Although the global burden of cancer falls increasingly on low- and middle-income countries (LMICs), much of the evidence for cancer prevention and control comes from high-income countries and may not be directly applicable to LMIC settings. In this paper, we focus on the following question: When the majority of the evidence supporting an evidence-based intervention or implementation strategy comes from high-income countries, what local, contextual evidence is needed when transferring and adapting an intervention or strategy to a specific LMIC setting?We draw on an existing framework  for assessing transferability of interventions between distinct settings and apply the model to two case studies as learning examples involving implementation of tobacco use treatment guidelines and self sampling for human papillomavirus DNA in cervical cancer screening.These two case studies illustrate how researchers, policymakers, practitioners, and consumers may approach the need for local evidence from different perspectives and with different priorities. As uses and expectations around local evidence may be different for different groups, aligning these priorities through multistakeholder engagement in which all parties participate in defining the questions and cocreating the solutions is critical, along with promoting standardized reporting of contextual factors.Local, contextual evidence can be important for both researchers and practitioners, and its absence may hinder translation of research and implementation efforts across different settings. However, it is essential for researchers, practitioners, and other stakeholders to be able to clearly articulate the type of data needed and why it is important. In particular, where resources are limited, evidence generation should be prioritized to address real needs and gaps in knowledge. The US National Cancer Institute's Evidence Based Cancer Control Programs database, for example, includes more than 200 entries.Key ObjectiveWhen a cancer control intervention or strategy is transferred from one context to another, particularly when moving from a high-income to a low- or middle-income setting, questions are often raised about the need for local evidence. We draw on the Population, Intervention, Environment, Transfer-T process model for assessing transferability of interventions to understand contextual data needs.Knowledge GeneratedTwo case studies involving tobacco control and cervical cancer prevention illustrate how researchers and practitioners may approach the need for local evidence from different perspectives and with different priorities. Multistakeholder engagement, in which all parties participate in defining the questions and cocreating the solutions, is critical to ensure that relevant data needs are addressed.RelevanceThrough researchers and practitioners working together from the start to identify data gaps relative to the local context, evidence generation can be focused where it is most critical to support implementation of evidence-based interventions across diverse contexts.3 Effective implementation of evidence-based cancer control measures in LMICs is critical to addressing the global cancer burden. However, much of the evidence for cancer prevention and control comes from HICs and may not be directly applicable to LMICs because of competing health priorities, limited resources, health system structure and capacity, and other cultural or sociopolitical differences. Cancer control interventions and implementation strategies developed in HICs may require adaptation for successful implementation in LMICs.5 For example, human papillomavirus (HPV) vaccinations have been scaled up across many HICs, but implementation lags in LMICs. In response, the WHO launched a global initiative in 2020 that acknowledged the need to develop context-specific strategies to accelerate the elimination of cervical cancer across diverse settings.6 Additionally, breast cancer, now the most frequently occurring cancer worldwide, is increasing in many LMICs. However, large-scale mammography programs used in many HICs may not be appropriate in some settings because of cost and limited health care infrastructure; thus, resource-constrained settings may require greater reliance on other strategies such as community-level awareness and training of frontline health workers to promote early detection.7Although cancer incidence rates have been falling in HICs, they have been rising in many low- and middle-income countries (LMICs), and this disparity is projected to increase.8 Thus, it is important to understand factors at the individual, community, and systems level that may influence how an intervention is delivered and adopted in a novel setting. At the same time, however, a narrow focus on the local context may lead to excessive reliance on small pilot studies (termed pilotitis), which may hinder or slow efforts to bring interventions to scale.9 Thus, striking the right balance of responding to the local context and not undertaking overly burdensome or unnecessary research or data collections tasks is of critical importance to accelerating cancer control in LMICs.When transferring an intervention or implementation strategy  from a HIC to an LMIC setting, questions are often raised about the need for local evidence. Will the intervention be effective in this setting? Will it be accepted by the community? What adaptations are needed? The successful translation of cancer control interventions and practices in LMICs is a function not only of the effectiveness of the intervention, but also of how the intervention fits within the environment in which it is applied.In this paper, we focus on the following question: When the majority of the evidence supporting an evidence-based intervention (EBI) or implementation strategy comes from HICs, what local, contextual evidence is needed when transferring and adapting an intervention or strategy to a specific LMIC setting? What factors should researchers, practitioners, and decision makers consider when weighing the need for local evidence? We review key concepts of transferability of interventions and use two case studies in cancer control to demonstrate how these concepts can help to identify when local, context-relevant evidence is needed. We draw on an existing framework  for assessing transferability of interventions between distinct settings and apply the model to two case studies. This exercise yielded novel lessons for considering local data needs for transferring an intervention or strategy to a new setting. We conclude by suggesting best practices for researchers engaged in adapting and testing cancer control interventions in LMIC settings.10 We contrast local evidence with global evidence, which is generalizable but may not take into account characteristics or important nuances of a specific setting. There are a variety of situations where local data may be expected or required, particularly when the target setting population and environmental context differs significantly. For example, local evidence may be needed when there are no equivalent data available for a particular cultural or health system context. Local evidence may also be required to guide development or testing of adaptations to existing interventions and implementation strategies. Beyond translation, there may be differences in culture or climate11 in the way people communicate risk that influence modifications in how screening and prevention programs are promoted and implemented. For example, although the addition of graphic warning labels on cigarette packages is likely to affect smokers in a similar way across countries and regions, the specific content of those labels should be tailored to the local cultural and legal context. In addition, local evidence can be essential to estimate cost,12 acceptability, and feasibility in a given context, and local evidence may be required in response to demands from policymakers as a condition for action, decision making, or prioritization. In practice, however, such needs for local data are sometimes made with little explanation of or justification for what kind of data or evidence is needed or without a definition of what is meant by local evidence. Additionally, stringent expectations for local evidence may lead to discounting of evidence-based public health interventions, as has occurred around decisions to adopt tobacco control policies or incorporate HPV self-sampling into cervical cancer prevention programs.14 Thus, substantive ongoing engagement with all systems stakeholders is essential to generate research questions and answers that are relevant to transferring an intervention to an LMIC.16Local evidence has been defined as evidence that is available from the specific setting(s) in which a decision or action on a policy or program option will be taken. Implementation science offers methods and frameworks for evaluating factors influencing implementation of EBIs at multiple levels and identifying and tailoring implementation strategies to address barriers across varying settings. The concept of transferability is essential here, as researchers and stakeholders consider the spectrum of evidence needed to take an intervention from one setting to another and assess the extent to which outcomes observed in the original context can be achieved in the target context.17 Analyses of these factors can provide decision makers and researchers with the data to determine if or what additional research is needed, any necessary adaptations, further develop the intervention, and design implementation strategies for EBI transfer to the target context.The conceptual PIET-T process model, on the basis of a systematic review, provides a set of criteria for evaluating transferability of health interventions. The model includes four domains to consider when taking an intervention into a new setting: population , intervention , environment , and transfer .We emphasize the role of measures of implementation in the T transfer component of PIET-T because this step goes beyond communication and knowledge transfer and encompasses a wide range of factors that may influence the adoption and sustainability of the intervention in the new setting. Thus, in addition to the elements of T described in the PIET-T model , it is important to assess outcome measures for implementation such as reach, adoption, feasibility, and cost. Additionally, the transfer process may involve not only the intervention itself but also strategies for its implementation. For example, a diagnostic test may perform similarly in a HIC or LMIC setting, but its adoption and implementation within the health system may require very different strategies in distinct contexts. In the following section, we will apply the PIET-T model to two case studies as learning examples that involve implementation of tobacco use treatment guidelines and self sampling for HPV DNA in cervical cancer screening Table .21 This literature is the basis for the international guidelines for promoting adequate treatment for tobacco dependence.22 Additional research, conducted primarily in HICs, provides evidence for effective strategies to increase adoption and implementation of these evidence-based tobacco cessation interventions in health care systems.There is an extensive literature showing that health care worker–delivered brief advice to quit, multisession counseling, and pharmacotherapy are effective and affordable approaches to increasing tobacco cessation compared with placebo.In LMICs, local data on effective strategies for implementing tobacco use treatment in health care settings in LMICs are lacking and there is often a lack of local data demonstrating clinical outcomes that match those achieved in trials conducted in HICs. The lack of local evidence may create roadblocks to achieving equitable access to treatment.23 The most frequently reported barriers include a lack of political will or prioritization among policymakers, a lack of health care system infrastructure , and lack of funding, which is largely related to lack of political support for associated resource allocations.24 In the case of Vietnam, despite significant progress implementing the WHO Framework Convention on Tobacco Control policies and programs, there was no plan to implement treatment in community health centers (CHCs), the foundation of the primary care delivery system. Exploring this issue with policymakers indicated a skepticism about workforce capacity in CHCs to effectively treat tobacco dependence and a lack of resources to test that hypothesis.The WHO has defined tobacco control policies and interventions, including tobacco cessation services as a best buy for reducing the burden of noncommunicable diseases, including cancer. This designation acknowledges