailand 1,879 40. Norway 569 16. Egypt 1,760 41. Poland 569 17. UAE 1,491 42. Iran 542 18. Brazil 1,488 43. Hungary 532 19. Netherlands 1,431 44. Jordan 527 20. Hong Kong 1,346 45. Belgium 513 21. Germany 1,337 46. Iraq 512 22. South Korea 1,284 47. Czech Republic 489 23. Nigeria 1,151 48. Switzerland 467 24. Kenya 1,072 49. Russia 448 25. Turkey 1,001 50. Nepal 418 Total overall: 262,476 users across 214 countries Google Analytic Data from14th November 2014 (go live date) to 31st July 2020 The most popular PMM website pages (Table 2 ) relate to clinical assessment (pGALS, pREMS ( 34 ) normal development [gait/milestones], normal variants), frequent falls, fractures, MSK infections, limping child and guidance on when to be concerned (‘red flags’). Users spend approximately 2 minutes on the site (Mean: 01.58, Range: 5 seconds to 5 minutes, 53 seconds) and view 2 pages per session (Mean: 2.08, Range 1–24). Table 2 Top 20 PMM Website Pages Page Title Page views 1. Gait and motor milestones 41,539 2. Frequent falls case 27,661 3. Common fractures in children 20,509 4. Septic Arthritis & Osteomyelitis 20,130 5. Limping child - abnormal gait patterns 15,327 6. pGALS 15,146 7. Tip toe walking 13,558 8. Clinical assessment - children differ from adults 12.627 9. pREMS 9,261 10. Causes of foot, heel and ankle pain 8,621 11. Clinical examination 8,449 12. Arthritis module homepage 7,965 13. Non accidental injury 7,794 14. Red flags 7,782 15. Personal dashboard 6,394 16. Normal variants - when to refer 5,902 17. Red flags - knee pain 5,873 18. Kawasaki Disease 5,761 19. Resources 5,610 20. Clinical assessment top tips 4,842 Google Analytic Data from 14th November 2014 (go live date) to 31st July 2020 The pGALS app has had 12,670 downloads from 70 countries (data 31st July 2020). The iOS version had 8,067 downloads from 54 countries (Top 3: China (2,372), UK (1,498) and US (706) (see additional file 3). The android version had 4,603 downloads from 63 countries (Top 3: UK (940), Mexico (756) and India (358)) (see additional file 4). The ELM data includes 150 registered users from 30 countries across Asia, Africa, America, Europe and Oceania (data 30th May 2019, updated data in progress). Most (n = 101, 68%) are from the UK and Ireland with a range of clinical roles: nurse and AHP (n = 50), training doctors (n = 36) and clinicians (n = 35) (see additional files 5 and 6). Most users completed one ELM (n = 128) and the remainder completed > 1 (n = 22); ‘pGALS and clinical examination skills for medical students’ had the highest uptake (n = 130 users) followed by ‘Assessment of childhood MSK presentations in family medicine’ (n = 31 users), and ‘The paediatricians approach to a child with fever ‘ (n = 11 users). Survey and Interview Data The response rate to the survey is not clear as the link to the survey was sent to PMM collaborators and forwarded to students and trainees. We do however know that minimum of 592 received the invite (from our random selection of PMM website users and all the ELM registered users at that time) - we received 164 completed responses to the survey, hence we can assume a maximum response rate of 28%. Survey respondents from 25 countries (across Africa, Asia, Europe, North and South America) comprised a range of roles and levels of experience within community and hospital care (see additional files 7 and 8). Table 3 describes feedback on all three e-resources within the ‘PMM portfolio’ (n = 120) and an additional 44 provided feedback on 2 or less (PMM website and pGALS app (n = 10), PMM website and ELM (n = 3), PMM website alone (n = 31). Some had experience using the e-resources (PMM website n = 103/164, 63%; pGALS app n = 48/131, 37% ELM n = 50/123, 41%) and others did not have experience (PMM website n = 61/164, 37%; pGALS app n = 83/131, 63%; ELM n = 73/123, 59%). Users and non-users held comparable job profiles and were from a similar varied mix of countries (see additional files 7 and 8). Table 3 Use of E-Resources Frequency of Reported Use PMM n (%) pGALS n (%) Reported Use ELM Use of Resource 103 (62.80%) 48 (36.64%) Completed short course 50 (40.65%) − Daily 14 (13.59%) 6 (12.50%) − pGALS and clinical examination skills for medical students 42 (34.15%) − Weekly 15 (14.56%) 10 (20.83%) − Assessment of childhood MSK presentations in family medicine 21 (17.07%) − Fortnightly 7 (6.80%) 3 (6.25%) − The paediatricians approach to a child with fever 14 (11.38%) − Monthly 29 (28.16%) 11 (22.92%) − Less often 32 (31.07%) 12 (25%) Other* 6 (5.83%) 6 (12.50%) Not Used Resource 61 (37.20%) 83 (63.36%) Not completed short course 73 (59.35%) Total n = 164 Total n = 131 Total n = 123 *Other included: PMM portfolio recent users accessing resources for the first time on in progress with ELM Users of the ‘PMM portfolio’ e-resources who completed the survey comprised mainly AHP (PMM website n = 49/103, 48%; pGALS app n = 17/48, 35%; ELM n = 33/50, 66%), followed by general paediatricians (PMM website n = 13/103, 13%; pGALS app n = 7/48, 15%), paediatric rheumatologists (PMM website n = 16/103, 16%; pGALS app n = 11/48, 23%) and medical students (n = 4/50, 8%) for the ELM. They resided across 24 countries with highest survey uptake in India (PMM website n = 38/98, 39%; pGALS app n = 13/44, 30%; ELM n = 21/44, 48%). See additional files 7 and 8. Most respondents judged the e-resources to be ‘useful’ or ‘very useful’ and reported being able to use them quickly and easily (Table 4 ). The main reasons to access the PMM website and ELM were Continuing Professional Development (CPD)/Continuing Medical Education (CME) and ‘to understand a clinical problem’, whereas to ‘help examine a patient’ and ‘teaching’ were reported as the main reasons to access the pGALS app. There was a difference by user group (see Table 5 ), with students and trainees reporting pGALS guidance relating to patient examination and ‘exam revision’ being the main reasons to access the PMM website and pGALS app; ‘CPD/CME’ and ‘exam revision’ the main reasons to access the ELM. In contrast, clinicians reported ‘teaching’ as the main reasons to access the e-resources with nurses and AHP citing ‘CPD/CME’ (PMM website), ‘to help examine a patient (pGALS app) and ‘to understand a clinical problem’ (ELM) as their main indications. Table 4 Resource Use and Impact on Education or Clinical Practice PMM Website pGALS App ELM How useful did you find the resource? Very useful 54 (52.43%) 25 (53.19%) 23 (46.94%) Useful 46 (44.66%) 20 (42.55%) 26 (53.06%) Neither 2 (1.94%) 1 (2.13%) 0 Not useful 1 (0.97%) 1 (2.13%) 0 Not very useful 0 0 0 n = 103 n = 47 (1 did not answer this question) n = 49 (1 did not answer this question) Are you able to use the resource for your required purpose quickly and easily? Yes 92 (89.32%) 44 (91.67%) 41 (89.13%) No 11 (10.68%) 4 (8.33%) 5 (10.87%) n = 103 n = 48 n = 46 (4 did not answer this question) Do you feel the resource has or could have any impact on the medical education of yourself or others? Yes myself 69 (67.65%) 31 (65.96%) 35 (77.78%) Yes others 26 (25.49%) 14 (29.79%) 7 (15.56%) No 7 (6.86%) 2 (4.26%) 3 (6.67%) n = 102 (1 did not answer this question) n = 47 (1 did not answer this question) n = 45 (5 did not answer this question) Do you feel the resource has or could have any impact on your clinical practice? Yes 87 (88.78%) 40 (85.11%) 40 (90.91%) No 11 (11.22%) 7 (14.89%) 4 (9.09%) n = 98 (5 did not answer this question) n = 47 (1 did not answer this question) n = 44 (6 did not answer this question) Do you use any of the resources/ information available in the resource within your clinical practice? Yes 66 (66%) 33 (70.21%) 33 (78.57%) No 34 (34%) 14 (29.79%) 9 (21.43%) n = 100 (3 did not answer this question) n = 47 (1 did not answer this question) n = 42 (8 did not answer this question) Table 5 Resource Use by User Group Training Doctors Clinicians Nurses & AHP Overall PMM Website Main Reason of Use To find the answer to a clinical problem 7 (53.85%) 17 (45.95%) 26 (49.06%) 50 (48.54%) To find an answer for an educational reason (e.g. essay, MCQ, exam) 5 (38.46%) 13 (35.14%) 15 (28.30%) 33 (32.04%) For Continuing Professional Development (CPD) / For Continuing Medical Education (CME) 4 (30.77%) 15 (40.54%) 38 (71.70%) 57 (55.34%) For exam revision 8 (61.54%) 8 (21.62%) 9 (16.98%) 25 (24.27%) For teaching 5 (38.46%) 24 (64.86%) 15 (28.30%) 44 (42.71%) To access pGALS guidance 9 (69.23%) 15 (40.54%) 15 (28.30%) 39 (37.86%) To access pREMS guidance 6 (46.15%) 9 (24.32%) 14 (26.42%) 29 (28.16%) Other 0 2 (5.41%) General learning. Improve skills in MSK assessment. 3 (5.66%) Improve knowledge and experience. Assess milestone. 5 (4.85%) n = 13 n = 37 n = 53 n = 103 pGALS App Main Reason of Use To help examine a patient 4 (40%) 10 (47.62%) 14 (82.35%) 28 (58.33%) To improve my examination technique 5 (50%) 10 (47.62%) 11 (64.71%) 26 (54.17%) To improve the examination technique of others 2 (20%) 12 (57.14%) 8 (47.06%) 22 (45.83%) For exam revision 5 (50%) 8 (38.10%) 4 (23.53%) 17 (35.42%) For teaching 4 (40%) 19 (90.48%) 5 (29.41%) 28 (58.33%) n = 10 n = 21 n = 17 n = 48 ELM Main Reason of Use To understand a clinical problem 2 (33%) 4 (40%) 25 (73.53%) 31 (62%) To learn more for an educational reason (e.g. essay, MCQ, exam) 3 (50%) 4 (40%) 13 (38.24%) 20 (40%) For continuing professional development (CPD)/continuing medical education (CME) 3 (50%) 5 (50%) 23 (67.65%) 31 (62%) For exam revision 3 (50%) 4 (40%) 6 (17.65%) 13 (26%) For teaching 1 (16.67) 6 (60%) 10 (29.41%) 17 (34%) Other 0 0 1 (2.94%) Updated. 1 (2%) n = 6 n = 10 n = 34 n = 50 *’Training doctor’ included medical student, general paediatric trainee, paediatric rheumatology trainee, family medicine trainee; ‘Clinician’ included, general paediatrician, paediatric rheumatologist, family medicine doctors, orthopaedic surgeon & clinical lecturer/ research fellow/medical laboratory; ‘Nurses & AHP’ included nurse/nurse practitioner, physiotherapist, podiatrist, occupational therapist, extended scope practitioner & additional needs practitioner – see additional file 7 for breakdown. Most users reported that the e-resources ‘have’ or ‘could have’ an impact on their current clinical practice and the education of themselves or others (Table 4 ); improved clinical skills and knowledge, aiding teaching and increasing awareness about MSK issues in CYP amongst other providers cited as the main benefits (Table 6 ). Table 6 Impact of E-resources on Clinical Practice and Learning 1. Improved clinical skills and knowledge in practice PMM website pGALS app ELM • Used to improve knowledge within this area and as a refresher to update and review current knowledge base. Not all countries have access to a paediatric rheumatology specialism and for these people the site enables them to view clinical cases they might otherwise not have access to within their learning environment. • Provides an intuitive source to better inform decision-making and practice, guide patient treatment and aid explaining condition to families. In particular, it Informs users about systematic approach to examination and this in turn thought to enhance confidence and ability to examine children proficiently. • Informs users about simple systematic approach to examination and serves as useful refresher or revision aid. Increased knowledge gained from the app thought to make examination easier, enhance confidence and improve examination technique. • Equips the user with the necessary knowledge and skills to discern between abnormal and normal, screen asymptomatic and symptomatic patients and distinguish musculoskeletal conditions. • Used to expand knowledge within a particular area of interest and to consolidate and review current knowledge base or as part of CPD. • Provides content to better inform decision-making and practice and give additional reasoning that can be applied when assessing patients or explaining condition to families. Increased knowledge gained from ELM thought to aid clinical reasoning and make MSK examination easier, improve examination technique and enhance confidence particularly in relation to assessment and examination. “It has improved my confidence and skills to facilitate better outcomes”. “In my country no one have a paediatric rheumatology specialty so we can learn a lot about cases from PMM and teach our student”. “When I don’t have any protocol (in Brazil some hospitals doesn’t have at all) to guide me, I choose PMM to help me and solve some problems”. “Its easy, for free and intuitive way to find answers and guide a treatment for a patient”. “It will enhance my capability to check paediatrics efficiently”. “ Making easier the clinical examination”. “Increases my capability in diagnosis”. “Improve in terms of examination, assessment, investigation and management”. “Gaining wider knowledge of signs, symptoms and examination of a child”. “It helped me improve my technique to perform pGALS”. “I think it came from wanting to consolidate what I had read. It was almost like a test to yourself. Did I actually understand what I read and what would I be inclined to do if I were presented with a certain situation”. 2. Improved Teaching of others PMM website pGALS app ELM • Used within undergraduate and trainee teaching material and students and trainees directed to site for self-directed learning or review. • Used within undergraduate and trainee teaching material and students and trainees directed to app for self-directed learning. • Used to prepare teaching material and inform teaching topics; and students and trainees directed to ELM for self-directed learning. “I refer all trainees and CME candidates to it”. “I can revise the knowledge of clinical history and examination skills before my teaching session”. “Clear, focused especially on the basics that were not taught in med school. Therefore this resource is excellent as I want to teach the topics to medical students”. “I use for teaching and signpost students to it”. “Acts as an introduction for me before lectures”. “This is very informative and attractive for us…by this we can increase our capabilities to give suggestions to others”. “I really want to do as much online courses as possible to have edge when enrolling for my masters”. 