Societal polarization over contested science has increased in recent years. To explain this development, political, sociological, and psychological research has identified societal macro-phenomena as well as cognitive micro-level factors that explain how citizens reason about the science. Here we take a radically different perspective, and highlight the effects of metacognition: How citizens reason about their own reasoning. Leveraging methods from Signal Detection Theory, we investigated the importance of metacognitive insight for polarization for the heavily contested topic of climate change, and the less heavily contested topic of nanotechnology. We found that, for climate change (but not for nanotechnology), higher insight into the accuracy of own interpretations of the available scientific evidence related to a lower likelihood of polarization over the science. This finding held irrespective of the direction of the scientific evidence (endorsing or rejecting anthropogenicity of climate change). Furthermore, the polarizing effect of scientific evidence could be traced back to higher metacognitive insight fostering belief-updating in the direction of the evidence at the expense of own, prior beliefs. By demonstrating how metacognition links to polarization, the present research adds to our understanding of the drivers of societal polarization over science.The online version contains supplementary material available at 10.3758/s13423-021-01993-y. Belief polarization, the tendency of individuals to update prior beliefs in opposing directions after observing the same evidence  can be found at: 10.6084/m9.figshare.13139351A total of N = 354 participants completed the experiment. Participants were recruited via Mturk, an online participant pool that provides samples that are reasonably representative of the general US population  the anthropogenicity of climate change , and comprised (a) attention checks as well as (b) task-comprehension checks.The main study was completed in the following order for both topics (climate change and nanotechnology): (i) prior beliefs; (ii) provision of each text summarizing scientific evidence, text-specific assessment of the (iia) interpretation of each text, and (iib) confidence in the accuracy of the interpretation; (iii) posterior beliefs; (iv) demographics .Order of the topics, as well as the summaries within each topic, were randomized. Each summaries was displayed on a separate page, and the respective text-specific questions  were displayed on the consecutive page, so that participants needed to answer from memory. This was done to ensure that the questions assessed actual interpretation, including potential distortions of the evidence, rather than a simple look-up of the information provided. Participants went through the survey at a self-paced speed.The same items were used to assess prior and posterior beliefs. For climate change, participants indicated: “Do you think human activity is the cause of increasing temperatures?” on a 17-point scale ranging from from -8 (“I think that human activity is NOT the cause of increasing temperatures”) to 8 (“I think that human activity is the cause of increasing temperatures”). For nanotechnology, participants indicated: “Do you think that the positive outcomes of nanotechnology outweigh the risks?” on a 17-point scale ranging from -8 (“I think that the risks of nanotechnology strongly outweigh the positive outcomes”) to 8 (“I think that the positive outcomes of nanotechnology strongly outweigh the risks”), for the texts on nanotechnology.Participants indicated their interpretation of the direction of evidence for climate change, and nanotechnology, each on a 17-point scale. Specifically, participants indicated their interpretation “This summary provides evidence that...” on a scale from -8 (“human activity is NOT the cause of increasing temperatures”) to 8 (“human activity is the cause of increasing temperatures”) for climate change, and from -8 (“the risks of nanotechnology strongly outweigh the positive outcomes”) to 8 (“the positive outcomes of nanotechnology strongly outweigh the risks”).Participants provided item-specific confidence judgment by indicating, after each interpretation of each text: “How certain are you that your assessment is correct?” on a 6-point scale ranging from 50% (“I guessed”) to 100% (“I am certain”).task sensitivity d’ as specified in a Signal Detection Theory (SDT) framework by calculating the difference of the Z(True Positive) and the Z rate, with Z being the inverse cumulative density function of the normal distribution. Task sensitivity d’ reflects participants’ ability to correctly distinguish between evidence as endorsing or rejecting anthropogenicity and risks, respectively. Ratings above 0 were classified as endorsement, ratings below zero were rated as rejection. Since accuracy was coded only with respect to rejection versus endorsement, ratings of 0 were rated as incorrectTo measure the accuracy of the interpretation of the scientific evidence, we determined meta-d’ for each participant . These participants would only differ in their metacognitive abilities: For participant A, confidence ratings are more often lower for incorrect answers and higher for correct answers, resulting in a higher meta-d’ (meta-d’A = 1.9) compared to participant B, where confidence ratings reflect correct and incorrect answers to a considerably lower degree (meta-d’B = 1.2).To illustrate, two participants could have the same task performance (d’ = 2) but two different values of metacognitive sensitivity  indicates the interpreted direction of the evidence (endorsement or rejection). That is, positive values of α signify that a text was interpreted as endorsement on average, negative values of α signify that a text was interpreted as rejection.This analysis provides the unique benefit of delivering regression parameters that can be readily interpreted by providing direct psychological meaning. First, the constant α corresponds to the of the influence of the prior belief on the interpretation of evidence. Positive values signify the extent to which an interpretation is influenced in the direction of the prior belief, that is, the extent to which the prior belief enhances the interpretation of the evidence in the direction of the prior. Negative values signify the extent to which an interpretation is influenced in the direction opposite to the prior belief. Values of zero signify that the prior belief had no influence on the interpretation of evidence. For example, consider a participant who has a strong prior belief that nanotechnology benefits outweigh its risks. In this case, positive values of γ signify that evidencet supporting this belief has a reinforcing influence on that belief – that is, further strengthens the belief in the direction of the prior.More importantly, second, the regression parameter γ corresponds to the direction and strength The regression analysis was performed in R employing the linear model-function (lm)  and metacognitive sensitivity (meta-d’) moderate the relationship between prior beliefs and the interpretation of the evidence, participants were split into high and low scorers for each variable. Splitting participants into categories provides the unique advantage that the slope γ remains a psychologically interpretable variable, namely the influence of prior beliefs on the interpretation of the evidence. As a consequence, high and low scorers of task sensitivity and metacognitive sensitivity can be directly compared on the same scale to assess whether they differ in the extent to which the prior influences the interpretation of the evidence.Individuals were categorized based on their individual value relative to the mean for each variable such that individuals with values higher than the mean were categorized as high scorer, and individuals with values lower than the mean as low scorer.The influence of the variables P on the relationship of prior beliefs and evidence interpretation is calculated as follows:where P denotes the subgroups for d’, and meta‐d’.Tables Figure The total proportion of polarizers was higher for climate change (11.9% ± 0.63%) compared to nanotechnology (8.76% ± 0.46%). Distinct polarization “fingerprints” emerged for the two topics. For nanotechnology Fig. , panel Apanel A) and climate change (panel B). The figure demonstrates, first, that participants were able to correctly classify the direction of the evidence in that endorsing evidence was rated as endorsing on average, and rejecting evidence was rated as rejecting on average. More importantly, second, the direction and strength of the influence of the prior beliefs γ on the interpretation of the evidence was positive, for both directions of evidence, and for both climate change and nanotechnology  and metacognitive sensitivity (meta-d’) relate to polarization over the science  even as confirming their prior.Does metacognitive sensitivity (meta-d’) moderate the relationship between prior beliefs and evidence interpretation? To explore the anticipated cognitive process behind the effect that metacognitive sensitivity relates to polarization, we investigated whether metacognitive sensitivity (meta-d’) moderates the relationship between participants’ prior beliefs and their interpretation of the scientific evidence.NT_Endorsement = 0.353±0.034 compared to participants with high metacognitive sensitivity γNT_Endorsement = 0.091±0.025. For participants with low metacognitive sensitivity the relationship between prior beliefs and evidence interpretation was not significantly different for the negative direction of evidence (rejecting) γNT_ Rejection = 0.232±0.038 compared to the relationship for participants with high metacognitive sensitivity γNT_Rejection= 0.096±0.038.Figure NT_Endorsement(790) = .24, 95%CI = , and for the negative direction of evidence (rejecting): rNT_Rejection(790) = -.16, 95%CI = . For participants high in metacognitive sensitivity, the relationship between prior beliefs and the interpretation of the evidence was virtually non-existent for the positive direction of evidence (endorsing): rNT_Endorsement(622) = .01, 95%CI = . However, for the negative direction of evidence (rejecting) the strength of the relationship was similar to that of participants with low metacognitive sensitivity: rNT_Rejection(622) = -.15, 95%CI = .Furthermore, we calculated the correlation between metacognitive sensitivity and summary ratings for participants high and low in metacognitive sensitivity. For participants with low metacognitive sensitivity, there was a significant relationship for the positive direction of evidence (endorsing): rCC_Endorsement = 0.296±0.03 compared to participants with high metacognitive sensitivity γCC_Endorsement = 0.073±0.018. For participants with low