The ability to successfully transfer knowledge across international boundaries to improve health across the European Region is dependent on an in-depth understanding of the many factors involved in policy creation. Across countries we can observe various approaches to evidence usage in the policy-making process. This study, which was a part of the Models of Child Health Appraised (MOCHA) project assessing patterns of children’s primary care in Europe, focused on how and what kind of evidence is used in child health policy-making processes in European countries and how it is applied to inform policy and practice.In this study, a qualitative approach was used. The data were analysed in accordance with the thematic analysis protocol. The MOCHA project methodology relies on experienced country agents (CA) recruited for the project and paid to deliver child health data in each of 30 European countries. CAs are national experts in the child health field who defined the country-specific structured information and data. A questionnaire designed as a semi-structured survey instrument asked CAs to indicate the sources of evidence used in the policy-making process and what needed to be in place to support evidence uptake in policy and practice.In our data we observed two approaches to evidence usage in child health policy formulation. The scientific approach in our understanding refers to the so-called bottom-up initiatives of academia which identify and respond to the population’s needs. Institutional approaches can be informed by scientific resources as well; however, the driving forces here are governmental institutions, whose decisions and choices are based not only on the population needs but also on political, economic and organizational factors. The evidence used in Europe can also be of an external or internal nature. Various factors can affect the use of evidence in child health policy-making. Facilitators are correlated with strong scientific culture development, whereas barriers are defined by a poor tradition of implementing changes based on reliable evidence.Focusing on the facilitators and actively working to reduce the barriers can perceivably lead to faster and more robust policy-making, including the development of a culture of scientific grounding in policy creation.The online version contains supplementary material available at 10.1186/s12961-021-00786-y. There are many different patterns of children’s primary care in Europe, which leads to many different policies and different health outcomes of children throughout the European Union (EU) and European Economic Area (EEA) countries . One aimThe use of evidence in the process of policy formulation is one of the prerequisites for successful policy-making. Evidence, understood as “findings from research and other knowledge that may serve as a useful basis for decision-making in public health and health care” , 4, helpIt is important, therefore, to investigate the impact of context in the process of policy-making and also in the use of evidence to support the policy. Bowen and Zwi highlight an important aspect of the context within which evidence is used: “A key challenge to public health is to better contextualize evidence for more effective policy-making and practice” .Across countries, there are various approaches to evidence usage in the policy-making process. For example, in Australia , a “stroEven though awareness of evidence-based solutions is increasing, there is still a significant need for the development of standardized tools and identification of appropriate measures. Key global and European institutions are undertaking actions to support evidence-based policy-making. Developed by the European Commission, the “Knowledge for policy” portal provides support “to make informed policy decisions regarding the design of research and innovation policies or strategies” , with thIn this study, we focused on the kind of evidence that is used in decision-making processes and how it is implemented to inform policy and practice in child health policy-making in Europe . This reHow is evidence used in child health policy formulation?What are the facilitators of and barriers to evidence usage in child health policy formulation?This transferability analysis was supported by an assessment of the culture of evidence-based policy-making. Our aim was to establish the extent of use of evidence, and the types of evidence that influence and underpin policy-making for children’s health and healthcare. We explored how policy decisions are made in the different countries, and the most common patterns of evidence used at the national health policy level in each MOCHA project country. To this end, we asked two research questions of national correspondents of countries within the EU and EEA Europe:The MOCHA project was funded as an integrated research programme by the European Commission's Directorate-General (DG) for Research and Innovation. The research protocol, as enshrined in Grant Agreement 634201, recognized the interlinking work between partners to holistically address the core research topic, and was explicit in the use of country agents (CA) as field-level contributors, drawing on local sources but not involving personal data. The nature of a dynamic integrated study is such that each interdependent component, one of which is reported in this paper, cannot be individually reviewed in an informed way at the institutional level. The Ethical Committee of the European Commission's DG for Research and Innovation Horizon 2020 programme was seen as the supranational ethical review committee, assessing the project in whole and as the sum of the parts. The strand of work reported here was explicitly included on page 10 of Grant Agreement 634201, and the CA methodology on pages 128–129 of that document, which was scrutinized and approved by the Ethical Committee of the European Commission's Research and Innovation Directorate as a prior requisite to the project being funded.We used a qualitative approach in this study. The data were analysed in accordance with the thematic analysis protocol proposed by the experienced qualitative researchers Braun and Clarke . We condThe MOCHA project methodology relies on the experience of CAs in each of 30 EU and EEA countries. CAs were national experts in the child health field who defined country-specific structured information and data. The CAs were recruited, based on their knowledge and professional experience, by the project coordinators  and were paid to deliver child health data for each of the 30 European countries studied. Their contributions ensured that the findings of this paper were based on detailed and local indigenous knowledge. In line with the overall methodology developed by the MOCHA project, CAs were encouraged and trusted to gain a range of opinions within the country prior to distilling it into the formal answer to the question. The answers from CAs were not personal opinions, and regular meetings with CAs confirmed that they were totally opposed to expressing personal opinions and always identified local robust sources according to each topic before providing the final answers to MOCHA researchers.To analyse evidence-based approaches to child health policy in Europe, a questionnaire designed as a semi-structured survey instrument was created  that affect child primary healthcare service provision. Examples of such policies which were put forward included vaccination policy, services for children with special needs, approaches to dealing with abused children, mental health promotion in primary care and changes to out-of-hours service availability. Other types of policy might concern general issues involving the provision of and access to care, human resources, or the organization of the system of financing. For each of their three selected examples, CAs were asked to (a) identify the policy, (b) characterize evidence used in formulating the policy and (c) point out what needed to be in place to support evidence uptake in policy and practice in their countries  approach , but it The data collection was carried out between July 2017 and January 2018. The 30 CAs received the questionnaire by email from the research coordinator. CA representatives of 23 countries—all of the EU member states at that time except Belgium, France, Germany, Latvia, Luxembourg, the Netherlands and Sweden, plus the EEA countries Iceland and Norway—responded to the questionnaire. Lack of responses to the questionnaire by seven CAs was the result of work overload at that time, and overriding personal issues.In total, 34 policy topics were identified which were related to child primary healthcare in European countries and described in terms of evidence used.Familiarizing with the data in order to mark some ideas for coding. At that stage, we pre-reviewed the data and incorporated it into the computer software for qualitative analysis (NVivo 11).Generating initial codes by creating a list of ideas about what is in the data that results in the creation of meaningful groups of data. We identified our data as latent (interpretative). For coding the data we used computer software. This helped us to tag and name selections of text within each data item. The data were coded phrase by phrase.Identification of themes which, as recommended by Braun and Clarke , concentReviewing and refining themes, which led us to create a thematic map.Defining and naming themes.Producing the report in the form of the presented paper.Braun and Clarke  define tAs previously explained in other works  under HoThe results presented below are based on the CAs’ responses obtained. From the characteristics of the evidence usage in child health policy formulation, we identified several structural approaches.In our data we observed two approaches to evidence usage in child health policy formulation Fig. . On the Additionally, we observed that the data used in the child health policy formulation can be of an external or internal nature. External evidence refers to international resources and exchange of good practices between European countries, and internal evidence indicates domestic data produced nationally.To understand our data in wider context we refer to the final MOCHA report where we explain how to bring MOCHA lessons to provided services , 21.Scientific data is a vital tool in the process of child health policy-making, and often it is the baseline for the development of national and international recommendations and guidelines. Examples emerged from Austria, Greece and Spain, with subjects covering child health policy and primary healthcare reform.The Greek reform of primary healthcare and implementation of urgent amendments under the mandate of the Ministry of Health and other provisions used a report by a working committee of academic professors and medical doctors as a stimulus. The document “Basic Principles, Positions and Proposals for the Development of Primary Health Care in Greece”, was created in 2015 in order to “identify problems of the primary health care system in Greece and provide suggestions on how to rectify them based on evidence” (Greek CA).Several CAs reported the use of research in the process of developing child health policy in their countries. For example, in Austria, when the new law on health reform implementation was enacted, the strong voice of paediatricians was noticeable in the discussion on the new law, as they criticized the inadequate consideration of primary healthcare for