3. Raised awareness in other providers PMM website pGALS app ELM • Enables clinicians working in different specialties or areas to consider things from a rheumatology perspective. • Highlights key issues with MSK medicine. • Increases awareness of JIA and other rheumatological conditions in children in healthcare providers within and outside of the specialism. • Increases knowledge in colleagues and AHP. • Completion of the courses thought to increase awareness of rheumatological conditions in children and encourage those outside the specialism to consider MSK diagnoses when assessing patients. “Being an orthopaedic surgeon its useful to see problems from a rheumatological perspective”. “PMM is a very useful website for non paediatric rheumatologists. Highly recommend as a learning resource”. “Increases knowledge in colleagues and AHP”. “List out the common MSK problems of paediatrics”. Most users reported using the ‘PMM portfolio’ within their own learning, clinical practice or teaching (Table 4 ). The PMM website content deemed most useful related to clinical assessment and examination skills (e.g. pGALS and pREMS), normal variants, red flags, limping child guidance, links to guidelines and access to videos. The pGALS guidance, ‘Top Tips’ and translations were highly rated in the pGALS app. The ELM users most valued clinical assessment of common MSK presentations, cases and images to illustrate abnormalities and when to be concerned (‘red flags’). Self-rated confidence (before and after accessing the PMM portfolio, using a Likert scale range: 1 (not very confident) – 5 (very confident)), about MSK knowledge and skills increased for all three e-resources: PMM Website p = < 0.01 t(99)=-6.59. Before: Mean score: 3.51 (S.D. 1.19). After: Mean score: 4.23 (S.D. 0.87) pGALS App: p = < 0.01 t(46)=-3.94. Before: Mean: 3.70 (S.D. 1.38). After: Mean: 4.30 (S.D. 1.02) ELM: p = < 0.01 (t( 43 )=-4.37. Before: Mean: 3.57 (S.D. 1.21). After: Mean: 4.16 (S.D. 0.91) Non-users of the e-resources (PMM website n = 61, pGALS App n = 83, ELM n = 73) reported lack of awareness of their existence as the main reason (PMM website: n = 48/60, 80%; pGALS app: n = 66/83, 80%; ELM: n = 48/73, 66%). Most non-users reported that following the study participation they were planning to access the e-resources for their clinical practice and / or teaching. Increasing awareness of the ‘PMM portfolio’, especially amongst junior clinicians and AHPs, integration into local training systems or curricula, linking with professional organisations, CME/CPD and existing meetings were suggested ways to increase reach and impact of all the e-resources. In addition, expanding the ELM topics, further signposting to key content targeted to user groups, providing offline access (e.g. apps) and maintaining content pertinent to global practice were suggestions for future development of the ‘PMM portfolio’ Discussion The ‘PMM portfolio’ has been developed to address the reality that many CYP will present to a myriad of clinicians and in most health care systems, not directly to a paediatric MSK specialist. Making a prompt correct diagnosis and to know when a specialist referral is needed (or not), are important to optimise clinical outcomes. Many clinicians who are involved in care pathways do not have experience or training in paediatric MSK medicine ( 12 , 14 , 15 , 35 ). Hence the range of target audiences for the ‘PMM portfolio’ is wide with the aim of improving awareness, knowledge and clinical skills and ultimately improving access to the ‘right care’. Furthermore nursing and medical students are an important target audience as embedding essential skills early is beneficial ( 18 , 29 , 36 ). Our evaluation demonstrates wide spread use of the ‘PMM portfolio’ which has expanded since launch in 2014 and provides substantial evidence that we are reaching our target audiences. The most popular pages of the PMM website judged by the analytics, survey and interviews, focus on clinical assessment (including pGALS, pREMS, normal development, normal variants), limping, MSK infection and indicators of when to be concerned (red flags); these observations reflect users being non-experts in paediatric MSK medicine and the known learning outcomes for medical students ( 37 ) and family medicine ( 16 ). We have shown that most users of the PMM website were initially from the UK and US but over time, uptake has increased across many countries around the world and amongst trainees and AHPs. Positive feedback included ease of use, open access and content being appropriate for users (either for their own learning needs or to aid the teaching of others). Notably there was variation by user groups for accessing the e-resource; e.g. students and trainees use of the PMM website and pGALS app for clinical skills guidance and revision, AHPs reporting use of the ELM (which focus on cased based common MSK conditions) and clinicians accessing the PMM website and pGALS app for teaching. There was a significant increase in self rated confidence in clinical skills and knowledge following access to all e-resources and many users reported using the e-resources having a positive impact on their learning, their clinical practice and the teaching of others to raise awareness. The international uptake of the e-resources reflects the wide stakeholder engagement utilised in the ‘PMM portfolio’ development (design, format and content). Our global partners are integral to the PMM website content and pGALS translations ensuring relevance to target audiences. The global partners have also likely facilitated dissemination and reach; notably the countries of several PMM global partners rank highly in those accessing the ‘PMM portfolio’. Dissemination has been further facilitated through endorsement by professional societies (e.g. Paediatric Rheumatology European Society (PReS), Royal College of Paediatrics and Child Health (RCPCH), Royal College of Nursing (RCN), India Rheumatology Society and National Institute for Health and Care Excellence (NICE)). The ‘PMM portfolio’ is embedded in NICE Clinical Knowledge Summaries for family medicine, PReS Basic Courses for paediatric rheumatology, RCPCH guidance for postgraduate examinations, the RCN Competency Framework, postgraduate paediatric rheumatology training programmes (e.g. India and Kenya) and the strategy of the Paediatric Task Force for Global Musculoskeletal Health ( 38 ). Our evaluation gave insights for additional content and to further increase reach. We firmly believe that ongoing engagement of users is integral to iterative development and optimising impact as a means of knowledge transfer ( 39 ). Increasing awareness of the ‘PMM portfolio’ especially amongst students, trainees and AHPs is important and notably was the most cited reason amongst non-users for lack of access to the e-resources. Despite high interest within the ELM from the survey respondents most ELM registered users reside in the UK/Ireland suggesting more work is needed to promote these. More needs to be done to integrate the ‘PMM portfolio’ into curricula, training programmes through links with professional organisations, training bodies and increasing exposure at CME/CPD events. Furthermore, expanding the current range of ELMs, offline access and addressing the global context for content would facilitate uptake and impact of the ‘PMM portfolio’. With this in mind, work is already underway to develop a PMM app and the ELM now includes a module targeting physiotherapists, and a further ELM for school teachers is planned. All the e-resources are free of charge other than one ELM (‘The paediatricians approach to a child with fever’), which had higher development costs; the charge may have contributed to the low uptake of this ELM. We aim for all the e-resources to be free and funding is a major barrier to further ‘PMM portfolio’ development. To date all contributions have been forthcoming without financial reimbursement and we gratefully acknowledge the valuable input from all our PMM partners. We are actively working on ways to secure sustainability and growth whilst maintaining the ethos of PMM being free and open to all. Limitations of our study . Our informal approach to recruitment resulted in the survey response rate being imprecise. However, this approach to recruitment enabled reach to both users and non-users of the e-resources and gave valuable insights into barriers to use and ways to encourage uptake further. There was not an even spread amongst the numbers of responders per user group or by country and this may have introduced bias. For example, there was a high proportion of survey respondents from India and amongst AHPs (who gave very favorable feedback). Their responses were nonetheless comparable to other respondent groups so we suggest that any effect on the overall findings is minimal. Their feedback was very valuable for future work to target clinicians, especially AHPs who are integral to paediatric MSK care in areas of the world with workforce challenges ( 35 , 38 , 40 , 41 ). Our methods explored reach and impact on learning and clinical practice; ideally evaluation would include influence on clinical outcomes (such as access to specialist care) but given that referrals are dependent on several variables (including local referral pathways and availability of specialists), a different evaluation approach would be needed. Implications for research and practice Our work is timely and relevant given the COVID-19 pandemic and rapid escalation of e-learning in clinical education ( 42 ). E-learning platforms are now increasingly utilised ( 43 ) and there is great potential for e-technology and telehealth ( 44 ) to reach many users around the world at relatively low cost. This is particularly relevant to the ‘PMM portfolio’ given the evidence that many CYP with MSK conditions live in parts of the world (Asia and Africa) with little or no access to specialist care ( 45 ). Our evaluation and iterative approach highlights the importance of user engagement to optimise reach and impact. The ‘PMM portfolio’ is an exemplar model to facilitate workforce capacity building in global paediatric rheumatology ( 38 ) and more work is needed to integrate e-learning with face to face training schemes. The role of e-resources and understanding how to tailor them for maximum impact is of increasing importance given the financial investment needed to set up and sustain e-learning programmes. Conclusions The ‘PMM portfolio’ is fulfilling an important role reaching many target user groups across the world. The ‘PMM portfolio’ continues to grow and engagement with users will facilitate future iterations maintaining relevance for the global context. List Of Abbreviations AHP Allied Health Professionals CME Continuing Medical Education CPD Continuing Professional Development CYP Children and Young People ELM E Learning Module HCP’s Health Care Professionals NICE National Institute for Health and Care Excellence pGALS Paediatric Gait, Arms, Legs and Spine pREMS Paediatric Regional Examination of the Musculoskeletal System PReS Paediatric Rheumatology European Society PMM Paediatric Musculoskeletal Matters RCN Royal College of Nursing RCPCH Royal College of Pediatrics and Child Health Declarations Ethics approval and consent to participate Ethical approval obtained from Newcastle University UK Ethics Committee. Consent for publication Informed consent was obtained for all participants. As part of this, participants were informed that anonymised, exemplar, extracts of their data may be used in a study report. Availability of data and materials To maintain anonymity no additional data is available. Participants only consented to anonymised, exemplar, extracts of the data to being shared. Competing interests The authors declare they have no competing interests. Funding This work was supported by funding from The JGW Patterson Foundation. Authors' contributions HF/SJ conceived the concept of the e-learning resources, led the development of the resources and contributed to study design, analysis and writing of the manuscript. NS contributed to the study design, undertook the evaluation work and contributed to analysis and writing of the manuscript. All authors read and approved the final manuscript. Acknowledgements We are grateful to all the participants in the study. The development of the ‘PMM portfolio’ was funded by unrestricted educational grants from Pfizer Pharmaceuticals with subsequent additional unrestricted educational / investigator led research grants from Sobi, BioMarin, and Genzyme. Our evaluation work was funded by a grant from the JGW Patterson Foundation. We acknowledge the considerable input of all the PMM collaborators ( http://www.pmmonline.org/doctor/about-us ) and medical students at Newcastle University UK in the development of our portfolio. We also acknowledge the support of Dr. Sarah Cope (family doctor), Dr. Graeme Denman (family doctor), Dr. Josh Bennett (general paediatric trainee) and Mr. Ashley Reynolds (e-technologist) in the developing of ELM. References Tan A, Strauss VY, Protheroe J, Dunn KM. Epidemiology of paediatric presentations with musculoskeletal problems in primary care. BMC musculoskeletal disorders. 2018;19(1):40. Prathivadi Bhayankaram N, Lacey R, Barnett L, Jordan K, Dunn K. Musculoskeletal consultations from childhood to adulthood: a longitudinal study. Journal of Public Health. 