metacognitive sensitivity the relationship between prior beliefs and evidence interpretation was not significantly different for the negative direction of evidence (rejecting) γCC_ Rejection = 0.210±0.044 compared to the relationship for participants with high metacognitive sensitivity γCC_Rejection= 0.057±0.037. Furthermore, we calculated the correlation between metacognitive sensitivity and summary ratings for participants high and low in metacognitive sensitivity. Results corroborate our findings in that: for participants with low metacognitive sensitivity, there was a significant relationship for the positive direction of evidence (endorsing): rCC_Endorsement(388) = .36, 95%CI =  and for the negative direction of evidence (rejecting): rCC_Rejection(388) = -.21, 95%CI = ). For participants high in metacognitive sensitivity, there was a low relationship for the positive direction of evidence (endorsing): rCC_Endorsement(316) = .16, 95%CI =  and for the negative direction of evidence (rejection) it was virtually non-existent: rCC_Rejection(316) = -.09, 95%CI=.Similarly, Fig. However, for the negative direction of evidence (rejecting) the difference between correlation coefficients for participants low and participants high in metacognitive sensitivity was non-significant.That is, for nanotechnology and climate change, metacognitive sensitivity moderated the influence of the prior for the positive direction of evidence (endorsing) but not for the negative direction of evidence (rejecting). Metacognitive sensitivity moderating the influence of the prior for the positive (but not negative) direction of evidence only might be due to very low numbers of participants holding strong initial beliefs in line with the negative direction of evidence (2.2% for nanotechnology and 5.1% for climate change).meta-d’), an insight into the validity and fallibility of own interpretations of the available evidence, were less likely to polarize over the heavily contested topic of climate change, but not the less heavily contested topic of nanotechnology. Specifically, among citizens with lower metacognitive sensitivity, the proportion of polarizers over climate change was four times higher than among citizens with higher metacognitive sensitivity.Civil polarization has long been the domain of political and religious worldviews. Recent years, however, have seen a marked increase in the polarization over seemingly emotionless science such as climate change, vaccination, COVID-19, or nanotechnology. Leveraging methods from Signal Detection Theory, we found that individuals with higher metacognitive sensitivity  the prior belief distributions of both topics were markedly different in that more participants started out with neutral views on nanotechnology compared to climate change; and (ii) the polarization fingerprints of both topics differed in that, for nanotechnology, participants who polarized were found almost exclusively among endorsers of nanotechnology benefits, whereas for climate change, participants polarized across the whole belief spectrum. Furthermore, metacognitive sensitivity moderated the relationship between prior beliefs and interpretation for endorsers of nanotechnology benefits/anthropogenicity of climate change, that is, only where participants held initially strong beliefs.These results highlight a novel factor that relates to a lower likelihood of polarization over contested science: metacognitive insight into the accuracy of interpretations of the available evidence. This may be particularly relevant in areas of politicized science where external information on the accuracy of information is noisy in that false and misleading information exists alongside information that is scientifically accurate. In noisy decision environments lacking unequivocal external feedback about the reliability of information, citizens might be particularly prone to relying on internal cues to accuracy such as metacognitive confidence , and by comparing a wider range of contested and less contested topics across the whole spectrum of scientific domains.Second, the comparability between both topics, climate change and nanotechnology, may be limited since the number of trials and wording of belief items differed between the two topics. Specifically, for nanotechnology, participants indicated whether they believe that the benefits of nanotechnology outweigh the risks, whereas for climate change, participants indicated whether they believe that climate change is anthropogenic. Hence, the assessed beliefs are markedly different, and being asked about anthropogenicity versus risks likely triggers different cognitive associations. However, both beliefs were chosen to be in line with prior literature on these topics . This may have reduced the extent of subsequent belief-updating: When participants perceive the encountered evidence as more open to interpretation , they may be less likely to update their beliefs. In line with this reasoning, it was found that communicating scientific consensus on climate change affects the beliefs citizens hold about the issue


Enhancing the contribution of practicing pharmacists into scientific evidence via practice-based research (PBR) is crucial in maintaining high-quality clinical practice and healthcare delivery. Involving community pharmacists in PBR can potentially can also help break barriers to the utilization of the current best evidence in everyday pharmacy practice. The impact of pharmacists’ attitude towards PBR on their utilization of current best evidence in pharmacy practice is understudied.The aim of the study was to investigate the impact of community pharmacists’ attitudes toward PBR on their utilization of current best evidence, barriers for conducting PBR in clinical practice were also investigated.In this cross-sectional study, 169 community pharmacists working across Jordan filled a questionnaire to assess their attitudes towards PBR, barriers to PBR, and their utilization of the current best evidence in clinical practice.Pharmacists in this study showed a positive attitude toward PBR (attitude mean score >3.5). A positive attitude towards PBR was associated with high utilization of the best current scientific evidence. We also investigated several barriers to PBR and their association with utilization those included; the lack of perceived benefits, lack of institutional support, and lack of self-engagements of community pharmacists to PBR. The lack of perceived benefit was found to be negatively associated with pharmacists’ utilization of the current best scientific evidence.In this study, pharmacists’ utilization of current best evidence was found to be significantly impacted by their attitude toward PBR. The current study findings highlight the importance of supporting, promoting, and facilitating PBR among community pharmacists which can potentially enhance their utilization of the current best evidence in their everyday pharmacy practice. The use of evidence based medicine in pharmacy practice is essential to improve health-related outcomes. Evidence based medicine is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” . CurrentEnhancing the contribution of practicing pharmacists into scientific evidence via PBR is crucial in maintaining high-quality clinical practice and healthcare delivery . The engWhile several studies from Australia, Canada, and the UK showed that pharmacists’ involvement in PBR is increasing, pharmacists are still underrepresented, and their contributions to PBR have proved to be low , 15–17. PBR is essential for the future progression of pharmacy, as a profession, and for providing evidence of the benefits of proposed changes in practice to the patients’ health outcomes . It can A face-to-face survey was provided to a sample of 220 pharmacists from different geographical areas in Jordan using convenient sampling teachnique. The pharmacists were randomly selected from a list of pharmacists who are registered at the Jordanian Pharmaceutical Association. The participating pharmacists were “the pharmacist in charge” (i.e. the pharmacist responsible for the safe and effective running of the registered pharmacy). Pharmacy students and Pharmacist assistants were excluded from the study. During a visit to their worksite, pharmacists were provided with a description of the study and its objectives by the research assistant, and those who agreed to participate (169 pharmacists) signed a consent form. The pharmacists were recruited over a period of four months from January through October, 2019.The study was approved by the Institutional Review Board committee at the Jordan University of Science and Technology .Based on the published literature, domains were selected to assess attitudes towards PBR and barriers to PBR among pharmacists in a community pharmacy setting , 21. TheIn addition to the literature, we used the help of seven experts in the field of clinical pharmacy and public health, with a minimum of ten years of experience. Those experts reviewed each of the domains separately; their feedback was used to amend the questionnaire to establish both face and content validity. The experts contributed to develop a well-defined and relevant statements to the constructs being measured. As a result, two items were deleted of the original draft before disseminating the survey, rewording through all studied domains was also performed based on their feedback which resulted in more concise and clear statements.Data were collected from 20 pharmacists was used as a pilot study before proceeding to the final version of the questionnaire. The feedback from the pharmacists was very thorough, it gave us insights on needed rephrasing of five questions, as well as change in the sequence of two questions. The data from the 20 pharmacists who participated in the pilot study was not included in the main study.The seven pharmacist’s attitude questions covered their beliefs of the value of PBR, their willingness, abilities, and engagement in PBR, and the six utilization questions covered their perceived utilization of current best evidence in clinical practice in the form of a 5-point Likert scale. Each item of the questionnaire was given from 1 representing strongly disagree to 5 representing strongly agree. Frequency distribution has been illustrated for the Likert scale items. The following ranking was followed: (1.00–2.33) Low score (Third Rank), (2.34–3.67) Medium score (Second Rank), (3.68–5) High score (First Rank). Cronbach’s alpha was used to examine the reliability of the attitude and utility, which was 0.79 and 0.77, respectively.P value of 0.05 implies that the findings are statistically significant.Data were analyzed using the statistical package for the social sciences (SPSS) version 25. Descriptive statistics were used to describe