WHO has recognised the need to improve its guideline methodology to ensure that guideline decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines.WHO convened a writing group drawn from the technical teams involved in its recent (2010–2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development.We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria , weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding ‘research evidence’ sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health.This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process.The online version of this article (10.1186/s12961-019-0468-4) contains supplementary material, which is available to authorized users. Decision-makers typically have a range of questions when deciding whether to recommend or implement a particular health intervention, including the effectiveness of the intervention, its acceptability and feasibility, equity impacts and the resources needed for implementation . EffortsAs a guideline producing organisation, WHO has recognised the need to improve its guideline methodology to ensure that these processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable , 4. To hAs discussed in paper 1 in this series, to address EtD framework criteria such as the acceptability and feasibility of interventions, guideline producers are now exploring the use of qualitative evidence , 8. ThisThe first WHO guideline to draw systematically on findings from QES was produced by the WHO Department of Reproductive Health and Research in 2012 . Since tThis paper is the second of a series of three papers that describe and discuss the use of QES to inform the development of clinical and health system guidelines Fig. . The firThe aim of this paper is to describe and discuss how findings from QES can be used to populate key EtD framework criteria for decision-making in guideline development and to inform recommendations. As members of technical teams responsible for producing evidence for WHO guidelines, we describe lessons learnt from our experiences and areas in which further research and development are needed.WHO convened a core team of authors who had been involved in WHO guideline technical teams since 2010 and in developing QES to support these guidelines. The team included people with extensive experience in qualitative research and qualitative evidence synthesis methods, methods for guideline development and the use of evidence-to-decision frameworks.The core author team reflected on the guideline development processes in which we had been involved (see list below), focusing on the role of QES findings in these processes. We also received informal feedback on these processes from other WHO staff involved in guideline development, and from participants in several guideline training workshops at WHO. These reflections and feedback led us to identify three key areas that each became a focus for one of the papers in the series, namely how QES methods need to be adapted for the context of producing guidelines; how to use findings from QES to populate EtD frameworks; and how to use QES findings to develop implementation considerations and inform implementation guidance and processes.The lead author for each paper then drafted an outline for their paper, and these were discussed during a 4-day author workshop. In the workshop, authors discussed the most important factors in the use of qualitative evidence in this context to date and agreed on what worked and what could be improved in the future. The outlines were then developed into full papers, using an iterative process of sequential writing and discussion. We also identified relevant examples from the guidelines in which we had been involved. The core authors then reviewed the draft to clarify the ideas and processes described and to add further examples where needed.We then circulated the draft papers to key stakeholders to obtain their feedback on the ideas and processes described. These stakeholders included members of WHO guideline panels , methodologists, guideline commissioners and implementation experts.The experiences, guidance and data presented in this series of papers are the result of a range of processes that have evolved over a decade of engagement with qualitative research in the context of developing healthcare guidelines at WHO. To develop this series of papers, we used a pragmatic and iterative approach that included the following steps:Optimizing health worker roles for maternal and newborn health through task shifting (2012) Expanding health worker roles to help improve access to safe abortion and post-abortion care (2015) WHO recommendations on antenatal care for a positive pregnancy experience (2016) WHO recommendations on intrapartum care for a positive childbirth experience (2018) Guidance on communication interventions to inform and educate caregivers on routine childhood vaccination in the African Region WHO recommendations on digital interventions for health systems strengthening We selected examples from the following WHO guidelines in which members of the core author team had been involved:All of these guidelines were health systems focused or had a health system component, and all used the GRADE EtD frameworks . As alluIn a WHO guideline, the technical team creates EtD frameworks for each guideline question. The team then uses relevant evidence to populate each of the framework’s criteria . These frameworks are the main documents used by the guideline panel during the final guideline meeting. Here, guideline panel members are asked to assess and make judgements about the evidence for each of these criteria before making a recommendation.Figure Through already-published syntheses that address the guideline questions directly or indirectlyThrough one or more syntheses commissioned for the guideline (Box 1). These may include both broad QES covering multiple guideline interventions and ‘mini-QES’ focusing on a specific interventionFindings from a QES may enter a guideline process in two ways:www.epistemonikos.org), for a limited time period, for instance, the last 5 years. A judgement on whether new syntheses need to be commissioned could then be made based on the syntheses identified (if any), including their scope, the synthesis approaches used and when the syntheses were conducted.Undertaking simple searches for relevant syntheses early in the guideline process may help the technical team decide whether it is necessary to commission new syntheses. For example, the technical team could search a database of systematic reviews in health, such as Epistemonikos  and sometimes a pragmatic decision will need to be taken on where to place the finding. Overall, the technical team needs to ensure that the relevant findings are reported somewhere in the framework so that they can be taken into account in decision-making.Because qualitative evidence is often broad in nature, it may be relevant to more than one of the frameworks included in a guideline. Additionally, findings from several QES may be relevant to one or more frameworks. For example, a QES conducted for forthcoming WHO guidance on communication interventions to inform and educate caregivers on routine childhood vaccination in the African Region included a broad finding that the acceptability of vaccination communication interventions appears to be influenced by several factors, including people’s trust in and relationship with the information source as well as the manner in which the information is presented . This fiAnother reason to use an overarching or cross-cutting approach is that it can be challenging to summarise qualitative evidence succinctly without losing meaning and data on context. Where an overarching narrative is developed, the technical team need to ensure that it is clear to the guideline panel that the qualitative evidence for several frameworks is presented in an overarching document, and each EtD needs to link to this document. Importantly, whilst the qualitative evidence might be the same for different guideline questions, the guideline panel’s judgements for each criterion might differ, depending on the intervention evaluated in each question.Wider, less specific findings may need to be used in relation to an intervention where more specific findings are not available. For instance, a finding may be available regarding people’s views of receiving health messages via mobile phones but not on people’s views regarding such messaging for the particular health issue that is the focus of the guideline question.Qualitative evidence may have direct relevance to a guideline question or may be indirectly relevant. Indirect evidence, for example, qualitative evidence regarding a related intervention or context to the one of interest, can be included in the ‘Research evidence’ section of the EtD framework. However, it may be helpful to indicate clearly to users, for instance, through the CERQual assessment of confidence, that the evidence is indirectly relevant.Overall, the technical team needs to ensure, firstly, that each framework includes sufficient information to inform a recommendation and, secondly, that people using the recommendations are able to understand the justification for each recommendation from the evidence presented.Once the findings have been allocated to a specific criterion, the guideline technical team needs to weave these findings into a single, short narrative for inclusion in an EtD framework. This narrative should also include the CERQual assessments for the included findings. In our experience, it