2019. Douglas SL. A consumer perspective on embedding research in paediatric rheumatology. Oxford University Press; 2014. Fedorak GT, DeRosa DC, Brough AK, Miyamoto RH. Increased time between diagnosis and surgery in slipped capital femoral epiphysis results in increased radiographic deformity. Journal of children's orthopaedics. 2018;12(3):232-5. McErlane F, Foster HE, Carrasco R, Baildam EM, Chieng SE, Davidson JE, et al. Trends in paediatric rheumatology referral times and disease activity indices over a ten-year period among children and young people with Juvenile Idiopathic Arthritis: results from the childhood arthritis prospective Study. Rheumatology (Oxford, England). 2016;55(7):1225-34. Dang-Tan T, Trottier H, Mery LS, Morrison HI, Barr RD, Greenberg ML, et al. Delays in diagnosis and treatment among children and adolescents with cancer in Canada. Pediatric Blood & Cancer. 2008;51(4):468-74. Foster HE, Eltringham MS, Kay LJ, Friswell M, Abinun M, Myers A. Delay in access to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic arthritis. Arthritis and rheumatism. 2007;57(6):921-7. Barber CE, Barnabe C, Benseler S, Chin R, Johnson N, Luca N, et al. Patient factors associated with waiting time to pediatric rheumatologist consultation for patients with juvenile idiopathic arthritis. Pediatric Rheumatology. 2020;18(1):1-5. Chausset A, Pereira B, Echaubard S, Merlin E, Freychet C. Access to paediatric rheumatology care in juvenile idiopathic arthritis: what do we know? A systematic review. Rheumatology. 2020. Consolaro A, Giancane G, Alongi A, van Dijkhuizen EHP, Aggarwal A, Al-Mayouf SM, et al. Phenotypic variability and disparities in treatment and outcomes of childhood arthritis throughout the world: an observational cohort study. The Lancet Child & adolescent health. 2019;3(4):255-63. Foster H, Rapley T. Access to pediatric rheumatology care -- a major challenge to improving outcome in juvenile idiopathic arthritis. The Journal of rheumatology. 2010;37(11):2199-202. Jandial S, Myers A, Wise E, Foster HE. Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills. J Pediatr. 2009;154(2):267-71. Saxena S, Francis N, Sharland M. Primary care of children: the unique role of GPs. British Journal of General Practice; 2012. Modi N, Simon C. Child health care: adequate training for all UK GPs is long overdue. Br J Gen Pract. 2016;66(646):228-9. Wise EM, Walker DJ, Coady DA. Musculoskeletal education in general practice: a questionnaire survey. Clinical rheumatology. 2014;33(7):989-94. Goff I, Boyd DJ, Wise EM, Jandial S, Foster HE. Paediatric musculoskeletal learning needs for general practice trainees: achieving an expert consensus. Educ Prim Care. 2014;25(5):249-56. Smith N, Foster H, Wyllie R, English C, Davies B, Jandial S, et al. Development of Paediatric Musculoskeletal Matters Nursing–a free online evidence based education e-resource for nurses. Rheumatology. 2017;56(suppl_6). Chehade M, Gill T, Kopansky-Giles D, Schuwirth L, Karnon J, McLiesh P, et al. Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health. Best Practice & Research Clinical Rheumatology. 2016;30(3):559-84. Smith N, Rapley T, Jandial S, English C, Davies B, Wyllie R, et al. Paediatric musculoskeletal matters (pmm)--collaborative development of an online evidence based interactive learning tool and information resource for education in paediatric musculoskeletal medicine. Pediatric rheumatology online journal. 2016;14(1):1. Smith N Jandial S, Wyllie R, English C, Davies B, Khubchandani R, Chan MO, Munro J, Ferriani V, Saad Magalhães C, Yan J, Scott C, Charuvanij S, Khawaja K, Vojinovic J, Rapley T, Foster HE. Globalisation of Paediatric Musculoskeletal Matters’ (PMM). British Society for Paediatric and Adolescent Rheumatology; 2017: Rheumatology; 2017. Foster HE, Jandial S. pGALS - paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatric rheumatology online journal. 2013;11(1):44. Sukharomana M, Charuvanij S. The Thai Translation of the Pediatric Gait, Arms, Legs, Spine Tool is Useful for Pediatric Residents in Detecting Musculoskeletal Abnormalities in Children. Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases. 2020. Goff I, Bateman B, Myers A, Foster H. Acceptability and practicality of musculoskeletal examination in acute general pediatric assessment. The Journal of pediatrics. 2010;156(4):657-62. Smith E, Molyneux E, Heikens GT, Foster H. Acceptability and practicality of pGALS in screening for rheumatic disease in Malawian children. Clinical rheumatology. 2012;31(4):647-53. Moreno-Torres LA, Hernández-Garduño AG, Arellano-Valdés CA, Salinas-Rodríguez A, Rubio-Perez N, Peláez-Ballestas I. Cross-cultural validation of the paediatric Gait, Arms, Legs, Spine (pGALS) tool for the screening of musculoskeletal disorders in Mexican children. Rheumatology international. 2016;36(4):495-503. Chan MO, Sen ES, Hardy E, Hensman P, Wraith E, Jones S, et al. Assessment of musculoskeletal abnormalities in children with mucopolysaccharidoses using pGALS. Pediatric rheumatology online journal. 2014;12:32. Abujam B, Aggarwal A. Hypermobility is related with musculoskeletal pain in Indian school-children. Clinical and experimental rheumatology. 2014;32(4):610-3. Sabui TK, Samanta M, Mondal RK, Banerjee I, Saren A, Hazra A. Survey of musculoskeletal abnormalities in school‐going children of hilly and foothill regions of Eastern Himalayas using the pediatric Gait, Arms, Legs, Spine screening method. International journal of rheumatic diseases. 2018;21(5):1127-34. Baker KF, Jandial S, Thompson B, Walker D, Taylor K, Foster HE. Use of structured musculoskeletal examination routines in undergraduate medical education and postgraduate clinical practice - a UK survey. BMC Med Educ. 2016;16(1):277. Cope S, Jandial S, Foster HE, editors. A Blended Learning Approach to Clinical Skills Teaching: E-Learning for Paediatric Gait, Arms, Legs and Spine Examination (pGALS). Arthritis & Rheumatology; 2017: Wiley 111 River St, Hoboken 07030-5774, NJ USA. Ratcliff C, Denman G, Jandial S, Foster H. Diagnosing arthritis in children. Paediatrics and Child Health. 2019;29(12):503-14. Cope S, Denman G, Foster H, Jandial S. Paediatric Gait, Arms, Legs and Spine examination (pGALS)–a case based discussion. Paediatrics and Child Health. 2018;28(2):73-83. Rapley T. Some pragmatics of data analysis. Qualitative research. 2011;3:273-90. Foster H, Kay L, May C, Rapley T. Pediatric regional examination of the musculoskeletal system: A practice‐and consensus‐based approach. Arthritis care & research. 2011;63(11):1503-10. Scott C, Chan M, Slamang W, Okong'o L, Petty R, Laxer RM, et al. Juvenile arthritis management in less resourced countries (JAMLess): consensus recommendations from the Cradle of Humankind. Clinical rheumatology. 2019;38(2):563-75. Al Maini M, Al Weshahi Y, Foster HE, Chehade MJ, Gabriel SE, Al Saleh J, et al. A global perspective on the challenges and opportunities in learning about rheumatic and musculoskeletal diseases in undergraduate medical education. Clinical rheumatology. 2019:1-16. Jandial S, Stewart J, Foster HE. What do they need to know: achieving consensus on paediatric musculoskeletal content for medical students. BMC Med Educ. 2015;15:171. Foster HE, Scott C, Tiderius CJ, Dobbs MB, Ang E, Charuvanij S, et al. Improving musculoskeletal health for children and young people–A ‘call to action’. Best Practice & Research Clinical Rheumatology. 2020:101566. Gagnon ML. Moving knowledge to action through dissemination and exchange. Journal of clinical epidemiology. 2011;64(1):25-31. Foster HE, Scott C, Tiderius CJ, Dobbs MB. The paediatric global musculoskeletal task force-‘towards better MSK health for all’. Pediatric Rheumatology. 2020;18(1):1-3. Henrickson M. Policy challenges for the pediatric rheumatology workforce: Part III. the international situation. Pediatric Rheumatology. 2011;9(1):26. Wijesooriya NR, Mishra V, Brand PL, Rubin BK. COVID-19 and telehealth, education, and research adaptations. Paediatric Respiratory Reviews. 2020. Woodward AL, Harris ZL. Employment of a needs assessment survey to shape a novel web-based pediatric rheumatology curriculum for primary care providers. Pediatric Rheumatology. 2013;11(1):1-8. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. New England Journal of Medicine. 2017;377(16):1585-92. Dave M, Rankin J, Pearce M, Foster HE. Global prevalence estimates of three chronic musculoskeletal conditions: club foot, juvenile idiopathic arthritis and juvenile systemic lupus erythematosus. Pediatric Rheumatology. 2020;18(1):1-7. Supplementary Files AdditionalFile8AdditionalTable7.docx AdditionalFile6AdditionalTable5.docx AdditionalFile7AdditionalTable6.docx AdditionalFile5AdditionalTable4.docx AdditionalFiles.docx AdditionalFile4AdditionalTable3.docx AdditionalFile3AdditionalTable2.docx AdditionalFile2AdditionalTable1.docx AdditionalFile1BlankCopyofOnlineSurvey.pdf Cite Share Download PDF Status: Published Journal Publication published 09 Jun, 2021 Read the published version in Pediatric Rheumatology → Version 1 posted Editorial decision: Major revision 26 Dec, 2020 Review # 4 received at journal 17 Dec, 2020 Review # 2 received at journal 09 Dec, 2020 Review # 3 received at journal 09 Dec, 2020 Reviewer # 4 agreed at journal 04 Dec, 2020 Reviewer # 3 agreed at journal 02 Dec, 2020 Reviewer # 2 agreed at journal 02 Dec, 2020 Review # 1 received at journal 01 Dec, 2020 Reviewer # 1 agreed at journal 28 Nov, 2020 Reviewers invited by journal 27 Nov, 2020 First submitted to journal 29 Sep, 2020 Editor assigned by journal 29 Sep, 2020 Submission checks completed at journal 28 Sep, 2020 Editor invited by journal 28 Sep, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Delay in diagnosis and access to specialist care is a priority to address amongst parents (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and is often reported in conditions that present with MSK features (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) with adverse impact on clinical outcomes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The reasons for such delay are multifactorial (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e); including complex care pathways involving community care and various hospital care specialties (usually general paediatrics or emergency care) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) where self-rated lack of confidence in paediatric MSK clinical skills is reported (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Clinicians working in the community play a crucial role to diagnose and instigate specialist referral (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Family medicine practitioners are often the \u0026lsquo;gatekeepers\u0026rsquo; to specialist services (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and yet many training schemes do not include paediatrics (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), or MSK medicine (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) despite the learning needs being known (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Other clinicians including nurses and allied health professionals (AHP) may encounter CYP in their clinical practice and there is need for more knowledge about MSK problems (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWith these challenges in mind our group developed a portfolio of e-resources (the \u0026lsquo;PMM portfolio\u0026rsquo;) to up skill and support all clinicians who play an integral role in the early recognition, diagnosis and initial care of CYP with MSK conditions. The target audiences therefore include a spectrum of clinical learners who are not \u0026lsquo;paediatric MSK experts\u0026rsquo;; ranging from students in medicine and nursing, trainees in family medicine and paediatrics, through to practitioners in general paediatrics, family medicine, nursing and allied health.\u003c/p\u003e \u003cp\u003eThe \u0026lsquo;PMM portfolio\u0026rsquo; encompasses the Paediatric Musculoskeletal Matters (PMM) website (launched 2014), the paediatric Gait, Arms, Legs and Spine (pGALS) app (added 2015) and e-learning modules (ELM) (added 2017) to aid signposting through the website.