the wealth of data supporting effective tobacco use treatment interventions. Yet, implementation has lagged, particularly in LMICs.A partnership between local experts and both local and US investigators identified barriers and facilitators, and resulted in a plan that balanced policymakers' priorities to generate local evidence for the effectiveness of treatment delivered by trained providers and community health workers (does it work?) with the opportunity to simultaneously demonstrate the effectiveness of strategies, adapted to local context, to enhance implementation and guide scale up in CHCs nationally (how do we get it to work in varying contexts). A stakeholder-engaged formative assessment resulted in training and system changes , adapted to local language, culture, health care provider workflows, and CHC infrastructure, which were feasible to incorporate into routine care and acceptable to end users. The partnership leveraged the existing public health system infrastructure, which includes a national village health worker program, to create a task-sharing model that linked CHCs with this community-based workforce, to facilitate implementation of evidence-based tobacco use treatment and smoking abstinence.There is extensive evidence for best practices in treating tobacco use as well as effective strategies to integrate treatment into routine practice. However, deferring to country partners' expertise and local knowledge is an important component of program adaptation, implementation, sustainability, and scale up. Policymakers may continue to require some degree of local data on treatment effectiveness to support decisions about resource allocation and scale up. It is possible to respond to these priorities in a timeline consistent with local needs for data by applying a range of rapid-cycle pragmatic designs to assess the quality of an adapted intervention, and the usefulness and acceptability of adapted strategies and patient outcomes. The findings from this approach can strengthen confidence that outcomes can be reproduced, thus, accelerating translation of tobacco use treatment evidence into public health policy and practice.27 In a meta-analysis, participants who took their own samples were twice as likely to accept HPV screening.28 Additionally, numerous studies have shown that women can properly collect their own samples for HPV-based cervical cancer screening and that HPV DNA can be detected in a way that is noninferior to HPV DNA detection on paired clinician-collected samples.30There is an extant global literature showing that almost all women across diverse settings around the world say that HPV self-sampling is acceptable.Despite evidence from a variety of settings, local leaders sometimes remain skeptical about whether a self-sampling protocol will be accepted and successful in their setting and may be reluctant to support it without local evidence. In some settings, pilot studies continue to be conducted to test whether local women will adopt self-sampling. It is not always clear what drives these calls for local evidence, but they appear to be driven by a belief that data on acceptability are needed from the specific setting and population. In fact, there are two questions related to local evidence that may arise as national or local leaders decide whether or how they should adopt the self-sampling strategy for cervical cancer screening: (1) Will women here do self-sampling? (2) Does self-sampling work here to detect HPV DNA in a manner noninferior to clinician-collected samples?The WHO has called for the elimination of cervical cancer, and has laid out three pillars to achieve this goal: vaccination of 90% of girls by age 15 years; screen 70% of women by age 35 years and again by age 45 years; and treatment or management of 90% of women with cervical precancer or cancer. They have put forth guidance on what screening strategies to adopt but implementation challenges, including cost, have resulted in delayed or minimal scale up of HPV-based screening in many LMICs. Self-sampling for HPV represents a promising strategy for cervical cancer screening since it could reduce the time a woman spends at a health clinic , require fewer human resources without the need for a speculum examination, and the test is very sensitive with a high negative predictive value.At the start, it is important to understand why key stakeholders believe that data in their exact context are needed despite an extensive and diverse literature to support the intervention. Is it a gap in the knowledge of the context under which the evidence was generated, a gap in translating this evidence to key decision makers, or a belief that their setting differs in some meaningful way that has not been researched or reported? Are political, institutional, or other interests driving the call for local evidence in a well-studied area? Understanding the why can help researchers and stakeholders to prioritize data needs and direct limited resources. This highlights a fundamental partnership: content matter experts and local context experts. Together, they can undergo a process of knowledge exchange to understand how the evidence base for HPV self-sampling relates to, or could operate in, the local setting to determine whether additional pilot testing is, in fact, needed. Related, this partnership could work to broaden the role of pilot or demonstration projects, to go beyond effectiveness questions to concurrently collect implementation data to guide efforts to bring cervical cancer screening programs to scale with the goal of sustainability.Because HPV self sampling has been used in so many different populations and settings, little additional evidence with regards to acceptability and efficacy should be needed to transfer to a new setting. However, understanding the local health system structure and constraints is important to selecting or adapting dissemination and implementation strategies to support self sampling. Additionally, existing evidence highlights how the intervention must be conducted within the context of a strong continuum of care that can ensure proper management and referral to higher-level care facilities. Thus, for integration of HPV self sampling, system-wide stakeholder engagement is essential to create scalable, faithful, and sustainable impacts on cancer control.These two case studies illustrate how researchers, policymakers, practitioners, and consumers may approach assessing or addressing the need for local evidence from different perspectives and with different priorities. Stakeholders' requests for local evidence may appear to researchers to be inconsistent with the existing evidence base. At the same time, some forms of local evidence, such as data to guide implementation or understand specific barriers, may be overlooked despite their importance. Researchers are concerned with applying rigorous methods to explain how local context influences the effectiveness of interventions and what strategies can improve adoption, implementation, and sustainable impact. Implementers may seek local evidence to also help with priority setting and to answer questions about whether results across target populations are equitable, and what systems are needed to monitor the effects of the program. As uses and expectations around local evidence may be different for different groups, aligning these priorities through multistakeholder engagement in which all parties participate in defining the questions and cocreating the solutions is critical.31 Capturing and reporting data from real-world implementation efforts could help address calls for local evidence and build a robust evidence base for implementation of EBIs across diverse settings. Additionally, the process of implementation mapping provides a practical tool for developing and evaluating implementation strategies, including conducting a local needs assessment, identifying implementation outcomes, and planning for evaluation.32In practice, implementation of cancer control interventions may occur with or without this local evidence base. There are already many efforts to implement cancer control interventions in LMICs, sometimes using innovative approaches to overcome constraints in resources or capacity. However, limited data are available to evaluate these implementation efforts. A systematic review of more than 10,000 articles published between 1998 and 2016 on a range of health interventions in LMICs found that < 5% captured information to inform implementation efforts, such as understanding contextual barriers and facilitators or documenting adaptations.33 Theobald et al16 outlined the defining characteristics of implementation science in global health, including the importance of contextualization of an intervention, addressing challenges relevant to the community, using responsive methods, being demand driven, democratizing research through multistakeholder and multidisciplinary approaches, focusing on processes and outcomes, and being real-world and real-time focused. Peek et al15 also highlighted the importance of substantive ongoing participation by stakeholders to produce research that is relevant, which is a critical consideration when taking an intervention developed in a HIC setting and studying it in an LMIC.Local evidence can be relevant at multiple points along the stages of implementation research, moving from the preimplementation phase, through the process of implementation, to the postimplementation phase.Engage stakeholders: Whole system stakeholders should be involved from the start in identifying priorities, framing research questions and participating in study design decisions to both build commitment and to ensure that relevant data needs are addressed. Stakeholder groups should include implementers as well as policymakers.34; Reach, Effectiveness, Adoption, Implementation, Maintenance35; or the Exploration, Planning, Implementation, Sustainment framework,36 can help to define the context of intervention implementation at multiple levels and anticipate data needs, particularly related to barriers and facilitators. Frameworks and theories can also inform adaptations and design of strategies on the basis of local data.Apply conceptual frameworks: Conceptual frameworks and theories, such as the Consolidated Framework for Implementation Research37Use hybrid study designs when feasible: Study designs should consider and include process, context, and outcome measures aligned with stakeholder priorities. In situations where general evidence is limited in LMICs, hybrid designs allow for rigorous tests of both the intervention effectiveness and the implementation strategy and, at a minimum, should include studying contextual factors relevant to implementation, sustainability, and scale up.38 More comprehensive reporting will aid others in understanding how findings from one setting may or may not relate to other settings.Promote standardized context reporting: Publications often lack information about context. Standardized reporting of the context in which an intervention was tested would allow for greater understanding of the role of local factors and transferability. This could be developed in a manner similar to guidelines for reporting adaptations to interventions to support ongoing research.39Embed capacity building: To account for local context in the design, conduct, and interpretation of research studies, it is essential to have participation of skilled local researchers. In LMIC contexts where research capacity may be limited, contributing to training and capacity building is an important step for future research. Capacity building to inform implementation and build local evidence should be embedded in research activities to promote equity, identification of local priorities, and to strengthen stakeholder partnerships and roles.Thus, in closing, we draw from the broader literature and our own experiences in global cancer control to offer some additional tools and best practices for researchers to consider:Local, contextual evidence can be important for both researchers and practitioners, and its absence may hinder translation of research and implementation efforts across different settings. However, it is essential for researchers, practitioners, and other stakeholders to be able to clearly articulate the type of data needed and why it is important. In particular, where resources are limited, evidence generation should be prioritized to address real needs and gaps in knowledge. Through researchers and practitioners working together from the start to identify data gaps relative to the local context, evidence generation can be focused where it is most critical and can support efficient implementation of EBIs across diverse contexts to support global cancer control.


Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is essential to ensure trainees possess the skills needed for independent practice. Traditionally, ERCP training has used the apprenticeship model, whereby novices learn skills under the supervision of an expert. A growing focus on procedural quality, however, has supported the implementation of competency-based medical education models which require documentation of a trainee’s competence for independent practice. Observational assessment tools with strong evidence of validity are critical to this process. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated.To conduct a systematic review of ERCP assessment tools and identify tools with strong evidence of validity using a unified validity evidence frameworkWe conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively.From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one on simulated ERCP, and one on simulated and clinical ERCP. Validity evidence scores ranged from 2-12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality was strong, with scores ranging from 10-12.5 (maximum 13.5).The BESAT, ERCP DOPS, and TEESAT have strong validity evidence compared to other assessments. Integrating tools into training may help drive learners’ development and support competency decision-making.CAGNone Declared


The biochemical machinery involved in matrix vesicles-mediated bone mineralization involves a specific set of lipids, enzymes, and proteins. Annexins, among their many functions, have been described as responsible for the formation and stabilization of the matrix vesicles′ nucleational core. However, the specific role of each member of the annexin family, especially in the presence of type-I collagen, remains to be clarified. To address this issue, in vitro mineralization was carried out using AnxA6 (in solution or associated to the proteoliposomes) in the presence or in the absence of type-I collagen, incubated with either amorphous calcium phosphate (ACP) or a phosphatidylserine-calcium phosphate complex (PS–CPLX) as nucleators. Proteoliposomes were composed of 1,2-dipalmitoylphosphatidylcholine (DPPC), 1,2-dipalmitoylphosphatidylcholine: 1,2-dipalmitoylphosphatidylserine (DPPC:DPPS), and DPPC:Cholesterol:DPPS to mimic the outer and the inner leaflet of the matrix vesicles membrane as well as to investigate the effect of the membrane fluidity. Kinetic parameters of mineralization were calculated from time-dependent turbidity curves of free Annexin A6 (AnxA6) and AnxA6-containing proteoliposomes dispersed in synthetic cartilage lymph. The chemical composition of the minerals formed was investigated by Fourier transform infrared spectroscopy (FTIR). Free AnxA6 and AnxA6-proteoliposomes in the presence of ACP were not able to propagate mineralization; however, poorly crystalline calcium phosphates were formed in the presence of PS–CPLX, supporting the role of annexin-calcium-phosphatidylserine complex in the formation and stabilization of the matrix vesicles’ nucleational core. We found that AnxA6 lacks nucleation propagation capacity when incorporated into liposomes in the presence of PS–CPLX and type-I collagen. This suggests that AnxA6 may interact either with phospholipids, forming a nucleational core, or with type-I collagen, albeit less efficiently, to induce the nucleation process. A lattice . A nucle lattice . In this lattice ,12. It w lattice . Indeed, lattice . Our res lattice .2+ precipitated in the presence of AnxA6 in solution and bound to the proteoliposomes in the presence of PS–CPLX. An increase of 0.1 in turbidity is equivalent to the precipitation of approximately 10% of the total Ca2+ in SCL  (deg), which is defined as:n g·mL−1 . The amoequation :(ƒH) = −p ≤ 0.05 or p ≤ 0.001, as indicated.Kinetics and mineralization data are reported as the mean ± SD of triplicate measurements of three different proteoliposome preparations, which was considered to be statistically significant at 2+, AnxA6 binds to phosphatidylserine (PS) on the inner leaflet of the MVs’ lipid bilayer and could contribute to the formation of a nucleational nucleus, possibly with the aid of AnxA5 . A. A2+, Anductance , it is uance [2+  or if anance [2+  and thatMembrane models, such as proteoliposomes and Langmuir monolayers bearing specific proteins, have been useful to investigate the mechanisms of apatite formation and the role of several proteins/enzymes in biomineralization ,61,62,63


According to the World Health Organization, addressing the mental health care gap for adolescents, especially in low-resource contexts, is a priority. Evidence-based assessment is crucial for selecting treatment strategies and for quality management.To develop a digital platform for evidence-based assessments and implement it in different low-resource settings.https://digitalprinciples.org/), including designing with the user, user testing, understanding the ecosystem, resusing software and being open source, think about sustainability and addressing privacy and security.The project operates according to the principles of digital development  will be presented.The learned lessons will be presented to the audience.MHIRA is a promising tool that helps bridge the gap regarding adolescent mental health in low-resource settings. Challenges include the clinicans attitude towards evidence based assessment, sustainability of the project and integration with the existing information technology eco-system and regulations.No significant relationships.


Age-related macular degeneration (AMD) is the third largest cause of blindness worldwide, accounting for 8.7% of all cases. A considerable number of preventive or therapeutic interventions have been used for AMD. This study presents a critical view of the interventions that have been assessed through Cochrane systematic reviews. Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). Review of Cochrane systematic reviews about interventions for AMD. The 18 systematic reviews included assessed the effects of surgical techniques, laser/photo/radiotherapy, intravitreal injections, systemic drugs and phytotherapy/vitamins/supplements. The Cochrane systematic reviews found evidence that use of bevacizumab, ranibizumab, pegaptanib, laser photocoagulation, photodynamic therapy and multivitamin compounds may present some benefits for treating AMD. There was insufficient evidence for supporting the use of macular translocation, submacular surgery, steroid implantation, radiotherapy, intravitreal aflibercept, interferon alfa, statins or omega-3 fatty acids for treating AMD; or the use of multivitamin antioxidant vitamins or mineral supplementation for preventing AMD. Future randomized controlled trials are imperative to reduce the uncertainty in several clinical questions regarding AMD. Age-related macular degeneration (AMD) is a degenerative disease of the macula  that causes loss of central vision. This type of vision is essential for performing activities of daily living.AMD is the third largest cause of blindness worldwide, accounting for 8.7% of all cases of definitive loss of vision.AMD is differentiated into the early (often asymptomatic) or intermediate stages with drusen (amorphous extracellular sediments in the retina) and characteristic pigmentary changes, and the late stages. For clinical purposes, the late stages of AMD have been classified as dry (non-neovascular and atrophic) or wet (neovascular and exudative). In the wet stages, new blood vessels can lead to leakage and tissue lesions.A considerable number of preventive or therapeutic interventions are available and have been used for both types of AMD. This study presents a critical view of the interventions that have been assessed through Cochrane systematic reviews (SRs).To synthetize and present the results from Cochrane SRs assessing interventions for preventing and treating age-related macular degeneration.We carried out a narrative review of Cochrane SRs in the Discipline of Evidence-Based Medicine of Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). This manuscript was elaborated for the section Cochrane Highlights. This initiative is a formal collaboration between the São Paulo Medical Journal and Cochrane, and it is supported by Cochrane Brazil. The aim of this initiative is to disseminate the evidence from Cochrane SRs.We included only the latest published version of Cochrane SRs. We did not consider protocols, or any SR marked as “withdrawn” in the Cochrane Database of Systematic Reviews (CDSR).In relation to reviews examining therapeutic methods, we considered any participant with the diagnosis of AMD, as defined by the review authors’ criteria. SRs including cases of AMD and other clinical situations were included only if the subset of data on AMD participants was provided separately. In relation to reviews examining preventive methods, no restrictions on participants were applied.We considered any surgical or pharmacological  intervention, compared with placebo, no intervention or any other intervention.We considered all clinical and laboratory outcomes addressed by the SRs.We carried out a systematic search in the Cochrane Database of SRs (via Wiley) on January 8, 2019. The search strategy is presented in The selection process was performed by two authors (RLP and RR), who independently assessed all titles and abstracts that had initially been obtained through the electronic search for potential reviews. These authors confirmed the eligibility of these SRs by assessing their full texts. Any divergences in the selection process were resolved through reaching a consensus.We summarized and presented the following characteristics from the SRs that were included: PICOs , goals, methods, main findings, certainty of evidence in accordance with the GRADE approach ,,,,,,,,,,,,,,,,,The initial search retrieved 90 abstracts of systematic reviews (SRs), and 18 of them fulfilled our inclusion criteria and were considered for the analysis.,,,,,,,,,,,,,The 18 SRs included assessed the effects of surgical techniques (n = 4),A mini-telescope is an implantable ophthalmic device for amending visual acuity after impairment of vision due to AMD. It has been used to enlarge objects in the central visual field and focus them onto healthy areas of the retina, thus making it possible to view objects that otherwise could not be seen. This reviewThe authors could not draw any conclusions regarding this clinical question. There is one ongoing RCT that is comparing the OriLens intraocular telescope with standard low-vision training for coping with end‐stage AMD. The results from this trial are expected in 2020.