Few validated guidelines exist for developing messages in health promotion practice. In clinical practice, the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument is the international gold standard for guideline assessment, development, and reporting. In a case study format, this paper describes the application of the AGREE II principles to guide the development of health promotion guidelines for constructing messages to supplement the new Canadian Physical Activity Guidelines (CPAG) released in 2011.The AGREE II items were modified to suit the objectives of developing messages that (1) clarify key components of the new CPAG and (2) motivate Canadians to meet the CPAG. The adapted AGREE II Instrument was used as a systematic guide for the recommendation development process. Over a two-day meeting, five workgroups  of five to six experts  reviewed and discussed evidence for creating and targeting messages to supplement the new CPAG. Recommendations were summarized and reviewed by workgroup experts. The recommendations were pilot tested among end users and then finalized by the workgroup.The AGREE II was a useful tool in guiding the development of evidence-based specific recommendations for constructing and disseminating messages that supplement and increase awareness of the new CPAG . The process also led to the development of sample messages and provision of a rationale alongside the recommendations.To our knowledge, these are the first set of evidence-informed recommendations for constructing and disseminating messages supplementing physical activity guidelines. This project also represents the first application of international standards for guideline development  to the creation of practical recommendations specifically aimed to inform health promotion and public health practice. The messaging recommendations have the potential to increase the public health impact of evidence-based guidelines. Public health practice is often criticized for a lack of evidence-based decision-making in program development and implementation in the area of health behavior change . Indeed,In clinical medicine , the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument is the international gold standard for guideline assessment, development, and reporting . Encompahow to achieve the recommended activity level and why this is relevant to them . The responsibility for delivering these motivational messages largely falls to stakeholder organizations and practitioners disseminating the guidelines through their physical activity promotion initiatives . Thus to optimize uptake of the guidelines, organizations and practitioners need to be informed about the new guidelines, and given strategies for constructing motivational messages. To address this need among Canadian organizations, we undertook a two-phase process for developing recommendations for constructing messages to supplement the new CPAG specifically. In Phase 1, a systematic process was used to review the relevant literature. In Phase 2, an expert panel convened to develop the practical recommendations for the constructing messages to supplement the CPAG. The purpose of this case study is to provide an overview of these processes and a model for developing practice recommendations in other health behaviour change domains.Several countries  and international organizations  have recently released new or updated physical activity guidelines -13. ThesA systematic process to inform the development of messages supplementing the CPAG was undertaken by the Canadian Society for Exercise Physiology (CSEP). Initially, the CSEP received funding from the Public Health Agency of Canada (PHAC) and the First Nations and Inuit Health Branch of Health Canada to support an evidence-informed review of the physical activity and messaging literature . With ad● Brawley and Latimer  recommen● Latimer, Brawley, and Bassett  conclude● Rhodes and Pfaeffi  identifiTaken together, these three reviews provided the foundational principles for developing the message construction recommendations (Phase 2).In Phase 2 of the message development process, an expert panel was convened. The panel was responsible for interpreting the evidence from Phase 1 and developing practical recommendations for constructing and disseminating messages supplementing the new CPAG. We followed a systematic protocol modified from the AGREE II Instrument  to ensurThe two lead authors of this paper consulted one of the developers of the AGREE II Instrument to gain an understanding of: a) the methodological underpinnings of each of the 23 AGREE II items and b) how AGREE II principles applied to the objective of developing evidence-based messaging recommendations. With this knowledge, we modified the tool by tailoring the item wording to suit our objective. The modified items are described in Additional file The objectives and the practical questions addressed by the recommendations were determined initially by the project leaders in consultation with three key stakeholders – CSEP, ParticipACTION, and PHAC. These three organizations were involved in defining the scope and purpose because they are considered leaders in physical activity promotion within Canada and were slated to jointly disseminate the CPAG. The objectives and practical questions addressed by our recommendations are listed in Additional file The expert workgroups determined the target populations for each of the messages and recommendations specific to each CPAG. The target populations were determined by reviewing evidence of key social influences on physical activity behavior  of the recommendations. The recommendations specifically were directed towards organizations  and individual health professionals using the CPAG to promote physical activity participation.Key stakeholders were involved at multiple points throughout the process. For example, the project was directed by CSEP, ParticipACTION, and PHAC – with input from researchers with expertise in theoretical approaches to physical activity promotion and messaging. Twenty-eight experts from across Canada participated in small workgroups during a 2-day meeting. Experts included researchers from multiple disciplines, health professionals, and representatives from government and non-governmental organizations. The table included in Additional file The evidence-base included systematic reviews related to physical activity determinants, message development, and message delivery -16, artia) The systematic reviews prepared in Phase 1 of the project served as the focal evidence for the recommendations. In a further attempt to ensure broad inclusion of relevant literature and to minimize bias, the evidence-base also included additional review articles that were identified by the project directors while preparing their systematic reviews in Phase 1.b) A sample of articles reporting the success of past efforts to communicate the guidelines in Canada and of physical activity mass media campaigns in North America were selected from personal libraries. To reduce potential selection bias, the expert workgroup members were asked to identify any additional published messaging research specific to the North American context. No additional articles were circulated.and supplemental messages.c) The evidence base also included a summary of findings from a series of public consultations and a nation-wide survey regarding stakeholders’ preferences for the delivery of messages supplementing the new CPAG. The consultations and survey were completed by the PHAC just prior to the meeting. A representative from the PHAC delivered a presentation at the start of the meeting summarizing key findings related to Canadians’ preferred messengers and format for delivering the new CPAG The strengths and limitations of the messaging evidence were considered extensively in each of the articles that the workgroups were provided. Common strengths of the evidence were: a) the application of a theoretical framework to guide physical activity behavior change e.g.,,17); b) ; b) 17])In cases where the evidence provided did not adequately support a messaging recommendation, workgroup members were asked to seek out supplemental evidence from the peer-reviewed scientific literature. The quality of this supplemental evidence was not assessed directly; instead, expert panel members determined its appropriateness for use. For example, the work group focusing on the CPAG for children used several supplemental references to support the important role of parents in promoting physical activity in this age group.We developed the messaging recommendations through a multi-step process. One week in advance of the meeting, delegates were provided with a set of four to six articles from the evidence base to review. The resources provided to each workgroup are listed in a table included in Additional file The recommendations have direct practical implications. The practical benefit is that they are the first set of evidence-based recommendations for creating messages supplementing physical activity guidelines. The application of these recommendations to practice has the potential to increase the effectiveness of the uptake of physical activity guidelines through the creation of message-based resources and tools.The larger group also discussed procedures for updating the messaging recommendations. Due to resource limitations within the end users’ organizations, regular updates to the messages in the absence of a subsequent revision to the CPAG were not viewed as feasible. The consensus was that there already were limited resources for the release of the new CPAG let alone for constantly updating materials promoting the guidelines. The CPAG are slated for review and update every three to five years . This woFor each CPAG, multiple recommendations were provided to allow flexibility in formulating messages. To create a concise resource for practitioners, the first author extracted these recommendations from the final summary document and created a series of information sheets. The information sheets include the recommendations and a preamble stating the objective of the recommendations. These information sheets were evaluated through a web-based survey by 81 practitioners including representatives from all levels of government (36.9%), fitness professionals (20.0%), staff/board members from non-governmental organizations (18.5%), and allied health professionals (10.8%). Each recommendation was rated on a 7-point scale for clarity, comprehensiveness, and ease of use. Participants also indicated their agreement with the recommendation and their likelihood of using the recommendation in practice. Overall, the responses to the survey were positive with all means falling above the scale midpoint and ranging from 4.48 to 5.43.There were several suggestions to identify additional message target groups and channels of dissemination. Many participants requested additional details, examples, and resources. The specific recommendations were not modified in accordance with these requests. There was not adequate evidence to extend beyond the target groups and channels of dissemination already identified in the recommendations. Providing additional examples and resources was beyond the parameters of the recommendations. To address this feedback, the scope of the recommendations was clarified in the general preamble added to the beginning of the recommendations.The applicability of the recommendations was thoroughly considered by the panel. Sample messages and possible channels for message dissemination were provided with the recommendations to facilitate their application to practice. The panel discussed potential barriers to implementing the messaging recommendations. Concerns were raised regarding how to transition between existing materials and new materials promoting the new CPAG. For example, some provincial organizations were in the middle of mass media campaigns that included messages and materials promoting the older guidelines. Uncertainty regarding the financial resources available to produce new materials to supplement the new CPAG and the lack of a comprehensive