is often the case that several synthesis findings, from one or more QES, are relevant to a single framework criterion.The narrative should include the key points from the findings that are relevant to the decision that the framework will inform.The narrative should include enough information on the context of the findings  to reduce ambiguity and allow interpretation, including of the relevance of the evidence as assessed using CERQual.www.optimizemnh.org.A graded entry or layered approach to presenting information may be helpful , 29, witUsers should be able to trace back from the narrative to the individual findings that informed the narrative. Traceability can be enhanced by giving a unique code to each QES finding and including these codes in the narrative.We do not have evidence on the optimal length of the narrative text for framework criteria and this is influenced by the nature of the findings and the number of frameworks that a guideline panel has to consider as part of a guideline process. However, the following principles may be helpful:As technical team members, we have found that the narrative summarising relevant QES findings usually needs several iterations before it is finalised for inclusion in an EtD. Tables Descriptions of conceptual or theoretical frameworks that help in understanding the QES findings or that place these within a wider contextFindings from individual qualitative studies that provide important contextual information related to the setting of the recommendation or decision but were not eligible for inclusion in the QESPlausible reasons for anticipating that the intervention might or might not be acceptable to key stakeholders or might be difficult to implement, particularly where little or no evidence on acceptability or feasibility was found for an interventionAny assumptions made in relation to the findings presented and, if relevant, the basis for those assumptionsThere may be circumstances in which other qualitative, or related, evidence or information needs to be included for a particular framework criterion, in addition to the findings of the contributing QES. This additional information may also be needed where no relevant evidence was found by the QES. This additional evidence might include :DescriptThis additional evidence or information can be included in the ‘Additional considerations’ section for the relevant framework criterion.Here, we describe in more detail how we have used qualitative evidence to identify issues relevant to specific criteria within the EtD framework and present examples of the approaches we have used.To ensure that all relevant stakeholders and contexts are considered in a QES commissioned for a guideline, it is helpful at the scoping stage for the guideline panel to consider which stakeholders and contexts are most important. In doing so, they should take into account the anticipated coverage of the guideline  and those affected both directly and indirectly by the guideline . This is discussed further in paper 1 in this series .The guidance on populating an EtD framework notes that the direction of a recommendation may change where there is uncertainty about how those affected by this intervention value the outcomes of interest. Additionally, the strength of a recommendation may be affected by research evidence showing that different groups value the desirable and undesirable effects differently .directly measure the choices people make when presented the probabilities of the desirable and undesirable effects, a description of those outcomes  and information about when they would occur and how long they would last” ; maintaining physical and sociocultural normality; maintaining a healthy pregnancy for mother and baby; effective transition to positive labour and birth; and achieving positive motherhood” ..maintainshould evaluate potential impacts on equity in relation to specific characteristics that are likely to be associated with disadvantage in relation to the question they are addressing” . . should Secondly, where a QES undertaken for a guideline does not identify gender, health equity or human rights issues explicitly, it may be possible to infer these from the findings through discussion within the technical team or experts in the field. A narrative summary of the issues can then be created Table . Where tthe extent to which that intervention is considered to be reasonable among those receiving, delivering or affected by the intervention” ([the likelihood that it can be properly carried out or implemented in a given context” ([We have defined acceptability as “ention” ( p. 186).ontext” ( p. 187).In our experience, qualitative evidence on the acceptability and feasibility of different interventions is often linked. For example, when an intervention involves additional costs for service users, it may be associated with both lower acceptability and lower feasibility. The technical team will often need to take pragmatic decisions on whether to report QES findings in the acceptability or feasibility sections of the EtD framework. As a recommendation is based on judgements regarding all of the evidence presented in a framework, where best to place a specific relevant QES finding is less important than ensuring it is included.Our experience has also highlighted that qualitative studies often do not include in-depth data on intervention feasibility. This may be because these studies often focus on the views of service users or providers regarding a health issue, and do not include the views of healthcare managers or explore factors affecting the governance or financing of interventions or programmes . This evWhen the technical team starts to develop the summary narratives for the acceptability and feasibility sections of the EtD framework, they should also consider how to convey the extent to which the evidence shows similarities and differences across stakeholders and contexts. In some cases, it may be appropriate to include separate narratives for different stakeholders or contexts. When no specific qualitative evidence for a particular option, stakeholder group or context is found, it may be possible for the technical team to draw inferences from findings for other options, stakeholders or contexts. For instance, findings on the acceptability to mothers of childhood vaccination communication interventions may also apply to other caregivers. Where inferences are made, this should be made clear in the relevant framework.Tables When making a recommendation, a guideline panel should take into account all of the evidence presented in the EtD framework. The extent to which the qualitative evidence included in a framework influences or drives a decision regarding a particular recommendation will vary across the questions considered by a guideline – in some cases, a decision may be driven by other information presented in the framework. Regardless, all judgements should be supported by a clear justification that refers to the key criteria that drove the decision.Two examples from recent guidelines illustrate how qualitative evidence can inform decisions in different ways. The first example is from the WHO antenatal care guideline  and concThe second example is from the WHO guideline on digital interventions for health systems strengthening  and concProvide guideline panels, in advance of their meeting, with information on the purpose of the EtD framework; the criteria within it; the types of evidence that will be used to address each criterion, including how qualitative evidence will be used; what constitutes research evidence and what additional information can be considered; and how the decision-making process will work . This caReiterate this information at the start of the guideline panel meetingPresent the different types of evidence as clearly and succinctly as possible; using an EtD framework assists with thisPrompt guideline panels to justify their recommendations in relation to the full body of evidence, including the qualitative evidence, in an EtD frameworkAt present, we have limited knowledge of how best to integrate different types of evidence within EtD frameworks and how to present these different types of evidence to guideline panels. We also do not yet have a good understanding of how guideline panels use and adjudicate different types of evidence  addressing different types of questions  in making a decision. Further research is needed in these areas –39. The As members of the technical teams for a series of WHO guidelines, we used QES as our main source of information to populate specific EtD framework criteria, and this paper reflects the lessons we have learnt to date. As Graham et al.  noted soThis paper is based on our experience of using QES findings within WHO guideline development. In drawing out the lessons we have learnt, we have tried to ensure that these could be applied across a wide range of health guidelines. The approaches we describe may also be useful for decision-making processes in other sectors that aim to utilise qualitative evidence. However, we acknowledge that our experiences are limited to the WHO context and the range of guidelines in which we have been involved, and also to the EtD framework approach. As we note below, further work is needed to explore the application of the learnings described in this paper to guidelines in other areas. Further research on how qualitative evidence is understood and used within decision-making processes may also lead to insights that enhance and extend the guidance outlined in this paper.Synthesising