The Neurocritical Care Society (NCS) launched its clinical practice guideline program in 2012 with the publication of “Guidelines for the Evaluation and Management of Status Epilepticus” , which hWith the emergence of multiple GRADE-based guidelines since standards were developed, concerns were also raised about lack of adherence to published GRADE criteria in the development of these guidelines. In 2020, the US GRADE Working Group critically reviewed GRADE guidelines published in the National Guideline Clearinghouse . Of the Over the course of the past decade, NCS has produced a number of guidelines and related projects, the majority of which used methodology derived from GRADE publications  and geographic diversity are considered, along with traditional metrics of diversity among panel members. Panelists from varied related specialty areas, such as rehabilitation, neurological surgery, epileptology, or other relevant areas, may also be included on the basis of the topic. A more recent addition to this process involves engagement with health care consumers. As such, the panel will recruit patient or family representatives. Incorporation of the patient/family perspective can be invaluable in deciding on patient-centered outcomes and offering insight into the impact of recommendations.It is often difficult for organizations to assemble and retain an internal team of methodologists with adequate expertise in GRADE and experience in performing systematic reviews. Basic criteria for this role have been suggested by the GRADE Working Group. Our survey has shown that many organizations enlist professional methodologists for this purpose  may require downgrading of the evidence quality.Once PICO questions have been refined with up to seven patient-important outcomes that have been identified with ranking of relative importance , a search strategy is developed with a research librarian. Important trade-offs between global inclusiveness  and feasibility (retrieving a large number of irrelevant or unusable studies) require close collaboration between the panel and the information specialist. Search strategies that are too broad will produce an avalanche of irrelevant studies, whereas stringent strategies are likely to miss important evidence. Once a search strategy is applied, the articles are then screened for inclusion or exclusion by using SR software . The vast majority of references are removed via screening in this multilayered, labor-intensive process.The next task, data extraction from the selected studies, introduces important innovations of the GRADE approach. First, it does not assign an evidence quality rating  to any individual study. Rather, evidence quality (certainty in the evidence) is an attribute of the entire body of evidence for a given outcome. What GRADE evaluates in each study is its risk of bias (otherwise known as study limitations). In this process, randomized controlled trials (RCTs) are initially considered to be of high quality because randomization is felt to be the only secure way to eliminate residual confounding and bias in patient selection; nonrandomized  studies (NRS) begin as low quality.In neurocritical care, there is a paucity of high-quality evidence, particularly in terms of well-designed and well-executed RCTs. Thus, there is increasing interest in the wide variety of NRS. Cochrane’s risk of bias tool uses domains familiar to many as the appropriate instrument to apply to RCTs . Many toThe second important innovation of GRADE is that evidence is aggregated, and quality of evidence is assessed, according to the critical and important outcomes prespecified in the PICO question . That isRisk of bias is only the first of the domains GRADE uses for assessing the quality of a body of evidence see Fig. . Four otAn existing high-quality published SR could be adapted or adopted for use in a new guideline, but more commonly, a new SR is performed by the writing group itself. This has been the practice for NCS guidelines. Our experience over a decade of work has highlighted two interrelated problems with this approach. The first problem is that to apply GRADE methodology properly, dedicated study, training, and experience are required. This is difficult to achieve in a volunteer organization, such as NCS, in which there is little carryover in writing group personnel from one project to another, resulting in a lack of consistency and institutional memory.A second problem, which contributes to the first, is the heavy workload encountered by the panel of volunteer subject matter experts in screening and extracting data from hundreds or thousands of studies. Knowledge and experience gained in each project do not carry forward seamlessly to the next. Experienced panelists find it difficult to commit to another project, realizing the labor required to complete a guideline. Moreover, in recent years there have been many important advances and refinements in GRADE methodology and in clinical epidemiology; the earliest GRADE publications lacked necessary specific and detailed guidance. Thus, a guideline methodologist faces the additional challenge of providing expertise in a field undergoing rapid evolution.Journal of Clinical Epidemiology in the GRADE series, and the GRADE handbook; (3) experience with producing at least three GRADE/Cochrane SRs, with meta-analyses, and GRADE evidence profile/summary of findings tables using GRADEpro Guideline Development Tool software; (4) familiarity with using the ROBINS-I tool to evaluate NRS; and (5) experience using the Evidence to Decision Frameworks to arrive at recommendations.With the widespread adoption or endorsement of GRADE by medical societies and health care organizations worldwide, the need for appropriately trained methodologists to assist in creation of high-quality GRADE guidelines has become paramount. Inappropriate use of GRADE methodology has been described by senior GRADE authors . The GRAIt is not necessary for the methodologist performing an SR to be a subject matter expert. In fact, in a voluntary society, such as NCS, it may be particularly challenging to find volunteers with appropriate background training in GRADE who would also be available to commit their time to a series of guideline projects. On the basis of our experience and the survey result, there is an increasing trend for medical societies and health care organizations to rely on outside experts given the above-mentioned challenges.A defining feature of GRADE is the structured manner in which it moves from evidence to recommendation. An SR produces an evidence summary and judgment of certainty in the evidence that is relevant for the specified population. What is lacking in an SR, and what is required in a guideline, is a framework for describing the context of the individual patient encounter.Each PICO question should be answered by a clear, actionable recommendation, not a statement of fact. GRADE describes recommendations in terms of strength  and direction (for or against a management strategy). Strength refers to “the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects” . It is fCertainty in evidence of effect of the management strategyValues and preferences of the patient/caregiverBalance of desirable and undesirable effects, from the patient’s perspectiveResource implications, acceptability, and equityHowever, the balance of benefit and harm is not necessarily the same for each clinical circumstance, and concepts such as “applicability” used in some guidelines are too vague and undefined to provide useful guidance . Thus, GA strong recommendation implies that “all or almost all informed people would make the recommended choice for or against an intervention” . A condiGreat emphasis is placed on determining the patient’s perspective and circumstances as well as the relative importance of various outcomes to that individual. Together with the best available evidence and clinician expertise, explicit consideration of the individual patient’s circumstance is what defines evidence-based practice . How canIs the statement clear and actionable?Is the message really necessary?Is the net benefit large and unequivocal?Is the evidence difficult to collect and summarize?Has the rationale been made explicit?Should this statement be GRADE-ed? Does a large body of indirect evidence that can be convincingly linked to the PICO support the management strategy?A common and vexing problem arises when the evidence base for a PICO question proves to be of low or very low quality. Low  or very low certainty  are encountered frequently in neurocritical care because many of the clinical studies available are NRS. GRADE assigns an initial “low” quality rating to all such studies, and deficiencies in design and conduct may lead to rating down the body of evidence further to “very low.” In this circumstance, guideline panels may be tempted to create recommendations that are not explicitly supported by an analysis of evidence quality. These may be termed “good practice” or “best practice” statements. These statements essentially represent the expert opinion (which GRADE does not consider to be evidence) of the panel. GRADE provides an analysis of when these may be justified  and suggThus, although there may be instances when these questions can be answered affirmatively, we recognize that overuse of such statements carries the risk of diminishing the confidence of guideline users in the rigor and trustworthiness of the guideline. The US Preventive Services Task Force specifically advises that “decision makers do not have the luxury of waiting for certain evidence. Even though evidence is insufficient, the clinician must still provide advice, patients must make choices, and policy makers must establish policies” . This isClinicians will rarely explore the evidence as thoroughly as a guideline panel, nor devote as much thought to the trade-offs, or the possible underlying values and preferences in the population. We therefore encourage panels to deal with their discomfort and to make recommendations even when confidence in effect estimate is low and/or desirable and