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011140.pub2/full.For further details and to access all the analyses, see the original abstract, available from: Macular translocation is a surgical procedure that includes displacement of the retina to a less‐damaged area, which could improve vision. This reviewGain of three or more lines read during the ETDRS (Early Treatment Diabetic Retinopathy Study) test ;Change of visual acuity ;Change of near visual acuity score .However, there was no difference between the interventions groups regarding these other outcomes:Progression of loss of vision (loss of three or more lines) ;Change of contrast sensitivity ;Recurrence of choroidal neovascularization .Complications were minor and less frequent in the PDT group. The complications observed in the macular translocation group included: retinal detachment (6/25 patients), diplopia requiring prismatic correction (5/25 patients), macular edema  and need for muscle surgery (23 eyes).The authors concluded that the current evidence was insufficient for them to be able to recommend macular translocation for AMD, which is also associated with significant harm. This technique is complicated and long surgical training is needed in order to be able to perform it.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006928.pub2/full.For further details and to access all the analyses, see the original abstract, available from: Surgical removal of the submacular tissue underlying the macula  might limit the development of AMD. This reviewPrevention of loss of vision ;Probability of visual gain .However, cases of cataracts requiring surgery  and retinal detachment  were more frequent in the surgical group. Detachment was observed in 5% of the participants without extensive blood under the macula and in 18% of those with this.In another small pilot RCT, submacular surgery was compared with laser photocoagulation (n = 70) and no difference was found for any of the outcomes measured.The authors of the SR concluded that submacular surgery for choroidal neovascularization did not provide any benefit for individuals with AMD.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006931.pub2/full.For further details and to access all the analyses, see the original abstract, available from: Steroids have anti‐inflammatory and antiangiogenic properties that can be useful for treating AMD. This reviewAnecortave acetate (3 mg) versus placebo: no difference between the interventions ;Anecortave acetate (15 mg) versus placebo: slight difference favoring steroids, but clinical relevance needs to be discussed ;Anecortave acetate (30 mg) versus placebo: no difference between the interventions ;Triamcinolone acetonide versus placebo: no difference between the interventions ;Anecortave acetate versus PDT: no difference between the interventions The authors of the SR did not find any evidence that antiangiogenic steroids prevented loss of vision due to AMD.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005022.pub3/full.For further details and to access all the analyses, see the original abstract, available from: Drusen, which consist of an amorphous yellowish aggregate that accumulates under the retina, are considered to be risk factors for developing AMD. This reviewRisk of choroidal neovascularization at two years of follow-up: odds ratio (OR) 1.07; 95% CI 0.79 to 1.46; eleven RCTs; 2159 participants; 3580 eyes; high certainty of evidence.Risk of geographic atrophy: OR 1.30; 95% CI 0.38 to 4.51; two RCTs; 148 participants; 148 eyes; low certainty of evidence.Progression to loss of vision : OR 0.99; 95% CI 0.81 to 1.22; nine RCTs; 2002 participants; 2386 eyes; moderate certainty of evidence.No further adverse events  were reported.The authors of this SR concluded that laser photocoagulation of drusen led to their disappearance but did not reduce the risk of developing choroidal neovascularization, geographic atrophy or loss of visual acuity. Ongoing RCTs are being conducted to evaluate the effects of extremely short laser pulses (i.e. nanosecond laser treatment) and the results will be available in the future.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006537.pub3/full.For further details and to access all the analyses, see the original abstract, available from: This reviewIn comparing direct photocoagulation of the entire choroidal neovascularization versus no intervention, the risk of progression to loss of vision  was found to be more frequent in the photocoagulation group at three months , but less frequent at two years . In comparing perifoveal photocoagulation versus observation, a benefit from the intervention was observed at two years . For other comparisons, no other differences were found.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004763.pub2/full.For further details and to access all the analyses, see the original abstract, available from: PDT has been investigated as an option for managing neovascular membranes in cases of AMD without affecting the retina. This reviewProgression of loss of vision at 24 months:Loss of three or more lines of visual acuity: benefit with PDT/verteporfin ;Loss of six or more lines on visual acuity test: benefit with PDT/verteporfin .The results at 12 months were similar to those at 24 months.Adverse outcome, within one week of treatment:Risk of severe decrease of visual acuity: no difference between interventions ;Infusion-related back pain: higher with PDT/verteporfin .Two other trials compared different treatment regimens: (a) standard versus delayed light application; and (b) retreatment every two months versus every three months. No difference in effectiveness was found in either of these.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002030.pub3/full.For further details and to access all the analyses, see the original abstract, available from: This reviewProgression of loss of vision:Loss of three or more lines on visual acuity test: no difference between the groups at 24 months ; four RCTs, 428 participants; low certainty of evidence) or at 12 months ;Loss of six or more lines on visual acuity test: no difference between the groups at 24 months , but lower occurrence with radiotherapy at 12 months .The frequency of adverse events was low and there were no reports of radiation retinopathy, optic neuropathy or malignancy.The authors of this SR concluded that there was no convincing evidence that radiotherapy was an effective treatment for neovascular AMD.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004004.pub3/full.For further details and to access all the analyses, see the original abstract, available from: Aflibercept is a biological drug that blocks the biological activity of vascular endothelial growth factor (VEGF) and inhibits abnormal growth of blood vessels. This reviewChange in best‐corrected visual acuity (BCVA): no difference between the groups at one year ; and insufficient results for assessing the outcome at two years .Gain of 15 or more letters in BCVA test: no difference between the groups at one year  or at two years .Loss of 15 or more letters in BCVA test: no difference between the groups at one year .Serious systemic adverse events: no difference between the groups at one year .Any serious ocular adverse event: no difference between the groups .https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011346.pub2/full.For further details and to access all the analyses, see the original abstract, available from: This reviewVisual acuity (assessed from the proportion of patients with a gain of 15 letters or more): no difference between the interventions after one year ; Progression to loss of vision (loss of 15 letters or more): no difference between the interventions after one year ;Number of serious systemic adverse events: higher with bevacizumab after one year .Visual acuity (assessed from the proportion of patients with a gain of 15 letters or more): favored pegaptanib after one year ;Progression to loss of vision (loss of 15 letters or more): favored pegaptanib after one year ;Proportion of participants with serious adverse events: no difference between the interventions after one year, although the estimate was very imprecise because of the low number of events .Progression to loss of vision (loss of 15 letters or more): favored ranibizumab after one year ;Proportion of participants with serious adverse events: no difference between the interventions after one year, but the evidence was imprecise and no important differences could be excluded .Visual acuity (assessed from the proportion of patients with a gain of 15 letters or more): favored bevacizumab after one year ;Progression to loss of vision (loss of 15 letters or more): favored bevacizumab after one year ;Proportion of patients with serious systemic adverse events: no difference between the interventions after one year, but this result was very imprecise .The review authors concluded that the results indicated that there were benefits from use of anti-vascular endothelial growth factor, for patients with AMD. The assessment of adverse events was impaired by the low number of events.