Fibromyalgia is a chronic disorder characterized by widespread muscular tenderness, pain, fatigue, and cognitive difficulties. Nonpharmacological treatment options, such as physical activity, are important for people with fibromyalgia. There are strong recommendations to support engagement in physical activity for symptom management among adults with fibromyalgia. Dance is a mode of physical activity that may allow individuals with fibromyalgia to improve their physical function, health, and well-being. Dance has the potential to promote improved pain processing while simultaneously providing the health and social benefits of engaging in physical activity that contributes to symptom management. However, we are unaware of current evidence on dance as a nonpharmacological/physical activity intervention for adults with fibromyalgia.The aims of the study are to provide an overview of the extant evidence to understand how dance is used for individuals with fibromyalgia; to examine the extent, range, and nature of research activity in the area; and to determine the value of undertaking a full systematic review.Scoping reviews are useful to comprehensively and systematically map the literature and identify key evidence, or research gaps. The search strategy will involve electronic databases including Medline, Embase, Cochrane Library, PsycInfo, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Literature in the Health Sciences in Latin America and the Caribbean (LILACS), Allied and Complementary Medicine (AMED), International Bibliography of Theatre and Dance, Physiotherapy Evidence Database (PEDro), Trip, Proquest Theses/Dissertations, Web of Science, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. The study will be mapped in seven stages: (1) identifying the research questions, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, (5) collating, summarizing and reporting the results, (6) consulting, and (7) disseminating the knowledge.The search, title, and abstract are now completed; full text screening was carried out and authors are awaiting interlibrary loans and translations. Data extraction will start shortly after full text ‘screening’ is completed. Completion is expected in Fall 2017.To our knowledge this will be the first attempt to systematically identify knowledge of dance as a potential intervention for adults with fibromyalgia. This scoping review offers a feasible means for describing the evidence specific to dance and fibromyalgia; results will provide unique insights concerning the breadth and depth of literature in the area. An analysis of this body of literature as a whole may reveal new research directions or unknown ways this intervention could strengthen current management approaches of the disease. Fibromyalgia is a chronic disorder characterized by widespread muscular tenderness, pain, fatigue, and cognitive difficulties ,2. IndivFibromyalgia is common worldwide with the prevalence reported to be 2% to 4% of the general population, with diagnosis in females outnumbering diagnosis in males ,5. InsigThere is vast evidence supporting exercise interventions for individuals with fibromyalgia; in the most recent European League Against Rheumatism guidelines, Macfarlane et al  concludeThere is evidence describing benefits of dance for chronic disease conditions. Dance among individuals with heart failure has demonstrated increased functional and cardiovascular benefits as well as increased motivation for participation , qualityOne specific dance-based therapeutic approach common in the literature of individuals with chronic conditions is dance movement therapy (DMT). The American Dance Therapy Association defines DMT as a psychotherapeutic use of movement that furthers the emotional, social, cognitive, and physical integration of the individual. This form of dance has a systematic treatment approach, is goal-oriented, and may include a variety of dance movement methods . ChronicDance contributes to the physical training of balance, coordination, strength, flexibility, aerobic capacity, bone health, and proprioception . Additionally, dance promotes increased motivation to exercise , increasWidespread pain and fatigue are hallmark symptoms of fibromyalgia and are known factors limiting an individual’s participation in treatment . During Dance is an engaging and enjoyable form of physical activity. Group or social dance facilitates social bonds through working in synchrony (performing the same movements at the same time) ,45. SyncThe authors of this scoping review have worked extensively on synthesizing the evidence of exercise training for adults with fibromyalgia -48. To dScoping review methodology is particularly useful for examining the breadth of the research in a specific topic area. Also, scoping reviews are useful to comprehensively and systematically map the literature and identify key evidence or research gaps. Unlike most synthesis reviews, scoping reviews do not narrow the review to specific research designs. Nonetheless, this type of review is rigorous and methodical in its approach to examining the extent, range, and nature of research activity in a particular field -52 whileIn designing the protocol for this scoping review, we drew primarily upon Arksey and O’Malley’s seminal work  on a 6-sFollowing Arksey and O’Malley’s suggestion, we followed an iterative process for developing the research questions. We continued doing this as we became increasingly familiar with the literature. We realized the need for an iterative process and first ran a trial search.Our intention to comprehensively examine and map the evidence on dance in adults  with fibromyalgia prompted us to develop the following initial questions:What is known from the literature about dance for adults with fibromyalgia ?What type of dance is commonly used  and what are the characteristics of dances reported ? Who is in charge of the instruction, and what is the setting in which dance occurs?What type of publications are reporting dance, what is the quality of the publications, and what are the main outcomes measured and reported?Do studies report the acceptability, feasibility, and applicability of dance for clinical practice?Have studies reported any challenges or limitations upon implementation of a dance class/intervention?The aim of this scoping review will be to comprehensively address ‘the above’ broad research questions; however, parameters are required to guide the search strategy.The following inclusion criteria will be used to guide the search and review the articles:Published in any language Human subjectsAdults aged 18 years and older with fibromyalgiaPublications that target adults with fibromyalgia of any gender or ethnicity in any setting  and type of dancePublications including research projects, pilot experience, and protocolsScope limited to include published literature  and grey literatureConcepts of dance/therapy/movement and fibromyalgia evident either in title or abstract during screening phaseExplicit exclusion criteria identified:Publications with a population that is not exclusively adults with fibromyalgia or we cannot isolate the results for adults with fibromyalgiaPublications in which individuals are nonactive participants The nature of a scoping review is to include multiple forms of evidence and not exclusively randomized controlled trials. Our inclusion criteria were established to identify and include research reports of participation in dance and exclude research reports of observation of dance. Therefore, self-report data, such as published case studies or reports in the grey literature, of participants engaging in dance as related to fibromyalgia symptoms would meet inclusion criteria.An experienced information specialist will establish and test the search strategy. Based on her expertise and the outline of this project, she will select keywords and controlled vocabulary terms to maximize sensitivity and specificity within the search. She will be instrumental in choosing and applying search terms to comply with databases in the health and social sciences. The complete and final search strategy will be provided in a follow-up publication. Upon completion, the results from each database will be documented, and the references will be imported into a bibliographic management software to eliminate duplicates. References will be imported to a review software for screening.Databases used:Medline in-process and other nonindexed citations (Ovid)—1946 to presentEmbase and Embase Classic (Ovid)—1947 to presentCochrane Library (Wiley)PsycINFO (Ovid)—1806 to presentCumulative Index of Nursing and Allied Health Literature (CINAHL) (EBSCO)—1937 to presentLiterature in the Health Sciences in Latin America and the Caribbean Allied and Complementary Medicine (AMED) (Ovid)—1985 to presentInternational Bibliography of Theatre and Dance (EBSCO)—1984 to presentPhysiotherapy Evidence Database (PEDro)TripProQuest Theses and Dissertations—1997 to presentWeb of Science Core Collection (Thomson Reuters)—1900 to presentWorld Health Organization International Trial Registry PortalClinicalTrials.govSearching other resources:We will search the bibliographies of relevant studies and reviews.Corresponding authors of previously found dance randomized controlled trials will be contacted regarding their knowledge of ongoing studies or groups involved in the area.An a priori set of fibromyalgia associations will be selected and their associations’ webpages will be screened for annual reports or findings that these associations produce based on their own research, which will be retrieved.We will use a 2-stage selection process. In the first instance, 2 reviewers will independently screen citations and abstracts for inclusion. At this stage, uncertainties from the reviewers will not automatically eliminate the record. We will determine final inclusion at the second level (full text screening). A third reviewer will arbitrate in cases where there is disagreement at the final stage. All authors will be trained in software use, and a predetermined and piloted criteria will be followed at both stages.The full text of all papers identified as having potential for inclusion will be requested. Non- English articles will be translated. Data will be extracted from papers included by independent review authors. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram  will be We will collect and sort information from the selected full text articles see . We willGiven the authors’ backgrounds in systematic review of interventions for adults with fibromyalgia, the appraisal of included studies will be restricted (if found) to those scientific publications explicitly addressing intervention effectiveness. This may provide direction for future research.The unique purpose of a scoping review is to aggregate the findings and present an overview.We plan to do the following:Map results  from the literature.Provide a descriptive summary: extracted data from all included publications will be summarized to describe the use of dance in adults with fibromyalgia. Because this is a scoping review, there is no principal summary measure. However, if possible, the following analyses will be completed:Descriptive statistics will be used to summarize the data. Frequencies and percentages will be used to describe nominal data.Conceptual definitions will be subject to a comparative analysis where verbatim ‘extracts’ will be coded by review authors. The purpose will be to identify the dimensions and properties of each definition as well as their relationships with other components. This analysis will involve identification of dimensions of the concept of dance, recurrent themes, variations, contradictions, and connections.If possible, we will use computer-assisted clustering techniques to present the information in graphical form  ,55.A glossary of terms will be created to clarify definitions found in the literature.We will follow and adapt PRISMA reporting guidelines for systematic reviews , PRISMA With the aim to ensure applicability and usability of results, the findings of this scoping review will be shared throughout the protocol writing, collating, and summarizing phases with the consumers associated with the team. They will provide their comments and thoughts throughout the scoping review’s duration. We will also engage research experts in dance, fibromyalgia, and synthesis methods to review the project protocol and provide objective feedback in findings and final reporting. The fibromyalgia and physical activity team (led by AJB) will be asked to validate our findings and provide feedback and guidance on the completion of the final manuscript. All responses and opinions will be integrated into the study.Although not part of Arksey’s framework, we believe it is important to make the content of this scoping review available to clinicians and consumers with the goal of increasing awareness of the literature and helping to make evidence-informed choices for clinical management of fibromyalgia. Some of the steps we plan to take include writing a scientific publication, presenting the results at a conference, distributing a plain language summary report to self-help groups and organizations working with individuals with fibromyalgia, posting a summary of the results to the fibromyalgia and exercise team website, and exploring the dance4healing app as a venue to distribute our results. Additionally, we plan to develop teaching material from this scoping review  to be used in chronic disease management courses in health and rehabilitation programs involving undergraduate and graduate students.The search, title, and abstract are now completed; full text screening was carried out and authors are awaiting interlibrary loans and translations. Data extraction will start shortly after full text ‘screening’ is completedCompletion is expected in Fall 2017.A large body of evidence from the past decades supports the use of physical activity as one of the main nonpharmacological interventions for adults with fibromyalgia. Exercise training  is often part of the overall management of fibromyalgia, decreasing peoples’s symptoms and improving their quality of life. However, our understanding of dance use in this population is limited. To our knowledge this will be the first attempt to systematically identify knowledge of dance as a potential intervention for adults with fibromyalgia.This scoping review offers a feasible means for synthesizing the evidence specific to dance and fibromyalgia; results will provide unique insights concerning the breadth and depth of literature in the area. We anticipate we will be able to identify research trends and potential gaps specific to our research questions as well as novel ideas for primary research concerning this intervention. An analysis of this body of literature as a whole may reveal new research directions or unknown ways this intervention could strengthen current management approaches of the disease.