undesirable consequences are closely balanced. Such recommendations will inevitably be weak, and may be accompanied by qualifications .Review of a decade of work by NCS guideline panels together with a survey of the guideline practices of other organizations has revealed a number of opportunities for improvement in the conduct and methodological rigor of our clinical practice guidelines.The crucial role of the methodologist was evident in the GC survey. Thus far, NCS has used members who have undergone GRADE workshop training as methodologists. Other surveyed organizations employ staff who serve as methodologists across projects. Such individuals have deep experience and strong institutional support from other internal experts. These organizations also have a long history of creating guidelines that closely follow a well-established methodology, whether GRADE or other. Institutional memory is key.The most successful guideline programs in our survey use professional methodologists to perform the SR and to produce the evidence synthesis, with evidence tables and meta-analysis meeting GRADE or Cochrane standards. Close collaboration between the methodologist, the panel chairs, and the oversight body (GC or other) throughout the project was a common theme. This coordination ensures that the topic and scope are both appropriate and feasible and that PICO questions are correctly formulated. The methodologist provides the writing panel with education and mentoring regarding the GRADE process so that additional advanced training in GRADE for chairs and panelists may not be needed. In addition, the methodologist benefits from frequent clinical guidance as the SR progresses.NCS has not developed a sufficient pool of experienced members with the ability to work intensively on successive projects. The GC has found that attendance at one or more workshops does not make one a methodologist. Competence in these techniques cannot be gained from slide presentations or by reading summary reviews. Past guideline chairs have typically not had formal training in GRADE or SR methodology. They have relied on an NCS member volunteer who has served as a GRADE methodology advisor after one or more guideline experiences and attendance at a GRADE workshop.Panel members have usually been overwhelmed by the large commitment of time and effort involved in a formal SR. Inexperience with GRADE methodology may add to the burden on chairs as well as panelists. This may result in evidence summaries that deviate significantly from GRADE principles and practice, incorrectly formulated PICO questions, chosen topics with a scope that is excessive in relation to what is feasible, and recommendations in which the linkage to evidence quality is inappropriate and the rationale is unclear. Importantly, inexperience has contributed to significant difficulty in conforming to a clear timeline.The topic is commonly encountered in neurocritical careThere is equipoise between different management strategies, resulting in significant variation in practiceA reasonable amount of evidence is currently available from clinical trials and can be synthesized by using GRADE methodologyThe topic lends itself to 6–15 tightly constructed clinical questions with both defined populations or subgroups and critical and important outcomes that lend themselves to quantitative analysisThere is sufficient overlap between adult and pediatric care that questions can address both populations, when appropriate and possibleThere has not been a recent high-quality guideline directly addressing the topicThe topic has not been the subject of current or recent NCS projectsSuggestions for guideline topics will be solicited from the GC and NCS membership. However, the process of choosing a topic will rely on established criteria and compatibility with GRADE methodology. Adherence to the following criteria can avoid common pitfalls and contribute to the success of future guideline efforts:The GC will make deliberate efforts to assemble a diverse panel of stakeholders across health care organizations, genders, roles, and specialties. The GC is also committed to including public members for the perspectives of patients and caregivers.Panel chairs will draft PICO questions with input from the writing panel. These draft questions will be reviewed by the GC and by the methodology team prior to forwarding to an information specialist working with our methodological partners.The guideline practices survey revealed high standards for methodological rigor, consistency, and clarity among successful programs. To meet these standards, NCS will collaborate with a group of professional methodologists well versed in GRADE techniques. The society has committed to collaboration with Guidelines in Intensive Care, Development and Evaluation (GUIDE), a group of methodologists at McMaster University . GUIDE will perform the entire SR and provide instruction in GRADE techniques to the team. Panelists will gain from the streamlined and shortened process and reduction in workload.A defining feature and innovation of GRADE is a structured process for applying population-level evidence to the individual patient encounter, referred to as the Evidence to Decision Framework. This process is facilitated and made clear, deliberate, and explicit by the use of GRADE software, which is provided and managed by our external methodology partners.Successful guideline programs strive for a consistent and recognizable format and brand in their products, even if methodologies differ. This is particularly true for the presentation of recommendations. NCS will follow strict GRADE guidance in formulating recommendations and minimize the inclusion of good practice statements based on expert opinion.The GC performed a review of past NCS guideline practice and a survey of the practices of a number of other organizations. A principal finding was that most successful guideline programs incorporate professional methodologists into their working groups. By adopting this practice, NCS will be able to significantly improve the quality of its guidelines and establish a reliable, consistent, and trustworthy brand. To that end, the NCS Board has adopted the GC recommendation to collaborate with a team of external GRADE methodologists, an alliance that affirms the society’s commitment to developing high-quality resources to support and advance the practice of neurocritical care.Embarking on this partnership, the GC anticipates three significant benefits. First, NCS members will find the experience to be more aligned with their expectations and hence will be more likely to volunteer their time on guideline development. Second, we expect guideline production to follow a more predictable and efficient timeline, with likely reduced time to publication. Last but not the least, our guidelines will achieve a consistent level of quality that can be favorably compared to those of other societies. This could greatly improve the dissemination and implementation of our guidelines.Supplementary file1 (DOCX 59 kb)Below is the link to the electronic supplementary material.


Good eHealth literacy and correct beliefs about medicines are beneficial for making good health care decisions and may further influence an individual's quality of life. However, few studies have discussed these two factors simultaneously. Moreover, gender differences are associated with health literacy and beliefs about medicines. Therefore, it is important to examine the multiple relationships between college students’ eHealth literacy and beliefs about medicines, as well as gender differences.This study aims to (1) examine the multiple relationships between eHealth literacy and beliefs about medicines and (2) analyze gender differences in eHealth literacy and beliefs about medicines with Taiwanese college students.t tests and canonical correlation analyses.We used a paper-and-pencil questionnaire that included age, gender, 3-level eHealth literacy, and beliefs about medicines to collect data. In total, 475 data points were obtained and analyzed through independent t test  showed that women had lower functional eHealth literacy and more specific concerns about medicines than men. Canonical correlation analyses indicated that the first and second canonical correlation coefficients between eHealth literacy and beliefs about medicines reached a significant level, implying that a multivariate relationship indeed existed.The These findings reveal that women in Taiwan have lower functional eHealth literacy and stronger concerns about medicines than men. In addition, students with higher eHealth literacy have more positive perceptions of and beliefs about medicines. Beliefs about medicines refer to a concept related to the cognitive representation of medicines. Such beliefs are used to evaluate individuals’ beliefs regarding the necessity of and problems associated with prescribed medication and their more general beliefs about the overuse and detrimental effects of medicines . AccordiIn addition to directly help people establish correct notions of medication use, enhancing individuals’ health literacy may be another useful approach because the process of forming beliefs about medicines may depend on information seeking and processing. Health literacy is the capability of individuals to access, comprehend, and effectively utilize health-related information, and it is a critical factor in the disease management and health promotion arena . When paThe internet has become a popular way to search for, obtain, and share health-related information over the last decade. Nevertheless, the abilities needed to collect and evaluate information through the internet differ from those needed to use books and other hard copies. In the cyberworld, individuals must be equipped with the ability, resources, and motive to seek, understand, and evaluate web-based health information . eHealthIn Taiwan, one can quickly and conveniently find information about medicinal drugs and disorders via the internet . Before Therefore, to obtain a comprehensive understanding of this topic and to address the