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005139.pub3/full.For further details and to access all the analyses, see the original abstract, available from: This reviewThe authors of this SR concluded that there were no significant results that could support use of bevacizumab or ranibizumab.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011230.pub2/full.For further details and to access all the analyses, see the original abstract, available from: This reviewhttps://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009300.pub2/full.For further details and to access all the analyses, see the original abstract, available from: Interferon alpha is an antiangiogenic drug that inhibits migration and proliferation of vascular endothelial cells. This reviewFurther RCTs are needed in order to increase confidence in this estimate. The next update of this review will probably assess the certainty of the evidence using the GRADE approach.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005138.pub2/full.For further details and to access all the analyses, see the original abstract, available from: Recent studies have shown that AMD and atherosclerosis present some risk factors in common, and that statins may present benefits for patients with AMD. This reviewVisual acuity: there was no difference between the groups at three months of treatment ; at 45 days after the completion of treatment ; or at 12 months .Drusen score and visual function results were reported to be similar between the groups at 12 months (42 participants), but no effect estimates or confidence intervals were provided.Progression of AMD: there was no difference between the groups at three years .Adverse events: only one RCT reported adverse outcomes, and it was stated that there were no differences between the groups regarding death, muscle aches or acute hepatitis.The authors of this SR concluded that the current evidence from RCTs was insufficient to confirm that statins had any benefit with regard to preventing or delaying the onset or progression of AMD.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006927.pub5/full.For further details and to access all the analyses, see the original abstract, available from: Observational studies have suggested that a diet enriched with antioxidant vitamins (carotenoids and vitamins C and E) or minerals (selenium and zinc) may reduce the risk of development and progression of AMD. This reviewOverall risk of AMD: no difference between the groups ;Risk of late AMD: no difference between the groups ;Adverse events: two RCTs reported similar numbers of adverse events for both groups. A third RCT reported that there was higher risk of hemorrhagic strokes in the vitamin E group .Overall risk of AMD: no difference between the groups ;Risk of late AMD: no difference between the groups ;Adverse events: use of beta‐carotene was associated with increased risk of lung cancer among people who smoked (high certainty of evidence).Overall risk of AMD: no difference between the groups ;Risk of late AMD: no difference between the groups .Centrum Silver is composed of zinc (15 mg), vitamin E (45 IU), vitamin C (60 mg), beta‐carotene (5000 IU), vitamin A (20% as beta carotene), folic acid (2.5 mg), vitamin B6 (50 mg) and vitamin B12 (1 mg).Overall risk of AMD: slightly higher with multivitamin ;Risk of late AMD: no difference between the groups ;Adverse events: skin rashes were slightly more frequent in the multivitamin group .The authors of this SR concluded that vitamin E, beta‐carotene, vitamin C and the multivitamin (Centrum Silver) did not reduce the risk of developing AMD. There was no evidence regarding other antioxidant supplements, such as lutein and zeaxanthin. Although vitamin supplements are commonly assumed to be safe, they may have harmful effects. Hence, sound evidence of benefit is needed before they can be recommended.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000253.pub4/full.For further details and to access all the analyses, see the original abstract, available from: This reviewProgression to late AMD: less frequent with multivitamins ;Progression of loss of vision (loss of three or more lines on logMAR chart): lower with multivitamins ;Quality of life : higher with multivitamins ;Adverse events: no difference between the groups regarding mortality , but participants in the antioxidant arms more commonly reported presenting yellow skin .Progression to late AMD: no difference between the groups ;Progression to loss of vision (loss of three or more lines on logMAR chart): no difference between the groups ;Quality of life: no difference between the groups ;Adverse events: no difference between the groups regarding mortality .Progression to late AMD: no difference between the groups ;Progression to visual loss (loss of three or more lines on logMAR chart): no difference between the groups ;Adverse events: no serious adverse events were reported. No difference between the groups was found regarding withdrawal due to adverse effects (four versus seven), any adverse events (91 versus 83) or ocular adverse events (105 versus 90) (very low certainty of evidence).Progression to late AMD: slightly lower with zinc ;Progression to loss of vision (loss of three or more lines on logMAR chart): no difference between the groups ;Adverse events: gastrointestinal symptoms was more frequently reported as a reason for withdrawal in the zinc group . Anemia was more common in the zinc group . However, serum hematocrit levels were similar between the groups.The authors concluded that use of multivitamins, antioxidant vitamins and mineral supplementation may delay the progression of AMD. This finding was based on a single large trial, including only American individuals, and the external validity considering different populations is uncertain. Although vitamin supplements are commonly assumed to be safe, they may have harmful effects.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000254.pub4/full.For further details and to access all the analyses, see the original abstract, available from: Ginkgo biloba extracts are used for treating some health conditions, including peripheral vascular diseases, and may present benefits for treating AMD. This reviewThe outcomes reported in the RCTs were generally different from those of relevance for the review, and the safety results were very sparse. The certainty of evidence was not assessed. Further RCTs are needed in order to reduce the uncertainty of the evidence and to provide a basis for practical recommendations.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001775.pub2.For further details and to access all the analyses, see the original abstract, available from: This reviewProgression to advanced AMD: no difference between the groups ;Progression to loss of vision (loss of three or more lines): no difference between the groups at 24 months  or at 36 months ;Adverse events: no difference between the groups .The authors concluded that there was no evidence of benefits from use of omega-3 among patients with AMD.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010015.pub3/full.For further details and to access all the analyses, see the original abstract, available from: This review included 18 Cochrane systematic reviews (SRs) that evaluated three surgical techniques, three interventions based on laser/photo/radiotherapy, four different drugs for use in intravitreal injections, three systemic drugs and four complementary interventions for preventing or treating age-related macular degeneration (AMD). The following interventions may present some benefits for AMD: (a) use of bevacizumab, ranibizumab or pegaptanib; (b) laser photocoagulation; (c) photodynamic therapy; and (d) use of multivitamin compounds.The Cochrane SRs found insufficient evidence to support use of the following: (a) macular translocation ; (b) submacular surgery; (c) steroid implantation; (d) radiotherapy; (e) aflibercept; (f) interferon alpha; (g) statins; (h) multivitamins, antioxidant vitamins and mineral supplementation as preventive interventions; and (i) omega-3 fatty acids.No published RCT was found assessing: (a) use of an implantable ophthalmic mini-telescope device for improving visual acuity after impairment of vision due to AMD ; and (b) use of complement inhibitors.Among the 18 SRs included, four did not assess the certainty of the body of evidence based on the GRADE approach, since they were developed before this approach became recommended as mandatory in the Cochrane Handbook. It is strongly desirable that SRs should be updated after two years have elapsed, or more frequently if new studies are available. Indeed, the lack of an approach of this nature for supporting SR conclusions is a factor that limits practical applicability.We observed an issue involving the comparison between ranibizumab and bevacizumab, which was addressed through two different SRs and led to an overlapping of safety assessments. The first SR focused on the overall effects (benefits and harm) of any intravitreal anti-VEGF drug.Additional ongoing Cochrane SRs addressing other interventions for treating AMD will be available over the coming months and may contribute towards expanding the body of evidence available for management of AMD.Further well-designed and well-conducted randomized controlled trials are still necessary, in order to reduce the uncertainties regarding the clinical questions that surround AMD.This review found 18 Cochrane systematic reviews that evaluated interventions for preventing or treating AMD. Overall, use of bevacizumab, ranibizumab, pegaptanib, laser photocoagulation, photodynamic therapy and multivitamin compounds may present some benefits for treating AMD. Further randomized controlled trials are still necessary, in order to reduce the uncertainties regarding most clinical questions that surround AMD.