The Swedish government initiated an investigation of how to secure and develop the competence of the occupational health services. The primary aim of the present study was to investigate whether the development of evidence-based practice (EBP) in the Swedish occupational health services in relation to attitudes, knowledge and use improved during the first 3 years of the government’s initiative.The study has a mixed methods design combining questionnaires and interviews with data collection at baseline and at 3-year follow-up.p = 0.002; 95% CI 0.01; 0.21). Practitioners experienced lower levels of organizational and managerial support for EBP at follow-up . The results revealed that managers viewed responsibility for implementing EBP as a matter for individual practitioners rather than as an organizational issue.The response rate was 66% at baseline and 63% at follow-up. The results show that practitioners’ knowledge of EBP was moderate at baseline and improved at follow-up (Occupational health service managers and practitioners are generally positive to EBP. However, the findings emphasize the need to educate managers in how to support EBP at the organizational level by creating an infrastructure for EBP in the OHS. The concept of evidence-based practice (EBP)  in 2011. A random sample of these 251 OHS companies was selected using a stepwise approach  were private external and dominated by three very large OHS enterprises running a large number of clinics. Consequently, in the second step, private external OHS companies were divided into three subgroups based on the number of OHS clinics they ran: (1) OHS companies with more than 50 OHS clinics; (2) OHS companies with 5–50 OHS clinics and (3) OHS companies with less than five clinics. The number of companies in the three subgroups was 2, 13 and 187, respectively, with 172, 145 and 226 clinics. Given the varying number of clinics in each subgroup, a random selection from each subgroup was made to obtain 15 clinics each from subgroup 1 and 2, and 30 clinics from subgroup 3. Each OHS clinic was treated as a separate functional unit in the sample. The random sampling was performed without replacement using an SPSS random sample generator. All private in-house and municipality/county council in-house OHS companies were included in the sample.The selection gave 91 OHS companies covering 115 OHS clinics, all of which were invited to participate. The same sample was contacted 3 years later, in 2014. Ten of the previously included OHS no longer existed as a result of reorganization or merger. The 2014 sample therefore consisted of 71 OHS companies covering 105 OHS clinics.n = 853) at the selected clinics in October 2011, with two reminders at 1-week intervals sent to non-respondents. A covering letter explained the purpose of the survey, and a definition of evidence-based practice was given at the start of the questionnaire. Follow-up data were collected in September 2014 by sending the questionnaire to all practitioners at the selected clinics, i.e., the clinics from the baseline population (n = 795). Four reminders at 1-week intervals were distributed by e-mail. The response rates were 66% (n = 560) in 2011 and 63% (n = 498) in 2014. For further information regarding respondents and non-respondents . Fourteen questions were taken from Schaafsma et al.  and had Participant characteristics were obtained by means of questions about age, sex, years of work experience, type of position, education and occupational health service profession. OHS practitioners’ interest in working according to EBP, as well as their need and opportunity to do so, were assessed by questions about their views of EBP, collegial support, education and training in EBP practice and the use of EBP in the OHS practice. Obtaining information about the latest developments in their vocational field was measured by questions about information-seeking strategies and activities, training in search strategies and critical appraisal of evidence, and whether they were involved in research and development. To gauge the influence of organizational factors on opportunities to work according to EBP, participants were asked about managerial support for and encouragement of EBP at their OHS clinic and whether they had the necessary expertise to work with EBP. They were also asked about access to help with retrieving information from scientific databases or libraries, the purchase of medical literature, and whether their clinic facilitated participation in research and development projects. The response format was a Likert scale ranging from 1 to 5, with the anchors 1 = completely disagree, and 5 = completely agree. The participants were also asked to self-rate the top three facilitators and barriers with regard to EBP and there was an open text section for additional comments (the open text responses are not reported in this paper).Semi-structured telephone interviews with open-ended questions were conducted between November 2014 and January 2015. The interviews were conducted by five occupational health nurses and one psychologist, all with prior training in qualitative methods and interview techniques. The interview guide addressed: the use of EBP at the OHS clinic; the OHS practitioner’s competence for working with EBP; staff recruitment strategies; client companies’ interest in and attitudes towards EBP; and barriers to and facilitators of EBP. The interviews lasted 20–45 min, were digitally recorded and transcribed verbatim.P < 0.05.The data from the questionnaire were analyzed by using SPSS version 22.0. The demographic characteristics of the participants are presented as descriptive statistics. Differences between baseline and follow-up were analyzed using Mann–Whitney test. All results were considered significant at t test.Differences between the baseline and follow-up data in terms of type of OHS organization , age, profession and work experience were analyzed using To be able to construct indices based on the 25 core area items in the questionnaire, the quantitative analysis was carried out in three steps. Initially, ordinal exploratory factor analysis using Kendall’s tau-b was carried out on all 25 core area items in order to investigate the factor structures, the multidimensionality and the distribution of the items in the subscales. A loading criterion of 0.40 was applied and considered as the threshold for acceptance. On the basis of the analysis, 19 items could be grouped into three subscales, whilst the remaining six items that did not meet the loading criterion 0.40 were kept as single items  at baseline and 63% at follow-up (n = 498). The response rate differed between the four OHS categories. The profession with the highest proportion of women was occupational nurses . Nurses accounted for the largest proportion of respondents at both time-points . Men dominated among work environment engineers (89 and 82%). The mean age of the respondents was 52 years (SD 8.9) and the respondents had an average of 13 years’ (range 1–37) OHS work experience  was found, which decreased from 3.6 to 3.3 between the two time-points. When the analyses were stratified according to type of OHS organization, the municipality/county council in-house OHS was the only OHS category with significantly lower point estimates at follow-up. For the single items included in the subscale . Respondents largely agreed that EBP was part of their work, with mean scores at baseline and follow-up of about 4. In line with addressing EBP as a part of their routine work, a significant reduction in educational needs was reported, indicating that the respondents may have improved their EBP-related skills during the follow-up. Where acquiring new knowledge was concerned, the respondents were less likely to agree that they needed to find information on the Internet at follow-up. They also agreed slightly less than at baseline that EBP will become more important for the OHS.For the subscale Implementation and development of EBP, the comparison between the two time-points revealed a significant decrease for the whole study group from 4.2 to 4.0 . All types of OHS had significantly better scores in 2014 than in 2011, except for private in-house OHS. A significant change was demonstrated for the single item about the reliability of information, which implies that the respondents considered the reliability of information in their professional field as lower than before.For the subscale lack of knowledge and skills regarding EBP, the comparison over time showed a significant improvement in EBP knowledge and skills for the study group as a whole—from 2.7 to 2.6  , physiotherapist/ergonomist (n = 6), psychologist/behavioral