Healthcare systems invest in leadership development of surgeons, surgical trainees, and teams. However, there is no agreement on how interventions should be designed, or what components they must contain to be successful. The objective of this realist review was to generate a programme theory explaining in which context and for whom surgical leadership interventions work and why.Five databases were systematically searched, and articles screened against inclusion considering their relevance. Context-mechanism-outcome configurations (CMOCs) and fragments of CMOCs were identified. Gaps in the CMOCs were filled through deliberation with the research team and stakeholder feedback. We identified patterns between CMOCs and causal relationships to create a programme theory.Thirty-three studies were included and 19 CMOCs were developed. Findings suggests that interventions for surgeons and surgical teams improve leadership if timely feedback is delivered on multiple occasions and by trusted and respected people. Negative feedback is best provided privately. Feedback from senior-to-junior or peer-to-peer should be delivered directly, whereas feedback from junior-to-senior is preferred when delivered anonymously. Leadership interventions were shown to be most effective for those with awareness of the importance of leadership, those with confidence in their technical surgical skills, and those with identified leadership deficits. For interventions to improve leadership in surgery, they need to be delivered in an intimate learning environment, consider implementing a speak-up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to the needs of surgeons. Leadership of surgical teams can be best developed by enabling surgical teams to train together.The programme theory provides evidence-based guidance for those who are designing, developing and implementing leadership interventions in surgery. Adopting the recommendations will help to ensure interventions are acceptable to the surgical community and successful in improving surgical leadership.The review protocol is registered with PROSPERO (CRD42021230709).The online version contains supplementary material available at 10.1186/s13012-023-01274-3. Contributions to the literatureThe paper provide the first theoretically informed realist review of the scientific evidence-base for leadership development interventions used in surgery.We provide a novel programme theory to explain in which context and for whom, leadership interventions in surgery work and why.The realist review findings provides evidence-based guidance for those who are designing, planning, and implementing evidence-based leadership interventions in surgery.Investment in leadership development in healthcare is substantial. Reports indicate an estimated annual spend on leadership development in the USA at $50 billion (USD) , 2. In 2In the context of surgery, the surgical profession has increasingly recognised the need for high quality leadership both in and outside of the operating theatre , 8. For In the UK, the Department for Health and Social Care (DHSC) recently called for more inclusive leadership in the healthcare professions, which aims to adopt a collaborative approach to leadership practice . HoweverIn contrast, Ability, Motivation, and Opportunity (AMO) theory describes how the interplay between ability, motivation, and opportunity  to enact leadership, gives us a measure of an leadership performance and performance-related outcomes . This enDespite the significant investment in healthcare leadership development, and the numerous systematic reviews which have been conducted to determine the effectiveness of specific leadership interventions (such as team-training and co-leadership) –19, therWe aimed to fill this gap by conducting a realist review of interventions and strategies to promote evidence-based leadership in healthcare. The goal of our review, is to develop a programme theory to answer the following question: In which context and for whom, can interventions and strategies improve the leadership of surgical trainees, surgeons, and surgical teams and why?Realist reviews are a theory-based approach to synthesising existing evidence. This review follows the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and reporting standards  which inAccording to realist philosophy, interventions that are context-dependent, and those that are successful in certain contexts but not in others, can be described as complex. Leadership development is an inherently complex intervention , realistThe review scope was developed iteratively through a scoping search of the literature, multiple expert stakeholder consultations and discussion between the research team. Experts included orthopaedic surgeons at various career stages and surgical trainees, an orthopaedic Training Programme Director, members of a orthopaedic leadership Action Learning Set and academics with expertise in clinical leadership. We developed the study protocol which was registered with PROSPERO CRD42021230709 and published . To infon = 4012). Included papers were obtained at full text and read for relevance to the review. Potentially relevant articles were summarised and discussed with the wider project team. During this process it became apparent that the theoretical papers were unhelpful in progressing our initial programme theory. Many articles appeared generic, describing the importance of ‘good’ leadership at different levels  of healthcare, but not specifically how leadership should be conceptualised, or which component parts could form the basis of future interventional research. Following discussion with experts we therefore, ceased this theoretical scoping activity and focused our resources on the identification of empirical studies, which we considered more informative for narrowing the scope of our initial programme theory.The theory search identified 8382 articles. Two authors independently screened the titles and abstracts identified in one database search  by our information specialist (RC). The search was conducted in July 2021 and adapted to a variety of bibliographic databases relevant to the scope of the review (MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), Cochrane Library (Wiley), HMIC (Ovid), Abi/INFORM Global (Proquest).Surgical Leadership: A guide to best practice’ guidance was first published by the Royal College of Surgeons of England (an updated 2018 version has since been published) [A range of relevant search terms were included, combining the concepts of leadership interventions with surgeon/surgical team. The empirical search was limited to literature published in English after 2014, the year in which the ‘Studies were screened at title and abstract stage against the inclusion criteria listed in Table Two reviewer pairs independently screened all titles and abstracts identified through the empirical search . Full text articles were obtained and screened independently by two reviewers (MH + AW). Full-text articles were screened against the inclusion criteria and with consideration to their relevance , 27.Disagreements were resolved through discussion including a third reviewer (AG or JG). Two reviewer pairs (AW + MH) independently screened the reference lists of identified reviews and all included studies to identify relevant articles.A data extraction template was piloted (JG) by the research team members  and minor adaptations were made. Data was extracted by one research team member (MH or AW) and checked by one research team members (JG). We abstracted all data from the study that might be relevant to the research question into one document per study for review by the team . ExtractRelevance for purpose was the most important factor in determining relevance for inclusion in our review and articles were not be excluded based on their quality . NeverthAll studies relevant to the individual surgeon leadership were grouped into the four skill categories suggested by Mumford et al. . For exaDiscussion between the research team and expert stakeholders generated additional categories of leadership intervention where the focus was broader, for example team-based simulations. Next, the first author (JG) identified CMOCs and CMO fragments  which were copied into a separate word document for each type of leadership intervention  for discussion with the wider team. An excerpt from each article was selected as supporting evidence of the CMOC or CMO fragment. Next, we reviewed, compared, and contrasted all CMOCs and CMO fragments and tried to identify patterns and causal relationships between them.We synthesised CMOCs and CMO fragments iteratively through verbal discussion, reading and commenting on each other’s configurations. We documented the CMOCs and CMO fragments in Word documents and in a programme theory diagram. We refined the diagram through discussion with the research team members. In several CMOCs, a mechanism or mechanisms were not immediately obvious, and not directly referred to in the literature. In these cases, the review team would suggest mechanisms that offered a potential ‘fit’ with the data . We tookA group of expert stakeholders was identified through the established network of the research team members and included two senior academics, four consultant surgeons and one surgical trainee. Stakeholders’ feedback on the consistency and plausibility of CMOCs and the programme theory was discussed in virtual meetings and incorporated into the final programme theory.Thirty-three articles were included in our review –64 see . An overIndividual leadership skills influenced by interventions were grouped into four categories  showed that immediate critique from consultants after scenario simulations (referred to as ‘freeze-frames’) were effective for improving participants’ leadership learning . This waEvidence suggests that for feedback to improve leadership, it needs to be provided more than once , 59, 63.Several studies suggest that feedback delivery through a trusted, respected person is an important context for improving the leadership of surgeons , 57, 63.We found that obtaining feedback from a range of people, for example from junior residents, advanced practitioners and nurses , is crucGregory et al.  found thAs outlined in the previous CMO, stakeholders felt that feedback was most effective in improving leadership if it was provided directly (rather than anonymously) from a peer or someone more senior. They reasoned that if feedback is provided from someone at your level or above, (i.e. consultant to consultant) you would want to maintain their trust and working relationship and therefore, improve your leadership skills.Our stakeholders suggested that openness to self-improvement is an important mechanism in several contexts. In line with this, two studies indicated that negative feedback is delivered best in a private context , 53. EssThe timing in professional career was an important context for improving leadership. Jaffe et al.  describeEvidence suggests that leadership interventions are more effective in improving leadership of