To identify evidence-based strategies to improve adherence to the preventive measures against the coronavirus disease (COVID-19) at the community level.This is an evidence brief for policy, combining research evidence specific to contextual knowledge from stakeholders. A systematic search was performed in 18 electronic databases, gray literature, and a handle search, including only secondary and tertiary studies that focused on the adherence of the general population to COVID-19 preventive measures in the community. Two reviewers, independently, performed the study selection, data extraction, and assessment of the quality of the studies. Relevant evidence has been synthesized to draft evidence-based strategies to improve adherence. These strategies were circulated for external endorsement by stakeholders and final refinement. Endorsement rates >80%, 60–80% and <60% were considered high, moderate, and low respectively.n = 3), moderate (n = 3), low (n = 1), and critically low (n = 4). Three evidence based strategies were identified: i. Risk communication; ii. Health education to the general public, and iii. Financial support and access to essential supplies and services. The rates of endorsement were: 83% for risk communication, 83% for health education, and 92% for financial support and access to essential supplies and services. The evidence showed that an increase in knowledge, transparent communication, and public awareness about the risks of COVID-19 and the benefits of adopting preventive measures results in changes in people's attitudes and behavior, which can increase adherence. In addition, the guarantee of support and assistance provides conditions for people to adopt and sustain such measures.Eleven studies, with varying methodological qualities were included: high (These strategies can guide future actions and the formulation of public policies to improve adherence to preventive measures in the community during the current COVID-19 pandemic and other epidemics. In 2020, the coronavirus disease 2019 (COVID-19) quickly spread around the world, causing a global health and economic crises, unprecedented and, uncertain prospects for the period post-pandemic , that was first identified in December 2019 in China .So far, there is no prophylactic drug treatment. As such, the disease is mostly controlled through non-pharmacological community measures and vaccination , 5. VaccThe combination of these non-pharmacological interventions aims to delay/decrease the spread of the virus and avoid the overburdening of health systems . DespiteThe implementation and adherence to these measures are particularly more difficult in low and middle-income countries, especially in vulnerable populations, as observed in the previous epidemics . The pooIn this context, it is crucial to contain the pandemic by improving the population's adherence to effective community measures for the prevention and control of COVID-19. However, the results and impact depend on collective behavior and interventions from government agencies. This study identified the best available evidence and described strategies to improve adherence to COVID-19 preventive measures in the community.We conducted an evidence brief for policy (study that package research evidence to inform deliberations among policymakers and stakeholders)  combininStudies were selected based on the following inclusion criteria:We included systematic reviews (SR), rapid reviews (RR), overviews, evidence brief, clinical practice guidelines and policy guidelines. Guidelines were only considered if GRADE Evidence to Decision (EtD) was used.Studies involving the general population exposed to COVID-19 and other severe acute respiratory syndromes (SARS).Any type of strategy to promote or improve adherence to community measures, such as handwashing, quarantine, social distancing, and use of facemasks for the prevention and control of COVID-19 and other SARS.Studies that only suggested interventions to increase adherence but did not measure these were excluded.There were no restrictions on the types of comparisons.Primary outcomes: number/proportion of people who adhere to community measures for the prevention and control of COVID-19 and other SARS; reduction of incident cases, hospitalizations, and mortality.Secondary outcomes: cognitive or behavioral changes; changes in the knowledge, awareness, attitudes, acceptability, and behavior; factors associated with adherence or not adherence; knowledge/understanding of concepts or skills relevant to the critical appraisal of health claims.A systematic search was conducted in the following databases: MEDLINE, LILACS, The Cochrane Library, Health System Evidence, Health Evidence, EMBASE, CINAHL, Global Index Medicus, Epistemonikos, International Initiative for Impact Evaluation (3ie), Campbell Collaboration, Clinical Trial Registry, WHO ICTRP—International Clinical Trials Registry Platform (ICTRP) and GIN Guidelines International Network. It was also searched in some specific database for COVID-19: Coronavirus (COVID-19) Special Collections from Cochrane, COVID19 Study register from Cochrane, COVID-END from McMaster and COVID-19 Evidence database from Epistemonikos.In addition, reference lists, gray literature and handle searches were also performed using a search strategy developed by two specialists. The supplement  shows thA pilot exercise was conducted using 50 abstracts for the entire screening team to calibrate and test the review form. Subsequently, titles and abstracts were screened independently according to the selection criteria by pairs of reviewers . Disagreements regarding the eligibility of studies were resolved by discussion, and a third reviewer (LCL) was consulted when necessary.The full texts of the potentially relevant papers were retrieved for examination. The inclusion criteria were then independently applied to the full-text version of the papers by the same pairs of reviewers. Conflicts were resolved by discussion, and a third reviewer (LCL) was consulted when necessary.The following data were extracted from the included studies: study objectives, designs, number of studies included, number and type of participants, intervention/strategy, main findings, country of study, and date of the last search. Data extraction was performed independently by the same pairs of reviewers and checked by another reviewer. Disagreements were resolved through discussion and consensus.The qualities of SRs were independently assessed by a pair of reviewers, using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) . The quaTo assess the quality of clinical practice guidelines or policy recommendations, three reviewers used the AGREE checklist . The AGR20. We chose the topic “implementation strategies.”After extracting data, pairs of reviewers independently categorized the strategies using the taxonomy from Health Systems Evidence . It consConflicts and disagreements during this process were resolved through discussion and consensus.Data from the included studies were synthesized using tables and a narrative summary.Key people from the health departments and committees dealing with COVID-19 from Brazil and civil society with contextual knowledge were identified. Among 29 people who were invited, 20 agreed to participate in Phase B.We circulated the recommendations electronically to this same group of 20 stakeholders  for external endorsement using an online survey.We asked stakeholders whether they fully endorsed, did not endorse, or had no opinion about recommendations. Participants were also invited to provide comments. We considered endorsement rates of >80% as high, 60%−80% as moderate, and <60% as low levels of endorsement. The results were discussed during an online meeting with the research team and stakeholders, and the results were incorporated into the final version of the evidence brief and refinement of the strategies.We had stakeholders , were included. Risk communication is defined as the “exchange of information, advice and opinions, in real-time, among experts, community leaders or officials, and people at risk who face threats to their health and social well-being” . This stThe information must be easily found in legitimate/reliable sources, and it should be clear, consistent, unified, practical, and up-to-date. It should discuss the risks , the benefits, the need, the effectiveness and the rationality of adopting community measures to prevent COVID-19 , 29. TheThese messages must be constantly reinforced  and dissCommunicating and recognizing uncertainties, errors, and changes in information. Negative information, such as the number of victims, should not be occulted , 29.Identification and involvement of people that the community trusts  in the development and dissemination of the messages , 29. TheIn this way, risk communication is effective as it produces cognitive changes in the perception of disease risk, which in turn encourages behavior change and increases adherence to preventive measures . RepeateFailures in communication can have negative effects on the acceptability and adherence to preventive measures , 23. ConFour studies with varying methodological qualities  were included.Health education refers to any type of combination of learning experiences designed to help individuals and communities improve their health, increase their knowledge, and/or influence their attitudes . It is aThis strategy plays a key role in the prevention and control of emerging infectious diseases . It shouHealth education increases knowledge and public awareness, which improves attitudes, practices, and behaviors during the pandemic . It alsoTwo studies with varying methodological qualities .Several practical elements need to support or sustain behavior change and the population's response to certain preventive measures, especially quarantine or social distancing. The population may have the desire, motivation, and knowledge to adhere to preventive measures, but if there are no means to do so, they will not adhere .It is essential to offer certain types of support/assistance to the population, especially those most affected by the pandemic, and ensure that they know clearly which are available and how they can be accessed . This shDespite the economic and social impact, ensuring of financial support and access to essential supplies increases adherence to preventive measures and mitigates long-term effects on the physical and mental health of the population. Hard-to-access support services cause stress and non-adherence , and theTwenty stakeholders participated and completed the online endorsement survey, of which 2 (10%) were policy-makers, 2 (10%) frontline health professionals, 13 (65%) were researchers , and 3 (15%) were civil society organization representatives. The rates of total endorsement for the recommendations were: 83% for risk communication, 83% for health education, and 92% for financial support and access to essential supplies and services.Emphasis was placed on the importance of customizing risk messages according to the target audience and on empowering the primary health care team in the elaborating and disseminating these messages. Participants tended to endorse the health education, but they highlighted that it would be the most challenging recommendation during a pandemic. Furthermore, e-learning, one of the most commonly used forms, could have difficulties impacting a specific part of the population. Support was considered the most important because it enables the adoption of preventive measures during the pandemic.This evidence brief presented strategies for improving the adherence to COVID-19 prevention measures in the community using complex knowledge synthesis of evidence from literature and contextual expert knowledge from stakeholders. The available evidence from 11 studies identified three strategies that may be useful in dealing with non-adherence, which was highly endorsed by stakeholders.The time required to produce evidence is not always the same for decision making. Sometimes, robust evidence obtained from studies of high methodological quality may not be available when decision-makers need it, as in this case. The strategies were derived from some low-quality studies with varied evidence levels. As such, we included information on uncertainties and gaps.There were more studies for strategy 1 than