\u003c/p\u003e \u003cp\u003eThe PMM website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.pmmonline.org\" target=\"_blank\"\u003ewww.pmmonline.org\u003c/a\u003e\u003c/span\u003e\u003c/span\u003e) is a free and open evidence based, peer reviewed e-resource with user engagement to inform content and website design functionality (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). PMM Nursing (2017) is a further version of PMM to address the needs of the wider nursing community (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The PMM website includes an open anonymised online survey and since 2014, 84 responses from 19 countries (data not shown but available on request), has informed \u0026lsquo;PMM portfolio\u0026rsquo; development with requests for more global content and signposting. \u0026lsquo;PMM International\u0026rsquo; was hence developed and replaced the original PMM website in September 2018 following collaboration with paediatric rheumatologists in 11 countries (within Asia, Africa, Americas, Australasia and Europe) who developed additional content reflecting case mix and the health care in their country (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). New content focused on infections and infection-related disease with MSK features, or differential diagnoses of rheumatic disease with further cases and images to reflect ethnic diversity. All contributions were subject to editorial review to ensure consistency of language and compliance with our governance framework (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePaediatric Gait, Arms, Legs and Spine (pGALS) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) is a simple MSK examination schedule useful in clinical practice (\u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26 CR27\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and is widely taught (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The free pGALS app (launched in 2015) was developed with medical students at Newcastle University UK to inform format and content with exam revision notes and links to PMM website key pages (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Language translations of pGALS produced with our PMM International collaborators (to date 20 languages) and a version for telehealth (V-pGALS) are freely available on the pGALS app and PMM website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.pmmonline.org/doctor/approach-to-clinical-assessment/examination\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe PMM E-Learning Modules (ELM) aid navigation through the PMM website and were developed with our multi-professional team (including family medicine doctors, paediatricians, medical students) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). At the time of our evaluation there were three e-modules (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cpd.ncl.ac.uk/courses\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003ei) pGALS and clinical examination skills for medical students\u003c/p\u003e\n\u003cp\u003eii) Assessment of childhood MSK presentations in family medicine\u003c/p\u003e\n\u003cp\u003eiii) The paediatricians approach to a child with fever\u003c/p\u003e\n\u003ch2\u003eAims\u003c/h2\u003e\n\u003cp\u003eThis study focuses on evaluation of the \u0026lsquo;PMM portfolio\u0026rsquo; to describe and understand reach and impact on learning and clinical practice. Furthermore the evaluation aimed to inform future development of the \u0026lsquo;PMM portfolio\u0026rsquo; and strategy to optimise impact.\u003c/p\u003e"},{"header":"Methods","content":" \u003cp\u003eWe adopted a mixed methods approach comprising e-resource analytics, an online survey (including self-rated confidence before and after access to the e-resources) and telephone interviews to explore themes raised by the survey.\u003c/p\u003e \u003cp\u003eGoogle Analytics described access to PMM website (site hits, page hits, accessing countries) and resource analytics described pGALS App Store data (country and number of downloads) and ELM data (country, number of users, clinician role).\u003c/p\u003e \u003cp\u003eAn online survey using \u0026copy;Survey Monkey (see additional file 1) was used to explore how the \u0026lsquo;PMM portfolio\u0026rsquo; resources impact on learning and clinical practice. The survey included sections about each of the \u0026lsquo;PMM portfolio\u0026rsquo; e-resources and respondents were asked to provide feedback on all the resources including those that they had not accessed. The survey was piloted and included Likert Scale questions (\u003cem\u003eon perceived usefulness and impact on confidence on MSK knowledge and skills\u003c/em\u003e), free text options and open-ended questions to encourage comment. A random selection of PMM website registered users (n\u0026thinsp;=\u0026thinsp;450) and all the users registered for the ELM at the time of survey recruitment (n\u0026thinsp;=\u0026thinsp;142, July 2019) were invited to complete the online survey in addition to purposive sampling amongst user groups within the UK and through our PMM global partners. Selected 1\u0026ndash;1 telephone interviews followed the online survey to explore the findings in more detail. Interview participants comprised medical students (n\u0026thinsp;=\u0026thinsp;2), clinical lecturer paediatricians (n\u0026thinsp;=\u0026thinsp;2) and family medicine doctors involved in teaching alongside their clinical practice (n\u0026thinsp;=\u0026thinsp;2); 4/6 were from the UK.\u003c/p\u003e \u003cp\u003eUtilising various recruitment sources was important to include a wide range of target audiences and to enable recruitment of users and non-users of the \u0026lsquo;PMM portfolio\u0026rsquo;. Written consent was obtained from interview participants and survey respondents consented to participation through an online response. All participant information was anonymised. Interviews were audio-recorded and transcripts anonymised before data analysis. E-resource analytic and survey data was analysed using descriptive statistics, with free-text comments and interview transcripts analysed following standard procedures for qualitative analysis, including open and focused coding, constant comparison and deviant case analysis (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Reflexivity was maintained throughout the analysis and writing, by recording, discussing and challenging established assumptions. A Paired T Test (\u0026copy;Minitab) compared self-rated confidence scores (Range: 1 not very confident \u0026ndash; 5 very confident) before and after use of the e-resources. The study had ethical approval from Newcastle University, UK.\u003c/p\u003e "},{"header":"Results","content":" \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eResource Analytics\u003c/h2\u003e \u003cp\u003eThe PMM website has had 662,827 hits and 262,476 users across 214 countries (data 31st July 2020 - see Fig.\u0026nbsp;1 and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Usage has continued to grow since launch (2014) and furthermore following evolution to PMM International (September 2018). Most PMM users are from the US and UK although the total number of countries accessing PMM has increased over time (see additional file 2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTop 50 Countries Accessing PMM Website\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Users\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of Users\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. US\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79,928\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26. Spain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e962\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. UK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65,417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27. Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e890\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Australia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,487\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28. France\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e865\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. India\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13,895\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29. Taiwan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e804\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Canada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30. Sri Lanka\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31. Colombia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e788\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Ireland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,825\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32. Mexico\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e780\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. New Zealand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33. Japan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e779\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Saudi Arabia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34. China\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e749\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Philippines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35. Israel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e749\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. South Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36. Bangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e738\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Pakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37. Sweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Indonesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38. Greece\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Singapore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39. Portugal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e581\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Thailand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40. Norway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Egypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41. Poland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. UAE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42. Iran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e542\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Brazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43. Hungary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Netherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44. Jordan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e527\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20. Hong Kong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45. Belgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21. Germany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46. Iraq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e512\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22. South Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47. Czech Republic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e489\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23. Nigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48. Switzerland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24. Kenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49. Russia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25. Turkey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50. Nepal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e418\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eTotal overall: 262,476 users across 214 countries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \n\u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eGoogle Analytic Data from14th November 2014 (go live date) to 31st July 2020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e\u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most popular PMM website pages (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) relate to clinical assessment (pGALS, pREMS (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) normal development [gait/milestones], normal variants), frequent falls, fractures, MSK infections, limping child and guidance on when to be concerned (\u0026lsquo;red flags\u0026rsquo;). Users spend approximately 2 minutes on the site (Mean: 01.58, Range: 5 seconds to 5 minutes, 53 seconds) and view 2 pages per session (Mean: 2.08, Range 1\u0026ndash;24).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTop 20 PMM Website Pages\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePage Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePage views\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Gait and motor milestones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41,539\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Frequent falls case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27,661\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Common fractures in children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20,509\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Septic Arthritis \u0026amp; Osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20,130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Limping child - abnormal gait patterns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,327\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. pGALS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Tip toe walking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13,558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Clinical assessment - children differ from adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.627\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. pREMS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,261\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Causes of foot, heel and ankle pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8,621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Clinical examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8,449\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Arthritis module homepage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,965\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Non accidental injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,794\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Red flags\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,782\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Personal dashboard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,394\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Normal variants - when to refer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,902\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. Red flags - knee pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,873\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Kawasaki Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,761\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,610\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20. Clinical assessment top tips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,842\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eGoogle Analytic Data from 14th November 2014 (go live date) to 31st July 2020\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\n\u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cp\u003eThe pGALS app has had 12,670 downloads from 70 countries (data 31st July 2020). The iOS version had 8,067 downloads from 54 countries (Top 3: China (2,372), UK (1,498) and US (706) (see additional file 3). The android version had 4,603 downloads from 63 countries (Top 3: UK (940), Mexico (756) and India (358)) (see additional file 4).