strategic plan for developing these materials were considered barriers to applying our messaging recommendations.A subgroup of six experts was convened to discuss strategies for evaluating the dissemination of the new CPAG and supplemental materials. The use of existing data collection mechanisms  was recommended. The group also suggested using the hierarchy of effects model  and the The process was funded by CSEP and PHAC. Although these organizations participated in the process of developing the recommendations, their involvement did not influence the recommendations for creating messages. Their involvement did influence discussions related to facilitators and barriers to implementation, resource implications and evaluation. Delegates from these organizations were able to present the real challenges facing the release of the new CPAG and the production of supplemental materials. The depth of the discussion related to evaluation was blunted by uncertainties related to available funding.None of the workgroup members declared a conflict of interest.Through a systematic process guided by the AGREE II, we developed evidence-based specific recommendations for constructing and disseminating messages supplementing the new CPAG for children, youth, adults, and older adults. Recommendations also were developed to raise awareness of the new guidelines in general guided process. The recommendations are summarized in Tables At the time of the consensus meeting, several opportunities for uptake of the messaging recommendations were anticipated through the three key stakeholder groups involved in the project. Initially, we intended our recommendations to inform the development of messages accompanying the CPAG when they were released in January 2011 (two months after the consensus meeting). This uptake did not come to fruition due to changes in our stakeholder involvement and delay in producing the final messaging recommendations.While some supplementary materials were produced for the release of the CPAG, they were limited. Some of the materials did incorporate content that aligned with our recommendations.To our knowledge, our efforts for constructing and disseminating messages supplementing the new CPAG represent the first set of evidence-informed recommendations for creating messages supplementing physical activity guidelines. Given that we drew from existing evidence of effective messaging interventions , theAlthough the messaging recommendations have potential for shaping practice, their limitations must be acknowledged. Our recommendations do not have direct health benefits– they target an intermediary group (message developers) rather than the end users per se. However, if practitioners effectively apply the recommendations, there are potential indirect effects on health because the resulting messages will promote physical activity in accordance with the new CPAG.The recommendations are further limited as a result of methodological constraints – many of which could easily have been addressed by involving a guideline development methodologist as part of the research team from the onset. First, the evidence-base was determined by the primary authors with suggestions from expert panel members. It also included findings from an unpublished government report that included newly collected data critical to informing the guidelines. Rigorous systematic review methods that include evaluation of study quality and strict inclusion criteria are optimal.Second, the messaging recommendations were not sent for external review outside of the panel of experts who participated in the development process. The panel had substantial breadth in expertise; nonetheless external reviewers might have suggested modifications to strengthen the recommendations. Had we opted for additional external review, we could have sought the opinions of international experts, health communication technology researchers, and marketing and advertising professionals as individuals with this type of expertise were underrepresented in our workgroups. Indeed, the addition of individuals with expertise in the application of technology for health communications would have brought forward emerging evidence of promising technology-based approaches for disseminating our messages. With regards to marketing experts, only one panel member had specific expertise in this area. Public health often neglects to consult with this highly knowledgeable group of professionals. This shortcoming is unfortunate as marketing experts have potential to enhance reach of messages within the target audience and assist in designing visual, graphic and print copy of the final messages.Third, we did not formally engage a methodologist throughout our process to participate in evaluation of the evidence, and to assess our process . HoweverTo our knowledge, this case study represents the first application of international standards for guideline development set out in the AGREE II Instrument to the development of practical recommendations specifically aimed to inform health promotion practice. Of benefit, the AGREE II Instrument provided a foundation for guiding the steps in the recommendation development process, for determining the make-up of our expert panel, and for reporting the process. The Instrument was quite easily adapted to suit our objective. Modifications primarily centered around shifting the guideline focus from patient groups to guideline message developers, using a modified evidence-review process, and considering the practical implications of the recommendations versus the direct health implications. With further development and validation, the adapted AGREE II Instrument has potential to become the standard for developing evidence-based health behavior change recommendations and, more generally, knowledge tools that facilitate the application of existing clinical practice guidelines.We encountered practical challenges developing our messaging recommendations. Final messaging recommendations occurred over 1 year following our consensus meeting. The messaging consensus meeting was held in November 2010; the recommendations were not finalized until July 2011 and evaluated by stakeholders in January 2012 – more than one year following the consensus meeting. The lag could have been addressed by setting and adhering to clear time deadlines for the AGREE II steps following the consensus meeting.Two factors impaired progress: a) the timeline for finalizing the recommendations and b) the absence of funds to develop messages supporting the guidelines. The timeline for developing recommendations was ambitious. The consensus panel meeting was held in November 2010, recommendations were needed by the key stakeholder groups almost immediately to begin production of messages to accompany the guidelines for a January 2011 launch. This timeline would have been feasible with adequate personnel to support the initiative; however, in the absence of resources, no personnel were available. As a temporary measure, the three key stakeholders were provided with a summary report from the expert panel to use in preparation for the guideline launch.Finally, at the time of the consensus meeting it seemed promising that some resources would be allocated to developing materials supplementing the guidelines that would apply our recommendations. However, shortly after the meeting, the partnership between the three key stakeholders  dissolved. Plans for developing a comprehensive set of supplemental materials were halted and the immediate need for message construction recommendations was lessened.As a result of these practical challenges, the application of the recommendations has been limited . Much shThere is growing demand for evidence-informed decision-making in the design and implementation of health behavior change programming. Practitioners are challenged to meet these demands in the absence of evidence and specifically of recommendations that consolidate available evidence into a usable knowledge tool. This case study documents a two-phased process for translating this research into practical recommendations. To our knowledge, these are the first set of evidence-informed recommendations for constructing and disseminating health behavior change messages supplementing clinical practice guidelines. This project also represents the first application of international standards, the AGREE II, for the development of recommendations specifically aimed to inform behavior change practice. Application of these standards to other health behavior change initiatives has potential to facilitate the process of translating research into practice, and consequently strengthening health promotion programming.The authors declare that they have no competing interests.AELC, RER, MEK, and MD participated in the conception, design, and coordination of the study. ALC, RER, MEK and JRT helped to draft the manuscript. HLG assisted with manuscript revision. JRT, HLG, KK, GN, and MJP participated in the acquisition of data and study coordination. The CPAG Messaging Recommendation Workgroup developed and reviewed the recommendations. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/419/prepubModifications to AGREE II items. The table lists the AGREE II items and includes descriptions of how the items were modified and applied in the case study.Click here for fileResources provided to workgroups. This table lists the references for the materials provided to each workgroup.Click here for fileSupporting Evidence for the Messaging Recommendations for the New Canadian Physical Activity Guidelines for Overarching Messages. This file provides the rationale and lists the supporting evidence for each of the overarching messaging recommendations.Click here for fileSupporting Evidence for the Messaging Recommendations for the New Canadian Physical Activity Guidelines for Children. This file provides the rationale and lists the supporting evidence for the messaging recommendations for the CPAG for Children.Click here for fileSupporting Evidence for the Messaging Recommendations for the New Canadian Physical Activity Guidelines for Youth. This file provides the rationale and lists the supporting evidence for the messaging recommendations for the CPAG for Children.Click here for fileSupporting Evidence for the Messaging Recommendations for the New Canadian Physical Activity Guidelines for Adults. This file provides the rationale and lists the supporting evidence for the messaging recommendations for the CPAG for Children.Click here for fileSupporting Evidence for the Messaging Recommendations for the New Canadian Physical Activity Guidelines for Older Adults. This file provides the rationale and lists the supporting evidence for the messaging recommendations for the CPAG for Older Adults.Click here for fileExpert panel. This table lists the names, expertise, and roles of the individuals who participated in the recommendation development meeting.Click here for file