therapist/social worker (n = 4), work environment engineer (n = 3), biomedical scientist (n = 1), physician (n = 1), and unknown (n = 3). The results are presented under the headings of the identified categories.Of the 24 participants, 20 were women. Ten participants were employed at private external OHS and 14 at private in-house OHS. The mean age was 54 (min 37–max 68), the participants had between one and 20 years of managerial work experience in OHS settings (mean 5 years), and the following backgrounds: nurse .The OHS managers reported that little time and few resources were set aside for their practitioners to develop their own evidence-based guidelines. They therefore called for short, easy-to-use and cost-effective guidelines to facilitate EBP. They also commented that some guidelines were too comprehensive and that corporate clients were not willing to pay for EBP-based treatment, even if it was the recommended one. One participant gave the following description:“We have cognitive behavioral therapists; they do not have the time to perform evidence-based therapy. As an example, we offer interpersonal therapy which is manual-based and one of the few therapies which is supported by evidence. But a well-adapted therapy involves about 16 h. It would be rare for a client company to pay for these sessions.” (IP 3).All OHS managers said that their clients expected the OHS to keep up-to-date and to offer high-quality services based on evidence. The managers felt that they did address issues related to best practice clinical decision-making in order to bring about changes in future contracts. Even if they regarded EBP as important for the delivery of high-quality treatments, they did not see the use of EBP as a “sales argument”, due to the fact that results from evidence-based care can never be guaranteed. As one participant commented during the interview:“It could be devastating if you think you know for sure what the best evidence-based treatment is and if you use that as an argument for selling the treatment. If the treatment doesn’t give the effects that the client company expected, it doesn’t matter whether you have used an evidence-based treatment or not.” (IP 14).Some of the OHS managers reported that their OHS units were in touch with RD-units  and that these contacts were dealt with by OHS practitioners with a particular interest in EBP. The interface between the OHS and the RD-unit gave the OHS access to new evidence and the opportunity to participate in the development of evidence-based guidelines. Moreover, supported by the RD-units the OHS practitioners were offered training in evidence-based guidelines or methods. Some of the larger OHS companies had an in-house RD-unit, which assisted with the latest research findings and evidence-based methods.The primary aim of the present study was to investigate whether the development of evidence-based practice in relation to attitudes, knowledge and use in the Swedish occupational health service improved during the first 3 years of the government initiative. Our aim was also to investigate facilitators of and barriers to the implementation of EBP and whether these changed during the follow-up period. Overall, the results reveal a slight deteriorating trend. They indicate that the respondents experienced a lower degree of organizational competence, attitude and managerial support for EBP after 3 years. The only positive trend was an improvement in knowledge about EBP. The follow-up period saw the establishment of a knowledge base and research infrastructure in the OHS.In the present study, quantitative data from the web-based questionnaires were combined with qualitative data from interviews. The use of more than one data source improves the validity of results Padgett .The overall response rate of the questionnaire was 66% in 2011 and 63% in 2014, which can be seen as acceptable for a web-based survey (Draugalis et al. Most of the questions were based on previous questionnaire studies (Gummesson and Nordmark In general, the changes over time were small. Even if several of the analyses were statically significant it is hard to draw conclusions regarding their practical significance with regard to EBP. The survey results should therefore be interpreted with some caution.The respondents reported slightly less organizational competence, attitude and managerial support for EBP in 2014 than in 2011. Previous research indicates that support from the management or the board is an important facilitator for the implementation of EBP (Weiner et al. The findings of our study reveal a positive trend in knowledge about EBP, even if the changes are small. In recent years, technological advances such as access to information on the Internet and the launch of the first OHS guideline have contributed to a rapidly increasing availability of knowledge and information, even as teaching and training methods have improved. The findings from the interviews revealed that the OHS managers regarded guidelines and collaboration with RD-units as facilitating EBP, since such collaboration implied access to education in EBP-guidelines and/or evidence-based methods. However, previous studies suggest that the effect of continuing education on compliance with desired practice is small (Forsetlund et al. The definition of EBP used in the questionnaire was quite general and not linked to the use of evidence-based guidelines or assessment protocols. Our findings demonstrate a slight decrease in positive attitudes towards the implementation and development of EBP. The point estimates at baseline and follow-up indicate that the respondents largely agreed with the items included in the subscale. Practitioners’ attitudes towards EBP are known to be a predictor of future use (O’Donnell When the analysis was stratified according to type of OHS organization, the results demonstrated significant differences in relation to the implementation and development of EBP for all types of OHS organizations except private in-house OHS. Previous research supports the notion that public sector organizations are more bureaucratic than private sector agencies, have more formal rules and regulations and hierarchical authority structures. These factors have been linked to a lower degree of interest in innovation and change (Aarons et al. In summary, the results indicate that EBP continues to interest OHS practitioners, even if they experienced slightly less organizational and managerial support during the 3-year follow-up. At both time-points the respondents demonstrated a positive attitude towards implementing EBP. However, they saw the relatively low levels of organizational support and skill development support as a barrier. The first 3-year period of the government initiative was characterized by passive dissemination of EBP and a lack of support and feedback for the OHS units. This might explain the study’s findings that OHS practitioners as well as OHS managers observed a lack of organizational and managerial support. In fact, it takes more than the drive of the individual practitioner to succeed in implementing EBP. In line with previous research, we therefore conclude that active implementation strategies which include support for management and organizations are needed in order to achieve a sustainable implementation of EBP among OHS practitioners and in OHS organizations. The next 3-year period should be accompanied by more active implementation strategies, such as the development of practice guidelines through a partnership model, seminars and workshops. It is also necessary to actively direct interventions at OHS company managements in order to improve the implementation of EBP within OHS. On the basis of our findings, we suggest that future research evaluates the active strategies for implementation that are used in the next 3-year period of the government initiative, in order to evaluate those factors which facilitate and hinder the implementation of EBP in OHS. Furthermore, future research should address issues related to senior management, their support for EBP and how EBP could be facilitated at different levels in the organizations.In general, one can say that OHS managers and practitioners are positive to EBP. However, the questionnaire and the interviews indicate that important cornerstones for the successful implementation and development of evidence-based practices in OHS are missing. EBP was seen as the responsibility of the individual practitioner rather than an organizational issue. Thus, the findings underscore the need to educate managers in how to support EBP at the organizational level by creating an infrastructure for EBP in the OHS.