for other strategies; however, the quality was quite varied. Different approaches to risk communication were promising, but it was not possible to determine the best approach , 25. EviDespite the relevance of the role of the strategy 2 in emerging diseases, the format of the educational process became more complicated in a pandemic scenario. The studies only suggested providing health education by media campaigns, telephone, or web-based programs , 27. In Strategy 3 shows the essential elements to support and sustain preventive measures, especially quarantine. Financial support and access to essential supplies (food and medicines) and services  result in significant economic and social impacts, but robust economic assessments are needed . Some otThe impact of strategy 3 may be even greater in low-income countries groups, or places that are potentially at a disadvantage. These include populations without clean water and those unable to buy masks, soap, or alcohol, or to keep their distance in crowded houses or slums.The diverse group of stakeholders engaged in the endorsement process ensured the review, assessment of the feasibility, and refinement of the strategies in real practice. This phase was important as it weighed the research evidence with the knowledge, values, insights, and experiences of stakeholders. The approach of including stakeholders in the process has grown in the past several years and is critical for implementing promising interventions and improving the health of communities .Bringing together evidence producers and users contributes to the dissemination and application of global and local evidence in real-world settings, reducing the gap between research and practice.Although it was not the focus of our research and was not discussed among stakeholders, it is important to note that both strategies 1 and 2 could also help in the vaccination adherence to COVID-19. Vaccine hesitancy is another major challenge that countries are facing probably due negative and unclear information spread by media, lack of education and health literacy , 36.Observational studies conducted in some countries identified that high adherence to COVID-19 preventive measures was associated with willingness to vaccinate against the disease , 37. TheRisk communication and health education could contribute to address positive and true information about the COVID-19 vaccination, to avoid the spread of misinformation, reduce disbeliefs, hesitancy and resistance, increase the confidence within the population about the benefits of vaccination and the percentage of vaccine definite people , 36.Finally, our findings could be used by practitioners and policy-makers working in the field of prevention and control of COVID-19 to improve the adherence to COVID-19 preventive measures and the willingness of the community to vaccine and combat COVID-19.To our knowledge, this was the first study to address this objective and involved relevant stakeholders for the endorsement of effective strategies.While the three strategies are well outlined, it is important to mention that social influences could be a key motivation for some people's adherence to COVID-19 preventive measures. For instance, people have more motivation to adherence when their close social circle did .The variability in the quality of the included studies may cause some uncertainties and limit the confidence in the findings. Further studies should be conducted to assess the effectiveness of interventions to improve adherence to preventive measures in the community for future epidemics. Furthermore, rigorous methods in order to provide high-quality evidence.The majority of the studies also focused on high-income countries. This limits their application in low-income countries, which face different challenges, mainly in relation to its implementation. Additionally, if those implementing the strategy do not take into account and nurture the local culture, the project is doomed. Therefore, more studies need to be conducted in low- and middle-income countries.Based on the best available evidence, this evidence brief identified three strategies for improving adherence to preventive measures against COVID-19 in the community, which may guide future actions and policymaking during this pandemic or future epidemics. In addition, two of these strategies could contribute to improve the vaccination adherence and reduce the hesitancy and resistance in the community.The intention is not to recommend specific strategies but to inform policymakers and stakeholders and contribute to assertive decision-making in public health, according to the needs, financial resources, feasibility, local reality, and the engagement of the main actors. This evidence brief provides relevant information for planners and policymakers to choose the most effective strategy.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Research Ethics Committee of the University of Sorocaba, on 15 October 2020, (CAAE: 38351620.9.0000.5500) according to Resolution CNS 466/12 of the National Health Council. The patients/participants provided their written informed consent to participate in this study.IF and LL led the conceptual design of the original study, acquisition of funding, drafted the manuscript and conducted the methodological quality assessment. JB, SB-F, CB, and IF selected tittles and abstracts and extracted data from included studies. All authors read and approved the final manuscript.National Council for Scientific and Technological Development—CNPq, Brazil, grants n°401924/2020-3 and Ministry of Health (MOH).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Researchers at the KEMRI-Wellcome Trust Research Programme (KWTRP) carried out knowledge translation (KT) activities to support policy-makers as the Kenyan Government responded to the COVID-19 pandemic. We assessed the usefulness of these activities to identify the facilitators and barriers to KT and suggest actions that facilitate KT in similar settings.The study adopted a qualitative interview study design.Researchers at KWTRP in Kenya who were involved in KT activities during the COVID-19 pandemic (n=6) were selected to participate in key informant interviews to describe their experience. In addition, the policy-makers with whom these researchers engaged were invited to participate (n=11). Data were collected from March 2021 to August 2021.A thematic analysis approach was adopted using a predetermined framework to develop a coding structure consisting of the core thematic areas. Any other theme that emerged in the coding process was included.Both groups reported that the KT activities increased evidence availability and accessibility, enhanced policy-makers’ motivation to use evidence, improved capacity to use research evidence and strengthened relationships. Policy-makers shared that a key facilitator of this was the knowledge products shared and the regular interaction with researchers. Both groups mentioned that a key barrier was the timeliness of generating evidence, which was exacerbated by the pandemic. They felt it was important to institutionalise KT to improve readiness to respond to public health emergencies.This study provides a real-world example of the use of KT during a public health crisis. It further highlights the need to institutionalise KT in research and policy institutions in African countries to respond readily to public health emergencies. This study employed in-depth interviews to elucidate the engagement between researchers and policy-makers and how evidence is used in a pandemic.The study provides lessons that can inform knowledge translation practice in similar settings.Including researchers as participants in the study may have introduced bias.The COVID-19 pandemic has required policy-makers to make decisions that have significant health, social and economic consequences. Incorporating the best available research evidence to guide decision-making is essential for an effective response. However, public health emergencies (PHEs) present several challenges to evidence-informed decision-making (EIDM). These include: (1) a rapidly increasing and evolving evidence base; (2) increased uncertainty and risk; and (3) sheer time pressure to make quick decisions.There are several documented barriers to effective KT in low-middle-income regions, such as Africa. For researchers, these include lack of capacity to plan and implement KT, poor relationships between researchers and policy-makers, competing demands for time, a lack of institutional incentives to participate in KT, the complexity of the policy process and difficulty in communicating research evidence.The EEVIDEM project was a KEMRI-Wellcome Trust Research Programme (KWTRP) initiative based on the KT push, exchange and integrated models that sought to promote EIDM in Kenya using four interventions. The first intervention was researcher embeddedness into policy-making spaces, such as technical working groups. The second intervention was reciprocal secondment. In this arrangement, a policy-maker from the Ministry of Health (MoH) spends 50% of their working hours at KWTRP, allowing them to participate in research activities. Likewise, one researcher from KWTRP spends 50% of their time at the MoH. The third intervention was hosting regular policy dialogues. The fourth intervention was knowledge synthesis and dissemination (hereafter collectively referred to as ‘KT activities’). This intervention involved generating evidence and disseminating KT products to policy-makers and is the paper’s focus.While KWTRP had engaged in KT activities before EEVIDEM, these were ad hoc, inconsistent and driven by few individual researcher initiatives. Institutionalising KT means taking steps to ensure that the systems, structures, resources and support needed for KT to become standard practices are available. The EEVIDEM project supported the institutionalisation of KT within KWTRP by facilitating the development of a policy engagement and KT strategy, creating mechanisms for documentation and evaluation of KT efforts, providing financial resources for KT, staffing with KT capacities, formation of structures that support linkages between researchers and policy-makers, and providing technical support to researchers to develop and implement KT strategies.We sought to describe the experiences of the researchers and policy-makers involved in EEVIDEM’s KT activities that supported the COVID-19 response and assess the influence of these activities. The lessons learnt from these experiences can strengthen the processes that promote evidence-informed responses during PHEs in African settings.In Kenya, the MoH has established organisational structures to support using evidence in policy-making. The Kenya Medical Research Institute (KEMRI), of which KWTRP is a part, is mandated to generate this evidence. During the pandemic, the MoH established the National COVID-19 taskforce. Its membership was drawn from the MoH and other government agencies, research and academic institutions, United Nations agencies, civil society organisations and the private sector. The taskforce coordinates and mobilises technical advice to the MoH and advises other ministries on appropriate measures. The taskforce’s action points are implemented within the MoH’s departmental structure, which includes the Director General’s Office and the Emergency Operations Centre. KWTRP researchers provided research evidence and engaged with policy-makers within these structures.To guide the assessment of the influence of KWTRP’s KT activities on evidence uptake during the COVID-19 pandemic, we adapted a determinant framework  that conInitially, the researchers synthesised evidence on questions they thought were of high priority. As the pandemic progressed, policy-makers started engaging with researchers to identify priority questions and coproduce COVID-19 evidence. The evidence was packaged as rapid response evidence briefs and/evidence summaries. Dissemination was primarily through email, and in some cases, researchers were invited to do oral presentations.This study adopted a qualitative interview cross-sectional design. A total of 17 key informant interviews (KIIs) were carried out on two groups: researchers and policy-makers . All KWTThere was no patient or public involvement in the study.Audio recordings were transcribed verbatim in