\u003c/p\u003e \u003cp\u003eThe ELM data includes 150 registered users from 30 countries across Asia, Africa, America, Europe and Oceania (data 30th May 2019, updated data in progress). Most (n\u0026thinsp;=\u0026thinsp;101, 68%) are from the UK and Ireland with a range of clinical roles: nurse and AHP (n\u0026thinsp;=\u0026thinsp;50), training doctors (n\u0026thinsp;=\u0026thinsp;36) and clinicians (n\u0026thinsp;=\u0026thinsp;35) (see additional files 5 and 6). Most users completed one ELM (n\u0026thinsp;=\u0026thinsp;128) and the remainder completed\u0026thinsp;\u0026gt;\u0026thinsp;1 (n\u0026thinsp;=\u0026thinsp;22); \u0026lsquo;pGALS and clinical examination skills for medical students\u0026rsquo; had the highest uptake (n\u0026thinsp;=\u0026thinsp;130 users) followed by \u0026lsquo;Assessment of childhood MSK presentations in family medicine\u0026rsquo; (n\u0026thinsp;=\u0026thinsp;31 users), and \u0026lsquo;The paediatricians approach to a child with fever \u0026lsquo; (n\u0026thinsp;=\u0026thinsp;11 users).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSurvey and Interview Data\u003c/h2\u003e \u003cp\u003eThe response rate to the survey is not clear as the link to the survey was sent to PMM collaborators and forwarded to students and trainees. We do however know that minimum of 592 received the invite (from our random selection of PMM website users and all the ELM registered users at that time) - we received 164 completed responses to the survey, hence we can assume a maximum response rate of 28%.\u003c/p\u003e \u003cp\u003eSurvey respondents from 25 countries (across Africa, Asia, Europe, North and South America) comprised a range of roles and levels of experience within community and hospital care (see additional files 7 and 8). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e describes feedback on all three e-resources within the \u0026lsquo;PMM portfolio\u0026rsquo; (n\u0026thinsp;=\u0026thinsp;120) and an additional 44 provided feedback on 2 or less (PMM website and pGALS app (n\u0026thinsp;=\u0026thinsp;10), PMM website and ELM (n\u0026thinsp;=\u0026thinsp;3), PMM website alone (n\u0026thinsp;=\u0026thinsp;31). Some had experience using the e-resources (PMM website n\u0026thinsp;=\u0026thinsp;103/164, 63%; pGALS app n\u0026thinsp;=\u0026thinsp;48/131, 37% ELM n\u0026thinsp;=\u0026thinsp;50/123, 41%) and others did not have experience (PMM website n\u0026thinsp;=\u0026thinsp;61/164, 37%; pGALS app n\u0026thinsp;=\u0026thinsp;83/131, 63%; ELM n\u0026thinsp;=\u0026thinsp;73/123, 59%). Users and non-users held comparable job profiles and were from a similar varied mix of countries (see additional files 7 and 8).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUse of E-Resources\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of Reported Use\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePMM n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epGALS n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReported Use\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eELM\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse of Resource\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (62.80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (36.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eCompleted short course\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50 (40.65%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003eDaily\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (13.59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (12.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003epGALS and clinical examination skills for medical students\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42 (34.15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003eWeekly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (14.56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (20.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003eAssessment of childhood MSK presentations in family medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (17.07%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003eFortnightly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003eThe paediatricians approach to a child with fever\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (11.38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003eMonthly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (28.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus; \u003cb\u003eLess often\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (31.07%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (12.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNot Used Resource\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (37.20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (63.36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNot completed short course\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73 (59.35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;123\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e*Other included: PMM portfolio recent users accessing resources for the first time on in progress with ELM\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003eUsers of the \u0026lsquo;PMM portfolio\u0026rsquo; e-resources who completed the survey comprised mainly AHP (PMM website n\u0026thinsp;=\u0026thinsp;49/103, 48%; pGALS app n\u0026thinsp;=\u0026thinsp;17/48, 35%; ELM n\u0026thinsp;=\u0026thinsp;33/50, 66%), followed by general paediatricians (PMM website n\u0026thinsp;=\u0026thinsp;13/103, 13%; pGALS app n\u0026thinsp;=\u0026thinsp;7/48, 15%), paediatric rheumatologists (PMM website n\u0026thinsp;=\u0026thinsp;16/103, 16%; pGALS app n\u0026thinsp;=\u0026thinsp;11/48, 23%) and medical students (n\u0026thinsp;=\u0026thinsp;4/50, 8%) for the ELM. They resided across 24 countries with highest survey uptake in India (PMM website n\u0026thinsp;=\u0026thinsp;38/98, 39%; pGALS app n\u0026thinsp;=\u0026thinsp;13/44, 30%; ELM n\u0026thinsp;=\u0026thinsp;21/44, 48%). See additional files 7 and 8.\u003c/p\u003e \u003cp\u003eMost respondents judged the e-resources to be \u0026lsquo;useful\u0026rsquo; or \u0026lsquo;very useful\u0026rsquo; and reported being able to use them quickly and easily (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The main reasons to access the PMM website and ELM were Continuing Professional Development (CPD)/Continuing Medical Education (CME) and \u0026lsquo;to understand a clinical problem\u0026rsquo;, whereas to \u0026lsquo;help examine a patient\u0026rsquo; and \u0026lsquo;teaching\u0026rsquo; were reported as the main reasons to access the pGALS app. There was a difference by user group (see Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), with students and trainees reporting pGALS guidance relating to patient examination and \u0026lsquo;exam revision\u0026rsquo; being the main reasons to access the PMM website and pGALS app; \u0026lsquo;CPD/CME\u0026rsquo; and \u0026lsquo;exam revision\u0026rsquo; the main reasons to access the ELM. In contrast, clinicians reported \u0026lsquo;teaching\u0026rsquo; as the main reasons to access the e-resources with nurses and AHP citing \u0026lsquo;CPD/CME\u0026rsquo; (PMM website), \u0026lsquo;to help examine a patient (pGALS app) and \u0026lsquo;to understand a clinical problem\u0026rsquo; (ELM) as their main indications.\u003c/p\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResource Use and Impact on Education or Clinical Practice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePMM Website\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epGALS App\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eELM\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow useful did you find the resource?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery useful\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (52.43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (53.19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (46.94%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUseful\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (44.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (42.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (53.06%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeither\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot useful\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.97%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot very useful\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;47 (1 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;49 (1 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAre you able to use the resource for your required purpose quickly and easily?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (89.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (91.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (89.13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (10.68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (10.87%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;46 (4 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you feel the resource has or could have any impact on the medical education of yourself or others?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes myself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (67.65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (65.96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (77.78%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (25.49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (29.79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (15.56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.67%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;102 (1 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;47 (1 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;45 (5 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you feel the resource has or could have any impact on your clinical practice?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (88.78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (85.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (90.91%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (11.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (14.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (9.09%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;98 (5 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;47 (1 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;44 (6 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you use any of the resources/ information available in the resource within your clinical practice?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (70.21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (78.57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (29.79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (21.43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;100 (3 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;47 (1 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;42 (8 did not answer this question)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResource Use by User Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining Doctors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinicians\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurses \u0026amp; AHP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePMM Website Main Reason of Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo find the answer to a clinical problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (53.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (45.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (49.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50 (48.54%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo find an answer for an educational reason (e.g. essay, MCQ, exam)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (38.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (35.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (28.30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (32.04%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor Continuing Professional Development (CPD) / For Continuing Medical Education (CME)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (30.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (40.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (71.70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57 (55.34%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor exam revision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (61.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (21.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (16.98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (24.27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (38.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (64.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (28.30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44 (42.71%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo access pGALS guidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (69.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (40.