{"@context":{"@language":"en","Affiliation":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","AggregatedSourceRepository":"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider","Campus":"https:\/\/open.library.ubc.ca\/terms#degreeCampus","Creator":"http:\/\/purl.org\/dc\/terms\/creator","DateAvailable":"http:\/\/purl.org\/dc\/terms\/issued","DateIssued":"http:\/\/purl.org\/dc\/terms\/issued","Degree":"http:\/\/vivoweb.org\/ontology\/core#relatedDegree","DegreeGrantor":"https:\/\/open.library.ubc.ca\/terms#degreeGrantor","Description":"http:\/\/purl.org\/dc\/terms\/description","DigitalResourceOriginalRecord":"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO","FullText":"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note","Genre":"http:\/\/www.europeana.eu\/schemas\/edm\/hasType","GraduationDate":"http:\/\/vivoweb.org\/ontology\/core#dateIssued","IsShownAt":"http:\/\/www.europeana.eu\/schemas\/edm\/isShownAt","Language":"http:\/\/purl.org\/dc\/terms\/language","Program":"https:\/\/open.library.ubc.ca\/terms#degreeDiscipline","Provider":"http:\/\/www.europeana.eu\/schemas\/edm\/provider","Publisher":"http:\/\/purl.org\/dc\/terms\/publisher","Rights":"http:\/\/purl.org\/dc\/terms\/rights","RightsURI":"https:\/\/open.library.ubc.ca\/terms#rightsURI","ScholarlyLevel":"https:\/\/open.library.ubc.ca\/terms#scholarLevel","Supervisor":"http:\/\/purl.org\/dc\/terms\/contributor","Title":"http:\/\/purl.org\/dc\/terms\/title","Type":"http:\/\/purl.org\/dc\/terms\/type","URI":"https:\/\/open.library.ubc.ca\/terms#identifierURI","SortDate":"http:\/\/purl.org\/dc\/terms\/date"},"Affiliation":[{"@value":"Medicine, Faculty of","@language":"en"},{"@value":"Medicine, Department of","@language":"en"}],"AggregatedSourceRepository":[{"@value":"DSpace","@language":"en"}],"Campus":[{"@value":"UBCV","@language":"en"}],"Creator":[{"@value":"Li, Jacqueline","@language":"en"}],"DateAvailable":[{"@value":"2023-04-03T22:28:38Z","@language":"en"}],"DateIssued":[{"@value":"2023","@language":"en"}],"Degree":[{"@value":"Master of Science - MSc","@language":"en"}],"DegreeGrantor":[{"@value":"University of British Columbia","@language":"en"}],"Description":[{"@value":"Background \u2014 Developmental dysplasia of the hip (DDH) represents a range of hip joint instability, present at birth or developed during infancy, ranging from mild instability to a complete dislocation. In India and other Global South countries, DDH is often diagnosed after walking age, requiring more complex and invasive surgeries with greater risk of complications and long-term disability. A DDH care pathway is a decision-making tool that coordinates and standardizes screening, with the aim of reducing late detections. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India.\r\n\r\nMethods \u2014 In Phase I, seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. Group members also developed specialty-specific surveys for local providers in India, which were distributed to organizational memberships. During Phase II, panelists participated in a modified Delphi method to reach consensus on a list of best practice statements regarding DDH screening in the Indian context. Phase III applied the statements to build the care pathway. \r\n\r\nResults \u2014 The entire process was completed within a one-year time span, with all procedures conducted remotely using virtual communication and requiring minimal funds or resources. Specialty surveys demonstrated low awareness about DDH, limited practice of DDH screening, and variability in the quality of ultrasound. The Delphi method concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country\u2019s immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging. \r\n\r\nDiscussion\/Conclusion \u2014 In Global South countries, there is a need for DDH care pathways that are specific to local contexts. Care pathway development is strengthened through the involvement of a multidisciplinary team of local providers and stakeholders. The methodology requires strategies to identify country-specific barriers to care and facilitate group engagement. The cost- and time-effective approach used in India is feasible and can be applied to other conditions and\/or countries wishing to establish care pathways.","@language":"en"}],"DigitalResourceOriginalRecord":[{"@value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/84135?expand=metadata","@language":"en"}],"FullText":[{"@value":"DEVELOPMENT OF A DDH CARE PATHWAY FOR INDIA: A STUDY METHODOLOGY TO GUIDE SIMILAR EFFORTS IN OTHER COUNTRIES AND FOR OTHER CONDITIONS  by JACQUELINE LI B.A., Colgate University, 2019  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE  in  The Faculty of Graduate and Postdoctoral Studies (Experimental Medicine)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  March 2023 \u00a9 Jacqueline Li, 2023 ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled:  DEVELOPMENT OF A DDH CARE PATHWAY FOR INDIA: A STUDY METHODOLOGY TO GUIDE SIMILAR EFFORTS IN OTHER COUNTRIES AND FOR OTHER CONDITIONS  submitted by Jacqueline Li in partial fulfillment of the requirements for the degree of Master of Science in Experimental Medicine  Examining Committee: Dr. Kishore Mulpuri, Professor, Department of Orthopaedics, UBC Supervisor Dr. Emily Schaeffer, Research Associate, Department of Orthopaedics, UBC Supervisory Committee Member Dr. Ian Pike, Professor, Department of Pediatrics, UBC Supervisory Committee Member Dr. Caroline Forsythe, Professor, Department of Surgery, Quebec-Universit\u00e9 Laval  Laval Additional Examiner          iii  Abstract Background \u2014 Developmental dysplasia of the hip (DDH) represents a range of hip joint instability, present at birth or developed during infancy, ranging from mild instability to a complete dislocation. In India and other Global South countries, DDH is often diagnosed after walking age, requiring more complex and invasive surgeries with greater risk of complications and long-term disability. A DDH care pathway is a decision-making tool that coordinates and standardizes screening, with the aim of reducing late detections. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India.  Methods \u2014 In Phase I, seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. Group members also developed specialty-specific surveys for local providers in India, which were distributed to organizational memberships. During Phase II, panelists participated in a modified Delphi method to reach consensus on a list of best practice statements regarding DDH screening in the Indian context. Phase III applied the statements to build the care pathway.   Results \u2014 The entire process was completed within a one-year time span, with all procedures conducted remotely using virtual communication and requiring minimal funds or resources. Specialty surveys demonstrated low awareness about DDH, limited practice of DDH screening, and variability in the quality of ultrasound. The Delphi method concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into iv  35. The developed care pathway for India features periodic clinical hip examinations integrated with the country\u2019s immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging.   Discussion\/Conclusion \u2014 In Global South countries, there is a need for DDH care pathways that are specific to local contexts. Care pathway development is strengthened through the involvement of a multidisciplinary team of local providers and stakeholders. The methodology requires strategies to identify country-specific barriers to care and facilitate group engagement. The cost- and time-effective approach used in India is feasible and can be applied to other conditions and\/or countries wishing to establish care pathways.    v  Lay Summary  Developmental dysplasia of the hip (DDH) is a common condition in babies and children, describing a range of hip joint instability from a mildly unstable to a completely dislocated hip. Late diagnosis, defined here as after a child reaches walking age, is problematic, requiring more complex and invasive surgical procedures with greater risk of complications and long-term disability. In Global South countries such as India, there is evidence that DDH is still frequently diagnosed late. A DDH care pathway, which is a simple decision-making tool that guides healthcare providers through the process of screening for DDH, may assist in decreasing late diagnoses; however, it must be designed specifically for the local context. The goal of this thesis was to develop a time- and cost-effective methodology for the design of context-specific DDH care pathways. We describe here the method that was developed and how it was used in the Indian context.   vi  Preface This study was conducted at the Hippy Lab, an Orthopaedic Research team at BC Children\u2019s Hospital. Projects were approved by the University of British Columbia Research Ethics Board (H17-02487, H20-02620). The study procedures were designed and facilitated by the author (JL) under the supervision of the research supervisor, Dr. Kishore Mulpuri (KM), and with support from supervisory committee members Dr. Emily Schaeffer (ES) and Dr. Ian Pike. Dr. Alaric Aroojis (AA), project lead for the DDH India Care Pathways Project, provided support and feedback at all stages, as well direct assistance with the consensus-building process. Undergraduate co-op student, Mr. Luke Wu, assisted with survey development. A condensed version of this thesis has been published [Li J, Aroojis A, Mulpuri K, Shea KG, Schaeffer EK. Development of a DDH Care Pathway for India: A Study Methodology to Guide Similar Efforts in Other Countries and for Other Conditions. Indian J Orthop. 2021;55(6):1549-1558. doi:10.1007\/s43465-021-00534-y]. JL is the primary author and was responsible for manuscript composition. All authors contributed to the revision of the article and approved of the published version. The developed DDH guideline for India, described in Section 2.4, has been published in Indian Pediatrics [Aroojis A, Anne RP, Li J, et al. Surveillance for Developmental Dysplasia of the Hip in India: Consensus Guidelines From the Pediatric Orthopaedic Society of India, Indian Academy of Pediatrics, National Neonatology Forum of India, Indian Radiological and Imaging Association, Indian Federation of Ultrasound in Medicine and Biology, Federation of Obstetric and Gynaecological Societies of India, and Indian Orthopaedic Association. Indian Pediatr. 2022;59(8):626-635.]. JL was responsible for data collection and analysis, and all authors contributed to manuscript writing and\/or editing. The results of the survey of pediatricians and neonatologists, described in Section 2.2.2, have been published in the Indian Journal of vii  Pediatrics [Anne RP, Li J, Schaeffer E, Aroojis A, Mulpuri K, Murki S. Care Practices of Indian Pediatricians for the Screening and Diagnosis of Developmental Dysplasia of the Hip. Indian J Pediatr. 2022;89(9):911-915. doi:10.1007\/s12098-022-04200-5]. JL was responsible for data collection and analysis, and all authors contributed to manuscript writing and\/or editing.   viii  Table of Contents  Abstract ......................................................................................................................................... iii Lay Summary ................................................................................................................................ v Preface ........................................................................................................................................... vi Table of Contents ....................................................................................................................... viii List of Tables ................................................................................................................................ xi List of Figures .............................................................................................................................. xii List of Abbreviations ................................................................................................................. xiii Acknowledgements .................................................................................................................... xiv Dedication .................................................................................................................................... xv Chapter 1: Introduction ............................................................................................................... 1 1.1 Developmental Dysplasia of the Hip ............................................................................ 1 1.1.1 Definitions ............................................................................................................... 1 1.1.2 Natural History ........................................................................................................ 2 1.1.3 Risk Factors ............................................................................................................. 3 1.2 Screening and Diagnosis of DDH ................................................................................. 4 1.2.1 Clinical Examination ............................................................................................... 4 1.2.2 Imaging .................................................................................................................... 5 1.2.3 Early vs. Late Diagnosis and Management ............................................................. 6 1.2.4 Existing Screening Programmes for DDH .............................................................. 8 1.3 The Indian Healthcare System ..................................................................................... 9 1.3.1 DDH in India ......................................................................................................... 10 1.4 Care Pathways ............................................................................................................. 11 1.5 Rationale ....................................................................................................................... 12 ix  1.6 Research Aim ............................................................................................................... 13 Chapter 2: Methodology and India Use-Case .......................................................................... 15 2.1 Overview of Study Design ........................................................................................... 15 2.1.1 Study Participants .................................................................................................. 16 2.1.2 Methods of Communication and Data Collection ................................................. 16 2.2 Phase I........................................................................................................................... 17 2.2.1 Working Group Formation .................................................................................... 