MS Word. The transcripts were coded using NVIVO qualitative data analysis software . For analysis, a predetermined coding structure consisting of the core thematic areas of the conceptual framework was used. Any other theme that emerged in the coding process was included. Code reports were generated and analysed once all data were coded in their respective themes (FHG and AN).Fifty-six rapid response evidence briefs and summaries were developed. These briefs shared evidence from primary studies, including modelling studies, genomic surveillance of SARS-CoV-2, seroprevalence of SARS-CoV-2 antibodies, health systems assessment and economics studies, clinical surveillance, and the synthesis of existing evidence on topics requested by policy-makers . Briefs Participants described several facilitators and barriers that shaped their experience, as summarised in The researchers felt that their KT efforts increased evidence availability and accessibility. A significant facilitator of this was the support of existing KT capacity in KWTRP through EEVIDEM that provided guidance and supported researchers in the consistent and timely development of KT products.It has been the existence of the structures that we've managed to create with this platform [EEVIDEM]. It’s something that we don't emphasise enough, having that pool of people. KII-R05, ResearcherPolicy-makers also reported that the briefs enhanced their access to research evidence. They highlighted the format of the briefs as important in making evidence more accessible as they were concise and used simple language.I found the format fairly useful. I like that there was a section summarising what the rest of the brief held. It was beneficial as one can quickly garner some of the key evidence from that particular brief very quickly. KII-PM08, Policy-makerBoth groups reported the importance of augmenting written briefs with an oral presentation of evidence, which provided them with an opportunity to discuss the evidence and reduce misinterpretation:They [the researchers] present most of the information and not only presented in writing, they normally present there [at the MoH]. So you can always seek clarification should there be a need to. KII-PM01, Policy-makerThe presentations are best because they involve you interacting with the people who are making the decisions or who will interpret the evidence. So, you get to communicate far more information unlike these other modes of communication. KII-R03, ResearcherThe main barrier to evidence availability and accessibility for both groups was timeliness. The time it took to generate and synthesise high-quality evidence was often longer than the time within which evidence was needed for timely policy-making.Sometimes they are required urgently, and I have to turn them around while ensuring that they're of reasonable quality which can be a challenge KII-R01, ResearcherThe challenge that is experienced is the length of time from once a request is sent out for a certain matter to the time a brief is submitted on the same KII-PM01, Policy-makerOther barriers mentioned by researchers included the limited availability of local data, making it difficult for researchers to adapt evidence to local settings. In addition, the lack of a feedback mechanism left some researchers unaware of how useful briefs were to policy-makers as they rarely got direct feedback. Policy-makers mentioned two more barriers. One was the length of the briefs; they felt that when a brief was long or too technical, it lowered the accessibility of the evidence. In addition, policy-makers shared that there was unequal access to evidence among them:In my position, getting evidence is not as difficult; however, other officers within the directorate find it a bit difficult to access the evidence and are told write officially or show that it comes through like Director General’s office so that they can access the evidence. KII-PM01, Policy-makerResearchers highlighted three factors that could improve evidence availability and accessibility. These included expanding KT capacity in KWTRP, increasing availability of local data to researchers to support the contextualisation of evidence to the local setting, and more feedback from policy-makers to help researchers determine if policy-makers found evidence easier to use through their KT activities. Suggestions by policy-makers included making briefs even easier to read by using more illustrations and tables and depositing briefs on open platforms so that more policy-makers have access to evidence.Both groups reported that regular sharing of briefs enhanced policy-maker motivation to seek and use research evidence. A key facilitator was the relevance of the evidence. Motivation was enhanced as long as the evidence answered a priority question:To a certain extent, the larger the crisis, the more the need for research. However, the endless loop for motivation would be the need to answer a question at the forefront of policy-makers' minds. KII-PM03, Policy-makerBoth groups also felt that the availability and willingness of researchers to generate and share evidence with policy-makers was an important motivator.I think just knowing that we are available to them is a huge motivator. That someone else can search for evidence and summarise it and then present it to them is a huge motivator. KII-R06, ResearcherPolicy-makers mentioned other facilitators including the positive feedback loop generated when evidence-informed policies were implemented and prior engagement between the two groups. These factors enhanced policy-makers’ confidence in the researcher’s credibility.For researchers, the barriers to enhancing motivation included the risk of sharing evidence that clashed with policy-makers’ expectations. This could create conflict between the two groups and limit the researcher’s agency.Sometimes, the evidence we generate is at odds with policy-makers' position or expectations. That puts us in uncomfortable situations. KII-R02, ResearcherTo enhance the motivation of policy-makers, researchers felt that sustaining engagement with policy-makers would be necessary. Policy-makers suggested that researchers should sensitise more policy-makers on the importance of considering evidence during policy-making.Both groups felt that participation in KT activities enhanced the capacity of policy-makers to use evidence. They felt that regular interaction with researchers and evidence increased policy-makers’ ability to interpret and use evidence during policy-making:Working with researchers has built confidence in using information for making decisions, yes. KII-PM07, Policy-makerA challenge identified by researchers in increasing the capacity of policy-makers to appraise and use research evidence is the lack of time for policy-makers to participate in capacity-building activities:We know that policy-makers do not have time. KII-R02, ResearcherPolicy-makers also mentioned that short staffing in the department meant that they did not have the staffing available to continue training while attending to their everyday tasks.Overall, both groups felt that more KT training and workshops to improve capacity to appraise and use evidence were needed when policy-makers were available.Both groups reiterated that their relationships were valuable and had strengthened during the pandemic. For policy-makers, an important facilitator for this was informal relationships with researchers. This meant that researchers were more accessible to them. Some noted that their relationship with some of the researchers was established even before joining the MoH, but further engagement deepened this relationship:They weren't new to me, but of course, the deepening of the relationships has come about now by us engaging further on this pandemic response that much I would say. KII-PM01, Policy-makerAccording to the researchers, consistently sharing KT products that were timely and relevant made policy-makers aware of researchers’ value, which cultivated a good working relationship. However, several barriers to relationship building were identified. From the researchers’ perspective, these include: (1) the constant personnel changes at the MoH; (2) being perceived as political players rather than evidence generators; and (3) building and maintaining relationships took time and effort which was usually not accounted for as part of their research activities. From the policy-makers’ perspective, one barrier was the researchers' failure to meet all collaboration expectations. The policy-maker expected more capacity building but conceded that due to COVID-19 restrictions, there were fewer opportunities. Suggestions for addressing relationship barriers included strengthening institutional relationships and ensuring that engagement and communication between the two groups were sustained. Finally, researchers noted that they needed training on communicating with policy-makers and navigating policy spaces without being seen as political.Participating researchers felt that the KT activities they were involved in were useful in informing the COVID-19 response. This was reflected in the way policy-makers regularly referred to briefs produced by the researchers and used evidence produced. According to the policy-makers, the evidence disseminated by the researchers was used to inform COVID-19 policy-making as noted by several policy-makers:Much of the evidence shared was whether we should be able to strengthen some areas and also reinforce lockdowns. Some of the measures put in place have come from the reports that researchers provide. KII-PM07, Policy-makerThe briefs from genome sequencing have enabled us to map out hot spot areas which we used to give an advisory about movement. We also used the recommendations that came off the sero-surveillance evidence to advise the people in Nairobi on how to conduct themselves. KII-PM09, Policy-maker.et al reported that when policy-makers knew researchers socially, they were more open to considering their research.16The KT activities described here promoted evidence use for COVID-19 response. Some key facilitators of evidence uptake were highlighted. First were the tools used to communicate evidence, including rapid response evidence briefs and oral presentations. Similar to our finding, previous studies also report that the evidence briefs and summaries are well received by policy-makers and increase the likelihood of using them.Lack of time has consistently been identified as a critical barrier to evidence uptake.It was noted that institutions in LMICs are less prepared to conduct KT that responds to the pandemic.Institutionalisation of KT is particularly needed in African countries, where the use of evidence during decision-making is still challenging.The researchers in this study also participated in the KT activities described here, which may impact analysis. However, the participatory nature of our KT approach made it inherently collaborative, which inadvertently set the researcher up as a participant. To address trustworthiness, the researchers were transparent about their relationship to the topic of the investigation and maintained reflexivity throughout the process. In addition, the analysis was presented to the participants for sense checking to see if their views were correctly represented. The study was also presented to broader forums to check for objectivity. Finally, we interviewed 17 participants, which limited statistical generalisability. However, as is consistent with qualitative studies, the aim was not statistical generalisability, but rather analytical generalisability, typically achieved with relatively small sample sizes that facilitate in-depth exploration of participants’ perspectives.The key learning from this study is the importance of institutionalising KT in research and government institutions to support PHEs. In this study, we sought to increase evidence uptake by enhancing four main determinants of uptake: accessibility, motivation, capacity and relationships. We found that by using this framework, we had relative success in informing policy-making during COVID-19. The novelty of the approach lies in the context within which it is applied. By accurately recording our experiences, interventions and outcomes we can derive lessons to inform the establishment of institutionalised KT that responds to PHEs .