The Demand-Driven Evaluations for Decisions (3DE) programme was piloted in Zambia and Uganda in 2012–2015. It aimed to answer evaluative questions raised by policymakers in Ministries of Health, rapidly and with limited resources. The aim of our evaluation was to assess whether the 3DE model was successful in supporting and increasing evidence-based policymaking, building capacity and changing behaviour of Ministry staff.Using mixed methods, we compared the ex-ante theory of change with what had happened in practice, why and with what results (intended and unintended), including a qualitative assessment of 3DE’s contribution. Data sources included a structured quality assessment of the five impact evaluations produced, 46 key informant interviews at national and international levels, structured extraction from 170 programme documents, a wider literature review of relevant topics, and a political economy analysis conducted in Zambia.We found that 3DE had a very limited contribution to changing evidence-based policymaking, capacity and behaviour in both countries as a result of having a number of aspirations not all compatible with one another. Co-developing evaluation questions was more time-consuming than anticipated, Ministry evidence needs did not fit neatly into questions suitable for impact evaluations and constricted timeframes for undertaking trials did not necessarily produce the most effective results and value for money. The evaluation recommended a focusing of objectives and a more strategic approach to strengthening evaluative demand and capacity.Lessons emerge that are likely to apply in other low- and middle-income settings, such as the importance of supporting evaluative thinking and capacity within wider institutions, of understanding the political economy of evidence use and its uptake, and of allowing for some flexibility in terms of programme targets. Fixating on one type of evidence is unhelpful in the context of institutions like ministries of health, which require a wide range of evidence to plan and deliver programmes. In addition, having success tied to indicators, such as number of ‘policy decisions made’, provides potentially perverse incentives and neglects arguably more important aspects such as incremental programmatic adjustments and improved implementation.The online version of this article (doi:10.1186/s12961-017-0250-4) contains supplementary material, which is available to authorized users. Evidence can shape policy decisions in a variety of ways. Our primary interest is often in understanding whether and under what circumstances robust evidence directly contributes to a policy decision. Yet, as Johnson describes , the appThe literature suggests that the extent of uptake of evaluation evidence  in policy is often relatively modest. A comprehensive report on relevance, quality and influence of impact evaluations conducted by the World Bank Group found that, while impact evaluation evidence was observed in some cases to make a positive contribution to development practice and policy debate, systematic use of evidence was weakened by a number of constraints, such as lack of government demand or champions . This coBoth reviews note that detecting or measuring the extent of evidence uptake is challenging, especially given that some of the broader level influences on how knowledge is used in the policy process may be intangible such as relationships between researchers, departments and wider stakeholders , 6, 7. HIn order to be relevant, information presented to policymakers should be salient (relevant to the problem), credible  and legitimate  , 9. One Some policy questions that governments are concerned with are also not well suited to ostensibly rigorous evaluation techniques such as randomised controlled trials (RCTs) , 14, eitSecondly, evaluation evidence is often not available when policy decisions need to be made , 10, 11.A third factor identified in the literature is that empirical evidence is not well communicated to policymakers since reports may be excessively technical , 15 or tThe failure of some evaluators to deliver high quality, timely, policy-relevant and appropriately communicated findings to policymakers points to a wider concern that the priorities of the producers and users of evaluation are not closely aligned. This is in part due to the fact that evaluations in lower- and middle-income countries tend to be commissioned by international development partners . There iA prerequisite for the actual use of evaluations in policy is that key political actors demand evidence to be made available and are receptive to the findings. Guidance produced by the World Bank Group on strengthening government capacity in generating and using M&E evidence argues that weak demand for evaluation evidence can pose an even greater limitation to the use of evaluation evidence in policy than the issues around evaluation characteristics described above , 18.There are mixed findings in the literature on whether this demand exists in different contexts. Hyder et al.  find thamaximise the likelihood of alignment between the evaluation and departmental willingness to use the findings” . ndings”  pilot was designed by the Clinton Health Access Initiative (CHAI) and IDinsight. It was based on the recognition that Ministry of Health (MoH) officials often lack evidence on the most effective and efficient ways in which to deliver known clinical interventions and services. Further, where evidence is generated, it is often not relevant to the operational needs of MoH officials or done within a period that meets decision-making timeframes. The 3DE pilot model aimed to facilitate a more demand-driven approach to the evaluation of health interventions by 1) identifying relevant, suitable and priority evaluation questions from the ministries, (2) conducting these evaluations rigorously but rapidly and in an affordable manner, and (3) catalysing the response to their findings and sharing the lessons learned from this process more widely, so as to influence future evaluation processes. Under this pilot, 3DE was expected to conduct eight (later revised to five) impact evaluations that influenced managerial decisions in six instances (later revised to four) in Uganda and Zambia. The interventions that were evaluated under the 3DE pilot are summarised in Table  identifyThis article presents findings from the evaluation of the 3DE pilot. Its main objective is to provide lessons on how to design evidence support programmes or initiatives for the health sector . It builds on the small but growing literature documenting attempts to support evidence-based policy at institutional level in low- and middle-income countries.The overall aim of the evaluation, conducted in 2015, was to assess whether the 3DE model had been successful in supporting and increasing evidence-based policymaking, building capacity and changing the behaviour of Ministry staff in terms of demanding and using evidence (as these were the 3DE objectives).As the evaluation was commissioned ex-post and there was no credible counterfactual, the evaluation took a theory-based approach, starting from the theory of change for 3DE, structured by process, outputs and outcomes Fig. . AssumptThe evaluation considered 3DE as a whole, including consideration of how it was established and the prioritisation of evaluation questions that the 3DE evaluations would seek to answer. However, each individual evaluation conducted by 3DE constituted a case study within the overall framework, which could be compared in order to generate a richer understanding of differences and similarities.As most of the work had been undertaken in Zambia, this was the focus of the evaluation; nevertheless, a modified set of questions was used in Uganda to learn from the experience there. The evaluation was therefore able to draw from evidence from two national settings and across five different evaluations.Five main sources of evidence were used for the evaluation.Given the overall objective of the intervention, the purpose of this component was to test the effectiveness of the programme in generating high quality evaluations. The quality of the 3DE evaluations was assessed against a set of specific questions, including the relevance and clarity of the evaluation questions; the extent to which contextual factors that could affect the evaluation were considered; the clarity and level of detail with which the intervention was described; the extent the evaluation considered other programmes that may have affected key indicators; the appropriateness of the evaluation methodology, including the adequacy of the sample size, and the extent to which baseline differences, spillover effects, externalities, imperfect compliance, non-response and attrition were dealt with appropriately; the appropriateness and rigour of the data sources and data collection; the rigour of the analysis including appropriate calculation of standard errors and use of sampling weights; the clarity and plausibility of the links between data, interpretation and conclusions; and the external validly of the evaluation.The assessment was applied to all five evaluations conducted by 3DE, although only three were finalised at the time of evaluation and so could be examined in relation to all quality assurance questions. Details of the assessment have been previously published .Forty-six key informant interviews were conducted, using semi-structured topic guides. The participants included a range of stakeholders internationally and in the two focal countries from government (n = 17), the 3DE programme (n = 16), and development partners and other institutions (n = 13). The interviewees were initially sampled purposefully to maximise information-rich cases augmented by snow-balling during the evaluation. The interviews were thematically coded and entered into an analysis spreadsheet, which was structured according to the key nodes in the theory of change. By reading down the columns, views from informants and evidence from 3DE programme documents could be triangulated on each topic, and a summary of evidence created.Over 170 documents of various types  were read, thematically coded and entered into the same spread sheet used for the key informants . An impoA literature review was undertaken to understand the background and wider global context for 3DE. This focused on a number of topics, including evidence on general experience and the efficacy of demand-led evaluations; evidence on evaluation use and uptake by policymakers; evidence on formal and informal barriers and enablers for conducting and using impact evaluations by policymakers/government officials; other global initiatives and experiences of demand-led evaluations; and reviews of on-going and recent impact evaluations in the health sectors of Zambia and Uganda.The body of literature reviewed included research papers, articles, theoretical discussion papers and synthesis reports drawing together the findings of other work.A political economy analysis of the health sector in Zambia was conducted to better understand the contextual factors influencing the outcomes of the 3DE model, with particular focus on resource allocation and decision-making within the two Ministries being studied, and how evidence was used in their policymaking processes.Some important limitations should be noted, including the relatively short timeframe of 3DE, which did not allow for the assessment of health outcome changes or the necessary maturation of catalysation activities. As a result, the evaluation focused on processes more than outcomes. The Ugandan experience also received more limited analysis compared to the Zambian one, given that no evaluation had yet been completed in Uganda.The theory of change of 3DE Fig.  stipulatAlthough the approach of starting from MoH questions was laudable, one challenge faced was that ministries do not generally have a prioritised set of research questions and are often institutionally divided. In Zambia, a set of ministerial research priorities had been established but it was more of a theoretical wish list and many questions were not amendable to answer by impact evaluation. In Uganda, individual disease programmes had research agendas but these had not been prioritised across the ministry as a whole. Developing options and assessing them was a much more intensive process than anticipated by the 3DE programme, and depended on strong links to specific groups within the MoH, which also biased the selection towards certain favoured programmes . In Uganda, a number of ‘false starts’ were made with different units within the MoH, which is one reason why ultimately just one impact evaluation was delivered there.Another challenge faced by 3DE implementers was identifying questions which met the rigorous criteria of the programme. These included that the intervention was feasible to