17 2.2.2 Survey of Specialty Groups ................................................................................... 19 2.2.3 Literature Review .................................................................................................. 23 2.2.4 Preparatory Meeting for Consensus-building ........................................................ 23 2.3 Phase II ......................................................................................................................... 24 2.3.1 The Delphi Method ................................................................................................ 24 2.3.2 Modifications to the Delphi Method ...................................................................... 25 2.3.3 Delphi Rules and Criteria ...................................................................................... 25 2.3.4 Procedure ............................................................................................................... 26 2.3.5 Preliminary Delphi \u201cpre-Delphi\u201d Survey .............................................................. 28 2.3.6 Delphi Surveys ....................................................................................................... 29 2.3.7 Statement Finalization ........................................................................................... 30 2.4 Phase III ....................................................................................................................... 32 2.4.1 Final DDH Care Pathway in India ......................................................................... 34 Chapter 3: Discussion of Methodology ..................................................................................... 37 3.1 The Delphi Method in DDH Research ....................................................................... 38 3.2 Rationale for the Modified Delphi Method ............................................................... 38 3.2.1 Time-effectiveness and Cost-effectiveness ........................................................... 39 3.2.2 Face-to-Face Interactions ....................................................................................... 40 3.3 Identified Knowledge Gaps ........................................................................................ 40 3.3.1 Awareness of DDH Screening Practices ............................................................... 40 3.3.2 Radiation ................................................................................................................ 42 3.3.3 Imaging Controversy ............................................................................................. 42 3.4 Applicability in the Indian Context ........................................................................... 43 x  3.4.1 Timing of Examinations ........................................................................................ 43 3.4.2 Healthcare Providers for Screening ....................................................................... 44 3.4.3 Imaging Flexibility ................................................................................................ 44 3.5 Study Strengths ............................................................................................................ 45 3.5.1 Group Diversity ..................................................................................................... 45 3.5.2 Future Buy-in of the Care Pathway ....................................................................... 47 3.5.3 Maximizing Group Engagement and Participation ............................................... 47 3.6 Limitations ................................................................................................................... 49 3.7 Future directions ......................................................................................................... 50 3.7.1 Uses in other countries and for other conditions ................................................... 51 3.8 Conclusion .................................................................................................................... 52 References .................................................................................................................................... 53 Appendices ................................................................................................................................... 66 Appendix A: IAP\/NNFI Survey ....................................................................................... 66 Appendix B: IRIA\/IFUMB Survey .................................................................................. 73 Appendix C: Preliminary Delphi Survey ........................................................................ 80 Appendix D: Round 1 Delphi Survey .............................................................................. 96 Appendix E: Round 2 Delphi Survey............................................................................. 120 Appendix F: Consensus Results of the Delphi Surveys ................................................ 142    xi  List of Tables  Table 1: List of participating organizations in India and their approximate membership size .... 18 Table 2: Results of the IRIA\/IFUMB specialty survey  ............................................................... 21 Table 3: Demographic characteristics of the 29 respondents to the preliminary Delphi survey  . 28 Table 4: Final list of 35 consensus statements developed for the DDH India Care Pathway subdivided into five categories  .................................................................................................... 31 Table 5: Key Features of the DDH Care Pathway for India  ........................................................ 35    xii  List of Figures  Figure 1: Severity spectrum of developmental dysplasia of the hip  .............................................. 2 Figure 2: Flow diagram of the multi-phase process used for care pathway development  ........... 15 Figure 3: A second round Delphi survey statement asked during the India care pathway consensus-building process  .......................................................................................................... 27 Figure 4: Flow diagram of the consensus-building process for DDH care pathway development in India  ......................................................................................................................................... 33 Figure 5: Timeline of the Delphi method and care pathway development in India  .................... 34 Figure 6: The final DDH care pathway algorithm developed for India  ....................................... 36     xiii  List of Abbreviations AAOS\u2014American Academy of Orthopaedic Surgeons AP\u2014 anteroposterior AVN \u2014 avascular necrosis DDH \u2014 developmental dysplasia of the hip FOGSI \u2014 Federation of Obstetric & Gynaecological Societies of India IAP \u2014 Indian Academy of Pediatrics IFUMB \u2014 Indian Federation of Ultrasound in Medicine & Biology IOA \u2014 Indian Orthopaedic Association IRIA \u2014 Indian Radiological & Imaging Association NNFI \u2014 National Neonatology Forum of India OA \u2014 osteoarthritis PCPNDT \u2014 Pre-Conception and Pre-Natal Diagnostic Techniques POSI \u2014 Paediatric Orthopaedic Society of India RBSK \u2014 Rashtriya Bal Swasthya Karyakram REDCap \u2014 Research Electronic Data Capture   xiv  Acknowledgements  This project was supported by the I\u2019m a HIPpy Foundation, the Peterson Fund for Global Hip Health, the Divis Foundation for Gifted Children, and BC Children\u2019s Hospital Foundation.  Dr. Kishore Mulpuri\u2014it has been a joy and honour to learn from you. Thank you for instilling in me the value of thinking globally, and for supporting me through all of life\u2019s obstacles.  Dr. Emily Schaeffer\u2014thank you for your mentorship. You are the embodiment of kindness, patience, and strength. I am unbelievably grateful for the endless encouragement and guidance you have provided me throughout this journey.  Dr. Ian Pike\u2014thank you for sharing your expertise and your time. You helped to shape this project into what it is today and I am so grateful to have had you on the committee team.  The DDH India Care Pathway Working Group\u2014thank you for trusting me. Together, we did something incredible! Dr. Alaric Aroojis, better known as \u201cmotivator-in-chief\u201d, this project was made possible because of your passion, your leadership, and your unwavering enthusiasm.   The HIPpy Team\u2014you are the kindest and most supportive group, whom I am privileged to work alongside. Ashley and Stacey, I cannot thank you both enough for your support.  Mom and Dad\u2014I would not be here without your unconditional love. Thank you for supporting me as I continue to chase my dreams. I love you both.  xv  Dedication To my grandma, Rose.  1  Chapter 1: Introduction  1.1 Developmental Dysplasia of the Hip Developmental dysplasia of the hip (DDH) is the most common pediatric hip condition, representing a spectrum of hip abnormalities that ranges from mild dysplasia to a complete dislocation of one (unilateral) or both (bilateral) sides of the hip.1,2 In a normal hip, which is a ball-and-socket joint, the femoral head fits tightly in the acetabulum. In DDH, however, there are structural changes of the femoral head, the acetabulum, or both.2 These changes, which include abnormalities in the shape and position of the femoral head, as well as deformities in the cup-shaped structure of the acetabulum, result in progressive incongruency and instability.2 While the condition has historically been referred to as congenital dysplasia or dislocation of the hip, evolution in the understanding of the disorder, which may be present at birth or develop during infancy, has resulted in a shift to the term DDH.1,3  1.1.1 Definitions In mild dysplasia the hip is stable and reduced, with the femoral head situated within an acetabulum that is slightly shallow or misshapen. In a more severely dysplastic hip, the femoral head is still reduced, although further deformities allow for increased movement within the acetabulum. A hip becomes unstable when the femoral head is reduced but can be subluxated or dislocated upon physical manipulation.1,4,5 In a subluxable hip, the femoral head can be moved from its normal position, although partial contact with the acetabulum remains.1,2,4,5 If a hip is dislocatable, the femoral head can be completely displaced, which results in a complete loss of contact between the femoral head and acetabulum.1,2,4,5 A frank dislocation is the severest form of DDH, with the hip dislocated at rest. A dislocation is classified as reducible if the femoral 2  head can be relocated back into the acetabulum upon physical manipulation or irreducible if relocation cannot be achieved.2 The complete severity spectrum encompassed in DDH is depicted in Figure 1.   Figure 1. Severity spectrum of developmental dysplasia of the hip. Copyrighted to the International Hip Dysplasia Registry [IHDR] and reproduced with permission.6  1.1.2 Natural History The natural history of DDH is largely dependent on the age at presentation, the severity of the dysplasia, and the duration of dislocation.1 While mild to moderate DDH may not display symptoms until later in adulthood, more severe forms usually become symptomatic during 3  childhood.7 Most instabilities or dysplasias that present in early infancy have been shown to normalize without treatment during normal hip joint maturation and development, though some may still progress to subluxations or complete dislocations, particularly more severe DDH pathologies.8\u201310 However, by approximately six months of age, spontaneous resolution becomes unlikely and intervention is required.4 Persistent untreated DDH that continues into adolescence and adulthood develops progressive anatomical changes over time due to the codependency of femoral head and acetabular development.1,2,11 If either or both are deficient, physical deformities such as the flattening or distortion of the femoral head, increased femoral anteversion, and shallowing of the acetabulum become increasingly severe.1,2,4 Structures such as an inverted labrum and a hypertrophied ligamentum teres may also block the hip reduction and cause continued instability.2,4,12,13 The consequences of these changes include pain, gait abnormalities, loss of strength, and leg length differences, with unilateral dislocations often faring worse than bilateral dislocations due to resulting asymmetry.4,12 With prolonged untreated DDH, degenerative changes progress more rapidly and put individuals at greater risk of developing early-onset hip osteoarthritis (OA).14   1.1.3 Risk Factors While the etiology of DDH is unknown, a variety of factors have been suggested to increase risk. The most frequently reported risk factors include a family history of DDH, breech presentation, and female sex, with frank breech in females having the highest risk.15\u201319 Tight swaddling, which forces the hips into extension and adduction for prolonged periods, is also believed to influence the development of DDH and has been shown to be a more frequent risk factor in late presentations.18,20,21 Risk factors alone, however, are not always good predictors of DDH, 4  particularly late-presenting cases which often have fewer of the traditional risk factors.11,21 Thus, careful screening of all infants is required.   