evidence and producing guidance are just two elements of what has been termed the ‘evidence ecosystem’ –43 , research will be needed on strategies for including findings that are based on multiple types of data in frameworks, and how to assess how much confidence to place in these findings. Mixed method approaches may be particularly relevant to the ‘values’ and ‘acceptability’ criteria within the EtD framework as survey data on these issues are sometimes availableIn populating an EtD framework, a technical team has to strike a balance between informativeness and length. To keep EtD frameworks to a manageable length, we have typically used summarised QES findings in these documents and then referred guideline panel members to the relevant Summary of Qualitative Findings for further detail. Future research needs to explore guideline panel members’ views on the level of detail they find useful in an EtD framework and their experience of graded entry formats to present information for decision-makingFuture research should consider the circumstances in which it might be appropriate to use findings from individual qualitative studies in an EtD frameworkFuture research should explore guideline panel’s preferences regarding different ways of presenting qualitative evidence that cuts across several guideline questions, and therefore frameworksFuture research should explore how guideline panels understand, use and adjudicate the different types of evidence that may be included in EtD frameworks, including qualitative evidence, and the roles of the technical team in prompting these groups to take account of qualitative evidence during their deliberationsFuture research needs to explore the application of the learnings described in this paper to guidelines in other areas such as social care and educationThis paper explores how QES findings can be used to populate key evidence to decision framework criteria in the context of guideline development. We have demonstrated the value of investing in QES as part of a guideline development process, and the roles that qualitative evidence can play in representing the views and experiences of stakeholders . We haveBox 1 Commissioning a qualitative evidence synthesis (QES) to inform a guidelineIdentifying the areas and topics for a QES – the guideline technical team identifies the broad areas or topics for which a QES will be needed; this could include a QES to inform the scoping of the guideline or a QES to inform specific criteria that are part of an evidence-to-decision (EtD) framework (such as the acceptability and feasibility of an intervention)Identify synthesis leads and teams – ideally teams should include at least one person with extensive experience in qualitative evidence synthesis and a person with content area expertise in relation to the guideline topicDiscussion of the scope of each synthesis – where more than one synthesis is being commissioned for a guideline, it may be helpful to hold a meeting of the guideline technical team and the synthesis lead authors to consider the scope and objectives of each synthesis. This discussion should include the range of questions that the synthesis will consider, in relation to the EtD criteria used for the guideline. For example, should the synthesis consider equity and human rights issues and resource use issues, in addition to intervention acceptability and feasibility? The discussion should also cover which synthesis approach/es to use, based on which would be most appropriate for addressing the synthesis objectives, how the QES findings will be used within the EtD frameworks, and how best to tailor the synthesis to address the specific needs of a guideline processPreparing the terms of reference – this would include which databases will be searched; how the synthesis findings will be prepared for the guideline, including the types of information and data that will be included in the CERQual Qualitative Evidence Profiles and Summary of Qualitative Findings tables; how an assessment of confidence in the evidence will be made; the content of the final manuscript; and how the technical team and synthesis leads will communicate during the process of producing the synthesesDevelop a protocol for each synthesis – where more than one synthesis is commissioned for a guideline, it may be helpful to ensure (as far as possible) that the synthesis processes are standardised across protocols and make sense in relation to the synthesis objectives. Where possible, the protocol/s should be made publicly available Stages:A budget for the review should be estimated. In addition to time to conduct the review, person-time needs be included for undertaking a CERQual assessment; several rounds of discussion of the review findings between the synthesis team and the guideline technical team, to ensure that the findings are written as clearly as possible and are congruent with the underlying data; reviewing any summarised findings prepared for different domains of the EtD frameworks; and preparing the synthesis for publicationA qualitative evidence synthesis is labour intensive process and the additional stages needed to prepare the findings for a guideline process generally add additional person-time to the processAdditional file 1:Example of a GRADE evidence-to-decision framework. (DOCX 206 kb)Additional file 2:Example of using qualitative evidence to populate the evidence-to-decision framework criterion on how people value the outcomes. (DOCX 16 kb)Additional file 3:Example of using qualitative evidence to populate the evidence-to-decision framework criterion on gender, health equity and human rights impacts – ‘direct’ equity impacts. (DOCX 16 kb)Additional file 4:Examples of using qualitative evidence to populate the evidence-to-decision framework criterion on the acceptability of the intervention. (DOCX 21 kb)Additional file 5:How qualitative evidence has influenced the formulation of recommendations – example from the WHO antenatal care guideline. (DOCX 16 kb)


This study shows that home literacy activities contribute to kindergarten children’s higher-level comprehension processes, namely knowledge integration and knowledge access. Kindergarten children completed measures assessing literacy and language skills and then their performances on these measures were correlated with home literacy activities, which were assessed via a parental questionnaire. Consistent with previous research, the results revealed that informal home literacy activities were positively related to language comprehension and vocabulary but not to letter-word decoding and phonemic decoding skills. The results also revealed that home literacy activities were positively related to knowledge integration and knowledge access, two strong predictors of language and reading comprehension. Finally, the present results suggest that the contributions that home literacy activities make to language comprehension are the same contributions that home literacy activities make to higher-level comprehension processes. In other words, the contributions that home literacy activities make to language comprehension are not independent of the contributions that home literacy activities make to higher-level comprehension processes. Word decoding skills are used to both orthographically and phonemically decode letters and identify meanings of words; higher-level knowledge integration processes access and integrate prior knowledge with new explicit and implicit information from a text; and planning/organization skills organize active information in a reader’s working memory so that a mental representation of a text can be constructed . These c1.2Considerable research has documented the importance of the home literacy environment as a precursor to a number of early literacy and language skills . For insHome Literacy Model, a model developed by Sénéchal and colleagues, for example, separates home literacy activities into two dimensions--formal literacy activities and informal literacy activities--and each dimension of activities makes a separate and independent contribution to the development of children’s literacy and language skills  but not receptive vocabulary . In contrast, an informal literacy activity, such as parent-child shared storybook reading, was predictive of receptive vocabulary  but not alphabet knowledge . Similarly, r = .36) and alphabet knowledge  but not vocabulary knowledge . In contrast, informal home literacy activities were predictive of language comprehension  and vocabulary knowledge  but not phonemic awareness  and alphabet knowledge (r = .08).The Home Literacy Model has considerable support in the literature with some of the most cogent research showing independence between measures of formal and informal home literacy activities. For example, Nevertheless, absent from this research is an examination of the contributions of the home literacy environment to specific higher-level comprehension processes, such as memory for new facts, memory for implicit facts, and knowledge integration . The absence of this research is problematic because specific higher-level comprehension processes are important contributors to early language comprehension abilities .1.3bridge ideas in a text, (ii) infer meanings of words or themes from a text, (iii) identify the antecedent referents of pronouns, and (iv) predict future outcomes of a text— because these cognitive components are strong predictors of early language comprehension  connect or ehension . For exaehension .With respect to the Home Literacy Model, given that higher-level