implement in the timescale (9 months), had potential for wide impact, could be addressed through a rigorous experimental or quasi-experimental counterfactual-based impact evaluation, was being rolled out in a way and timeframe that could be used for the study, and where the chances of catalysing change in the future were strong. It is clear that these criteria were, in combination, very demanding, and this in part explained the difficulty of identifying successful questions in Uganda and reaching the targeted four evaluations in Zambia.3DE implementers worked closely with Ministry partners  in Zambia) to source questions, but partners found it harder to engage in the prioritisation of questions that involved more technical issues about research design. This reduced their ultimate ownership in the process.The research questions posed by the evaluations were all shown to address relevant healthcare challenges in Zambia and Uganda and, in at least one case, the evaluation was timed to meet an important opportunity . The others addressed less urgent issues and took longer to conduct than originally prescribed. The rationale for the particular interventions evaluated in each study, including a description of underlying challenges and how the intervention mechanism was expected to address them, was not always well described in the evaluation reports.The overall quality of the design of the 3DE evaluations was assessed as variable, with some weaknesses stemming from the constraints placed on the evaluations in terms of timeframes and budgets.One aspect of the evaluation design that was consistently conducted well was the choice of primary outcome given the available study period. The evaluations all focused on measures that could be plausibly expected to change over a period of months if the intervention was effective. Although all evaluations did make an appropriate choice of primary outcome, there were some issues with the indicators used to track these outcomes. The evaluations were also well designed to make efficient use of the available budget and were organised to minimise additional workload for health staff by being aligned to a large degree with current practices in health facilities.The overriding concern with the design of 3DE evaluations was that the findings were not easily generalisable to other contexts . Many of the evaluations were only able to cover a limited geographic area and a small sample due to the relatively low budget and timeframe to implement the evaluation. There was also a concern that some of the 3DE evaluations may not have delivered sufficient internal validity despite their randomised design, given the small size of the treatment groups. The time and budget constraints also affected the implementation of the interventions themselves, which in some cases may have been too ambitious for the short evaluation period.In view of some of these concerns it was not clear that the choice of a given RCT always made the best use of the available budget. In some cases, a simple operational pilot or process study might have provided sufficient evidence around the implementation of interventions to help guide future programming decisions. This was particularly the case for interventions that sought to reinforce existing practices rather than providing new and previously untested solutions (such as the Early Infant Diagnosis simple intervention and the decongestion intervention).The evaluations appeared to have collected good data using appropriate techniques. Where the data-collection processes were reported on, these processes were assessed as good. Sample sizes were an issue for some of the evaluations. Quantitative findings were for the most part presented well. The explanation and interpretation of results could, however, have been further developed, with the overall findings better situated within a broader discussion of the context and likely mechanisms involved.We concluded that 3DE generally had a good awareness of entry points as well as of key stakeholders and disseminated evaluation findings well to key stakeholders, mostly to the implementers of the interventions they were evaluating. However, in order to provide rapid feedback, presentations preceded the finalisation of reports, which was problematic when final findings later changed. The ensuing ‘policy decisions’  took the form of advisory notes. The implications of the evaluations were largely managerial, rather than implying larger changes in programming or resource allocation. There was also limited scope for ‘catalysation’ work  and uptake had been limited at the time of evaluation. There was no resourcing for 3DE to follow-up on what had happened after ‘policy decisions’ were taken.3DE did not have a specific capacity-building plan beyond working closely through the stages of the programme with MoH/MCDMCH partners. Interviews indicated that individuals who worked closely with 3DE did benefit in terms of capacity development. More broadly, there was an expression of latent demand for evidence, although not necessarily for evaluations specifically. Both ministries (MoH and MCDMCH) lacked a wider strategic approach to evidence and research, and there was no indication that this had changed as a result of 3DE.Key stakeholders did not always have a clear understanding of the findings and raised questions about the external validity of results for other areas of the country and in ‘normal’ health system conditions. Ownership of findings was partial. Limited staff time, a lack of capacity in terms of research staff in key partner agencies, and a lack of incentives for evidence use were some of the factors behind this.Although the timeframe of our evaluation did not permit assessment of outcomes, the expected impact was unlikely to be transformational. Some 3DE evaluations supported a reinforced implementation of the status quo. Others suggested potential for some cost savings, though only in some contexts in Zambia, and with careful attention to ensure replicability of results. Others suggested a potential saving but largely for donors.There were a number of issues relating to context and internal factors that contributed to the failure of the 3DE pilot to achieve its key objectives. Among the contextual factors, the lack of an effective strategic prioritisation of evidence-based decision-making within government was highlighted as a constraint, along with unclear ministry roles in Zambia (linked to the split of the MoH into two ministries in 2012).The evidence that was deemed as most in need by Ministry officials in Zambia was operations research and situation analyses to identify and rectify bottlenecks in delivery or service and research to better understand the behaviour and motivation of end-users in regard to non-utilisation, as well as synthesis of evidence from other contexts. National reports also highlight insufficient use of data at all levels of government and further note that capacity and funding for research is limited . Demand Internal programme factors included positive ones, such as a strong starting base for CHAI, which was well embedded in the MoH, as well as negative, such as an initial understaffing of the 3DE Uganda programme. The degree of involvement of the MoH Principal Investigators and co-Investigators also varied across the studies and contexts, as might be expected, according to individual time and interest; these affected ownership and legacy.This evaluation adds to a small but growing body of evidence on how to support evaluation evidence uptake in the sub-Saharan African context. Mijumbi et al. , for exaThis evaluation of the 3DE programme faced limitations in terms of the ex-post design and its timing in relation to the interventions. However, the theory-based approach, combined with triangulation of different data sources derived from mixed methods, and a collaborative relationship between the evaluation specialists based in the programme implementing partner (CHAI), the commissioning group  and the evaluation team resulted in rich results and engagement to absorb the lessons learned.The evaluation concluded that 3DE had made a very limited contribution to changing evidence-based policymaking, capacity and behaviour in both countries. The main reasons behind this limited impact were judged to be two-fold. First, 3DE’s goal was inherently over-ambitious for a 3-year pilot. The overall goal, particularly in terms of building capacity and changing behaviour, requires a longer timeframe. Secondly, the programme had a number of aspirations that were not all compatible with one another. 3DE aimed to be demand-led, focused on robust impact evaluations, rapid, responsive and affordable, as well as catalysing action. A number of tensions or trade-offs exist within and between these aspirations. The overall lesson from the pilot is that even a very professional partnership cannot deliver on all of these in a short-term project in contexts like Zambia and Uganda, which are relatively typical of low- and middle-income settings. The necessary conditions for success are laid out in the revised theory of change  .encompasses both the capacity to find, evaluate and use…different forms of evidence and the motivation to use them to make evidence-informed policy” ,policy”  also needs to be classified as a policy decision in this context, if this is what the evidence recommends.In addition, if contribution to a policy decision is used as a target, then ‘policy decision’ should be broadened to include implementation, given the implementation gap which is so common in low-income countries . A focusThe evaluation also questioned the privileging of RCT-based impact evaluations as a higher form of knowledge. Different kinds of evidence are suited for different types of questions, and the 3DE modality could have focused on trying to generate or broker evidence that was suitable for the Ministry’s priority questions rather than privileging RCTs. RCTs are less suited to understanding processes, mechanisms, how and why implementation occurred, and the influence of context. Ministries rightly look for a range of information, including on equity and sustainability of interventions. Demand-generation or evidence-supply programmes should focus on supporting and providing appropriate tools for different questions. Evidence should fit with policy needs, so there should also be more flexibility about timeframes, for example. In some cases, having a longer time period would generate more useful and valuable information for the MoH than information generated rapidly. Overall value for money is also an important consideration. This was not assessed by the team and is itself a complex question . HoweverThere is a broader question about the primary purpose of conducting evaluations. The 3DE approach viewed evaluations as tools for providing answers to policy questions. In this model, engagement with civil society and stakeholders is primarily a vehicle for improving the evidence to inform those answers. Yet, in Zambia, as in other low-income countries, civil society is generally weak. A complementary model of the evaluation process might view evaluations also as tools for engaging civil society and stakeholders around an issue, helping build local capacity to define and measure progress by creating robust and engaged evaluation processes. Thus, a stronger emphasis on the evaluation process, with the aim of building evaluative thinking and capacity, might help provide ‘answers’ that have a greater degree of legitimacy than evaluations that take a more extractive approach to citizen and stakeholder evidence.The evaluation of the 3DE programme in Uganda and Zimbabwe illustrates the complexity of the process of supporting evidence-based policymaking in healthcare, as in other sectors, and the need for clarity of focus and realism of expectations. The 3DE programme promised an ambitious set of targets, some of which were in tension with one another. It focused on producing evaluations whose characteristics would support evidence-based policymaking, while neglecting the wider context and the characteristics of evaluation users. A number of important lessons have been derived which are likely to apply in other low- and middle-income settings, such as the importance of supporting evaluative thinking and capacity within the wider institutions, of understanding the wider political economy of evidence use and its uptake, and of allowing for some flexibility in terms of programme targets. Fixating on one type of evidence is unhelpful in the context of institutions like ministries of health, which require a wide range of evidence to plan and deliver programmes. In addition, being tied to ‘policy decisions’ provides perverse incentives and neglects arguably more important aspects for evaluators, such as contributing to incremental programmatic adjustments and improved implementation.