the demographic characteristics, attitudes towards and barriers for PBR, and the utilization of current best evidence. A five-point Likert scale ranging from “strongly disagree” to “strongly agree” was used to evaluate the response of participants to the items in each domain. The student’s t-test (t-test) and one-way analysis of variance (ANOVA) are statistical procedures for comparing mean values between groups. The t-test is used to compare the means of predictor variables with two groups, whereas the ANOVA is used to compare the means of predictor variables with three or more groups. To predict the relationship between the dependent variables of interest  and other independent variables, linear regression models were applied. A Because the initial survey developed comprised 36 variables designed to assess PBR-related barriers, which could result in a large set of data, exploratory factor analysis (EFA) was performed. EFA with Varimax rotation was used to reduce the dimensionality of large data sets and avoid potential multicollinearity by identifying a smaller number of uncorrelated variables known as factors, which are required to represent the data . Keiser-In total, 169 community pharmacists agreed to participate in the study and successfully submitted the filled questionnaire. Around 30% of participating pharmacists were working in chain pharmacies. The majority of the respondents were female (64.5%) and in the “18–25” age group (46.7%). More than half of the participants attained a postgraduate degree in the field of Pharmacy (51.5%) and had less than five years of experience (59.8%). The participants’ characteristics are shown in The majority of participants expressed positive attitudes towards PBR and the use of clinical research tools in daily practice and were very receptive to the practical implementation of these research tools . PharmacThere were no significant differences in pharmacists’ overall attitudes regarding PBR and utilization of best current scientific evidence in pharmacy practice based on their age or gender. There was a statistically significant variation in pharmacists’ overall attitudes toward PBR based on their educational levels and workplace settings. Responses to the utilization of current best evidence in pharmacy practice varied significantly according toyears of experiencewith more experienced pharmacists having a lower utilization score. The results are illustrated in 2) value was 0.39.A multiple linear regression model was generated. The forward and backward stepwise selection methods revealed that attitudes and lack of perceived benefit of PBR were significant variables that best fit the data see . The adjPharmacists are cornerstones of the health care system. The integration of current best evidence in daily pharmacy practice has been reported among pharmacists in different practice settings. Among those settings, community pharmacists were reportedly the least likely to utilize the current best evidence in everyday pharmacy practice .As evident from the utilization score, pharmacists in this study showed high utilization of the current best evidence (mean scores >3.5). These findings are higher than the reported moderate level of utilization of current best evidence among pharmacists , 4, 24. This is the first study to explore the impact of pharmacists’ attitude towards PBR on their utilization of current best evidence in pharmacy practice; attitude toward PBR was a statistically significant predictor of pharmacists’ utilization of current best evidence; a positive attitude was associated with high utilization of current best evidence in daily practice (p<0.05). Despite the lack of studies on the impact of attitude of pharmacists attitude on their utilization of research in their practice, attitudes toward research in general, have been shown to relate to research utilization .Although PBR is now more acknowledged and supported by pharmacy regulatory bodies worldwide, pharmacists have been reported to be reluctant to participate in PBR . To addrLack of perceived benefit of BPR has been reported as one of the barriers to PBR as well as to the utilization of current best evidence .p<0.05). The lack of perceived benefit was found to be negatively associated with pharmacists’ utilization of the current best evidence.In this study, we investigated several barriers to PBR those included; the lack of perceived benefits, lack of institutional support, and lack of self-engagements of community pharmacists to PBR. Also, there was a significant correlation between the lack of perceived benefit of PBR and their utilization of current best evidence Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 File(PDF)Click here for additional data file.


According to prior research, teacher readiness and capability are key contributors for successful transition towards disability inclusive education, yet in‐service teacher professional development for disability inclusion remains an under‐researched area. The key objective of this evidence and gap map (EGM) is to locate evidence on interventions for disability inclusion focused teacher professional development (TPD) in low‐to‐middle‐income‐countries (LMICs) in the Asia‐Pacific region. As such, it will illustrate different levels of evidence for TPD interventions as well as where there is no evidence . In other words, the EGM can make agencies aware where they might be operating in an area that is evidence‐free or evidence‐weak so they can take up interventions that are evidence‐based or collect evidence for the intervention they are presently supporting. Thus, the ultimate goal for the EGM is to assist funders and implementing agencies when making decisions as to how to support LMICs in the region to reach their aim of developing quality teachers for the global inclusive education agenda (target SDG 4.c). IAdvocates of educational inclusion call for a fundamental reform of schools and the modernisation of education systems  where infrastructure and resources tend to be scarce, leading to additional challenges for disability inclusion into education settings DFAT, . More sp UNESCO, .Evidence from LMICs also suggest that teachers often lack the knowledge and skills for recognising and supporting students with disabilities Ghimire, . Moreove1.1.2In the Asia Pacific region, around one‐third of the children who are out‐of‐school have a disability  of teacher professional development (TPD) interventions supporting the inclusion of students with disabilities is useful and timely.1.2TPD programmes are the key to transitioning to disability IE CRPD, . Since d2016 Policy on Special and Inclusive Education which documents the need for preparing teachers for screening and referring students with disabilities   list of in‐service TPD interventions only for various reasons.In‐service programmes can have a more immediate impact on the inclusion of students with disabilities in classrooms as they focus on practices and attitudes of current teachers.In‐service learning programmes are usually practice‐oriented with suggestions of how to make pedagogical practices more inclusive.Preservice education does not always equip teachers with competencies required to deal with everyday classroom challenges Forlin, . “WhetheMany teachers who have been in the profession for decades may not have received any formal training on disability IE. A study examining the skills of regular primary and secondary school teachers in Delhi in India found that nearly 70% of regular schoolteachers did not get training in special education and lacked experience of working with children with special needs  offices in India, Indonesia, and Malaysia—where stakeholders agreed on the need to have more information about the TPD interventions focused on disability inclusion in this region.In summary, while most EGMs tend to have a broader scope, given the importance of the issue in this region, the authors are focused on synthesising evidence of TPD interventions for disability IE in the Asia‐Pacific LMICs only. This study and its scope have been supported by discussions with key funders and education experts in the region—such as DFAT and Australian Council 1.3Research shows that the provision of high‐quality IE is mainly influenced by teachers and their ability to support and acknowledge students' heterogeneous needs  by Kuper et al.  of What In summary, prior research identifies teacher readiness as a major factor for a successful transition towards disability IE while relevant work summarised here either does not cover TPD or cover interventions only from countries outside the Asia‐Pacific region. Hence, this EGM is timely and highly focused to provide a useful information base for targeted stakeholders.2As researchers and policy makers are often unaware of the extent of the evidence base, an EGM is a way of making explicit and accessible different interventions on a certain topic in a specified geographic area, to “guide users to available relevant evidence to inform intervention and design and implementation” . In other words, the EGM can make agencies aware where they might be operating in an area that is evidence‐free or evidence‐weak so they can take up interventions that are evidence‐based or collect evidence for the intervention they are presently supporting , in addition to helping them attain the targets for SDG 4.1  and SDG 4.5  UNESCO, .33.1SystematicThe type of evidence includedThe content of the mapThe structure of the mapGraphical displayAccompanying description of mapIntended users.EGMs “are a systematic evidence synthesis product” .The visual representation of the results is intended to be published as an EGM through the ACER data visualisation website  will be used.The World Network of Users and Survivors of Psychiatry suggested a change in the way persons with mental health disabilities are described and are to be referred to as persons with psychosocial disabilities WNUSP, . While wmental health condition  are defined by Zablotsky et al. , and write (dysgraphia) or other areas of learning, such as mathematics , or interventions that teach/train teachers in specialised tools, approaches and techniques .Another way of grouping interventions will be using special interest groups, for example the EGM will cover interventions which support particular 3.2.2Attitudes, knowledge and understandingPedagogical practicesEnabling positive student behaviourConfidence and efficacy to implement inclusion.As the EGM is focussed on TPD, for interventions to be included must have at least one of the following outcomes aimed at teachers:Learning and achievementBehaviour and engagementSocial and emotional learning/wellbeing.In addition, interventions may also have intended student level outcomes such as:These are discussed in detail in Table The