Limited literacy skills are common in the United States (US) and are related to lower HIV knowledge and worse health behaviors and outcomes. The extent of these associations is unknown in countries like Mozambique, where no rigorously validated literacy and numeracy measures exist.A validated measure of literacy and numeracy, the Wide Range Achievement Test, version 3 (WRAT-3) was translated into Portuguese, adapted for a Mozambican context, and administered to a cross-section of female heads-of-household during a provincially representative survey conducted from August 8 to September 25, 2010. Construct validity of each subscale was examined by testing associations with education, income, and possession of socioeconomic assets, stratified by Portuguese speaking ability. Multivariable regression models estimated the association among literacy/numeracy and HIV knowledge, self-reported HIV testing, and utilization of prenatal care.Data from 3,557 women were analyzed; 1,110 (37.9%) reported speaking Portuguese. Respondents’ mean age was 31.2; 44.6% lacked formal education, and 34.3% reported no income. Illiteracy was common  and the mean numeracy score (10.4) corresponded to US kindergarten-level skills. Literacy or numeracy was associated (p<0.01) with education, income, age, and other socioeconomic assets. Literacy and numeracy skills were associated with HIV knowledge in adjusted models, but not with HIV testing or receipt of clinic-based prenatal care.The adapted literacy and numeracy subscales are valid for use with rural Mozambican women. Limited literacy and numeracy skills were common and associated with lower HIV knowledge. Further study is needed to determine the extent to which addressing literacy/numeracy will lead to improved health outcomes. In 2009 there were an estimated 22.5 million individuals living with HIV infection in sub-Saharan Africa and 1.8 million new infections. Literacy skills include an individual’s ability to read, write and comprehend written language (print literacy), speak and understand spoken language  and understand and use numbers in daily life (quantitative literacy or numeracy). Ogumaniha* - Strengthening Communities through Integrated Programming (SCIP) Project baseline survey. There are currently no direct measures of general literacy and numeracy that have been validated and published in the literature for use in non-English speaking populations in sub-Saharan Africa. We sought to adapt a measure of general literacy and numeracy, the Wide-Range Achievement Test, version 3 (WRAT-3) The study protocol was reviewed and approved by the National Committee of Bioethics for Health in Mozambique and the Institutional Review Board of Vanderbilt University. Written informed consent was obtained for all study participants.Ogumaniha-SCIP Project baseline survey was designed to measure a range of socioeconomic and health issues pertaining to women, children and families living in Zambézia Province, Mozambique. A provincially representative sample of 264 enumeration areas was selected, with probability proportional to size according to the most recent census; this method intends for all households to have equal probability of selection. Using topographic and satellite maps, survey teams divided the enumeration areas into four quadrants. Starting in their assigned quadrant, an interviewer would systematically approach the first four households for interview. Interviewers conducted the survey with female head-of-households, defined as the principal wife of the immediate family of the household, from August 8 to September 25, 2010. The survey was translated into Portuguese and the five languages most commonly spoken in the province ; all language versions were piloted prior to the start of the survey. Except for the literacy measure, all survey questions were orally administered in the respondent’s language of choice; responses were entered using a cell phone application. The overall response rate was 99% of all households approached. Data from all respondents were eligible for analysis, however respondents with missing data for literacy or numeracy were excluded.The st grade math skills. Both items were field tested prior to the start of data collection. The numeracy scale was administered in the respondent’s language of choice, and the literacy scale was administered in Portuguese only.The WRAT-3 is a validated, English language measure of general literacy and numeracy; Demographic data and Portuguese speaking ability were collected by participant self-report. Respondents who reported Portuguese as their native language or who responded “yes” to an item asking if they “spoke Portuguese well” were classified as Portuguese speakers. Distance from the center of the enumeration area to the nearest health center was calculated in kilometers using GPS coordinates. HIV knowledge was measured with five items adapted from Demographic Health Survey 5 that assess knowledge of HIV transmission, transmission prevention, and HIV treatment; Summary statistics are reported for demographics, literacy score category, and numeracy as unweighted sample size, and weighted means or proportions. The weighted proportions of correct responses for each numeracy item are also reported. Estimates of descriptive statistics were weighted by the inverse of the household sampling probability. All data analyses were stratified by self-reported Portuguese speaking status; weighted summary data were compared for Portuguese speakers and non-Portuguese speakers by adjusted Wald test for mean values and Pearson chi-squared test for proportions.a priori that lower literacy or numeracy would be associated with higher age, less education and income, fewer reading materials in the home and household assets, non-motorized transportation, languages other than Portuguese spoken at home; these associations were tested by Spearman rank correlation, Wilcoxon rank sum and Kruskal-Wallis tests, as statistically appropriate. Effects of clustering were not considered in construct validation analyses. Internal consistency reliability was tested by Chronbach’s alpha for the HIV knowledge items and Kuder-Richardson 20 for numeracy items.To evaluate the construct validity of the adapted literacy and numeracy measures, we examined the association of literacy and numeracy scores with selected characteristics. We hypothesized a priori, including: respondent age, reported income, language of survey administration, and distance from health center (km). A third set added education into the adjusted model. All analyses were conducted using STATA™ statistical software package .Multivariable linear regression models accounting for the effects of clustering by enumeration area were used to examine the relationship of literacy or numeracy and HIV knowledge; logistic regression was used to examine the relationship between literacy or numeracy and receipt of antenatal care and HIV testing. A second set of multivariable regression models adjusted for important covariates identified Meticais ($34 USD). The mean distance to the nearest health facility was 7.7 km (range: 0.2–37.3 km). The mean HIV knowledge score was 3.3 (range: 0–9); alpha was 0.75 for these items. Respondents who reported the ability to speak Portuguese were younger, had more education and higher income, were more likely to have electricity in their home and lived closer to a health center than those who did not speak Portuguese.We interviewed 3,636 female heads-of-households. Case-wise deletion of participants with missing responses excluded 33 missing literacy and 46 missing numeracy such that 3,557 respondents (98%) were included in analyses. Women had a mean age of 31.2 years; 37.9% reported that they spoke Portuguese well and were classified as Portuguese-speakers Table 1.Over half (50.4%) of Portuguese speakers and nearly all (93.7%) non-Portuguese speakers scored in the lowest category of literacy, corresponding to either no reading ability or the ability to read individual letters only. A perfect score of 57 was demonstrated by 26.4% of Portuguese speakers and 2.6% of non-Portuguese speakers Table 2.For both Portuguese and non-Portuguese speakers, literacy was independently associated with HIV knowledge after adjusting for respondent age, stated income, distance to the nearest health center, and the language of the survey in models with and without an adjustment for education; for non-Portuguese speakers this association was observed only for those with the highest literacy scores Table 4.The Kuder-Richardson coefficient for numeracy items was 0.84 for Portuguese speakers and 0.87 for non-Portuguese speakers. Mean numeracy scores were higher for Portuguese speakers (12.6) than for non-Portuguese speakers (9.1); performance for each item of the numeracy scale is summarized in For both Portuguese and non-Portuguese speaking respondents, higher numeracy scores were correlated with younger age , more education , more reading materials in the home  more HIV knowledge  and with higher literacy scores . Portuguese and non-Portuguese speaking respondents who reported more income, used motorized transportation, owned a house with a metal or cement roof, owned a cell phone and spoke Portuguese at home had higher median numeracy scores compared to their counterparts. For Portuguese speaking respondents, individuals who reported having bank accounts or electricity in their home had higher median numeracy scores than those who lacked them; there was no such association among non-Portuguese speaking respondents Table 5.In multivariable linear regression, numeracy was significantly associated with HIV knowledge independent of respondent age, income, distance from the hospital and the language of survey administration; this association remained significant with education included in the model Table 4.In this provincially representative sample of 3,557 women, the adapted WRAT-3 was reliable and valid for measuring general literacy and numeracy. Poor literacy and numeracy were common for women living in Zambézia Province, and similarly many women had difficulty with items that assessed basic numerical concepts and computational skills. For both Portuguese speakers and non-speakers, poorer literacy and numeracy skills were associated with less HIV knowledge but not lower self-reported utilization of HIV testing or prenatal care. To our knowledge, this is the first study in the literature that reports directly measured literacy and numeracy skill in a representative population in rural sub-Saharan Africa. Our use of representative data to estimate the literacy and numeracy skills for all female heads-of-household in the province is a major strength of this study.The prevalence of illiteracy in our study is substantial, and higher than the recent estimate of the Mozambican national literacy rate of 54%. The deficits in numeracy for many women in this study are stark, and may have serious implications for behaviors necessary for utilization of health care for themselves and their children. To our knowledge, previous to this study there was no measure published in the literature estimating numeracy by direct measurement in persons living in sub-Saharan Africa. Work in the US looking at literacy and medication administration have shown that individuals with low literacy have difficulty appropriately dosing liquid medications for their children per se. The use of self-reported outcomes may also limit the ability to examine these associations, as individuals with poor literacy may be more likely to be unaware of past HIV testing.The positive associations of literacy and numeracy with HIV knowledge are similar to evidence from US studies among individuals living with HIV infection. In addition to the limitation of our use of a general literacy scale in this study , there are potential methodological limitations with using a word list for measuring literacy in the Portuguese language. The WRAT-3 reading list uses pronunciation of words as a proxy measurement for reading comprehension; while rapid to administer and valid, this approach may overestimate literacy. Our study introduces valid instruments to measure general numeracy and literacy that could be adapted for other settings and languages, and also demonstrates clearly some of the skill disparities facing women within one rural province in Mozambique. These data suggest that literacy and numeracy may be important independent factors in the acquisition of HIV knowledge, and have implications for public health efforts in rural settings such as Zambézia where literacy and numeracy skills are limited. The level of literacy and numeracy skill should be taken into consideration when developing HIV educational messages in resource-limited settings such as Zambézia. While efforts to improve primary school education access and quality for women is clearly a high national priority, interventions designed to improve the quality of provider health communication or improve the applied literacy and numeracy skills of patients during HIV care and treatment programs may be simple, inexpensive and have a more immediate impact.