those with more confidence in their technical skills , 54. SurWe found evidence to suggest that those who were identified as having leadership deficits, via feedback interventions, demonstrated more improvement in leadership compared to their competent colleagues , 45. StaStudies evaluating leadership courses found that variation in the component leadership learning activities was important for improving leadership , 57, 62.Brindle (2018) found that if all members of a surgical team were allowed to speak-up, about errors for example, this led to an improvement in communication and improved sense of collective leadership . In suppEvidence from the literature suggests that leadership interventions are effective in improving surgeons’ leadership skills if they are customised to individual surgeons’ needs , 57, 59.Evidence suggests that interventions improve leadership if they occur in a more intimate learning environment, meaning interventions delivered in person and in small groups or one-to-one. For example, mentoring studies showed that surgeons preferred one-on-one and face-to-face meetings, rather than larger group sessions , 59. SimStakeholders stated that it would be important for surgical teams to be given time to train in leadership together and to run through operations together to reinforce learning in practice (the opportunity required in AMO theory). Our stakeholders stressed that leadership is a process and only through training together could you build trust, rapport, friendship, and mutual respect leading to surgical team leadership.The concept of ‘genuine investment’ was important for leadership development. We found that if surgeons deem an intervention important in context, and delivered for ‘the right reasons’, then it was more likely to be successful in impacting leadership , 36. ForRealist review methods were used to review the literature describing interventions and strategies which aim to promote evidence-based leadership in healthcare. We aimed to generate a programme theory to explain in which context and for whom surgical leadership interventions work and why. Thirty-three studies and seven stakeholders contributed towards the development of our programme theory which consists of 19 CMOCs. Our findings suggest that surgical leadership interventions improve leadership when feedback is delivered in a timely manner, on multiple occasions and by a range of trusted and respected people. With regard to negative or more developmental feedback, we identified that it is best provided privately. Feedback from seniors to juniors or peers should be delivered directly, whereas feedback from juniors to seniors should be provided anonymously.While numerous systematic reviews have described the effectiveness of individual leadership interventions in healthcare settings –18, 65, As we anticipated, most of the leadership interventions identified in our review targeted the leadership development of individual surgeons. Many studies in our review report surgeons learning leadership skills through standalone interventions, for example in the studies by Pradarelli et al. and Ramjeeawon et al., but there was very little evidence to describe how and whether this skill-based approach to learning extends into clinical practice , 58. TraThis individualised focus reflects the proliferation of clinical leadership programmes and courses targeted at medical professionals across the globe –6. For eSome might argue that more rigorous approaches to the measurement and evaluation of leadership interventions are required. Firstly, to overcome the apparent responder bias in the literature and secondly, to move a step closer to determining whether the large investment the healthcare sector makes in developing leaders is delivering a return. Yet, we recognise that studies which have sought to establish links between leadership and performance have long been criticised as circumstantial or an anecdotal . Indeed,Nevertheless, the interventions and strategies shown to be most effective in our review include those which aim to raise awareness of the importance of leadership for surgical practice, those that attract people with established confidence in their technical surgical skills, and interventions aimed at surgeons who have been labelled with leadership deficits. Our findings suggest that perceived openness to leadership development, whether that be because surgeons’ have identified deficits or because their technical surgical skills are becoming more innate, was motivational for leadership development. Therefore, leadership interventions can build abilities and capabilities and give surgeons time to focus on their leadership, and an opportunity to practice leadership in the context of clinical practice.The timing of leadership interventions in surgical careers seems to be a key aspect to their effectiveness. Traditionally, the literature on the timing for the implementation of innovations and behavioural change interventions has focused on discrete events such as triggers to Acton , 72. HowWe found that for interventions to improve leadership in surgery, they need to be delivered in contexts where there is an intimate learning environment within a speak up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to surgeons’ needs. Therefore, leadership of surgical teams may be best developed by allowing mixed discipline surgical teams to train together, rather than training distinct professional groups in isolation, which was the case in most of the literature we reviewed. This was reinforced by expert stakeholders who emphasised that healthcare leadership is rarely enacted in isolation or in distinct professional groups.This review represents the first use of realist review methodology to explore how surgical leadership interventions need to be designed to improve the leadership of surgeons, their teams, and trainees. The strengths of the study stem from adopting rigorous methodological guidance for realist reviews as described in the RAMESES quality standards  see Add. Use of Our study limitations lie in the topic under consideration. The leadership literature is extensive . For this reason, we did not include articles which focused on distal outcomes outlined in our initial programme theory  . This deOur decision to limit distal outcomes was not just a pragmatic choice to prevent being overwhelmed by literature, but a methodological one. The further we extend outcomes, the less confident we can be that the cause can be attributed to the leadership intervention. Organisational and patient level outcomes are likely more affected by a complex set of variables. Hence, our design to limit our study to outcomes that are proximate to the setting in which leadership intervention took place, the surgical unit. Nevertheless, our decision to reduce our focus had consequences for the review as it limited our ability to fully achieve our initial aim, which was to understand how surgical interventions work and generating a strong evidence base to support use of surgical interventions. We may have excluded effective leadership interventions due to their setting, for example interventions delivered at a national scale, such as those programmes offered by the NHS Leadership Academy in the UK . That beIn secondary research, the resulting synthesis is only as good as the primary data on which the synthesis is built. Whilst most included studies were of medium and high quality, a major limitation we encountered in our review was that most primary studies included only insight into the impact of surgical leadership interventions on individual leadership in isolation and did not consider the impact on the team or wider department. Because of this limitation in the literature scope, we adopted an individual skills-based framework to summarise the results in Table In some cases, our CMOCs had gaps that could not be filled via the literature; most notably, this included a lack of mechanisms evidenced in the literature. This is a not uncommon when conducting realist reviews, and something faced by Price and colleagues in their review of patient safety . They foIdeally, we would have conducted the stakeholder consultations in person as this can help build trust and rapport between participants. However, doing the consultations online was crucial to ensure surgeons could attend and fit the consultations around their work. Further, we would have liked to have consulted a more diverse range of stakeholders, and we acknowledge, for example, that we did not have any female surgeons or early-stage surgical trainees  sharing their views. We acknowledge that doing this may have led to changes in the CMOCs. We did invite a range of surgeons and surgical trainees to our stakeholder events, but many declined due to availability.It is clear that effective leadership can be important for the surgical profession, but it is by no means a panacea for success. An overarching finding of our review was the lack of literature which examined the entire surgical profession  and leadership in surgery more generally, i.e. not confined to an operating theatre. Most literature we identified positioned the surgeon as the target of the intervention and very few studies described the mechanism through which leadership was be improved. This finding is evidence to support additional qualitative research which seeks to explore and illuminate mechanisms, to unpack the ‘black box’ that is leadership improvement.Whilst it is in important to understand what works in surgical leadership, we also need to understand the changing context in which leadership plays out, both in and outside of the operating theatre and beyond into the hospital and wider surgical community. We suggest that it is the enactment of leadership in context which will become important for improving leadership. Therefore, future research should consider surgical leaders embedded within surgery teams as a unit of analysis. We found that most leadership interventions are not grounded in theory, or evidence. For example, we suggest that the AMO  theory may be well suited to design interventions which improve surgeons’ performance in the context of practice . We therIn healthcare, evidence-based practice reigns. Yet, when it comes to leadership development in surgery, the same approach to building and adopting the evidence-base in practice falters. Investment in leadership development in healthcare is substantial. To see a return on this investment we need to ensure that the interventions we implement in practice to improve the leadership of surgeons and surgical teams are evidence based and theoretically informed.Our realist review identified 19 CMOCs which are the starting point for this evidence base. We used the CMOCs to develop the first programme theory to explain in which context and for whom leadership interventions in surgery work and why. The programme theory provides evidence-based guidance for those who are conducting research on leadership in surgery or who are planning or designing evidence-based leadership interventions in surgery.Additional file 1.