children (Austrian CA). Systematic reviews, questionnaire surveys and overviews of reviews were carried out when the new mother and child health passport (MKP) was developed (Austrian CA).The development of the “National Strategic Plan for Childhood and Adolescence 2013–2016 (II PENIA)” in Spain, a “strategic plan that seeks out the ‘need to formulate a comprehensive strategy for children based on the principles and provisions of the Commission on the Rights of the Child’ is part of a global and international strategy for children and adolescents” (Spanish CA). The main principles of II PENIA are the best interest, non-discrimination, development of child potential and the right to quality education and participation (Spanish CA). To gain a better understanding of the situation of children, general statistical analyses were conducted to “continue the development of statistical compilations or publications about the ‘situation of children in Spain’ or ‘Children in figures‘ on a regular basis in order to develop series” (Spanish CA) and to “offer new statistical information on issues that affect children between 0 and 18 years, disaggregated by sex, age, disability status and habitat” (Spanish CA). Additionally, the Spanish CA reported that a statistical bulletin of measures for child protection and a statistical bulletin of measures imposed on young offenders were in use.CAs reported several key sources of evidence from governmental institutions and organizations. Examples from Denmark, Poland and Ireland show that the institutional initiatives to create evidence- and experience-based policies can be relevant here.In Denmark, the amendment of the law on the use of coercion in psychiatry was the result of a political field of interest and discussion among the political spokespersons. The Danish CA stressed that “the government's psychiatric committee completed a report that highlighted some points of impacts and recommendations in the field of psychiatry, and the possible need for changes in the Danish Mental Health Act” (Danish CA). The amendment “was based on a report, prepared by the government's psychiatric committee. It was, therefore, more experience-based rather than evidence-based. There was little focus on whether there was good evidence for the amendment of the law” (Danish CA).In Poland, a new plan of coordinated care within primary care was preceded by several studies. In recent years, four main analyses have been undertaken in the field of primary healthcare in Poland, summarized in a report prepared by a team of experts appointed by the Minister of Health to develop strategies for systemic solutions in the area of primary care. The reports were titled “Analysis of Primary Health Care in Poland and proposal of systemic changes” 2016; the National Health Fund research report, “Primary Health Care—the potential and its usage” 2016; the audit report of the Supreme Audit Office, “Functioning of Primary and Outpatient Specialist Care Financed from public funds” 2014; and Ernst & Young Research Report “Optimization of the Polish System of Financing Primary Health Care” 2012 (Polish CA).In Ireland, debate emerged on Medical Card eligibility as part of the National Medical Card Unit Strategic Plan 2016–2018. The Irish CA explained that “a Medical Card allows people to access Family Doctor or GP [general practitioner] services, community health services, dental services, prescription medicine costs, hospital care and a range of other benefits free of charge. The provision of a Medical Card is based on a means test. However, if a person’s income exceeds the threshold, but their individual circumstances place them at risk of ‘undue financial hardship', including, for example, a child with a chronic illness, they may be granted a Discretionary Medical Card which provides the services as outlined above” (Irish CA). The evidence used in the national public debate comprised the findings of two reviews which were commissioned by the Health Service Executive to inform the development of the policy (Irish CA).Austria, Croatia, Denmark, Poland and the United Kingdom looked beyond their own boundaries to gain ideas on screening schedules, amblyopia, healthy living, oral health, anti-bullying environment and primary care coordination. External evidence seemed to be called upon most when countries were already aware they needed new ideas.The policy described by the Austrian CA had the goal of “evaluation, qualitative advancement, attractiveness and increased use as an instrument for the early screening and promotion of children”. To reach these objectives, the Ministry of Health launched an interdisciplinary process aimed at the contemporary development of the MKP, which has operated since 1974 and is regularly amended. The planned implementation of the new mother–child screening, scheduled for 2018, was a further development of the MKP. It developed the assessment of each item of the new screening concept based on international criteria and guidelines  (Austrian CA). Additionally, systematic reviews, budget impact analyses, questionnaire surveys, overviews of reviews and guidelines were carried out. The issues were also discussed during conferences such as the European Forum for Evidence-based Health Promotion and Prevention in June 2017. In the second case described by the Austrian CA, international guidelines were used when the health reform legislation (Gesundheitsreformumsetzungsgesetz 2017 - GRUG 2017) establishing primary healthcare centres was prepared. “Research regarding the evidence of PHC [primary healthcare] as well as international comparisons of different models of PHC were the basis for the recommendations for the Austrian model” (Austrian CA).The Croatian CA identified three areas of child health. Two of these, the national children’s Amblyopia plan and the national “Healthy Living” programme were directly linked with child health. The national strategic plan to improve oral health, despite not being exclusively focused on children’s oral health, devoted most of the document and almost all of the activities to a focus on children. In achieving this, an important role was played not only by professional pressure but also by international comparisons.Experiences from other countries were used in Denmark in implementing the “Act on the Educational Environment for Students”. This law was an anti-bullying policy that “gives children the right to complain to state authority, if the school/municipality does not take adequate action to stop bullying” (Danish CA). The evidence on how bullying affects children's health in the short and long term was used in formulating these recommendations. In particular, the experiences from Norway and Sweden were taken into account, as both of those countries have for many years had similar complaint boards against bullying.In Poland, the implementation of a model of coordinated care in primary healthcare was discussed. In accordance with the newly proposed model of coordinated care, all care provided to a child should be performed by a team of health professionals. Such team should consist of a physician, nurse, and midwife and in the future a health educator and dietician as well. In the process of preparing the reform, its authors referred to scientific studies and international experiences such as a report prepared by a team called to develop strategies for systemic solutions in the area of primary care, appointed by the Minister of Health—“analysis of Primary Health Care in Poland and proposal of systemic changes” 2016.The need for a policy on female genital mutilation (FGM) was raised in the United Kingdom. The United Kingdom CA stressed that the grassroots movement that raised the profile of FGM comprised London-based community groups such as Forward. A Member of Parliament (MP), Ann Clwyd , took up the cause and lobbied parliament to make FGM illegal in the United Kingdom, as well as to develop a policy to aid healthcare professionals. She added that “evidence collected by Forward and other community groups who lobbied for FGM to be made illegal in the United Kingdom was used”. Data from international charities were also used in campaigning by Ann Clwyd (United Kingdom CA).Other policies drew more upon national material. This seemed to apply primarily to situations when a current policy was being reviewed for effectiveness, as opposed to looking for new ideas, and occurred in the Czech Republic, Finland, Norway and Romania concerning patient rights for children, coercion in psychiatry, child and family service reform, free medical service eligibility, early intervention in families, legal framework for vaccination and sustaining healthy eating. These examples have a common theme of seeking to fine-tune and improve established policies; external evidence might be used as a secondary benchmark, as in one example.In Norway, when the policy “Patients’ rights for children”, aimed at empowering children and youngsters, was introduced, “the white paper documented cases reminding of root cause analysis as in patient safety” (Norwegian CA). A unified political approach to safeguard children was presented in the major newspapers and television.When a Finnish project of the Ministry of Social Affairs and Health and the Ministry of Education and Culture—called "The programme to address reform in child and family services”—for the years 2016–2018 was created, an analysis of both the shortcomings and the strengths of the current situation was conducted. “Shortcomings in the management and integration of the services and in encountering clients are well documented. Services in many health and social care settings are scattered to many sectors and are mainly organized based on administrative branches. At the same time, there are numerous examples of successful developments of new service structures and services. The programme plan combines these results” (Finnish CA).Denmark’s policy on early intervention for vulnerable families (Tidlig indsats for sårbare familier) is a political agreement. It was funded by a public funding pool, the Satspuljemidler, which specializes in supporting social, health and work-related dimensions, particularly the most vulnerable in society. “Prior to the implementation of the policy, a mapping was carried out to determine who the vulnerable and disadvantaged children and families are, what initiatives the municipalities have for the families, and the detection and categorization methods used in the different municipalities” (Danish CA).In Romania, the decline in vaccine coverage and an increase in measles outbreaks, as well as a lack of some of the vaccines in the national vaccination scheme, prompted the Ministry of Health to establish a legal framework for vaccination and the purchase of vaccines. The evidence used in the process of policy development was based on government documents and analyses. “Evidence for drafting the new Law on Immunization was presented in the Exposure of Motives published on the 10.04.2017 by the Ministry of Health” (Romanian CA). This report also relies on “examples from 11 of the 28 EU countries, where vaccination is compulsory and children cannot be admitted in public education institutions without certificates of immunization” (Romanian CA).In the Czech Republic a campaign called “Prepare your snack yourself” was initiated. It aimed to change the eating habits of Czech school children and involved children in preparing their own nutritionally balanced snacks. This