BCG pantothenate auxtroph (ΔpanCD) is safer to use as a live vaccine vector than wild-type BCG. We constructed 3 recombinant BCGΔpanCD candidate vaccines expressing HIV-1 subtype C Gag, RT and Env (gp120). The current study investigated immune responses in rhesus macaques following a prime with a mixture of these rBCG vaccines and a boost with SAAVI MVA-C (MVA).Chinese rhesus macaques (n=8) were primed twice with a mixture of rBCG, 12 weeks apart. A control group (n=4) was mock-primed with a control BCG. Both groups were boosted with MVA. Two weeks after the MVA vaccination, two macaques from the rBCG-primed group were euthanased and jejunum, spleen and inguinal, mesenteric, iliac and bronchial lymph nodes were harvested for isolation of mononuclear cells. HIV-1-specific IFN-gamma ELISPOT responses were measured in the blood and these tissues using pools of overlapping HIV-1 peptides.6 PBMC. After boosting with MVA, HIV-specific responses were detected in 6 of the 8 animals (mean: 932±1100 sfu/106 PBMC). These responses were directed to Gag, RT, and Env proteins but not Nef or Tat. No responses were detected in the control animals before or after MVA vaccination. At necropsy, HIV-specific responses were detected in the peripheral blood, spleen, inguinal, iliac and bronchial lymph nodes of 1 of 2 animals. The cumulative responses ranged from 112 to 714 sfu/106 cell input.Vaccination with rBCG elicited modest HIV-specific responses in the blood in 5 of 8 animals, 4 of which responded after the first rBCG vaccination. These responses were to either Env or to both Env and Gag proteins and the cumulative responses ranged from 50 to 172 sfu/10These data demonstrate that our rBCGΔpanCD candidate vaccines, when given in a prime-boost combination with SAAVI MVA-C, induce vaccine-specific immune responses in both the peripheral blood and MALT.


The objective of this research is to generate quality of care indicators from systematic reviews to assess the appropriateness of obstetric care in hospitals.A search for systematic reviews about hospital obstetric interventions, conducted in The Cochrane Library, clinical evidence and practice guidelines, identified 303 reviews. We selected 48 high-quality evidence reviews, which resulted in strong clinical recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The 255 remaining reviews were excluded, mainly due to a lack of strong evidence provided by the studies reviewed.A total of 18 indicators were formulated from these clinical recommendations, on antepartum care (8), care during delivery and postpartum (9), and incomplete miscarriage (1). Authors of the systematic reviews and specialists in obstetrics were consulted to refine the formulation of indicators.High-quality systematic reviews, whose conclusions clearly claim in favour or against an intervention, can be a source for generating quality indicators of delivery care. To make indicators coherent, the nuances of clinical practice should be considered. Any attempt made to evaluate the extent to which delivery care in hospitals is based on scientific evidence should take the generated indicators into account. Quality of care has been defined as the degree to which health services increase the likelihood of desired health outcomes for individuals and populations and are consistent with current professional knowledge. Scientide novo the evidence relevant to each case. The establishment of a priori clinical indicators to be used as performance measures might be more efficient for systematically assessing the degree to which scientific evidence is applied in clinical practice.Too little attention has been paid to the correlation between the availability of scientific evidence and clinical practice. A series of studies-7 faced Development of indicators based on professional consensus has a long history,9, whileIn the present study, we restricted the source of indicators of quality of care to systematic reviews (SR), based on the assumption that they provide the highest degree of reliability, are incIn summary, we generated a set of quality indicators of obstetric care related to childbirth, based on SRs, which could be applicable in different settings and circumstances.The first phase of our project consisted of a literature search and generation of a set of recommendations based on sound evidence, either in favour or against interventions in delivery care; the second phase consisted of developing and validating a set of indicators.Table A literature search was conducted in the Cochrane Database of Systematic Reviews , the Database of Abstracts of Reviews of Effects, and Clinical Evidence to identify SRs assessing obstetric interventions performed in a hospital setting. To retrieve supplementary relevant SR, we consulted the available CPG from the main obstetrical medical societies  and CPG of obstetric care from main guideline producers , and the New Zealand Guidelines Group).Two researchers (MA and DR) independently applied selection criteria to the identified SR: pharmacological or non-pharmacological interventions, under the responsibility of the clinical team and registered at the clinical record or any other database. In case of disagreement, the criterion from a third author (XB) was applied.Two researchers (MA and DR) independently appraised each SR and restricted the inclusion to SR that met all internal validity items established by the Scottish Intercollegiate Guidelines Network (SIGN), as asseFor each selected SR, we classified the outcomes by relevance . Two authors (MA and DR) independently rated the quality of evidence and assessed the strength of recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. ApplicaTwo authors (MA and DR) independently selected recommendations that were considered strong (either in favour or against the application of a given intervention) and based on high quality evidence, at least for the most critical outcomes. In case of disagreements, a third author (XB) was consulted.From the selected clinical recommendations, we proceeded to construct indicators, following an adaptation of the methods proposed by the American College of Cardiology/American Heart Association (ACC/AHA) and the We subsequently consulted two specialists in obstetrics (CF and AV) to assess our design interpretation of the indicators, and the relevance of the indicators in current practice. This was followed by an email consultation with the authors of the SR on which the indicators were based, asking to what extent they agreed with the formulation of the indicator . The comments received from the review authors or consultants led us to modify or redefine various indicators.FigureThe selected reviews consisted exclusively of Cochrane reviews. No SR was excluded based on their quality assessment. In the following stage, 28 SR were excluded for not providing a base for any strong recommendation (either in favour or against an intervention). Thus, we generated 20 clinical recommendations that were both strong and based on high-quality evidence.Approximately 75% of the authors of the selected SR responded to our request to review the indicator. Overall, they agreed on the indicator proposal, and their comments were used for further improvement of their definition and formulation.Following advice of the obstetric consultants, two indicators were removed: the proportion of women with singleton pregnancies at risk of preterm delivery to be treated with a combination of corticosteroids with thyrotropin-releasing hormone, and theThe 18 indicators eventually accepted are shown in Table Indicators are expressed in proportions and refer to process of care, while none refer to structure or outcome. To illustrate the process  to conste.g., a clinical guideline) and the necessity of providing personalized care to individuals who are different. In our opinion, only with such an approach can the evaluation of quality of care provided be made, taking the existing evidence and the characteristics and values of each patient simultaneously into account.At the end of the process, 18 quality indicators for the delivery of obstetric care in hospitals were identified. Illustrated in Table The 18 generated indicators represent a conservative sample of the available evidence, since the criteria of consistency, meaningfulness and applicability had priority. We do not expect them to be unique; however, we propose that they should be included in any quality assessment or performance measurement that is made relating to the delivery of care. Since they have been formulated while taking criteria of flexibility and feasibility into account, they could be applied in very different hospital obstetric settings.e.g., assessing that an episiotomy was not performed unless justified). Second, the identified indicators reflect only those aspects of care that are supported by adequate evidence, which do not necessarily cover all the desirable dimensions; however, the reviews represented in the Cochrane Pregnancy and Childbirth Group encompass the most used interventions in the field. Therefore, the results of the present study are very specific  but probably less sensitive (some indicators could be lacking due to the aforementioned limitations) in relation to all possible cases. Third, the rigour applied in our methodology for defining indicators, necessary to guarantee its internal validity, might limit its external validity or applicability in clinical practice. Strictly defining the target population might reduce its applicability, leaving out large groups of people for whom an indicator is not suitable. Finally, calculation of detailed indicators in daily practice might involve the need for accurate information systems and is quite sensitive to the quality of clinical data registration. If clinicians know in advance the criteria applied for calculating quality indicators, they will likely be more aware of the actions that must be considered in each clinical scenario and the necessity of registering them or justifying an alternative. Indicators could not only be included in local clinical guidelines, but could also be part of electronic alarms or clinical reminders to be activated when the hospital information system detects one of the situations labelled as a priority . Future research should concentrate on establishing the corresponding standards for the proposed indicators and interpreting the influence of local circumstances and patient preferences on their observed values.Some potential limitations of the present study should be noted. First, since indicators help to identify quality problems over time, their applicability and usefulness may depend on the evolving needs of their potential users: policy-makers, health professionals, medical societies, etc., and, theoretically, indicators that specifically address all the issues that are relevant for different stakeholders should be available. However, one characteristic of our methodology is that we have generated indicators based on strong evidence, which should be equally important for all involved parties (The present study demonstrated that the generation of healthcare quality indicators from SRs is feasible and efficient. This is not a simple process, and not all reviews are equally useful in generating indicators. We believe that the thoroughness of the proposed methodology makes these indicators essential references to assess the extent to which the delivery of care is based on scientific evidence. We propose that this methodology be applied to other areas of care where there is sufficiently sound evidence.The authors declare that they have no competing interests.MA and DR carried out the search selection, data extraction, and evidence assessment. MR and DO helped to methodologically refine the indicators. AV and CF helped to interpret the clinical data and refine the quality indicators. XB conceived the study and participated in its design and coordination. MR, DR and XB drafted the manuscript. All authors read and approved the final manuscript.Adapted GRADE system for assessing clinical recommendations. Table presenting the adapted GRADE system used in this project to assess clinical recommendations derived from sound systematic reviews.Click here for fileExample of an indicator. Full text of a quality indicator developed in this project and an example of computation based on fictional data.Click here for file