comprehension processes account for large portion of variance in language comprehension  and give1.4Although the contributions of the home learning environment to the precursors of literacy acquisition have been researched for nearly three decades, based on a literature review this research has yet to investigate the contributions of the home literacy environment to some of the most important predictors of reading and language comprehension, namely specific higher-level comprehension processes. Therefore this study examines the contributions that informal home literacy activities, such as the number of books that are read to a child and the number of questions that are asked per book, make to the higher-level comprehension processes  of preschool children. Finally, measures of letter-word decoding and phonemic awareness were included in order to confirm discriminant validity of the informal home literacy activities. That is, given that informal home literacy activities are not predictive of letter-word decoding and phonemic awareness e.g., , measureThe measure of specific higher-level comprehension processes was 2.2.1M age = 5.75 years. These native English-speaking children were recruited from local schools and libraries. Eighty-seven were of Hispanic descent and 33 were of non-Hispanic descent. Reports from parents and teachers indicated that all of children were free of learning and/or psychological disabilities. Children received a toy package for participating.One hundred and twenty children  were tested in kindergarten, The education level of parents was a control variable. This control variable was calculated by averaging the mother’s and father’s education. In instances of single-family households the education level of the single parent was used. The education level of the parents was average, with 11% completing high school, 59.2% completing some community college after high school, and 30% completing a university degree.2.22.2.1SD = 3.61 books. For the purposes of this study this dependent variable is called books per week. Second, parents were asked the number of questions they asked per book. On average, 1.82 questions were asked per book, SD = 1.00 questions. For the purposes of this study this dependent variable is called number of questions per book. A composite z-score of informal home literacy activities was calculated using parent’s responses to these two questions. Formal literacy activities were not assessed.Two open-ended questions were used to assess informal home literacy experiences. First, parents were asked how many storybooks they read with their child each week, regardless of the time of day. On average, 4.4 books were read each week, 2.2.2The standardized measure of language comprehension was the PR version of the Gates MaccGinitie, which is suitable for kindergarten children . This me2.2.3m, d, cat, dog, then and examples of stimuli from the letter-word attack subtest are: k, n, nat, ep, tiff. The Cronbach alphas for these subtests were .95 and .93 respectively.Letter-word decoding skills and phonemic awareness were assessed using the letter-word identification and letter-word attack subtests of the Woodcock Reading Mastery Test-Revised ; both su2.2.4Vocabulary knowledge was assessed using the Assessment of Literacy and Language  and nonsense terms  that are depicted in the pictures. Following the paragraph, children answer Yes/No test statements assessing different comprehension processes; half of the statements are true and half are false. Text memory statements assess memory for explicit information presented in a paragraph; no prior knowledge is required . Text inferencing statements assess memory for implied information in a paragraph; no prior knowledge is required . Knowledge access statements assess the ability to access facts from prior knowledge; no visual or aural text-based information is required . Finally, knowledge integration statements assess the ability to access facts from prior knowledge and integrate these facts with new text-based information. . There are three types of knowledge integration statements that vary in their use of abstract information.An In total, children completed 24 text memory statements, 8 text inferencing statements, 4 knowledge access statements, and 24 knowledge integration statements. In order to make the results easier to interpret, composite z-scores were calculated for text processing , and knowledge integration . The Cronbach alphas for the test statements ranged from .69 to .73.3.3.1st percentile  to the 99th percentile . In addition, the skews and kurtosis were all < 3.0, which suggests normal distributions. There was no missing data.The descriptive statistics for all of the measures are reported in 3.2r’s = .61 and .71 versus r’s = .42, .34, and .43 respectively.r = .20 and r = .21 versus r’s = .09 respectively.According to the Home Literacy Model, the composite measure of informal home literacy activities should be significantly related to the measures of language comprehension and vocabulary knowledge but not measures of letter-word decoding and phonemic awareness. As r’s = .25 and .31 respectively. However, inconsistent with this proposal the composite measure of informal home literacy activities did not correlate significantly with text processing, r = .14. As With respect to specific higher-level comprehension processes, given that the Home literacy Model suggests that informal home literacy activities contribute to language comprehension  and give3.3In order to examine the contributions that home literacy activities make to language comprehension and specific higher-level comprehension processes, two regression models predicting language comprehension were completed. The first regression entered the composite measure of informal home literacy activities into the model first and the measures of higher-level comprehension processes second. The second regression entered the measures of higher-level comprehension processes into the model first and the composite measure of informal home literacy activities second. The logic here is that if informal home literacy activities independently contribute to both language comprehension and higher-level comprehension processes  than the composite measure of informal home literacy activities should account for a significant amount of variance in both regression models, regardless of the order that the composite measure of informal home literacy activities is entered into the models. Such findings also support earlier research that suggests that informal home literacy activities make direct contributions to language comprehension e.g., . On the As 4.This study extended the Home Literacy Model in three important ways. First, the results showed that a composite measure of informal home literacy activities was positively related to measures of specific higher-level comprehension processes, which are strong predictors of reading and language comprehension. Second, the results showed that the contributions that informal home literacy activities make to language comprehension perfectly overlap with the contributions that informal home literacy activities make to higher-level comprehension processes. Third, the present results potentially links the Home literacy Model to a frequently used model of reading, namely the Simple View of Reading. These findings are discussed below.The present results suggest that informal home literacy activities are associated with two higher-level comprehension processes, namely knowledge integration and knowledge access. This new finding is important because although a number of studies have shown that informal home literacy activities are associated with preschoolers’ language comprehension and vocabulary knowledge, no study has determined whether home literacy activities are associated with higher-level comprehension processes, some of the most important, if not the most important, components of preschoolers’ language comprehension.comprehending a text, which requires the comprehender to access their prior knowledge and integrate this prior knowledge with text-based information. Indeed, by definition informal home literacy activities are incidental . In addition, the present results also showed that informal home literacy activities predict language comprehension but not letter-word decoding and phonemic awareness, a finding that is consistent with a number of previous studies e.g., . MoreoveWhat will happen next? How does the story relate to our home? and so on. By understanding the varying contributions that different types of questions make to different specific higher-level comprehension processes parents can then begin using more specific types of questions during storybook reading. Finally, because the present study did not include measures of formal home literacy activities, the relationship between formal home literacy activities and high-level comprehension processes is unknown. Given that previous research suggests that language comprehension is correlated with both formal and informal home literacy activities  of kindergarten children. Further analysis showed that the shared variance between informal home literacy activities and language comprehension is the same shared variance between informal home literacy activities and higher-level comprehension processes. In other words, the contributions that informal home literacy activities make to language comprehension are not independent of the contributions that informal home literacy activities make to higher-level comprehension processes.