online EGM will use the intervention‐outcome dimensions shown in Table The total number of interventions includedFirst author's name and year of study publicationCountry where the intervention was conducted.The EGM will also include functionality to enable studies and reviews to be filtered by country through a drop‐down menu. More information about the included studies will be available by hovering over the circles, such as:Title of the study/systematic reviewAuthor informationPublication yearLink to the study/reviewStatus of the intervention Study design/methodFunding/implementing agency (if available) particularly for practice‐based interventions.An interactive geographical map will also be generated that indicates evidence availability in each LMIC in the Asia‐Pacific region. By clicking on each of the countries where evidence is available the following information will appear around the included studies and reviews.3.3The criteria detailed in Table 3.3.1Since the main purpose of this review is to map the evidence for in‐service TPD for disability inclusion in classrooms, a wide variety of study designs will be accepted if they add information on the topic of interest and help to identify evidence gaps.This review will therefore consider both qualitative and quantitative   will be included in the data extraction and mapping.The included interventions will cover strategies to support disability inclusion related outcomes in classrooms.3.3.4Practicing teachers or special needs educators in early childhood centres or child‐care services, preschools, and schools who are working with children/students between the ages of 0–18 years.The review also includes teachers and educators who work with students with special needs in mainstream schools or special schools or special education classrooms in mainstream schools.3.3.53.3.5.1An intervention must have a teacher outcome and may also report student outcomes.Attitudes, knowledge and understandingPedagogical practicesEnabling positive student behaviourConfidence and efficacy to implement inclusion.Teacher outcomesLearning and achievementBehaviour and engagementSocial and emotional learning/wellbeing.Student outcomesSee Section 3.3.5.2Any potentially adverse or unintended outcomes of the interventions will also be noted in the EGM report for the final studies included in the EGM.3.3.63.3.6.1Studies which explore interventions in LMICs in the Asia Pacific region will be included. The reason for this geographical focus is due to the Asia‐Pacific region being an area of strategic interest for many development partners (DPs) who value evidence and gap maps when making key investment/funding decisions Campbell Collaborations Systematic Reviews and EGMs portal (Better evidence for a better world)EPPI (UCL‐UK) Database of Educational ResearchTeacher Reference Centre (EBSCO)Google scholar.A broad range of bibliographic databases and repositories will be electronically searched to help develop the search strategy. The search platforms include:However, ongoing studies found through such systematic searches, which are past their registration cut‐off date or with uncertainty about their completion, or without sufficient details will not be included.A sample search statement has been provided . Potential papers will be sought through “snowballing” as a result of searching bibliographies and reference lists of papers located during the search process, as well as specific searches of relevant grey literature. Potential on‐going interventions that are identified through any of the above‐mentioned sources will also be screened for inclusion in the EGM.Programme/Project websites: DFAT  DisabiliUniversity research websites: Monash University (2016) Pacific Indicators for Inclusive Education (Pacific‐INDIE): Case Studies—There are four case studies presented from Fiji, Vanuatu, Samoa and the Solomon Islands—the four key countries involved in the development of the Pacific INDIE final set of indicators. Each of the four countries have made varying progress towards IE and face their unique contextual challenges. Common challenges across all four countries include the translation of policy to practice, the need for ongoing advocacy and the need for training of teaching staff.The EGM will clearly distinguish where evidence is practice‐based or emerging from ongoing interventions that are selected from grey literature and match the inclusion criteria. For example, the following grey literature sources will be searched to look for any evidence that can be included in this EGM:The search will be rerun by the review team close to publication of the EGM by Campbell Collaboration if the initial search date is more than six months from the planned publication date. The additional results will be thoroughly screened for potentially eligible interventions/studies. The research team will fully incorporate any new interventions/studies identified in the search rerun if this can be accomplished within the proposed timeframe for publication.3.53.5.13.5.1.1All search records will be screened against inclusion and exclusion criteria. During this first round of screening, two reviewers will independently look at the titles and abstracts and only those deemed relevant to the topic will make it to the next round of full‐text screening.3.5.1.2The full text for the studies which will be included from the title and abstract screening stage will also be screened against inclusion and exclusion criteria. At the end of this stage, only studies which are expected to be included in the EGM will remain and data will be extracted and charted from these.The entire search process and the screening outcomes will be documented using a PRISMA Flow Diagram The aim, brief description, content, and length of each intervention/studyThe setting  and countryTarget population and sample sizeThe intended professional development outcomesThe research outcomes of the intervention The purpose and methodsThe number of studies included, and key themes analysedThe intended outcomes and/or any effectiveness data (such as effect size) reported.The data extraction process will involve gathering information about:At least two reviewers will independently extract data from each study and resolve any differences through consultations. This will involve in‐depth discussion of the study and the inclusion/exclusion criteria until an agreement is reached. Any contextual information about the reason for an intervention or descriptive information about how it had achieved its effects will also be recorded. The entire data extraction process will be managed using MS Excel. A template for data extraction is provided in Supporting Information Appendix 44.1For this EGM, each study about an intervention will be considered as the unit of analysis for primary studies. Therefore, if multiple studies report on the same intervention all of the individual studies will be included as separate pieces of evidence.Besides, having the intervention rather than the study as the unit of analysis is problematic as different study designs will address different questions about an intervention. In addition, as mentioned earlier, no quality appraisal of studies will be undertaken. Therefore, it will not be possible to decide which study reporting on an intervention would be better to include over another.4.2Findings from the EGM will be presented in two ways, namely a cost‐free and publicly accessible online EGM and an accompanying report.The EGM is intended to be an online representation of Table Location of the interventions Setting type .Length of interventionDelivery mode The accompanying EGM report will be developed in line with the structure suggested by the Campbell Collaboration. This accompanying EGM report, will provide:A synthesis of the findings of the EGMAn in‐depth discussion of particular areas of interest Observations about potential implications for policy, practice, and researchA plain language statement of EGM findings.Depending on the evidence found as a result of the study, the EGM may also include filters which can be applied to select interventions in terms of additional characteristics, such as:55.1Initial consultations with the GEM Centre Executives of the value of this study for ACER and its alignment with the GEM Centre's principles.Sharing of the initial proposal with DFAT Education Section and their Disability Technical Partners Christian Blind Mission (CBM) Global Disability Inclusion Group during December 2019.Guidance on the scope and inclusion/exclusion criteria from subject experts—Dr David Armstrong, Editor, Journal of Research in Special Educational Needs (JORSEN) and Dr Jane Jarvis, Cochair, Research in Inclusive & Specialised Education (RISE), Flinders University.Educational Research (Re) connecting Communities (ECER) 2020, online conference (in the Network 4: Inclusive Education forum), organised by the European Educational Research Association (EERA) during August 2020.Presentation of the scope, methods, and initial findings at the Advice on an earlier version of the EGM proposal from DFAT and CBM has contributed to refining the direction of this study. In addition to first scans of evidence emerging from initial topical searches, feedback from the following stakeholder engagements has further clarified the topic and scope of this EGM:Working closely with the GEM Centre, this EGM is being undertaken by a team from the Australian Council for Educational Research (ACER) led by Ms. Syeda Kashfee Ahmed. Ahmed has been trained through The Centre for Evidence‐based Practice South Australia (CEPSA): A Joanna Briggs Institute Centre of Excellence. She has worked extensively in the field of education and has contributed to papers in teacher professional learning and development. Some recent relevant reports include: Ahmed et al.  and Dix The core review team also includes Dr. David Jeffries, Ms. Anannya Chakraborty and Dr. Petra Lietz. Dr. Lietz was a coauthor of several systematic reviews , who has recently contributed to a related thematic review on assessments for students with disabilities in the Asia‐Pacific region along with Ms. Chakraborty  and ACER's literature search specialist with more than ten years' experience as a librarian in ACER's Cunningham Library. Ms. Trevitt has also been directly involved with information retrieval for previous systematic reviews. The team is further supported by Mr Toby Carslake  who will be developing the online interactive EGMs for graphically presenting the results of this review.The authors declare no conflict of interest.Ms. Ahmed will be responsible for updating this EGM every five years, subject to funding availability from the GEM Centre.Supporting information.Click here for additional data file.Supplementary InformationClick here for additional data file.