1.2 Screening and Diagnosis of DDH As DDH in infants and young children is often asymptomatic, screening is key to detecting the condition.11 Diagnosis is commonly made through a combination of clinical examination and imaging, which shift with age due to the natural development of the hip joint and the tightening of surrounding soft tissue.4 Although the potential for spontaneous resolution has raised controversy over best treatment practices, it does not undermine the need to screen all children and ensure that those suspected to have DDH are referred appropriately for further evaluation and follow-up. Additionally, since a variety of healthcare providers involved in infant care may be involved in detecting hip instability, all must receive education on DDH and be adequately trained in screening and referral practices.22,23  1.2.1 Clinical Examination Clinical examinations are useful in identifying abnormalities involving hip instability in infants and children and are considered the foundation of DDH screening.11,24 An examination performed at birth is widely accepted, with most advocating for routine surveillance, which entails periodic hip examinations performed during well-baby checks. These hip examinations are often continued until the child reaches walking age due to the wide age range that DDH may present and the potential for examiners to miss clinical signs of hip instability.11,25,26  The most common tests in the younger infant include the Barlow and Ortolani maneuvers.8,27 The Barlow maneuver is a test for hip laxity\u2014the reduced hip is adducted and a gentle downward force is applied in an attempt to subluxate or dislocate the femoral head.5,8,11 5  The Ortolani maneuver, in contrast, attempts to relocate a subluxated or dislocated femoral head back into the acetabulum through the application of a gentle upward force with the hip in abduction.5,11,27 Both tests are used in tandem to detect hip instability; however, a positive Ortolani is of greater clinical significance.11,22  By approximately three months of age, the Barlow and Ortolani maneuvers become less clinically relevant due to the development of soft-tissue contractures that limit hip motion.1,2,4,5 Instead, older infants are more preferably examined for leg length discrepancy (also known as the Galeazzi sign) and any differences in or resistance to hip abduction range of motion.1,4,5 However, bilateral cases of DDH are generally more difficult to diagnose due to the symmetry of hip abduction.2,4,11,22 At walking age, children with unilateral and bilateral dislocations often present with an abnormal limp or waddling gait.1,4,22   1.2.2 Imaging Despite the usefulness of clinical examination, the sensitivity of clinical tests varies widely and clinical signs of DDH may be subtle or even absent, making it difficult for even the most experienced examiners to diagnose all cases.28 Additionally, many of the clinical tests used, particularly those in older infants, are nonspecific. As such, imaging is frequently used to supplement clinical examination, as it provides a direct visualization of the femoral head in relation to the acetabulum and can more clearly diagnose and classify the severity of the dysplasia.12 In addition to its use as a diagnostic tool, imaging is used for surveillance, particularly of high-risk individuals, and to monitor the reducibility and stability of the hips of DDH patients throughout the treatment and follow-up period.5,12,22  6  Ultrasound is often considered to be the gold standard in DDH diagnosis. This modality is usually preferred for younger infants, when the hip is primarily cartilaginous and the ossification of the femoral head has not yet occurred.22 An ultrasound exam can be static or dynamic, with the former assessing the hip morphology and the latter assessing stability while provocative stress tests are applied.22,29 However, the use of ultrasound is limited by the need for expertise to perform and interpret imaging, its availability, and its subjectivity.22 Between four and six months of age, a single anteroposterior (AP) X-ray is often preferred to an ultrasound, as the femoral head begins to ossify and obscures key sonographic landmarks.30 However, an affected hip will often demonstrate a delay in the ossification of the femoral head, which permits the continued use of ultrasound.2 The older T\u00f6nnis radiographic classification for DDH uses the ossific nucleus as a reference point to grade the severity of dysplasia.31 However, the emergence of the IHDI classification in 2015, which quantifies femoral head displacement on a radiograph with or without the presence of the ossific nucleus, has made X-ray a viable option to screen for DDH at younger ages.32  1.2.3 Early vs. Late Diagnosis and Management Given the progressive nature of DDH and the decline of remodelling capacity with age, the timing of diagnosis can drastically affect available treatment options as well as the potential to achieve good long-term outcomes.4 Early diagnosis and management is essential to alter the natural history, particularly of more severe cases, and promote normal hip joint development and maturation.2 While all treatment options share the common goal of obtaining a stable and congruent reduction, increasing age of the child and severity of the dysplasia necessitate 7  increasingly complex and invasive treatment options that are associated with increased rates of re-dislocation, risk of residual dysplasia, and other complications.5,33  Infantile hips that do not spontaneously resolve within the first few weeks of life can usually be managed non-operatively with abduction splinting, such as a Pavlik harness.2,4,5,22 The harness maintains the hip reduction as the hip capsule tightens and stabilizes the joint, which can then normalize.22 Treatment with the Pavlik harness has shown high rates of success with few complications, although the failure rate increases with increased age and in more severe cases.34\u201336 Avascular necrosis (AVN), a potentially devastating complication where the femoral head loses blood supply, and femoral nerve palsy may also occur.36\u201338 If abduction splinting fails to reduce the hip, surgical management needs to be considered. A closed reduction may be performed, which requires general anaesthesia.2,4,5 Surgery is typically followed by an extended period of immobilization in a hip spica cast or rigid abduction brace and may require secondary procedures if residual dysplasia is present.2,4,5,39  In those whose hips fail to achieve a hip reduction through closed means, more invasive and complex surgical management is required to achieve a concentric hip reduction.2,4 DDH that presents or is diagnosed in the older child also commonly requires such procedures as remodeling potential declines and deformities become fixed.4 An open reduction with pelvic and\/or femoral osteotomies aims to remove barriers to reduction and improve the bony coverage of the femoral head through reconstruction and reorientation.4,5,33 The radiographic and functional adverse outcomes of both open and closed procedures include insufficient sphericity, residual dysplasia, re-dislocation, and AVN.33,40\u201342 These complications can cause pain, limp, and often require further corrective surgeries. Thus, it remains clear that early diagnosis and timely management of DDH, ideally before walking age, 8  is needed to avoid more complex management and improve long-term outcomes.5,23 Additionally, the need to avoid the potential financial, social, and emotional burden associated with the treatment and recovery of late-diagnosed cases cannot be understated.  1.2.4 Existing Screening Programmes for DDH Different screening programmes around the world have been developed with the goal of reducing the incidence of late diagnoses of DDH, with the majority located in high-income European countries.29 Universal clinical examination is widely accepted and practiced; however, there is debate on the inclusion of universal or selective imaging.43\u201346 The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines found moderate evidence to support not performing universal ultrasounds on newborns.7 Instead, they found strong evidence in favour of selective imaging before six months of age conducted for those with risk factors (breech presentation, family history, or a history of clinical hip instability).7 Arguments against universal screening include an unnecessary commitment of resources, potential over-diagnoses, and subsequent over-treatment.7 However, long-standing universal ultrasound screening programmes, including those in Austria and Germany, have demonstrated success at reducing costs and the need for surgery.47\u201350 A recent systematic review similarly found support for universal ultrasound screening and its cost-effectiveness, though the authors cite important logistical and financial challenges that would hinder the implementation of such a programme in developing nations.51 The timing and frequency of screening also vary widely between programmes, although surveillance is widely recommended. There remains ongoing debate over best screening practices, largely due to the lack of clear evidence in the literature. However, there 9  is very little doubt that hip screening is important for the identification\/monitoring of DDH and that all surveillance programmes are critical to reduce the late detection of DDH.45    1.3 The Indian Healthcare System  The healthcare system in India is mixed, with both a private and public sector. The private sector provides most secondary, tertiary, and quaternary care in urban centres, while the public system focuses on primary healthcare delivery in rural areas.52,53 Despite rural areas accounting for approximately 69% of India\u2019s population, the private sector accounts for the majority of India\u2019s health expenditure.54  The public system has three tiers, beginning at sub-centres staffed by a minimum of an auxiliary nurse midwife and a community health worker for every 3000-5000 people.52,53 Sub-centres are supported by The Ministry of Health & Family Welfare and are an individual\u2019s first point of contact with the system, providing basic health services including those related to maternal and child health.52 The second tier are the four to six-bed primary health centres for every 20,000 to 30,000 people. These centres are maintained by the State governments and must staff a minimum of one medical officer and 14 paramedical personnel, with a focus on curative and preventative care.52,53 The third tier is the 30-bed community health centers. Like the primary health centres, these centres are maintained by the State governments. At minimum, a community health centre must staff a surgeon, general physician, pediatrician, and obstetrician-gynaecologist, as well as a minimum of 21 paramedical staff.52,53  X-ray is also available at community health centres.52,53  Within the public healthcare sector is the Rashtriya Bal Swasthya Karyakram (RBSK), a Government of India program that trains healthcare workers on the early detection and 10  management of a variety of health conditions, including DDH.55 Under this program, children are screened multiple times throughout development and are referred if positive clinical findings or risk factors are present.55 However, despite the implementation of government initiatives, the private sector continues to dominate, even in the poorest rural regions. There also remain critical healthcare issues in India. Some of the most pressing issues include a lack of high-quality health services; a shortage of formally trained healthcare providers; financial, geographic, and social barriers to access to care; and a lack of public awareness about health issues.56\u201357 These issues present large barriers to receiving equitable and quality healthcare in both sectors, especially for those living outside of urban areas and those in poor communities.56\u201357  1.3.1 DDH in India The wide severity spectrum that DDH encompasses and the different definitions used have made it difficult to estimate its true incidence. In India, the estimated incidence of DDH varies widely, with studies reporting a range of 0-75 per 1000 live births.58\u201360 This is similar to the global incidence reported by Loder and Skopelja (2011), ranging from 0.06 to 76.1 per 1000 live births.61 Although a recent scoping review by Chand et al. (2021) estimated the incidence in India to be between 0 and 2.6 per 1000, the absence of large, population-based studies hinders the ability to estimate the true incidence of DDH in the country.62  While the incidence is not well known, there is evidence of late detections in India that occur after a child reaches walking age. A recent survey of orthopaedic surgeons practicing in India found that over two-thirds of respondents had performed initial assessments on children with DDH older than one year of age, which corroborates the finding that most existing studies on DDH in India reported that children present for treatment at a mean age >20 months.62,63 This 11  raises concerns about the current state of DDH screening in India and the effectiveness of existing initiatives.  In addition to the general challenges faced in the Indian healthcare system, there are other factors within the country that are likely to influence DDH rates. Swaddling is commonly practiced in India, with a 2020 study by Pinto et al. reporting that 90% of caregivers swaddled their infants in the traditional manner with hips extended and adducted.64 The large population living across the rural landscape is also at greater risk for late detection, as has been shown in rural areas of Canada and Australia.65,66 The lack of accessibility to screening may also be compounded by the 1994 Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act banning pre-natal sex determination in India, which has been argued to severely limit rural access to diagnostic ultrasound.67  1.4 Care Pathways  A care pathway is a decision-making tool that guides or manages the care of a specific population of patients with a well-defined condition or problem for a well-defined period, with the aim of enhancing care, such as through the improvement of patient outcomes and the optimization of resources.68,69 Care pathways are often developed by a multidisciplinary team, are evidence-based, and are meant to introduce a standardized patient-centered approach to care.68 In this study, we define a DDH care pathway as a decision-making algorithm that guides healthcare providers through the process of routine hip screening of an individual patient for DDH. The pathway begins at initial clinical evaluation and concludes when the individual is 12  either referred to an orthopaedic surgeon for suspicion of DDH or reaches a stage where surveillance can be concluded.  The DDH care pathway aims to reduce the total number of missed or late diagnoses in the country and subsequently reduce the need for operative treatment through the introduction or improvement of hip screening, ensuring that children suspected of DDH receive a timely referral to an orthopaedic surgeon. The care pathway must be feasible in the region of interest\u2014this requires attention to the local context, including the structure of the healthcare system, the screening resources and expertise available, and the complex needs of various populations, especially underserved groups such as those residing in rural and remote regions. The care pathway must also be comprehensive, covering all touchpoints of screening and offering alternative pathways when the ideal plan of care is not attainable.   