Vibrio cholerae occurs from consuming contaminated food and water, contact with cholera cases and transmission from contaminated environmental point sources. WASH guidelines recommending interventions for the prevention and control of cholera are numerous and vary considerably in their recommendations. To date, there has been no review of practice guidelines used in cholera prevention and control programmes.Cholera remains a frequent cause of outbreaks globally, particularly in areas with inadequate water, sanitation and hygiene (WASH) services. Cholera is spread through faecal-oral routes, and studies demonstrate that ingestion of We systematically searched international agency websites to identify WASH intervention guidelines used in cholera programmes in endemic and epidemic settings. Recommendations listed in the guidelines were extracted, categorised and analysed. Analysis was based on consistency, concordance and recommendations were classified on the basis of whether the interventions targeted within-household or community-level transmission.Eight international guidelines were included in this review: three by non-governmental organisations (NGOs), one from a non-profit organisation (NPO), three from multilateral organisations and one from a research institution. There were 95 distinct recommendations identified, and concordance among guidelines was poor to fair. All categories of WASH interventions were featured in the guidelines. The majority of recommendations targeted community-level transmission (45%), 35% targeted within-household transmission and 20% both.Recent evidence suggests that interventions for effective cholera control and response to epidemics should focus on case-centred approaches and within-household transmission. Guidelines did consistently propose interventions targeting transmission within households. However, the majority of recommendations listed in guidelines targeted community-level transmission and tended to be more focused on preventing contamination of the environment by cases or recurrent outbreaks, and the level of service required to interrupt community-level transmission was often not specified. The guidelines in current use were varied and interpretation may be difficult when conflicting recommendations are provided. Future editions of guidelines should reflect on the inclusion of evidence-based approaches, cholera transmission models and resource-efficient strategies. Vibrio cholerae El Tor began in 1961 [Cholera remains a major public health threat in many parts of the world , particu in 1961 . Sub-Sah in 1961 , 21, wit in 1961 .V. cholerae can originate from a susceptible person ingesting the bacteria from environmental point sources  [V. cholerae can also occur between infected and susceptible individuals [V. cholerae through contaminated environmental point sources, due to sustained contamination of the environment by symptomatic and asymptomatic cholera cases [Diarrhoeal diseases such as cholera are transmitted through the faecal-oral route. Infection with ronment) : this isronment) , 27. Infividuals , 29, froividuals –37 or waividuals  that hasividuals : this isra cases , 44, 45.ra cases .V. cholerae through environmental point sources, or environment-to-human transmission, cannot explain the steep rise in case numbers usually seen in outbreaks [Transmission models that only include ingestion of utbreaks , 45, 47.utbreaks –50, and utbreaks , 51–54. utbreaks , 55–58, utbreaks –62.These relatively recent findings suggest that efforts to prevent and control cholera could benefit from focusing on the domains of transmission: within-household and community-level. Typically, cholera response measures for prevention and control have included a mix of WASH interventions, Oral Cholera Vaccination (OCV) and, in some cases, prophylactic antibiotics. Strategies that seek to control and contain cholera outbreaks in epidemic and endemic settings could implement these measures to the household–delivered through case-centred strategies (i.e. delivery of interventions to cases and their households or close contacts) or case area targeted interventions (CATIs) (i.e. delivery of interventions to a defined area surrounding cases) –and takeThere is currently global momentum to tackle cholera and an internationally agreed road map to eliminate the disease by 2030 . While iGiven the above, we conducted a scoping review of current, international and accessible WASH guidelines for cholera prevention and control to analyse consistency and concordance among recommended interventions, and to assess how guidelines seek to prevent and control cholera whilst aligning with current conceptual models of cholera transmission, in order to make recommendations for their improvement.The search strategy sought to identify all relevant international guidelines (published and in press) and was limited to English and French languages. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines . The revThe websites of organisations who typically respond to cholera were searched, including the Global WASH Cluster (GWC), World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations High Commissioner for Refugees (UNHCR), International Organization of Migration (IOM), Médecins Sans Frontières (MSF), Oxfam, International Committee for the Red Cross and Red Crescent (ICRC), International Federation of the Red Cross and Red Crescent Societies (IFRC), Action Contre la Faim (ACF), Care International, Save The Children, Norwegian Refugee Council, the Sphere Project, United States Centers for Disease Control and Prevention (CDC) and International Centre for Diarrhoeal Disease Research Bangladesh (ICDDR’B).Reference sections of guidelines were hand-searched for any additional relevant guidelines. Journal articles did not meet the inclusion criteria for this review and reference databases were not searched for guidelines. A full list of websites searched can be found in Guidelines were eligible for inclusion if they were available after 1999 and up to and including January 2019, and recommended interventions for cholera prevention and control. Only household- and community-level WASH interventions were included. Any guideline in which interventions were proposed for high-, middle- or low-income countries was included in the review.Guidelines for infection prevention and control (IPC) or WASH in Cholera Treatment Centres or Units (CTCs or CTUs) or Health Care Facilities (HCFs) were excluded as these will be addressed in a separate review. Guidelines published in languages other than English or French, guidelines for non-human subjects or for other water-related or outbreak-prone diseases were excluded. Historical versions of guidelines that have been subsequently updated, and have been assumed by the authors to be no longer in use, and country-specific guidelines were also excluded from the review.All retrieved documents were transferred to Endnote X9  and de-duplicated. Records were screened according to the inclusion criteria described. Data were extracted by two reviewers (LDG and KG) and cross-checked for accuracy. Any disagreement between reviewers was resolved through discussion and consensus. Data were extracted into an MS Excel  sheet for each of the guidelines on the following: agency/author and year of publication, overall content of the guideline and whether the guideline proposed interventions for urban, rural, endemic and/or epidemic contexts.Moving through the guidelines chronologically, the evidence synthesis consisted of four stages:extracting all recommendations from the different guidelines and classifying them according to 11 categories of WASH interventions, consistent with definitions used