The Prevention Research Center in St. Louis developed a course on evidence-based public health in 1997 to train the public health workforce in implementation of evidence-based public health. The objective of this study was to assess use and benefits of the course and identify barriers to using evidence-based public health skills as well as ways to improve the course.We used a mixed-method design incorporating on-site pre- and post-evaluations among US and international course participants who attended from 2008 through 2011 and web-based follow-up surveys among course participants who attended from 2005 through 2011 (n = 626). Respondents included managers, specialists, and academics at state health departments, local health departments, universities, and national/regional health departments.We found significant improvement from pre- to post-evaluation for 11 measures of knowledge, skill, and ability. Follow-up survey results showed at least quarterly use of course skills in most categories, majority endorsement of most course benefits, and lack of funding and coworkers who do not have evidence-based public health training as the most significant barriers to implementation of evidence-based public health. Respondents suggested ways to increase evidence-based decision making at their organization, focusing on organizational support and continued access to training.Although the evidence-based public health course is effective in improving self-reported measures of knowledge, skill, and ability, barriers remain to the implementation of evidence-based decision making, demonstrating the importance of continuing to offer and expand training in evidence-based public health. Public health is a global, transdisciplinary field, drawing a workforce from various backgrounds ,2. PractEvidence-based public health (EBPH) is defined as the process of integrating evidence from scientific research with community preferences to improve population health . Recent To meet the training needs of the state and local public health workforce, the Prevention Research Center in St. Louis (PRC–StL) began an EBPH course in 1997 and in 2002 expanded the course to Europe in cooperation with the Collaboration for Integrated Noncommunicable Disease Intervention Programme . The couIn a 2001–2004 evaluation of course participants, 90% of respondents indicated that the course helped them make more informed decisions in the workplace, communicate more effectively with coworkers, and better understand reports . The couThe objective of this mixed-method evaluation was to assess the EBPH course among a new set of participants by examining their use of the training, the benefits of and barriers to using the training, and how those differ by location, education, and other characteristics. We measured participants’ skills and development and identified barriers to using EBPH skills with the goals of improving the course and assessing changes in evidence-based practice since the previous evaluation .A mixed-method study design incorporated on-site evaluations at each course from 2008 through 2011 and off-site follow-up surveys sent to all course participants from 2005 through 2011. We administered pre- and post-evaluations to 393 participants at 15 EBPH courses offered from 2008 through 2011 to assess the immediate impact of the course; these on-site evaluations were not available from 2005 through 2007. We asked participants to report their knowledge, skill, or ability level for 11 items on a 5-point Likert scale (from strongly disagree to strongly agree) immediately before and after the course.We sent a follow-up survey  to all participants (n = 626) in courses from May 2005 to December 2011, including those who had completed the on-site evaluation. Names of participants in 26 EBPH courses  were compiled into a master list of eligible participants, each of whom received an e-mail explaining the study and providing a link to the secure online survey; e-mail addresses were provided during course registration. In June 2009, 217 US course participants received the follow-up survey, followed by 87 international course participants in December 2009, and 322 additional US and international course participants in June 2012. Each survey was open for approximately 2 months, and we sent 2 or 3 reminder e-mails. US participants in 2009 received reminder telephone calls at work, if necessary; telephone numbers were provided during course registration.The 15-question online survey was adapted from a tool developed collaboratively by course instructors for a previous evaluation . To asset tests to analyze the on-site pre- and post-evaluations. We used descriptive statistics, χ2 tests, independent-samples t tests, and analysis of variance to analyze quantitative data from the follow-up survey. Data were stratified by course location , agency type , highest level of education , job type , and years of experience in public health  to discern differences in the use of and benefits and barriers to use of course content. We categorized use of course content into 2 dichotomous variables (used at least monthly and used at least quarterly). We examined benefits of and barriers to use of course content as the percentage of respondents who agreed or strongly agreed  to the survey statements. US participants’ agencies were categorized as state or local  health departments.We used paired-samples Participants’ responses to the 2 open-ended questions were analyzed by using focused coding qualitative analysis . ResponsP < .001). Having a good enough understanding of economic evaluation to assist in the design and implementation of an economic evaluation was most improved , whereas the ability to develop a concise statement of the issue was least improved (0.47 point increase).Pre- and post-evaluations were given to 393 course participants between 2008 and 2011 and completed by 352 participants for a response rate of 89.6%. We found significant increases from pre- to post-evaluation for all 11 measures (P < .001); all international respondents reported postgraduate training. Most US respondents worked for state health departments (72.4%), whereas international respondents primarily worked for national or regional health departments (36.0%). Most respondents (56.7%) worked in managerial positions. Respondents were more likely to have a graduate degree in something other than public health (61.7%) than public health (18.1%).The follow-up surveys were completed by 358 participants (response rate 57.2%) . US respRespondents reported high levels of use of EBPH course materials. Most respondents reported at least quarterly use of EBPH course materials in 5 of 6 categories. A quarter of respondents reported at least monthly use in 3 of 6 categories . Use difMost respondents indicated agreement with 10 of 13 statements on benefits of EBPH course content . RespondP = .047) and that the information was too complex (P = .02). Respondents with a doctoral degree were significantly more likely than those with a nursing degree to report a lack of funding for continued EBPH training (P = .001); and respondents with a public health master’s degree were significantly more likely than those with a bachelor’s degree to report working with people who do not have EBPH training (P = .02).Generally, respondents showed a higher level of agreement with statements on barriers related to implementing evidence-based decision making than with statements on barriers related to the course itself. The most frequently cited barriers were lack of funding for continued EBPH training and working with people who do not have EBPH training. International respondents were more likely than US respondents to agree with statements on barriers; we noted 3 significant differences . Among aProvided with a detailed definition of an evidence-based program, 248 respondents reported that an average of 62% of the programs at their agency was evidence-based . US respondents (n = 207) reported that 64%  of the programs in their agency were evidence-based, whereas 41 international respondents reported 56% . US state health department workers (n = 145) reported that 62%  of programs in their agency were evidence-based, whereas 27 US local health department workers reported 72% .The most frequently mentioned theme in response to the question on how to increase evidence-based decision making was lack of training for public health professionals. Many respondents indicated that training of all staff within an organization was particularly important. Respondents also mentioned easy, quick access to journals, articles, and more information on evidence-based practices. One respondent requested “more information about specific programs that work. The community guide is very vague. Specific programs . . . are more realistic to implement.” Respondents also stressed the importance of better means of sharing information within and across organizations. As one respondent noted, “I think we need to have better communication across units so that more people understand what resources are available to help them make evidence-based decisions.”The next set of themes reflected barriers to implementation of evidence-based decision making. The second most frequent theme was time for implementation and practice of EBPH as well as general and program planning. One respondent noted, “For me it is the lack of time to practice these concepts. . . . Implementation is not possible when so many issues are coming at you.” The third most frequent theme was the lack of funding for evidence-based programs, staff, and evaluation. Respondents endorsed funders that require evidence-based practices.The fourth most frequent theme was leadership. One respondent said, “Leaders at the very top need to indicate this approach is mandatory. . . . It needs to be made one of our values.” Other respondents agreed, indicating that leaders, administrators, and managers need to understand and encourage the use of EPBH within an organization. The leadership theme dovetailed with the expressed need to make EBPH part of the culture and values of an organization. The importance of increasing buy-in from coworkers was also frequently mentioned.The main themes in response to the question on how to improve EBPH training were course follow-up, course length, and coursework level. The strongest and most frequently mentioned theme concerned the examples and activities integrated into most modules. Respondents indicated that these could be made more effective by using “one consistent area . . . throughout the modules,” choosing “one topic . . . for all examples and group work,” and using “examples that are specific to the location of the participants.” The second most frequent theme was providing postcourse follow-up. Respondents specified that follow-up sessions “that might keep it fresh in our memories” would be useful. Respondents endorsed the benefits of web-based sessions . Course time was the third most frequent theme, with respondents indicating that the course was too short, with too much information “to digest in the allotted timeframe,” and suggesting “precourse reading and work to help students prepare for class.” The fourth most frequent theme was coursework level: one respondent said the coursework was “too elementary for my knowledge,” several requested more advanced coursework, and others found parts of the course too challenging.Our practitioner-focused EBPH course seeks to address the need for training and education throughout the public health workforce to fill the gaps in the background of public health practitioners ,18. ThisDirect comparison between this current evaluation and the 2008 evaluation provides a unique view of the evolution of the course and EBPH from 2005 to 2011 . MonthlyAlthough support for EBPH is increasing, barriers to implementation remain . OrganizRespondents suggested several solutions to these barriers. Both our quantitative and qualitative findings showed the importance of leadership in fostering evidence-based decision making, consistent with previous literature ,20,21. LEven in the presence of strong leadership, a critical mass and social network in support of evidence-based decision making are needed . The perRespondents emphasized both the need for additional types of training and training for more public health practitioners. Although evidence-based practice is moving toward a transdisciplinary model, it remains important for those offering EBPH training to recognize the breadth of experience in the public health workforce and tailor their trainings to specific groups, as reported in