In 2001, an outbreak of acute respiratory disease occurred among persons working at a Native American archeological site at Dinosaur National Monument in northeastern Utah. Epidemiologic and environmental investigations were undertaken to determine the cause of the outbreak. A clinical case was defined by the presence of at least two of the following symptoms: self-reported fever, shortness of breath, or cough. Ten workers met the clinical case definition; 9 had serologic confirmation of coccidioidomycosis, and 8 were hospitalized. All 10 were present during sifting of dirt through screens on June 19; symptoms began 9–12 days later (median 10). Coccidioidomycosis also developed in a worker at the site in September 2001. A serosurvey among 40 other Dinosaur National Monument workers did not find serologic evidence of recent infection. This outbreak documents a new endemic focus of coccidioidomycosis, extending northward its known geographic distribution in Utah by approximately 200 miles. Coccidioides immitis, a soil-dwelling fungus endemic to the southwestern United States and parts of Mexico, Central America, and South America. The organism is recovered from soil in areas with yearly annual rainfall averaging 5–20 inches, hot summers, infrequent winter freezes, and alkaline soil  of C. immitis–endemic areas for in Utah  antibody titer of From July 2 to 4, 2001, 18 people  were interviewed by using a standardized questionnaire to determine symptoms and activities from June 18 to 29. In addition, clinical information was gathered from emergency room and hospital records of persons who sought medical care and recorded on another standardized form. Differences in categorical variables were assessed with the Fisher exact test.Francisella tularensis, Yersinia pestis, Mycoplasma species, Histoplasma capsulatum, and C. immitis by using standard techniques at laboratories at the Centers for Disease Control and Prevention. In addition, all persons had serologic tests for Rickettsia rickettsii, five for Legionella, and five for hantavirus at local laboratories. Blood cultures for bacterial pathogens were obtained during hospitalization.Acute-phase serum samples were obtained on July 1 or July 3 from persons meeting the clinical case definition and were tested for antibodies to C. immitis by CF and immunodiffusion (IDCF), primarily to detect immunoglobulin (Ig) G antibodies. Acute-phase serum samples were assayed by immunodiffusion (IDTP) primarily to detect IgM antibodies (IDTP) . Daily rainfall data were obtained from weather station records at the monument.Monthly average temperature and precipitation data for the Dinosaur National Monument quarry area (approximately 0.5 miles from Swelter Shelter) for 1958 to 2002 were obtained from the Western Regional Climate Center . The two ill archeologists worked on June 19, when dirt near the petroglyphs was sifted with screens , with an average of 80% neutrophils (range 67%–92%). Results of tests of liver and renal function, including urinalysis, were within normal limits. The average oxygen saturation was 93% (range 88%–97%) by pulse oximetry. Chest radiographs of all 10 case-patients showed bilateral patchy infiltrates. All persons hospitalized were treated with fluconazole and discharged within 3 days.With June 19 being the most likely time of exposure, the median incubation period for the 10 persons who met the clinical case definition was 10 days (range 9–12). These persons reported difficulty breathing (10 persons), nonproductive cough (9 persons), fever (9 persons), fatigue (8 persons), shortness of breath (7 persons), myalgia (6 persons), skin rash (6 persons), and nausea/vomiting (4 persons). Eight persons were hospitalized; the one person who did not report fever had a temperature of 37.8°C on hospital admission. The mean temperature on admission was 38.3°C (range 36.9°C–39.4°C) and the average respiratory rate was 23 per minute (range 18–32). Results of a pulmonary examination were relatively unremarkable except for dry cough. At the time of evaluation, five patients had a maculopapular rash on the neck, trunk, and extremities. The mean leukocyte count at admission was 11,800 mmC. immitis, as determined by IDTP by using concentrated serum samples; one was positive by IDTP before serum concentration. The patient without demonstrable IgM antibodies on convalescent-phase serologic testing had pulmonary infiltrates and a skin rash typical of the other patients. Two of the eight patients with convalescent-phase samples had at least a fourfold increase in CF titer. Initial serologic tests for antibodies to F. tularensis, Y. pestis, Mycoplasma species, R. rickettsii, Legionella, and hantavirus were negative. Blood cultures were negative for bacterial pathogens.Acute-phase serum specimens from 9 of 10 persons who met the clinical case definition contained IgM antibodies to C. immitis infection. Five persons completed work on the retaining wall and steps on September 24 and 27, 2001. Although the soil was watered periodically during both days, the workers only wore masks on September 24. On October 5, 2001, left shoulder and chest pain, shortness of breath, fever, headache, diaphoresis, and shaking chills without skin rash developed in one worker. A chest radiograph on October 16 indicated left lung pneumonia. Serum samples drawn on October 15 and November 7 demonstrated elevated and rising C. immitis IgG and IgM antibody levels by enzyme-linked immunosorbent assays at a commercial diagnostic laboratory, a finding consistent with acute coccidioidomycosis.On August 24, state and local health departments jointly recommended that employees minimize soil disturbance and dust inhalation  at Swelter Shelter to reduce their risk for Weather data indicated an unusually long dry period before the 2001 outbreak. No rain fell from May 3 to June 25. For May and June 1958 to 2002, the average temperatures were 14.9°C (standard deviation 1.4) and 20.1°C (standard deviation 1.6), respectively. The average temperatures in May and June 2001 were 17.1°C and 22.5°C. Since 1958, only 1 year (1994) had a warmer average temperature in both May and June.C. immitis antibodies were negative for all 40 persons.Forty employees were enrolled. Their mean age was 43 years; 26 (65%) were male. They had worked at DNM for a median duration of 26 months (interquartile range 9–126 months) and had spent an average of 13.8 years living within 100 miles of the monument. Employee activities included digging up soil or rock (27.5%), sifting sand or dirt (7.5%), and preparing paths or trails (12.5%). A quarter (27.5%) reported work duties that exposed them to dust every day. Serologic tests for C. immitis; none had previously lived in an area endemic for coccidiodomycosis. All five ill persons worked at Swelter Shelter in August 1964 or June and July 1965. None of those working at other sites had known illness.To investigate the possibility that a similar outbreak occurred during the 1964–1965 archeological excavations at the monument, we interviewed by telephone the leaders of that 25-person, archeological team in January 2003. They identified five team members in whom acute respiratory illness occurred in 1964 to 1965. These five were contacted by telephone; all reported fever, dry cough, and chest pain with onsets toward the end of, or shortly after, the archeological activities. One was hospitalized for 10 days with pulmonary infiltrates; a skin rash and severe arthralgias also developed in this person. Three persons reported subsequent positive skin or serologic tests for C. immitis; the alkalinity of the soil was favorable to the growth of C. immitis; a prolonged dry period occurred before the outbreak; and the archeological activities, particularly the sifting of the very fine-grained soil, caused considerable dust exposure.This outbreak provides evidence of an endemic focus of coccidioidomycosis within Dinosaur National Monument in northeastern Utah, expanding the known geographic distribution of coccidioidomycosis. Multiple factors likely contributed to this outbreak: most patients lived in areas where coccioidomycosis was not endemic and probably were without preexisting immunity to C. immitis exposure among other Dinosaur National Monument workers, although many reported frequent occupational exposure to soil or dust. However, the serologic survey could not rule out prior exposures since serologic tests are insensitive for past infection (Several lines of evidence indicate that the endemic focus at Swelter Shelter is highly localized and does not represent a larger unrecognized region of activity in northeastern Utah. First, the serologic survey failed to find recent serologic evidence of C. immitis from the soil at the burial site were possible for at least 7 years, even though soil immediately surrounding the burial site remained uncontaminated (Consistent with the hypothesis of a highly focal endemic area at Swelter Shelter, a study of outdoor workers in California indicated that even in disease-endemic areas, highly focal areas of high risk for coccidioidomycosis exist and persist (C. immitis (C. immitis is highly concentrated in Native American middens, indicating that the organism was highly prevalent among these people (C. immitis have been made at old Native American campsites in endemic areas (C. immitis to study the genetic diversity of the fungus has shown that isolates from North America are geographically partitioned. This finding suggests that C. immitis was spread throughout the Americas by migrating populations of Native Americans (The endemic focus at Swelter Shelter may have been established centuries ago. This outbreak and the three that occurred at Native American archeological sites in California outside the known range for C. immitis can apparently persist at Swelter Shelter, an area well outside the known disease-endemic region, is not known. One possibility is that average soil temperatures within the shelter are higher than surrounding areas. Swelter Shelter is the only known Native American site at Dinosaur National Monument that faces south, is relatively sheltered, and receives considerable reflected heat from surrounding rock.Why Attack rates during outbreaks at Native American sites outside of disease-endemic areas have been high. During the three California outbreaks, attack rates ranged from 48% to 77% (C. immitis exists at a Native American archeological site in northeastern Utah. Archeologists working at Native American sites in the western United States are at risk for coccidioidomycosis, even outside recognized disease-endemic regions. Sifting of dirt during archeological activities may put persons at a particularly high risk for exposure to C. immitis. Measures to decrease dust and aerosolization of spores, such as soil wetting, and the use of appropriate masks while performing archeological work at these sites may reduce the risk. Archeological workers might benefit from vaccination; efforts are currently focused on developing a vaccine for coccidioidomycosis (We conclude that a newly identified endemic focus for


Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines.A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team.The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic.Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use. Guidelines are syntheses of best available evidence that support decision making by clinicians, managers, and policy makers about the organization and delivery of healthcare, but continue to be underused. Numerous population-based studies demonstrate low compliance with guidelines produced by prominent government and professional agencies for chronic and acute conditions -7. It haMany existing implementation strategies have limited effectiveness and are not routinely applied outside of experimental research due to their cost and complexity -18. As aObservational studies have shown that use of guidelines is associated with the complexity of the recommended clinical action so a promising, but untested option is to alter guideline recommendations to make them more easily implementable by target users ,27. ImplFor example, in a systematic review of 256 studies, 41 of them found that lack of comprehensible structure and local applicability were barriers of guideline use . Two ranIt appears that guideline format and content may be important aspects of implementability that may influence use, and specific content may be required to support different types of decision making, including evidence-informed, experiential, shared, and resource allocation decision making. Including implementability information within guidelines to help users apply the recommendations represents a less-threatening, practice-relevant approach to guideline implementation compared with complex, costly, inconsistently effective implementation strategies often viewed negatively by guideline users . It may To date, there has not been a systematic analysis of guideline features that may improve their use. The purpose of this study was to create a taxonomy of these attributes, and assess whether current guidelines contain these features, thereby identifying ways in which guidelines could be modified to potentially improve their use. This implementability framework could inform the development of modified