was a plan to combat the childhood obesity trend. An association called “Healthy eating in schools” composed of parents, students, counsellors, nutritional therapists and other professionals on healthy lifestyle wanted to involve more than 150 schools in this initiative. This led to the formulation of the “Snack Decree” and methodical recommendations of the Ministry of Education, Youth and Sports and the Ministry of Health, and nutrition recommendations from the Czech Ministry of Health for evaluation of food provided by school canteens/cafeterias/restaurants. The evidence used in the preparation of the documents was based on the opinions of nutrition health experts of the Ministry of Health and National Institute of Public Health and in consultation with children's nutritionists from the Czech Medical Association (Czech CA).CAs were asked to describe the elements which facilitate and impede the approach to evidence-based practice in their country. This led to the identification of facilitators and barriers in the evidence uptake in child health policy and practice in European countries. Several patterns were observed.Based on the responses of the CAs, we created categories of codes and grouped them as main themes which describe elements that facilitate and impede the evidence-based approach in Europe Fig. .Fig. 2FaAmongst the facilitators, we identified the following categories: education of actors/stakeholders/public, awareness, funds, supportive environment, quality, lobbying, assistance with moving from evidence to decision, and finally scientific culture development, which can include all the components mentioned above.Barriers were grouped as follows: difficulties with applying and using research/systematic reviews, poor data and information “control” or “management”, lack of will, lack of popularization achieved by scientific research, lack of mechanisms to stimulate cross-sectoral cooperation, lack of proper coordination and intersectoral collaboration, lack of time, lack of resources, lack of national monitoring, lack of culture of neutral and impartial information, and poor tradition of implementing political changes based on reliable evidence, which can include all the components mentioned earlier.Education is a key factor in evidence use in policy-making. Decision-makers should be knowledgeable about the sources and possibilities for use of evidence, which can be beneficial for the policy and decision-making process. Support of evidence-based practice and policy through education about evidence-based solutions was stressed by the Norwegian CA. In Denmark, “the Danish Health Authority offers method courses in working with national clinical guidelines. Such courses contain an introduction to and explain how to assess the risk of bias and other sources of uncertainty in studies and across studies. The purpose of these courses is to disseminate information and knowledge about the method and the work with the national clinical guidelines” (Danish CA). Finland proposed the use of a handbook of early intervention to implement evidence-based early support, care and parental skills tools in practice (Finnish CA).Educative initiatives increase awareness about evidence use. In Portugal, “there is a general recommendation about increasing the recognition of research, related to health and to the definition of health needs, program implementation and program evaluation” (Portuguese CA). The Portuguese CA also stressed the importance of lifelong training as a measure which provides sustainability, and she highlighted the role of “professional life long training; support from evaluation agencies that may monitor implementations and feedback the public policies” (Portuguese CA).It is not only the awareness of existing evidence that matters; awareness of the context—for example, the social factors or patients’ preferences—is also significant in facilitating evidence usage. The Bulgarian CA stressed that “the obvious truth is that the outcome of treatment of many chronic diseases depends on the effect of the medical measures, depends on the social environment in which these measures are undertaken. If these social factors are not taken into account, there is a high risk that the medical measures are not implemented” (Bulgarian CA). From the perspective of the Austrian CA, “elements which will facilitate evidence-based practice are, for instance, that objective facts which should be taken as decision support, (…) evidence should be seen as complementary by considering experience and patients’ preferences” (Austrian CA).Both categories, education and awareness, can assist with moving from evidence to decision and recommendations—in other words, from evidence to policy-making. Evidence should be highly relevant to existing problems. The Norwegian CA recommended conducting systematic literature searches with the sorting of results (as a brief report) as an important starting point for a specific review.The Irish CA stressed that, amongst the elements which can facilitate evidence usage, there might be a mixture of political orientation and access to funds with supportive staff aimed at providing evidence-based medicine and healthcare services within their given budget (Irish CA). This led us to identify two new categories of facilitators: funds and supportive environment.Sufficient time and funding as a key factor in evidence use was stressed by the British CA, who noted that “clinical practitioners need to be encouraged to participate in research and so require time as well as funding to do this” (United Kingdom CA). This goes hand in hand with the financial possibilities of the formulation of a unit contributing to evidence-based decisions. Such an institution was created in Norway in 2011. Several Norwegian directorates established a “Unit for Social Welfare Research” whose mandate was to “contribute to evidence-based decisions about policy and practice in Norwegian welfare services, especially by conducting systematic reviews” (Norwegian CA).The concept of a supportive environment refers to the support from evaluation agencies that may monitor implementation and feedback regarding public policies (Portuguese CA) and “the strong engagement of public services stakeholders , and also third sector organisations (…) together with child rights advocacy groups and research and educational institutions” (Spanish CA). Performing consultancy work such as assistance with applications, research bids, assessing single studies, and research and development was significant from the perspective of the Norwegian CA. Amongst factors influencing the support of evidence uptake in policy and practice is the literacy of the involved stakeholders, as stressed by the Czech CA. He pointed out that “the involvement of the various Societies of the Czech Medical Association of J. E. Purkyně: Czech Society of Adolescent Medicine, Czech Endocrinology Society, Czech Society for Obesitology, Czech Pediatric Society, Society of PLDD (GPs for Children and Adolescents)” is beneficial (Czech CA).The Finnish CA stressed how consultation with experts can affect evidence-based policy-making. He noted that “the major decisions are made by politicians, but the civil servants usually ask expert opinions before decision-making. In Finland, the national and regional authorities with knowledge on child and adolescent health and services as well as evidence-based practices are frequently consulted. In this case, a larger scale project was initiated and it was given to THL, the National Institute for Health and Welfare, which is the leading institute in health and welfare services in Finland” (Finnish CA).In addition to the importance of stakeholder involvement, the quality of the network of experts was mentioned by the Slovak CA. He proposed to “create expert working groups with these experts as well as significant authorities from public service involved” (Slovak CA) to support evidence use in his country. The Polish CA added that access to highly qualified scientific staff and high-quality education in medical professions are significant facilitators as well. In Romania, it is important that “correct information should always come from professionals who can provide scientific evidence” (Romanian CA).This would consequently affect the quality of evidence and encourage its use. The Norwegian CA added that “further research development work in summarizing qualitative studies” (Norwegian CA) is a crucial facilitator as well. Another facilitator of evidence use worth stressing is the development of “evidence for informed decision-making on the effect of interventions in social welfare services by conducting systematic reviews and other secondary research—by producing plain-language summaries of existing systematic reviews” (Norwegian CA).Lobbying and professional pressure were mentioned by Croatian and Polish CAs as elements which can significantly affect the design, uptake and implementation of evidence-based solutions.Quality improvement is an important element of scientific culture development. An Italian expert added that “schools should improve the scientific culture of pupils. Citizens should take greater account of the scientific preparation of people who they are willing to elect. The ways of selecting political representatives should be changed and improved” .Openness to the adoption of evidence-based recommendations is another component of scientific culture development. In Greece, “significant improvements have been made in the last few years, particularly in the area of medical prescriptions. For example, regarding the management of chronic diseases, evidence-based national guidance and management protocols have been adopted and are mandatory within the e-prescription system” (Greek CA).For building the scientific culture, collaborative partnership between researchers and policy-makers and appropriate communication of new  synthesized research relevant to the directorates (Norwegian CA) is needed. Facilitating active collaboration and communication among welfare directorates in Norway seems to be crucial for supporting evidence usage.One of the barriers which we observed based on analysis of the data provided by CAs was a very poor tradition of implementing political changes based on reliable evidence, which can be interpreted as a lack of tradition of previous reforms with specific analyses of the present state of the health system—as reported by the Polish CA. Additionally “short experience in the field of science, business and politics” (Polish CA) was stressed.The Norwegian CA considered as a challenge difficulties with applying and using systematic reviews to inform policy. In Croatia, data and information “control” or “management” nationally needs to be improved, with the goal of focusing on “evidence-based policy-making” (Croatian CA). The CA from Cyprus also stressed that there is a lack of will to use evidence in the policy-making process, and it can significantly affect the use of evidence.The resistance of the medical environment before implementing changes was also highlighted as a barrier by the Polish CA. Additionally, lack of popularization of achieved scientific research and lack of mechanisms to stimulate cross-sectoral cooperation were also mentioned as difficulties in applying evidence-based policy-making in practice. This is closely correlated with lack of proper coordination and intersectoral collaboration highlighted by the Greek CA. In Greece, this problem is