our qualitative data ,5,29. ReStrengths of this evaluation include building on previous evaluations to discern trends in EBPH use and continuing benefits and barriers of the EBPH principles in this course as well as the use of mixed methods to triangulate results. Limitations include a relatively low response rate (possibly introducing selection bias), possible inaccuracy in self-reported data, and the inability to draw a causal relationship between course attendance and behavior change due to lack of a control group. Language may also have been a barrier in survey response for international participants, and the smaller international sample may decrease generalizability of the results for international practitioners.This evaluation gathers new information from public health practitioners nationally and internationally. These data show that the PRC-StL’s EBPH course appears to be effective in increasing skills in and use of EBPH among course participants. The survey data build on past evaluations to gain additional insight into the remaining barriers to implementation of EBPH principles, and the qualitative data provide new strategies for overcoming those barriers. Leadership support within organizations and funder support from without are needed both to encourage the use of EBPH principles and to build organizational cultures that value EBPH. A need remains for additional and more diverse training in EBPH at national and international levels, tailoring EBPH learning to practitioners’ needs, and working toward a multi-disciplinary understanding of evidence-based practice. Courses with varying levels of rigor, specific areas of focus, and novel delivery methods, such as distance learning are warranted. There is also a need among practitioners for increased access to the scientific literature and other resources integral to evidence-based practice. This evaluation allows for the PRC-StL and others to better understand the barriers remaining to successful implementation of evidence-based practices and to take steps to overcome them.


To review the current evidence on therapeutic agents for burns pruritus and use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) classification to propose therapeutic protocols for adult and paediatric patients. All published interventions for burns pruritus were analysed by a multidisciplinary panel of burns specialists following the GRADE classification to rate individual agents. Following the collation of results and panel discussion, consensus protocols are presented. Twenty-three studies appraising therapeutic agents in the burns literature were identified. The majority of these studies (16 out of 23) are of an observational nature, making an evidence-based approach to defining optimal therapy not feasible. Our multidisciplinary approach employing the GRADE classification recommends the use of antihistamines (cetirizine and cimetidine) and gabapentin as the first-line pharmacological agents for both adult and paediatric patients. Ondansetron and loratadine are the second-line medications in our protocols. We additionally recommend a variety of non-pharmacological adjuncts for the perusal of clinicians in order to maximise symptomatic relief in patients troubled with postburn itch. Most studies in the subject area lack sufficient statistical power to dictate a ‘gold standard’ treatment agent for burns itch. We encourage clinicians to employ the GRADE system in order to delineate the most appropriate therapeutic approach for burns pruritus until further research elucidates the most efficacious interventions. This widely adopted classification empowers burns clinicians to tailor therapeutic regimens according to current evidence, patient values, risks and resource considerations in different medical environments. Pruritus is a common and distressing symptom affecting the majority of burns patients’ rehabilitation. Recent work has confirmed the lack of a unified approach in assessing and managing the symptom in UK burns units. One of tPruritic stimuli are transmitted by a subpopulation of C-fibres extending from the skin to the dorsal root ganglion of the spinal cord. Subsequently, impulses are conveyed onto higher central nervous system centres to reach the cortical areas, including the somatosensory, motor, prefrontal cortical and cingulated gyral areas.–8 The twA small number of protocols for burns pruritus have been published in the literature. One uses oral antihistamines and topical emollients as first line, followed by the recruitment of a clinical psychologist and a variety of third-line agents, including capcaisin, transcutaneous electrical nerve stimulation (TENS), massage and silicone sheets.The hierarchy of this therapeutic algorithm is largely based on the risk of adverse effects, which increase from the first to the last step of the protocol. One of tSince the 1970s, a growing number of organisations have used various different systems to grade the quality of evidence and stratify the strength of recommendations in medical practice.The most popular techniques described in the literature are the Delphi method, the nominal group technique and a combination of these two approaches. The DelpThe GRADE working group began as an informal collaboration of individuals with an interest in tackling the shortcomings of previous grading systems. The principles governing the system allow for more consistent judgements and communication by using two discrete categories of recommendations; strong and weak. Key factors determining the strength of recommendation are:The balance between desirable and undesirable consequences of a particular and alternative management strategies.The quality of evidence, with randomized controlled trial results carrying more weight than observational studies.Patient values and preferences variability.Cost/resource allocation. This is variable over time and geographical location.It is evident that quality of evidence is only one of the factors implicated in the decision about whether a particular intervention will be recommended strongly or weakly by members of the panel. A strong recommendation reflects the consensus judgement that the desirable effects of an intervention outweigh the undesirable effects . A weak recommendation implies that the desirable effects will outweigh the undesirable effects but the panel is not confident about the tradeoffs, either because key evidence is of low quality or because the benefits and drawbacks are closely balanced. The apprThe Surviving Sepsis Campaign employed a GRADE approach to classify the quality of evidence regarding managing severe sepsis and septic shock, recruiting 50 experts from more than 10 countries.Since 2006, the British Medical Journal has requested in its “instructions to authors” that authors should preferably use the GRADE system for appraising evidence when submitting a clinical guidelines article. Additionally, the World Health Organization and the Cochrane Collaboration are among the 25 organisations that have adopted this classification. The advaClear separation of quality of evidence and recommendation.Explicit, comprehensive criteria for downgrading and upgrading quality of evidence ratings and acknowledgement of patient values and preferences.A transparent process of moving from evidence to recommendations.Disadvantages of the GRADE classification include a degree of arbitrariness in the discrete categorisation of quality of evidence and recommendation strength with both being a continuum.We adopted the following methodology to appraise the literature and derive our multidisciplinary protocolsIdentification of the evidence. Our assigned librarian conducted a comprehensive literature search using the Cochrane Database of systematic reviews, MEDLINE and Embase between 1966 and the present time. We also collected data from internet journal sources and abstracts from relevant conferences in an attempt to be exhaustive in our search.We categorised papers on burns pruritus in terms of levels of evidence using the NHS Centre for Reviews and Dissemination (CRD) as shown below.Level 1: Experimental studies .Level 2: Quasi-experimental studies .Level 3: Controlled observational studies.3a: Cohort studies.3b: Case–control studies.Level 4: Observational studies without control groups.Level 5: Expert opinion based on pathophysiology, bench research or consensus.Formation of the multidisciplinary panel. The first author and panel coordinator (IG), who has an active ongoing interest in the pathophysiology and treatment of burns pruritus, invited the following experts to appraise the studies individually using the GRADE system:MC is a senior occupational therapist with 27 years of experience in acute and reconstructive burns care.CU is a senior physiotherapist with 8 years of experience in burns scar management.PMR is an anaesthesiology consultant with 10 years service in a regional burns centre and has an ongoing interest in the management of burns pain and itch.SJG is a consultant in burns surgery with 10 years of experience in acute burns care provision and rehabilitation.Presentation of evidence. Three separate tables were compiled summarising the salient points of relevant papers identified for adult, paediatric and mixed(adult and paediatric) patients Tables , 2, 3. TGrading the strength of recommendation. All members of the panel were presented with the data for all eligible studies and were given scoring sheets, which comprised of four choices of scores for each agent as shown below.Score+1: strong recommendation in favour of an intervention.Score+2: weak recommendation in favour of an intervention.Score-2: weak recommendation against an intervention.Score-1: strong recommendation against an intervention.Each panel member assigned a particular grade to each study using the GRADE system and was encouraged to review the final individual scoring before submission to the panel coordinator. Subsequently the median score for each intervention was calculated to stratify the strength of the panel’s recommendation for individual agents . The preliminary results were distributed to all panel members for final comments and adjustments before an agreement for the final version of the protocols was reached [Figures Analysis of the available literature in the subject of postburn itch reveals that the overwhelming majority of studies (16 out of 23) are of an observational design, which corresponds to CRD levels 3 and 4. Any attempt to rely on an evidence-based approach to derive therapeutic protocols is severely hindered by the lack of high-quality studies. The employment of the GRADE classification has the potential to dictate the best available agents for therapy by using four different parameters, with quality of evidence being one of these. We present the principles underlying our consensus treatment templates for adult and paediatric patients.Pruritus is one of the many distressing symptoms that burns patients will experience during their rehabilitation. Successful assessment and treatment needs to be viewed in the context of a holistic multidisciplinary approach.We advocate the early involvement of all members of the burns team, including surgeons, anaesthesiologists, physiotherapists, occupational therapists, nurses and psychologists. Each member of the team has a unique role to play in identifying and managing nociceptive symptoms and multidisciplinary meetings are crucial in coordinating therapeutic strategies for individual patients.Quantification of symptom severity is paramount in planning optimal therapeutic interventions and defining the clinical response. Recent work has confirmed that higher itch scores before treatment predict the need to recruit a combination of agents to achieve satisfactory relief from pruritic symptoms. There isThe use of topical emollients and cooling agents to the pruritic wounds/scars is a widespread practice in burns units. There are no studies to support the use of these agents. Nevertheless, they form an integral part of skin care routine, and the globally positive clinical experience allows their inclusion in our protocols.P < 0.001).Gabapentin forms the first-line, centrally acting agent in both the adult and the paediatric protocols. A comparative study of two stepwise protocols in inpatient burns victims has revealed that gabapentin monotherapy is four-times more effective than chlorpheniramine monotherapy .