guidelines or adjunct products, and evaluation of how various attributes influence perceptions about, and use of guidelines, prior to more definitive testing of whether their inclusion indeed improves use.This study involved two key phases. The first phase was to develop an implementability framework of guideline format and content apart from clinical recommendations that are desired by users, or influence use of guidelines. The second phase was to use the framework assembled in phase one to examine the content of current practice guidelines, and refine or extend the framework.Given the lack of controlled and observational studies on this topic, the methods were based on a modified meta-narrative approach . The metOne individual with health librarian training and experience conducting different types of reviews (ARG) performed searches in MEDLINE and EMBASE from 1996 to August 2009. We purposely used a broad search strategy based on few terms  knowing that sensitivity and specificity would be limited. Two individuals independently selected eligible items. Eligible titles included empirical quantitative  or qualitative  studies published in English language peer-reviewed journals describing guideline features desired by, or influencing the knowledge, decision making, or behaviour of health professionals. Studies were ineligible if they focused on guideline-informed tools such as clinical pathways; guidelines for non-medical interventions; clinical effectiveness of medical interventions; involved students, trainees, or patients as participants; investigated guideline use without examining views about guideline features that influenced use; evaluated interventions to promote guideline use; concluded that guideline features could be improved to promote their use without evaluating those features; or were in the form of abstracts, letters, commentaries, or editorials. All items selected by at least one individual were retrieved, and one individual extracted data. Quality assessment of studies was not undertaken to be inclusive of all relevant implementability elements.Desirable or influential features potentially associated with guideline use were annotated in eligible studies, then tabulated. This tabulated list included the features of guidelines identified in each study as desirable or influencing guideline use. From this list, common items were categorized and defined. Findings were reviewed independently, and as a group by the study team, which included individuals with clinical, management, and research perspectives; grounding in the disciplines of knowledge translation/implementation science, psychology, and organizational behaviour; and experience in guideline development, guideline implementation, and performance improvement. The research team met in person and by teleconference to review and refine the draft framework. This largely involved minor edits to domain definitions. The draft framework was used to guide content analysis of guidelines, which expanded the number of elements in framework domains. This extended framework was reviewed and refined by the research team in person and by teleconference.Manifest content analysis was used to examine guidelines for the presence of implementability elements. This is a method that describes explicit content as reported in written, verbal, or visual communication qualitatively and/or quantitatively, without interpretation of its underlying meaning . We selehttp://www.gacguidelines.ca), a program that systematically appraised and summarized guidelines. Eligible guidelines included all those identified by GAC using a comprehensive search strategy and judged by trained experts using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument to be high quality that covered comprehensive management of these conditions and were publicly available [Individual guidelines were chosen as the unit of analysis. Guidelines on topics representing a high burden of illness in primary  and institutional care  were selected from among those evaluated by the Guidelines Advisory Committee  independently reviewed coding of the elements for two guidelines on each clinical topic. ARG met with both independent reviewers to compare findings and resolve differences through discussion.Extracted data was tabulated. The presence of implementability elements within sampled guidelines was described using summary statistics including number, proportion, and mean or median. Detailed content was analyzed using Mays' narrative review method, based on verbatim reporting, rather than statistical summary or conceptual analysis of information . Data weA total of 18 studies were reviewed from among 1,348  identified by the literature search Table .Based on the implementability framework, data were extracted from 20 guidelines on the management of diabetes (n = 8), hypertension n = 4), leg ulcer n = 3) and heart failure (n = 5) from eight different countries, including Australia (n = 2), Brussels (n = 1), Canada (n = 4), the Netherlands (n = 1), New Zealand (n = 1), Singapore (n = 1), the United Kingdom (n = 4), and United States (n = 6) , regulatory (15.0%), human resources (5.0%), or professional competency (20.0%) information required to accommodate guideline use. When included, this content was generally limited in detail. For example, technical guidance included: 'organization of care to deliver the above recommendations is largely concerned with putting registration, recall and record systems in place to ensure care delivery occurs for all people with diabetes, and having the healthcare professionals trained and available (D12)' or 'multidisciplinary care programs improve patients' quality of life, satisfaction with care, and the risk of unplanned hospitalization for heart failure (HF23).' Regulatory instructions included: 'blood pressure instruments must be properly validated and regularly recalibrated according to manufacturer instructions (H04).' Guidance for human resources included: 'interdisciplinary team comprised of family physician, diabetes educators , and community health support (D15).' Professional competency criteria included: 'compression bandages should be applied by a practitioner who has received training in their application (LU05).'One-half of the guidelines included performance measures that could be used to monitor recommended clinical care. While 45.0% mentioned the need to actively promote guideline use, none thoroughly described how to undertake or evaluate this process. For example: 'implementation may be supported by a variety of activities including continuing education and training, and clinical audit (LU07)' or 'implementation programs are needed because it has been shown that the outcome of a disease may be favourably influenced by thorough application of clinical recommendations (HF26).' Less than a third included templates such as order forms or assessment checklists (30.0%), and fewer than this offered cursory instructions for identifying barriers of use (15.0%) or tailoring the guidelines to suit local circumstances (2.0%).Relatively few studies published over the last 15 years specifically examined guideline features desired by, or associated with use among health professionals, most of these focused on physicians, and it does not appear that studies were informed by preceding research to build a cumulative body of knowledge. Considerable research has examined other factors influencing guideline use such as physician and organizational characteristics, but these studies were not eligible for this review, nor were numerous studies that examined general attitudes to guidelines on specific clinical topics. Review of 18 eligible studies revealed several features related to format or content that may positively influence guideline use, and this was expanded by reviewing the content of high quality international guidelines on various clinical topics. Most guidelines we examined contained a large volume of graded evidence and numerous tables featuring complementary clinical information to the point of being cumbersome, despite the presence of navigational features such as tables of contents. Few contained additional features specified by users or suggested by research to improve guideline use. Guideline use could potentially be improved by developing alternate versions for different purposes, incorporating summaries of evidence and recommendations, including information to facilitate interaction with and involvement of patients, outlining resource implications, and describing how to locally plan, promote, and monitor guideline use. There were no consistent trends by guideline topic.Our findings simply suggest that more guidelines could be modified to include implementability content, but it remains unclear how various implementability features might influence guideline use. A recent analysis recommended that the reliability, relevance, and readability of knowledge resources be improved to support evidence-based decision making . EvidencInterpretation of the findings may be limited in several ways. We studied guidelines relevant to primary and institutional care. Other guidelines relevant to specialty care may differ in their implementability characteristics. However, while we reviewed few guidelines, they were specifically selected to represent different topics, countries, and types of developer. Each element may not have been relevant to all guidelines reviewed, but this exercise serves as an exploratory, baseline effort to develop the framework according to content available in a range of guidelines. The literature on this topic is sparse, and referred to conceptually in a variety of ways and therefore not consistently indexed in literature databases; the search strategy used was purposely broad in an attempt to identify all relevant studies, but it may not have retrieved all studies describing guideline features desired by, or influencing the behavior of health professionals. We are currently in the process of conducting a systematic conceptual review of theoretical and empirical research on the mechanisms by which implementability elements influencing decision making about guideline use. Still, by assembling a rudimentary implementability framework that was expanded by review of guideline content, numerous opportunities were revealed for potentially improving guideline development and use.Prior to testing these hypotheses, practical issues must be considered. Robust methods by which to operationalize concepts more specifically to enable accurate data capture would require further development. New governance structures may be required to accommodate the development of guidelines with these features. Future research should validate the framework by applying it to different types of guidelines, and by soliciting feedback from guideline development and implementation experts, clinicians, managers, policy makers, and patients/caregivers to further clarify and expand on its elements. Research is also required to examine precisely how the elements of implementability influence guideline use. Based on an expanded stakeholder-defined implementability framework, the cost-effectiveness of tailored guidelines or adjunct products could be established by examining short-term outcomes predictive of guideline use such as recall, attitude to, confidence in, and adoption intention, then long-term objective outcomes reflecting the adoption of processes and associated patient care outcomes.Numerous opportunities were identified by which guidelines could be modified to potentially facilitate their use. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.The authors declare that they have no competing interests.ARG conceptualized and designed this study and obtained funding. She performed primary data collection, analysis, interpretation and report writing. MCB, LLC and JMG assisted with design of this study and data interpretation. VAP assisted with design of this study, independently reviewed data extracted from guidelines, and assisted with interpretation. All co-investigators contributed to report writing, and read and approved the final version of this manuscript.