1.5 Rationale  Given the impact of late diagnosis on treatment protocols and functional outcomes, it is important that appropriate measures are taken to detect DDH at earlier ages. A DDH care pathway, designed to meet the needs of the country, would be beneficial at all levels. The care pathway will optimize the quality and accessibility of hip screening and allow patients to receive the same standardized care regardless of their life position or circumstance. Additionally, the financial, emotional, and social impact associated with complex procedures and the poorer functional outcomes resulting from late diagnoses can be minimized for patients and their families. For healthcare professionals, the care pathway and accompanying knowledge translation tools have the potential to improve and standardize screening practices, optimize resources, as well as promote interprofessional teamwork and coordination among those 13  involved in the continuum of care for DDH.70 Ideally, the care pathway will also align with government health priorities, including the reduction of infant morbidity and the economic burden of treatable conditions such as DDH.  The majority of screening programmes have been developed in high-income, Global North countries. In contrast, many countries in the Global South lack standardized DDH screening and surveillance, resulting in late detections. Existing screening programmes are unlikely to be applicable in other countries, which have unique healthcare systems and populations. Global South countries such as India may also face specific financial, geographic, and social barriers to care that must be addressed. Thus, to successfully implement standardized hip screening, countries need a care pathway designed with input from local providers and specifically for the local context. A methodology for its design must be feasible yet rigorous enough to ensure that the care pathway reflects best practices within the country. In India, there is clear evidence of DDH diagnosed after walking age. This, along with existing support for a DDH care pathway among local orthopaedic surgeons, provides a solid foundation to design a methodology for care pathway development and launch the process in India.63   1.6 Research Aim  The aim of this study was to generate a methodology to develop context-specific DDH care pathways in Global South countries, with a use-case in India. Our goals for the methodology were that it was a) cost-effective b) time-effective c) incorporated both evidence in the literature and the expertise of local providers and d) easily adaptable for use in other contexts (other countries and for other conditions). Our goals for the resulting care pathway were that it was comprehensive, feasible, and effective across the country\u2019s diverse landscape. 14  We describe here the multi-phased approach that was designed, how the process was applied in India to develop a national DDH care pathway for the country, and explain how this methodology can be applied to guide efforts in other countries and for other conditions.          15  Chapter 2: Methodology and India Use-Case 2.1 Overview of Study Design  A three-phased approach was designed for care pathway development, requiring successful completion of the previous phase to continue into the subsequent phase (Figure 2).   Figure 2. Flow diagram of the multi-phase process used for care pathway development. Adapted from Salkind NJ, eds. Encyclopedia of Measurement and Statistics. Thousand Oaks, CA: Sage Publications, Inc.; 2007: 242. Doi:10.4135\/9781412952644  16  Phase I focused primarily on preparation for Phase II, which used the Delphi method to reach expert consensus on statements regarding DDH screening. Phase III used the results from Phase II to develop and finalize the DDH care pathway. Time, logistical, and financial constraints were all considered during study design, while still maintaining a rigorous scientific approach that was grounded in evidence from the literature and incorporated the feedback of local experts. Ethics approval was obtained by the coordinating institution (The University of British Columbia).  2.1.1 Study Participants This study involved two tiers of participants. The main participants were the members of the working group, who were recruited through organizational partnerships throughout Phase I. These participants were all known to each other during the entire process and could choose to withdraw from the study at any point. Working group members participated in the literature review and preparatory meetings. They also participated as panelists during the Delphi method and provided feedback on the resulting care pathway. Some members were also involved in the development of specialty surveys, which were distributed to organizational memberships representing different specialty groups, including pediatrics, neonatology, and radiology. The respondents to the specialty surveys formed the next tier of study participants. Participation in specialty surveys was voluntary.  2.1.2 Methods of Communication and Data Collection The main study procedures required virtual group communication and survey collection. All meetings were hosted on the Zoom platform (Zoom Video Communications, Inc., San Jose, CA, USA), with a unique private link sent to group members beforehand. Zoom meetings were 17  recorded with consent from attendees and uploaded to a cloud-based server that was shared with group participants. Between meetings, email and the messaging platform WhatsApp (WhatsApp Inc., Mountain View, CA, USA) were used to facilitate communication between group members and distribute survey links. All surveys were administered using the Research Electronic Data Capture (REDCap) tool (REDCap., Vanderbilt University, Nashville, TN, USA), a secure web application designed for building and managing online surveys and databases, hosted at the coordinating institution.71,72 Surveys were designed to be completed within 30-minutes, and meetings were scheduled for one hour in length. Participants were asked to consent to their participation at the beginning of each survey. For meetings, attendance was implied consent.  2.2 Phase I  Phase I focused on preparation for the following phase. The initial step in Phase I was to establish organizational partnerships and subsequently recruit working group members for the consensus-building process in Phase II. Knowledge-building was also done during this stage\u2014a literature review was conducted to standardize an evidence base among the working group, while specialty surveys were developed and distributed to members of partnered organizations to better understand the current state of DDH screening among local healthcare providers in India.   2.2.1 Working Group Formation  The working group was formed with consideration to geographic diversity, positional leadership, expertise, and representation from all specialties involved in the continuum of DDH care. The Paediatric Orthopaedic Society of India (POSI) and the Indian Academy of Pediatrics (IAP) led this joint initiative in India, with participation from five additional national organizations and 18  support from international collaborators. A local project lead enlisted key members from POSI and IAP to join the expert panel, and partnerships were then formed with other organizations relevant to the care of DDH in India, including the National Neonatology Forum of India (NNFI), Indian Radiological & Imaging Association (IRIA), Indian Federation of Ultrasound in Medicine & Biology (IFUMB), Federation of Obstetric & Gynaecological Societies of India (FOGSI), and Indian Orthopaedic Association (IOA). The participating organizations, as well as their approximate memberships, are listed in Table 1. After extending invitations to lead organization members, each lead subsequently nominated representatives to join the group. The resulting group, designated as the DDH India Care Pathway Working Group, ultimately consisted of a group of local orthopaedic surgeons, pediatricians, neonatologists, obstetrician- gynaecologists, and radiologists.   Table 1. List of participating organizations in India and their approximate membership size.  Organization Membership  Paediatric Orthopaedic Society of India 650  Indian Academy of Pediatrics 33,000  Indian Orthopaedic Association 15,000  19    Organization Membership  Indian Federation of Ultrasound in Medicine & Biology 2500  Federation of Obstetric & Gynaecological Societies of India 37,000  Indian Radiological & Imaging Association 18,000  National Neonatology Forum of India 8500  2.2.2 Survey of Specialty Groups Specialty surveys were developed in collaboration with international investigators and working group members from respective organizations. In India, the pediatricians\/neonatologists and radiologists were queried on practice patterns, resource availability, screening and referral pathways, and attitudes toward care pathways. Discipline-specific questions were also asked\u2014pediatricians and neonatologists were queried on risk factors and swaddling, while radiologists were asked about imaging techniques and parameters. An orthopaedic surgeon survey was also developed and distributed to POSI membership, which occurred prior to thesis start.63 20  Finalized surveys were distributed to member lists of the target organizations. Responses were then analyzed for trends. Categorical and ordinal variables were described using percentages and frequencies, while continuous variables were described using mean and range. Aggregate results were shared and discussed with the working group during virtual meetings. The survey of pediatricians and neonatologists was initially sent to the membership list of IAP. However, due to a low number of responses (N=84), the survey was then sent to NNFI membership (Appendix A), where 231 responses were obtained. Because of overlapping membership between IAP and NNFI and a lack of collected personal identifiers, only the NNFI survey responses were analyzed.  Respondents to this survey had a mean practice experience of 11 years (range 0-50 years), with 92% working in an urban setting.73 The survey found that 97% who screen for DDH use clinical exam as a screening tool, followed by ultrasound (43%) and X-ray (11%).73 Approximately one quarter (25%) of respondents were not at all or only somewhat comfortable performing Ortolani and Barlow exams, and 53% were aware of hip-safe swaddling practices.73 Additionally, ultrasound was accessible to 92% of respondents; however, the quality of reporting was variable. Almost all respondents (97%) indicated a need for a DDH care pathway in India.73 The survey of radiologists was sent to members of IRIA and IFUMB (Appendix B). There were 44 respondents, with a mean practice experience of 17 years (range 1-40 years) and 89% who reported working in an urban setting. When queried on the need for a DDH care pathway in India, 95% indicated that it was necessary. Key results related to DDH screening, diagnoses, and referral practices are summarized in Table 2.    21  Table 2. Results of the IRIA\/IFUMB specialty survey.  Neonatal Hip Imaging Exams Performed Per Year (N=44)      <50      50-100      100-200      >200   35 (79.5%) 9 (20.5%) 0 (0.0%) 0 (0.0%) Screening Tools Used (N=24)      Radiographs      Ultrasound      Other  11 (45.8%) 24 (100%) 1 (4.2%) DDH Diagnoses in the Past 12 Months (N=43)      <25      25-50      50-75      >75  42 (97.7%) 1 (2.3%) 0 (0.0%) 0 (0.0%) Ultrasound Classification System (N=38)      Graf      Harcke      Other    38 (100%) 7 (18.4%) 0 (0.0%) X-ray Positioning (N=43)      Frog Leg Lateral      AP Pelvis      AIR (abduction-internal rotation)   35 (81.4%) 20 (46.5%) 13 (30.2%) 22  X-ray Classification System (N=34)      Tonnis      IHDI      Other  27 (79.4%) 11 (32.4%) 2 (5.9%)  Age Range of Referrals (N=42)      0-6 weeks      6 weeks - 3 months       3-6 months      6 months - 1 year      1-2 years      2-5 years      5-10 years      >10 years    20 (47.6%) 24 (57.1%) 17 (40.5%) 14 (33.3%) 4 (9.5%) 2 (4.8%) 3 (7.1%) 1 (2.4%) Percentage of Screening Ultrasounds <3 Months of Age (N=40)      <25%      25-50%      50-75%      >75%  17 (42.5%) 12 (30.0%) 2 (5.0%) 9 (22.5%) Ultrasound Access within 10 km (N=39)      Yes      No  32 (82.1%) 7 (17.9%)    23  X-ray Access within 10 km (N=39)      Yes   33 (84.6%)      No 6 (15.4%)  2.2.3 Literature Review The group literature review process occurred concurrently with the specialty surveys. Virtual meetings were held fortnightly over a three-month span, which included scheduled presentations by group members followed by questions and discussion. Presenters synthesized relevant high-quality articles on designated topics, including the importance of screening, the incidence of DDH, the role of clinical examination, and imaging with X-ray and ultrasound. An online repository of comprehensive literature was created for the group and stored on the cloud-based server for ready reference. Due to time constraints, group members were asked to familiarize themselves with the remaining literature on their own time.  2.2.4 Preparatory Meeting for Consensus-building Upon completion of the literature review, the consensus-building phase was introduced. During an introductory meeting, the external facilitator (JL) reviewed existing care pathways and explained the upcoming modified Delphi approach for consensus-building, outlining past uses of the Delphi in orthopaedic research along with their role, significance, and the extent of their expected commitment as a panelist in Phase II. The group then discussed and agreed upon criteria for the Delphi methodology.  24  2.3 Phase II   2.3.1 The Delphi Method The aim of Phase II was to reach consensus on a comprehensive list of statements reflecting the best practices for DDH screening and surveillance in India. To do this, the Delphi method was chosen, which is a structured consensus-building tool that employs iterative rounds of surveys and expert group feedback.74 Conducting the Delphi method requires an expert panel, that participates in consensus-building, as well as one or multiple facilitators who coordinate the study processes.  The iterative surveying begins with a preliminary survey that is distributed to panelists at the start of the Delphi. The facilitator then uses the preliminary survey results to generate statements for the first round of the Delphi survey. The panelists individually complete the Delphi survey, evaluating each statement using a defined measurement scale.75 The facilitator then collects all responses and analyzes each statement for a threshold of consensus, which is commonly a minimum level of agreement.75 Using these results, the facilitator designs the next iteration, with the goal of modifying the survey so that more statements reach consensus in the following round.75 In each consecutive Delphi survey, panelists are also provided feedback in the form of the overall group response from the previous rounds. The purpose of this feedback is to encourage panelists to reflect and potentially reconsider their responses to contentious statements.75 Ideally, with each consecutive round, the process leads to a convergence of opinion as more statements reach consensus. The process of iterative surveys and group feedback concludes when a pre-specified stop criterion is reached, which is usually once a certain amount of statements reach consensus or once the process reaches a point of diminishing returns.75  25  2.3.2 Modifications to the Delphi Method During the entire Delphi method, panelists are not known to each other and their only feedback is in the form of the aggregate group response.75 However, the process used in this study was modified to give respondents more flexibility, as well as greater opportunities for discussion and opinion-sharing. The modified procedure incorporated virtual meetings that were held following each round of survey to discuss results as a group. Additionally, optional comment boxes were added to the surveys, providing panelists with the opportunity to anonymously address concerns, propose changes, ask questions, and\/or explain the rationale for their selected level of agreement with each statement. A N\/A option was also included, which would exclude the respondent from the denominator if selected.  