[Additionally, gabapentin in combination with two antihistamines  rendered a statistically significant higher proportion of patients itch-free than the following combination of three antihistamines – chlorpheniramine, hydroxyzine and cyproheptadine (χ= 0.001).Gabapentin has also been shown to have an opioidsparing effect on acutely burnt patients. This appOndansetron forms the second-line, centrally acting agent in our adult protocol. No interventions focusing on the central nervous system pathway have been tested on paediatric patients, a fact that is reflected by the lack of a second-line, centrally acting agent in our paediatric protocol.Our protocols recommend the combination of cetirizine and cimetidine as the first-line choice of antihistamines for both adult and paediatric patients. The combination achieves comprehensive blockade of histaminic receptors employing a second-generation H1 partial agonist (cetirizine) and an H2 receptor antagonist (cimetidine).H1 receptor antagonists are divided into first-generation antihistamines, which bind to muscarinic, alphaadrenergic and serotonergic as well as histaminic receptors, and second-generation antihistamines, which have minimal activity at the nonhistaminic receptors. The latter generation has a more favourable side-effect profile  and a longer duration of action, necessitating less-frequent administration.Loratadine is another second-generation antihistamine that forms a second-line medication in our paediatric protocol.The use of TENS in adult patients is recommended as a first-line non-pharmacological intervention in our protocol. Second-line adjuncts include laser and pressure garment therapy in both adults and children and massage therapy in adult patients. Non-pharmacological adjuncts have a low level of uptake among UK burn units. We belieStudies in the subject have concluded that a single agent is most likely to be insufficient in eradicating postburn itch. Hence, a combination of interventions is needed to achieve satisfactory relief in the majority of patients.38 We advOur protocols categorise therapeutic options according to the GRADE strength of recommendation (first vs. second line) and nature of intervention . The choice between peripherally and centrally acting agents needs careful consideration and calls upon consideration of the likely pathophysiological mechanisms underlying the postburn itch.The pathophysiology of pruritus has been widely believed to be of peripheral origin, with histamine being the chief mediator for the generation of stimuli acting on primary neuronal afferents. There isRecent evidence suggests the existence of two subtypes of pruritus:Acute pruritus affecting the majority of patients and possibly relating to a period from wound closure to the early remodelling phase of healing, andChronic pruritus affecting a subgroup of patients with deeper burns and early posttraumatic stress disorder (PTSD) symptoms.The same work has identified an interesting pattern of risk factors at various times of rehabilitation. At 3 months, pruritic complaints were predicted by female sex, TBSA, number of surgical procedures undergone by the patient and PTSD symptoms as measured at 2 weeks postburn. At 12 months, female sex, number of surgical procedures and PTSD symptoms were significant predictors, whereas at 24 months, only the latter two variables persisted as predictors for postburn pruritus.This study provides an excellent platform towards identifying patients most likely to develop chronic pruritus and allows clinicians to tailor regimens using the most appropriate agents. In the current state of knowledge, we advocate the early employment of centrally acting agents in combination with peripherally acting agents in all patients, especially in those at a high risk of chronic pruritus development.We have conducted a detailed review of all the available evidence on therapeutic interventions for postburn itch to date. It is apparent that most studies are of not sufficient statistical power to allow the recommendation of certain agents for the treatment of burns pruritus. We additionally present our approach to derive a treatment template for adult and paediatric patients using the GRADE classification, which is a widely accepted system to make recommendations in clinical practice. Validation of treatment protocols in the subject area is of paramount importance, but is currently hindered by the lack of research to define the ‘gold standard’ for treatment. We recommend the judicious use of a combination of peripherally and centrally acting pharmacological agents as well as the use of nonpharmacological interventions for the treatment of postburn itch.


In their daily practice, editors face different problems and questions. To handle these situations, there are many policies and guidelines established by well-known influential organizations such as World Association of Medical Editors, International Committee of Medical Journal Editors, Committee on Publication Ethics, Council of Science Editors, European Association of Science Editors, and Eastern Mediterranean Association of Medical Editors, to name only a few.Like in other fields, many of regulations set by these editors’ organizations originate from our eminent predecessors. Many of such claims are mainly based on common sense and are supported by no solid evidence. As an example, one of the very basic rules that most of editors abide by and teach the authors about is that a good article title should be concise -3. HowevBMJ, was the first who coined the term “journalology” to describe the application of bibliometrics to journals’ evaluation  is as good as double-blind review (neither the reviewers nor the authors know each other [Comparison]) in a small scientific community (Population). The primary Outcome is to measure if the quality of the reviews increased and the secondary Outcome is to measure if the process is done with lower cost. Obviously, since our Population of reviewers  is not similar to the Population of reviewers studied by the two aforementioned studies (working in large scientific communities)  ,12, we cmagister dixit” and instead should only rely on the results obtained from standard research methods. However, not all research findings are useful for all settings. Employing the basic concepts of evidence-based practice we have to examine the current body of evidence to see if it is applicable to our setting or not. Perhaps, this is a time to extend the concepts of evidence-based practice to the field of journalism – a time for a paradigm shift from eminence-based to evidence-based journalism. We can take the universally accepted standards, customize them according to our own needs, culture, and setting and give feedback to the world. In this way, biomedical journalism, the most important aim of which is to improve human health and life, can progress in different parts of the world.We have to stop saying “Evidence-Based Medicine Working GroupEvidence-based medicine: A new approach to teaching the practice of medicine.JAMA19922682420510.1001/jama.268.17.24201404801


Meles meles). Policy to control bTB is vigorously debated and contentious because of its implications for the livestock industry and because some policy options involve culling badgers, the most important wildlife reservoir. This paper describes a project to provide a succinct summary of the natural science evidence base relevant to the control of bTB, couched in terms that are as policy-neutral as possible. Each evidence statement is placed into one of four categories describing the nature of the underlying information. The evidence summary forms the appendix to this paper and an annotated bibliography is provided in the electronic supplementary material.Bovine tuberculosis (bTB) is a very important disease of cattle in Great Britain, where it has been increasing in incidence and geographical distribution. In addition to cattle, it infects other species of domestic and wild animals, in particular the European badger ( HumanMeles meles  A strong evidence base involving experimental studies or field data collection on bTB with appropriate detailed statistical or other quantitative analysis.[Dxp_op] A consensus of expert opinion extrapolating results from other disease systems and well-established epidemiological principles.[Eupp_ev] Some supporting evidence exists but further work would substantially improve the evidence base.[Srojns] Projections based on available evidence for which substantial uncertainty exists that could affect outcomes.[PThe relevant literature on bTB in Great Britain was reviewed and a first draft evidence summary produced by a subset of the authors. At a workshop, most authors met to discuss the different evidence components and to assign to each a description of the nature of the evidence. Using existing systems such as GRADE , a tool These are explicitly not a ranking as, for example, some projections are firmly rooted in rich datasets, while some expert opinions are very much less so.A revised evidence summary was produced and further debated electronically to produce a consensus draft. This was sent out to 25 scientists involved in bTB research, as well as to representatives from the farming industry, non-governmental organizations concerned with culling and Defra, the UK government department responsible for bTB policy. The document was revised in the light of much helpful feedback.The project was funded by the Oxford Martin School (part of the University of Oxford), and though many groups were consulted, the project was conducted completely independently of any stakeholder.3.The summary of the natural science evidence base relevant to bTB policy-making in Great Britain is given in the appendix, with an annotated bibliography provided as the electronic supplementary material.4.We note several limitations of our project and how it might be extended.First, the project considered only the natural science evidence base. There are very important social science issues involved with bTB policy-making that would also benefit from a formal evidence summary. For example, there are complex behavioural and behavioural economic aspects to the implementation of bTB control measures by the farming industry. Furthermore, the spectrum of possible interventions available to government is moulded by debate in civil society. The European Union's Common Agricultural Policy, and how each member state interprets it, shapes the economics of the livestock industry in Europe. The way agriculture is supported in England and Wales affects the structure of the countryside, including the wild animals that can harbour bTB. An entry into the social science literature on bTB is provided in the electronic supplementary material.Bubalus bubalis) and brush-tailed possum (Trichosurus vulpecula), which act as reservoirs of infection. Differences in the regulatory and social structure of farming, the countryside, and the ecology of the different reservoirs all mean that lessons from other countries have to be taken with great caution, but the approach taken in this project might be usefully extended to consider more evidence from other countries. An entry into the literature on bTB control outside Great Britain is provided in the electronic supplementary material.Second, the review concentrates on the evidence base from Great Britain. bTB is also a major problem in the Republic of Ireland, where badgers are a major reservoir. In Australia and New Zealand, successful efforts to control bTB have included targeting, respectively, introduced water buffalo (Finally, the review has largely concentrated on bTB epidemiology. We have not tried to summarize the evidence base relevant to the technical or operational logistics of culling or vaccination campaigns, nor the animal welfare consequences of different interventions.We finish by stressing this is a consensus document written by the authors, and that we accept that a different group might have included or omitted different statements and might have categorized them in different ways. Policy-makers have to integrate evidence from the natural and social sciences, as well as to make political judgements about weighing the interests of different stakeholders. We hope the current summary will make it easier for evidence from the natural sciences to contribute to policy-making, and clarify where there is agreement and where dissent. We also hope that this restatement of the current evidence base will stimulate discussion about how to prioritize investment to address remaining uncertainties.