In public health and chronic disease prevention there is increasing priority for effective use of evidence in practice. In Ontario, Canada, despite various models being advanced, public health practitioners are seeking ways to identify and apply evidence in their work in practical and meaningful ways. In a companion article, “Strengthening Chronic Disease Prevention Programming: The Toward Evidence-Informed Practice (TEIP) Program Assessment Tool,” we describe use of a tool to assess and strengthen program planning and implementation processes using 19 criteria derived from best and promising practices literature. In this article, we describe use of a complementary Program Evidence Tool to identify, synthesize, and apply a range of evidence sources to strengthen the content of chronic disease prevention programming.The Program Evidence Tool adapts tools of evidence-based medicine to the unique contexts of community-based health promotion and chronic disease prevention. Knowledge management tools and a guided dialogue process known as an Evidence Forum enable community stakeholders to make appropriate use of evidence in diverse social, political, and structural contexts. Practical guidelines and worksheets direct users through 5 steps: 1) define an evidence question, 2) develop a search strategy, 3) collect and synthesize evidence, 4) interpret and adapt evidence, and 5) implement and evaluate. We describe the Program Evidence Tool’s benefits, strengths, challenges, and what was learned from its application in 4 Ontario public health departments. The Program Evidence Tool contributes to the development and understanding of the complex use of evidence in community-based chronic disease prevention. The ability to understand and incorporate evidence into practice is a public health core competency in Ontario , Canada Guide to Community Preventive Services (www.thecommunityguide.org) in the United States, and Health-evidence.ca  and the Canadian Best Practices Portal in Health Promotion and Chronic Disease Prevention (http://cbpp-pcpe.phac-aspc.gc.ca/) in Canada.Several approaches have been used to facilitate use of evidence, such as organizational diagnostic tools , measureDespite these supports, community-based practitioners face multiple challenges using evidence. For example, relevant evidence may not be available or readily accessible; skills, time and resources may be lacking; and organizational infrastructure may not facilitate knowledge exchange ,12. AdapToward Evidence-Informed Practice (TEIP) is a set of tools developed at the Ontario Public Health Association to facilitate the use of relevant evidence in community-based health promotion and chronic disease prevention. TEIP tools recognize the high level of engagement required among researchers, decision makers, and local stakeholders, as well as the need to build supports and overcome organizational barriers to facilitate the use of evidence.A Program Assessment Tool has been developed to identify strengths and areas for improvement in the planning and implementation of local chronic disease prevention programs . A revieThe Program Evidence Tool consists of a set of guidelines and worksheets that provide step-by-step support in identifying and applying relevant sources of evidence to strengthen local chronic disease prevention programming. The tool aims to balance scientific rigor with the needs and challenges of evidence use at the local level. Existing models of evidence use ,10,19–24The Program Evidence Tool (available upon request from the authors) consists of 5 steps: 1) define evidence question, 2) develop search strategy, 3) collect and synthesize evidence, 4) interpret and adapt evidence, and 5) implement and evaluate.The search for evidence begins with defining the evidence question. A well-defined question addresses a priority issue and keeps the search focused and manageable. Brainstorming potential evidence questions with program stakeholders facilitates the identification of relevant questions. Expressing the evidence question in PISO  format focuses the evidence question and identifies useful search terms. Finally, comparing potential evidence questions in 4 areas — measurability, actionability, relevance, and timeliness — facilitates selection of the priority evidence question. The evidence question worksheet  guides aWithout a map to guide the search for evidence, one can easily become lost in search engines, crisscrossing online and print journals and skipping from one reference list to the next. A search strategy sets out specific sites to be searched. Once sites are established, searching can be shared among colleagues.The Program Evidence Tool advocates the use of a broad range of evidence, including peer-reviewed literature, gray literature, content advisors, and informed colleagues and practice networks. Each category has strengths and weaknesses, and together the categories identify a broad range of evidence relevant to local programming.Guide to Community Preventive Services, the Canadian Best Practices Portal).Peer-reviewed literature includes publications indexed by major public vendors . With the proliferation of publications and the expense involved in keeping up with print and online journals, many practitioners see themselves as lost in the evidence rather than as being served by the evidence. As a practical solution, the Program Evidence Tool recommends many excellent and free sources of preappraised, synthesized, and web-based sources of evidence that address health promotion and chronic disease prevention  that are not peer reviewed or indexed by major databases. Ideally, a public health librarian or an academic will be invited to provide guidance and feedback on the search strategy for gray literature; guidance becomes of greater importance when an evidence question concerns an issue for which little or no peer-reviewed evidence is available. Content advisors can be researchers with expertise in the topic area or community stakeholders who offer insights from lived experience (or both). Academic content advisors can provide feedback on the search strategy and access to unpublished research and generally help to fill gaps in the evidence.The search strategy worksheet  is used The evidence collection spreadsheet  is a knoThe evidence synthesis worksheet summarizes and synthesizes the main findings, questions raised by the evidence — or lack of evidence — and potential implications for practice. Synthesizing and summarizing large amounts of information is challenging. People with experience in qualitative research or identifying key themes are best suited to this task.An evidence forum is a structured meeting among stakeholders to discuss the strengths of, gaps in, and implications of the evidence in local context. The evidence forum can occur in person or by teleconference. The main points from the forum discussion are recorded on the evidence forum worksheet . It is iThe objective of an evidence forum is to decide how to apply evidence findings. If current practice is consistent with evidence, little change may be required. If, however, the evidence suggests a significant departure from current practice, then local factors  must be considered. Challenges must also be overcome, such as evidence that is inconclusive or conflicting and feasibility of changing practice, including costs. Engaging a forum facilitator is recommended to ensure that all voices are heard and the discussion remains productive and reaches a timely conclusion.The suggested timeline for an evidence forum is 90 to 120 minutes. A second evidence forum may be required if, for example, participants have not familiarized themselves with the evidence collection spread sheet and the evidence synthesis worksheet before meeting.Making the case for changing practice based on evidence can be facilitated by using effective knowledge dissemination strategies. These strategies summarize the evidence into a few key findings and implications for practice, shape the message to match users’ information needs and presentation preferences, capture users’ interest and inspire them to act on the changes, and monitor and support the change process. The knowledge dissemination strategy worksheet  guides tPlans for change may unfold over months or even years, especially where resources are limited or resistance to change exists. In such cases, incremental change, beginning with the easier or more palatable changes, is a useful strategy. Finally, rather than assume that evidence-based change will have a positive impact, plans for process and outcome evaluation must be built in .In 2008, the Program Evidence Tool was used to conduct 12 evidence searches by local community partnerships affiliated with 4 small to midsize regional public health departments. None were formally connected to academic institutions, and access to literature was limited to abstracts via PubMed, public-access journals, and online resources. One of the 4 organizations had support from an in-house librarian. Examples of initiatives for applying the tool included the following: a workplace wellness program, a school-based heart-health program, an initiative to link public health and municipal planners for the purpose of building healthy communities, and a nutrition education and cooking program for low-income women with young children.The paragraphs below describe an example of using the Program Evidence Tool at a small, mainly rural public health department. The program selected for the evidence search was an initiative to provide a slow cooker and cooking classes featuring inexpensive slow-cooker recipes to low-income women with young children. The program was embraced by a public health nurse who wanted to address a need she saw in her community. A dietitian participated in the nutrition education aspect of the program. Health department management objected to the high cost of the program and wanted to discontinue it.The evidence question originally proposed was “Is the use of slow