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (28.30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39 (37.86%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo access pREMS guidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (46.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (24.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (26.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (28.16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.41%)\u003c/p\u003e \u003cp\u003eGeneral learning.\u003c/p\u003e \u003cp\u003eImprove skills in MSK assessment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.66%)\u003c/p\u003e \u003cp\u003eImprove knowledge and experience.\u003c/p\u003e \u003cp\u003eAssess milestone.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (4.85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003epGALS App Main Reason of Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo help examine a patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (47.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (82.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (58.33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo improve my examination technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (47.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (64.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26 (54.17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo improve the examination technique of others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (57.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (47.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 (45.83%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor exam revision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (38.10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (23.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (35.42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (90.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (29.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (58.33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eELM Main Reason of Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo understand a clinical problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (73.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31 (62%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo learn more for an educational reason (e.g. essay, MCQ, exam)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (38.24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor continuing professional development (CPD)/continuing medical education (CME)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (67.65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31 (62%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor exam revision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (17.65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (29.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (34%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.94%)\u003c/p\u003e \u003cp\u003eUpdated.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e*\u0026rsquo;Training doctor\u0026rsquo; included medical student, general paediatric trainee, paediatric rheumatology trainee, family medicine trainee; \u0026lsquo;Clinician\u0026rsquo; included, general paediatrician, paediatric rheumatologist, family medicine doctors, orthopaedic surgeon \u0026amp; clinical lecturer/ research fellow/medical laboratory; \u0026lsquo;Nurses \u0026amp; AHP\u0026rsquo; included nurse/nurse practitioner, physiotherapist, podiatrist, occupational therapist, extended scope practitioner \u0026amp; additional needs practitioner \u0026ndash; see additional file 7 for breakdown.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003eMost users reported that the e-resources \u0026lsquo;have\u0026rsquo; or \u0026lsquo;could have\u0026rsquo; an impact on their current clinical practice and the education of themselves or others (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e); improved clinical skills and knowledge, aiding teaching and increasing awareness about MSK issues in CYP amongst other providers cited as the main benefits (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImpact of E-resources on Clinical Practice and Learning\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e1. Improved clinical skills and knowledge in practice\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePMM website\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epGALS app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eELM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Used to improve knowledge within this area and as a refresher to update and review current knowledge base. Not all countries have access to a paediatric rheumatology specialism and for these people the site enables them to view clinical cases they might otherwise not have access to within their learning environment.\u003c/p\u003e \u003cp\u003e\u0026bull; Provides an intuitive source to better inform decision-making and practice, guide patient treatment and aid explaining condition to families. In particular, it Informs users about systematic approach to examination and this in turn thought to enhance confidence and ability to examine children proficiently.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Informs users about simple systematic approach to examination and serves as useful refresher or revision aid. Increased knowledge gained from the app thought to make examination easier, enhance confidence and improve examination technique.\u003c/p\u003e \u003cp\u003e\u0026bull; Equips the user with the necessary knowledge and skills to discern between abnormal and normal, screen asymptomatic and symptomatic patients and distinguish musculoskeletal conditions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Used to expand knowledge within a particular area of interest and to consolidate and review current knowledge base or as part of CPD.\u003c/p\u003e \u003cp\u003e\u0026bull; Provides content to better inform decision-making and practice and give additional reasoning that can be applied when assessing patients or explaining condition to families. Increased knowledge gained from ELM thought to aid clinical reasoning and make MSK examination easier, improve examination technique and enhance confidence particularly in relation to assessment and examination.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It has improved my confidence and skills to facilitate better outcomes\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;In my country no one have a paediatric rheumatology specialty so we can learn a lot about cases from PMM and teach our student\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;When I don\u0026rsquo;t have any protocol (in Brazil some hospitals doesn\u0026rsquo;t have at all) to guide me, I choose PMM to help me and solve some problems\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Its easy, for free and intuitive way to find answers and guide a treatment for a patient\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It will enhance my capability to check paediatrics efficiently\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMaking easier the clinical examination\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Increases my capability in diagnosis\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Improve in terms of examination, assessment, investigation and management\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Gaining wider knowledge of signs, symptoms and examination of a child\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It helped me improve my technique to perform pGALS\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I think it came from wanting to consolidate what I had read. It was almost like a test to yourself. Did I actually understand what I read and what would I be inclined to do if I were presented with a certain situation\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Improved Teaching of others\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePMM website\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epGALS app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eELM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Used within undergraduate and trainee teaching material and students and trainees directed to site for self-directed learning or review.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Used within undergraduate and trainee teaching material and students and trainees directed to app for self-directed learning.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Used to prepare teaching material and inform teaching topics; and students and trainees directed to ELM for self-directed learning.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I refer all trainees and CME candidates to it\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I can revise the knowledge of clinical history and examination skills before my teaching session\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Clear, focused especially on the basics that were not taught in med school. Therefore this resource is excellent as I want to teach the topics to medical students\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I use for teaching and signpost students to it\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Acts as an introduction for me before lectures\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;This is very informative and attractive for us\u0026hellip;by this we can increase our capabilities to give suggestions to others\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I really want to do as much online courses as possible to have edge when enrolling for my masters\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3. Raised awareness in other providers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePMM website\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epGALS app\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eELM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Enables clinicians working in different specialties or areas to consider things from a rheumatology perspective.\u003c/p\u003e \u003cp\u003e\u0026bull; Highlights key issues with MSK medicine.\u003c/p\u003e \u003cp\u003e\u0026bull; Increases awareness of JIA and other rheumatological conditions in children in healthcare providers within and outside of the specialism.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Increases knowledge in colleagues and AHP.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Completion of the courses thought to increase awareness of rheumatological conditions in children and encourage those outside the specialism to consider MSK diagnoses when assessing patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Being an orthopaedic surgeon its useful to see problems from a rheumatological perspective\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;PMM is a very useful website for non paediatric rheumatologists. Highly recommend as a learning resource\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Increases knowledge in colleagues and AHP\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;List out the common MSK problems of paediatrics\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost users reported using the \u0026lsquo;PMM portfolio\u0026rsquo; within their own learning, clinical practice or teaching (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The PMM website content deemed most useful related to clinical assessment and examination skills (e.g. pGALS and pREMS), normal variants, red flags, limping child guidance, links to guidelines and access to videos. The pGALS guidance, \u0026lsquo;Top Tips\u0026rsquo; and translations were highly rated in the pGALS app. The ELM users most valued clinical assessment of common MSK presentations, cases and images to illustrate abnormalities and when to be concerned (\u0026lsquo;red flags\u0026rsquo;).\u003c/p\u003e \u003cp\u003eSelf-rated confidence (before and after accessing the PMM portfolio, using a Likert scale range: 1 (not very confident) \u0026ndash; 5 (very confident)), about MSK knowledge and skills increased for all three e-resources:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePMM Website p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.01 t(99)=-6.59. Before: Mean score: 3.51 (S.D. 1.19). After: Mean score: 4.23 (S.D. 0.87)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003epGALS App: p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.01 t(46)=-3.94. Before: Mean: 3.70 (S.D. 1.38). After: Mean: 4.30 (S.D. 1.02)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eELM: p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.01 (t(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)=-4.37. Before: Mean: 3.57 (S.D. 1.21). After: Mean: 4.16 (S.D. 0.91)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eNon-users of the e-resources (PMM website n\u0026thinsp;=\u0026thinsp;61, pGALS App n\u0026thinsp;=\u0026thinsp;83, ELM n\u0026thinsp;=\u0026thinsp;73) reported lack of awareness of their existence as the main reason (PMM website: n\u0026thinsp;=\u0026thinsp;48/60, 80%; pGALS app: n\u0026thinsp;=\u0026thinsp;66/83, 80%; ELM: n\u0026thinsp;=\u0026thinsp;48/73, 66%). Most non-users reported that following the study participation they were planning to access the e-resources for their clinical practice and / or teaching.