linked with “differences in the legislation of public health care regarding administrative work, unbalanced funding and expense cuts, unclear job descriptions and relationships and cases of conflicting interests” (Greek CA).The consequence of a lack of interest in evidence-based practice in child healthcare and healthcare policy can be lack of time or lack of resources, with the result that “trajectories do not run smoothly, and it happens that some actions are initiated or finished without a proper evaluation” (Portuguese CA). Lack of funds disrupts the adequate monitoring of actions and impedes the training of professionals (Portuguese CA). The Danish CA stressed that evidence-based initiatives require a resource-intensive approach. He noted that “an element that impedes the approach to evidence-based practice is that evidence-based practices are resource-intensive and require the employees to have strong competencies” (Danish CA). Another factor pointed out by the Danish CA was a lack of national monitoring of whether the guidelines were implemented and whether they were followed.Lack of a culture of neutral information was observed by the Italian CA, who noted that “the habit of discussing on the basis of the opinion of authoritative experts is still deeply rooted. The culture of ‘neutral’ (as much as possible) information is lacking” .Use of evidence is strongly embedded in context. It was proved by the responses of CAs, which show that media can both facilitate and impede the development of the new health policies.The Austrian CA stressed that several discussions took place in conferences such as the European Forum for Evidence-based Health Promotion and Prevention, when the new mother and child screening was implemented. However, she also emphasized that “it is also not always possible to meet all criteria of the evidence-based medicine to one hundred percent. In some subjects, this is also difficult—for example, in paediatrics” (Austrian CA). In Croatia, it was the starting point for the vast majority of communications and discussion with the public when the national children’s amblyopia plan was introduced. Many countries reported that the information about the evidence used in the policy-making process was widely present in the media. This played a significant role in the broadcasting and distribution of evidence-based approaches in European countries.Media as facilitator in the discussions was mentioned by the Greek CA, who said that “results and suggestions by the report were used mainly through news media (TV and printed press), in facilitated discussions between representatives of the political parties, health professionals and administrative staff of the health system” (Greek CA).Media, including social media, also played a powerful role in Romania in influencing public opinion, when the new law on vaccination was drafted. However, the Romanian CA stressed that the media input did not necessarily, or did not always, produce accurate or positive messages. A lack of neutrality was expressed. According to the Romanian CA, at the beginning of the vaccine crisis, both state and private television invited at least one anti-vaccination physician or active anti-vaccination campaigner on social media to give their views. Most of the time, these people participated alone in shows, without the opportunity for debate or discussion of the plurality of opinions. These shows had a large audience and were broadcast at times when they would reach the maximum audience. The most challenged vaccines were measles and polio, which were presented as having dangerous health consequences; others such as the BCG  vaccination were considered to have no positive effects, serving only the interests of pharmaceutical companies, who were portrayed as only interested in profit. At a later stage, when measles epidemics occurred, shifts in risk perception were noticeable in the media. The national media became an important actor advocating in favour of vaccination: “Journalists from TV and print media turned their campaign around and reported illness and death, and pressured governments to take concrete measures to limit the epidemics. These pressures forced the Health Ministry to clarify through press releases and new legislative regulations to avoid the vaccine crisis, whose priority cause is the lack of dose requirements for populations entering the national vaccination scheme” (Romanian CA).It was also reported that the media were often focused on a single subjective case rather than objective debate. Lack of neutrality was identified by the Italian CA, who mentioned that “media often prefers to present a single pathetic case , instead of putting on a fair and objective debate (which would take a long time)” . Conversely “in the very intense public debate on media, expert opinions have been reported: ‘pro vs con's’ style. Probably, there was a lack of presentation of evidence from literature, especially for healthcare professionals” . The Polish CA added that “the provisions of the Act of Primary Health Care differ significantly from those presented by the media. The main changes have not been fully presented, and the media has focused only on certain elements. The media was presenting as especially controversial the fact that paediatricians were not included in the primary care team in the provisions of the Act (which was later changed). The critical voices of experts at the professional media portals dominated the discussion. Emotional media reports of tabloid media have also been reported, which caused alarm that children's health is at risk” (Polish CA).On the other hand, the Croatian national “Healthy Living” programme was also “highly visible in mass and social media in various forms including commercials and organising and visiting events and shows where the information, background and evidence together with education have been provided and awareness continuously raised” (Croatian CA). Similarly in Romania, where the high death rate among measles cases “has turned a large part of the media in favour of the vaccination (…) as it has consistently presented the victims of the measles epidemic and has put pressure on the health ministry to explain and find a solution” (Romanian CA), media played an educative role in increasing awareness in the population. However, the Portuguese CA stressed that “media may highlight issues, but public policies are not dependent on media news but rather from identified needs”.Recognizing the importance of evidence-based solutions in policy-making is crucial for effective implementation of innovation within child health policy. In the process of evidence-informed policy-making, understanding who is producing evidence is important. WHO stresses that “expert opinion is more than just evidence”  because Our study identified a few generic factors that may influence the efficiency and success of child health policy. We were particularly interested in the facilitators and barriers in the use of evidence in child health policy-making in Europe.We observed two key trends in potential evidence-based knowledge transition in policy-making. On the one hand, the importance of academia and its achievements was stressed, and on the other hand the role of institutional reporting was highlighted. We defined those types of approaches as scientific and institutional. The scientific approach comprises so-called bottom-up initiatives from the professional scientific environment, whereas the institutional approach involves top-down evidence production, which is initiated by administrative institutions. We found that the institutional approach seems to benefit from the scientific resources and presents its recommendations based on scientific achievements; thus the two groups are not mutually exclusive. This was also discussed by Cairney and Oliver , who repThe evidence used in Europe can also be described as of an external or internal nature. Such classification is consistent with the WHO approach, which considers evidence through both global and local prisms . InternaHasanpoor et al. highlighted that “the practical framework of evidence-based management should be based on the best resources from identifying barriers and facilitators” . In our We found that various factors can affect evidence use in child health policy-making. Head, in 2010, pointed out three elements that underpin modern conceptions of evidence-based policy: (i) high-quality information based on relevant topic areas, (ii) professionals with skills in data analysis and policy evaluation, and (iii) political incentives for using evidence-based solutions in governmental decision-making processes . Our anaThis was also found by Bach-Mortensen et al. , who notWe found that barriers to evidence-based policy-making include a poor tradition of implementing changes based on reliable evidence, which is also reflected in the paper by Bach-Mortensen et al.  as a setGeneric elements that were identified which affect evidence-based solutions in policy-making constitute the phenomenon of a “culture of evidence-based policy-making” Fig. , which cIn our understanding, the culture of evidence-based policy-making is broader, as it highlights not only challenges for the successful translation of evidence, but also explains the levels of evidence usage and shows the correlation between them. It is important to appreciate that the culture of evidence-based policy-making exists in parallel with the policy-making cycle. It is based on the appreciation of the value of scientific research which supports and draws from institutional data. These data can be expressed at two levels: national, which reflects the internal approaches to evidence-based policy-making, and international, which expresses external views. The culture of evidence-based policy-making is strengthened by facilitators and weakened by barriers.The study on evidence usage in child health policy-making in European countries is challenging, as evidence usage is strongly contextualized. Some elements such as perceptions and attitudes are often internalized and introspective, making their influences difficult to determine.In our research we tried to identify the types of evidence used and the factors which facilitate or impede evidenced-based policy-making. Although the MOCHA project had 30 national experts, we received responses from only 23 countries, as seven CAs did not provide responses to our questions. However, the nature of our research was not quantitative but qualitative; hence omission of some countries does not invalidate the data received. Our goal was to qualitatively investigate the key generic factors influencing evidence-based policy-making and its impact on child health policy.In this study we analysed factors which facilitate and impede evidence-based solutions within the context of child health policy in any country. We proposed guidance for stimulating effective reform processes with the goal of making the current factor analysis available to those who might wish to use it in their own reform process Fig. .Evidence-based child health policy-making needs an appropriate culture of evidence-based policy-making. Evidence usage is fundamental here; hence the creation of new policies and/or reforming current policies requires appropriate approaches based on available, high-quality evidence Fig. . This miEvidence usage in policy-making may be facilitated or impeded. The characteristics of both types of elements were presented previously