lack of other samples in previous studies, with a focus on health education in Taiwan, the present study aims to examine the multiple relationships between college students’ eHealth literacy and beliefs about medicines and to analyze gender differences. Specifically, we attempted to answer the following questions: What is the relationship between eHealth literacy and beliefs about medicines among college students? Further, what is the effect or role of gender in these two concepts? Based on the extant literature, we propose the following hypotheses:Taiwanese college students with higher eHealth literacy are more likely to have positive perceptions of and beliefs about medicines.Taiwanese women are more likely to have lower eHealth literacy and stronger beliefs about medicines than men.We collected 2 samples from Taiwan; 1 sample was used for pretesting, and the other sample was used for the formal study. Pretesting was employed to validate the appropriateness of the research instrument used in this study by performing an exploratory factor analysis (EFA) to confirm the construct validity. The formal study was used to analyze the relation between college students’ eHealth literacy and their beliefs about medicines and the associated gender differences.During pretesting, a convenience sampling approach was used to recruit students to participate in this investigation. We contacted our acquaintances who teach at other universities to help us promote this research and distribute the questionnaires. In total, 199 data points were returned and analyzed in the pretest study. A stratified random sampling method was adopted for the formal study. Specifically, we divided Taiwan into 3 regions and then used a computer to randomly select schools. For the selected schools, we contacted their instructors and asked whether they were willing to assist with distributing the questionnaire. Ultimately, 500 questionnaires were distributed, and 475 were returned. Among the 475 responses, missing values for each question did not exceed 2. We used the series mean to replace these missing data.P<.001), and the coefficient of correlation ranged from 0.70 to 0.85 (P<.01). The EFA and CFA results revealed that the Kaiser–Meyer–Olkin (KMO) measure was 0.83, the Bartlett test for sphericity was significant (P<.001), the factor loadings ranged from 0.53 to 0.90, the explained variance was 61.10%, the standardized factor loadings ranged from 0.60 to 0.86 (P<.001), composite reliability ranged from 0.75 to 0.84, and the average variance extracted for each dimension ranged from 0.50 to 0.52. In addition, for the goodness-of-fit indexes, χ251=139.00, comparative fit index=0.96, root mean square error of approximation=0.06, and standardized root mean square residual=0.05. Each item in the eHLS was rated by the respondents on a 5-point Likert scale, with 1 indicating strong disagreement and 5 indicating strong agreement. Higher eHLS scores indicated that the participants had higher eHealth literacy, and all the variables were regarded as continuous variables. According to Sharma’s [The participants’ eHealth literacy was measured by the eHealth Literacy Scale (eHLS) . The eHLSharma’s  guidelinThe Beliefs About Medicines Scale (BMS) was designed by the authors on the basis of Horne et al’s  scale. Tt tests, and a canonical correlation analysis to gain a better understanding of our samples and clarify the relationship among the research variables. Notably, all statistical analyses were performed using SPSS. A value of P<.05 was considered statistically significant.In the pretest study, peer review was employed to test the content validity of the 13-item BMS, and an EFA was used to assess its construct validity. In the formal study, we calculated the internal consistency coefficients  of each instrument and performed a descriptive statistical analysis, independent This study used an anonymous questionnaire to gather data, which is consistent with the government’s institutional review board rules for exempt review. All participation was voluntary and confidential. To ensure anonymity and confidentiality, we asked the students not to write any personal information on the questionnaire, and all the questionnaires were stored in a locked cabinet that only the researchers could access. Before distributing the questionnaires, the lecturer clearly informed the participants of the study aim and noted that they had the right to refuse to participate at any time without penalty; in addition, the participants were informed that their participation would not have any influence on their grades.Most of the students were under 22 years of age, except for 31 students whose ages ranged from 23 to 40 years, and the average age of our participants was 20.37 years. t test results shown in men 4.07, meanwomen 3.81; t473=3.73; P<.001) and that women had stronger concerns about medications than men .The P<.05).The results of the canonical correlation analysis presented in The results of the first canonical variate indicated that the students with relatively high functional and interactive eHealth literacy were less concerned about the 4 aspects related to the medicines used. The results of the second canonical variate revealed that the students with relatively high critical eHealth literacy were less concerned about the specific necessity of the medicines used.This study found that women had lower functional eHealth literacy and higher specific concern about medicines than men; hence, hypothesis 2 is only partially supported by our findings. Previous studies have found that female sex is associated with limited functional health literacy ,17. ReseFunctional literacy is closely linked to reading comprehension and numeracy skills . AlthougConsistent with Viktil et al , this stHypothesis 1 is also only partially supported by the results of the canonical correlation analysis. The first canonical result indicated that students with relatively high functional eHealth literacy were less concerned about the 4 aspects related to medicine. According to Taiwan’s Ministry of Health and Welfare, relevant indications should be printed on medication packaging, such as drug names, cautions, principal indications, and main adverse reactions . FunctioTherefore, compared to students with higher functional eHealth literacy, those with lower functional eHealth literacy might have poorer abilities to understand information related to their medications and thus believe that they need more personal medication and have more concerns about the potential negative effects of medicines; such students were also more inclined to believe that medicines are harmful and overused by physicians. Scholars have argued that illustrated medication information provides useful reinforcement , and forMoreover, the results of the first set of canonical correlations showed that students with higher interactive eHealth literacy tended to have positive perceptions and beliefs about medicines. In Taiwan, people can conveniently and quickly search for information about medications and disorders through the internet, news, and magazines . InteracFinally, the results of the second set of canonical correlation analysis revealed that students with adequate critical eHealth literacy were less likely to have stronger perceptions of a need for medications to maintain their present and future health. Critical eHealth literacy refers to the most advanced cognitive competency that is used to critically appraise and evaluate web-based information relevant to health ,21,36. GAlthough this study contributes to our understanding of the relevant correlates of eHealth literacy and beliefs about medicines, it has some limitations. First, this study used a cross-sectional design. Thus, we gathered data at a single time point and could not determine the development of beliefs about medicines along with eHealth literacy. Second, since the 2 scales (eHLS and BMS) applied in this study did not have predictive validity information, these scales’ utility may be questionable. We suggest that future studies should consider this issue, using more complete scales to address this concern. However, even with this flaw, the study provides a good starting point for further studies in general. Third, our participants may have been likely to overestimate or underestimate their eHealth literacy and beliefs about medicines owing to social desirability expectations. Future studies could adopt research methods other than self-reporting assessment to address this issue. Fourth, the sample in the current study was restricted by age to college students in Taiwan. The findings should be interpreted considering the sample’s homogeneity. In particular, students’ different demographic characteristics  may influence beliefs about medicines and eHealth literacy. Future studies can use diverse samples and perform covariance analysis to control for these potentially influential factors. Finally, students’ healthy skepticism of medications is not documented as part of this study. Healthy skepticism helps people wary of medicine information and gauges medications’ value from a different perspective. Future studies could consider this variable.To the best of our knowledge, this study is the first to explore the relationship among the 3 levels of eHealth literacy and 4 aspects of beliefs about medicines among college students, especially Taiwanese college students. Our study contributes not only to research but also to educational practice. Our results indicate that higher the eHealth literacy of Taiwanese college students, the more positive the perceptions and beliefs about medicines they held, thus providing some insights for health educational practitioners who could help college students build positive beliefs about medicines by promoting their eHealth literacy. In addition, this study found that women had lower functional eHealth literacy and stronger concerns about medicines than men. Therefore, health educators could develop gender-specific programs to improve women’s functional eHealth literacy and reduce their concerns about medicines.