The aim of this study was to evaluate the amount of micromotion of dental implants under immediate loading supported by Titanium (Ti) and Cobalt‐Chrome (Co‐Cr) superstructures.A model of tridimensional half‐edentulous maxilla with three dental implants was made using the Finite Element Analysis (FEA). Two standard and one zygomatic implants were connected to a superstructure with an elliptic section of 6x 3 mm (mm). Two study models were established. Model A: Titanium (Ti) alloy superstructure; Model B: Cobalt‐Chrome (Co‐Cr) alloy superstructure. To simulate an immediate‐loading situation, a friction coefficient of 0.71 was applied between the implant and the bone surface. An axial load of 252.04 [N] was applied on standard and zygomatic implants.The Micromotion of dental implants was similar in both superstructure situations. The amount of micromotion was slightly higher in B1 and B3 models  compared with A1 and A3 models . The micromotion values in two groups were greater than 150 μm in the incisive region (standard implant) and molar region (zygomatic). In general, the micromotion was higher on the implant that received the load with respect to the other implants. The greater difference was observed when the load was applied on the standard implant A1 (Model A1 = 189.12 μm) compared with standard implant B1(Model B1 = 263.25 μm).Within the limits of present study, all implants on different load application points showed micromotion; in general, the amount of micromotion was slightly higher in the implants connected with Co‐Cr alloy superstructure. In severely atrophic edentulous maxilla, a lower quantity and quality of bone exists and there is not enough bone to allow the support of dental implants  and zygomatic implant (molar site) was performed. Two models were established according to the alloy of superstructure. Model A: Titanium (Ti) alloy superstructure; Model B: Cobalt‐Chrome (CoCr) alloy superstructure. Micromotion was assessed in standard and zygomatic implants in both models when loads were applied.The study was performed in accordance with the principles of the Declaration of Helsinki. The protocol and the informed consent form were approved by the Ethics Committee of the Faculty of Dentistry at the University of Chile (certificate no. 2016/31).2.1A computed tomography (CT) of an edentulous left maxilla of a 68‐year‐old man was arbitrarily chosen. With this CT a 3‐dimensional FEA human model was constructed with the commercial Mimics® software . Three dental implants were inserted in the site of incisive, canine and molar teeth; two standard implants with a monoblock conical macrodesign, without thread. (4.0 × 10.0 mm) in the incisive site (Implant 1: group A1 and B1) and in the canine site (Implant 2: group A2 and B2) and a zygomatic implant with angled head, monoblock tronco‐conical shape, without thread (3.6 × 33.5 mm) in the molar site (Implant 3: group A3 and B3). A prosthetic superstructure was modeled with s 6 × 3 mm elliptical section; this cross section is used to compensate the interocclusal distance and to perform a rigid splint that prevents flexion of the same Figure  Drago &. Dental The models were assembled  Figure  and the As a model medium is being used, a restriction condition must be applied to the extra movement that simulates the symmetry conditions. For this purpose, a frictionless restriction is assigned to avoid movement in the direction of the X axis. Total restriction of movement is also added to the upper part of the maxilla, ensuring that it is in the furthest parts of the study area  and the cortical bone, equal to 0.65  were performed and six situations were established:Models A1 and B1: to simulate occlusal force, a vertical load on dental implant 1 (first standard implant) was applied, located in the incisive site (midline of maxilla).Models A2 and B2: a vertical load was applied on dental implant 2 (second standard implant) located in the canine site.Models A3 and B3: a vertical load was applied on dental implant 3 or zygomatic implant , The simulated occlusal force corresponds to the condition of maximum intercuspation of the teeth, a situation in which the implants receive a vertical compressive load. The magnitude of the applied load was the same for all implants  and Cobalt‐Chrome (CoCr) superstructures.It was observed that implants connected to the CoCr alloy superstructure  obtained slightly higher micromotion values compared to the Titanium alloy . The micromotion was greater in the implant where the load was applied compared to the other implants in all cases studied Figures  and 5. IThe amount of micromotion generated in the implant 1 that supported titanium alloy superstructure (model A1) was 189.1200 μm, while its homologous connected with a CoCr alloy superstructure (model B1), was higher by 39.2% (263.2500 μm).Dental implants located in the canine site  showed smaller micromotion than other implants, with values ranging from 25 to 67 μm independent of the site of application of the load and the alloy of superstructure Figures  and 5.When loading was applied in the molar region or implant 3 of the Ti and CoCr alloy (models A3 and B3), an increase in the amount of micromotion was observed in both the implant where load was applied (implant 3) and in implant 1 Figures  and 5.4Primary stability is an important variable that could affect the success of immediately loaded implants. The aim of this study was to compare, through FEA, the amount of micromotion in dental implants connected to superstructures of two different alloys (Co‐Cr and Ti) under immediate loading. The results obtained on this study showed that the implant micromotion was similar with both structures, being slightly superior in the Cobalt‐Chromium superstructures alloy Figure .The result obtained from a 39.2% greater micromotion in the structure of CoCr when applying an occlusal load on implant 1 (incisive zone) and comparing the micromotion generated in the group of Titanium alloy (A1/B1 respectively), would be explained by the greater stiffness of the CoCr alloys with respect to the Titanium, which would generate more Von mises stress in the bone‐implant interface, producing an increase of micromotion. The limited evidence available regarding the distribution of the load in a metallic structure supported by dental implants indicates that the tension of the implant abutment depends significantly on the type of metal alloy , the values of micromotion exceeded 150 μm only on the implants where the load was applied, while the implants located at distance from the load application point showed lower ranges of micromotion. In this regard, the results showed two situations: in the first, the greatest amount of micromotion occurred on the implant where the load was applied. The second situation observed was an increase in micromotion in the implant 1 (incisive area) when the load was applied on the implant 3 (molar area) Figures  and 5. IThe clinical evidence describes a successful osseointegration, with fluctuating implant micromotion range between 50–150 μm Brunski, . The resThe limited evidence available in the literature does not permit to draw any definite conclusions. The authors recommend that future research should consider the use of complete maxillary models with the presence of threads in the implants and preload to simulate biomechanical conditions closer to a real clinical situation.5In relation to the findings in this study and its limitations we can conclude that:All dental implants of this study showed micromotion under the different load conditions, either splinted with Ti or CoCr metal superstructure.The micromovement of splinted implants with a CoCr metal alloy was slightly greater than the micromovement in the splinted implants with Ti metal alloy.With respect to the micromotion observed in standard and zygomatic implants:The micromotion thresholds established in the literature, as a condition of success of the osseointegration, were exceeded when the load was applied directly on implant 1 either with a Ti or CoCr superstructure alloy.Implant 2, independent of the point of application of the load and the superstructure alloy, presented values of micromotion compatible with a success condition of osseointegration established in the literature.When the load was applied on implant 3 (zygomatic implant), in the Titanium and Cobalt‐Chrome superstructure, the micromotion thresholds were exceeded according to the literature as a successful condition of osseointegration.The authors declare no conflict of interest.Tobar‐Reyes Julio: Supervision and manuscript correction. Execution of three‐dimensional anatomical models. Execution ofmodels of materials in Oral Rehabilitation. Andueza‐Castro Luis: Supervision manuscript. Execution of three‐dimensional anatomical models. Execution of models of materials in Oral Rehabilitation. Jiménez‐Silva Antonio: Manuscript preparation and translation. Assistance in the execution of three‐dimensional anatomical models and the execution of the material models in Oral Rehabilitation. Bustamante‐Plaza Roger: Supervision and manuscript correction. Supervision in the use of specialized softwares in Finite Element Modeling. Review of the progress of the study. Carvajal‐Herrera Juan: Supervision and manuscript correction. Review of the progress of the study.


Adjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin’s place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.To produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.A list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be ‘adopted or adapted’ from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008–2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.We confirmed that no published guideline—of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.All 11 recommendations and 7 supporting good practice developed here were formulated de novo.These recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG. During the first years of antipsychotic treatment, approximately 80% of patients with first episode psychosis (FEP) gain a clinically significant amount of weight (>7% of their baseline body weight).Of all pharmacological interventions, metformin treatment is associated with the most consistent supporting evidence, having been assessed in several well-designed meta-analyses of randomised controlled trials (RCTs).Quality assess available recommendations and determine to what extent evidence supporting metformin is incorporated into recommendations.Identify whether there is a role for metformin as a first-line intervention—not solely where diet and lifestyle, or switching antipsychotics, have failed.Assess the optimum prescribing parameters that facilitate metformin’s use in managing AIWG, including when and how it should be used.An overview of the guideline development process can be found in 10.1136/ebmental-2021-300291.supp1Supplementary dataA systematic literature review is an essential first step when developing a guideline.The guideline development group (GDG) consisted of consultant psychiatrists, specialist pharmacists and psychiatric nurses, as well as those experienced in project management and guideline development. No conflicts of interest were reported.Following literature review completion, consensus meetings began. An informal consensus approach was chosen due to topic complexity and project resources. Consensus was defined as general group acceptance on direction and wording of all recommendations and good practice points. Whether to make a recommendation or good practice point, and the accompanying direction and strength of recommendations, were all decided on using the principles and processes of Grading of Recommendations Assessment, Development and Evaluation (GRADE).As per GRADE, recommendations can either be strong or weak . Their interpretations are contained in Recommendation development and assignment of recommendation strength is based on several factors, not solely quality of evidence.Available research and extensive clinician experience, reflective of both psychiatry and endocrinology perspectives,Detailed results of the systematic review, including all evidence from guidelines and supporting research evidence, along with their formal quality appraisal, are located in the Although two guideline recommendations, produced by the WHO in 2018 and the Scottish Intercollegiate Guidelines Network (SIGN) in 2013, were judged as being of acceptable quality for adaptation, it was agreed that the SIGN recommendation had lost currency due to significant research on AIWG management methods published since.A brief overview of the empiric evidence addressing all KHQs is outlined below. A full overview of reasons for downgrading evidence quality are outlined in GRADE evidence tables contained in the et al.2=85% (p<0.001). Subgroup analysis identified most heterogeneity was due to pooling of FEP and chronic participants (discussed further under KHQ 4).The most recent meta-analysis identified was a 2016 study by De Silva Short follow-up period .Uneven distribution of lifestyle interventions across RCTs.No grey or unpublished literature included—associated funnel plot found no evidence of publication bias.et al,  explored the impact of metformin dosing on anthropometric outcomes over 12 weeks. They found metformin 1000 mg treatment to be associated with significantly greater weight loss compared with baseline (p<0.05),et al, meta-analysis.2 (p=0.021) and 0.50 kg/m2 (p=0.017) in those assigned to metformin 500 mg and 1000 mg, respectively.A single RCT published after this meta-analysis by Chiu et al,et al.et al RCT,GRADE quality of evidence rating for this KHQ was moderate for all anthropometric outcomes due to unclear risk of bias in a minority of studies included in the De Silva andOne RCT that directly compared metformin to a combination non-pharmacological intervention was identified. This intervention involved psychoeducational, dietary and exercise components. As in Evidence quality was moderate across all outcomes for this KHQ. Downgrading was due to indirectness, as participants only included those with FEP.et al, meta-analysis was subsequently identified to be due to pooling of FEP and chronic psychosis participants. When assessed separately, significant between-group differences were seen (p<0.001). The associated I2 result was 0% (p=0.59) in FEP participants and 11% (p=0.35) in chronic psychosis participants. FEP participants (n=283) mean change in weight compared with placebo was −5.94 kg (95% CI −6.75 to −5.12) (p<0.001). Mean weight change among those with chronic psychosis (n=460) was −2.06 kg (95% CI −2.71 to −1.41) (p<0.001).Significant heterogeneity in the De Silva A range of doses between 500–2000 mg/day was applied across studies. The median dose was 1000 mg/day (IQR=1000 mg/day).Median trial length was 12 weeks (range 12–24 weeks).et al, meta-analysis reported data on discontinuation rates.et al, reported no significant diffences in adverse events or discontinuation rates between groups, and reported no serious adverse events in any group.et al, meta analysis.Five out of 10 adult studies  in the De Silva The following Box 1Recommendation 1: The use of metformin in the treatment of AIWG can be applied in two ways; as part of an early intervention strategy or in the treatment of established weight gain. We recommend that preference should be given to early intervention strategies, where possible.Strength of recommendation: Strong. Quality of evidence:LowRecommendation 2: For the purposes of this guideline, early intervention in the management of AIWG is defined as the implementation of an intervention following a ≥7% increase in baseline body weight, within 1 month of antipsychotic treatment. (good practice point)Recommendation 3: In the case of either early intervention or treatment, where non-pharmacological interventions are deemed appropriate and acceptable to the patient we recommend that these be offered before metformin.Strength of recommendation: Strong Quality of evidence: ModerateRecommendation 4: Where lifestyle interventions available to patients are unacceptable to them or are inappropriate, for example in the case of physical disability, we recommend the use of metformin as an alternative first-line intervention.Strength of recommendation: Strong Quality of evidence: ModerateRecommendation 5: Where non-pharmacological interventions are appropriate but seemingly ineffective, we recommend metformin be offered as an alternative. It should be noted that evidence supports improved efficacy of metformin in attenuating AIWG when initiated at earlier time points in antipsychotic treatment. Therefore, what constitutes an appropriate trial length of non-pharmacological interventions must consider this.Strength of recommendation: Strong Quality of evidence: ModerateRecommendation 6: We recommend the use of metformin to attenuate weight gain induced by any antipsychotic.Strength of recommendation: Strong Quality of evidence: Moderategood practice point)Recommendation 1: Baseline renal function must be assessed before treatment is started. Where the Estimated Glomerular Filtration Rate (eGFR) is <60 mL/min, dosing of metformin should be adjusted. Metformin is contraindicated in those with an eGFR of <30 mL/min. Recommendation 1: Renal function should be monitored annually. In those who are at increased risk of renal impairment for example, those with chronic kidney disease or the elderly, renal function should be measured every 3–6 months. (good practice point)Recommendation 2: Intermittent monitoring of vitamin B12 levels is recommended, especially where evidence of megaloblastic anaemia is present. (good practice point)Recommendation 3: Clinicians should also monitor the patients’ adherence and tolerability to both the antipsychotic and the metformin regularly. (good practice point)Recommendation 1: Gastrointestinal side effects are dose related and can be managed through dose reduction and/or a slower dose titration. (good practice point)Recommendation 2: The estimated incidence of lactic acidosis is 4.3 per 100 000 person-years in metformin users. Adjustment of dose to account for low levels of renal function will help to mitigate risk. Additionally, avoidance of metformin in certain groups—including those with a history of alcohol misuse or in those who are prescribed interacting medicines will also reduce risk of lactic acidosis occurring. (good practice point)Recommendation 1: Where treatment goals have been reached at 6 months, we recommend metformin be continued. However, lack of evidence to support the continuation of metformin beyond 6 months must be considered as part of the risk–benefit assessment.Strength of recommendation: Strong. Quality of evidence: LowRecommendation 2: Where agreed treatment goals have not been reached at 6 months, we recommend that treatment be reviewed and the following undertaken:The dose of metformin should be increased to 2000 mg/day, where possible.If treatment has been optimised as much as possible, treatment should be stoppedClinicians should check adherence, and stop if not mostly adherent.Strength of recommendation: Strong. Quality of evidence: LowThis work represents an approach to optimise use of a modestly effective AIWG management strategy,While direct comparisons are largely lacking, indirect evidence shows individualised lifestyle interventions to be associated with the largest comparative effect size for weight reduction, alongside a moderate effect size in BMI and waist circumference reduction. Group lifestyle interventions the current typical standard of delivery, were