2.3.3 Delphi Rules and Criteria A priori, the group agreed on a measurement scale, a consensus threshold, and stop criteria. They decided that consensus statements would be rated on a five-point Likert scale, ranging from Strongly Agree to Strongly Disagree. They also established 80% as the threshold of consensus for a given statement (\u2265 80% of respondents selecting \u201cagree\u201d or \u201cstrongly agree\u201d). Thus, if a statement reached this threshold, it was automatically removed from the survey and incorporated into the final list of statements. If a statement did not reach this threshold, it was either removed or modified at the discretion of the facilitator. New statements could also be developed. For the stop criteria, it was decided that the consensus process would conclude a) when 90% of statements reached consensus or b) after four rounds of Delphi.  Due to the iterative nature of the Delphi method, continued participation in each survey round was required. Therefore, if a panelist missed a survey round, they were unable to 26  participate in any future rounds. Meeting attendance was highly recommended; however, due to the busy schedules of group members and respect for privacy, individuals could opt to view a recorded version of the meeting or a slide deck containing the results and summary of the discussion, which would allow them to participate in the following round.  2.3.4 Procedure All surveys were administered using REDCap and distributed by email and WhatsApp messaging. Panelists were given two weeks to complete each Delphi survey\u2014non-respondents were sent reminders throughout the period.  Delphi surveys consisted of a set of statements that covered all touchpoints of DDH screening, including the timing, frequency, and method of examination via clinical tests, X-ray, and\/or ultrasound imaging. Statements that referenced clinical tests (e.g. Barlow, Ortolani), or classification systems (e.g. Graf, IHDI), were supplemented with graphics. In the second round of Delphi onwards, surveys also included relevant results from the previous round. An example of a statement asked in the second round is illustrated in Figure 3.      27   Figure 3. A second round Delphi survey statement asked during the India care pathway consensus-building process. This statement did not reach the threshold of consensus in the first round and was subsequently modified for the second round based on group feedback. The results from the first round are shown first, which includes the statement\u2019s level of consensus, a bar graph showing response frequencies, and anonymous group comments. The new statement is presented below.  Once the survey was closed, the facilitator analysed each statement for the level of agreement and determined whether it reached the consensus threshold of 80%. The cumulative 28  percentage of statements that reached consensus was also calculated to determine if another Delphi round was needed.  During the group meetings, the external facilitator presented the aggregate results, as well as the anonymous comments, in the form of frequency bar graphs. The facilitator also moderated group discussion of the results, focusing on contentious statements. Upon conclusion of the meetings, JL, ES, and AA evaluated all group feedback and modified the survey for the following round. This process was repeated until one of the stop criteria was reached.  2.3.5 Preliminary Delphi \u201cpre-Delphi\u201d Survey  The preliminary survey served as the foundation for the subsequent Delphi survey, and was developed after a review of existing DDH screening programmes and care pathways. For this study, panelists were asked 33 questions about their practice characteristics and opinions regarding DDH screening: risk factors, clinical exam, ultrasound, X-ray, and timing of referral (Appendix C). The demographic characteristics of the 29 respondents were also collected (Table 3). At the preliminary Delphi meeting, 16\/29 (55%) panelists were in attendance.  Table 3. Demographic characteristics of the 29 respondents to the preliminary Delphi survey.  Clinical Occupation       Orthopaedic Surgeon      Pediatrician      Radiologist      Obstetrician-Gynaecologist      Neonatologist  10 (34.5%) 10 (34.5%) 4 (13.8%) 3 (10.3%) 2 (6.9%) 29  Organization Representation       Pediatric Orthopaedic Society of India      Indian Academy of Pediatrics      Indian Radiological & Imaging Association      National Neonatology Forum of India      Indian Federation of Ultrasound in Medicine & Biology      Federation of Obstetric & Gynaecological Societies of India      Indian Orthopaedic Association  9 (31.0%) 9 (31.0%) 2 (6.9%) 3 (10.3%) 2 (6.9%) 3 (10.3%) 1 (3.4%) Private vs Public Sector Experience       Private      Public      Both  9 (31.0%) 5 (17.2%) 15 (51.7%) Solo vs Group Setting       Solo      Group      Partnership      Other  11 (37.9%) 16 (55.2%) 1 (3.4%) 1 (3.4%) Urban vs Rural Setting       Urban      Urban & Rural  28 (96.6%) 1 (3.4%)  2.3.6 Delphi Surveys The results of the preliminary survey were used to frame consensus statements for the Round 1 Delphi survey, which consisted of 37 statements (Appendix D). In total, 28\/29 (97%) 30  preliminary survey respondents completed the Round 1 Delphi survey and 13\/28 (46%) were in attendance at the meeting. In total 70% (26\/37) of statements reached consensus, thus necessitating another Delphi round. Following the group meeting, eight new statements were developed based on issues raised during discussion, 11 statements that had not reached consensus were re-worded into 13 statements, and one statement which was previously agreed upon was also re-worded and included. Round 2 of the Delphi survey in India thus consisted of 22 statements (Appendix E) and was completed by 25\/28 (89%) respondents from the first round. In total, 17\/25 (68%) panelists were in attendance at the meeting. In this round, 20\/22 statements reached consensus for a cumulative 96% (45\/47), thus meeting the criteria to end the Delphi process. Another meeting was held to share the survey results, discuss the two remaining statements that did not reach consensus, and formally announce the conclusion of the Delphi. The complete consensus results of the Delphi surveys can be found in Appendix F.  2.3.7 Statement Finalization The two remaining statements that did not reach consensus were re-distributed along with a rationale\/summary of the group discussion through email. All 25 participants who completed the Round 2 Delphi survey responded, with both statements reaching consensus. These statements were then incorporated into the list, for a total of 47 consensus statements. JL, ES, and AA then reviewed the complete list of statements and divided them into five categories. During this process, 18 statements were simplified into eight statements and two statements were deleted, resulting in a final list of 35 statements (Table 4).   31  Table 4. Final list of 35 consensus statements developed for the DDH India Care Pathway subdivided into five categories.   32  2.4 Phase III  In the third phase, a core writing group applied the finalized consensus statements to create the DDH care pathway algorithm for India and written guidelines. The written version included a brief outline of the study methodology and key rationale for specific recommendations. All materials were circulated to the working group for feedback. After multiple rounds of revisions, a final meeting was held to review the care pathway before finalization and formal endorsement from all organizations. A summary of the complete consensus-building process used in India, with results, is depicted in Figure 4. 33   Figure 4. Flow diagram of the consensus-building process for DDH care pathway development in India. N=number of survey respondents.  34  2.4.1 Final DDH Care Pathway in India The complete consensus-building and guideline development process was completed in approximately five months (Figure 5).    Figure 5. Timeline of the Delphi method and care pathway development in India.  The care pathway was designed to reflect the current expert-based consensus among physicians in India, covering all aspects of DDH screening from initial clinical evaluation until either orthopaedic referral or conclusion of surveillance. Key features of the care pathway are described in Table 5.   35  Table 5. Key features of the DDH Care Pathway for India.   The finalized care pathway algorithm is shown in Figure 6, with the supplementary guidelines published in Indian Pediatrics.76 36   Figure 6. The final DDH care pathway algorithm developed for India. Copyrighted to the Paediatric Orthopaedic Society of India [POSI] and reproduced with permission.77  37  Chapter 3: Discussion of Methodology This study demonstrates the successful design and application of a methodology for the development of a DDH care pathway in India. With a growing population of over 1.3 billion people and 25 million yearly births, the development of a care pathway was essential, as established programmes and care pathways in the Global North lack utility in the large and complex Indian healthcare setting. The developed care pathway emphasizes routine screening and surveillance, excluding post-screening treatment\/management practices. This decision was made due to the lack of high-quality studies comparing treatment methods as well as dependency of decision-making on the clinical experience of the treating orthopaedic surgeon, especially in the older patient.12 Only one known DDH care pathway has been developed in the past. A regional care pathway, developed for the St. Luke\u2019s Health System in Idaho, USA, considers the state\u2019s unique geographic characteristics and rural population.78 The pathway provides primary care practitioners and pediatricians with a simple algorithm to manage the individualized screening of infants under two years of age. While it is designed to standardize patient care and enhance the early detection of DDH throughout the health system, it also allows for flexibility, providing alternative pathways for those lacking access to ideal imaging, and ensuring that all children in the health system receive quality DDH screening regardless of their location or life circumstance. With the same intentions in mind, we sought to develop a methodology that could be applied on a much larger scale and in lower-resource settings. There are many benefits to care pathways; however, a variety of facilitators and barriers may impede successful implementation at all stages.79 In the development process, a primary barrier is a lack of involvement of relevant providers.79 During implementation, key barriers to 38  care pathway adherence include a lack of awareness or agreement with the guidelines, knowledge gaps, inconvenience or impracticality of the guidelines, and external barriers such as resource availability.79,80 These barriers were identified and addressed throughout all phases of the methodology in the current study.    3.1 The Delphi Method in DDH Research While the Delphi method was originally developed as a military forecasting tool, it has now become a popular consensus-building tool in healthcare research.74,75 Common uses in orthopaedics include the development of best practice guidelines, the identification of research priorities, and the establishment of surgical indications.81\u201387 Focusing specifically on DDH, Kelley et al. (2019) used the Delphi method to reach consensus on a set of principles for management with a Pavlik harness.88 Similarly, Roposch et al. (2011) established international consensus on diagnostic criteria for DDH in early infancy using a Delphi method; however, the consensus gained from these studies was more generalizable, informing practice and emphasizing global as opposed to regional or country-specific guidance.89 Consensus on screening practices, in contrast, is much less generalizable and more sensitive to local needs, such as the health system and the resources available.  3.2 Rationale for the Modified Delphi Method This is the first known study to use the Delphi method for the development of a DDH care pathway. While there are many techniques for consensus-building, two of the most popular include the nominal group technique and Delphi method.90 Both methods are suitable when there is incomplete knowledge on the subject, and where the judgement of a group of experts is 39  superior to individual opinion. The nominal group technique consists of a structured group meeting where members individually develop ideas, present their ideas to the group, then discuss and prioritize them through a vote.90,91 The Delphi method similarly consists of structured group interactions and involves expert consensus; however, unlike the nominal group technique, the Delphi incorporates iterative surveying, allowing statements to be developed and refined.92 As a result, the Delphi requires a longer commitment and is often conducted when dealing with a larger group.92 While the nominal group technique is better applied for brainstorming or idea generation, the Delphi method is preferred for guideline development.90,92 Thus, our decision to apply the Delphi method in this study, with modifications to improve group feedback, was due to its applicability to our study goals and its ability to accommodate a larger group size.   3.2.1 Time-effectiveness and Cost-effectiveness The existing controversy and lack of complete knowledge about best practices for DDH screening necessitated a consensus-building approach that integrated evidence in the literature with the best judgment of experts. The Delphi method was ideal, with an added benefit being the ability to conduct the method virtually. This resolved the logistical challenges of coordinating in-person meetings with a panel that was large and geographically dispersed across India, and with research collaborators located in Canada.93 Thus, the group could meet more frequently within a shorter time span, which mitigated the drawback of choosing a consensus-building method requiring long-term commitment. The virtual process also allowed us to continue despite the onset of the COVID-19 pandemic. Ultimately, the modified Delphi method proved to be cost-effective, as we avoided the costs associated with travel and required only minimal resources that 40  were either free of charge or already available in our research lab to complete the study procedures.  