Fig. . An enviScientific evidence identifies and guides actions which need to be undertaken in the appropriate area.Institutional evidence relates to problems which have already emerged and need response from national or local institutions.Policy-making based on evidence usage truly responds to the population needs, identified scientifically and/or institutionally.Understanding that the facilitators of and barriers to evidence-based policy-making which we identified in our paper affect policy effectiveness.With this in mind, we would like to propose the following guidance for decision-makers which we hope will facilitate and promote the culture of evidence-based policy-making in their countries.Two types of evidence usage exist: scientific and institutional. The first one we understand as initiatives of the professional scientific environment; the second refers to evidence production initiated by administrative institutions.The evidence used in Europe can be of an external or internal nature.Various factors can affect the use of evidence in child health policy-making. Facilitators are correlated with strong scientific culture development, whereas barriers are defined by a poor tradition of implementing changes based on reliable evidence.Media are an important influence on the culture of evidence-based policy-making by facilitating or impeding evidence usage.The phenomenon of a culture of evidence-based policy-making is a style of policy-making where evidence is fundamental.A culture of evidence-based policy-making highlights challenges for the successful translation of evidence into policy, explains the levels of evidence usage and shows the correlation between them.A culture of evidence-based policy-making is understood as a style of policy-making where evidence is fundamental. We identified a number of barriers and facilitators in the use of evidence to support policy development or policy change. Focusing on the facilitators and actively working to reduce the barriers can potentially lead to faster and more robust policy-making, including the development of a culture of scientific grounding in policy creation.Additional file 1: Questionnaire.


This review summarizes the evidence from six randomized controlled trials that judged the effectiveness of systematic review summaries on policymakers' decision making, or the most effective ways to present evidence summaries to increase policymakers' use of the evidence.This review included six randomized controlled studies. A randomized controlled study is one in which the participants are divided randomly (by chance) into separate groups to compare different treatments or other interventions. This method of dividing people into groups means that the groups will be similar and that the effects of the treatments they receive will be compared more fairly. At the time the study is done, it is not known which treatment is the better one.The researchers who did these studies invited people from Europe, North America, South America, Africa, and Asia to take part in them. Two studies looked at “policy briefs,” one study looked at an “evidence summary,” two looked at a “summary of findings table,” and one compared a “summary of findings table” to an evidence summary.None of these studies looked at how policymakers directly used evidence from systematic reviews in their decision making, but two studies found that there was little to no difference in how they used the summaries. The studies relied on reports from decision makers. These studies included questions such as, “Is this summary easy to understand?”Some of the studies looked at users' knowledge, understanding, beliefs, or how credible (trustworthy) they believed the summaries to be. There was little to no difference in the studies that looked at these outcomes. Study participants rated the graded entry format higher for usability than the full systematic review. The graded entry format allows the reader to select how much information they want to read. The study participants felt that all evidence summary formats were easier to understand than full systematic reviews.It is likely that evidence summaries are easier to understand than complete systematic reviews. Whether these summaries increase the use of evidence from systematic reviews in policymaking is not clear.Systematic reviews are long and technical documents that may be hard for policymakers to use when making decisions. Evidence summaries are short documents that describe research findings in systematic reviews. These summaries may simplify the use of systematic reviews.policy briefs, evidence briefs, summaries of findings, or plain language summaries. The goal of this review was to learn whether evidence summaries help policymakers use evidence from systematic reviews. This review also aimed to identify the best ways to present the evidence summary to increase the use of evidence.Other names for evidence reviews are This review summarizes the evidence from six randomized controlled trials that judged the effectiveness of systematic review summaries on policymakers' decision making, or the most effective ways to present evidence summaries to increase policymakers' use of the evidence.This review included six randomized controlled studies. A randomized controlled study is one in which the participants are divided randomly (by chance) into separate groups to compare different treatments or other interventions. This method of dividing people into groups means that the groups will be similar and that the effects of the treatments they receive will be compared more fairly. At the time the study is done, it is not known which treatment is the better one.The researchers who did these studies invited people from Europe, North America, South America, Africa, and Asia to take part in them. Two studies looked at “policy briefs,” one study looked at an “evidence summary,” two looked at a “summary of findings table,” and one compared a “summary of findings table” to an evidence summary.None of these studies looked at how policymakers directly used evidence from systematic reviews in their decision making, but two studies found that there was little to no difference in how they used the summaries. The studies relied on reports from decision makers. These studies included questions such as, “Is this summary easy to understand?”Some of the studies looked at users' knowledge, understanding, beliefs, or how credible (trustworthy) they believed the summaries to be. There was little to no difference in the studies that looked at these outcomes. Study participants rated the graded entry format higher for usability than the full systematic review. The graded entry format allows the reader to select how much information they want to read.. The study participants felt that all evidence summary formats were easier to understand than full systematic reviews.Our review suggests that evidence summaries help policymakers to better understand the findings presented in systematic reviews. In short, evidence summaries should be developed to make it easier for policymakers to understand the evidence presented in systematic reviews. However, right now there is very little evidence on the best way to present systematic review evidence to policymakers.The authors of this review searched for studies through June 2016.Systematic reviews are important for decision makers. They offer many potential benefits but are often written in technical language, are too long, and do not contain contextual details which makes them hard to use for decision‐making. Strategies to promote the use of evidence to decision makers are required, and evidence summaries have been suggested as a facilitator. Evidence summaries include policy briefs, briefing papers, briefing notes, evidence briefs, abstracts, summary of findings tables, and plain language summaries. There are many organizations developing and disseminating systematic review evidence summaries for different populations or subsets of decision makers. However, evidence on the usefulness and effectiveness of systematic review summaries is lacking. We present an overview of the available evidence on systematic review evidence summaries.This systematic review aimed to 1) assess the effectiveness of evidence summaries on policy‐makers' use of the evidence and 2) identify the most effective summary components for increasing policy‐makers' use of the evidence.We searched several online databases , websites of research groups and organizations which produce evidence summaries, and reference lists of included summaries and related systematic reviews. These databases were searched in March‐April, 2016.Eligible studies included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) studies, and interrupted time series (ITS) studies. We included studies of policymakers at all levels as well as health system managers. We included studies examining any type of “evidence summary”, “policy brief”, or other product derived from systematic reviews that presented evidence in a summarized form. These interventions could be compared to active comparators (e.g. other summary formats) or no intervention.The primary outcomes were: 1) use of systematic review summaries decision‐making  and 2) policymaker understanding, knowledge, and/or beliefs (e.g. changes in knowledge scores about the topic included in the summary). We also assessed perceived relevance, credibility, usefulness, understandability, and desirability (e.g. format) of the summaries.Our database search combined with our grey literature search yielded 10,113 references after removal of duplicates. From these, 54 were reviewed in full text and we included 6 studies  as well as protocols from 2 ongoing studies. Two studies assessed the use of evidence summaries in decision‐making and found little to no difference in effect. There was also little to no difference in effect for knowledge, understanding or beliefs (4 studies) and perceived usefulness or usability (3 studies). Summary of Findings tables and graded entry summaries were perceived as slightly easier to understand compared to complete systematic reviews. Two studies assessed formatting changes and found that for Summary of Findings tables, certain elements, such as reporting study event rates and absolute differences were preferred as well as avoiding the use of footnotes. No studies assessed adverse effects. The risks of bias in these studies were mainly assessed as unclear or low however, two studies were assessed as high risk of bias for incomplete outcome data due to very high rates of attrition.Evidence summaries may be easier to understand than complete systematic reviews. However, their ability to increase the use of systematic review evidence in policymaking is unclear. Policy makers are increasingly utilizing systematic reviews for decision‐making . The shiThere are several organizations that develop and disseminate evidence summaries for different populations or subsets of decision makers. For example, within the Cochrane Collaboration, the Evidence Aid Project was developed in response to the 2004 Indian Ocean Tsunami as a means of providing decision makers and health practitioners ‘on the ground’ with summaries of the best available evidence needed to respond to emergencies and natural disasters .www.support‐collaboration.org). Health Systems Evidence provides a one‐stop shop for systematic reviews related to health systems including policy briefs for policy‐makers and other stakeholders . Other examples include Cochrane Summaries (http://www.cochrane.org/evidence), Communicate to vaccinate (COMMVAC (http://www.commvac.com), Rx for change (www.cadth.ca/resources/rx‐for‐change), and Harvesting Evidence (http://www.harvesting‐evidence.org). A document analysis conducted by Adam et al. identified 16 organizations involved in the production of summaries for policymakers in LMICs (SUPPORT Summaries were developed for policy‐makers in low‐ and middle‐income countries (LMICs) making decisions about maternal and child health programs and interventions , health care providers), summaries containing contextual information were considered helpful for decision‐making about the applicability of the findings to their local setting .Evidence summaries of systematic reviews are identified using many different terms including evidence summaries, policy briefs, briefing papers, briefing notes, evidence briefs, abstracts, summary of findings, and plain language summaries . They arSystematic review summaries consist of summarized evidence from systematic reviews intended to assist policy‐makers in understanding the systematic review evidence and using it in their decision‐making. These interventions may include structured summaries , policy briefs which are based on systematic reviews , and plain language summaries, structured abstracts, and Summary of Findings tables (e.g. Cochrane reviews). These may be provided in print or web‐based formats and are aimed at policy‐makers, and other decision makers making decisions about health. The summaries may include information about the context in which the studies were conducted, the applicability of the results (e.g. SUPPORT Summaries comment on the relevance of the findings for disadvantaged communities), as well as the findings, methods and conclusions.Evidence suggests that policy makers are more likely to use systematic reviews when the evidence is provided in a timely manner, and aligns with interests, values, and political goals of policymakers . EvidencInterest in the production and use of systematic review summaries is increasing, as evidenced by the growing number of organizations developing and disseminating them . HoweverThe objectives of this review were to:1) assess the effectiveness of evidence summaries on policy‐makers' use of the evidence and;2) identify the most effective summary components for increasing policy‐makers' use of the evidence.The protocol for this review was published in the Campbell Library on 3 August 2017.Eligible studies included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) studies, and interrupted time series (ITS) studies.We included studies whose participants were health policymakers at all levels. We defined policymakers as health ministers and their political staff, civil servants, and health system managers, and health‐system stakeholders as civil society groups, patient groups, professional associations, non‐governmental organizations, donors, international agencies . We inclWe included studies of interventions examining any type of “friendly front end”, “evidence summary”, or “policy brief” or other product derived from systematic reviews or guidelines based on systematic reviews that presents evidence in a summarized form to policy‐makers and health system managers. Interventions had to include a summary of a systematic review and be actively “pushed” to target users. This means that the summary had to be disseminated or shown to the study participants via email, mail or other means. We included any comparisons including active comparators (e.g. other summary formats) or no intervention.1. Use of systematic review derivative product in decision‐making  as reported by the authors of the included studies .Perceived relevance of systematic review summariesPerceived credibility of the summariesPerceived usefulness and usability of systematic review summaries○ Perceptions and attitudes regarding the specific components of the summaries and their usefulnessUnderstandability of summariesDesirability of summaries  Some studies may use different terms to describe these outcomes, therefore, our team assessed each outcome and categorized them according to the above list. Studies were not excluded on the basis of outcomes. Outcome measures may include Likert scales to assess understandability, credibility, likelihood to use a summary in decision‐making, or other outcomes; knowledge scores or responses to questions regarding summary content; and preferred format styles.Two reviewers independently screened titles and abstracts to identify relevant studies meeting the pre‐specified inclusion criteria. The full text of each potentially included study was then screened independently by two authors.Information Specialists  developed and translated the search strategy using the PRESS Guideline . We expeWe used the search strategy developed by Perrier et al. and Murthy et al. for their systematic reviews of interventions to encourage the use of systematic reviews by health managers and policymakers to inform our search . This seWe identified and searched websites of research groups and organizations which produce evidence summaries building on the list of organizations identified by Adam et al. . We searWe also checked the reference lists of included studies and related systematic reviews to identify additional studies. We contacted researchers to identify ongoing and completed work. The results of the search are reported in References identified through database and grey literature searching were screened independently, in duplicate by two members of the research team using Covidence software.The data extraction form was pre‐tested, and included factors related to the population, intervention, comparison, and outcomes. Data extraction was completed by two authors independently using a structured Excel sheet. Disagreements were resolved by discussion and with a third member of the research team when necessary.Data were extracted for the following:CountrySettingStudy designParticipants○ Type of policy or decision makers○ Country○ Age○ Gender and/or sexIntervention○ Type of evidence summary○ Format of evidence summary○ Description of evidence summary components ○ Mode of delivery○ Topic of evidence summary○ Recommendation of evidence summaryOutcomes○ Policy‐ and/or decision makers' self‐reported use of summaries in decision‐making○ Policy‐ and/or decision makers' knowledge of the summary content and the measurement used○ Policy‐ and/or decision makers' understanding and measurement used○ Perceived relevance of the summaries and measurement used○ Perceived credibility of the summaries and measurement used○ Perceived usefulness and usability of the summaries and measurement used○ Perceived understandability of the summaries and measurement used○ Perceived desirability of the summaries and measurement usedProcess Indicators○ How the systematic review was selected for summary ○ How the evidence summary was developed (e.g. iterative process)○ Involvement of stakeholders in evidence summary development – which stakeholders, description of involvementThe methodological quality was assessed using the risk of bias tool from the Cochrane Handbook for randomized trials. If we had identified eligible ITS, CBA, or NRS we planned to use the Effective Practice and Organization of Care (EPOC) Review Group criteria for ITS and CBA studies  and RiskWe used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence for the outcomes reported in this review .We attempted to contact the authors of studies with missing data and the authors of ongoing studies.2 statistic according to guidance of the Cochrane Handbook for Systematic Reviews of Interventions . We were also thus unable to conduct planned meta‐regression to assess the role of mediating factors, such as: target audience of summary ; type of decision maker ; and components of friendly front end .Our included studies assessed interventions and reported outcomes that were too different to pool; therefore, meta‐analysis was not possible. If it had been, we planned to explore heterogeneity using forest plots and the IWe did not assess publication bias using funnel plots because only six studies were included.We planned to synthesize the results using meta‐analysis, if possible but, as stated in the protocol, we planned to present a narrative summary if the results could not be pooled. The interventions assessed in the studies we have included were too different with respect to their methods, populations, and outcomes to meaningfully pool results across studies.Meta‐analysis was not possible therefore we were unable to conduct subgroup analyses or assess heterogeneity.We planned to assess the impact of including studies assessed as high risk of bias or studies in which there were unit of analysis errors that could not be reanalysed but meta‐analysis was not possible.The search strategy yielded 11,733 references . We included six completed RCTs reported in seven articles in this review . The chaThe completed studies recruited participants from Canada (n=1), Kenya (n=1), the US (n=1), internationally without specifying countries (46% from high‐income countries) (n=1), and in countries in Europe, North America, South America, Africa, and Asia (n=1) . One stuDetails of the different evidence summary formats are reported in Carrasco‐Labra et al. compared a standard format summary of findings table to a new format that presented some of the data in a different way as well as provided supplementary data . All theDobbins et al. had three groups. The first had access to the online database, the second received targeted, tailored messages in addition to access to an online database, and the third group received the same intervention as the second group plus access to a full‐time knowledge broker .Masset et al., and the companion paper by Beynon et al., assessed three versions of a policy brief. The first was the standard policy brief, the second was the same policy brief with an additional commentary by a sector expert (the Director of the institution who conducted the review), and the third was the same except the commentary was attributed to an unnamed research fellow .The study by Opiyo et al. compared a systematic review alone to a systematic review with a summary of findings table and a ‘graded‐entry format’ which includes a short one page summary, a contextually‐framed narrative report including an interpretation of the main findings and conclusions (with a summary of findings table), followed by access to the full systematic review .Finally, the study by Vandvik et al. compared two versions of summary of findings tables with or without four formatting modifications  . These wAfter title and abstract screening, 10,059 references were excluded because they did not meet our eligibility criteria. After reviewing 55 full text references an additional 46 studies were excluded. The details of these exclusions are included in online supplement 3.The summary of the Risk of Bias assessments is presented in Two studies were assessed as low risk of bias for random sequence generation .For allocation concealment, four studies were assessed as unclear  and two Baseline outcome measurements were similar and therefore low risk of bias in two studies  and unclIncomplete outcome data was assessed as low risk of bias for four studies  but highKnowledge of allocated interventions was assessed as unclear for four of the studies . One stuAdequate protection from