\u003c/p\u003e \u003cp\u003eIncreasing awareness of the \u0026lsquo;PMM portfolio\u0026rsquo;, especially amongst junior clinicians and AHPs, integration into local training systems or curricula, linking with professional organisations, CME/CPD and existing meetings were suggested ways to increase reach and impact of all the e-resources. In addition, expanding the ELM topics, further signposting to key content targeted to user groups, providing offline access (e.g. apps) and maintaining content pertinent to global practice were suggestions for future development of the \u0026lsquo;PMM portfolio\u0026rsquo;\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eThe \u0026lsquo;PMM portfolio\u0026rsquo; has been developed to address the reality that many CYP will present to a myriad of clinicians and in most health care systems, not directly to a paediatric MSK specialist. Making a prompt correct diagnosis and to know when a specialist referral is needed (or not), are important to optimise clinical outcomes. Many clinicians who are involved in care pathways do not have experience or training in paediatric MSK medicine (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Hence the range of target audiences for the \u0026lsquo;PMM portfolio\u0026rsquo; is wide with the aim of improving awareness, knowledge and clinical skills and ultimately improving access to the \u0026lsquo;right care\u0026rsquo;. Furthermore nursing and medical students are an important target audience as embedding essential skills early is beneficial (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur evaluation demonstrates wide spread use of the \u0026lsquo;PMM portfolio\u0026rsquo; which has expanded since launch in 2014 and provides substantial evidence that we are reaching our target audiences. The most popular pages of the PMM website judged by the analytics, survey and interviews, focus on clinical assessment (including pGALS, pREMS, normal development, normal variants), limping, MSK infection and indicators of when to be concerned (red flags); these observations reflect users being non-experts in paediatric MSK medicine and the known learning outcomes for medical students (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) and family medicine (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe have shown that most users of the PMM website were initially from the UK and US but over time, uptake has increased across many countries around the world and amongst trainees and AHPs. Positive feedback included ease of use, open access and content being appropriate for users (either for their own learning needs or to aid the teaching of others). Notably there was variation by user groups for accessing the e-resource; e.g. students and trainees use of the PMM website and pGALS app for clinical skills guidance and revision, AHPs reporting use of the ELM (which focus on cased based common MSK conditions) and clinicians accessing the PMM website and pGALS app for teaching. There was a significant increase in self rated confidence in clinical skills and knowledge following access to all e-resources and many users reported using the e-resources having a positive impact on their learning, their clinical practice and the teaching of others to raise awareness.\u003c/p\u003e \u003cp\u003eThe international uptake of the e-resources reflects the wide stakeholder engagement utilised in the \u0026lsquo;PMM portfolio\u0026rsquo; development (design, format and content). Our global partners are integral to the PMM website content and pGALS translations ensuring relevance to target audiences. The global partners have also likely facilitated dissemination and reach; notably the countries of several PMM global partners rank highly in those accessing the \u0026lsquo;PMM portfolio\u0026rsquo;. Dissemination has been further facilitated through endorsement by professional societies (e.g. Paediatric Rheumatology European Society (PReS), Royal College of Paediatrics and Child Health (RCPCH), Royal College of Nursing (RCN), India Rheumatology Society and National Institute for Health and Care Excellence (NICE)). The \u0026lsquo;PMM portfolio\u0026rsquo; is embedded in NICE Clinical Knowledge Summaries for family medicine, PReS Basic Courses for paediatric rheumatology, RCPCH guidance for postgraduate examinations, the RCN Competency Framework, postgraduate paediatric rheumatology training programmes (e.g. India and Kenya) and the strategy of the Paediatric Task Force for Global Musculoskeletal Health (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur evaluation gave insights for additional content and to further increase reach. We firmly believe that ongoing engagement of users is integral to iterative development and optimising impact as a means of knowledge transfer (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Increasing awareness of the \u0026lsquo;PMM portfolio\u0026rsquo; especially amongst students, trainees and AHPs is important and notably was the most cited reason amongst non-users for lack of access to the e-resources. Despite high interest within the ELM from the survey respondents most ELM registered users reside in the UK/Ireland suggesting more work is needed to promote these. More needs to be done to integrate the \u0026lsquo;PMM portfolio\u0026rsquo; into curricula, training programmes through links with professional organisations, training bodies and increasing exposure at CME/CPD events. Furthermore, expanding the current range of ELMs, offline access and addressing the global context for content would facilitate uptake and impact of the \u0026lsquo;PMM portfolio\u0026rsquo;. With this in mind, work is already underway to develop a PMM app and the ELM now includes a module targeting physiotherapists, and a further ELM for school teachers is planned. All the e-resources are free of charge other than one ELM (\u0026lsquo;The paediatricians approach to a child with fever\u0026rsquo;), which had higher development costs; the charge may have contributed to the low uptake of this ELM. We aim for all the e-resources to be free and funding is a major barrier to further \u0026lsquo;PMM portfolio\u0026rsquo; development. To date all contributions have been forthcoming without financial reimbursement and we gratefully acknowledge the valuable input from all our PMM partners. We are actively working on ways to secure sustainability and growth whilst maintaining the ethos of PMM being free and open to all.\u003c/p\u003e \u003cp\u003e \u003cem\u003eLimitations of our study\u003c/em\u003e. Our informal approach to recruitment resulted in the survey response rate being imprecise. However, this approach to recruitment enabled reach to both users and non-users of the e-resources and gave valuable insights into barriers to use and ways to encourage uptake further. There was not an even spread amongst the numbers of responders per user group or by country and this may have introduced bias. For example, there was a high proportion of survey respondents from India and amongst AHPs (who gave very favorable feedback). Their responses were nonetheless comparable to other respondent groups so we suggest that any effect on the overall findings is minimal. Their feedback was very valuable for future work to target clinicians, especially AHPs who are integral to paediatric MSK care in areas of the world with workforce challenges (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Our methods explored reach and impact on learning and clinical practice; ideally evaluation would include influence on clinical outcomes (such as access to specialist care) but given that referrals are dependent on several variables (including local referral pathways and availability of specialists), a different evaluation approach would be needed.\u003c/p\u003e \u003ch2\u003e \u003cem\u003eImplications for research and practice\u003c/em\u003e \u003c/h2\u003e \u003cp\u003eOur work is timely and relevant given the COVID-19 pandemic and rapid escalation of e-learning in clinical education (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). E-learning platforms are now increasingly utilised (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) and there is great potential for e-technology and telehealth (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) to reach many users around the world at relatively low cost. This is particularly relevant to the \u0026lsquo;PMM portfolio\u0026rsquo; given the evidence that many CYP with MSK conditions live in parts of the world (Asia and Africa) with little or no access to specialist care (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Our evaluation and iterative approach highlights the importance of user engagement to optimise reach and impact. The \u0026lsquo;PMM portfolio\u0026rsquo; is an exemplar model to facilitate workforce capacity building in global paediatric rheumatology (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) and more work is needed to integrate e-learning with face to face training schemes. The role of e-resources and understanding how to tailor them for maximum impact is of increasing importance given the financial investment needed to set up and sustain e-learning programmes.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eThe \u0026lsquo;PMM portfolio\u0026rsquo; is fulfilling an important role reaching many target user groups across the world. The \u0026lsquo;PMM portfolio\u0026rsquo; continues to grow and engagement with users will facilitate future iterations maintaining relevance for the global context.\u003c/p\u003e "},{"header":"List Of Abbreviations","content":"\u003cp\u003eAHP Allied Health Professionals\u003c/p\u003e \u003cp\u003eCME Continuing Medical Education\u003c/p\u003e \u003cp\u003eCPD Continuing Professional Development\u003c/p\u003e \u003cp\u003eCYP Children and Young People\u003c/p\u003e \u003cp\u003eELM E Learning Module\u003c/p\u003e \u003cp\u003eHCP\u0026rsquo;s Health Care Professionals\u003c/p\u003e \u003cp\u003eNICE National Institute for Health and Care Excellence\u003c/p\u003e \u003cp\u003epGALS Paediatric Gait, Arms, Legs and Spine\u003c/p\u003e \u003cp\u003epREMS Paediatric Regional Examination of the Musculoskeletal System\u003c/p\u003e \u003cp\u003ePReS Paediatric Rheumatology European Society\u003c/p\u003e \u003cp\u003ePMM Paediatric Musculoskeletal Matters\u003c/p\u003e \u003cp\u003eRCN Royal College of Nursing\u003c/p\u003e \u003cp\u003eRCPCH Royal College of Pediatrics and Child Health\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval obtained from Newcastle University UK Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained for all participants. As part of this, participants were informed that anonymised, exemplar, extracts of their data may be used in a study report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo maintain anonymity no additional data is available. Participants only consented to anonymised, exemplar, extracts of the data to being shared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by funding from The JGW Patterson Foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHF/SJ conceived the concept of the e-learning resources, led the development of the resources and contributed to study design, analysis and writing of the manuscript. NS contributed to the study design, undertook the evaluation work and contributed to analysis and writing of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to all the participants in the study.\u003c/p\u003e\n\u003cp\u003eThe development of the \u0026lsquo;PMM portfolio\u0026rsquo; was funded by unrestricted educational grants from Pfizer Pharmaceuticals with subsequent additional unrestricted educational / investigator led research\u0026nbsp;grants from Sobi, BioMarin, and Genzyme. Our evaluation work was funded by a grant from the JGW Patterson Foundation.\u003c/p\u003e\n\u003cp\u003eWe acknowledge the considerable input of all the PMM collaborators (\u003ca href=\"http://www.pmmonline.org/doctor/about-us\"\u003ehttp://www.pmmonline.org/doctor/about-us\u003c/a\u003e) and medical students at Newcastle University UK in the development of our portfolio. We also acknowledge the support of Dr. Sarah Cope (family doctor), Dr. Graeme Denman (family doctor), Dr. Josh Bennett (general paediatric trainee) and Mr. Ashley Reynolds (e-technologist) in the developing of ELM.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTan A, Strauss VY, Protheroe J, Dunn KM. Epidemiology of paediatric presentations with musculoskeletal problems in primary care. BMC musculoskeletal disorders. 2018;19(1):40.\u003c/li\u003e\n\u003cli\u003ePrathivadi Bhayankaram N, Lacey R, Barnett L, Jordan K, Dunn K. Musculoskeletal consultations from childhood to adulthood: a longitudinal study. Journal of Public Health. 2019.\u003c/li\u003e\n\u003cli\u003eDouglas SL. A consumer perspective on embedding research in paediatric rheumatology. Oxford University Press; 2014.\u003c/li\u003e\n\u003cli\u003eFedorak GT, DeRosa DC, Brough AK, Miyamoto RH. Increased time between diagnosis and surgery in slipped capital femoral epiphysis results in increased radiographic deformity. Journal of children's orthopaedics. 2018;12(3):232-5.\u003c/li\u003e\n\u003cli\u003eMcErlane F, Foster HE, Carrasco R, Baildam EM, Chieng SE, Davidson JE, et al. Trends in paediatric rheumatology referral times and disease activity indices over a ten-year period among children and young people with Juvenile Idiopathic Arthritis: results from the childhood arthritis prospective Study. Rheumatology (Oxford, England). 2016;55(7):1225-34.\u003c/li\u003e\n\u003cli\u003eDang-Tan T, Trottier H, Mery LS, Morrison HI, Barr RD, Greenberg ML, et al. Delays in diagnosis and treatment among children and adolescents with cancer in Canada. Pediatric Blood \u0026amp; Cancer. 2008;51(4):468-74.\u003c/li\u003e\n\u003cli\u003eFoster HE, Eltringham MS, Kay LJ, Friswell M, Abinun M, Myers A. Delay in access to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic arthritis. Arthritis and rheumatism. 2007;57(6):921-7.\u003c/li\u003e\n\u003cli\u003eBarber CE, Barnabe C, Benseler S, Chin R, Johnson N, Luca N, et al. Patient factors associated with waiting time to pediatric rheumatologist consultation for patients with juvenile idiopathic arthritis. Pediatric Rheumatology. 