The objective of this study was to devise and implement a Europe-wide study on referral guidelines for radiological imaging in the EU Member States in order to identify potential major issues, important differences between Member States and good practices. A web-based survey was used to assess the availability of imaging referral guidelines, development methodology and preferences for future initiatives for European community action to facilitate justification and appropriate use of radiological diagnostic procedures. A questionnaire was distributed to representatives of national radiological and nuclear medicine societies as well as to competent authorities for radiation protection in 30 European countries, including all 28 EU Member States. Responses were collated and analysed to produce a series of conclusions and recommendations.Survey respondents in 21/30 countries were aware of legal requirements for Guidelines• Survey respondents in 18/30 countries were aware of the availability of Guidelines in their country.• The majority of responders support the development of European Guidelines. These may either be from a combination of multiple national Guidelines with consensus or Pan-European Guidelines developed centrally.• Guidelines developed in two countries included all of the following important features: radiation dose information; specific advice for imaging children; specific advice for the pregnant woman/unborn child; an evidence-based process; a formal consensus for recommendations.• Suggestions for additional measures needed to reinforce the use of Guidelines include: educational initiatives; integrating Guidelines into clinical decision support systems; clinical audit for monitoring of the availability, use and implementation of Guidelines.• The online version of this article (doi:10.1007/s13244-013-0300-6) contains supplementary material, which is available to authorized users. The European Council Directive 97/43/Euratom requires Member States “to ensure that recommendations concerning referral criteria for medical exposures, including radiation doses, are available to the prescriber of medical exposures”  .Many Member States have developed or adopted national imaging referral guidelines (Guidelines) for clinical imaging, principally to support the referring practitioner in selecting and justifying radiological procedures. The selection of the appropriate investigation promotes good medical practice and radiation safety of patients. Guidelines have been available in Europe since 1989 when the Royal College of Radiologists (RCR) first published “Making the best use of a department of clinical radiology”  in the UThe EC-sponsored project “Implementation of Council Directive 97/43/Euratom requirements concerning referral criteria for medical imaging in the European Union” was carried out by a consortium of European partners starting with this survey of the availability of Guidelines in 2012.www.myesr.orgEuropean Society of Radiology (ESR) www.rcr.ac.uk French Society of Radiology (SFR) www.sfrnet.orgRoyal College of Radiologists (RCR) www.cirse.orgCardiovascular and Interventional Radiology Society of Europe (CIRSE) www.espr.orgEuropean Society of Paediatric Radiology (ESPR) The consortium partners are:This paper outlines the development, implementation, results and conclusions drawn from the survey on imaging referral guidelines for radiological imaging in 30 European countries. The aim of this study was to identify the current position of European countries with respect to referral guidelines, to identify good practices in guideline development and implementation and to canvass opinion as to the way forward. A web-based survey was used to assess the availability of Guidelines, development methodology and preferences for future initiatives for European community action to facilitate justification, and to implement appropriate use of diagnostic and interventional radiological procedures.A web-based questionnaire was drafted by the RCR, together with other members of the Referral Guidelines Project Consortium, and distributed to representatives of national radiological and nuclear medicine societies, as well as to representatives of national competent authorities responsible for radiation protection, in 30 European countries including 28 EU Member States and two countries implementing EU legislation—Norway and Switzerland.Attention was paid to ensure delivery to the nominated representative, to avoid duplication and to encourage timely response to the questionnaire. Address lists were obtained from the ESR, EC Directorate General for Energy and the European Association of Nuclear Medicine (EANM). The EC Directorate General for Energy kindly assisted in encouraging completion of the questionnaire by competent authority representatives.Information regarding guideline availability, legal requirements and imaging requesting issues.Methodology for development and distribution of guidelines.Preferences for future guideline development, format, distribution, tools for reinforcement and monitoring.The design of the questionnaire was based on three sections:www.surveymonkey.com). It was designed to be easily understood with carefully chosen, unambiguous terminology and logical flow which led responders through only the relevant questions. The design facilitated statistical analysis, limiting the number of free text answers.To avoid bias and to facilitate analysis, input from an experienced psychologist was used. The survey was compiled in SurveyMonkey™ 20 from national nuclear medicine societies28 from national competent authoritiesResponses were received from representatives of all 30 countries surveyed. Eighty responses were received:Regarding the radiological societies, multiple responses were received from The Netherlands (two) and Romania (three). No response was received from Cyprus.Regarding the national nuclear medicine societies, three responses were received from The Netherlands. No response was received from Bulgaria, Estonia, Finland, France, Ireland, Lithuania, Luxembourg, Norway, Poland, Portugal, Slovakia or Slovenia.Regarding the national competent authorities, two responses were received from Spain, but none from Italy, Hungary and Latvia.In the analysis, all the responses received were taken into account using the majority response (rounding up) for those countries with multiple responses.Sixty-one percent of responders said that there was a legal requirement for Guidelines including radiation dose. Five responders were uncertain as to the existence of such legislation. It was confirmed at a later date that all EU member states had such a requirement.Most respondents report that the responsibility for making Guidelines available has been transferred to ministries of health. There was some discordance between national societies and competent authorities’ responses to the question about the transfer of responsibility for making Guidelines available.The majority of respondents (76 %) did not think that Guidelines must exist in order for insurance companies in their country to pay for an imaging investigation. Respondents indicated that most imaging requests are made by medical practitioners. Respondents report that general practitioners make more requests for plain radiographs, contrast radiography, and ultrasound (US), and fewer for computed tomography (CT), magnetic resonance imaging (MRI), interventional radiology and nuclear medicine examinations compared with hospital specialists.Respondents indicated that the most common modality for which a patient could self-present was US, followed by plain radiography and MRI.Twenty radiology societies, 12 nuclear medicine societies and eight competent authorities responded that there were nationally recognised imaging referral guidelines including radiation dose available.see Table Analysis by country showed that representatives in 70 % of European countries were aware of the legal requirement for guidelines and respondents in 60 % of countries were aware of the presence of referral guidelines , 4–24 .see Fig. The great majority of states have recommended European or national Guidelines see Fig. .Fig. 1Av“The professional societies are responsible for drawing up the referral guidelines.”“Our government would most probably accept competent international guidelines and the Croatian Society of Radiology is currently trying to introduce Royal College of Radiologists’ guidelines in our clinical practice modified according to our situation.”“Current regulation does not [recommend any guidelines] but new draft regulation and guidelines recommend European Guidelines.”“European guidelines are to be recommended in new legislation.”“If National guidelines are not available then European ones are implemented.”