in previous systematic reviews of WASH interventions , 96, lismeasuring concordance among guidelines, whereby all recommendations within each WASH intervention category were analysed through a Fleiss’ Kappa Statistic (κ) for interrater agreement on a scale from <0 to 1 for perfect agreement , 98;identifying consistent recommendations, whereby each recommendation was classified as “Recommended” when it featured in the guideline, “Not Recommended” if the guideline clearly stated that the intervention was not recommended by the authors/agency or “Recommendation not listed” if otherwise, see examples in categorising recommendations on the basis of whether they would interrupt within-household or community-level transmission. The conceptual framework also incorporates key transmission pathways within the two domains of transmission, based on recent models describing human-to-human and environment-to-human transmission of cholera , 61, 99,The details of each recommendation, including mode and frequency of intervention delivery, duration of the intervention and any other factors deemed relevant were also noted. A quality assessment for risk of bias among guidelines was not performed. A narrative summary of data extraction and analysis was developed by one investigator (LDG) and then reviewed by all authors.th February 2019. The search strategy identified a total of 48 records. After de-duplication and screening, eight guidelines met the inclusion criteria for review and are included in this scoping review. The guidelines were published between 2004 to 2019; three were authored by international non-governmental organisations (NGOs)–Médecins Sans Frontières (MSF) [Searches were finalised on 14es (MSF) , Oxfam [es (MSF) , Action es (MSF) ; one froes (MSF) ; three bes (MSF) , the Wores (MSF)  and the es (MSF) ; and onees (MSF) . The guies (MSF)  in S4 ApGuidelines were not restricted to specific contexts , except one guideline that was specific for cholera outbreaks in crisis contexts such as conflict settings, natural disasters, refugee camps, and among internally displaced populations or populations on the move .A total of 95 recommendations were extracted. UNICEF (2013) listed the most recommendations (n = 66) , followeRecommendations were classified across 11 categories of WASH interventions . Among tThe interrater agreement among guidelines, as to which WASH interventions they proposed, ranged from -0.14 to 0.36 (Fleiss’ Kappa Statistic (κ)), indicating a poor to fair level of agreement among guidelines . The meaTwenty consistent recommendations (defined as those mentioned by at least seven of the eight guidelines) were identified . These iSix interventions were explicitly described as not recommended for cholera prevention and control by four organisations –102, 104From the 95 recommendations found across guidelines, 33 (35%) would target within-household transmission, 43 (45%) community-level and 19 (20%) would affect both domains . Table 6A full list of the 95 recommendations, concordance among guidelines and whether an intervention was categorised to target within-household or community-level transmission, is provided in the supplementary materials . Each ofOur scoping review of current international guidelines found that guidelines generally recommend all categories of WASH interventions for cholera prevention and control, with 95 distinct recommendations extracted from the eight included guidelines. The guidelines had poor to fair concordance, and some had considerably fewer recommendations than others. Among the 95 recommendations identified, 20 recommendations were consistently recommended by seven or more guidelines. Overall, the guidelines proposed a balance between interventions addressing within-household and community-level transmission of cholera, however, the majority of guidelines focused on community-level interventions. We anticipate that undertaking this scoping review of WASH guidelines for cholera prevention and control has the potential to be a useful tool for both implementing organisations and national governments to further develop and guide response strategies. Particularly as our findings suggest that guidelines, notably those written by multilateral agencies and informing national policy, require more structured alignment, and, in terms of WASH interventions, should consider how interventions effectively reduce transmission pathways, as well as economic and feasibility criteria, when making recommendations for the prevention and control of cholera.Improvements to personal, domestic and food hygiene, water quantity and quality were the most consistently recommended interventions, many of which targeted within-household transmission of cholera. Accordingly, all, or some subset of, the 20 consistently recommended WASH interventions could be considered as the “minimum standard” interventions that organisations have proposed for effective cholera response programmes. Neither hygiene nor water improvements are new to public health nor to cholera control , 108–110A high number of recommendations does not necessarily render guidelines more useful or more likely to be used. Fewer, more focused recommendations may mitigate the potential for confusion at an operational level and incentivise uptake. To an extent, the low concordance among guidelines observed in this review could indicate the potential difficulty of using the available guidelines, by practitioners and policy makers, to decide which interventions to propose or which guidelines to follow. It may also disincentivise uptake or confuse the prioritisation of interventions among implementers. Only half of the included guidelines explicitly discouraged specific interventions, which in practice may be helpful to concentrate efforts and reduce the range of options considered. On the other hand, interventions that have not been recommended may point to mixed, inconclusive or low-quality evidence. During this review, we did not assess which of the interventions were based on concrete or published evidence. There is a lack of evidence regarding the effectiveness of the interventions across the guidelines, as well as concerns around timeliness, prioritisation of other interventions, cost-effectiveness and potential stigmatisation of the beneficiaries , 104. AlV. cholerae from cholera cases [Considering recent evidence on the heightened risk of intra- and interhousehold transmission of cholera, reactive interventions to control and contain cholera outbreaks should take advantage of this clustering by targeting cases, their households and the associated human-to-human transmission pathway , 67. Mosra cases  and lowera cases , or repera cases , 116, whHygiene promotion through house-to-house visits or community meetings” and “Hygiene promotion and cholera awareness using mass media ”. Whilst there is some evidence to support radio as a preferred or trusted communication means in cholera outbreaks [Behaviour change interventions were among the only recommendations for which the modality of delivery was specified, e.g. “utbreaks , guideliutbreaks –119, andutbreaks , 120. Reutbreaks , with anAvailable evidence also suggests that case-centred strategies or CATIs, which require targeting fewer people per case averted and delivery of interventions centred to cases, are more cost-effective and resource-efficient for delivery of interventions , 123. FoCholera affects communities already burdened with a lack of infrastructure, poor health systems and affected by crises. Any global map of poor water and sanitation services, and high levels of poverty and insecurity, is essentially the same as the map of cholera burden , 21. AltA free residual chlorine