3.2.2 Face-to-Face Interactions The classical Delphi method does not include face-to-face interaction and discussion with or between participants, and instead includes only the administration of iterative surveys to panel members in isolation.75 However, modifications to the Delphi method are frequently reported, such as the incorporation of group meetings between rounds.86,87 We believed that the addition of real-time debate would strengthen our ability to understand all viewpoints and ultimately design a care pathway that was best tailored to the local context. The implementation of face-to-face Zoom discussions between survey iterations, along with the shared email and messaging groups, allowed for more thorough discussion and exchange of information, which would not have been possible through surveys. We hypothesize that this allowed the group in India to achieve consensus faster than if a standard Delphi method was used. Additionally, as a large initiative with the goal of nationwide uptake, we decided that it was essential that group members were known to each other. We believe that the interactions strengthened rapport, facilitated group unity, and held participants more accountable for their responses, which subsequently increased the effectiveness of debate and discussion.   3.3 Identified Knowledge Gaps  3.3.1 Awareness of DDH Screening Practices The specialty surveys in Phase I were useful in identifying critical knowledge gaps and potential barriers to successful care pathway implementation. For the IAP survey, we hypothesized that 41  the low response rate was due to a lack of awareness about DDH, resulting in discomfort in completing the questions. As primary users of the care pathway, we believed it was important to raise awareness on the importance of DDH screening. To do this, infographics outlining the incidence of DDH, risk factors, diagnostic tools, and the importance of early detection and management were developed and circulated to organizational members.  The results of the NNFI survey corroborated our hypothesis, demonstrating low awareness about DDH, particularly on safe swaddling practices and risk factor screening.73 The survey also found limited experience with clinical examination and imaging tools, which are the foundation of screening. These results suggested the need to take additional measures with regard to education\u2014our team hired a professional illustrator to develop culturally-sensitive graphics depicting the recommended clinical examinations for screening as a supplement to the care pathway algorithm.  The radiologists survey also suffered from a low response rate, which may similarly reflect low awareness about DDH screening. Only half of respondents indicated screening for DDH. Additionally, 42.5% indicated that a quarter or less of their screening ultrasounds from referrals are performed when the child is less than three months of age, despite this time frame being critical for early detection. This supports the existing concerns of orthopaedic surgeons in India about under-referrals from primary care physicians, which frequently occur without satisfactory imaging.63 To assist radiologists in India and encourage the adoption of DDH screening, select group members worked to develop supplementary guidance for performing hip X-ray and ultrasound exams that were beyond the scope of our care pathway but nevertheless crucial for uptake. 42  Although many measures were taken to increase awareness, it is important to acknowledge that education and training of healthcare professionals, especially in a country as large as India, is a challenging and long-term process that will require additional action throughout implementation.  3.3.2 Radiation  One pressing concern that arose during the literature review was that of radiation exposure. This was raised by many group members when X-ray was discussed as a potential screening tool. To ensure that participant concerns were addressed, a presentation by KM was given to thoroughly explain the advantages and disadvantages of using X-ray as a screening tool, as well as the radiation dosage of a standard pelvic X-ray and its relative safety. It is likely that this concern is reflected in the greater population, and will need to be addressed through awareness and education campaigns in the future.  3.3.3 Imaging Controversy The specialty surveys and preliminary Delphi survey indicated that ultrasound and X-ray were available, but put into question the quality of obtained ultrasounds and the reliability of interpretation. These findings complicated the existing debate on selective versus universal ultrasound screening and necessitated discussions on the use of X-ray in cases where quality ultrasound, defined as both accessible and accurately interpreted, could not be obtained. While all panelists agreed that the availability of quality ultrasound reporting and interpretation must be considered when determining imaging modality, there was noteworthy variability in opinions on 43  the age range for ultrasounds and particularly on the lower age limit for X-rays. This was ultimately resolved through the consensus-building process.  3.4 Applicability in the Indian Context 3.4.1 Timing of Examinations A key consideration to improve reach was the timing of routine clinical examinations, as it became apparent that bringing children in solely for hip examinations would be challenging and many would be lost to follow-up. As such, the schedule for hip examinations was aligned with the recommended immunization schedule of the Universal Immunization Programme, which brings in millions of children for free vaccinations beginning at birth until five years of age.94 The timeframe for screening was also decided with the Indian context in mind. While a newborn clinical exam is universally accepted to screen for DDH, the AAOS has recommended routine clinical examinations up to six months of age, even after an initial normal physical exam.7 However, due to the evidence of late detections after walking age in India, along with concerns about missed or delayed care, it was decided to extend the schedule to include examinations of the older infant up to 18 months of age.  The guidelines are particularly encouraged for those that do not access public healthcare. Within the public sector, however, the guidelines seek to expand on the RBSK screening program, providing clearer and more detailed guidance on age-appropriate clinical tests, pathways for referral, and including X-ray as a screening tool.76 Leveraging existing programmes will be key to improving compliance from patients and providers alike, simplifying implementation and maximizing uptake. A similar approach should be considered when designing future care pathways.  44  3.4.2 Healthcare Providers for Screening An important consideration when designing the care pathway was that it was applicable in the entire healthcare system and the nation\u2019s diverse practice settings and geographic locations. The preliminary Delphi survey highlighted the need to incorporate trained paramedical personnel as potential users of the care pathway. Through group discussions, it became evident that healthcare in rural areas is often delivered by providers without formal medical training. Thus, with the goal of increasing reach, it was decided to open care pathway usage to providers specific to the Indian context, including auxiliary nurse midwives, accredited social health workers, mobile health teams at the community level, and medical teams at district early intervention centers and district hospitals. The simplicity of the algorithm, the accompanying graphics, and the supporting guidelines document, which provides more detailed instructions supported with rationale from the literature, is designed to encourage its use by healthcare providers of all levels.76 However, further support of care pathway users is required, such as through education and training initiatives.  3.4.3 Imaging Flexibility The designed care pathway addresses the variability in access to imaging that was made apparent in the specialty surveys. To ensure that more babies have the opportunity to be screened, it was decided to lower the minimum age of X-ray, which is more readily available than ultrasound. Ultimately, the group reached consensus to lower the minimum age of X-ray to 14 weeks, allowing it to be used as a screening tool in the absence of quality ultrasound access. The opportunity for providers to choose between an X-ray and ultrasound for infants requiring 45  imaging between 14 weeks and six months of age, a critical time frame for early detection, not only encourages care pathway use in lower-resource settings but also gives providers the opportunity to use their best judgement given their unique situation and level of experience\/familiarity with screening tools.  The timing of initial imaging was also flexible to accommodate for resource variability and the best interest of the patient. A common concern among many panelists was that patients would fail to return for hip imaging, which would hinder the potential for early diagnosis and referral. Thus, while the care pathway recommends waiting to perform an ultrasound until six weeks of age, one can be performed earlier if the healthcare provider is concerned about losing the patient to follow-up.   3.5 Study Strengths  3.5.1 Group Diversity As DDH care often involves a multidisciplinary team, we wished to recruit members from all relevant specialties.79 The initiative began with a group of orthopaedic surgeons, led by POSI; however, other organizations were added during Phase I through our evolving understanding of the Indian healthcare system and the various specialty groups involved in the care of patients with DDH. The main users of the care pathway were determined to be pediatricians and neonatologists, resulting in the onboarding of IAP and NNFI. Additionally, considering the importance of imaging for DDH screening, the restricted access to ultrasound due to the PCPNDT Act, and the potential variability in the quality and reliability of ultrasound reporting and interpretation in urban versus rural areas, it was also important to involve radiologists to provide feedback on the ideal timing and modality of imaging for DDH screening. After the 46  recruitment of IRIA and IFUMB, it was further decided to involve FOGSI. While obstetrician-gynaecologists may not be relevant to the care of DDH patients in many Global North countries, their participation was deemed important in the Indian healthcare setting as a frequent first point of contact with newborns and their families. In addition to serving as potential examiners of newborn hips, obstetrician-gynaecologists are an important resource for families in India, often guiding parents on various aspects of newborn care, such as hip-safe swaddling practices.  One challenge faced with involving a diverse group was a difference in expertise and familiarity with the current literature on DDH screening, which was particularly evident between specialties. The literature review and the creation of the online repository prior to consensus-building were thus included with the goal to develop a strong evidence base for all members to construct their opinions during the consensus-building phase. In case a panelist still felt they had inadequate knowledge to form an opinion on certain statements, we included an N\/A option in the Delphi surveys. The benefit of incorporating the literature review was evident in the results of the Delphi method, as the N\/A was infrequently selected in Round 1 (1.74%, 18\/1036) and even less in Round 2 (0.91%, 5\/550). The statements for which N\/A was selected most often were those regarding imaging classification systems. In future studies, it will be important to gauge the knowledge level of all group members to determine the extent of literature review that is necessary. With the multidisciplinary working group that we recruited, there was greater opportunity to understand alternative viewpoints and ensured a wide knowledge base. It also allowed us to resolve any disconnect between specialties prior to implementation and led to a coordinated care pathway that reflected unified consensus of all relevant physician providers. Although larger and more diverse groups require additional steps to ensure that the consensus-building process is fair 47  and inclusive; we believe it increased the value of the study and the applicability of the resulting care pathway.  3.5.2 Future Buy-in of the Care Pathway When composing the expert panel, we also considered the future challenge we might experience during nationwide implementation and potential lobbying for government support. Thus, we believed that it was critical to obtain organizational endorsement at the early stages of care pathway development to increase buy-in. The influence of each expert panel member was also important\u2014all panelists were leaders or nominated by leaders of their respective organizations. While this process could have been conducted with any group of physicians in India, the involvement of key leaders and stakeholders will have significant influence on future buy-in and implementation.  The specialty surveys, including the survey of orthopaedic surgeons by Hooper et al. (2020), built awareness among providers about the need for DDH screening and allowed us to confirm support for a DDH care pathway designed specifically for the Indian context.63,73 The unification of seven national organizations, which combined represent approximately 115,000 healthcare professionals, will allow us to target a large number of intended care pathway users.  