2020;18(1):1-5.\u003c/li\u003e\n\u003cli\u003eChausset A, Pereira B, Echaubard S, Merlin E, Freychet C. Access to paediatric rheumatology care in juvenile idiopathic arthritis: what do we know? A systematic review. Rheumatology. 2020.\u003c/li\u003e\n\u003cli\u003eConsolaro A, Giancane G, Alongi A, van Dijkhuizen EHP, Aggarwal A, Al-Mayouf SM, et al. Phenotypic variability and disparities in treatment and outcomes of childhood arthritis throughout the world: an observational cohort study. The Lancet Child \u0026amp; adolescent health. 2019;3(4):255-63.\u003c/li\u003e\n\u003cli\u003eFoster H, Rapley T. Access to pediatric rheumatology care -- a major challenge to improving outcome in juvenile idiopathic arthritis. The Journal of rheumatology. 2010;37(11):2199-202.\u003c/li\u003e\n\u003cli\u003eJandial S, Myers A, Wise E, Foster HE. Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills. J Pediatr. 2009;154(2):267-71.\u003c/li\u003e\n\u003cli\u003eSaxena S, Francis N, Sharland M. Primary care of children: the unique role of GPs. British Journal of General Practice; 2012.\u003c/li\u003e\n\u003cli\u003eModi N, Simon C. Child health care: adequate training for all UK GPs is long overdue. Br J Gen Pract. 2016;66(646):228-9.\u003c/li\u003e\n\u003cli\u003eWise EM, Walker DJ, Coady DA. Musculoskeletal education in general practice: a questionnaire survey. Clinical rheumatology. 2014;33(7):989-94.\u003c/li\u003e\n\u003cli\u003eGoff I, Boyd DJ, Wise EM, Jandial S, Foster HE. Paediatric musculoskeletal learning needs for general practice trainees: achieving an expert consensus. Educ Prim Care. 2014;25(5):249-56.\u003c/li\u003e\n\u003cli\u003eSmith N, Foster H, Wyllie R, English C, Davies B, Jandial S, et al. Development of Paediatric Musculoskeletal Matters Nursing\u0026ndash;a free online evidence based education e-resource for nurses. Rheumatology. 2017;56(suppl_6).\u003c/li\u003e\n\u003cli\u003eChehade M, Gill T, Kopansky-Giles D, Schuwirth L, Karnon J, McLiesh P, et al. Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health. Best Practice \u0026amp; Research Clinical Rheumatology. 2016;30(3):559-84.\u003c/li\u003e\n\u003cli\u003eSmith N, Rapley T, Jandial S, English C, Davies B, Wyllie R, et al. Paediatric musculoskeletal matters (pmm)--collaborative development of an online evidence based interactive learning tool and information resource for education in paediatric musculoskeletal medicine. Pediatric rheumatology online journal. 2016;14(1):1.\u003c/li\u003e\n\u003cli\u003eSmith N Jandial S, Wyllie R, English C, Davies B, Khubchandani R, Chan MO, Munro J, Ferriani V, Saad Magalh\u0026atilde;es C, Yan J, Scott C, Charuvanij S, Khawaja K, Vojinovic J, Rapley T, Foster HE. Globalisation of Paediatric Musculoskeletal Matters\u0026rsquo; (PMM). British Society for Paediatric and Adolescent Rheumatology; 2017: Rheumatology; 2017.\u003c/li\u003e\n\u003cli\u003eFoster HE, Jandial S. pGALS - paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatric rheumatology online journal. 2013;11(1):44.\u003c/li\u003e\n\u003cli\u003eSukharomana M, Charuvanij S. The Thai Translation of the Pediatric Gait, Arms, Legs, Spine Tool is Useful for Pediatric Residents in Detecting Musculoskeletal Abnormalities in Children. Journal of Clinical Rheumatology: Practical Reports on Rheumatic \u0026amp; Musculoskeletal Diseases. 2020.\u003c/li\u003e\n\u003cli\u003eGoff I, Bateman B, Myers A, Foster H. Acceptability and practicality of musculoskeletal examination in acute general pediatric assessment. The Journal of pediatrics. 2010;156(4):657-62.\u003c/li\u003e\n\u003cli\u003eSmith E, Molyneux E, Heikens GT, Foster H. Acceptability and practicality of pGALS in screening for rheumatic disease in Malawian children. Clinical rheumatology. 2012;31(4):647-53.\u003c/li\u003e\n\u003cli\u003eMoreno-Torres LA, Hern\u0026aacute;ndez-Gardu\u0026ntilde;o AG, Arellano-Vald\u0026eacute;s CA, Salinas-Rodr\u0026iacute;guez A, Rubio-Perez N, Pel\u0026aacute;ez-Ballestas I. Cross-cultural validation of the paediatric Gait, Arms, Legs, Spine (pGALS) tool for the screening of musculoskeletal disorders in Mexican children. Rheumatology international. 2016;36(4):495-503.\u003c/li\u003e\n\u003cli\u003eChan MO, Sen ES, Hardy E, Hensman P, Wraith E, Jones S, et al. Assessment of musculoskeletal abnormalities in children with mucopolysaccharidoses using pGALS. Pediatric rheumatology online journal. 2014;12:32.\u003c/li\u003e\n\u003cli\u003eAbujam B, Aggarwal A. Hypermobility is related with musculoskeletal pain in Indian school-children. Clinical and experimental rheumatology. 2014;32(4):610-3.\u003c/li\u003e\n\u003cli\u003eSabui TK, Samanta M, Mondal RK, Banerjee I, Saren A, Hazra A. Survey of musculoskeletal abnormalities in school‐going children of hilly and foothill regions of Eastern Himalayas using the pediatric Gait, Arms, Legs, Spine screening method. International journal of rheumatic diseases. 2018;21(5):1127-34.\u003c/li\u003e\n\u003cli\u003eBaker KF, Jandial S, Thompson B, Walker D, Taylor K, Foster HE. Use of structured musculoskeletal examination routines in undergraduate medical education and postgraduate clinical practice - a UK survey. BMC Med Educ. 2016;16(1):277.\u003c/li\u003e\n\u003cli\u003eCope S, Jandial S, Foster HE, editors. A Blended Learning Approach to Clinical Skills Teaching: E-Learning for Paediatric Gait, Arms, Legs and Spine Examination (pGALS). Arthritis \u0026amp; Rheumatology; 2017: Wiley 111 River St, Hoboken 07030-5774, NJ USA.\u003c/li\u003e\n\u003cli\u003eRatcliff C, Denman G, Jandial S, Foster H. Diagnosing arthritis in children. Paediatrics and Child Health. 2019;29(12):503-14.\u003c/li\u003e\n\u003cli\u003eCope S, Denman G, Foster H, Jandial S. Paediatric Gait, Arms, Legs and Spine examination (pGALS)\u0026ndash;a case based discussion. Paediatrics and Child Health. 2018;28(2):73-83.\u003c/li\u003e\n\u003cli\u003eRapley T. Some pragmatics of data analysis. Qualitative research. 2011;3:273-90.\u003c/li\u003e\n\u003cli\u003eFoster H, Kay L, May C, Rapley T. Pediatric regional examination of the musculoskeletal system: A practice‐and consensus‐based approach. Arthritis care \u0026amp; research. 2011;63(11):1503-10.\u003c/li\u003e\n\u003cli\u003eScott C, Chan M, Slamang W, Okong'o L, Petty R, Laxer RM, et al. Juvenile arthritis management in less resourced countries (JAMLess): consensus recommendations from the Cradle of Humankind. Clinical rheumatology. 2019;38(2):563-75.\u003c/li\u003e\n\u003cli\u003eAl Maini M, Al Weshahi Y, Foster HE, Chehade MJ, Gabriel SE, Al Saleh J, et al. A global perspective on the challenges and opportunities in learning about rheumatic and musculoskeletal diseases in undergraduate medical education. Clinical rheumatology. 2019:1-16.\u003c/li\u003e\n\u003cli\u003eJandial S, Stewart J, Foster HE. What do they need to know: achieving consensus on paediatric musculoskeletal content for medical students. BMC Med Educ. 2015;15:171.\u003c/li\u003e\n\u003cli\u003eFoster HE, Scott C, Tiderius CJ, Dobbs MB, Ang E, Charuvanij S, et al. Improving musculoskeletal health for children and young people\u0026ndash;A \u0026lsquo;call to action\u0026rsquo;. Best Practice \u0026amp; Research Clinical Rheumatology. 2020:101566.\u003c/li\u003e\n\u003cli\u003eGagnon ML. Moving knowledge to action through dissemination and exchange. Journal of clinical epidemiology. 2011;64(1):25-31.\u003c/li\u003e\n\u003cli\u003eFoster HE, Scott C, Tiderius CJ, Dobbs MB. The paediatric global musculoskeletal task force-\u0026lsquo;towards better MSK health for all\u0026rsquo;. Pediatric Rheumatology. 2020;18(1):1-3.\u003c/li\u003e\n\u003cli\u003eHenrickson M. Policy challenges for the pediatric rheumatology workforce: Part III. the international situation. Pediatric Rheumatology. 2011;9(1):26.\u003c/li\u003e\n\u003cli\u003eWijesooriya NR, Mishra V, Brand PL, Rubin BK. COVID-19 and telehealth, education, and research adaptations. Paediatric Respiratory Reviews. 2020.\u003c/li\u003e\n\u003cli\u003eWoodward AL, Harris ZL. Employment of a needs assessment survey to shape a novel web-based pediatric rheumatology curriculum for primary care providers. Pediatric Rheumatology. 2013;11(1):1-8.\u003c/li\u003e\n\u003cli\u003eTuckson RV, Edmunds M, Hodgkins ML. Telehealth. New England Journal of Medicine. 2017;377(16):1585-92.\u003c/li\u003e\n\u003cli\u003eDave M, Rankin J, Pearce M, Foster HE. Global prevalence estimates of three chronic musculoskeletal conditions: club foot, juvenile idiopathic arthritis and juvenile systemic lupus erythematosus. Pediatric Rheumatology. 2020;18(1):1-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical education, E-learning, E-resources, pGALS, Global health, Access to care, Evaluation, Workforce capacity building, Model of practice, Global paediatric rheumatology","lastPublishedDoi":"10.21203/rs.3.rs-87044/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-87044/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBackground \u003c/em\u003e\u003c/strong\u003eElectronic resources (e-resources) have considerable potential to reach users around the world to promote awareness and knowledge about musculoskeletal conditions. The ‘PMM portfolio’ targets non-specialists in musculoskeletal medicine and comprises the Paediatric Musculoskeletal Matters (PMM) website, the paediatric Gait, Arms, Legs and Spine (pGALS) app and e-learning modules (ELM). Our aim was to evaluate the ‘PMM portfolio’ to gain insights about it’s impact on learning and clinical practice. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMethods \u003c/em\u003e\u003c/strong\u003eMixed methods (e-resource analytics, online survey, interviews) with PMM and ELM registered users in addition to purposive sampling of users using UK and international contacts within paediatrics and paediatric rheumatology. Data was analysed using descriptive statistics and free-text comments using qualitative techniques. A Paired T-Test compared self-rated confidence before and after use of the e-resources. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResults\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eThere has been wide international reach for all e-resources PMM website (662,827 hits, 262,476 users, 214 countries, data 31\u003csup\u003est\u003c/sup\u003e July 2020), pGALS app (12,670 downloads, 70 countries, data 31\u003csup\u003est\u003c/sup\u003e July 2020); ELM (150 users, 30 countries, data 30\u003csup\u003eth\u003c/sup\u003e May 2019). There were 164 responses to the survey from 25 countries from a range of students, trainees and health care professionals. Most deemed the ‘PMM portfolio’ to be ‘useful or very useful’ for their learning (or when used to teach others) and reported significantly increased self-rated confidence in their clinical examination and reasoning skills following access to the e-resources (PMM website, p=\u0026lt;0.01; pGALS app, p=\u0026lt;0.01; ELM, p=\u0026lt;0.01). Easy, open access, clinical images, videos and cases were deemed the most valued features of the e-resources. The most popular PMM website pages related to clinical assessment. There was high uptake of the pGALS app and pGALS’ ELM especially from trainees and allied health professionals. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConclusions \u003c/em\u003e\u003c/strong\u003eThe ‘PMM portfolio’ has wide reach amongst a spectrum of our target users to raise awareness and improve knowledge and skills. Ongoing engagement with users will facilitate further iterations of the ‘PMM portfolio’ to remain relevant for the global context. PMM as a model of e-learning has increasing applicability with the ongoing Covid-19 pandemic and is an important way to expand global paediatric rheumatology.\u003c/p\u003e","manuscriptTitle":"A Mixed Methods Evaluation of The Paediatric Musculoskeletal Matters (PMM) Online Portfolio","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-10-08 22:28:27","doi":"10.21203/rs.3.rs-87044/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-12-27T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-18T00:00:00+00:00","index":4,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2020-12-10T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2020-12-10T00:00:00+00:00","index":3,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-05T00:00:00+00:00","index":4,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-12-03T01:00:00+00:00","index":3,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-12-03T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-02T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-11-29T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-28T00:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-09-29T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-29T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-28T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53dc506a-dd18-413f-9c6c-c86373c6d56d","owner":[],"postedDate":"October 8th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":723232,"name":"Pediatrics"},{"id":723233,"name":"Rheumatology"}],"tags":[],"updatedAt":"2021-07-27T20:49:59+00:00","versionOfRecord":{"articleIdentity":"rs-87044","link":"https://doi.org/10.1186/s12969-021-00567-5","journal":{"identity":"pediatric-rheumatology","isVorOnly":false,"title":"Pediatric Rheumatology"},"publishedOn":"2021-06-09 20:49:59","publishedOnDateReadable":"June 9th, 2021"},"versionCreatedAt":"2020-10-08 22:28:27","video":"","vorDoi":"10.1186/s12969-021-00567-5","vorDoiUrl":"https://doi.org/10.1186/s12969-021-00567-5","workflowStages":[]},"version":"v1","identity":"rs-87044","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-87044","identity":"rs-87044","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}