Science has no clear message regarding health effects of saturated fats, it seems. Different RCTs, prospective cohort studies and meta-analysis have led to contrasting conclusions. The aim of the present commentary is to discuss some possible reasons for an apparently never-ending fat controversy. They are of a purely scientific nature, which is important to recognize, but unfortunately hard to overcome. First is the placebo problem. In pharmaceutical science, evidence-based medicine is often synonymous with data on verified medical events from long-lasting double-blind randomized placebo controlled trials. In nutritional science the lack of double-blind design and lack of placebo food generate less conclusive data than those achieved in pharmaceutical science. Some scientists may apply the same type of scientific criteria used to evaluate the effects of drugs for foods. This leaves an impression of insufficient data since in this respect the fundamental criteria for evidence based medicine are not present. The next scientific problem is the energy balance equation. In contrast to pharmaceuticals, nutrients contain energy. An increased intake of one nutrient will lead to a decreased intake of another. The effect of change in only one nutrient is then difficult to isolate. Lastly, in nutritional science, generalizability is difficult compared to pharmaceutical science. Food culture interferes with lifestyle and food habits change over time. In conclusion, all available knowledge, from molecular experiments to population studies, must be taken in to account, to convert scientific data into dietary recommendations. Saturated fatty acids (SFA) do not increase the risk of cardiovascular disease (CVD), two recently published analyses of randomized controlled trials (RCTs) concluded ,2. ReplaA short commentary like this cannot elucidate the contradictions in depth, since each study must carefully be assessed, preferably by expert committees appointed by public authorities, without perceived intellectual or financial conflicts of interests, in order to avoid influence from various stakeholders. Many countries publish national dietary guidelines on a regular basis, and recently we reviewed nine national guidelines published from 2010 to 2016 for their recommendation on SFA :Eight out of nine guidelines recommended SFA intake to be 10 percent of total energy intake, or less.The ‘devil’ is in the study details. For example, in a recent cohort study reporting possible benefits of SFA , the dieErrors like under- and over-reporting of dietary intake tend to be more severe with SFA camouflaged in a diversity of foods such as sauces and snacks in contrast to easily countable items like cups of coffee . Few stuAn important reason for the never-ending saturated fat controversy is probably a purely scientific issue which is important to recognize, but unfortunately hard to overcome. In nutritional science, all RCTs on hard endpoints, such as CVD events or mortality, suffer from the serious limitation of being neither placebo-controlled nor double-blind. In pharmaceutical science, evidence-based medicine is often synonymous with data from double-blind randomized placebo controlled trials (placebo-RCT) vital to obtain approval from regulatory authorities .There are no possible placebo foods like placebo ham or steak that can be eaten for as many years as it takes to complete a study on hard endpoints. Without access to a real placebo, the double-blind design fails. The closest approach to a double-blind design on hard CVD endpoints in nutritional science is probably the Finnish Mental Hospital studies ,18 and tScientists may claim that without any placebo-RCTs on CVD events or mortality, the fundamental criteria for evidence based medicine is not present. Clinicians may apply the same types of scientific criteria used to evaluate the effects of drugs, for foods. This will result in the impression of insufficient data on almost every food item due to the lack of placebo. Importantly, the lack of placebo-RCTs in nutritional science may not be sufficiently recognized by those who demand causal evidence from placebo-RCTs in the name of evidence-based medicine. The lack of definitive causal evidence for a hypothesis may be interpreted as a proof for its faultiness or an argument for an alternative hypothesis, e.g. that SFA has no effects on health .Advocates of evidence-based medicine criticise the indirect evidence from observational data and may rely only on placebo-RCTs by default, but this is not without problems, as shown in the amusing parachute experiment . Since tIn contrast to pharmaceuticals, macronutrients like fat contain energy. In an experimental, energy-controlled design, this implies that an increased intake of one nutrient will lead to a decreased intake of another nutrient. If fat is replaced by carbohydrate or protein, the isolated effect of fat will be influenced by a change in the other macronutrients to keep the diet iso-caloric, making the isolated effect of one macronutrient difficult to measure.After a century of controversy on the role of cholesterol in atherosclerosis, finally a placebo-RCT showed that cholesterol-lowering statins reduced mortality .At this time, in the 1990s, the effects of statins were proven in middle-aged males only; data for females wereas yet not statistically significant. Today, evidence clearly shows statins to be equally efficient in both sexes . NeverthNutritional science suffers from the lack of placebo-RCTs. Thus, to convert scientific data into dietary recommendations, all available knowledge, from molecular experiments to population studies must be interpreted. Knowledge syntheses by independent public scientific committees form the basis for national guidelines. Hence, a transparent assessment of the quality of the evidence base on which a conclusion is based should be provided. Despite several ongoing controversies like the apparently never-ending SFA controversy, the message from science to consumers from national guidelines is clear: Keep your intake of SFA low (below 10 energy percent) by replacing them with unsaturated fats and unrefined carbohydrates.


Self-Awareness – is currently being offered in a smoking cessation program in 221 primary care clinics across Ontario to help smokers quit or reduce their harmful alcohol use. The patient engagement event was a useful way to co-create educational materials that incorporate both scientific research and patient needs.The purpose of this paper is to describe a patient engagement event designed to create an educational workbook with smokers who drink alcohol at harmful levels. The goal was to create a workbook that combined scientific evidence with patients’ values, preferences, and needs. Fourteen adult smokers who drink alcohol were invited to the Centre for Addiction and Mental Health (CAMH) to take part in a four-hour event to help design the workbook with the CAMH research team. Participants provided their opinions and ideas to create an outline for the workbook, including activities, images, and titles. The workbook – called BackgroundEvidence-based medicine is the integration of best research evidence with clinical expertise and patient values. There are few methodologies on how to design evidence-based programs and resources to include patient values. The latter is an important aspect of patient-centered care, and is essential for patients to trust the recommendations and empower them as consumers to make informed choices. This manuscript describes a participatory research approach to design patient-facing educational materials that incorporate both evidence-based and community-sensitive principles. These materials are intended to support smokers to reduce or stop harmful alcohol consumption.MethodsAdult smokers who report consuming alcohol were invited to a co-creation meeting at the Centre for Addiction and Mental Health’s Nicotine Dependence Service to guide the adaptation of evidence-based materials. The four-hour event consisted of individual reflections, group discussions, and consensus-building interactions. Detailed notes were taken and then incorporated into the material.ResultsSelf-Awareness – incorporating material from evidence-based workbooks and patient-driven features. Participants collaboratively selected the resource’s content, structure, and titles.Fourteen individuals participated in the event. The end product was a descriptive outline of an educational resource – entitled ConclusionsThis model describes a participatory research method that emphasizes the value of the patient perspective; preliminary evidence finds this adaptation approach can increase the adoption of resources. The process described in this article could be replicated in other settings to co-create evidence-based resources, interventions, and programs that reflect the needs of the community.Trial registrationNCT03108144. Retrospectively registered 11 April 2017.ClinicalTrials.gov The online version of this article (10.1186/s40900-018-0086-2) contains supplementary material, which is available to authorized users. Two important and interrelated paradigms have been gaining traction in Canadian medicine; a renewed interest in promoting community-sensitive and patient-centered care , and crecombined alcohol and tobacco users in primary care”, or, COMBAT [Canadian research funding agencies , 11,as w, COMBAT . The COMThis educational resource was developed to be distributed by health care practitioners to smokers in the STOP program who report drinking alcohol above the Canadian Cancer Society cancer prevention alcohol consumption guidelines . The purParticipant of the STOP program,Daily smoker trying to quit smokingCurrent alcohol user, as defined by reporting having consumed an alcoholic beverage in the past twelve monthsA total of 215 individuals met our research team’s eligibility criteria for a half-day event at CAMH. Eligibility criteria stipulated that participants must be:Alcohol consumption in the past twelve months - versus a more comprehensive alcohol use measure as the AUDIT-C – was used to define “current alcohol user” in an effort to broaden the sample of participants amongst whom recruitment could take place. By involving individuals who smoke and consume alcohol in the design of the educational resource, our intention was to reduce threats to social validity  by ensurFourteen participants  attended the event. Of those participants that provided responses to a STOP program baseline questionnaire, exactly half were female and half male; 86%  reported having up to a college degree; 72% reported an annual household income of $60,000 or less; 86%  reported smoking ten cigarettes or more per day; and 79%  reported consuming alcohol at hazardous levels, as defined by the AUDIT-C screening tool . The AUDThe patient engagement event was facilitated by two team members (NM and AN) who were responsible for guiding the discussion and eliciting relevant input from participants. Additionally, a support staff member (RR) was present to collect informed consent forms and field notes of the discussion, as well as to distribute refreshments and honoraria ($46 cash) to participants following the event. One facilitator (NM) was trained by ICA Canada in Group Facilitation Methods, and has over seven years of experience supporting