Punishments for norm violations are hypothesised to be a crucial component of the maintenance of cooperation in humans but are rarely studied from a comparative perspective. We investigated the degree to which punishment systems were correlated with socioecology and cultural history. We took data from the Standard Cross-Cultural Sample database and coded ethnographic documents from a sample of 131 largely non-industrial societies. We recorded whether punishment for norm violations concerned adultery, religion, food, rape or war cowardice and whether sanctions were reputational, physical, material or execution. We used Bayesian phylogenetic regression modelling to test for culture-level covariation. We found little evidence of phylogenetic signals in evidence for punishment types, suggesting that punishment systems change relatively quickly over cultural evolutionary history. We found evidence that reputational punishment was associated with egalitarianism and the absence of food storage; material punishment was associated with the presence of food storage; physical punishment was moderately associated with greater dependence on hunting; and execution punishment was moderately associated with social stratification. Taken together, our results suggest that the role and kind of punishment vary both by the severity of the norm violation, but also by the specific socio-economic system of the society. Social media summary: Socioecology drives the cross-cultural variation in the punishment of norm violations across human societies.Humans are remarkable among primates for our ability to form and maintain large, cooperative groups of unrelated individuals. We eat, socialise, work and cohabit with others to whom we may have few biological or social connections and, in some cases, do not know at all. This ultra-sociality and capacity for cooperativeness between individuals and groups is often suggested to be maintained by social norms Gintis, . Norms hSome norms, such as those promoting prosocial behaviour and shunning antisocial behaviour within groups, seem to be cross-culturally universal  cannot be fully explained by models based purely on kin-selection, reciprocal altruism or strong reciprocity , for violations of norms against adultery. Firth : 359 staIf a man kills another man who has committed adultery with his wife, the deceased need not be compensated. But if the adulterer kills his friend, whose wife he has seduced, the adulterer must compensate the deceased's family with two valuable old jars. If he fails to pay this, he must surrender himself to the relatives of the dead man, to become their slave, together with his descendants.Yet in some cases, there are very clear proscriptions. Describing punishment scenarios for adultery among the Iban, Sandin : 9 stateIf marriage … is a form of sanctioned or institutionalized possession, then it can be discussed in terms of the property concept. To deprive a person of his spouse, temporarily by adultery, or permanently by elopment is to commit a theft. ‘Robbery’ is the term the Tarahumara use to describe such behaviour. Several cases of trials involving such activities on the part of both men and women were described by native officials who tried the cases and exacted harsh punishments.Marriage, however, is an institution. Violations of marital ‘contracts’ may be punished institutionally. Among the Tarahumara, Fried : 192 expIn summary, although distinctions between institutionalised and inter-personal punishment and costly and non-costly punishment are important, they are beyond the scope of the current study, which focuses on societal-level patterns and cultural diversity, rather than inter-individual behaviours.Classic theories of social diversity and punishment, such as those put forth by Durkheim , often dMore recent social science on cultural variation in punishment is often biased towards post-industrial societal contexts . For each punishment type we developed a suite of hypotheses predicting socioecological variation and associations with evidence for punishments. Additionally, we assess the role of possible sources of ‘meta-ethnographic’ biases in our data. These aims are centred around a hypothesis-driven approach.We assess the prevalence of evidence for different types of norm violations and punishments across societies and interrelationships between norm violations and punishment types. To do so, we collected primary ethnographic data on five domains of norm violation  and four types of punishment  often discussed by evolutionary researchers (see the SI). We then test hypotheses for how punishment types are related to social and cultural ecological variability, accounting for cultural phylogeny. We tested six culture-level socioecological variables, drawn from existing cross-cultural data, as predictors of evidence for punishment, including two Reputational punishments will be positively associated with sociopolitical variables, i.e. the presence of external trade, food storage and social stratification and greater community size. This expectation assumes that reputation loss is more costly in hierarchical sociopolitical contexts, as well as in denser social networks where reputational information can be more quickly transmitted. This hypothesis also predicts that reputational punishments will be positively associated with the presence of food storage and external trade and decreased reliance on hunting. This expectation assumes that more diversified economic systems create more niches for reputation domain development, contributing to the importance of reputations and the availability of reputation-based sanctions , no discussion of punishment for each category of violation (no evidence), or direct mention of lack of punishment for each category of norm violation (evidence against). We documented only one case of evidence against, for material sanctions for adultery . When there was evidence for punishment types we also coded if evidence was ambiguous , from colonial or non-traditional institutions , a reference to older, traditional, or former punishments  or a reference that the punishment or lack of is new and not in former context . Because most coded evidence did not include any of these sub-codes  and the most frequent sub-code was traditional or former punishment, we ignored sub-coding in the analyses. Therefore, for each of the 131 documents, each of these nine variables was assigned a value of 1 if any returned paragraph provided supporting evidence and 0 if no evidence was documented.We leveraged the electronic Human Relations Area Files (eHRAF) and SCCS databases to assess ethnographic evidence for norm violations and punishment types and to test hypotheses related to socioecological diversity. For norm violations we coded for evidence that the norm violation was discussed in some context in ethnographic materials or if the norm violation was not discussed in ethnographic materials. For punishments we coded evidence that a punishment type was generally expected to be applied in a given context https://osf.io/9kjy5/). Data are available via the violationsandpunishments R data package  and includes 131 societies (see Table S1). Ethnographic sources including metadata and additional details on these sources, our sample and coding procedures are available in the SI repository (We use descriptive statistics to (1) report the prevalence of evidence for norm violations  and punishment types  and to (2) illustrate relationships between the domain of norm violation and associated punishment types .External trade (present/absent);Animal husbandry ;Dependence on hunting ;Food storage (present/absent);Community size ;Social stratification .We then use Bayesian phylogenetic regression analyses and a cross-cultural phylogenetic supertree  as robustness checks against suppressor effects owing to potential correlations between punishment types (the results and interpretations from both approaches do not strongly differ).We also investigated three possible sources of meta-ethnographic bias in our document sample. Specifically, we used document page count, document publication date and the presence of a female author or coauthor as predictors in the multi-response, multi-predictor, multi-level Bayesian phylogenetic modelling approach described above (reported in the SI). The results revealed that document page count was a predictor of evidence for all four punishment types, the presence of a female coauthor was a predictor of evidence for material punishments and publication year was not predictive of evidence for any punishment type . We therefore include document page count in our full model. Because only 21 of our 131 documents included a female coauthor and the effect was moderate, not obviously meaningful and limited to one outcome we did not include the measure in our full model. Our multi-response, multi-predictor Bayesian phylogenetic model incorporates weakly regularising priors to facilitate model convergence and impose conservatism on parameter estimates  or the proportion of the posterior distribution that is of the median's sign (i.e. greater or less than 0) , we performed multiple imputation using the mice R package  for the five violation domains and the four punishment types in any of the 20 within-violation domain punishment types within a culture document  was strongly related to the presence of evidence for the related violation measures (e.g. war cowardice violation) (the mean correlation of evidence for a violation measure (0/1) and evidence for any associated punishment type (0/1) = 0.95 and mean Jaccard index (similarity coefficient) = 0.93 (minimum correlation = 0.77 and maximum = 1)). Each document that provided evidence for at least one punishment type also provided evidence for the associated violation measure. The distribution of counts of evidence for each punishment type by violation domain is depicted in the mosaic plot in The presence of evidence for Within each norm violation measure, the relative frequency of associated punishment types was generally consistent, with a few exceptions. Regarding adultery violations, punishments were most often physical and least often reputational. For religious violations punishment types were generally equally applied, with the exception that evidence for reputational sanctions was relatively rare. Among food norm violations, material punishments were slightly more frequent. Evidence for punishments against rape were generally consistent across punishment types, with a slight bias in favour of greater material punishments. Among punishments for warfare violations, evidence for reputational sanctions was most frequent.We found evidence for minimal phylogenetic signals  in the cross-cultural distribution of evidence for punishment types . Evidence for reputational punishments and execution had very small phylogenetic signal . Evidence for physical and material punishments demonstrated slightly greater though still weak phylogenetic signals .There were moderate to low correlations between evidence for our four punishment type measures. Specifically, evidence for material punishments, physical punishment and executions was moderately correlated . Effect size posterior distributions for the culture-level predictors of each punishment type from the Bayesian phylogenetic model are displayed in pd = 0.96) and the absence of food storage (pd = 0.91). Thus, the two largest effects were in the opposite direction as predicted. Consistent with predictions, there was a moderate association with the presence of external trade (pd = 0.82).Hypothesis 1, which predicted positive associations of the presence of external trade and food storage, larger community size and social stratification with evidence for reputational punishments, was largely unsupported. Contrary to expectations, evidence for reputational punishment was associated with egalitarianism (pd = 0.94) and moderately associated with increased reliance on animal husbandry (pd = 0.84). Contrary to predictions, however, the presence of external trade was not associated with evidence for material punishments and there was a moderate association with absence of external trade (pd = 0.84). Reliance on hunting was not associated with evidence for material punishments (pd = 0.65).Hypothesis 2, which predicted effects of economic measures with evidence for material punishments  was partially supported. Consistent with predictions, evidence for material punishments was associated with the presence of food storage (pd = 0.84). In the univariate-response model and contrary to predictions, there were moderate associations between evidence for physical punishment and the absence of external trade, and a weak association with the absence of food storage (see Table S4).Hypothesis 3, which predicted positive associations between all socioecological measures and evidence for physical punishments, was largely unsupported with the exception that greater reliance on hunting was moderately associated with evidence for physical punishment (pd = 0.87). The effects of presence of external trade (pd = 0.65) and community size (pd = 0.6) were in the predicted direction, although associations were weak. Although not among our predicted relationships, the absence of food storage was moderately associated with evidence for execution punishments (pd = 0.86).The results of Hypothesis 4, which predicted associations among social stratification, the presence of external trade and greater community size with evidence for execution punishments, were mixed. Consistent with predictions, evidence for execution punishments was moderately associated with social stratification ; in an additional 50 societies extramarital sex was found to be allowed for men but condemned for women. Extramarital sex, however, is common. Broude and Greene  men commonly engage in extramarital sex and in 57% of societies  extramarital sex is common among women. Consistent with extensive norms against adultery and relatively high rates of extramarital sex, divorce rates are also high across populations, including among small-scale societies . Notably, it may seem surprising that reputational punishment was not more frequently documented given the fundamental role of reputations in human sociality and the ease with which reputations can be damaged via gossip , given the putative greater cost of reputation loss in more hierarchical societies. In fact we found the opposite – reputational punishment was associated with egalitarianism and the absence of food storage. These patterns, however, are consistent with the role of partner choice in driving cooperation among egalitarian hunter–gatherers, who often rely on daily food sharing and immediate return subsistence activities . Food surpluses can be costly to lose, if forced to use them in the payment of fines, but for individuals with excess reserves, material-based sanctions can be less costly than other types of punishments. Among populations with domesticates, livestock represent a standardised currency and many rural populations associate monetary or quantitative values with animals. External trade, however, was moderately and negatively associated with evidence for material punishments, contrary to predictions (H2). Inter-group economic transfers may increase the utility of material goods, thereby decreasing the effectiveness or group utility in material punishments. Alternatively, external trade may allow individuals or households to convert material wealth into other forms of capital, making local standards of item value more variable and challenging. Overall, our results associate material sanctions with the intensification of sociopolitical and economic structures.Physical punishments were not strongly associated with any socioecological variables but were moderately associated with greater reliance on hunting. Among populations that strongly rely on hunting, males may have greater bargaining power over females and are therefore able to use physical punishments against women Bowles, . AlternaWe found some evidence that executions were more likely to be associated with social stratification than egalitarianism, as predicted by H4. Most other socioecological variables, however, were not associated with evidence for executions except for food storage. The presence of food storage  may represent a mechanism by which material-based punishments are favoured and execution is disfavoured, independent of social stratification or other social complexity variables. Like Spitzer , we do nOverall the lack of strong phylogenetic signals across punishment types suggests that cultural variation in punishment tends to adapt quickly to local socioecology, and is not as strongly influenced by cultural history or inertia as some other cultural traits. Marriage norms, for example, are more highly conserved and demonstrate strong phylogenetic signals across societies  Our method also selected one representative ethnography we determined to be sufficient for our search strategy and broadly representative of the population. This methodological choice was an attempt to limit sample size and increase the feasibility of the coding process. Also, this method has the benefit that our sample of evidence for each population is relatively balanced (i.e. one ethnography per culture). Other ethnographies may, however, provide useful evidence and our sample then may have been too limited. Therefore, to more accurately assess prevalence rates of norm violations or punishments or more comprehensively measure cross-cultural relationships, a deeper sample of the ethnographic record could be developed.From a sample of 131 primary ethnographic and culturally unique documents we coded for evidence of norm violations within the domains of adultery, religious violation, food violation, rape and war cowardice, as well as evidence for reputational, physical, material and execution punishments. We discovered widespread evidence of adultery violations, moderate evidence for religious, food and rape violations, and minimal evidence for war cowardice as a norm violation. We also found evidence of physical, material and execution punishments in 38, 35 and 34% of societies respectively. Drawing on measures of socioecological variation from the SCCS we tested a series of hypotheses on cultural variation in evidence for punishment types. Accounting for the phylogenetic relationships among our cross-cultural sample, as well as correlations between evidence for punishment types, we found that egalitarianism  strongly predicted evidence for reputational punishments, whereas the presence of social stratification moderately predicted evidence for execution punishments.The presence of food storage predicted evidence for material punishments, whereas the absence of food storage predicted evidence for reputational punishments. Greater dependence on hunting moderately predicted evidence for physical punishments. We therefore suggest that economic intensification is associated with a transition towards a relative increase in the importance of material punishments and away from greater reliance on reputational sanctions. Despite some moderate effects, none of the socioecological variables were particularly strong predictors of evidence for physical punishments or execution, suggesting that economic transitions and socio-political structures are not driving the observed variation across human societies.