cookers in a nutrition education and cooking class an effective way to improve the nutrition of low-income families with young children?” Working through Step 1, it became apparent that the focus of the original question was too narrow, and, after much discussion, the team realized they needed to address the broader issue of food security. The evidence question evolved to “What approaches are effective in building food security among low-income families with young children?” During the evidence search, the team found the most practical evidence in the gray literature. This literature included position papers on the effectiveness of community food security initiatives by Dietitians of Canada, publications from several health units that have been leaders in addressing local food security issues, and reports from the provincial and federal governments.The content advisor selected by the team was a public health practitioner recognized as a leader in addressing food security in Ontario. She provided many useful sources of evidence and shared her experience of shifting the culture of her health department toward active engagement in local food security issues.To obtain input from informed colleagues, a listserv request for information was disseminated across Ontario. Several useful responses detailed local experiences and reference lists. Because of inadequate local capacity, a researcher was hired to assist with completing the evidence collection worksheet and the evidence synthesis worksheet and with facilitating the evidence forum.Participants at the evidence forum included the program manager, public health nurse, dietitian, content expert, consultant, and a representative from the Ontario Public Health Association. The group worked through seemingly contradictory evidence on whether community access to food security programs should be universal or targeted at the more marginalized subpopulations, opting for universal food delivery and targeted social support.A major shift occurred in the group’s work when participants realized their organizational culture was part of the problem. The more they learned about food security through the evidence, the more they recognized the need for an organizational education initiative. They envisioned a 3-year plan, beginning with inviting guest speakers to educate their organization about food security. In the medium term, they planned to modify their programming to empower clients to become involved in program planning and to develop peer leaders. In the longer term, they planned to reach out to local social service agencies on joint community food security initiatives.Use of the Program Evidence Tool transformed the vision of the participants and led to an ambitious plan to change the culture of their organization. Gray literature, content advisors, and informed colleagues were the most useful sources of evidence in this case. Management was impressed by the quality of the evidence collected and began to see links between the goals of community food security and requirements within the new Ontario Public Health Standards  to addreUsing the Program Evidence Tool presented some challenges to the public health practitioners involved in the 4 health departments that tested the tools. Finding time to complete the steps was difficult because this work had to be completed in addition to handling a full workload of regular activities. Some groups spent several weeks settling on a final evidence question. Challenges were also in identifying and organizing the evidence. Much support was needed to do these tasks, mostly from a consultant or graduate student.Organizational and contextual challenges were also evident. For example, community partnerships were challenged by insufficient time, limited organizational capacity and resources, and varied support from upper management in implementing evidence-informed recommendations. To overcome these challenges support for capacity building from the TEIP facilitator was provided. Strategies, such as train-the-trainer workshops, were developed subsequent to the pilot-testing phase, to address the identified need to build local capacity.Public health practitioners using the Program Evidence Tool reported many benefits. These benefits were felt at the individual and program/organizational levels. At the individual level, reported outcomes included an increase in individual capacity development, especially as it pertained to knowledge and skills enhancement for the use of evidence. Users felt more competent in using research evidence and learned innovative approaches to health promotion and public health program planning. In addition, participants felt they gained awareness of and access to existing resources to support their work in public health. They recognized the benefit of connecting with a content expert and gained confidence in developing such a relationship.At the program/organization level, many benefits for program planning and implementation were identified. Overall, participants felt they received increased support, especially from their managers, either in the expansion or in the continuation of their programs. Practitioners indicated that the Program Evidence Tool provided a way to review and systematically assess relevant evidence in their area of interest, which resulted in improved decision making and program planning.Chronic disease prevention programs are influenced by various social, political, and structural factors. Evidence is needed that is not only valid and robust but also contextual and practical ,26. The Once the appropriate evidence has been identified, the next step is how to apply it in making informed decisions in public health practice. The quality of the evidence found must be considered, assumptions must be made explicit, and the decision-making process must be transparent . In the Public health practitioners must be skilled in identifying and applying relevant evidence to community-based programs to have a positive impact on the health of populations. The Program Evidence Tool provides a practical set of guidelines and worksheets to achieve this goal. The tool captures a wide range of evidence that is pertinent to practitioners. Use of the Tool facilitates an opportunity to debate and reflect on available evidence and contributes to program development that is supported and inspired by different forms of evidence and multiple viewpoints. The process acknowledges the expertise and experience of local chronic disease prevention practitioners in making decisions to improve their programs and the health of their communities.


International guidelines pertaining to nutrition prescription in CKD were also reviewed from 2000 to 2013. Three hundred and eleven papers and eight guidelines were reviewed by three reviewers. Evidence was graded as per the National Health and Medical Research Council of Australia criteria. The evidence from thirty six papers was tabulated under the following headings: protein, weight loss, enteral support, vitamin D, sodium, fat, fibre, oral nutrition supplements, nutrition counselling, including protein and phosphate, nutrients in peritoneal dialysis solution and intradialytic parenteral nutrition, and was compared to international guidelines. While more evidence based studies are warranted, the customary nutrition prescription remains satisfactory with the exception of Vitamin D and phosphate. In these two areas, additional research is urgently needed given the potential of adverse outcomes for the CKD patient.In Chronic Kidney Disease (CKD), management of diet is important in prevention of disease progression and symptom management, however evidence on nutrition prescription is limited. Recent international CKD guidelines and literature was reviewed to address the following question  Chronic kidney disease (CKD) is a prevalent chronic condition and the incidence of End-Stage Renal Disease (ESRD) is expected to continue to climb in the coming decade . CKD hasEvidence based guidelines for the nutritional management of Chronic Kidney Disease (CKD) stages 1–5 [“What is the appropriate nutrition prescription to achieve positive outcomes in adult patients with chronic kidney disease?”In CKD, nutrition and diet play an important role both in prevention of disease progression and in symptom management. The Dietitians Association Australia’s (DAA) ages 1–5  provide ages 1–5 . The guiages 1–5  and togeA systematic literature review of studies was designed to answer the clinical question. Databases included in the search were Medline and CINAHL using EBSCOhost search engine, Embase and the Cochrane Database of Systematic Reviews. MeSH terms for Medline and CINAHL were “kidney failure, chronic” AND “diet therapy” OR “nutrition intervention” and for Cochrane “kidney failure, chronic”. M-tree headings in EMBASE were “chronic kidney disease” AND “diet therapy” and further derivatives of diet therapy such as protein, phosphate. Results were limited to those published from 2000 to 2009, papers reported in the English language and studies involving adult humans. Articles were excluded if they were not reported in full or if they were presented as tutorials, editorials, news, letters or comments. Articles were also excluded if they were included within any systematic reviews or meta-analyses retrieved. The research aims and outcome measures reported on were used to assess applicability of the studies. Reference lists of retrieved papers were also reviewed and studies included where relevant. Nutritional management of acute renal disease, transplantation and nephrotic syndrome were not included in this review.ERA/EDTNA European Best Practice Guideline on Nutrition, 2007 [European Renal Association/European Dietitian and Transplant Nurses Association on, 2007 ,Guidelines for the management of chronic kidney disease by the Canadian Medical Association, 2008 [on, 2008 ,Diagnosis and management of chronic kidney disease: A national clinical guideline by the Scottish Intercollegiate Guidelines