concentration of >0.5 mg/l measured at source” and “A turbidity less than 5 NTU at the water source, up to 20 NTU acceptable” [Historically, improvements to WASH infrastructure at a population level such as the community-level interventions listed across the included guidelines, have reduced the incidence of cholera, and other diarrhoeal diseases , 133–137eptable” . Howevereptable” , distanceptable” , 141 alleptable” –146. TheOur review only included current, international and accessible guidelines for the prevention and control of cholera. This may have affected how many recommendations were found and the review will have excluded any context specific or more detailed interventions from national guidelines and other sources. The review also does not systematically address the level of evidence supporting the different recommendations, and does not factor in which interventions would be more effective at reducing transmission than others.In this review, we have considered the risk of transmission within two domains: within-household and at the community-level. Although the separation of household and community is potentially more intuitive for practitioners and policymakers to understand and use, the conceptual cholera transmission framework may diminish the observed overlap of household and community-level transmission and the associated human-to-human and environment-to-human transmission pathways. Neither domains nor pathways of transmission are dichotomous and, aside from interpersonal contact, there is a close association of the risk factors among levels. Human-to-human transmission, or interpersonal contact between infected and susceptible cases, will also occur outside of the household  . AdditioConcordance or consistency of recommendations is not necessarily a measure of guideline quality, but rather of how much agreement there is among guidelines. Concordance scores may simply reflect a lack of detail or prioritisation of certain service areas, rather than explicit decisions to include specific interventions. Nevertheless, the less agreement, the more potential there is for inappropriate interventions or conflicted decision-making among national governments and responding organisations, and the more likely it is that evidence has not been considered systematically when developing guidelines , 150, suNone of the guidelines explicitly stated their process for guideline development such as using the GRADE system , 152 or The Global Roadmap for Cholera Elimination by 2030 has focused attention on current efforts to prevent and control cholera , and higNo single guideline included all recommendations or collated all available guidance. Interpretation of the guidelines may be difficult particularly where recommendations are omitted or contradict one another. Based on this review, we make five recommendations to strengthen the development of future guidelines for cholera prevention and control:Considering the different phases of cholera outbreaks, WASH interventions should target human-to-human transmission within the household and at the community-level for outbreak control, and environment-to-human transmission at a community-level for cholera prevention in recurrent settings and areas where reinfection during outbreaks is likely;Limiting the number of guidelines available and compiling fewer, more focused recommendations in guidelines so as to mitigate the potential for confusion at an operational level and incentivise uptake;Providing greater specificity in the language used in recommendations, e.g. specifying the timing of response, coverage required, minimum levels of service and modality of delivery ;Publishing or improving access to programme evaluations and practice literature to strengthen the evidence base for guideline development, and to support national cholera control plans as part of the Global Roadmap for Cholera Elimination by 2030;Standardising approaches in guideline development to consider the evidence base, from studies, programme evaluations or models, when deciding which interventions to recommend.S1 Table(DOCX)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.


The use of neuroscience in the courtroom can be traced back to the early twentieth century. However, the use of neuroscientific evidence in criminal proceedings has increased significantly over the last two decades. This rapid increase has raised questions, among the media as well as the legal and scientific communities, regarding the effects that such evidence could have on legal decision makers. In this article, we first outline the history of neuroscientific evidence in courtrooms and then we provide a review of recent research investigating the effects of neuroscientific evidence on decision-making broadly, and on legal decisions specifically. In the latter case, we review studies that measure the effect of neuroscientific evidence (both imaging and nonimaging) on verdicts, sentencing recommendations, and beliefs of mock jurors and judges presented with a criminal case. Overall, the reviewed studies suggest mitigating effects of neuroscientific evidence on some legal decisions . Furthermore, factors such as mental disorder diagnoses and perceived dangerousness might moderate the mitigating effect of such evidence. Importantly, neuroscientific evidence that includes images of the brain does not appear to have an especially persuasive effect (compared with other neuroscientific evidence that does not include an image). Future directions for research are discussed, with a specific call for studies that vary defendant characteristics, the nature of the crime, and a juror’s perception of the defendant, in order to better understand the roles of moderating factors and cognitive mediators of persuasion. The increased use of neuroscientific evidence in criminal proceedings has led some to wonder what effects such evidence has on legal decision makers  who may be unfamiliar with neuroscience. There is some concern that legal decision makers may be unduly influenced by testimony and images related to the defendant’s brain. This paper briefly reviews the history of neuroscientific evidence in the courtroom to provide context for its current use. It then reviews the current research examining the influence of neuroscientific evidence on legal decision makers and potential moderators of such effects. Our synthesis of the findings suggests that neuroscientific evidence has some mitigating effects on legal decisions, although neuroimaging-based evidence does not hold any special persuasive power. With this in mind, we provide recommendations for future research in this area. Our review and conclusions have implications for scientists, legal scholars, judges, and jurors, who could all benefit from understanding the influence of neuroscientific evidence on judgments in criminal cases.Over the last four decades, the number of incarcerated Americans has increased by 500%  scan of his brain to help bolster its argument that he suffered from schizophrenia, and should therefore be found not guilty by reason of insanity (NGRI). Although the prosecution opposed the introduction of Hinckley’s CT scans as evidence, the district court judge ruled that the scans were admissible. Hinckley was ultimately found NGRI.People v. Weinstein , which offered a more liberal standard for allowing scientific testimony to enter trial. Rather than requiring “general acceptance” of the scientific technique for admissibility, the standard set by the FRE deemed such an assessment to be only one of a number to consider, along with whether or not the methodology is testable, whether it has been subjected to peer review, and its known or potential error rate. In