Caudal epidural block (CEB), which injects drugs into the epidural space through a sacral hiatus, is considered a safer alternative to other approaches. Serious complications, such as cauda equina syndrome or spinal cord infarction, have been reported very rarely, but their coexistence after CEB, which may be related to the ruptured perineural cyst, also known as a Tarlov cyst, was not reported.A 40-year-old male patient presented with bilateral lower extremity radicular pain. CEB was performed without image guidance. The patient exhibited sensory deficits below L2, no motor function (0-grade), hypotonic deep tendon reflexes, and no pathological reflexes.Spinal cord infarction, cauda equina syndrome, and sacral level perineural cyst with hemorrhage.High doses of steroids and rehabilitation were performed.The patient was discharged after 28 days with persistent bilateral leg paralysis and sensory deficits below the L2 level. The patient demonstrated no neurological improvement.Magnetic resonance imaging, including the sacral area, should be performed before performing CEB, to confirm the presence of a perineural cyst. Further, epidural steroid injection (ESI) is one of the most common nonsurgical treatment methods that manage radicular pain by injecting steroids or anesthetics into the epidural space surrounding the spinal nerve. Mainly translaminar and transforaminal approaches are used under fluoroscopic guidance and are generally effective and safe. However, various severe complications were reported, such as dura puncture, stroke, spinal cord infarction (SCI), and nerve root damage. Thus, the caudal epidural block (CEB) is often considered a safer alternative for those approaches. CEB is another ESI technique in which a needle is inserted through the sacral hiatus and steroids are injected into the epidural space. Drugs could be successfully injected into the epidural space without deeply inserting a needle because the caudal sac usually ends at the S2 level. Thus, CEB is considered a safe procedure even when blindly performed. Reported severe complications are few compared to translaminar and transforaminal approaches,,7 but several cases of cauda equina syndrome (CES) following CEB have been reported.,9 Additionally, a case of SCI after a CEB was reported, although very rare, in a patient with tethered cord syndrome. Recently, we experienced a patient with paraplegia immediately after a CEB. We considered the paraplegia to be caused by SCI and CES. Additionally, the occurrence of hemorrhage in the sacral Tarlov cyst may be related to this case, and this association has never been reported. Thus, we would like to report this unusual case for further discussion. This case report was approved by the institutional review board with a waiver for informed consent (IRB no. 2023-06-043).Lumbar radicular pain is commonly caused by spinal nerve root irritation due to intervertebral disc pathology, followed by lumbar spinal stenosis.A 40-year-old male patient was admitted to our hospital due to weakness and sensory loss of both lower extremities after CEB. He had suffered chronic back pain and has got intermittent ESI for pain control over the past several years. However, he had experienced no significant side effects from ESI. He underwent another CEB at a local orthopedic clinic to manage his back pain just before visiting our hospital. The caudal ESI was performed blindly with a total volume of 16 mL, which included lidocaine 2% at 1.3 mL, dexamethasone at 0.5 mg, and a small amount of triamcinolone (approximately < 40 mg) mixed with normal saline. The patient experienced a tingling sensation throughout his body immediately after the injection, and bilateral leg paralysis developed subsequently. He felt no sensation below the L2 level and had zero motor grade on both lower extremities upon admission. Additionally, deep tendon reflexes and pathological reflexes were absent at both lower extremities. He also failed to urinate, so a Foley catheter was inserted. Initial T2-weighted images of the whole spinal magnetic resonance images (MRI) revealed a high signal intensity in the spinal cord from T9 to L2 levels, indicating SCI  originating between the T8 and L1 levels (89%). Therefore, ESI-related SCI has been usually reported in the case of the upper-mid lumbar region but rarely occurs in the lower lumbar or sacral region. Furthermore, CEB-induced SCI has not been reported.However, CES is not the only problem for the patient. T7 to L2 SCI, which is an even rarer occurrence than CES, was also observed after CEB. reported a similar case of a patient with tethered cord syndrome who experienced SCI following CEB.The authors indicate that a deeply inserted needle during the caudal injection may have pierced the dural sac, allowing the drugs to enter and cause SCI due to the presence of a tethered spinal cord, wherein the bottom of the dural sac is positioned too low. Additionally, a Tarlov cyst was observed at the S4 to S5 levels in our case, and the intracystic hemorrhage may have been caused by needle injury during CEB. Tarlov cyst is a cystic lesion located in the sacral region that communicate with the dural sac and are filled with cerebrospinal fluid. They are commonly observed in approximately 4.27% of cases, which are mostly asymptomatic. Hence, the Tarlov cyst can be considered to be punctured during the procedure in the present, and drug administration into the dural sac may have contributed to the occurrence of SCI, similar to the previous case.Another possible cause to consider is Tarlov cysts. Wang et al reported a case of a sacral Tarlov cyst with intracystic hemorrhage and an accompanying arteriovenous fistula, which was treated with transcatheter arterial embolization. Additionally, Duja et al reported a case of a hemorrhagic Tarlov cyst associated with cerebral infarction, possibly due to cerebrospinal fat embolism following cyst rupture, although not directly related to SCI. This indicates a vascular malformation within the Tarlov cyst in the present case, and vascular administration of fat embolism or particulate steroids might occur after hemorrhagic rupture, which finally caused SCI. However, establishing an exact relationship remains a challeng because of inadequate additional angiography in the presented case.Other notable case reports highlight the association between Tarlov cysts and SCI. Specifically, the occurrence of hemorrhage within a Tarlov cyst is rare and indicates a potential intracystic vascular malformation, such as an arteriovenous fistula. Yoshikawa et al–24 Vasospasm is also often accompanied by hemorrhagic events, such as subarachnoid hemorrhage, and causes severe complications. Vasoconstrictors play a role in protecting the blood vessel lining by constricting the muscles within them in case of hemorrhage. However, the concentration of vasoconstrictors in the blood may increase or their ability to protect the blood vessel lining may be compromised in certain circumstances. In our case, hemorrhage from the cyst might induce autonomic blood vessel regulation, potentially causing radicular artery vasospasm. Notably, the onset of the sharp tingling pain and paralysis occurred right after CEB, indicating that a protective response triggered by hemorrhage in a Tarlov cyst may have induced immediate vasospasm and subsequently ischemia of the thoracolumbar spinal cord region.Finally, vasospasm can be another potential cause of SCI. Vasospasm or vasoconstriction can be caused by various factors, including the use of drugs, such as cocaine and amphetamines, blood vessel endothelial lining damage, blood clot formation within vessel walls, and inflammatory reactions.CEB is a widely utilized and safe procedure, but the rare occurrence of severe complications should be acknowledged. In this particular case, the patient experienced the simultaneous onset of CES and SCI, suspected to be associated with a hemorrhagic injury of a sacral Tarlov cyst. Therefore, incorporating imaging techniques, such as MRI, before CEB procedures should be recommended to identify and assess the presence of Tarlov cysts, which may help mitigate potential risks and enhance patient safety.Conceptualization: Chung Reen Kim, Sunyoung Kim.Writing – original draft: Sunyoung Joo.Writing – review & editing: Chung Reen Kim, Sunyoung Kim.