Network, 2008 [rk, 2008 ,Chronic kidney disease: national clinical guideline for early identification and management in adults in primary and secondary care, 2008 [National Institute for Health and Clinical Excellence in the United Kingdom re, 2008 ,CARI guidelines), 2013 [Caring for Australians with Renal Impairment , 2013 ,15,16,Clinical practice guideline for the evaluation and management of Chronic Kidney Disease, 2012 [Kidney Disease: Improving Global Outcomes (KDIGO): se, 2012 ,17,Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline, 2010 [American Dietetic Association ne, 2010 ,Evidence-based guidelines for the protein requirements of adults undergoing maintenance haemodialysis or peritoneal dialysis, 2013 [British Dietetic Association is, 2013 .In addition to this systematic literature search, hand searches of recognised international guidelines published since 2006 and pertaining to nutrition were conducted. These included:Papers obtained through the literature search were categorized according to the aspect of nutrition prescription addressed in the research question, for example protein, phosphate, fat, vitamin D, oral nutrition support. The strength of evidence of these papers was then assessed by three independent reviewers and categorized according to recommendations from the National Health and Medical Research Council (NHMRC) evidence hierarchy . The NHMIn a similar fashion, evidence statements from international guidelines were then grouped according to aspects of the nutrition prescription addressed with their corresponding levels of evidence. The grading systems and definitions for levels of evidence and strength of practice recommendations used by the various institutions guidelines are compared in Database searches using the search terms described above yielded 325 individual papers. Following grading of the evidence quality and exclusion of papers of lower level evidence, 34 papers remained for inclusion in this review. Of these, five papers were systematic reviews, fourteen were randomized controlled trials, nine were prospective cohort or comparative studies with controls and six were interrupted time series or case series. p= 0.0002). For those with diabetes, both Types 1 and 2, reducing protein is associated with moderate non-significant slowing in progression of diabetic nephropathy resulting in renal failure [vs. routine care increased protein and energy intake and improved serum albumin by 0.23 g/dL but there was insufficient data to examine the effect on clinical outcomes [In  failure . Protein failure . One sys failure . This reoutcomes .p= 0.002) [2) of 0.97 (p< 0.001) [= 0.002) . In dial< 0.001) . The ass< 0.001) .The Australian CARI guidelines, shown in The British Dietetic Association’s guidelines on protein intake in both haemodialysis (HD) and peritoneal dialysis (PD) recommend a lower level of protein intake than previous guidelines at 1.1 g/kg ideal body weight/day for those undergoing maintenance haemodialysis and 1.0–1.2 g/kg ideal body weight/day for those on maintenance peritoneal dialysis . These ret al. aimed to explore the relationship between serum 25(OH)-hydroxy vitamin D (25(OH)D) in PD patients and long term clinical outcomes [i.e., <75 nmol/L) and that lower serum 25(OH)D levels were associated with an increased risk of cardiovascular events but not long term mortality [vs. placebo, with the intervention group demonstrating a 17.6% decrease in spot urinary protein-creatinine ratio vs. a 2.9% increase for controls (p = 0.04) [p = 0.01) [et al. similarly found that oral paricalcitol supplementation (mean dose 9.5 μg/week) was significantly associated with 51% vs. 25% (p = 0.004) reduction in proteinuria in the intervention group compared to controls and 3.2 greater odds for a reduction in proteinuria independent of treatment for Renal Angiotensin Aldosterone blockade [The guidelines on vitamin D  focus onoutcomes . They foortality . The eff = 0.04) . It was  = 0.01) . Agarwalblockade . The KDIblockade .et al. found that supplementation of 6 g omega-3 fatty acids had no effect on total homocysteine levels in HD patients over 6 months [et al. found that dietary compliance was a major issue [vs. 42%), better ventricular function and less intradialytic hypotension compared to those whose blood pressure was controlled by medication [vs. 2.7, p = 0.01) used in those with GFR < 30 mL/min, than those in the highest tertile (166.7 mmol/day). This effect was even more marked in those with GFR ≤ 15 mL/min [The evidence for the modification of fat in CKD to moderate cardiovascular outcomes is limited. Beavers 6 months . Saltissor issue . A dialyor issue . All guior issue ,12,15,18or issue . Sodium or issue . Activeldication . Using s5 mL/min .The effect of dietary fibre supplements and a high fibre diet, on patient reported symptoms of constipation amongst a PD population, suggested that 6–12 g/day of partially hydrolysed guar gum added to usual intake was as effective as usual laxative treatment for preventing constipation in the majority of included PD patients and was associated with less unfavorable side effects . Both SaCompliance with diet prescription remains an issue. Twenty-eight per cent (28%) of participants under-reported protein intake in both a very low protein diet (VLPD) of 0.3 g/kg/day plus keto-acids (KA) diet to a level of 0.66 g/kg/day and a low protein diet (LPD) of 0.6 g/kg/day in pre-dialysis patients. While compliance was poor in both groups, the prescription of the VLPD + KA delivered improved biochemical markers, with significant improvements noted in serum urea nitrogen, serum bicarbonate and urinary phosphorous . In 423 vs. nutrition counselling over six months resulted in significantly improved serum albumin (2.64 ± 0.35 vs. 3.05 ± 0.72 g/dL), energy intake , protein intake (1.0 ± 0.3 vs. 1.7 ± 0.7 g/kg) and nPNA (1.00 ± 0.23 vs. 1.18 ± 0.35 g/kg/day) amongst the intervention group when compared to baseline measures, and frequency of moderate-severe malnutrition decreased 28% in the intervention vs. 6% in the control group [In an open RCT in 28 PD patients, randomized to receive a powdered egg-albumin protein supplement (30 g/day providing 22 g protein) ol group . Intereset al. conducted a 12 month open RCT of 65 PD participants, comparing daily consumption of 200 mL 1.0 kcal/mL liquid oral nutrition support (ONS), in addition to usual dietary intake, against those who consumed only their usual dietary intake [p = 0.0066) between intervention and controls reached significance. The supplement was not found to be suitable for long term use due to non-compliance with 31% of the intervention group dropping out. A similar study by Caglar et al. with ONS showed improvements in albumin, pre-albumin and SGA [Teixido-Planas y intake . Based o and SGA , howeveret al. randomized 56 pre-dialysis patients (Stages 4 and 5) to fortnightly, individualized counseling on a prescription of 0.75 g/kg/day protein and 145 kJ/kg/day energy vs. written education material for 3 months [vs. 6 monthly counseling was unable to maintain a reduction in serum phosphate of 0.25 mg/dL at 3 months, at the 6 month follow-up [Five studies investigating the effect of structured dietetic counseling on compliance with dietary prescriptions have shown differing results. Campbell 3 months . The int3 months . Sulliva3 months . Conversollow-up . A retroollow-up .The evidence for the effect of nutrients in peritoneal dialysis solution is limited to two small studies ,52. ImprThe focus of guidelines on nutrition and CKD published since 2006 has been on early prevention and lifestyle modification required to prevent progression to ESRD ,12,15 orThe approach for managing elevated serum phosphate, through the use of phosphate binders as an adjunct to the restriction of dietary intake, has also been recognized. The KDIGO guidelines continue to recommend restricting dietary phosphate in combination with other treatments, however the evidence is poor . The CARIssues of compliance with restricted diets remains a weakness in many of the studies reported here and those promoting regular contact with a dietitian mostly report improved outcomes. The previous DAA guidelines  have hadOverall, the body of evidence supporting nutritional interventions for improving patient outcomes in CKD is primarily based on low level evidence or isolated randomized clinical trials. Much of the evidence around dietary prescription relies on retrospective and uncontrolled cohort studies and the quality of the body of evidence is poor. Most outcomes assessed are generally biochemical endpoints, such as change in serum levels, rather than clinical ones, such as mortality, hospitalization, cost and patient quality of life. There is general agreement across guideline recommendations for the levels of protein in early CKD and on dialysis; however, guidance on the use of very low protein diets with keto-analogues in conservative treatment of those with GFR < 15 mL/min is warranted. While the evidence from a few observational trials suggests that these diets pose no greater risk on mortality than dialysis as treatment, better controlled trials are required to confirm this. Further research on the optimal intakes of sodium, phosphate, fats and fibre in well controlled studies are required, as are studies into micronutrients and other components such as antioxidants. Studies on sun exposure combined with diet are required to determine optimal vitamin D status. The collaborative effort to use a global approach to international guidance in management of chronic kidney disease is welcome. While more evidence based studies are warranted, the customary nutrition prescription remains satisfactory with the exception of Vitamin D and phosphate. In these two areas, additional research is urgently needed, given the potential of adverse outcomes for the CKD patient. The role of nutrition in the management of CKD is important and needs to be included in further promotion of research outcomes and future guidelines.