Phoca vitulina) and grey seal  carcasses were analysed. This investigation is urgently needed since information on microplastic burden in grey seals, especially from the Baltic Sea, are still lacking. This information is particularly important as it allows a direct comparison of this species and its sympatric species, the harbour seal, from different waters. A slightly higher incidence of microplastics  was found in specimen found in the Baltic Sea. Moreover, higher microplastic loads were detected in stomachs compared to the intestinal samples, with first evidence of fragment retainment within the GIT. Nevertheless, an accumulation of microplastics in marine mammals could not be excluded for all categories since the egestion of those subjects is documented and no significant differences in life history parameters such as sex and age, nor parasite infestation were revealed.It is well known that the occurrence of microplastics (MP) is ubiquitous in both water compartments and in biota. Nevertheless, knowledge on the microplastic exposure of marine mammals is scarce. This study gives first evidence of microplastic burden in seal species inhabiting German waters of the North Sea and Baltic Sea. Accordingly, 63 gastrointestinal tracts (GIT) of harbour seal . In contrast, knowledge on the exposure to grey seals and particularly on specimen inhabiting the Baltic Sea (BS) are scarce. This study examined 63 gastrointestinal tracts (GIT) of harbour seals and grey seals originating from German waters (NS and BS) found between 2014 and 2019. Besides the documentation of microplastic findings, this study is dealing with life history and health parameters, attempting to identify correlations with microplastic presence. This study confirmed beside the presence, the egestion of microplastics  in the examined seals, without correlations in parasite infestations or inflammation responses. 540 suspected MPs were identified in 62 intestinal samples , and 228 MPs in seven stomachs . In accordance, first evidence of the retainment of fragments in the GIT were given. However, no significant difference in MP occurrence was indicated for different sex or age groups. The awareness of marine litter presence and its impacts on marine biota increased in recent years . In accoFirst evidence of the MP burden in the main regularly occurring top predator species are given in studies focusing on marine mammals found along the German and Dutch coastline; two studies investigated harbour porpoises ,15 and aFurthermore, Germany as part of the EU is obliged to monitor and inform on the burden caused by anthropogenic impacts on their waters  . TherefoPhoca vitulina) and grey seals  found along the German coastline. This allows for an insight into the MP burden of those species occurring in both, the German NS and BS. Moreover, this study is taking information on the age and sex of the investigated individuals into consideration, as well as records of gastrointestinal lesions and parasite infestations to reveal possible relations. The evaluation of lesions such as inflammatory responses and MP occurrence was focused, because a risk of damage in the GIT tissue by those small particles and consequently an inflammation cannot be totally excluded, since it is already well documented in invertebrates and mice [To fill the gap of this lacking information on MP occurrence in seals, this study investigated intestinal and stomach samples of harbour seals  and was selected in case faeces were present and the gastrointestinal tract (GIT) was undamaged [Since 1990, the Institute for Terrestrial and Aquatic Wildlife Research (ITAW) regularly conducts necropsies of stranded, bycaught or mercy-killed marine mammals found at the coasts of the federal state of Schleswig-Holstein in Germany ,28,29. Endamaged . The intndamaged . A detaindamaged .This study also investigates seven belonging stomachs of harbour seals and a grey seal in addition to the intestinal samples, all gathered in 2019. Those stomachs were taken into account to extend the analysis of the GITs focusing on MPs and enlarge the sample collection in addition to the priorly collected intestinal samples. In six out of the seven cases, both the intestinal sample and the stomach were examined. For the remaining stomach investigated, no intestinal sample could be analysed due to lacking faeces. The stomachs were completely removed from the carcasses, ligated with draw strings at the cardia and the pylorus to avoid any loss of the stomach content. Afterwards, the collected stomach was transported covered in aluminium foil to the working environment, the closed acrylic box, for further processing: The stomach was rinsed with MilliQ water from the outside and the drawstrings were removed prior opening it above the nylon fabrics. The suture, cleansing and all other subsequent steps were conducted after the same protocol, as it was used for the intestinal samples described above and after Philipp et al. .To select only specimen which already preyed independently, ensuring that an MP uptake is considerable, samples of adults and one year old individuals were primarily chosen. Moreover, individuals classified as under a year were chosen if their stomach was filled with prey remains. The further age determination was conducted according to the weight and length of each carcass  togetherNext to those categories, the samples were selected in dependence on the origin sea and the species to enable a comparison on similar sample size. In total, samples of 62 intestinal samples were investigated from harbour seals and grey seals of NS and BS between 2014 and 2019. This includes also one carcass of a female grey seal which was found on the Danish coastline, since this individual was tagged in German waters by ITAW employees. Moreover, the sample size includes also an individual whereof the origin sea (NS or BS) is unknown. Thus, this individual is excluded from the comparison between the two seas. Those specimens were not generally excluded out of the whole investigation, since this study focused on covering the same time span for both waters (six years) as well as investigating the approximately same number of samples for NS and BS, which were limited by the presence of carcasses. Thus, those two exceptional seals were also considered, next to the individual whereof only the stomach was investigated.Found MPs in the size range of 100–5000 µm were photographed, measured in size, and categorized as either fragments or fibres. In the following, the term “particle” includes both fragments and fibres. Fibres are particles characterised by a maximal width of 8–23 µm, an elongated shape and a measured length of at least the triple size of the maximal width. All particles not meeting these criteria were classified as fragments. The focused size range of 100–5000 µm was determined by the used mesh size of 100 µm for the washing process and a unified definition of MP .The aim of this study was to evaluate the occurrence of suspected MP and its impacts rather than identify polymer composition. For identifying those MPs under fluorescence light, the following attributes were applied: biogenic look, the fluorescence appearance, and property of the particle . For a detailed overview of all categories and a catalogue of examples, see Philipp et al. .The whole processing of the samples was conducted in closed acrylic boxes, which are cleaned with MilliQ water and ethanol (70%) prior and after each working step. To monitor the risk of secondary contamination, 27 procedural blanks  were considered for estimating the potential risk of secondary contamination. The procedural blank filters include filtrations of the used MilliQ water, NaCl solution and the processed washing sachets which were treated in the same manner than those filled with samples. Whereas the blank filters out of the working environment present the contamination risk from the necropsy room (sample taking) and within the closed acrylic box (sample processing). Those blanks run along with the samples and were handled after the same applied protocol (16). The use of blanks is essential to judge the contamination during sample handling and allow for a most precise evaluation of the actual burden of the animals by avoiding overestimation of the particles in the sample.The mean values of each procedural blank category were calculated and subsequently summed up. Accordingly, two fibres and seven fragments were determined as secondary contamination per sample and were subtracted from each intestinal or stomach specimen to avoid an overestimation of MPs. Lost fibres of the used nylon fabric were easily determined using fluorescence microscopy, since its unique fibre pattern is identifiable (16). As consequence, those fibres could easily be excluded in the data evaluation.Pathological lesions of the GIT lesions such as inflammations or parasitic infestations were determined as part of necropsies and histopathological investigations and recorded in an internal health database. For inflammatory lesions, e.g., gastritis and enteritis, character, severity , distribution and age of the lesions were determined by veterinarians and pathologists after highly established protocols for the whole GIT ,33,34,35p < 0.05) [p < 0.001). All graphs were created with the package ‘ggplot2’ [The statistical analysis was performed in R Version 4.0.2 . The amo < 0.05) , besides < 0.05)  to evaluggplot2’ . Based onintestines = 39). A total of 326 MPs were identified in those specimen . In the intestinal samples of seals found in the BS (nintestines = 22), 209 MPs were identified in total. The findings differed between zero and 48 particles per individual. The share of fibres and fragments is similar in individuals found in the BS . In seven seals originating from the NS and two individuals from the BS no MP were present, after subtraction of the considered secondary contamination. Unfortunately, no stomach samples were available for these nine examined individuals, since the intestinal samples were collected prior 2019 and no stomachs were taken into account for MP investigations at this time.In seals from the NS the MP findings range between zero and 43 particles per intestinal samples . Nevertheless, a slightly larger number of MPs was determined in intestinal samples of individuals from the BS .Five examined stomachs of harbour seals from the NS showed a MP load from 16 to 53 MPs per sample. The two investigated individuals from the BS both showed the presence of MPs in the stomachs . In general, the MP occurrence in the stomach was in five out of six related cases higher when compared to the intestinal samples . No signt-test . In addition, an intestinal sample of a grey seal with an unknown place of finding was processed, and five fibres and no fragments were determined. Harbour seals in the NS are more burdened than in the BS , whereas the intestinal samples of the grey seals showed a higher MP occurrence in the NS . The individual findings categorised by sea and species are given in In total, intestinal samples of 33 grey seals of both seas were investigated and showed an MP share of zero to 43 particles per individual (M ± SD = 7.91 ± 9.83). In comparison, a MP burden of zero to 81 MPs was determined in 30 harbour seals (M ± SD = 9.45 ± 16.81). No significant differences were revealed within the application of the p-value = 0.45) were identified.In female seals, the mean MP presence was higher (M ± SD = 10.37 ± 18.7) compared to the occurrences in males (M ± SD = 7.44 ± 7.31). In addition, the four highest MP findings