Cardiovascular clinical prediction rules (CPRs) are widely used in primary care. They accumulate research evidence through derivation, external validation, and impact studies. However, existing knowledge about the influence of research evidence on the use of CPRs is limited. Therefore, we explored how primary care clinicians’ perceptions of and experiences with research influence their use of cardiovascular CPRs.We conducted an exploratory qualitative interview study with thematic analysis. Primary care clinicians were recruited from the WWAMI  region Practice and Research Network (WPRN). We used purposeful sampling to ensure maximum variation within the participant group. Data were collected by conducting semi-structured online interviews. We analyzed data using inductive thematic analysis to identify commonalities and differences within themes.Of 29 primary care clinicians who completed the questionnaire, 15 participated in the interview. We identified two main themes relating to the influence of clinicians’ perceptions of and experiences with cardiovascular CPR research on their decisions about using cardiovascular CPRs: “Seek and judge” and “be acquainted and assume.” When clinicians are familiar with, trust, and feel confident in using research evidence, they might actively search and assess the evidence, which may then influence their decisions about using cardiovascular CPRs. However, clinicians, who are unfamiliar with, distrust, or find it challenging to use research evidence, might be passively acquainted with evidence but do not make their own judgment on the trustworthiness of such evidence. Therefore, these clinicians might not rely on research evidence when making decisions about using cardiovascular CPRs.Clinicians’ perceptions and experiences could influence how they use research evidence in decisions about using cardiovascular CPRs. This implies, when promoting evidence-based decisions, it might be useful to target clinicians’ unfamiliarity, distrust, and challenges regarding the use of research evidence rather than focusing only on their knowledge and skills. Further, because clinicians often rely on evidence-unrelated factors, guideline developers and policymakers should recommend cardiovascular CPRs supported by high-quality evidence.The online version contains supplementary material available at 10.1186/s12875-023-02155-w. Health research is valuable when it creates knowledge that can improve the decisions of patients, clinicians, and policymakers; or when other researchers can use the results to synthesize such knowledge . UnfortuClinical prediction rules (CPRs) are tools that estimate the likelihood of a health outcome using information from health history, physical examination, and test results of a person –13. CPRsClearly justified CPRs can accumulate high-quality evidence through well designed and conducted derivation, external validation, and impact studies by demonstrating their abilities to predict an outcome accurately, performances in different populations, and potentials to improve patient care , 30, 31.Unfortunately, there is limited existing knowledge about whether and how research evidence influences the use of CPRs. Previous studies described that the presence of research evidence about CPRs , 33, in Therefore, we conducted a qualitative interview study to examine how primary care clinicians’ perceptions of and experiences with cardiovascular CPR research influence their perceived use of cardiovascular CPR in practice. In preparation to accomplish this primary objective, we explored how primary care clinicians perceive cardiovascular CPR research and what they experience in using such research evidence as part of their practice.All methods were performed in accordance with the relevant guidelines and regulations of the Central University Research Ethics Committee (CUREC), University of Oxford. We conducted an exploratory qualitative interview study in accordance with an inductive thematic analysis approach suggested by Braun and Clarke . We alsoWe recruited participants from the members of the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region Practice and Research Network (WPRN). The WRPN is a network of diverse primary care practices located in urban, suburban, and rural areas across the five-state WWAMI region in academic, private, community, and public settings . One of Based on the numbers of participants included in existing exploratory qualitative interview studies conducted in primary care –46, we aWe sent an invitation to schedule an interview to selected participants based on a sampling frame aimed at maximizing diversities in the cardiovascular CPR use, research experience, and research evidence consideration in decisions about using cardiovascular CPRs. We stopped recruiting additional primary care clinicians when we determined that thematic saturation was achieved after analyzing data from 15 interviews with participants who responded to the invitation.One author (JWB) collected data by conducting qualitative semi-structured online interviews between 3 August 2020 and 10 September 2020. The Medical Sciences Interdivisional Research Ethics Committee (MS IDREC) of the University of Oxford conducted an ethical review and approved the study . All participants consented to participate in the interview: either by sending a completed and signed written informed consent form via post or e-mail in advance, or by giving audio-recorded verbal informed consent immediately before starting the interview.Data were collected through in-depth semi-structured interviews using an online platform (Microsoft Teams). By loosely following a pilot-tested topic guide but maintaining the natural flow of conversation, participants were asked about their use of cardiovascular CPRs, reasons for choosing the CPRs, views on research evidence regarding cardiovascular CPRs, experiences with such research evidence, and research evidence’s role in their decisions about using cardiovascular CPRs. The topic guide is included in Additional file All interviews were digitally recorded and transcribed verbatim using online software . WheneveWe conducted an inductive thematic analysis using methods described by Braun and Clarke to identify semantic themes . Using NThe characteristics of primary care clinicians who completed the online questionnaire are presented in Table Of 29 primary care clinicians who completed the questionnaire, 15 were purposefully selected for interview according to the sampling frame presented in Table We identified two main themes regarding how primary care clinicians’ perceptions and experiences in relation to cardiovascular CPR research might influence the way they interact with research evidence and make decisions about using cardiovascular CPRs: “Seek and Judge” and “Be acquainted and Assume.”This main theme includes four subthemes as illustrated in Fig. A.Familiarity, trust, and confidence2DS2-VASc score  do have cost-benefit analyses that show … there are cost benefits to using these clinical [prediction rules] in the right setting.” (IS78)Also, the Internist described the evidence behind some of the cardiovascular CPRs:“I’m pretty sceptical [about] pharma’s involvement in things … [But] I think, … for example… ASCVD [equation] …, just instinctively …, there isn't like a ton of possible corruption … With like ASCVD [equation], it doesn't seem to play as much, which is reassuring.” (BG35)Similarly, when clinicians trust and value the research evidence, their decisions on using cardiovascular CPRs might be influenced by research evidence. Some interviewed clinicians conveyed that they trusted and had a favourable opinion of cardiovascular CPR research and the evidence it generated. A Family Physician, who used the ACC/AHA pooled cohort equation  routinel“I tend to use PubMed … I think PubMed is pretty easy. There's also a section of PubMed that only looks at clinical studies … rather than … benchtop type research. So that tends to be helpful.” (FA84)Further, when clinicians feel confident in using research evidence, their decisions on using cardiovascular CPRs might be influenced by the research evidence. Some participants, especially younger and newly trained physicians, expressed their confidence in searching for, reading, and appraising primary studies about cardiovascular CPRs. For example, an Internal Medicine resident, who rarely used the ACC/AHA pooled cohort equation , felt co“My comfort level with reading primary literature is fairly good. I feel like I had pretty decent training in like Biostatistics and [have] ability to … read primary literature and interpret what they mean when they use sensitivity, specificity, specificity, [and] number needed to treat.” (SY54)Similarly, another Internal Medicine resident, who used various guideline-recommended cardiovascular CPRs, felt comfortable reading and interpreting primary studies:These clinicians who expressed confidence in using research evidence tend to be recent graduates from training or physicians in training with less than ten years of experience. They often indicated gaining their knowledge and skills during medical school and residency training through formal curricula on EBM  or informal teachings such as discussions with senior clinicians and colleagues.B. Actively search and assess“Residents were … using the PE rule criteria in a very high-risk patient. … So the question was, … ‘In high-risk patients, does the PE rule criteria apply?’ … I usually use a MeSH heading on PubMed to … look for [studies]. And … that was one … that had just come out in the last four to five years. And, so we pulled it in.” (GO38)When clinicians have favourable perceptions of or experiences with research, they might actively search and evaluate research evidence about cardiovascular CPRs. Some clinicians, who were familiar with, trusted, and felt confident in using research evidence, actively sought primary research evidence about cardiovascular CPRs using electronic databases, libraries, and online resources. For instance, a General Internist, who felt to be experienced with searching research evidence, recounted looking up a study about the PERC rule  while ro“I … go through their methodology and … do a literature appraisal to see if it's appropriate to the clinical question I have ... Some papers are real easier to read and understand than others.” (IS78)Some clinicians who were familiar with, trusted, and felt confident in using research evidence, questioned others’ assessments of evidence and tried to assess cardiovascular CPR studies' trustworthiness independently. Some found evaluating research evidence about cardiovascular CPRs easy and valuable but others felt lost and disappointed when they did not understand the information. A General Internist, who picked up searching and appraising skills during residency training, shared an expereince with cardiovascular CPR studies:p-value rather than study design and internal validity. A newly trained Family Physician, who had limited time reading research articles, discussed factors for determining trustworthiness.