Rx for Change to provide a comprehensive, online database of the evidence for strategies to improve drug prescribing and use.Globally, suboptimal prescribing practices and medication errors are common. Guidance to health professionals and consumers alone is not sufficient to optimise behaviours, therefore strategies to promote evidence-based decision making and practice, such as decision support tools or reminders, are important. The literature in this area is growing, but is of variable quality and dispersed across sources, which makes it difficult to identify, access, and assess. To overcome these problems, by synthesizing and evaluating the data from systematic reviews, we have developed We use reliable and valid methods to search and screen the literature, and to appraise and analyse the evidence from relevant systematic reviews. We then present the findings in an online format which allows users to easily access pertinent information related to prescribing and medicines use. The database is a result of the collaboration between the Canadian Agency for Drugs and Technologies in Health (CADTH) and two Cochrane review groups.Rx for Change currently contains over 200 summarised reviews, structured in a multi-level format. The reviews included in the database are diverse, covering various settings, conditions, or diseases and targeting a range of professional and consumer behaviors.To capture the body of evidence on interventions to improve prescribing and medicines use, we conduct comprehensive and regular searches in multiple databases, and hand-searches of relevant journals. We screen articles to identify relevant systematic reviews, and include them if they are of moderate or high methodological quality. Two researchers screen, assess quality, and extract data on demographic details, intervention characteristics, and outcome data. We report the results of our analysis of each systematic review using a standardised quantitative and qualitative format. Rx for Change is a novel database that synthesizes current research evidence about the effects of interventions to improve drug prescribing practices and medicines use. The safe and effective use of medicines is an important aspect of quality healthcare. While there is an abundance of data on the clinical effectiveness and safety of various drugs, this does not ensure that the drugs are being appropriately prescribed or taken; in fact, suboptimal prescribing and medication errors are common across countries . ResearcRx for Change http://www.rxforchange.ca.To address these problems, the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) program, within the Canadian Agency for Drugs and Technologies in Health (CADTH), and in collaboration with the Cochrane Effective Practice and Organisation of Care (EPOC) Group and the Cochrane Consumers and Communication Review Group (CC&CRG), have created and continue to update an online database of interventions to promote evidence-based prescribing and medicines use, called Rx for Change is a novel, publicly-accessible database that we initially developed and populated with review-level evidence, and made available online in April 2007. We update it regularly to reflect accumulating and changing evidence and provide decision makers with reliable, up-to-date, evidence-based information in the form of reader-friendly summaries. In the database, we present key findings from systematic reviews that evaluate the effects of interventions directed at professionals, consumers, and organizations in a systematic way. This paper describes the methods for developing and populating the Rx for Change database and highlights key content and the significance of the database for healthcare policy makers, researchers, professionals, and consumers.Rx for Change database is to provide an overall synthesis of the evidence from systematic reviews on the effectiveness of interventions for improving prescribing by healthcare professionals and medicines use by consumers. The methods that we used to populate the database parallels systematic review methodology. We use reliable and valid methods to search and screen the literature, and to appraise and analyse the evidence from relevant systematic reviews. We then present the findings in an online format which allows users to easily access pertinent information related to prescribing and medicines use.Our goal for the Rx for Change database online in a publicly accessible format and has recruited additional funding for this project.In partnership with the Canadian Federal, Provincial, and Territorial Health Ministries, COMPUS identifies and promotes optimal drug therapy and encourages evidence-based information in decision making among healthcare providers and consumers. COMPUS hosts the Rx for Change database, EPOC maintains and updates the evidence from published systematic reviews on professional interventions that impact on the delivery of care, as well as organisational, financial, and regulatory interventions that influence prescribing behaviour. For the purpose of this paper, the methods used to identify and evaluate interventions targeting prescribing will be described.EPOC produces systematic reviews of interventions to improve healthcare delivery and healthcare systems, such as audit and feedback, distribution of educational materials, and decision-support tools using a well-established taxonomy of interventions and methods. In addition, EPOC has conducted overviews of existing Cochrane reviews as well as non-Cochrane systematic reviews to assess and synthesise the evidence in the area of professional behavior change ,5. For tRx for Change database, the CC&CRG is responsible for maintaining and updating the evidence on the effect of consumer-targeted interventions, such as providing consumers with information or education on medicines use, or promoting medicines self-management skills among consumers.The CC&CRG produces systematic reviews of interventions targeted at consumers (patients and their family members or carers) to promote consumer participation in healthcare. The CC&CRG has developed resources and tools to help organise and synthesise the evidence in relation to consumer communication and participation, and members of the group are currently undertaking an overview of systematic reviews of interventions directed at consumers to improve medicines use . For theRx for Change equals four highly trained staff members shared between both Cochrane groups, in addition to supervision from senior research staff.Using the combined expertise of the two Cochrane review groups, we developed the methods used for the synthesis and the presentation of the findings for this database. Human resources required in successfully maintaining With the assistance of an information specialist, we conduct comprehensive regular searches of electronic databases, including MEDLINE, EMBASE, Database of Abstracts of Reviews of Effects (DARE), and the Cochrane Database of Systematic Reviews (CDSR). In addition, we systematically hand-search the CDSR and DARE databases as interventions targeting consumers' use of medicines are not well indexed.http://www.cadth.ca/index.php/en/compus/optimal-ther-resources/interventions/methods). A flow diagram illustrating the methods and procedures for the database can be found in Figure Each year, we identify several thousand potentially eligible citations. Using explicit inclusion criteria, two researchers independently screen titles, abstracts and full text articles for relevance, and compare results. We resolve disagreements through discussion and, when necessary, through consultation with a senior team member  out of the total number of studies for each comparison. We also include any additional review data, such as meta-analyses or effect sizes. We then compile the results from each comparison and present them in a 'Table of Results.' We use standardised decision rules and statements to descriptively report on the general and medicines-specific 'Results' and 'Conclusions' of each review. For example, we use the term 'generally effective' if two-thirds or more of the studies favor the intervention.We organize the reviews of interventions directed to professionals and the delivery of care using the EPOC taxonomy of interventions. This taxonomy groups interventions into five broad categories: interventions targeting healthcare professionals, changing the organization of healthcare, financial interventions, regulatory interventions, and structural changes. Each category includes a number of specific interventions. Examples of interventions targeting professionals include reminders, educational meetings, and audit and feedback. Because the consumer literature on medicines use had not been previously well organised, the CC&CRG developed a taxonomy of consumer directed interventions ,10. ExamWith each update of the database, we combine new evidence with existing evidence and intervention summaries are updated. We display flags that indicate which interventions have been recently updated with new evidence.We present the database in a multilevel approach. In the first level, we provide a list of interventions grouped into five categories: professional, consumer, organisational, financial, and regulatory Figure . In the Rx for Change database on professional behaviour change [We launched the database in April 2007 and have since updated it three times Table . We initr change  and consRx for Change is a well-designed database containing valuable information for researchers, healthcare providers, and policy makers. Since its inception, we have received positive feedback about the database from international users about its value, applicability, and quality. Within a year of its launch, it had accumulated more than 25,000 page views. With increasing awareness of the database and its ongoing updates, we anticipate that this interest will continue to grow. We will continue to disseminate key messages to local and international groups about which interventions are effective, and where gaps in the evidence exist. We will continue to explore methods to disseminate and translate key messages to end users, particularly as new evidence is found and added to the database.Rx for Change database has provided the opportunity for EPOC and CC&CRG to collaborate with organizations that have strong links with healthcare decision makers . This collaboration promotes the use of research evidence and ensures that the data is available to the general public, healthcare professionals, and policy makers.The Rx for Change database to facilitate and improve the processes of accessing, searching, identifying, and using research to inform evidence-based prescribing and medicines use. It provides reliable, up-to-date, evidence for a wide range of users and is organised in an easy-to-browse format. We take the quality of the evidence into consideration to provide useable summaries that are relevant to decision-makers. This database is a first-in-class tool, and we will continue to promote it to ensure that it is utilized to its full potential.We created the BL is currently employed by CADTH. MW, AM, JW, and AS have been or are currently employed by EPOC. JG is the Coordinating Editor of EPOC. RR, NS and DL are currently employed by CC&CRG. SH is the Coordinating Editor of CC&CRG.MW participated in the design, data collection, analysis, coordination of the study, and drafted the manuscript. RR, AM, JW, NS, DL, AS, and SH participated in the design, data collection, analysis, and coordination of the study and contributed to the manuscript. BL participated in the design of the study and provided feedback on the manuscript. JG conceived of the study, participated in its design and coordination and provided feedback on the manuscript. All authors read and approved the final manuscript.