contamination was assessed as unclear for four studies. The Dobbins study included public health departments from across Canada and therefore little risk of contamination was expected  and CarrAll studies were assessed as low risk of bias for selective outcome reporting.Most outcomes were assessed as moderate certainty of evidence using GRADE . ReasonsWe generated a Summary of Findings table for this review . This isTwo studies assessed self‐reported use of summaries in decision‐making. First, Dobbins et al. assessed the change in global evidence‐informed decision‐making (EIDM) which is defined as the extent to which research evidence was considered in a decision 18 months after the intervention. The authors found that the intervention had no significant effect on EIDM. The post‐intervention change for the group receiving targeted, tailored messages was ‐0.42  and ‐0.09 . This study also reported on evidence‐based public health policies and programs as a measure of the actual number of strategies, policies, and interventions for health body weight promotion among children that were implemented by the health department. For this outcome, the group that received the targeted, tailored messages had a statistically significant increase in evidence‐based public health policies and programs  compared with no change for the group with access to a knowledge broker  .The study by Brownson et al. asked policymakers how likely they would be to use the evidence summary in decision‐making. On a 5‐point Likert scale, where 1 is strongly disagree and 5 is strongly agree, there was little to no difference based on the type of policy brief (data‐driven versus story driven) (range 3.3 to 3.4). However, there were differences in self‐reported likelihood of using the policy brief depending on type of policymaker. Staff members reported being most likely to use the story‐focused brief with state‐level data  3.0 to 3.9) and least likely to use the data‐focused brief with state‐level data . Legislators reported being most likely to use the data‐focused brief with state level data  and least likely to use story‐focused brief with state‐level data  .Carrasco‐Labra et al. found that respondents receiving the new summary of findings format had a higher proportion of correct answers for almost all questions. These included the ability to interpret footnotes (risk difference (RD) 7%, p=0.18), ability to determine risk difference , understanding of quality of evidence and treatment effect , understanding of the quality of evidence , and ability to quantify risk  . HoweverThe Masset study examined changes in beliefs about the effectiveness of the intervention as well as the strength of the evidence included in the policy briefs. The authors found that the policy brief increased the number of participants who had an opinion about the strength of the evidence. For example, those who did not have an opinion at baseline formed an opinion based on the policy brief. The difference‐in‐difference coefficients indicate that the policy brief increased the percentage of participants with an opinion about the strength of the evidence by 20–25 decimal points . HoweverThe Opiyo study found little to no difference between interventions for the odds of correct responses to questions about the intervention. The adjusted odds ratio (OR) for the summary of findings table compared to the systematic review alone was 0.59(95% CI 0.32 to 1.07), and graded entry format compared to systematic review alone was 0.66 (95% CI 0.36 to 1.21). However, both of these indicated that the odds of correct responses were higher for the groups who received an evidence summary or summary of findings . When coFinally, Vandvik et al. reported that there was little to no difference in participants' understanding of information in the different table formats for most items  However, more participants with table A had correct answers for two items: time period for risk estimates  and the range in which the effect may lie  .Brownson et al. reported little to no differences in credibility for the different intervention formats (low certainty of evidence). Mean scores for perceived credibility ranged from 4.4 to 4.5 on a 5‐point Likert scale in which 5 indicated “strongly agree” . For difThe Carrasco‐Labra study reported that the new summary of findings format was more accessible than the standard format . This waOpiyo et al. measured this outcome by assessing the ‘value and accessibility’ of each intervention. The graded entry format received a higher mean score than the systematic review alone (MD 0.52 (95% CI 0.06 to 0.99). The odds of a one‐point increase for the graded entry format compared to the systematic review alone were 1.52 (95% CI: 1.06‐2.20). There was little to no difference in effect when comparing the summary of findings table and the systematic review alone . The odds of a one‐point increase were 0.91 (95% CI: 0.57‐1.46) .Vandvik et al. reported that accessibility of information for quality of evidence as well as absolute and relative effects was rated similarly with no significant differences between groups . Only poAll the groups in the Brownson et al. study reported that the summaries were easy to understand . Mean raThe study by Opiyo et al. reported that 60% (95% CI: 48% to 73%) of the participants found systematic reviews to be more difficult to read than the narrative reports included in the graded entry formats. Fifty‐one percent of participants (95% CI: 38% to 63%) found systematic reviews to be easier to read compared to 26% (95% CI: 15% to 37%) who found summary of findings tables easier. 53% (95% CI: 41% to 65%) of participants preferred the narrative report format (graded entry) compared to 25% (95% CI: 14% to 36%) who preferred the full systematic review . The majTwo studies of different summary of findings formats assessed this outcome. One study found that participants preferred the summary of findings table which presented study event rates versus the one without them  1, on 1‐7 scale in which 1 indicates ‘strong preference for’ and 7 indicates ‘strong preference against’). Participants preferred the table with the absolute risk differences versus presentation of absolute risks only . Additional information embedded in table was preferred versus having it as footnotes . No significant differences were found for the placement of the column for ‘overall quality of evidence’ either as the final column or before the effect size or the overall table format .The other study found that overall, respondents preferred the new summary of findings format  compared to the standard format .None of the included studies reported on policymakers' perceived relevance of the summaries.healthevidence.org) or access to a knowledge broker when the organization valued research evidence in decision‐making  for the questions about the ability to determine a risk difference. For the question assessing whether respondents understand the quality of evidence and treatment effect combined, the authors found that years of experience, familiarity with GRADE, and level of training modified the effect by more than 10%  .This review has summarized the evidence on the use of systematic review summaries in policy‐making, policy‐makers' understanding of systematic review evidence, and different components and design features. Overall, the results suggest that evidence summaries may be easier to understand than complete systematic reviews. However, their ability to increase the use of systematic review evidence in policymaking is unclear because not enough evidence is available.Six studies were included in this review. For our primary outcome, use of systematic review evidence in decision‐making, one study found that targeted, tailored messages increased the number of evidence‐based public health policies and programs. However, for the two studies that assessed effect on decision‐making or likelihood of using the summary in decision‐making there was little to no difference between intervention groups . We asseFor the secondary outcome of understanding, knowledge, and beliefs, there was little to no difference in effect and moderate certainty evidence in three of the four studies assessing this outcome . There wFor perceived desirability of summaries we found moderate certainty of evidence. One study found that the alternate version of the summary of findings table was preferred,  and the For perceived usefulness and usability of the summaries, we found moderate certainty evidence. The graded entry summary was rated higher than a systematic review alone for usability . SummariWe identified two protocols for ongoing studies which is promising as the results of these studies will enhance the available evidence about the effectiveness of evidence summaries . We alsoWe used the GRADE approach to assess the overall quality or certainty of the evidence included in this review. We assessed most of the evidence to be ‘moderate’ certainty. For perceived desirability of the summaries, we assess the evidence as ‘high’ certainty.Our primary outcome, policymakers' use of systematic review evidence in decision‐making is challenging to measure. Other studies have noted the inherent challenges in measuring this outcome because many factors contribute to decision‐making and it is often difficult for an individual to identify which factors had a role in their final decision . InsteadOur primary outcome was policymakers' use of evidence and therefore we restricted to studies that would provide a quantitative measure. We therefore limited inclusion to RCTs, NRCTs, CBA studies, and ITS studies but planned to extract qualitative data for these outcomes, when provided. Only one study presented qualitative data and and five studies were excluded because they were qualitative studies. These studies may provide additional data regarding the credibility, desirability, relevance, understandability, and usefulness of evidence summaries which would be helpful for understanding how and why evidence summaries could be useful in policymaking.We did not assess the use of health behaviour theory. This may be an important concept for understanding the effectiveness of evidence summaries and therefore we plan to include it in future updates of this review.Our review is limited by the indexing of studies in this area. To address this issue, we conducted a broad search using search strategies adapted from similar systematic review. Our search identified over 10,000 references but we had a low yield of included studies. The methods used in the included studies were poorly reported. For example, only two studies adequately reported on random sequence generation or allocation concealment, which means that most studies have unclear risk of bias.Previous systematic reviews have assessed the effectiveness of interventions for improving the use of systematic reviews in decision‐making by health system managers, policymakers, and clinicians ; interveMurthy et al. assessed the effectiveness of interventions for improving the use of systematic reviews in decision‐making by health system managers, policymakers, and clinicians . SimilarThe review by Wallace et al. assessed potential facilitators to the use of systematic review evidence by policy‐makers and identified five potential factors: the perception that systematic reviews may be used for improving knowledge, research, and evidence‐based medicine skills, content that assesses benefits, harms and costs and is perceived as