“Oh, I look at… the number of participants, … what the patient population was made up of, if it's similar to my patient population, … and then what the … the confidence interval is.” (PR88)But, when judging the trustworthiness of evidence, clinicians often relied on certain study characteristics and results such as sample size, population, setting, outcome, funding source, or “I look at … the size of the study, location and … multi-center. … I … look at who paid for it. … If it was being paid for by an imaging company or by the anticoagulation … company, really kind of puts my antennas on edge to the question how the statistics are going to be explained.” (GO30)An Internist was especially concenred about funding sources.Although some clinicians seem to actively seek and judge the research evidence about cardiovascular CPRs, their searches and appraisals may not necessarily have sufficient thoroughness and rigour according to the classic definition of EBM .C.Influence of evidence“It is easy to just plug the numbers into a rule, um, and … make snap judgments … Whether it's preventing stroke or preventing an MI, um I think we really have to know the data before throwing medications and interventions at our patients.” (GO38)When clinicians have positive perceptions of and experiences with research, their decisions about using cardiovascular CPRs might be influenced by research evidence. Some interview participants, who were familiar with, trusted, and felt confident in using research evidence, argued that clinicians should use research evidence when making decisions about using cardiovascular CPRs and indicated that reviewing research evidence influenced whether or how they used cardiovascular CPRs. For example, a General Internist, who was experienced in reading CPR studies, argued it was important to understand the evidence behind cardiovascular CPRs before using them:“It used to be anytime … someone had chest pain, I would use a TIMI. … Now, I really try to refine, … ‘is this the right person?’ or ‘is this someone … I think the HEART score makes more sense’ … you know, based on some of those initial studies.” (GO38)Further, the Internist indicated that reading articles about the TIMI and Heart scores , 55 led “I found it compelling. Yes, I found … it will be worth to change ... to the new numbers that they proposed compared to the older one. ... I have banked on those articles [and] decided to use those. … I tried to teach it to the residents also. … I asked all of them to download the ASCVD app to their phone. (FX91)Similarly, after reviewing an article about a new cardiovascular CPR, a Family Physician who was familiar with cardiovascular CPR research felt the evidence about the new CPR was “compelling” and recommended residents to use the CPR:Therefore, having familiarity, trust, and confidence regarding the use of research evidence might promote the involvement of research evidence in clinicians’ decisions about using cardiovascular CPRs.D.Evidence-related factorsWhen clinicians’ decision about using a cardiovascular CPR involves research evidence, certain factors related to evidence might play an important role in their decisions. Clinicians who took part in this study considered three evidence-related factors: having evidence behind the CPR, evidence of applicability, and features of evidence.“It's really nice to see a validation study in a different setting, before rolling out anywhere else. … I've taught … them that most prediction rules have never been validated. So ‘you better be really sure you're using one that's at least validated!’…” (GR91)To some clinicians, having evidence of accuracy, generalizability, and effectiveness was important. For example, an experienced Family Physician taught residents to use cardiovascular CPRs that had been evaluated in an external validation study:“I tried to look at my patient population on my outpatient panel and I tried to select one that was … going to envelop my patients most appropriately.” (FA84)However, the most important factor related to research evidence that influenced the participants’ decisions about using cardiovascular CPRs, was the evidence of applicability to their own patients. Clinicians assessed whether the populations and settings of CPR studies were sufficiently similar to their patients and settings. They felt confident when applying CPRs evaluated in populations and environments similar to theirs but were reluctant to use CPRs only studied in different populations or settings. A Internal Medicine resident, who believed clinicians should consider research evidence when choosing cardiovascular CPRs, explained the reason for deciding to use the ACC/AHA pooled cohort equation :“I tried“I think, a good doctor … would know … if something didn't apply to your population, then … you can't extrapolate them … So, … when you're looking at studies, … ‘does it apply to your patient population?’. … That's probably a fairly early decision in using that tool.” (IN63)Similarly, a Family Physician argued it was important to know that the research evidence applied to patients when choosing a cardiovascular CPR:“For me, the biggest thing would be the sample size. If … the sample size is super small, … [I] wouldn't … use those tools. [If] studies are underpowered, … [or] the p-value was not … appropriate, I probably wouldn't use those tools as well.” (IS78)To some clinicians, certain features of research evidence such as having a large sample size, higher power, extended follow-up, multiple locations, and statistically significant results were important. A General Internist, who changed the way cardiovascular CPRs were used in practice after critically appraising primary studies, discussed some of the features of research evidence that was important:“I think based on a large enough population, … I the size of the of the population data base …, statistical significance …” (KJ34)Likewise, having a large enough sample size was important to this Family Physician.This theme also consists of four subthemes, as presented in Fig. A.Unfamiliarity, distrust, and challenge2DS2-VASc and HAS-BLED scores  Doximity.” (TF63)A Physician Assistant who did not have time to look up research evidence because of busy work and family life came to know about cardiovascular CPR studies by reading e-mails:“It’s not so hard to get into the details that maybe go right over my head. But like, ‘do I really care about all of these little details?’ Yeah. So, I do more abstracts, skim them than … delve into the articles.” (SY54)Some clinicians, who were unfamiliar with, distrusted, or found it challenging to use research evidence, did not explicitly judge the validity of research evidence. For example, a resident in a General Internal Medicine did not pore over articles and judge the credibility of them because it was difficult to understand the details:“I assumed that somebody smarter than me already thought through this. … I assumed that there's smarter people out there that have figured this out, and I don't have to go down this path myself. That's a big assumption.” (IN63)Instead of critically evaluating research evidence, these clinicians assumed others who had more time, resources, and skills had already assessed the evidence. For instance, a Family Physician, who did not feel confident in evaluating research evidence, explained the reason for not reviewing the evidence behind cardiovascular CPRs:“I think, … in the life of a busy primary care clinician, … we're largely at the mercy of the medical journal editors, … other [specialty] societies, or … guideline writing organizations.” (ZY58)Some clinicians, who were unable to critically appraise cardiovascular CPR studies, felt they could not help but trust, have faith in, and go with others’ judgment on the evidence. For example, a family physician, who was unfamiliar with methods used in cardiovascular CPR studies and had difficulty interpreting the results, felt clinicians were led to trust the authors, editors, specialty societies, and guidelines:“I think it's helpful to go to a journal … like New England Journal or Annals of Internal Medicine. … I think … those papers are pretty tried and true. … If you are asking me, I'll say, ‘well, … let's look at some of the … reputable papers’…” (JA36)Some clinicians, who did not critically evaluate the evidence, assumed that information was credible if it came from certain sources. A busy senior Family Physician, who did not feel experienced with critically appraising cardiovascular CPR studies, described how the credibility of articles was judged:“I … sort of look at who are these authors, … you know. Are they people who I think are trustworthy? … I think as a practitioner, I think that there are a lot of leaps of faith. ... I depend on particular authors.” (PX33)Similarly, a family physician and researcher who did not critically appraise research evidence determined the credibility of information according to who the authors were.Therefore, when primary care clinicians do not make any deliberate judgement about research evidence, they assume that someone else had evaluated the evidence, they can go with others’ interpretation of the evidence, or they can trust the evidence from certain sources.C.Do not rely on evidence"I haven’t... done a whole lot of my own digging. … I ... haven’t looked up … the primary research behind it.” (SY54)When clinicians have negative perceptions of or experiences with cardiovascular CPR research, they may not rely on research evidence when making decisions about using cardiovascular CPRs. Some participants, who were unfamiliar with, distrusted, or found it challenging to use research evidence, did not seem to rely on research evidence for their decisions about using cardiovascular CPRs. Therefore, research evidence had little influence. For example, a General Internal Medicine resident who frequently used the ACC/AHA pooled cohort equation had not looked up research evidence behind this CPR:2DS2-VASc and HAS-BLED scores  included … a more complete set of predictors … So I … transferred over to it. (PX33)Some clinicians chose to use cardiovascular CPRs that had sensible, available, and comprehensive predictors, assessed clinically relevant outcomes, were easy to use, and were useful when managing their patients. A Family Physician who worked at a University clinic explained the reason for using the ACC/AHA pooled cohort equation:These features of cardiovascular CPRs seem to play an important role in primary care clinicians’ decisions about using cardiovascular CPRs when their decisions are not based on research evidence.In this qualitative interview study, we explored how research evidence influenced primary care clinicians’ interactions with and uses of research evidence in their decisions about using cardiovascular CPRs, and identified two main themes: “Seek and judge” and “be acquainted and assume”. Some clinicians were familiar with, trusted, or felt confident in using research evidence about cardiovascular CPRs. These favourable perceptions of and experiences, which were often noted in more junior clinicians who recently completed their training, led some clinicians to actively seave and evaluate the evidence about cardiovascular CPRs. These clinicians appeared to involve research evidence when deciding whether or how to use cardiovascular CPRs. However, rather than depending on study design or internal validity, they often relied on certain features of cardiovascular CPRs studies that might not be the most crucial in ensuring the evidence was high-quality , 57, 58,On the other hand, some clinicians were unfamiliar with, distrusted, or found it challenging to use research evidence about cardiovascular CPRs. Surprisingly, these negative perceptions of and experiences with cardiovascular CPR research were often seen in senior clinicians with more clinical, teaching, or research experiences. Instead of actively seeking and judging, these clinicians tended to be passively acquainted with research evidence about cardiovascular CPRs through their training, colleagues, and online resources. These clinicians seemed to assume that someone else had evaluated the evidence, they could go with others’ interpretation