communities to reflect o and develop their own appreciation of best practices, while at the same time being supported to share their knowledge of their health experiences and their local context. The other facilitator (AN) has specialized training in qualitative research focused on health behavior change and exploration.The patient engagement event design was adapted from the Institute of Cultural Affairs Canada (ICA) consensus building methodology  to facilWe began by describing the purpose of the event, including describing the health risks associated with smoking and drinking alcohol above recommended cancer risk guidelines, and our end goal of co-creating an educational resource to encourage alcohol reduction. Our intention was to develop a resource that was largely modeled from existing, evidence-based workbooks that were chosen based on the following criteria: developed by reputable public health agencies, designed for a North American audience, focused on risky alcohol use, and based on research evidence. Reference workbooks included the National Institute on Alcohol Abuse and Alcoholism’s “Rethinking your Drinking” ; BC PartAfter independently evaluating all features, participants were asked to gather into small groups to collectively reflect on the presented features, and brainstorm which concepts were missing from the list of evidence-based features, and which features should be prioritized for inclusion in the end product. Participants were asked to be as descriptive as possible when identifying features to be included  Small groups were asked to share at least three new ideas with the larger group.First individually, then as a small group, participants were asked to reflect on all features presented over the course of the event and discuss their favorite features to be included in the resource, as well as any adaptations they felt were needed to make the features more applicable to their lives. As a small group, participants collaboratively chose ten to fifteen features they proposed for inclusion in the resource. This process ensured the resource’s features captured the diversity of ideas in the group and reflected participants’ preferences and values. They were asked to record each proposed feature on an index card, again with as much description as possible.In this step, NM began collecting index cards from each group, a few at a time, and affixed them to a wall in front of the room. As more cards were collected, participants were asked to begin clustering cards by common themes, concepts, or purposes. This activity helped achieve “sections” or “chapters” of the educational resource.Participants were encouraged to come to consensus on a title for each cluster of index cards, with support from the facilitators. These title cards would be used to name the resource’s sections. Participants were next asked to rearrange the clusters in the order they wished to see them presented in the resource; this process required group discussion to rationalize why certain sections would be better suited earlier versus later in the resource.Facilitator NM encouraged the group to reflect on the overall purpose of the educational resource, its newly-arranged content, and its primary audience. With this information, they came to consensus on a title for the educational resource.Upon completion of the engagement event, participants completed a brief evaluation form to offer feedback on the event’s activities, moderators, and setting. Participants rated their agreement, on a 5-point Likert scale, with statements including, “This event offered a supportive and friendly environment” and “The instructor explained the activities clearly,” and responded to open-ended questions regarding overall impressions of the event.Following individual, small group, and large group reflections, 29 index cards were presented to the moderators. These cards represented the evidence-based and/or participant-informed features that were identified for inclusion in the co-created educational resource on alcohol reduction among smokers. The cards were categorized by participants into five sections: 1. Internal and External Supports; 2. Self-Awareness Strategies; 3. Strategies for Success; 4. Dealing with Setbacks and Slips; and 5. Health Effects. Each section – described in greater detail below – was carefully selected to cover the range of topics discussed during the patient engagement event, including evidence-based principles for reducing risky alcohol use, and participant-driven features.During the engagement event, participants expressed the importance of having a support system easily accessible in the event of a crisis. Therefore they chose the first section of the resource to be a source of contact information for patients’ support networks, both external  and internal, where patients can write in details of individuals in their personal support team.A consistent theme participants recognized across existing evidence-based resources was an opportunity to understand one’s own behaviors. For example, participants chose to include a daily tracking log for keeping record of cigarettes smoked and alcohol beverages consumed, an evidence-based strategy for encouraging behavior change . ParticiSelf-Awareness Strategies section, since patients first understand their behaviors, then make a plan to change them. However, there were mixed feelings about whether that guidance should be more prescriptive or self-guided. As a result, the section – Strategies for Success – offers a combination of evidence-based tips for reducing alcohol consumption  and open-ended questions for patients to write in their preferred reduction strategies During the event, participants expressed interest in evidence-based resources that offered guidance on how to make a change. Participants felt this section was a natural progression from the A participant-driven feature that was not initially presented, but rather arose from participant discussion, was a savings calculator – a tool to estimate the amount of money saved by reducing or quitting alcohol consumption. The tool was meant to act as a strategy for success by motivating patients to reduce alcohol use in order to save money for other activities of interest.Strategies for Success section of the resource, participants chose for this section to offer guidance to patients, and allow patients to decide what steps they will take to deal with relapse Participants appreciated that most evidence-based resources normalized setbacks and offered recommendations for addressing them. Similar to the The final section of the workbook was selected for inclusion by participants since most evidence-based resources to which they had exposure included health risks associated with the behavior being addressed. Participants felt patients would be less interested in this section compared to the behavioral exercises outlined in previous sections, and therefore chose for this section to be placed at the end of the resource. At participants’ request, our team depicted all health information in a visually-appealing, graphic format [see Fig. Self-Awareness. The resource was designed to meet standards of the Accessibility for Ontarians with Disabilities Act [Self-Awareness workbook [see Additional file All features were consolidated by a CAMH graphic design team into a 30-page alcohol reduction resource, entitled ties Act . Refer tGeneral impressions of the patient engagement event were overall positive. All participants agreed the organization and format of the session were good, and that the event offered a supportive and friendly environment. Nearly all participants (93%) agreed the small table discussions allowed their voice to be heard, and they were able to imagine how the session might apply in their community. In response to open-ended questions, one participant shared liking “how others can be in a large majority agreement and that basically everyone has the same concerns,” while others enjoyed “meeting new people” and the “knowledgeable and very inclusive” event. Though most participants expressed they wouldn’t have done anything differently to make the event better for them, one participant expressed the session “could have focused more on the connection between drinking and smoking and the related harms.”Self-Awareness educational resource by their health care practitioner. Utility and effectiveness of the resource in this real world setting is being evaluated.In April 2016, 221 Ontario primary care clinics participating in the STOP smoking cessation program started offering this resource to eligible patients. In thirteen months, 4110 smokers in the STOP program reported consuming alcohol at levels exceeding the Canadian Cancer Society’s cancer prevention alcohol consumption guidelines), of which 1871 (46%) were offered the The methodology described in this paper aims to diminish the growing gap between two prevailing paradigms in medicine – evidence-based practice and community-sensitive care – by creating a dynamic process that integrates the best research evidence with community values to create recommendations that will be widely adopted by the population and will achieve the best outcomes. The final resource offers unique features not currently available in existing, evidence-based resources. For example, the final resource reflects the interplay between tobacco and alcohol use, versus either health behavior alone. Compared to other evidence-based resources, , 25 it i.The patient engagement event approach described in this paper provides a rich description of the way a community interprets evidence-based recommendations, helps to identify key community concerns and assets, and describes how they can fit with community values, and how they have to be adapted in order to be adopted . This coDespite the benefits of this inclusive research methodology, there are some limitations to the process used. First, the patient engagement event was a one-time, half-day workshop, which reflects a limited snapshot of the participant group’s values and preferences. Allowing participants more time to reflect on the presented materials, or inviting additional participants to provide input on the resource, may have minimized the effect of this limitation. Second, one-third of individuals confirmed to participate in the event did not attend, presenting threat of selection bias among those that did attend. Lastly, although this resource was developed via participatory research , we cannAfter the patient engagement event, CAMH was able to produce a 30-page evidence-based, community-sensitive workbook that includes information on the health effects of smoking and drinking, information on where participants can access help if needed, as well as several activities for participants to understand their health behaviours and develop a plan to change them. The systematic process used to develop this resource allowed for patients’ opinions and needs to be reflected, while reaching consensus in a larger group. This participatory research method showcases a more inclusive way of developing resources, where value is placed on both patients’ viewpoints and research evidence. This engagement event process could be replicated in other settings to co-create evidence-based resources, interventions, and programs that reflect the needs of the community.