were found in females . Nevertheless, no significant differences between the sexes . In addition, the age  seems to have more impact on the MP burden than the sex . The grey line in Moreover, the numbers of suspected MPs decrease from adults to individuals younger than a year . Two of those seven stomachs showed multifocal mural inflammatory lesions . Furthermore, in both cases a mild parasite infestation of nematodes was found. Besides these lesions, those two specimens showed a medium range of MP findings (23 and 27 particles). In addition, no correlation between the number of parasites and the number of MPs in both, the stomach or in the intestine could be identified. In the remaining five stomachs, no inflammatory or degenerative changes were identified although three were infested with nematodes (16 to 53 MPs per specimen).Within the 62 intestinal samples, a range of zero to 81 MP particles were identified. Nine out of these specimens were assumed to be unburdened by microplastics, since no particles remained after subtraction of considered secondary contamination. In addition, no or mild parasite infestation in these intestines were determined. The highest number of MPs was found in a harbour seal originating from the BS with a moderate acanthocephalan and a severe nematode infestation. In other 16 individuals, a mild to moderate enteritis with different disease patterns was identified. In three out of those, no parasite infestation was determined. Furthermore, out of all 62 intestines, nine showed activated Peyer‘s patch cells, in which the MP presence ranged between 0–5 found particles per specimen. In total, 42% of all suspected MP in the intestinal samples were categorised as fibres and the remaining 58% as fragments. Nevertheless, no statistically significant correlation between MP occurrence and inflammatory lesions or parasite infestations was identified, when comparing the findings in this study.This study was conducted to evaluate the MP burden in seals from German waters as well as gaining an overview of possible correlations between life history parameter and MP uptake. In addition, this is the first study dealing with an extended amount of specimen originating from seal species of the German NS and BS. Compared to information from the BS, research results of MP burden in species from the Northeast Atlantic area are available. Thus, in the following we will mainly focus on this region for discussing our results and to put it into the right context.In total, 535 MP particles were found. To avoid an overestimation of the actual burden, 27 blanks were taken into account. Furthermore, Philipp et al.  already However, to allow a further stabilised and detailed overview of a microplastic burden and their effects in marine mammals, it is in general recommended for future studies to investigate additional samples of the GIT (stomach and intestine) and a specific number of specimens being investigated exclusively on MP research, as it was already performed by different studies in the past ,19,40. ISince it is already considered that the MP occurrence in predatory marine mammals occurs exclusively through the uptake of prey species ,9,17, itp-value = 0.78). Nevertheless, a larger sample size and an equal sample size out of both seas, and per species are recommended for future studies to further underline these results.The MP burden in the investigated individuals originating from the BS (M ± SD = 9.45 ± 16.92) is higher than in those found in the NS (M ± SD = 8.29 ± 11.62), even no significant differences were identified . Moreover, laboratory studies focusing on mice or mammalian cells found further evidence for relations between MP presence and cell lesions in the GIT (26). Nevertheless, the knowledge of MP occurrence and resulting lesions in free-ranging mammals, especially in marine mammals, is lacking. Since it is not possible to feed marine mammals with plastic due to ethical reasons, the only option is to compare results from laboratory studies with invertebrates or laboratory species to gain first evidence.n = 16), the etiology was more likely due to parasitic infection. Furthermore, 50% out of 16 individuals displayed a mild to moderate gastritis possibly due to parasitic infestation. In addition, the specimen with the highest MP burden of 81 particles also showed a severe parasite infestation by an acanthocephalan species in the intestine. However, no clear connection can be proven here since these acanthocephalan species are common endoparasites in seals from the NS and BS [In accordance, this study revealed that in 31.25% out of all displayed enteritis  detect MP and lesions in the tissue itself and (2) to determine the likelihood of the specific MP found, triggering the indicated lesion. However, all recent applied protocols focusing on MP burden in marine mammal GITs are dealing only with the gut content ,19,40, sFurthermore, the main part of the investigated carcasses in this study (37 out of 63), were in a state of starting or advanced decomposition , which n = 5), and an inconsistent distribution of MP presence , no correlation between a bycaught specimen and MP presence was identified, as it was evidenced in harbour porpoises [This is the first study dealing with MP occurrence and life history parameter of seals from the North Sea and Baltic Sea found on the German coastlines. Since no significant differences between sexes or ages could be identified, this study coincides with an already published research of no accumulation of MPs within the intestine of marine mammals . Neverthorpoises .Moreover, all findings of marine litter in a size which is visible by the naked eye are recorded for the here examined seal carcasses as it is already published in a previous study . In accoStudies investigating MP presence in seals from the BS are still missing. Thus, this study gives first evidence on the addressed burden in harbour seals and grey seals occurring in German waters (NS and BS). Nevertheless, no significant difference was identified between those two sympatric species. This indicates that the MP exposure for each species is at a similar level. In accordance, comparable surveys between the NS and BS, and the two seal species are lacking, so this study was needed to highlight differences in the occurrence of MP and its possible effects in harbour seals and grey seals from those areas. Similar to previous studies, the MP presence in marine mammal specimen from the BS were higher, if compared with those originating from the NS. Consequently, a higher MP exposure in the BS to marine mammals, especially for seals as indicated, is assumed. Nevertheless, no significant differences in microplastic loads between sexes or ages were revealed, which underlines the hypothesis of the egestion of MP particles (100–5000 µm). However, an accumulation of indigestible particles in the stomach compartment is considerable since the higher numbers of found MP within this investigation and previous studies indicate a restraint. Since information on undersized particles is still missing, further studies should focus on particles smaller than 100 µm, and their fates and pathways in vivo.


Low health literacy affects one-third of adults in the United States and can have a negative effect on health behavior and outcomes.The goal of this study was to examine attitudes and knowledge of health literacy among pediatric residents and faculty in pediatric resident continuity clinics across the country.p < .05). Qualitative data were analyzed using emergent coding and grounded theory to determine themes.An online mixed-methods survey was distributed to pediatric faculty and residents through the Academic Pediatric Association's Continuity Research Network. The 20-question survey included questions about the participants' health literacy knowledge and health literacy practices in continuity clinics, such as use of universal health literacy precautions. Categorical answer choices were dichotomized into positive and negative groupings and resident and faculty responses were compared using the Chi-squared test . Only 19% of residents and 26% of faculty were familiar with universal health literacy precautions. Many residents and faculty had received no training in health literacy (37% residents vs. 38% faculty). Barriers and challenges around health literacy included time, language, limited training or resources, low literacy, disease mismanagement, and fixed misconceptions.HLRP: Health Literacy Research and Practice. 2022;6(1):e51–e60.]Despite ample evidence in the literature to the contrary, most respondents believed they could correctly identify individuals with low health literacy. Additionally, most participants had not heard of universal health literacy precautions and were unaware of their usage in their practice setting. This is not consistent with current expert recommendations. These findings are troubling as they are from academic residency programs, indicating an educational deficit. These findings point toward a next step in health literacy education for pediatric residents. [Pediatric residents and faculty in continuity clinics were surveyed about their opinions, health literacy knowledge, ability, and practices in continuity clinics. Despite evidence to the contrary, most respondents believed they could correctly identify individuals with low health literacy and had not heard of universal health literacy precautions. These findings highlight the need for more health literacy education for pediatric residents. Health literacy is defined by the Institute of Medicine as: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” . Low heaUnfortunately, studies have also shown that not only do physicians have difficulty identifying caregivers or patients with limited health literacy, but pediatricians feel they have inadequate communication skills and time to meet the needs of these caregivers . AdditioThere is a potential gap in pediatric graduate medical education regarding health literacy, but this gap is not unique to pediatrics. Internal medicine and family medicine programs recognized a similar deficit and have implemented health literacy training curricula with positive results . SeveralAlthough general guidelines and content recommendations exist and can aid in the development of this curriculum, it is important to first understand the extent and characteristics of health literacy training in U.S. pediatric residency programs . The goaPractices were recruited through the Academic Pediatric Association's Continuity Research Network (CORNET) from March 2019 until March 2020. At the time of the study, there were 125 pediatric training programs enrolled in CORNET, which includes more than 50% of all pediatric residency training programs nationally . Among tThe online, anonymous research survey was a 20-item electronic survey structured with branching logic such that additional follow-up questions were presented based on participants' responses. The survey gathered general information about the participants including their position  and years in that role, continuity clinic practice setting , and the zip code of their practice. We asked health literacy knowledge and perceived ability questions adapted from evaluations developed by the Centers for Disease Control and Prevention and a continuing education online course on health literacy developed by Mackert et al.  and the Because this was a descriptive study, we powered this study to describe the 125 CORNET practices nationally, which include a total of approximately 7,500 faculty and