“American guidelines (US).”Where “other” was chosen as the question response, the specified other options for the preference of the source of Guidelines included:see Fig. Guidelines were reported (by respondents from just 14 countries) to be developed nationally in half of the countries and modified or adopted with modifications from another source in the others see Fig. .Fig. 2GuThere was a good concordance between radiology and nuclear medicine societies for two countries (France and UK), which provided radiological and nuclear medicine guidance within the same publication.The year of the first edition of the Guidelines varied from 1989 to 2005 for radiological societies and from 1998 to 2011 for nuclear medicine societies. The approximate duration of the review cycle has varied between countries from 3-4 years to >6 years.In the majority of countries (67 % for radiology and 90 % for nuclear medicine), the source of funding for the development of the Guidelines was the Ministry of Health or other governmental department.The imaging modalities involving ionising radiation (radiography and nuclear medicine) were included in the great majority of Guidelines (83-92 %), whereas the non-ionising radiology modalities  were present in only 75 % of Guidelines.The majority of National Guidelines include separate guidance for children (67 % for radiology and 80 % for nuclear medicine) and pregnant women (83 % for radiology and 78 % for nuclear medicine).Most radiological Guidelines focus on clinical presentations, whereas most nuclear medicine guidelines focus on indications for procedures. Most of the radiological societies’ Guidelines and the nuclear medicine societies’ Guidelines cover multiple groups of diseases and medical conditions for adults, including: breast, cancer, cardiovascular, chest, gastrointestinal, neurological, trauma and urogenital. Guidelines for children cover fewer clinical conditions.The radiological societies’ Guidelines included between 200 to 500 clinical conditions or diagnostic problems, and the nuclear medicine societies’ Guidelines between 16 and 300.Very few Guidelines have included recognised evidence levels  and grading recommendation using a recognised system .Radiation dose, strength of evidence and grading of recommendations were considered in most Guidelines. Cost effectiveness and availability of equipment or expertise were far less frequently taken into consideration.Two radiological societies graded their recommendations (France and UK). Both used the grades of recommendation as defined by The Oxford Centre for Evidence-Based Medicine—Evidence levels and grades of recommendations, 2009 . In the Delphi process was used in three radiological societies’ Guidelines . Expert meeting for consensus was used by four radiological societies and five nuclear medicine societies.Radiation dose was obtained from recognised sources in eight radiological and nine nuclear medicine societies.Regarding the format and dissemination of the National Guidelines Fig. , almost The majority of Guidelines are routinely circulated to providers of the service, general practitioners, emergency department clinicians and specialists/hospital doctors. Only a few of these Guidelines are routinely circulated to non-healthcare professionals, medical students, funders and the public.Reinforcement of Guidelines is advocated through periodical reminders in half and through educational message by most of the radiological societies.Guidelines are also used for education and academic research.For the remaining items in the survey, respondents were asked to rate agreement on a seven-point balanced Likert scale regarding preferences for European Guideline development, format, media, barriers and their solutions, and methods for monitoring. There were 28 responses from radiology societies, 18 from nuclear medicine societies and 27 from competent authorities. All responses were taken into account. Positive responses rated 5-7 on a seven-point scale were taken as agreement and consensus considered strong where there was agreement by at least 75 % of respondents.see Fig. Eighty-two percent of radiology societies and 78 % of competent authorities support European Guidelines developed by a combination of multiple national Guidelines agreed by consensus. This is also supported to a lesser extent by nuclear medicine societies (61 %). Seventy-five percent of radiology societies support Pan-European Guidelines developed centrally see Fig. .Fig. 4Prsee Fig. Most societies and competent authorities support tabular and flowchart format for the Guidelines see Fig. .Fig. 5Gusee Fig. Most societies and competent authorities support an open web version for distribution mode. Seventy-five percent of radiology societies support provision of Guidelines through electronic requesting systems as a future development see Fig. .Fig. 6Gusee Fig. Resource limitation, limited awareness and limited clinician involvement are common barriers to the effective distribution of Guidelines see Fig. .Fig 7Guisee Fig. Education and involvement of referring clinicians are mostly proposed by competent authorities as potential solutions to overcome the barriers limiting the availability of Guidelines see Fig. .Fig. 8Gusee Fig. All respondents and particularly competent authorities strongly support local internal and external clinical audits to monitor Guideline use see Fig. .Fig. 9PrThe results of the initial survey indicated that imaging referral guidelines are available in two-thirds of the EU Member States with a legal requirement for guidelines, and only in one-third of countries who do not have a legal requirement for guidelines.It is recognised that a limitation of this study is the paucity of responses to the section of the survey dealing with guideline methodology. This may be partly explained by the popular principle of adopting and adapting Guidelines from other countries. Furthermore discordance in replies from representatives of professional societies and competent authorities from within a country may be due to limited awareness of the current position in a specialised area. At the Project Workshop in Vienna, Austria, September 2012, participants considered that limited awareness, rather than limited availability, may have been a reason for the reported availability of legal requirements and Guidelines availability.The decision was made to re-audit the legal requirement for and availability of referral guidelines in those countries previously reporting that referral guidelines were not available. In addition it was felt that the encouragement of good practices shared through the workshop and survey, together with facilitation of processes for adopting, adapting and translating referral guidelines, may have had a positive influence.To update the situation, those countries previously reporting no guideline availability were re-audited with surveys sent out to national professional societies and competent authorities enquiring as to the awareness of availability of national legislation and to the availability of referral guidelines, including work in progress.This re-audit showed that since the initial survey, carried out during the spring of 2012, a further seven countries had either begun measures to make referral guidelines available or had identified existing national referral guidelines, bringing the number of countries with such guidelines available to 25 out of a total of 30.In addition, the re-audit confirmed awareness of a legal requirement for referral guidelines in all 30 countries targeted by the survey.The following conclusions were made from the Guidelines survey based on responses from radiological societies, nuclear medicine societies and radiological competent authorities:Sixty percent of respondents indicated that they have a legal requirement for imaging referral guidelines including radiation doses.Survey respondents in 21/30 countries were aware of legal requirements for Guidelines.Twenty-three national radiology societies (77 %), 12 national nuclear medicine societies (66 %) and 14 competent authorities (52 %) indicated that there are nationally recognised imaging referral guidelines including radiation doses available.Survey respondents in 18/30 countries were aware of the availability of Guidelines in their country.From responses, two out of three countries with a legal requirement for Guidelines have Guidelines available, whereas only one in three countries without a legal requirement has Guidelines available.Responses to survey questions concerning Guideline methodology may not be fully representative of the whole EU as only 23 respondents  from 17/30 countries replied to this section. The low response rate is in part due to the popular principle of adoption.The majority of responders support the development of European Guidelines. These may either be from a combination of multiple national Guidelines with consensus or Pan-European Guidelines developed centrally.Not all national Guidelines available are based on clinical presentations. Some nuclear medicine Guidelines are based on indications.Radiation dose informationSpecific advice for imaging childrenSpecific advice for the pregnant woman/unborn childAn evidence-based processFormal consensus for recommendations.Good practices were demonstrated in several countries which included some of the important methodological features shown below. Guidelines developed in two countries included all of these features:Agreement that additional measures were needed to reinforce the use of Guidelines.Educational initiatives are highly favoured to improve implementation.There is strong support for the concept of integrating Guidelines into clinical decision support systems.Clinical audit should be used for monitoring of Guidelines’ availability, their use and implementation.ESM 1(PDF 442 kb)Below is the link to the electronic supplementary material.