Sparganothis sulfureana Clemens) (Lepidoptera: Tortricidae) is a serious pest of cranberry (Vaccinium macrocarpon Aiton), a native North American fruit cultivated in northern regions of the United States and southeastern Canada. This study assessed antibiosis in several cranberry cultivars commonly grown in Wisconsin. Five cultivars previously shown to host different levels of populations of S. sulfureana in commercial cranberry were assessed in this study to evaluate the performance of S. sulfureana amongst these cultivars. We measured growth and time to developmental stages of newly emerged larvae to adulthood on selected cranberry cultivars in the laboratory. There was no difference in the rates of survival to pupation and to adult emergence among any of the cultivars tested. Mid-instar larvae that fed on the cultivar ‘Ben Lear’ were heavier than those feeding on ‘GH-1’, ‘Stevens’, or ‘HyRed’, and larvae that fed on ‘Mullica Queen’ were heavier than those feeding on ‘HyRed’. However, there were no significant differences in pupal weights or in the number of days from neonate to adult emergence among varieties. Therefore, this study did not provide evidence of antibiosis among the cultivars tested, and found that larval weight was not correlated with other measurements of performance.Sparganothis fruitworm ( An essential part of Integrated Pest Management (IPM) is the strategy of host plant resistance (HPR), by which growers plant crop cultivars with heritable properties that protect them against damage from insects, fungi, and pathogens . ResistaVaccinium macrocarpon Aiton) is a native North American fruit, which has only been cultivated from wild populations for about 200 years [Limotettix (=Scleroracus) vaccinii (Van Duzee) (Hemiptera: Cicadellidae), became a major threat to the cranberry industry. This led to the establishment in 1929 of the first USDA cranberry breeding program with the purpose of searching for traits that provided resistance to the insect vector [The American cranberry  (Lepidoptera: Eribidae), a damaging East Coast pest, and have suggested a possible chemical basis for resistance [Recent studies have shown differences in resistance among cranberry cultivars grown on the East Coast to gypsy moth  (Lepidoptera: Tortricidae), commonly known as sparganothis fruitworm, is a serious pest of commercial cranberry, alongside Acrobasis vaccinii Riley , also known as cranberry fruitworm. Sparganothis sulfureana is a native North American species, and is highly polyphagous, with host plants including cranberry and blueberry (Ericaceae), apple (Rosaceae), alfalfa (Fabaceae), celery (Apiaceae), and pine (Pinaceae), among others [Sparganothis sulfureana is a bivoltine pest that overwinters as a first instar larva and feeds on new foliar growth in the spring, reducing the photosynthetic capacity of the plants. The second, more damaging larval generation burrows into berries as soon as the fruit begins to enlarge. Each larva of this generation hollows out and destroys 3–5 berries during its development, causing significant economic damage to growers [g others . Studiesg others . Spargan growers . Rarely, growers .S. sulfureana to organophosphate insecticides has decreased the effectiveness of these chemicals [S. sulfureana control [To control this damaging pest, many cranberry growers use IPM strategies such as the careful monitoring of insect populations  and floohemicals . The use control ,24. The  control . Given tThe state of Wisconsin produces ca. 60% of the nation’s cranberries  and therS. sulfureana were reported in beds of ‘Stevens’ and ‘GH-1’ than in beds of ‘Ben Lear’, ‘Mullica Queen’, or ‘HyRed’, indicating higher overall S. sulfureana populations in these cultivars [Using pheromone traps in commercial cranberry marshes, higher population densities of adult male ultivars . It is uS. sulfureana growth and time to development in the laboratory on five of the most commonly grown cultivars in the leading cranberry-producing region, i.e., ‘Stevens’, ‘Ben Lear’, ‘GH-1’, ‘HyRed’, and ‘Mullica Queen’. Based on field observations [The goal of this research was to assess rvations , we hypoFive cranberry cultivars commonly grown in Wisconsin—‘Stevens’, ‘Ben Lear’, ‘GH-1’, ‘HyRed’, and ‘Mullica Queen’—were assessed for resistance. Due to its prevalence in production and its use as a standard cultivar in other research ,27,29, t® 366 P Series; Sun Gro®, Agawam, MA, USA), and 10% autoclaved sand collected from a commercial cranberry marsh. Plants were grown in a controlled environment greenhouse , watered at least every other day, and fertilized weekly, or as needed with Miracid fertilizer .Rooted cuttings of all five cultivars were acquired from a commercial nursery  in the spring of 2015. Cuttings all came from the propagator’s stock, with the exception of the ‘Ben Lear’ cuttings, which were collected by the propagator from a commercial marsh the previous fall, and were overwintered and planted under the same environmental conditions as the other cultivars. Cuttings were then transplanted into 10 cm × 36 cm × 51 cm black plastic flats  in a medium of 80% peat moss, 10% commercial substrate  with a 16:8 L:D photoperiod at 24 °C. Insects were reared on a wheat germ-based diet  in 29.6-mL lidded clear plastic cups  to eliminate preference for any cranberry cultivar. Pupae were removed and allowed to emerge in mesh-lidded 355-mL clear plastic cups . Upon emergence, moths were allowed to mate and oviposit, and eggs were checked daily for hatch. Immediately after hatching, neonates were used in the experiment.The source of the The experiment employed a hydroponic growing system made with 2.54 cm-thick stiff foam insulation  with 20 or 35 circular indentations (4.6 cm in diameter), each with a hole (1.8 cm in diameter) through the center a. Foam wS. sulfureana larva was added to each vial using a paintbrush. Neonates did not all hatch on the same day, so an equal number of replicates for each cultivar were added on 30–31 May 2014. Larvae were allowed to feed freely, and an effort was made to minimize disturbance. Larvae were checked daily to assess survival, and fresh uprights were added every three days or as needed to maintain optimal food quality. No more than four uprights accumulated before the old ones were removed. An exception was made if the larva had woven several uprights together  of each of the five cultivars were set up in the hydroponic system. One neonate together b, and upAfter 16 days, midway through their development, larvae were weighed, and returned to the uprights to continue feeding. Upon pupation, insects were removed from the uprights, and pupae were weighed, sexed , placed p values were found, Fisher’s LSD (Least Significant Difference) was used to further analyze differences between cultivars [Differences in insect survival rates among cultivars were analyzed using a Chi-squared test  . Larval ultivars .Χ2 (df = 4) = 2.14, p = 0.71) (Χ2 (df = 4) = 1.13, p = 0.89)  ranged from 80% to 94.7% among cultivars with an average survival rate of 85.8%. There was no significant difference in percent survival to pupation among cultivars ( = 0.71) . Surviva = 0.89) .F4,68 = 5.42, p = 0.0008) (n = 19) than those feeding on ‘GH-1’ , ‘Stevens’ , or ‘HyRed’ . Larvae feeding on ‘Mullica Queen’ were significantly heavier on average  than those feeding on ‘HyRed’.There was a significant difference between cultivars in larval weights at 16 days ( 0.0008) . Larvae F4,60 = 1.83, p = 0.13)   . There w = 0.19) .S. sulfureana, an important insect pest of cranberry, despite differences observed in field populations of this pest among the same varieties [S. sulfureana performance in a laboratory setting. Interestingly, although S. sulfureana mid-instar larval weights differed among cultivars, the trends were not supported throughout the development of the insects. By the time the insects pupated, there was no significant difference among any of the cultivars tested.Overall, our results did not demonstrate differences in resistance through antibiosis among the selected cranberry cultivars towards arieties . We provWe found that larvae feeding on ‘Ben Lear’ were heavier than those feeding on other cultivars, which supports previous results obtained with gypsy moth . The preHeliothis zea larvae after feeding for 10 days, but only a 4.6% reduction in pupal weight and a 15% increased time to development [Vaccinium species, demonstrated a difference in larval weight gain and developmental time among cultivars, but found no significant differences in pupal weight among cultivars [This study reinforces the suggestion that short-term changes in larval weight may not accurately represent changes in the weight of the insect over its entire development, and that differences in larval weight gain alone may not be an accurate predictor of host plant resistance . Farrar elopment . A studyultivars . These fRhopobota naevana Hübner, prefers to feed on younger cranberry leaves and their development and survival are both affected by the age of the leaves, with a slower developmental time and higher mortality reported with older cranberry leaves [Several studies have demonstrated that early instar lepidopteran larvae are more sensitive to plant secondary compounds, including growth-inhibiting flavonoids and phenolics, in comparison to later instar larvae. These chemical defenses induced higher levels of mortality and decreased growth rates in these early instars ,36,37. Hy leaves . S. sulfureana female pupae were significantly larger than the males , possibly impacting average larval and pupal weights. However, in this study, the only significant difference among cultivars was in the weight of larvae at 16 days, and no difference was found between the weights of male and female larvae at that stage . When the sexes were separated and analyzed as pupae, there was no significant difference in weight among cultivars for either males  or females , and the lack of significant difference with sexes pooled was confirmed.At the initiation of our experiment, neonates were randomly allocated to each experimental container without being sexed, thus we had different sex ratios on each cultivar. In other lepidopteran species, females are generally larger than males ,44 and iS. sulfureana on the foliage only and did not include performance on the fruit of the cranberry plant. Thus, this study reflects the activity of the first generation of insects in the field that feed exclusively on the foliage before the cranberries form. The success of the first generation will likely impact the population size of the second, more damaging, generation. Pupal size is positively correlated with adult female fecundity in many insect species [This laboratory experiment measured larval performance of  species ,46, thusS. sulfureana adult male population densities in beds of ‘Ben Lear’, ‘Mullica Queen’, and ‘HyRed’ compared to beds of ‘Stevens’ and ‘GH-1’ [A recent field study found lower d ‘GH-1’ . The resd ‘GH-1’ . S. sulfureana, yet there are several other important pest species, including cranberry fruitworm (Acrobasis vaccinii Riley) and blackheaded fireworm (R. naevana), that have yet to be tested.This study did not observe antibiosis in any of the five commonly grown cranberry cultivars tested. However, there are over 140 known cultivars of cranberry, a majority of them selected from the wild , so manyS. sulfureana to the selected cranberry cultivars evaluated. An unforeseen outbreak such as that of false blossom disease has the capacity to threaten the entire cranberry industry, and host plant resistance has rescued growers in the past [In this study, we did not find evidence of antibiosis in the past . Geneticthe past ,48. Ther