residents. Using a 95% confidence level and setting a confidence interval of ±5 for the point estimate on training in health literacy, we planned to recruit a sample size of at least 365 participants. If we recruited at least 85 faculty, the sample size would also give us 80% power to detect at least a 15-point difference in estimates between faculty and residents, setting alpha at 0.05.Response rate was calculated both on the program and individual level. For the individual level calculation, total program enrollment and faculty count at participating sites was used as the denominator. Respondents with insufficient data for analysis (missing basic demographics such as resident/faculty status) were noted and excluded. Basic descriptive statistics of the sample were calculated and reported. Geographic range was determined by mapping participant zip code.p < .05). All data analysis was done using the R statistical package. For the two qualitative questions, participant responses were coded by three researchers . Emergent coding employing grounded theory was used with holistic perspective . These outcomes were as follows: identification of care-giver low health literacy, familiarity with universal health literacy precautions, use of health literacy assessment tool, and receipt of training in health literacy. Dichotomized responses between the resident and faculty groups were compared using the Chi-squared test  agreed to participate and subsequently sent the survey to their residents and faculty. These programs contained 1,381 residents and 331 continuity clinic preceptors. There were 249 (18%) residents and 153 (46%) faculty that responded to the survey. Two respondents did not indicate resident or faculty status and were excluded from further analysis. Based on zip code information there was a wide geographic range of the participants ranging from New York to California across the Mid-Atlantic region, South, Upper Midwest, and Plains states. There were no participants from the northwestern part of the U.S. The majority (70%) were practicing in hospital-based practices, with the remaining participants roughly evenly distributed over private practices, community health centers, FQHC's, and other non-specified practice types.p < .001). A minority of participants indicated that they were familiar with the term universal health literacy precautions, and there was no significant difference between residents and faculty . Only a small fraction of participants had ever used a health literacy assessment tool, and there was not a significant difference between residents and faculty . Many residents and faculty stated that they had received no training in health literacy, and there was no difference between the two groups . Notably, among residents there were no significant differences in response between interns and upper-level residents.The overwhelming majority of the participants (99%) were able to correctly identify the definition of health literacy used by the Institute of Medicine. Most participants agreed or strongly agreed that they could correctly identify participants with low health literacy, and this opinion was especially prevalent among residents more so than faculty  time, (2) language, (3) limited training or resources, and (4) identifying low health literacy.Table 2.Most comments from providers mentioned some aspect of time as an unexpected challenge in addressing health literacy. Responses in this category focused on not having enough time to adequately address low health literacy in parents. Providers highlighted limited appointment times and busy schedules as challenges. They commented on the added time required for the incorporation of health literacy strategies. Responses pertaining to language highlighted the barrier that non-English–speaking families face. Providers expressed concern that interpreters may not always accurately translate and commented on the added difficulty of knowing if patients understand what they were being told. Responses within the limited training/resources theme demonstrated the lack of resources and training that providers perceive around health literacy. Comments included not having enough resources but also not knowing what resources would be most helpful. Within the theme identifying low literacy, residents and faculty expressed trouble identifying low literacy parents. They also emphasized that some families try to hide their low literacy level. Representative quotes are found in Please elaborate on an experience with a patient/care-giver where health literacy was a barrier and you felt that it impacted care. Six themes emerged from the coding and consensus: (1) general literacy or obvious confusion, (2) indicating understanding when not present, (3) disease mismanagement, (4) resource use or nonuse, (5) language, and (6) fixed misconceptions.Table 3.Faculty and residents had a wide range of responses for how health literacy was a barrier influencing medical care. Most comments for the theme general literacy or obvious confusion emphasized families not understanding medical information and how this affected their children. Here, physicians noted that parents with illiteracy made providing care more challenging. The theme, indicating understanding when not present, highlighted how families can agree to things that they do not understand and how that has unintended consequences. The theme of disease mismanagement mostly centered around asthma care, missed appointments, and families not understanding their child's diagnosis and treatment plan. Physicians also commented on families not knowing how to use their child's medication correctly. For resource use and nonuse, comments included missing appointments from lack of transportation and not following up with referrals. The theme also highlighted the extra use of resources like the emergency department that families require when they do not understand their child's diagnosis, treatment, and medication regimens. Again, language emerged as a theme. Many faculty and residents remarked that language, especially in written form, caused significant barriers. For the theme, fixed misconceptions, comments spotlighted families not believing in the diagnosis or treatment plans such as routine vaccinations. Representative quotes are found in The most striking findings in our study are the lack of knowledge regarding universal health literacy precautions, the widely held assumption that informal physician assessment of caregiver literacy is accurate, and the lack of reported education received regarding health literacy. These reported responses directly contradict available evidence and best practices. Although the term “universal health literacy precautions” may be specific to the AHRQ health literacy toolkit, the qualitative comments on barriers and unexpected challenges also highlights the lack of knowledge of basic health literacy strategies and techniques. Also, because most residents and faculty believe that they can effectively identify participants with low health literacy, the need for universal precautions seems irrelevant. These findings taken together suggest strongly there is a substantial number of patient visits in which appropriate communication is not taking place, and there are not adequate interventions in place to correct the situation.There are ample data demonstrating that clinician assessment of health literacy of both patients and caregivers is poor , yet mosConsidering the above data, the frustration and confusion expressed by participants in their qualitative responses is unsurprising. Our qualitative results emphasize that providers in continuity clinics identify many varied challenges in addressing health literacy in clinical practice. Whereas the challenge of time is less easily addressed, standardized health literacy training could certainly be used to a greater extent. In addition, providers should be made aware of universal health literacy precautions, including the following strategies: plain language and clear communication, Teach-Back method, demonstrate/draw pictures, follow up with patients, brown bag medicine review, and addressing language differences. There were various identified challenges related to patients and families who do not speak English. Finding ways to promote improved language access and interpreter services can and should be a priority in pediatric continuity clinics. The effect of poor health literacy was most profoundly outlined in the responses from providers concerning examples of when they had experienced health literacy as a barrier in patient care. These real-life examples show the far-reaching consequences of unaddressed poor health literacy and emphasize the essential nature of addressing poor health literacy in a clinical setting.The response rate for our study was less than 50%, and although this may make our quantitative results difficult to generalize, it was noted during qualitative data analysis that saturation was reached in qualitative data collection. Thus, the qualitative results of this study appear to be a valid representation of our study population. In addition, membership of CORNET is program-based, so study recruitment requires a residency program representative to enroll in their program and disseminate the study to colleagues. It is possible that residency programs that place a greater emphasis on or interest in health literacy would be more inclined to participate. This could make the study findings more impressive, as it shows that even in potentially more interested programs, there are incorrect assumptions and practices and a general lack of knowledge on some subjects. Although we powered the study to test for differences between residents and faculty, we did not have sufficient power to confidently detect differences by level of training. However, given the overall low percentage of reported training, such differences would not add much to our conclusions.The major strength of this study was its diversity of respondents. Participating programs were from a broad geographic distribution, and there was robust participation from all years of training and from faculty. The data serve as a critical needs assessment to drive educational interventions to improve resident and faculty knowledge of health literacy principles and strategies to improve communication with patients in the primary care pediatric setting. In follow up to this work, we plan to recruit residency programs to participate in the development and testing of a strategy to disseminate tools such as the AHRQ Health Literacy Toolkit to educate residents and faculty nationally. In addition to dissemination of the AHRQ Toolkit, we plan to use a quality improvement framework within the context of a learning collaborative.Physician knowledge of health literacy and the incorporation of associated best practices are essential to proper care of pediatric patients. Although almost every survey participant could define health literacy, the majority had never heard of universal health literacy precautions. Additionally, most participants made the dangerous assumption that they could accurately assess a caregiver's health literacy level, which prior research has shown to be false. These findings, paired with the evidence that health literacy training is not a standard part of pediatric residency programs, indicate that many providers may have risk factors for providing suboptimal care. Addressing these important issues in pediatric graduate medical education will foster more competent physicians and ultimately improve patient care.