How can we encourage ongoing development, refinement, and evaluation of practices to identify and build an evidence base for best practices? On the basis of a review of the literature and expert input, we worked iteratively to create a framework with 2 interrelated components. The first — public health impact — consists of 5 elements: effectiveness, reach, feasibility, sustainability, and transferability. The second — quality of evidence — consists of 4 levels, ranging from weak to rigorous. At the intersection of public health impact and quality of evidence, a continuum of evidence-based practice emerges, representing the ongoing development of knowledge across 4 stages: emerging, promising, leading, and best. This conceptual framework brings together important aspects of impact and quality to provide a common lexicon and criteria for assessing and strengthening public health practice. We hope this work will invite and advance dialogue among public health practitioners and decision makers to build and strengthen a diverse evidence base for public health programs and strategies. In an ideal world, decision makers and practitioners would have access to evidence-based programs and strategies to improve health and reduce health problems with the highest preventable burden. Decision makers would also have tools to guide their selecting and adapting appropriate approaches for specific contexts. In reality, much work needs to be done to achieve this goal, and many pressing public health problems exist where evidence is not yet fully established. Moreover, public health agencies at all levels face substantial fiscal constraints and challenges to improving health across varying contexts. Therefore, the need grows for evidence-based practices that afford maximum efficiency and effectiveness. Many agencies and organizations in the United States have acknowledged such challenges, including the White House , the Govwww.thecommunityguide.org)  . The Comide.org) ,12.best practice.There is a need to assess the evidence for, categorize, and encourage additional study of strategies without enough evidence to undergo review by The Community Guide but that hold potential for public health impact. Practitioners and decision makers need tools to guide them toward selecting and evaluating the best available practices when published best practices are unavailable. Although systematic reviews identify what many public health professionals consider best practices, the public health field lacks a consensus definition and commonly accepted criteria for the designation best practices, along with criteria and processes for classifying diverse practices in relationship to best practice. Through these efforts, the workgroup also aimed to encourage further development of practices that show promise for improving public health outcomes. We describe the development, structure, and use of the workgroup’s conceptual framework for creating a set of best practices. Our purposes in presenting the framework are to promote dialogue among scientists and practitioners about a consistent taxonomy for classifying the evidence for public health practices and to help researchers, practitioners, and evaluators show how their work contributes to building the evidence base for particular practices.Consequently, the Office for State, Tribal, Local and Territorial Support at the Centers for Disease Control and Prevention (CDC) convened the CDC Best Practices Workgroup to develop a working definition of The CDC Best Practices Workgroup (see list of members in “Acknowledgments”) consisted of 25 CDC staff members with varying backgrounds  and topic expertise . The workgroup reviewed the literature to find models and frameworks for classifying evidence, including best practices. The following question guided the review: What is known about the scope and definitions of best practices? The review included a keyword search of peer-reviewed and gray literature; workgroup members also identified relevant literature. The scope of the review was intentionally broad and included concepts related to evidence-based programs and policies as well as practice-based evidence.www.cdc.gov/nphpsp/essentialservices.html). This broad definition of practice includes activities designed to improve specific outcomes  or to focus on increasing the effectiveness and efficiency of program operations and services.The workgroup defined practice as “field-based or research-tested actions intended to effect a positive change.” Practices could include interventions, programs, strategies, policies, procedures, processes, or activities encompassing the 10 essential public health services and related activities (http://www.effectiveinterventions.org/en/HighImpactPrevention/Interventions.aspx); documents from The Community Guide  1. What is the practice’s intended and critical target population ?2. What beneficiaries are affected?3. What is the proportion of the eligible population affected by the practice?4. How much of the population could ultimately be affected ?5. How representative are the groups that are currently affected compared with groups ultimately affected by the problem?6. In considering representativeness, does the practice promote health equity?7. To what extent does the practice affect the intended and critical target population(s)?Feasibility: Extent to which the practice can be implemented1. What are the barriers to implementing this practice?2. What are the facilitators to implementing this practice?3. What resources are necessary to fully implement the practice?4. Does the practice streamline or add complexity to existing procedures or processes?5. What is the cost-effectiveness and what are the available resources to implement the practice?Sustainability: Extent to which the practice can be maintained and achieve desired outcomes over time1. How is the practice designed to integrate with existing programs or processes or both?2. How is it designed to integrate with existing networks and partnerships?3. What level of resources is required to sustain the practice over time?4. What long-term effects or maintenance or improvement of effects over time can be achieved?5. How has the practice been maintained to achieve its desired outcomes over time?Transferability: Extent to which the practice can be applied to or adapted for various contexts1. How has the practice been replicated in similar contexts, and did it achieve its intended outcomes?2. Was adaptation required in different contexts?3. How has the practice been adapted?4. What is the impact of varying political, organizational, geographic, social, and economic climates?5. Has the practice been proven to be effective in different settings?6. To what extent has the practice been applied to or adapted for a variety of contexts?Some elements of the public health impact component are more challenging to assess than other elements, such as sustainability and transferability. To address this issue, the workgroup developed questions that users can ask to determine the extent to which the practices they are developing or evaluating address each element . The queThe quality-of-evidence component refers to where a practice lies on an evidence-based practice continuum . These eAt the intersection of impact and quality of evidence, a continuum of evidence-based practice emerges, depicted by the arrow at the center of the Figure. This continuum represents the ongoing application of knowledge about what is working to strengthen impact in a given context. Building on the work by Brennan and colleagues , a lexicThese classifications are hypothesized to be dynamic and can change over time for a given practice. For example, a practice may be assessed as promising at one point and be promoted to leading or best as stronger evidence is developed. Conversely, practices once considered “best” may become outdated as the field and environmental conditions evolve. The dynamic quality of these classifications highlights the importance of regularly re-evaluating practices at all points on the continuum, including updating systematic reviews of best practices. Such updates, incorporating all emerging evidence, are a critical component of the work of the Community Preventive Services Task Force and other review groups . By encoThe framework as it now appears has several limitations: 1) it is conceptual and has not been fully evaluated, and 2) the two axes will be challenging to measure and balance against each other. Classifying a particular practice reliably using the framework depends on the background, perspective, and skill of the individuals assessing the practice.Because substantial variation exists in practices needed to address various public health challenges, the questions and guidance used to make the designation of emerging, promising, leading, or best require ongoing refinement. Additional tools are needed to guide users in consistently examining the evidence related to a given practice in diverse circumstances. Helping users to develop a clear definition that addresses scope and boundaries for each practice being assessed is important because the development and implementation of public health practices often vary from one setting or population to another. The framework would benefit from additional input by diverse users and stakeholders to inform an iterative process of improvement and refinement over time.To address these limitations, tools were developed to apply the framework, to determine quality and impact, and to begin to address the complexity of combining 5 elements. The framework and tools are undergoing pilot testing in numerous CDC programs. Pilot testing will assess the validity, intrarater and interrater reliability, and utility of the framework. Results of this pilot testing and further application of the framework will be published.CDC is congressionally mandated to support the Community Preventive Services Task Force in developing the systematic reviews and related evidence-based recommendations found in The Community Guide . CDC alsThe value of the framework lies in offering a common lexicon and processes to strengthen the evidence for public health practice. The Federal Interagency Workgroup for Healthy People 2020 has adapted the evidence continuum components of the framework as developed by the CDC workgroup. Other stakeholders may use the framework, definitions, and criteria to communicate more clearly about the continuum of evidence for a wide spectrum of programs, including those that do not currently qualify as best practices but may benefit from additional study. Initial feedback from scientists, evaluators, and practitioners, both internal and external to CDC, supports both the face validity of and the need for this framework.Applying the elements identified in the conceptual framework might assist with program planning, evaluation, and dissemination. The framework could potentially increase transparency and accountability for public health programming by clarifying the components and definitions of evidence. It could help practitioners and evaluators identify gaps in the evidence for a given practice and determine how their work contributes to building the evidence base. Practitioners might attend to the framework’s effectiveness criteria as part of logic model development to help identify potential gaps between activities and intended outputs and outcomes. Several of these criteria already have been adopted in protocols to identify practice-based strategies for more rigorous evaluation . The fraThe conceptual framework is offered to promote dialogue among researchers, evaluators, practitioners, funders, and other decision makers. With this framework, we seek to foster a shared understanding for assessing standards of evidence and motivate organizations to implement and improve strategies that move practices along the continuum from emerging to best.


Evidence-Based Medicine (EBM) is a methodological and systematic approach, which is considered as the most robust form of the empirical medicine as it sorts evidence according to their credibility. It is widely used in clinical decision-making and has several advantages, including: (1) provision of a very well-founded and objective method to adhere to high quality and safety standards in medical practice, (2) facilitation of translation of clinical research findings into clinical practice, and (3) significant reduction of health care costs. EBM can be summarized into five practical steps include searching for an answer to a clinical question, searching for the evidence, critically appraising and reviewing the existing evidence, combining credible evidence with clinical experience and the patients' viewpoints, and finally, evaluating the process.As it is widely believed that evidence is not properly classified and there is no credible assessment method in data on biomedical literatures, it could be suggested that EBM is of limited use in this branch of science  can be considered as a novel method in biomedical literatures. This technique focuses on the evaluation and ranking of different articles with widely available techniques in the field based on their credibility, limitations, and biases. The aim of this letter is to analyze the effectiveness of EBBM in order to shed some light on its limitations. It could lead to classification of evidence on biomedical science issues and facilitate their practical application with the view of addressing the raised issue in this letter.Various studies have been carried out in order to shed some light on the genetic susceptibility to thyroid cancer using molecular diagnostic and predictive biomarker  that aimed to detect genetic variants with gradually smaller effects, but force to publish the outcomes of the studies of new genetic associations has narrowed the time available for watchful consideration of all of their methodological aspects. A survey of the literature from 2007 to 2010, to offer empirical evidence on the methods used in meta-analyses of GWAS, showed that a great variety of methods are being used, but the logic of their selection is often unclear  laboratory techniques used (3) “omics” approach to the hypothesis testing like genomics, proteomics, and (4) Utilize a checklist to classify and grade the evidence in biomedicine. Moreover, further investigation and testing of the validity of these tools is needed, which indicate that the EBBM scales are valid and reliable instruments for measuring biomedical datas' confidence in the process and the outcomes basing on the evidence.Finally, it could be suggested that different levels of evidence should be based on: (1) the study types such as Hopefully, this may encourage scientists in the field of biomedicine, molecular epidemiology, bioinformatics, and translational medicine to contribute in the foundation of a novel and functional methodological approach using different levels of evidence raised above.