3.5.3 Maximizing Group Engagement and Participation The Delphi method is more effective when there is greater participation, so it was important that appropriate measures were taken to maximize the engagement of group members during the consensus-building process.75 High participation motivation is a criterion for a successful Delphi method, and sustained motivation is one of the greatest challenges due to the long-term 48  commitment that is required as well as the gaps of time between Delphi rounds.75,90 This proved to be an even greater challenge in this study, as the commitment that was required extended beyond just the Delphi method. While the purpose of the group meetings during Phase I was to standardize an evidence base, it also allowed the members to meet and establish rapport. We posit that fostering relationships with and among group members increased engagement, reduced dropout, and made panelists more open to idea-sharing.75  The time spent explaining the Delphi method and the commitment required further increased motivation.75 By clarifying the process and outlining expectations, we believed that participants who ultimately chose to continue into Phase II would be less likely to drop out. Throughout Phase II, participants were also consistently reminded of the value of their participation, which has been suggested to enhance response rates.75 Within Phase II, the sustained motivation of the group is reflected in our high retention rates of 97% from the preliminary Delphi round to the first Delphi round, and 89% from the first Delphi round to the second Delphi round. Strategies that were used included frequent personalized follow-ups with survey non-respondents via phone calls, messaging, and email.75 These processes were spearheaded by the local project lead. With the group in India, a two-week window was ideal to maximize survey response rates while also maintaining momentum, although this length of time should be adjusted in accordance with specific group needs in future care pathway initiatives.  To maximize attendance at group meetings, a weekly time was chosen that best fit the majority\u2019s schedules and was postponed or rescheduled based on group feedback. Multiple reminders to attend meetings were also sent out in the days prior. Meeting recordings and detailed discussion notes made available to participants also reduced dropout rates\u2014those unable 49  to attend the meeting could participate in the next Delphi round if they reviewed these materials beforehand. When developing future care pathways, investigators must be wary of declining motivation and implement appropriate strategies to facilitate and maintain engagement.   3.6 Limitations One limitation of the use-case in India was the lack of representation from healthcare providers practicing in rural areas, both in the working group and the specialty surveys. Although the Indian population continues to urbanize, measures must be taken to ensure that babies in rural areas are not overlooked, as their risk for late detection may be greater due to limited resources and barriers to accessing care.  Despite the lack of rural representation, we continued the process with the assumption that the identified barriers were more pronounced in rural areas. The Delphi statements and resulting care pathway algorithm addressed these identified barriers, including resource variability, at every step. This included permitting a wide variety of trained physicians and paramedical personnel to perform clinical examinations and providing flexibility in the timing and\/or modality of imaging. Ideally, when developing future care pathways, further measures are needed to promote greater rural participation, such as the nomination of a rural representative in the working group and focused specialty surveys or interviews of rural providers.  Other key stakeholders, including nurses, paramedical personnel, and parents, were also not included in the working group. While these groups will be involved during the implementation and knowledge translation process in India, it will be important to consider their involvement in future care pathways at earlier stages. 50  Another inherent limitation of the methodology was the lack of anonymity during consensus-building due to the choice to modify the Delphi method to include group discussions between rounds. The purpose of anonymity in the standard Delphi is to remove obstacles that are often experienced in group settings, including the pressure to conform, and power dynamics leading to dominating voices.75,90 To address this, we incorporated strategies to reduce group pressures and ensure fairness, inclusion, and respect for participant privacy in all study procedures. Group participation in the literature review in Phase I standardized the knowledge base and gave panelists the opportunity to make informed opinions based on a combination of the existing evidence and their own experience. During consensus-building, participants were given multiple opportunities to contribute their opinions, whether during discussion or anonymously within the surveys. Surveys were also distributed outside of meeting times, as opposed to live voting, to reduce pressures. At the virtual meetings, the facilitators moderated discussions to incorporate outside perspectives, encourage respectful conduct, and ensure that all members who wished to speak had the opportunity to do so. Conflicting viewpoints, as well as the sharing of opinions from all specialties, were also encouraged. Additionally, the success of the initiative relies on the presence of a local stakeholder in the country to serve as the project lead. This individual must have the experience, expertise, passion, and positional leadership to unify all relevant organizations and motivate group members through all phases to ensure that the project goals are met.   3.7 Future directions There is an urgent need for action to reduce global inequities in DDH screening. A context-specific DDH care pathway such as this has the potential to benefit the millions of infants born 51  each year in the country. However, upon the conclusion of care pathway development, there is still more to be done. The success of the care pathway in India will depend upon its implementation and knowledge translation, and it will need to be revised periodically based on user feedback, new evidence, and the shifting healthcare landscape.   3.7.1 Uses in other countries and for other conditions The cost and time-effective methodology we have described can be used to develop care pathways in other countries, and may be particularly useful in regions with limited funds and other resources. The methodology is currently being used to develop a national DDH care pathway in Sri Lanka, with members of the India Care Pathway Working Group assisting in this process to share their expertise and lessons learned. Using a pay-it-forward model, this methodology can continue to be expanded to other Global South countries that would benefit from a standardized care pathway aimed at reducing late diagnoses of DDH. Our own experience has demonstrated that this methodology can be adapted not only in other countries but also for other conditions with a similarly large burden and controversy regarding best practices. Recently, our team worked to develop guidance for the surveillance of hip displacement in children with cerebral palsy in India. For this initiative, seven professional organizations collaborated, representing physiotherapists, orthopaedic surgeons, occupational therapists, pediatricians, neurologists, and professors of medicine. This initiative used the same three-phased approach, resulting in expert consensus on a national hip surveillance schedule based on a child\u2019s GMFCS level.  52  3.8 Conclusion  The late detection of DDH in Global South countries such as India necessitates global health initiatives to combat such delays. The three-phased methodology outlined in this paper integrates the best available evidence from the literature with the expertise of a diverse group of local experts, requiring a preparatory phase, a consensus-building phase using a modified Delphi approach, and a care pathway development\/writing phase. Execution of the methodology was conducted entirely virtually, required only limited funds and existing resources, and was completed in a relatively short timeline. The resulting DDH care pathway in India addresses local barriers to screening, is comprehensive, and can be implemented across the nation\u2019s diverse and complex health landscape. Other countries can apply this methodology to develop DDH care pathways, or care pathways for other conditions, that are unique to their local context.    53  References 1. Aronsson DD, Goldberg MJ, Kling Jr TF, Roy DR. Developmental Dysplasia of the Hip. Pediatrics. 1994;94(2):201-208. doi:10.1542\/peds.94.2.201 2. 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Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016\/J.JBI.2008.08.010 72. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95. doi:10.1016\/J.JBI.2019.103208 73. Anne RP, Li J, Schaeffer E, Aroojis A, Mulpuri K, Murki S. Care Practices of Indian Pediatricians for the Screening and Diagnosis of Developmental Dysplasia of the Hip. Indian J Pediatr. 2022;89(9):911-915. doi:10.1007\/S12098-022-04200-5 74. Dalkey N, Helmer O. An Experimental Application of the DELPHI Method to the Use of Experts. Manage Sci. 1963;9(3):458-467. doi:10.1287\/MNSC.9.3.458 75. Keeney S, McKenna H, Hasson F. The Delphi Technique in Nursing and Health Research. Blackwell Publishing; 2011.  76. Aroojis A, Anne RP, Li J, et al. Surveillance for Developmental Dysplasia of the Hip in India: Consensus Guidelines From the Pediatric Orthopaedic Society of India, Indian Academy of Pediatrics, National Neonatology Forum of India, Indian Radiological and Imaging Association, Indian Federation of Ultrasound in Medicine and Biology, 63  Federation of Obstetric and Gynaecological Societies of India, and Indian Orthopaedic Association. Indian Pediatr. 2022;59(8):626-635. 77. Algorithm for DDH screening in India. Paediatric Orthopaedic Society of India. https:\/\/posi.in\/DDH-screening-guideline-for-India.html. Accessed February 21, 2023.  78. Shea K, Price C. Turning a CPG into a Care Map. American Academy of Orthopaedic Surgeons. Published October 1, 2016. Accessed February 21, 2023. https:\/\/www.aaos.org\/AAOSNow\/2016\/Oct\/Research\/research03\/ 79. Evans-Lacko S, Jarrett M, McCrone P, Thornicroft G. Facilitators and barriers to implementing clinical care pathways. BMC Health Serv Res. 2010;10(1):1-6. doi:10.1186\/1472-6963-10-182 80. Cabana MD, Rand CS, Powe NR, et al. Why don\u2019t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-1465. doi:10.1001\/JAMA.282.15.1458 81. Roye BD, Simhon ME, Matsumoto H, et al. Establishing consensus on the best practice guidelines for the use of bracing in adolescent idiopathic scoliosis. Spine Deform. 2020;8(4):597-604. doi:10.1007\/S43390-020-00060-1 82. Vitale MG, Riedel MD, Glotzbecker MP, et al. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013;33(5):471-478. doi:10.1097\/BPO.0B013E3182840DE2 83. Roberts HJ, MacKechnie MC, Shearer DW, et al. Orthopaedic Trauma Research Priorities in Latin America: Developing Consensus Through a Modified Delphi Approach. J Bone Joint Surg Am. 2021;103(24):2318-2323. doi:10.2106\/JBJS.21.00271 64  84. Schneider PJ, Evaniew N, McKay P, Ghert M. Moving Forward Through Consensus: A Modified Delphi Approach to Determine the Top Research Priorities in Orthopaedic Oncology. Clin Orthop Relat Res. 2017;475(12):3044-3055. doi:10.1007\/S11999-017-5482-7 85. Perry DC, Wright JG, Cooke S, et al. A consensus exercise identifying priorities for research into clinical effectiveness among children\u2019s orthopaedic surgeons in the United Kingdom. Bone Joint J. 2018;100:680-684. doi:10.1302\/0301-620X.100B5.BJJ-2018-0051 86. McCarthy J, Shrader MW, Graham K, et al. Establishing surgical indications for hamstring lengthening and femoral derotational osteotomy in ambulatory children with cerebral palsy. J Child Orthop. 2020;14(1):50-57. doi:10.1302\/1863-2548.14.190173 87. Rutz E, McCarthy J, Shore BJ, et al. Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study. J Child Orthop. 2020;14(5):405-414. doi:10.1302\/1863-2548.14.200145 88. Kelley SP, Feeney MM, Maddock CL, Murnaghan ML, Bradley CS. Expert-Based Consensus on the Principles of Pavlik Harness Management of Developmental Dysplasia of the Hip. JB JS Open Access. 2019;4(4): e0054. doi:10.2106\/JBJS.OA.18.00054 89. Roposch A, Liu LQ, Hefti F, Clarke NMP, Wedge JH. Standardized diagnostic criteria for developmental dysplasia of the hip in early infancy. Clin Orthop Relat Res. 2011;469(12):3451-3461. doi:10.1007\/S11999-011-2066-9 90. Cantrill JA, Sibbald B, Buetow S. The Delphi and nominal group techniques in health services research. International Journal of Pharmacy Practice. 1996;4(2):67-74. doi:10.1111\/J.2042-7174.1996.TB00844.X 65  91. Van de Ven AH, Delbecq AL. The nominal group as a research instrument for exploratory health studies. Am J Public Health. 1972;62(3):337-342. doi:10.2105\/ajph.62.3.337 92. McMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38(3):655-662. doi:10.1007\/s11096-016-0257-x 93. Geist MR. Using the Delphi method to engage stakeholders: A comparison of two studies. Eval Program Plann. 2010;33(2):147-154. doi:10.1016\/J.EVALPROGPLAN.2009.06.006 94.  Universal Immunisation Programme. National Health Portal of India. Accessed February 21, 2023. https:\/\/www.nhp.gov.in\/universal-immunisation-programme_pg                         66 Appendices  Appendix A: IAP\/NNFI Survey     67   68   69   70   71   72    73 Appendix B: IRIA\/IFUMB Survey     74   75   76   77   78   79  80 Appendix C: Preliminary Delphi Survey 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 Appendix D: Round 1 Delphi Survey  97   98   99   100   101   102   103   104   105   106   107   108   109   110   111   112   113   114   115   116   117   118   119    120 Appendix E: Round 2 Delphi Survey      121   122   123   124   125   126   127   128   129   130   131   132   133   134   135   136   137   138   139   140   141    142 Appendix F: Consensus Results of the Delphi Surveys  Delphi Survey Consensus Results (Coded) ROUND 1  1. All babies should be screened for DDH using clinical examination. (96.4%) 20 Strongly agree 7 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   2. For the purpose of DDH screening, babies should receive a clinical hip examination at birth before the mother and baby are discharged and during well baby checks\/vaccination schedule. (100%) 20 Strongly agree 8 Agree 0 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   3. Clinical hip examinations can be performed by pediatricians, family doctors, neonatologists, orthopaedic surgeons, obstetricians, and paramedical personnel (e.g. Auxiliary Nurse Midwives\/ Accredited Social Health Workers\/ Anganwadi Workers\/Mobile health teams\/ Medical teams at District Early Intervention centers). (89.3%) 16 Strongly agree 9 Agree 2 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A       143 4. With regards to DDH screening, the minimum clinical tests for babies < 3 months of age include Ortolani and Barlow maneuvers. (96.3%) 17 Strongly agree 9 Agree 0 Neutral 0 Disagree 1 Strongly Disagree 1 N\/A   5. With regards to DDH screening, the minimum clinical tests for babies 3-6 months of age is limited hip abduction and Galeazzi test (unequal height of knees). (96.3%) 11 Strongly agree 15 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 1 N\/A   6. With regards to DDH screening, the minimum clinical tests for babies >6 months of age is limited hip abduction and Galeazzi