Citizens are increasingly turning to social media to open up debates on issues of utmost importance, such as health or education. When analyzing citizens’ social media interactions on COVID-19, research has underlined the importance of sharing and spreading information based on scientific evidence rather than on fake news. However, whether and how citizens’ interactions in the field of education, particularly in mathematics, are based on scientific evidence remains underexplored. To contribute to filling this gap, this article presents an analysis of citizen debates in social networks about didactic resources for mathematics. Through social media analytics, 136,964 posts were extracted from Reddit, Instagram, Twitter and Facebook, of which 1755 were analyzed. Results show that out of the 213 posts of citizen debates on didactic resources for mathematics, only two contained scientific evidence and eight claimed to contain scientific evidence. These findings highlight the importance of promoting actions to encourage citizen debates around didactic resources for mathematics based on scientific evidence. Today, as a result of the dialogic turn in society and in science ,2, reseaAlong this line, research has stressed the importance of investigating the dialogues between science and society in order to fathom the social improvements science is generating and, thus, promote citizens’ engagement with it . Social Now more than ever, the COVID-19 pandemic has drawn attention to the spread of information (or misinformation) in social networks. Citizens have used social media to obtain information on essential topics such as the novel COVID-19 virus, face masks, disinfectant or the symptoms caused by the virus . AlthougIn short, as more and more people are turning to social networks to discuss, share or seek information about health-related issues, more and more research is being focused on what those tweets, posts and other social media interactions look like. To a lesser degree, the interactions that citizens are having in social networks about education-related issues are also increasingly being studied. For instance, scientific literature has evidenced that some teachers who participate in social media share resources among them as a means of professional learning . In thisALLINTERACT, Widening and diversifying citizen engagement in science, founded by the European Commission’s Horizon 2020 Framework Programme, is currently being developed with the aim of shedding light on how citizens currently or potentially interact with scientific evidence in order to promote their participation with science, thus contributing to all citizens’ human right to science. Running from October 2020 to May 2023, researchers from 16 institutions throughout Europe are and will be contributing new knowledge on how to promote citizens’ engagement in scientific evidence on two particular Sustainable Development Goals: Quality Education and Gender Equality. In spite of being of utmost relevance for citizens, more efforts are needed to make them aware of the social impact of research on education and gender in order to promote their engagement with it. Parents, teachers and students need to know, among other things, that there are currently thousands of schools implementing Successful Educational Actions based on scientific evidence of the social impact that are fostering the educational success of all students, including the most vulnerable such as the Roma community, in mathematics [For teachers and other citizens to use mathematics resources that help improve students’ achievements and learning, such resources need to be based on scientific evidence of social impact, that is, there needs to be scientific evidence that shows the improvements linked to using those resources. The project The increasing citizen debates on social networks around topics such as education, as well as the increasing accessibility and openness of scientific evidence, leave great potential for enhancing citizens’ engagement with scientific developments in mathematics in social networks. Although sharing information in social networks often entails the risk that many users will post or share content that contains false information, there are some initiatives and studies focused on promoting the sharing of information based on scientific evidence. Such initiatives, following the European Commission’s line on co-creation promoted in the current Horizon Europe Framework Programme, aim at engaging diverse citizens and scientists in dialogues in order to co-create scientific evidence and distinguish them from hoax or misinformation, promoting the spread of evidence among social networks. An example would be the Adhyayana and Sappho Scientific Evidence Platforms, the former based on education and the latter on gender. In these science-based participatory tools, developed from a bottom-up approach, researchers, practitioners and citizens engage in an egalitarian dialogue based on validity claims, that is, that any person can make any claim as long as this is supported by either scientific evidence or by arguments from everyday experiences. After 14 days, the platform evaluates whether such a post contains scientific evidence and categorizes it either as hoax or as evidence. Such bottom-up approaches, therefore, provide citizens with more knowledge and arguments to be able to distinguish when information shared in social networks is based on misinformation or on scientific evidence. Hence, while these initiatives do not overcome the use of misinformation in social networks, they provide social network users with more knowledge, arguments and tools to be able to promote the spread of information containing scientific evidence and to distinguish it from and disregard false information.However, in order to develop more actions and programs such as the aforementioned, scientists need further analyses that will allow us to know whether or not there are citizens already engaging in debates on mathematics based on scientific evidence. This area of research is still underexplored. To contribute to it, the present study explores whether and how citizen debates in social networks about didactic resources for mathematics are based on scientific evidence.The present research has been developed following the communicative approach ,22,23, wFirst, 136,964 posts were extracted through searching hashtags (in Instagram and Twitter), pages (in Facebook) and communities (in Reddit). Criteria for selecting hashtags on Instagram and Twitter were based on (a) their popularity, (b) the correspondence with the topics of the ALLINTERACT project, (c) the level of interactions among citizens in them and (d) the presence of citizens in the posts. Regarding Facebook pages, selection criteria corresponded to (a) a high level of activity and interaction, (b) outreach of the page and (c) the type of content shared (such as presenting scientific evidence). Last, the selected Reddit communities met the criteria of (a) having interactions through debate, (b) having a high outreach and level of interactions and (c) including topics related to the ALLINTERACT project.The extraction of data was conducted following the two approaches that characterize SMA, as defined by Cabré-Olivé and colleagues . On the All the social media data were extracted through NVivo and Python. The chosen hashtags, pages and subreddits in each social network are presented in Following the postulates of the communicative approach, a communicative content analysis  was condThe analysis was conducted in two stages. In the first stage, the scientific content, or lack thereof, of all the posts extracted was analyzed. To that end, three main categories were established according to the scientific sources of each post: 0 not scientific evidence (when the post did not contain scientific evidence); 1 certified scientific evidence ; 2 supposed scientific evidence (when the post claimed to be based on scientific evidence but no reference to the study or article was made). In the cases where a link was provided in the post, the link was also included in the unit of analysis.All the posts were analyzed by pairs of researchers. The first researcher assigned a number depending on the scientific sources of the posts (0–2), and the second researcher double checked the analysis already made. When the two researchers did not share the same view, they dialogically discussed and reached an agreement to categorize the post. This criteria definition and the analysis have been developed by researchers from 6 different institutions.At the second stage, the analysis focused on whether the posts’ content was related to didactic resources for mathematics or not. To that end, researchers dialogically defined 7 keywords related to didactic resources for mathematics: calculation, numbers, numeracy, numeracy skills, manipulatives, resources and math. A total of 3555 posts were extracted through the keyword search, of which 1800 were reposts or posts appearing more than once with different keywords. All posts found for each of the keywords were read through several times by researchers. As a result of this analysis, those posts that included content related to mathematics didactic resources were selected first. After reading those selected posts again several times, a number of posts were discharged because they were used for marketing of some mathematics didactic resources, rather than being citizens talking about or discussing them. In order to grant anonymity of the users whose posts comprise the sample of this study, researchers will not disclose any personal information about the users, nor will they quote any post literally. Moreover, for this manuscript, Facebook pages and Reddit communities have been anonymized. In addition, when conducting the analysis, researchers did not enter into the profiles of the users who made the posts. All data have been anonymized and fulfilled the Regulation (EU) 2016/6791, the EU General Data Protection Regulation (GDPR) and the Terms and Conditions of each social network. The study was approved by the Ethics Committee of the University of Barcelona.In this section we present the results of the analysis of those posts that fit the inclusion criteria. We will first show the qualitative results of this analysis, following with a sub-section on the qualitative results achieved.Results reveal that out of the 1755 posts analyzed, 213 contain interactions related to didactic resources for mathematics. The social network with most posts related to didactic resources for mathematics is Facebook, with 139 posts (65.2%). The second social network with most posts related to didactic resources for mathematics is Reddit, with 43 posts (20.1%), followed