associated with a small effect size on weight and BMI reduction Metformin, alone and in combination with lifestyle interventions, was associated with a moderate effect size on weight reduction. Switching antipsychotics to attenuate AIWG was associated with non-significant effect sizes.For a significant proportion of patients, uptake of any lifestyle intervention will be refused, inappropriate at the time of offering or ineffective.Psychological impact of AIWG.Prevalence of AIWG and its significant contribution to obesity rates in schizophrenia.Ease of recommendation implementation.Raised standardised mortality ratio compared with the general population, including pre-antipsychotic.Low cost and associated resource use.Established long-term safety profile in T2DM.Very rare likelihood of catastrophic harm.Current lack of other pharmacological methods with a similar cost, safety and risk profile.Objectivity of weight outcomes.Potential for improvement in quality of care.Equitable access across socioeconomic groups compared with effective diet and lifestyle interventions.No interaction with the cytochrome P450 system and therefore, minimal pharmacokinetic drug interactions—there are no known interactions with any antipsychotics or other psychotropics, including mood stabilisers, antidepressants and antianxiety medications.To encourage prompt action, the GDG provided a definition of what constituted an ‘early intervention’, highlighted what is considered clinically significant AIWG, and introduced a new goal of treatment—early plateau of AIWG.Some recommendations were rated as ‘strong’ in the absence of supporting high-quality evidence. As per GRADE, recommendations strength depends in part—not solely on the level of confidence in the intervention effects.A comprehensive review of AIWG management is well overdue. Replication of a similar hierarchical model applied in the general population does not account for the unique challenges faced by those with psychotic illnesses, including the disproportionate numbers of risk factors present for becoming overweight or obese.To date, interventions have focused on what patients should do to reduce their weight. In contrast possible routes for clinicians and psychiatric services to make changes have been neglected. This includes improving access to medications that manage weight and other cardiometabolic risk factors. Set against its clear and unarguable effects, negative associations with metformin become relatively less important. On balance, coprescription of metformin to a much wider range of patients is evidently desirable.Limitations of metformin as an intervention have been discussed in detail elsewhere.This work represents the first guideline solely dedicated to the use of metformin to manage AIWG, and builds on both the quality and number of recommendations available. Our view is that this research represents a significant step forward towards improving the application of an inexpensive and well-studied management method.


Borrowing behavior may be more resistant to formal educational treatments than other financial behaviors. In order to study the process and results of infographics-based debt education, we used eye tracking technology (SMI RED 500 Hz) to monitor the oculomotor behavior of 108 participants  aged 18 to 60 who were shown 4 infographics. The study used an experimental design with repeated measures and an internal comparison group. We also used scales of debt literacy and a set of information literacy scales: numerical, graph, and linguistic. The results confirm that short-term infographics-based debt education can improve debt literacy significantly. The difference in processing the educational contents that were not known to participants before the educational session suggests that participants with better information literacy make more considerable debt literacy progress. Specifically, we found that numerical literacy is a significant mediator of debt education results, depending on the initial level of debt literacy; this relation is moderated by the focus of visual attention on negatives of debt. We found no significant relationship between debt literacy education results and those of graph and linguistic literacy. The question of whether to save or invest is, thus, rhetorical in this case.Financial decisions are unavoidable, at least in adulthood. As in any other domain of life, the ability to make the right decision depends on the extent to which the individual possesses appropriate knowledge and skills—something known as a core of “financial literacy” Huston, . FinanciHowever, the question is not rhetorical on the liabilities side of household budgets. In contrast to saving or investing decisions, a wrong borrowing decision may lead to a literal financial default, that is, the inability to repay debt. As a result, consumers' attitudes toward debt (loans) are more likely to be negative than positive  and output , but we do not know their internal mechanism. Therefore, we designed our study to go one step further and test the processes underlying effective education in the field of debt education. In our study, we decided to focus on visual educational techniques because they are likely to be particularly efficient . Another form is one based on interaction without direct expert participation , resembling typical e-learning courses—e.g., multimedia presentations, scripts with case studies, video or audio material, infographic material available online and many others.While traditional print materials and in-person workshops are still the most common, advances in technology have created online financial education opportunities in recent years  due to the possible data loss resulted in minimal sample size N = 144. Finally, 176 persons participated in the experiment, which ensured meeting requirements for minimal statistical power of results.Setting the alpha level at 0.05, and expecting a medium effect size (Cohen's d = 0.5), we assumed minimal statistical power 8 Cohen,  and partvia the electronic administration system among extramural and postgraduate students  of the University of Economics and Innovation in Lublin (Poland). The information provided to participants described the experiment as being focused on the assessment of the correlates of debt literacy and infographics stimuli that were best for educational purposes. The participants were informed about the use of eye-movement tracking. Participants could select one of the following incentives proposed: a financial fee, compensating proportionally time spent in the lab  or up to 5% of the semester exam points. The compensation in both groups depended on the sum of points collected in the Debt Literacy tests, which were administered twice in the experiment. Almost 99% of students selected semester exam points and received course credit for participation.The participants were invited to take part in the experiment Participants with significant vision defects, such as astigmatism, myopia of above 5 dioptres, or uncorrected myopia of an unknown scale were excluded from participation before the start of the experiment. Random dropouts also occurred during other stages of the data collection process. We recorded the drop-out of 38% of participants from the experimental procedure due to visual impairment and errors in completing the questionnaires. The eye tracker calibration for 27 participants did not meet the acceptable threshold. Their participation in the experimental procedure was accepted with no comments to avoid stress and frustration, and all data were collected. However, their results were excluded from all analyses. Eighteen participants omitted at least one answer in the questionnaires, resulting in a lack of data. The 23 participants who showed a lack of fixation on at least one of the presented infographics were excluded during the data processing that took place before the final calculations; however, compensation points were granted to all participants. Final analyses were performed on data collected from 108 participants . The mean age of the participants was 33.46 years (SD = 9.66). The sample is representative for the general population of working adults in Poland in terms of age. However, the gender gap  and theex post two subgroups of participants of the experimental group using the change in the debt literacy score: those participants who increased their debt literacy were classified to the first group and those who had no increase in debt literacy were in the other group.To avoid selection bias, participants were randomly assigned to an experimental (E) or a control (C) group of the ratio 5:4−60 participants to the experimental group and 48 to the control group. Due to the fact that individuals usually acquire information from left to right and from top to bottom , defined after Lusardi and Tufano, as “the ability to make simple decisions regarding debt, applying basic knowledge about interest compounding to everyday financial choices,” , which means that PLN 4,500 will be effectively available to you on the day the loan is granted.A one-time payment of PLN 500 at the end of the year, which means that PLN 5,500 will have to be returned to the lender on the day of repayment.Which is the more advantageous option?”Each answer was assessed as correct (1) or incorrect (0), and points were allocated on a scale ranging from 0 to 4.Information literacy was limited in the current study to information presented numerically, graphically, and verbally (variable C). These three dimensions were assessed by using brief subjective assessment scales administered separately. Two standardized self-reported scales for numeracy and graph literacy were adapted, and a new scale for assessing linguistic literacy was applied. Numeracy was assessed using the eight-item subjective numeracy scale  using E-Prime 2.0 software . The behavioral responses were collected using a standard computer USB keyboard. An SMI RED500 eye tracker at a sampling frequency of 500 Hz was used for the registration of eye movements and fixations in areas of interest (AOI). The spatial accuracy of RED500 was 0.4 degrees. Calibration accuracy was kept below 1° of visual angle, which ensured high time resolution and spatial precision of fovea location.An ecological protocol exploited stimuli selected