current,transparent and timely; a ‘graded entry’ format; training in use of systematic reviews and peer‐group support . We did The interventions assessed in the studies included in our review are quite diverse with a variety of outcome measures. We included a broad range of interventions to provide an overview of the evidence on systematic review derivative products. These products have important differences in design and source material. For example, a policy brief includes evidence from one or more systematic reviews and includes information from additional sources  whereas Overall, the studies included in our review suggest that evidence summaries may be easier to understand than complete systematic reviews. To facilitate the use of systematic review evidence by policymakers, reviews need to be perceived to be of high quality and assess a relevant research question . SystemaFuture studies should include an assessment of delivery strategies because the effectiveness of the systematic review derivative product in practice will be affected by policymakers' knowledge of and access to the summaries themselves. Our included studies suggest that evidence summaries have a small effect on improving knowledge and understanding and may be easier for policymakers to understand. However, we have very little evidence to inform the design of evidence summaries because we only found a handful of different formats (none the same), and there was little to no difference between formats when compared directly.It is important to note that only two of the included studies compared the evidence summary to a full systematic review or access to a database of systematic reviews. The others compared different versions of evidence summaries and, in general, found little to no differences in the effects. Had these studies included systematic reviews as a control group the results may be different.Future studies should ensure that derivative products are compared to complete systematic reviews. Qualitative methods may be appropriate for future evaluations to assess the effectiveness, credibility, desirability, understandability, usefulness, and relevance of evidence summaries. Similarly, future reviews may consider qualitative synthesis which may add a deeper level of understanding to our findings.Additional research on the use of evidence summaries derived from systematic reviews is needed. Researchers should consider the primary goal of these derivative products, which is to increase the uptake of systematic review evidence, and aim to assess this in future studies. The production of evidence summaries and other systematic review derivative products is increasing and therefore, more evaluation of their effectiveness on increasing the use of systematic reviews by policymakers and health system managers is needed to ensure they have the desired effect of increasing the use of systematic review evidence in decision‐making.The lead author is the person who develops and co‐ordinates the review team, discusses and assigns roles for individual members of the review team, liaises with the editorial base and takes responsibility for the on‐going updates of the review.Content: Jennifer Petkovic, Peter Tugwell, Vivian WelchSystematic review methods: Jennifer Petkovic, Peter Tugwell, Vivian WelchStatistical analysis: Jennifer Petkovic, Vivian WelchInformation retrieval: Ana Patricia Ayala, Heather Cunningham, Manosila YoganathanThe authors thank Christian Charbonneau who assisted with the screening and data extraction.This work was supported by JPs CIHR Doctoral Research Award and Campbell Systematic Review Award.None to declare.Jennifer Petkovic will be responsible for ensuring that this review is kept up‐to‐date.Supplementary materialClick here for additional data file.


The spleen is a vital lymphoid soft organ that demands constant attention from the clinical point of view. It is a multi-dimensional organ that enlarges in its all dimensions during some disease condition. The detection of the spleen by palpation is not an indicator of an enlarged spleen because normal spleen may be palpable. Therefore, this study aimed to assess the morphometry of spleen dimensions and its determinants among individuals living in Arba Minch town by sonographic examinations.Community-based cross-sectional study was conducted in Arba Minch town from February 1 to March 30, 2020. Seven hundred and eight study participants were selected using a multi-stage systematic random sampling technique. Data were checked for completeness, edited, coded and entered into Epi-Data version 3.1 and exported to STATA software version 16 for analysis.3, respectively. The mean spleen length, width, thickness and volumes among males were 10.64 cm, 4.92 cm, 4.05 cm and 119.81 cm3 and among females were 9.75 cm, 4.63 cm, 3.78 cm and 96.50 cm3 respectively. As age increased by one year the mean spleen length, width, thickness and volume was decreased by 0.032 cm, 0.018 cm 0.004 cm and 0.012 cm respectively. As height increased by 1 cm the mean spleen width and volume were increased by 0.096 cm and 0.052 cm respectively. As we go from male to female the mean spleen length decreased by 0.294 cm.The mean splenic length, width, thickness and volume were 10.24 cm, 4.79 cm, 3.93 cm, and 109.34 cmThe spleen dimensions were higher in males than females. Splenic length was determined by age & sex, the spleen width was determined by age & height, the spleen volume was determined by age & height and the spleen thickness was determined by age. The spleen is the largest lymphoid organ located in the left hypochondrium between the fundus of the stomach and the diaphragm where it is entirely covered by the inferior thoracic rib cage . It exteThe spleen is an encapsulated intraperitonial organ entirely covered with peritoneum except for its hilum where the splenic branches of the splenic artery and vein enter and leave . It is sIn diseases condition spleen enlarges at different rates in its all dimensions. A variety of diseases condition alters spleen dimensions, where splenomegaly and its consequence becomes a primary clinical concern in developing countries . It is cSplenic atrophy is also another common problem seen in diseases like sickle cell anaemia where the progressive atrophy as a result of repeated attacks of vaso-occlusion and infarction caused by these diseases leads to auto splenectomy .The average dimensions of the spleen are 12.5 cm, 7.5 cm and 2.5 cm in length, width and thickness respectively and 150–200 g in weight, but its dimensions vary considerably . The litIn clinical practice, palpation is commonly used to detect spleen enlargement. However, detection of spleen by palpation is not reliable or (not accurate) and might lead to misdiagnosis , 22, 23.Although, literatures indicates radiological imaging modalities like ultrasound can detect the extent, complications, and classify the severity of cases, yet enough attention is not given in clinical practice . On sonoEven though there are several studies in which the spleen dimensions have been analysed in many countries, there is still a lack of adequate information in African populations including Ethiopia. Therefore, the study was aimed to assess the morphometry of spleen dimensions and to determine its variations with sex, age, height, weight, body mass index (BMI), and body surface area (BSA) among individuals living in Arba Minch town.The community-based cross-sectional study was conducted from February 1 to March 30, 2020, in Arba Minch town, Southern Nations, Nationalities and Peoples Region (SNNP) which is located at an altitude of 1285 m above sea level and 437 km south of Addis Ababa .The data was collected using data collection checklist. The data collection checklist was developed in English after reviewing different literature and the face validity was assessed by a public health specialist, radiologist and anatomist. The checklist was composed of socio-demographic factors (age and sex); anthropometric measurements  and spleen dimensions .Seven hundred and eight individuals  fulfilling inclusion criteria were selected by multi-stage systematic random sampling technique. During the procedures, individuals were first selected randomly at household levels by distributing questionnaires which include the inclusion criteria. Then the individuals fulfilling the inclusion criteria were sent to the nearest health center or selected private clinics for clinical and sonographic examination. During examinations, history and physical examination of individuals were taken before sonographic examination by physician. Then sonographic examinations were performed by two radiology technologists using portable and stationary ultrasound machines equipped with 3.5 MHz convex probes. During sonographic examination, the subjects were examined in the supine or right oblique positions. After assessment of overall abdominal sonographic examinations, the spleen dimensions measurements were performed for those with no case findings. The measurement was performed during suspended respiration. The splenic length was measured in a longitudinal plane between the dome of the spleen and the splenic tip  All apparently healthy individuals and age greater than 13 years .Individuals with a recurrent clinical history of malariaRecurrent history of typhoid feverIndividuals with a history of infections .Recent history of upper abdominal surgeryIndividuals with any case finding on sonographic examinations Individuals with Diabetic Mellitus (DM) cases.Hypertensive individualsIndividuals with a history of heart diseaseIndividuals with a recent abdominal traumatic condition (within the previous 6 months)Pregnant womenHistory of sickle cell anaemiaVery old ageApparently healthy individuals: is defined as the absence of disease based on clinical signs and symptoms of individuals assessed by history, physical evaluation and sonographic examinations , 34.p < 0.05 was taken as statistically significant. Linear regression model were fitted to identify determinants of spleen dimension. Square root and logarithmic transformation were used for thickness and volume respectively to full fill the assumption of linear regression.Data was checked for completeness, edited, coded and entered into Epi-Data version 3.1 and exported to STATA software version 16 for analysis. A descriptive summary was used to present the result. Independent- Samples t-test was conducted to compare the mean spleen dimensions among sex and one-way ANOVA was conducted to compare the mean spleen dimensions among age groups. T and F statistics were calculated and 3, respectively  and more than one third (39.3%) were between the age group of 21–30 years. Majority of participants (82.49%) had normal BMI , 11–20 year compared to > 50 years , 21–30 years compared to 41–50 years , 21–30 years compared to > 50 years , and 31–40 years compared to 41–50 years . The change in spleen width was significantly higher for 11–20 years compared to > 50 years old , 21–30 year compared to > 50 years , and 31–40 years compared to > 50 years . The change in spleen thickness was significantly higher for 31–40 years compared to 41–50 years old , 11–20 year compared to > 50 years , and 31–40 years compared to > 50 years . The change in spleen volume was significantly higher for 31–40 years compared to 41–50 years old , 21–30 year compared to > 50 years , and 31–40 years compared to > 50 years   for the sonographic measurement is the other limitation of the study.