by Twitter with 23 posts (10.7%). Last, the social network where the least posts related to didactic resources for mathematics were found was Instagram, with 8 posts (3.7%).Regarding the scientific evidence classification, the category in which most posts were found was the “not scientific evidence” category, with 203 posts (95.3%) in total. In contrast, the category in which the least posts were found was the “certified scientific evidence” category, with 2 (0.9%) posts belonging to this one. Last, 8 posts (3.7%) were found in the “supposed scientific evidence” category. As the table shows, Facebook is the social network with most posts related to didactic resources for mathematics that claim to contain scientific evidence, with four posts in total (1.8%). It is also the only one with a post about didactic resources for mathematics that includes certified scientific evidence, having two in total (0.9%). Reddit and Twitter have the same number of posts related to didactic resources for mathematics claiming to contain scientific evidence, with two each (0.9%). Last, Instagram is the only social network in which no post about didactic resources for mathematics has been found to include certified nor supposed scientific evidence.Whereas those posts categorized as containing certified scientific evidence or supposed scientific evidence were the least among all posts related to didactic resources for mathematics in the social networks analyzed, a diversity of interactions and users can be found in them in terms of what types of resources they share and debate. Although researchers have not viewed the profiles of any of the posts analyzed, in some of those posts users reveal information about themselves, such as saying they are teachers, or they are parents who want to teach their children, or need to study math-related content.The two posts categorized as containing scientific evidence are framed within a Facebook debate in which different users are engaged in a discussion about whether or not children should use their fingers when conducting math problems. Whereas many of the users contributing to this discussion are teachers, the two posts marked as containing scientific evidence do not provide information about the users. The two share the same article from a scientific dissemination journal that provides arguments and scientific evidence supporting the idea that children should use their fingers in math classes. One of the posts only contains the link of the article, whereas the other includes one of the authors of the article and directly addresses another Facebook user in their post.In addition, one of the posts categorized as containing supposed evidence is also engaged in the debate about using fingers. In that case, the user does not provide any link to scientific evidence, but he or she refers to a book by the same author of the article shared in the other two posts and provides a quote supporting the argument in favor of finger counting.Other posts categorized as containing supposed evidence also refer to different pedagogies or learning strategies for mathematics. Two of them explicitly mention scientific research, although they do not provide any link or source to such research. One of them explains that research shows students need to be scaffolded when they do not understand math-related content, and the other talks about a particular mathematics curriculum based on research. Others do not explicitly mention research in the post, but they do provide links to articles that do talk about research—which, in turn, do not include evidence from articles indexed in JCR and/or Scopus.The remaining posts categorized as containing supposed evidence provide links to different blogs or webpages where resources for teaching and/or learning mathematics can be found. Again, the posts themselves do not talk about scientific research. However, the websites or blogs linked in the posts do talk about scientific research, although they do not include scientific articles indexed in JCR and/or Scopus. For example, a user shares a newspaper’s learning resources, which includes different resources that teachers can use in their classrooms. Yet not all of those resources are based on research or, at least, it is not specified that they are based on articles published in JCR and/or Scopus journals.Regarding those citizen debates that have been categorized as not containing scientific evidence, a variety of resources and ways in which those resources are shared and/or discussed can be found. Some users share books, webpages, free online repositories, blogs, apps or other social networks in which math resources can be found. Some of these posts respond to other users’ posts in which they ask for resources to learn or teach a variety of mathematics-related knowledge. In other cases, users share with their followers or potential viewers mathematics resources they find useful as teachers or learners.Similar to some of those posts categorized as containing supposed scientific evidence, many posts categorized as not containing scientific evidence are posts in which users share techniques, games or activities for learning or teaching mathematics with other users. In some cases, users share videos—either made by themselves or which they have found on the internet—teaching, for instance, how to solve math problems or how to understand math concepts. In other posts, teachers or parents share math-related activities and games they have undertaken with children, such as using chocolate bars to teach them fractions, integrating mathematics concepts into arts classes or playing with cards. Other posts contain advice that teachers share about specific pedagogical strategies to help children understand math-related content or how to solve mathematical problems, such as scaffolding children’s problem solving.In the same line as the two posts categorized as containing scientific evidence, some posts categorized as not containing scientific evidence revolved around discussions about pedagogies or strategies, such as using fingers or not, memorization, or using the calculator, among others. Whereas the large majority of posts engaged in this debate do not include nor mention scientific evidence, one of the users asks what the scientific literature says about using fingers versus memorization.To improve citizens’ lives, researchers need not only bring their voices and experience to the research we are conducting; we also need to bring the evidence we are co-creating with them to them . In lighFollowing existing research on teachers’ use of social media to share and seek didactic and pedagogic resources, findings from this study confirm that several users in the social networks analyzed do engage in debates about didactic resources for mathematics. Although this study did not inquire into the users’ profiles due to privacy issues, the posts analyzed allowed researchers to see a variety of users, from school teachers to parents to students at different grades, and other citizens. Therefore, this study contributes evidence that there are citizens with diverse connections to education, not only teachers, who are turning to social networks to talk about their concerns or questions, to seek help or to offer help and advice on didactic resources for mathematics. However, as previous studies have highlighted, not all mathematics resources shared on social media improve students’ results . This miNow, in order to promote citizens’ engagement with scientific evidence on mathematics, researchers need to know whether and how citizens are using and/or talking about it. This study has advanced a step in this direction by analyzing whether and how citizens use scientific evidence in debates about didactic resources for mathematics in social networks. Through conducting SMA in Reddit, Instagram, Twitter and Facebook, this study has found that there are posts about didactic resources for mathematics that either include some reference to scientific research or claim to be based on scientific research. Granted, posts that contained certified or supposed scientific evidence were the least among the categories analyzed. However, the fact that there are users who already introduce scientific evidence when talking about didactic resources for mathematics in social networks points out that some citizens are beginning to incorporate a discourse of scientific evidence in social networks when talking about education-related issues. Even those cases in which users claim to introduce scientific evidence, or in which they ask what the scientific literature says about a particular issue in didactic resources for mathematics, these findings indicate that there is a concern among some citizens regarding what the scientific research on mathematics-related issues says, and that they turn to social media to talk about or share that concern. Based on these findings, future research should explore new ways and pathways to foment more social network users to engage in a discourse of scientific evidence when discussing didactic resources for mathematics.The limitations of the present research must be addressed. First, although the social networks analyzed are among the 17 most popular in the world, other highly used networks such as TikTok or Sina Weibo have not been included. In spite of having analyzed diverse networks, the inclusion of other social networks could help to obtain a more profound insight on the interactions on didactic resources in mathematics among other profiles of citizens. On the other hand, through the use of other keywords, other kinds of interactions could have been found. Future research should investigate more social networks taking into account cultural differences in these debates.To improve public health, the need for citizens to know and discuss scientific evidence is being stressed more and more by the scientific literature, in order to be able to make decisions that affect their health with the most information possible. Although this is very clear in the field of health, more efforts need to be made in the educational areas to promote citizen engagement with scientific evidence on education. However, the present study shows an optimistic landscape by evincing that some individuals are debating about mathematics resources in social media, and some are even including the discourse on scientific evidence when talking about these resources. To continue promoting this pathway and engage more citizens in this discourse, researchers and citizens should engage in collective actions to continue engaging citizens with scientific evidence on mathematics. Their engagement in educational scientific evidence would improve the achievement of many students in mathematics.