from the debt educational campaign as a sequence of infographics reflecting each aspect of debt literacy described in the Debt Literacy Scale. Each stimulus was prepared as an RGB bitmap of 1920 x 1080 px containing two infographics: the first one informing about the positive aspects of debt , and the other one informing about the negatives . The size of each infographic was set to a width of 500 px and a height of 400 px, which subtended 11.2° x 9.0° of visual angle in size, with 268 px (6°) separation between infographics.Each stimulus had two versions: (1) an infographic that had the negatives on the left-hand side of the screen and positives on the right-hand side; and (2) another infographic with the positives on the left and negative on the right. The presentation of stimuli versions was counterbalanced in the groups of participants so that an equal number of stimuli were assessed with the positives located on the left and right. http://dx.doi.org/10.17632/f5s6cxk38f.1.The infographics were arranged sequentially, representing the increasing complexity of the properties of loans , age , and education level .The experimental and control groups were comparable in gender composition . The results are presented in The presence of educational debt information in infographics significantly improved the debt literacy score in the experimental group. The mean of the debt literacy score in the experimental group increased by 69% compared to the initial value—from 0.67 pt. (SD = 0.73) to 1.10 pt. (SD = 1.09). The effect of short-term debt education with the use of infographics in the experimental group was statistically significant , but not significant in the first measure . The result of presenting infographics with neutral information in the control group was not statistically significant .In the control group, debt literacy was 8.8% lower than the initial value, falling from 0.77 pt. (SD = 0.88) to 0.71 pt. (SD = 0.99). The difference between the experimental and control groups was significant in the second measure . Participants from the group in which the debt literacy increased spent less time  processing information presented in the first infographic (Infographic 1) than participants from the other group . Differences between the mean dwell times pertaining to visual processing of other infographics were not significant . There was a significant interaction between these two aforementioned groups in the experimental group (no increase vs. increase) and the mean dwell time of visual attention pertaining to the area of the presented infographics (first vs. second vs. third vs. fourth) .The interaction between the two groups, which demonstrates the different effects of education on debt literacy in the experimental group (no increase vs. increase) and focus on the positives of debt shown in the infographics (first infographic vs. second vs. third vs. fourth) was significant, and lower-bound correction was applied . The interaction between the two groups, which demonstrates the different effects of education on debt literacy in the experimental group (no increase vs. increase) and focus on negatives in infographics (first vs. second vs. third vs. fourth) was significant, and the lower-bound correction was applied , graph literacy , or linguistic literacy .F = 3.50, p = 0.003, R2 = 0.355]. The initial level of debt literacy is the most significant predictor of debt education results with the use of infographics . The higher the initial debt literacy, the higher the final debt literacy, and the lower the debt education increase.The unstandardized weights of the beta coefficient from the mediation test are shown in t(51) = 2.87, p = 0.006]. Visual attention on the negatives of debt in infographics moderates the process of debt education reducing outcomes ; however, the interaction between initial debt literacy and focus on negatives is not significant . Graph and linguistic literacy, as well as the focus on positives in infographics, are insignificant as mediators and moderators .Numeracy mediates the relationship between the initial and final debt literacy, thereby strengthening the results of debt education [This study provides evidence that infographics-based education may be effective, at least in the short run. The scale of debt literacy growth of 2/3 of the entry level in the experimental group after exposition to a series of 4 simple infographics is very promising, suggesting the high potential of using infographics in debt education. It is likely that even such a short-term infographics-driven intervention, leading to a significant though small increase in debt literacy, may be relevant in educational programs supporting healthy financial behavior. For instance, infographics-based educational material similar to the one designed in our study could be shared immediately before the credit decision , as a part of the creditworthiness evaluation process, or as a part of the contents displayed on the website that allows various credit offers to be compared. Additionally, the advantage of such an educational intervention is its relatively low cost, which comes down mainly to the design and production of the infographics.The effect size of short-term debt education results is satisfying, but the final level of debt competencies measured after the micro scale of the experimental process is still low. Our study showed a low level of debt literacy among the participating individuals. To a large extent, the participants lacked the knowledge and skills deemed useful in typical debt-related situations. These results are consistent with the findings of previous studies  and those who did not (no increase group). These groups were compared in terms of visual attention to infographics and the components of information literacy selected: numerical, graph, and linguistic.We found that the increase group focused visual attention on educational material for a shorter time than the no-increase group—an effect that provided the basis for the rejection of H1. The differences in the mean dwell time were quite considerable (~20%) and occurred almost exclusively when the participants were exposed to the first infographic. The three remaining infographics attracted the visual attention of both groups for comparable lengths of time. This result is interpreted as not being contradictory to findings proving the need for attention to be paid to the processed information for better learning , with a high school or college education, and predominantly female. Future research should verify our findings both in a larger study sample and over a longer period of time. Overall, there is very little research dedicated to different formats of financial education. Therefore more studies are needed to test different formats, particularly those most promising in terms of online opportunities.In our study, we did not analyze the role of learning styles in the effectiveness of the tested infographics. Nonetheless, the mediating influence of numeracy can be inferred also from this theory. Future research could consider this factor by examining how individuals with different learning styles respond to the educational material we designed.In our study, we focused on debt literacy. While we surmise that domain-specific content will not make much difference to the effectiveness of using infographics in financial education as such, scientific integrity dictates that we examine how they perform with respect to other aspects of financial literacy—e.g., investment literacy, insurance literacy, etc.—as well as with respect to financial literacy in general.Our findings have implications for both the theory and practice of financial education, and for both the academic world and for policy- and decision-makers. Social learning theory Bandura,  posits tIn our experiment, we showed that financial infographics, which are perfect for online education, increase debt literacy. We confirmed the supporting role of numerical competencies in the process. One new interesting result of the current study is that focus on negatives of debt is detrimental to the results of debt education. Focus on negatives can be attributed to risk-aversion as well as to negative attitudes toward borrowing, developed during economic education. Future studies may examine whether social factors  or support for rational attitudes toward debt can amplify the positive effects of such programs. This could shed a new light on this very timely aspect of social learning theory.We also showed that laboratory experiments—including those using innovative measurement techniques like eye tracking—are a useful method for evaluating the outcomes of financial education. The effectiveness of micro-education could be a predictor for general education. The methodological paradigm of studies on micro-education using eye trackers can be applied to investigate educational outcomes in any subject. It is worth considering the verification of different stimuli properties, like the amount of text, the shape and color of the objects and the background  formats using pictorials, ideally suited for online use, can be effective in financial education. Given that financial education to date has focused primarily on content and less on form, our findings may be useful for those who design financial education interventions and implement educational programs.From a purely practical standpoint, our results can be taken as a very clear indication of how infographic educational material should be designed. Our educational material has a user-friendly format, is interactive, reusable, and closely linked to key aspects of the annual percentage yield (APY), a particularly important parameter for understanding the implications of using different loan products.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The University of Economics and Innovation Ethics Committee. The patients/participants provided their written informed consent to participate in this study.RP: design of the work, data collection, data analysis and interpretation, and drafting the article. AC: conception, data interpretation, drafting the article, and critical revision of the article. WC: critical revision of the article and final approval of the version to be published. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.