of the evidence, or they could trust the evidence if it came from certain sources. Therefore, these clinicians did not rely on research evidence when deciding about using cardiovascular CPRs but referred to guideline recommendations, others’ use, comfort, intuition, assuming infallibility, and features of cardiovascular CPRs.In an ethnographic study of two general practices by Gabbay and May , the autFurther, based on the findings that younger, more recently trained clinicians tended to express confidence in using research evidence, it can be hypothesized that advances in the EBM education might have improved clinicians’ perceptions about using research evidence over the years. In fact, evidence shows that physicians’ exposures to EBM education during their training have been increasing. For example, a 1998 national survey of Internal Medicine residency programmes in the USA showed that only 36.8% (99 of 269) offered a dedicated EBM curriculum . SimilarWe also found that more senior clinicians with more clinical, research, or teaching experiences who might be in a position to teach EBM tended to be less confident about the ability to search for, appraise, and use research evidence about cardiovascular CPRs. Existing literature also consistently shows that a lack of appropriately trained enthusiastic faculties is one of the biggest barriers to EBM education –70. For One of the most important evidence-related factors for clinicians’ decisions about using cardiovascular CPRs in our study was their understanding from research evidence that the CPRs were applicable to clinicians’ own patients. Similarly, a survey and focus group study found that GPs distrusted the accuracy of cardiovascular CPRs in their specific patient populations because these CPRs were derived from different populations .We found that clinicians’ decisions about using cardiovascular CPRs were influenced by several factors unrelated to research evidence. One of these evidence-unrelated factors was the features of cardiovascular CPRs. Many existing studies also identified CPR related features, such as whether CPRs included adequate predictors, evaluated relevant outcomes, were easy to use, or integrated into electronic health records (EHRs), as the key factors that influenced the use of CPRs , 71–78. We purposively selected a maximum variation sample of 15 primary care clinicians in regards to factors that might determine perceptions and experiences with cardiovascular CPR research. Hence, we were able to identify two common themes among clinicians with a wide range of use of cardiovascular CPRs, research experience, and consideration of research evidence in decisions about using cardiovascular CPRs. However, because the participants were recruited from the WWAMI region Practice and Research Network (WPRN), it is possible that clinicians with interests in research were overrepresented; 33.3% of our participants had some research experience.Because there was little prior knowledge about this topic, we used an inductive approach to generate hypotheses about how clinicians’ perceptions of and experiences with cardiovascular CPR research influence their decisions about using cardiovascular CPRs. However, we did not test the credibility of these hypotheses. Further, although there is no reason to suspect that our study's findings will not apply to CPRs in other clinical domains, our findings' transferability should be confirmed in a new study.We did not to carry out respondent validation in our study for the following reasons. Firstly, respondent validation in qualitative research is still a somewhat debated topic , 84 and A systematic review showed that teaching EBM to trainees improved knowledge about EBM but did not change attitude or behaviour . One of All stakeholders involved in generating research evidence, including researchers, journal editors, and funders, should understand that clinicians’ unfamiliarity, distrust, and challenges regarding the use of research evidence might hinder them from using research evidence in decision making. Therefore, these stakeholders of research should ensure that the evidence generated is not only high-quality but also easy for clinicians to access, read and understand, and use in their clinical decisions.Those clinicians who are already familiar with, trust, and confident in using research evidence might be able to maintain, promote, and reinforce their familiarity, trust, and confidence to use research evidence by continuing to seek, judge, and use research evidence in their decisions. However, understanding that primary care clinicians often depend on various factors unrelated to research evidence when making clinical decisions, guideline developers and policymakers should systematically evaluate existing evidence and carefully base their recommendations on the best available evidence.CPRs are designed to be used by clinicians and patients to make evidence-informed healthcare decisions. Evidence from cardiovascular CPR research cannot be valuable unless it is utilised by clinicians, patients, or policymakers to support the use of cardiovascular CPRs. In this study, we found that primary care clinicians’ perceptions of and experiences with cardiovascular CPR research might influence the use of research evidence in this process. Therefore, future efforts to promote the use of research evidence in decisions about cardiovascular CPRs should consider targeting and evaluating clinicians’ familiarity, trust, and confidence, in addition to knowledge and skills to use evidence. At the same time, it is important to recognize clinicians’ unfamiliarity, distrust, and challenges regarding the use of evidence as key barriers in evidence-based decision-making, which might not be easily resolved. Because these clinicians often rely on factors other than research evidence such as guideline recommendations, stakeholders of research such as guideline developers and policymakers should ensure that their recommendations are based on the best available knowledge from systematically reviewing relevant existing evidence.Additional file 1. Search strategy to identify studies that evaluated the influence of research evidence on the uptake of clinical prediction rules.Additional file 2. Interview topic guide.


Against the background of an arguable dearth of scholarship on the sociocultural dimensions of Nigeria’s solid waste management strategies and practices, this rapid review searched for evidence in the literature. A rapid evidence review and qualitative meta-summary procedure were implemented to utilize the rigor of systematic literature review that met the timelines and limited funding available for this study. It is more appropriate to identify, extract, and synthesize a mixture of qualitative and/or quantitative empirical evidence in the literature. This rapid review found little substantive evidence of scholarly sociocultural approaches in Nigeria’s solid waste management. It also discovered constant factors of inadequate and weak multidisciplinary or non-holistic approaches to driving innovation and effective social impact in Nigeria’s solid waste management practices. The results were interpreted vis-à-vis the need to leverage the social sciences, particularly the range and scope of social work practice configurations and possibilities, to scientifically advance and substantially accelerate the implementation of evidence-based policy and practice in Nigeria’s solid waste management system. This rapid review concluded that the negative results are due to the insufficient conceptual and theoretical bases for Nigeria’s solid waste management strategies and/or practices. Arguably, there is a dearth of scholarship on the sociocultural dimensions of Nigeria’s solid waste management (SWM) strategies. Whereas, to reduce waste, interventions that draw on the social sciences are needed, particularly science of behavior change , which mIn other words, (solid) waste management, in particular, generally attracts multiple disciplines because it is a major area of public policy and a subject of a burgeoning area of multidisciplinary academic research . The socThe economic and political foundations of societies have, over time, distorted nature. Even modern societies often intentionally and accidentally violate urban and suburban architecture and/or planning and designs that are put in place to mitigate human distortion of nature. Thus, we have huge behavioral  problems that are inimical to the sustainability of contemporary societies. In particular, waste disposal  across the world—including Nigeria’s solid waste —is a categorical part of the global environmental sustainability challenge. (See page 13 of the Scientific Committee on Problems of the Environment (SCOPE) in the United Nations Environment Programme  for a fuThe environmental problem of municipal solid waste in Nigeria, consisting of paper, metal, glass, textile, plastic, ash dust, organic content, and other micro-elements , is estiIn particular, a multiple disciplinary approach to research seems to have created the basis for a systems-thinking perspective in SWM practices generally and for knowledge and innovation in SD locally. Both seem applicable to waste management challenges in Nigeria. Although the concept of sustainability has been postulated to have multiple meanings and to be in danger of overuse   that nature does not waste anything and more of the relevant socioeconomic transitions obvious in many developed and industrial economies. Some interventions in industrial economies from linear to circular are to reduce waste or dwindling economic and ecological resources and to control the negative effects of increasing global warming and environmental stressful situations, pollution resulting from mining accidents, and poor WM practices. Such a transition embraces industry, innovation, and infrastructure (SDG9) in line with  SDG TargIn contrast, recently some scholars of social work—which is a social scientific discipline in continental Europe—have over time established a conceptual relationship between eco-social sustainability and social work, as well as the role the profession is playing in promoting the issue of sustainability. However, there is no evidence that such an approach has been leveraged in Nigeria’s SWM approaches. For example, Rambaree et al.  exploredIn other words, environmental issues are inclusively an issue of citizens’ participation and patriotism, visionary leadership, and honesty, which are of concern to professional social work. It leverages the social science perspectives or focuses on attitudes, beliefs, cultural values, knowledge, and many more to foster social development and/or the well-being of individuals, groups, and communities that may be experiencing sustainability or environmental challenges, which is contrary to the view of  (p. 20),The issues of SD, or especially SWM services, appear at the intersection of architectural design and planning of the environment, policies, and laws, economics, technology, and transitions or innovation as well as the interactions of stakeholders. In particular, because Nigeria’s SWM practices ought to be all-inclusive issues of many disciplines, the popular multi-level perspective on sociotechnical systems  deveregime , and niche (domain of novelties). Therefore, the sociocultural dimension in this RER is defined as the influence of cultural and demographic characteristics, which include education, knowledge, religion, beliefs, laws, advocacy, governments, demographics, social classes, gender, lifestyles, behavior, and attitudes as well as individual, group, and community values and the