test (unequal height of knees). (96.3%) 15 Strongly agree 11 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 1 N\/A    7. A baby < 3 months of age with a positive Ortolani test should obtain an ultrasound. (89.3%) 19 Strongly agree 6 Agree 3 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A    144 8. A baby < 3 months of age with a positive Ortolani test should be referred to an orthopaedic surgeon. (92.9%) 17 Strongly agree 9 Agree 1 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A   9. A baby < 1 month of age with a positive Barlow test should obtain an ultrasound. (75.0%) 11 Strongly agree 10 Agree 2 Neutral 4 Disagree 1 Strongly Disagree 0 N\/A   10. A baby < 1 month of age with a positive Barlow test should be referred to an orthopaedic surgeon. (71.4%) 13 Strongly agree 7 Agree 3 Neutral 4 Disagree 1 Strongly Disagree 0 N\/A    11. A baby 1-3 months of age with a positive Barlow test should obtain an ultrasound. (92.9%) 14 Strongly agree 12 Agree 1 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A     145 12. A baby 1-3 months of age with a positive Barlow test should be referred to an orthopaedic surgeon. (85.7%) 13 Strongly agree 11 Agree 1 Neutral 3 Disagree 0 Strongly Disagree 0 N\/A   13. A baby 3-6 months of age with limited hip abduction should obtain an ultrasound. (71.4%) 11 Strongly agree 9 Agree 2 Neutral 5 Disagree 1 Strongly Disagree 0 N\/A   14. A baby 3-6 months of age with limited hip abduction should be referred to an orthopaedic surgeon. (96.4%) 17 Strongly agree 10 Agree 0 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A   15. A baby 3-6 months of age with a positive Galeazzi test (unequal height of knees) should obtain an ultrasound. (67.9%) 9 Strongly agree 10 Agree 3 Neutral 6 Disagree 0 Strongly Disagree 0 N\/A     146 16. A baby 3-6 months of age with a positive Galeazzi test (unequal height of knees) should be referred to an orthopaedic surgeon. (96.4%) 16 Strongly agree 11 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   17. A baby >6 months of age with limited hip abduction should obtain an x-ray. (92.9%) 16 Strongly agree 10 Agree 2 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   18. A baby >6 months of age with limited hip abduction should be referred to an orthopaedic surgeon. (100%) 18 Strongly agree 9 Agree 0 Neutral 0 Disagree 0 Strongly Disagree 1 N\/A   19. A baby >6 months of age with a positive Galeazzi test (unequal height of knees) should obtain an x-ray. (85.7%) 15 Strongly agree 9 Agree 4 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A     147 20. A baby >6 months of age with a positive Galeazzi test (unequal height of knees) should be referred to an orthopaedic surgeon. (100%) 17 Strongly agree 11 Agree 0 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   21. A baby >6 months of age with a sign of limp should obtain an x-ray. (92.3%) 12 Strongly agree 12 Agree 1 Neutral 1 Disagree 0 Strongly Disagree 2 N\/A   22. A baby >6 months of age with a sign of limp should be referred to an orthopaedic surgeon. (88.9%) 16 Strongly agree 8 Agree 2 Neutral 1 Disagree 0 Strongly Disagree 1 N\/A   23. For babies with a normal clinical exam, the presence of risk factors should be assessed to determine the need for any follow-up. (96.4%) 15 Strongly agree 12 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A     148 24. For the purpose of DDH screening, risk factors include breech presentation, family history of DDH, improper swaddling practices, and a history of hip instability. (96.4%) 17 Strongly agree 10 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   25. A baby at any age with normal clinical exam and no risk factors present can return to routine health supervision. (77.8%) 14 Strongly agree 7 Agree 5 Neutral 1 Disagree 0 Strongly Disagree 1 N\/A   26. All babies < 3 months of age with a normal clinical exam but positive risk factors present should have a follow-up visit scheduled with an orthopaedic surgeon. (60.7%) 9 Strongly agree 8 Agree 6 Neutral 5 Disagree 0 Strongly Disagree 0 N\/A   27. All babies between 3-6 months of age with a normal clinical exam but positive risk factors present should have a follow-up visit scheduled with an orthopaedic surgeon. (53.6%) 9 Strongly agree 6 Agree 9 Neutral 4 Disagree 0 Strongly Disagree 0 N\/A    149 28. All babies >6 months of age with a normal clinical exam but positive risk factors present should have a follow-up visit scheduled with an orthopaedic surgeon. (53.6%) 9 Strongly agree 6 Agree 7 Neutral 6 Disagree 0 Strongly Disagree 0 N\/A   29. For the purpose of DDH screening, an ultrasound can be obtained any time from birth to 6 months of age. (75.0%) 9 Strongly agree 12 Agree 1 Neutral 6 Disagree 0 Strongly Disagree 0 N\/A   30. The Graf method should be used for ultrasound classification of DDH. (88.0%) 8 Strongly agree 14 Agree 3 Neutral 0 Disagree 0 Strongly Disagree 3 N\/A   31. For the purpose of DDH screening, the earliest age to obtain an x-ray is 3 months. (67.9%) 7 Strongly agree 12 Agree 4 Neutral 5 Disagree 0 Strongly Disagree 0 N\/A     150 32. For the purpose of DDH screening, an x-ray (after 3 months of age and in the presence of positive clinical exam and\/or positive risk factors) should be obtained if quality ultrasound reporting\/interpretation is not available in the area of practice. (89.3%) 13 Strongly agree 12 Agree 0 Neutral 3 Disagree 0 Strongly Disagree 0 N\/A   33. If an x-ray is needed, both an AP (anteroposterior) and Frog leg lateral are the minimum radiographs required for DDH screening. (85.7%) 12 Strongly agree 12 Agree 2 Neutral 2 Disagree 0 Strongly Disagree 0 N\/A   34. With regards to radiographs, IHDI classification should be used to grade dysplasia if the ossific nucleus is not present. (88.0%) 11 Strongly agree 11 Agree 3 Neutral 0 Disagree 0 Strongly Disagree 3 N\/A              151 35. With regards to radiographs, both IHDI and Tonnis classification should be used to grade dysplasia if the ossific nucleus is present. (79.2%) 11 Strongly agree 8 Agree 4 Neutral 1 Disagree 0 Strongly Disagree 4 N\/A   36. A baby with abnormal ultrasound findings should immediately be referred to an orthopaedic surgeon. (92.9%) 13 Strongly agree 13 Agree 1 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A   37. A baby with abnormal x-ray findings should immediately be referred to an orthopaedic surgeon. (96.4%) 15 Strongly agree 12 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A               152 ROUND 2  1. In all statements agreed upon in the previous round, the age cut-offs and ranges will be modified to fit the vaccination schedule as follows:        -  < 1 month of age \u2192 < 6 weeks of age         - < 3 months of age \u2192 < 14 weeks of age         - 1\u20133 months of age \u2192 6 weeks\u201314 weeks of age         - 3\u20136 months of age \u2192 14 weeks\u20136 months of age Do you agree with these changes? If you select no, please explain why in the comment box below: (88.0%) 22 Yes 3 No  2. \"Routine health supervision\" entails regular clinical hip examinations using age-appropriate tests that occur at birth and during vaccination schedules\/well-baby checks. Private sector: 6 weeks, 10 weeks, 14 weeks, 6 months, 9 months, 12 months, 15 months, 16-18 months. Government sector: 6 weeks, 10 weeks, 14 weeks, 9 months-12 months, 16-24 months. (92.0%) 10 Strongly agree 13 Agree 2 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   3. If an x-ray is needed, an AP radiograph is the minimum radiograph required for DDH screening. (100%) 12 Strongly agree 12 Agree 0 Neutral 0 Disagree 0 Strongly Disagree 1 N\/A           153 4. With regards to radiographs, IHDI and\/or Tonnis classification can be used to grade dysplasia if the ossific nucleus is present. (86.4%) 6 Strongly agree 13 Agree 2 Neutral 1 Disagree 0 Strongly Disagree 3 N\/A   5. If quality ultrasound is available, it CAN (not necessarily should) be used as a DDH screening tool any time from birth to 6 months of age if desired. If you select neutral, disagree, or strongly disagree, please indicate the oldest age you believe ultrasound COULD be used in the comment box below: (92.0%) 11 Strongly agree 12 Agree 1 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A   6. For the purpose of DDH screening, the earliest age to obtain an x-ray (if quality ultrasound is unavailable) is 14 weeks of age (to match vaccination\/well-baby schedule). If you select neutral, disagree, or strongly disagree, please indicate the earliest age you believe an x-ray COULD be used (if quality ultrasound is unavailable) in the comment box below: (96.0%) 7 Strongly agree 17 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A           154 7. Ideally, a baby < 6 weeks of age with a positive Barlow exam should wait to obtain an US at 6 weeks of age (if quality ultrasound is available). (83.3%) 10 Strongly agree 10 Agree 1 Neutral 3 Disagree 0 Strongly Disagree 1 N\/A   8. If a baby with a positive Barlow exam is < 6 weeks of age and the healthcare provider believes the child is at risk for loss to follow-up, an US (if quality ultrasound is available) may be conducted at that time. (92.0%) 13 Strongly agree 10 Agree 2 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   9. A baby < 6 weeks of age with a positive Barlow exam and subsequent abnormal imaging findings should be referred to an orthopaedic surgeon. (96.0%) 19 Strongly agree 5 Agree 0 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A              155 10. A baby < 6 weeks of age with a positive Barlow exam, subsequent normal imaging findings and no risk factors present can return to routine health supervision.\"Routine health supervision\" entails regular clinical hip examinations using age-appropriate tests that occur at birth and during vaccination schedules\/well-baby checks. (92.0%) 12 Strongly agree 11 Agree 1 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A   11. A baby < 6 weeks of age with a positive Barlow exam, subsequent normal imaging findings and risk factors present requires follow-up imaging. (92.0%) 8 Strongly agree 15 Agree 2 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   12. A baby 14 weeks-6 months of age with limited hip abduction requires further follow-up imaging (ultrasound\/x-ray at the discretion of the medical personnel). (92.0%) 11 Strongly agree 12 Agree 1 Neutral 0 Disagree 1 Strongly Disagree 0 N\/A             156 13. A baby 14 weeks-6 months of age with a positive Galeazzi test requires further follow-up imaging (ultrasound\/x-ray at the discretion medical personnel). (96.0%) 12 Strongly agree 12 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   14. A baby at any age with normal clinical exam and no risk factors present can return to routine health supervision.\"Routine health supervision\" entails regular clinical hip examinations using age-appropriate tests that occur at birth and during vaccination schedules\/well-baby checks. (100%) 12 Strongly agree 13 Agree 0 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   15. All babies < 6 weeks of age with a normal clinical exam but risk factors present (breech presentation, family history of DDH, improper swaddling practices, and a history of hip instability) should be screened with an US at 6 weeks (if available) or return for an x-ray at 14 weeks. (84.0%) 10 Strongly agree 11 Agree 2 Neutral 2 Disagree 0 Strongly Disagree 0 N\/A             157 16. All babies 6-14 weeks of age with a normal clinical exam but risk factors present should be screened with an US (if quality ultrasound is available) or return for an x-ray at 14 weeks. (80.0%) 9 Strongly agree 11 Agree 3 Neutral 2 Disagree 0 Strongly Disagree 0 N\/A   17. All babies between 14 weeks-6 months of age with a normal clinical exam but risk factors present should be screened with either an US\/x-ray. (72.0%) 7 Strongly agree 11 Agree 5 Neutral 2 Disagree 0 Strongly Disagree 0 N\/A   18. All babies between >6 months of age with a normal clinical exam but risk factors present should be screened with an x-ray. (72.0%) 6 Strongly agree 12 Agree 4 Neutral 2 Disagree 1 Strongly Disagree 0 N\/A               158 19. All babies < 6 weeks of age undergoing risk factor screening who obtain subsequent normal imaging can return to routine health supervision. \"Routine health supervision\" entails regular clinical hip examinations using age-appropriate tests that occur at birth and during vaccination schedules\/well-baby checks. (92.0%) 7 Strongly agree 16 Agree 1 Neutral 1 Disagree 0 Strongly Disagree 0 N\/A   20. All babies 6-14 weeks of age undergoing risk factor screening who obtains subsequent normal imaging can return to routine health supervision. \"Routine health supervision\" entails regular clinical hip examinations using age-appropriate tests that occur at birth and during vaccination schedules\/well-baby checks. (88.0%) 6 Strongly agree 16 Agree 3 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A   21. All babies 14 weeks-6 months of age undergoing risk factor screening who obtains subsequent normal imaging can return to routine health supervision. \"Routine health supervision\" entails regular clinical hip examinations using age-appropriate tests that occur at birth and during vaccination schedules\/well-baby checks. (96.0%) 9 Strongly agree 15 Agree 1 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A       159 22. All babies >6 months of age undergoing risk factor screening who obtains subsequent normalimaging can return to routine health supervision. \"Routine health supervision\" entails regular clinicalhip examinations using age-appropriate tests that occur at birth and during vaccinationschedules\/well-baby checks. (100%)7 Strongly agree 18 Agree 0 Neutral 0 Disagree 0 Strongly Disagree 0 N\/A ","@language":"en"}],"Genre":[{"@value":"Thesis\/Dissertation","@language":"en"}],"GraduationDate":[{"@value":"2023-05","@language":"en"}],"IsShownAt":[{"@value":"10.14288\/1.0429360","@language":"en"}],"Language":[{"@value":"eng","@language":"en"}],"Program":[{"@value":"Experimental Medicine","@language":"en"}],"Provider":[{"@value":"Vancouver : University of British Columbia Library","@language":"en"}],"Publisher":[{"@value":"University of British Columbia","@language":"en"}],"Rights":[{"@value":"Attribution-NonCommercial-NoDerivatives 4.0 International","@language":"*"}],"RightsURI":[{"@value":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/","@language":"*"}],"ScholarlyLevel":[{"@value":"Graduate","@language":"en"}],"Supervisor":[{"@value":"Mulpuri, Kishore","@language":"en"}],"Title":[{"@value":"Development of a DDH care pathway for India : a study methodology to guide similar efforts in other countries and for other conditions","@language":"en"}],"Type":[{"@value":"Text","@language":"en"}],"URI":[{"@value":"http:\/\/hdl.handle.net\/2429\/84135","@language":"en"}],"SortDate":[{"@value":"2023-12-31 AD","@language":"en"}],"@id":"doi:10.14288\/1.0429360"}