indigenous approach to SWM practices in Nigeria. Consequently, the study includes a search for evidence of interdisciplinarity, transdisciplinary, and multidisciplinary approaches and sociocultural dimensions in Nigeria’s SWM system. Therefore, this study implemented an RER of qualitative and quantitative academic literature published between 1986 and 2022 generated from Scopus, Business Source Elite (EBSCO), EBSCOhost Academic Search Premier, and SocINDEX databases via UEF Primo  for evidence of multiple disciplines and sociocultural focus on Nigeria’s SWM practices. The following research questions guided the RER:Q1: What evidence of interdisciplinarity and/or transdisciplinary and multidisciplinary approaches can be found in the literature on Nigeria’s SWM system?Q2: What inclusive evidence of sociocultural dimensions or social work/social science perspectives can be found in the literature on Nigeria’s SWM practices?Q3: What inclusive interventional modalities and conditionalities of sociocultural dimensions or social science perspectives can be found in the literature on Nigeria’s SWM strategies?In In other words, quantitative and qualitative peer-reviewed studies focusing on Nigeria’s SWM system could provide evidence of interdisciplinarity, or transdisciplinary and multidisciplinary approaches, and sociocultural factors or social science perspectives and their possible interventional modalities and conditionalities for this RER.One contribution of this RER is the provision of a basis for seemingly needed evidence-based recommendations for sociocultural dimensions and sociotechnical transformation of Nigeria’s SWM strategies amid recurrent challenges of solid management in the country. Such a transformation could be replicable in other countries that need to strengthen their SWM systems, particularly developing countries. In addition, the potential outcomes of this study may strengthen the existing bases for the implementation of SDG9  and SDG12 (Responsible Consumption and Production) in Nigeria and elsewhere. Another significance of this RER is the focus on an advanced search for the literature on interdisciplinarity and/or transdisciplinary and multidisciplinary approaches to SWM vis-à-vis sociotechnical theory as a result of the need to systematically identify and highlight the main gaps and recurrent challenges in Nigeria’s SWM approaches amid the global trend for collaborating on issues concerning SD. Moreover, a simple search of indexed databases revealed a seeming dearth of standard literature reviews focused on multiple disciplines and sociocultural approaches to Nigeria’s SWM practices, either as systematic literature reviews (SLRs), quick scoping reviews (QSRs), evidence reviews (ERs), rapid qualitative reviews (RQRs), or rapid evidence assessments (REAs), which are possible options (see ). FinallAn overview of the major techniques implemented in this RER is as follows. First, the research questions were subjected to rapid review criteria. Second, an information specialist at the University of Eastern Finland’s (UEF) library was engaged, and search strategies were developed. Third, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 flow diagram often used in SLRs was deployed to identify and screen the literature generated from the indexed databases search. Thereafter, for generic and comparative typification, extraction, and analysis of evidence relevant to this RER, the desired characteristics in the literature reviewed were coded A, AB, AC, or ABC and ABCD  and vice versa in the manner of Boolean algorithms. See ,44 for aTo ensure that the research questions were well-defined and developed for focus and feasibility, they were subjected to the Feasibility, Impactful, Novel, Ethical, and Relevant (FINER) criteria developed by  as a necAn information specialist at the UEF’s library conducted a search in electronic databases for indexed relevant journal publications. From 21 February 2022 to 29 September 2022, two search strategies were implemented. The first search implemented via UEF Primo was  AND TITLE (nigeria*). The search was limited to peer-reviewed literature, and 149 publications published between 1986 and 2022 were identified in the Scopus database. The second search was conducted on 29 September 2022 in the same search engine and included (circular econom* OR circular ecosystem* OR recycling) AND nigeria*. However, this search was limited by date (2010–2022) and academic journals, and it identified 76 publications in three databases: the Academic Search Premier, Business Source Elite, and SocINDEX. In other words, four electronic databases were searched via UEF Primo.Subsequently, the characteristics of all identified publications—title, abstract, date, and authors’ information—were generated from quantitative and qualitative peer-reviewed literature (and some gray literature). The information was compiled in a Microsoft Word file and hard copies made for selection and screening. The following were the eligibility criteria for screening literature for the RER: peer-reviewed literature on Nigeria’s SWM system, practices, and approaches; peer-reviewed literature on the circular economy; and peer-reviewed literature published between 1 March 1986 and 29 September 2022.In other words, any publication that did not exhibit the eligibility criteria above, such as gray literature, conference proceedings, or book chapters, was excluded. The PRISMA 2020 flow diagram, which is recommended for SLR processes and steps , was adan = 70) was defined and was keyworded as follows: one, collaborative studies (two authors minimum) and coded A; two, trans-, inter-, or multidisciplinary approaches (two different disciplines or departments or faculties as minimum) and coded B; three, with evidence of sociocultural dimensions or social science perspectives and coded C, and four, with (their) interventional modalities and conditionalities and coded D.Each work included in the rapid review  is in the The results for the grouping and abstracting of data are reported in this section, and a complete list of the literature included in the RER (n = 70) created two groups of relevant literature: Group 1, with ABCD characteristics (n = 52), and Group 2, with b (n = 12) indicating single authors from different disciplines but no interdisciplinarity, and those with BCD characteristics (n = 6) that provided relevant evidence, as indicated in First, the defining and coding of the included literature (n = 6) and ABC (n = 13), that are evidence of sociocultural dimension or social science perspectives, as well as the single-author papers (n = 6) of the BCD category. These patterns are more obvious in the illustration of the abstracting of evidence in In other words, the abstracting of evidence, referencing, and taking note of their frequencies focused on the relatively small number of studies, ABCD  in The results for the computation of how often particular evidence appeared in the reviewed literature or the relative magnitude of an AE, which is equivalent to the FES, are illustrated in The outcomes of the methods implemented to ascertain and synthesize the best available descriptive evidence on probable sociocultural factors in the country’s SWM practices are further interpreted in The results’ interpretations have different facets. First, the purpose of the rapid review was to analyze and synthesize the best available descriptive evidence from the literature, particularly of probable sociocultural factors, among others, in Nigeria’s SWM strategies. Almost all of the seventy works included (spanning about three decades) acknowledged the increasing SWM challenges in Nigeria, thus the need for a holistic strategy that combines the expertise of different disciplines, professions, government, and non-government intervention at different levels to devise an innovative solution that is line with current trends and the goals of SDGs of the United Nations’ 2030 Agenda.Second, although there is substantive evidence of sociocultural dimensions in Nigeria’s SWM practices in the literature, the number of studies from 1986 to 2022 is too small. However, those few studies agree (1) that social science approaches are needed to effectively tackle the challenges of managing refuse. Those small number of studies also agree (2) that refuse management is a burgeoning area of interdisciplinarity and/or transdisciplinary and multidisciplinary academic research. The Scopus, Academic Search Premier, Business Source Elite, and SocINDEX databases together generated only six studies (excluding the BCDs) of the ABCD category, which is the best available evidence of probable sociocultural dimensions in Nigeria’s SWM approaches. In other words, the data presented in Third, challenges implementing research findings exist in Nigeria because SP9 (2020), SP16 (2018), SP40 (2002), SP46 , and SP48 (2012)—all six in the ABCD category that represent the finest level of evidence for this review—were published over two decades (2002 to 2020). In addition, this connotation suggests that there is a huge gap between research and evidence-based policy practice in Nigeria. In contrast, in agreement with ,27, the Therefore, as a matter of urgency, this paper recommends a strong multidisciplinary research and practice approach with strong cultural or social scientific input to lead the social impact team. In this case, the inherent expanded mandate of the social work profession for intervention in the physical environment agrees with the increasing multidisciplinary solution  to globaThe best practices of the performance economy (model)—services or commodities through rents or lease—and/or CE models   is a gooThe multicultural situation in Nigeria calls for a broader and culturally sensitive research evaluation and implementation in relation to SWM strategies, which can also create opportunities for simultaneous evaluation vis-à-vis good governance and the effects of policies and legislation on citizens. Social inclusion, citizen engagement, and knowledge creation are currently three of the eight guiding objectives of  SWM projNotwithstanding the recommendations, it seems appropriate to acknowledge the limitations of this RER. The number of databases that were searched did not seem to have freely available and valuable literature with relevant evidence of concern. For example, the literature such as  that impThis rapid review searched, examined, highlighted, and summarized or evaluated the best available or existing evidence for scholarship impact on sociocultural factors in Nigeria’s SWM strategies. Generally, the constant factors in the very few studies that revealed substantive evidence of sociocultural dimensions in Nigeria’s SWM practices in the literature seem to expose the inadequate and weak multidisciplinary or non-holistic approach to driving innovation and effective social impact in Nigeria’s WM practices. In other words, for more effective and efficient refuse management practices in Nigeria, there is an urgent need to examine the positions of social science interventions in existing SWM policies, laws, and practices. There is also a need to reconcile SWM policy documents and relevant evidence-based vis-à-vis holistic approach research because the emerging gaps are clearly due to an insufficient conceptual and theoretical basis for circular economy and waste management, on the basis of which it would be possible to build comprehensive legislation, professional expertise, policy strategies, and, ultimately, the necessary national and local waste management infrastructure, not forgetting the key role of citizens as grassroots waste managers.