Daubert, the Supreme Court replaced Frye’s supremacy in federal cases with the standard set forth by the FRE, which has come to be known as the “Daubert standard.” This opened the door for the more liberal use of scientific evidence in modern courtrooms. Specifically, the Daubert standard allowed scientific techniques and results that had not yet achieved general acceptance to appear in courtrooms. Thus, new imaging tools that were not yet widely used became admissible thanks to Daubert.Only a year after ls, Inc. , two famAlong with its development in scientific contexts, the opportunity for neuroscience to be used as evidence in criminal trials has predictably increased since the turn of the century. Theoretically, neuroscientific evidence (broadly construed as any information related to the brain) can be used like any other type of evidence to establish or dispute any claim in a criminal case. It could be used, for example, to support or cast doubt on the testimony of an expert, to support or rebut a medical diagnosis, to corroborate a defendant’s testimony about his frame of mind at the time of the crime, to establish that a defendant’s conduct caused severe harm, or used demonstratively to help the judge or jury understand some other kind of evidence, and so on. In practice, the standard described in the prior section regulates the admission of such evidence in various courtrooms.Meixner  reviewedIn an analysis of US cases between 2005 and 2012, Farahany  reportedDenno  providedStrickland v. Washington , with defense counsel’s inadequate use of neuroscientific evidence forming the basis of all but one successful claim. This success rate is especially striking given that Strickland claims are typically unsuccessful. For example, Benner . Finally, the “effect” of neuroscientific evidence is measured via the legal judgments rendered by such mock jurors .To focus this review further, we used the framework suggested by Jones  who helpAccordingly, this review focuses on studies that examined the use of neuroscientific evidence as buttressing, detecting, or sorting devices. We chose to focus on these categories because there is both legal precedent and a relatively substantial body of research on the use of such neuroscientific evidence, while the other categories are in relatively earlier stages of examination. Therefore, in the reviewed studies, neuroscientific evidence is used to support an argument put forth by the criminal defense attorney, reveal brain damage relevant to the criminal case, or provide evidence for a diagnosable mental disorder. Finally, although technically within Jones’ category of detection, studies that focused on the use of neuroscientific evidence for lie detection purposes in criminal cases  judgments. In one of the pioneering studies on the broad persuasiveness of neuroscience outside of a courtroom context, Weisberg, Keil, Goodstein, Rawson, and Gray  presenteWhile Weisberg et al.  examinedHowever, these findings were later challenged by studies with similar designs that failed to replicate the persuasive influence of neuroimages. For example, Gruber and Dickerson  comparedNevertheless, Weisberg and colleagues  by comparing mock juror decision-making in its presence versus its absence Table . For exaSaks et al.  found a Greene and Cahill  also comThe authors reported that the defendant’s risk of future dangerousness moderated the effect of neuroscientific testimony on death sentences. Specifically, when the defendant was described as low-risk, the neuroscientific testimony did not affect sentences. However, neuroscientific testimony was significantly mitigating when the defendant was described as high-risk. In fact, mock jurors were 12 times less likely to sentence the defendant to death in the neuroscientific testimony condition compared with the control condition. Again, results from this study suggest neuroscientific expert testimony can have a mitigating effect on death penalty sentences under some conditions, in this case when the defendant is characterized as being at high risk of future dangerousness.Testing the effects of neuroscientific testimony on guilty/not guilty verdicts, Schweitzer et al.  performeAcross all four experiments, the presence of neuroscientific testimony regarding the defendant’s defective frontal lobe failed to mitigate either verdicts or sentences. Their meta-analysis similarly found no effects of neuroscientific testimony on these outcomes, suggesting that neuroscientific testimony does not affect guilty verdicts or sentencing decisions  by Schweitzer and colleagues  was mitigating in several studies describing death penalty and NGRI cases, similar effects were not found for neuroimages  has varied the race of the defendant. This is a particularly important point when there is mounting evidence of racial bias in everyday judgments of various types  is likely to moderate the degree to which neuroscientific information is mitigating. For instance, we predict that jurors  who receive training on interpreting neuroscientific evidence, and/or determining its relevance, might respond differently to such evidence than those who have not received such training , thus rendering the defense’s argument more satisfying or impactful. This explanation seems likely because, outside of the legal arena, it has been consistently reported that people find neuroscience explanations of psychological phenomena more satisfying  may be high. However, the majority of cases within the criminal justice system are not murder and assault cases, but rather lesser crimes. Edersheim, Brendel, and Price  analyzedFinally, it is important to remember that neuroscience is already being used in criminal cases without regard to how well understood its effects are Meixner, . Therefo


A functional neurologic disorder is a prevalent and disabling condition at the intersection of neurology and psychiatry  with a cFunctional neurology represents a paradigm of healthcare that utilizes an evidence-based approach to quantify human performance and function. It does not represent a theory or hypotheses or any diagnostic or treatment modalities . DemortiThere is an abundance of evidence-based literature reporting diagnostic and treatment modalities under a FN paradigm. Functional connectivity (FC) , 12–14, In an attempt to find evidence for FN, the authors have elevated select empiricism over other forms of knowledge important to clinicians, patients and society. This is problematic in this case as their conclusions are made based upon a review of my published work that does not reflect the topic of their interest.


Informing the health policymaking process with the best available scientific evidence has become relevant to health systems globally. Knowledge Translation Platforms (KTP), such as the World Health Organization’s Evidence Informed Policy Networks (EVIPNet), are a recognized strategy for linking research to action.This report describes the experience of implementing EVIPNet in Chile, from its objectives, organizational structure, strategy, activities, and main outputs, to its evolution over the course of its first year. Lessons learned are also covered.Of the activities initiated by EVIPNet-Chile, the Rapid Response Service proved to be a good starting point for engaging policymakers. Capacity building workshops and policy dialogues with relevant stakeholders were also successful. Additionally, EVIPNet-Chile developed a model for engaging academic institutions in policymaking through a network focused on preparing evidence briefs. A number of challenges, such as changing methods for producing rapid evidence syntheses, were also identified. This KTP implementation model located in a Ministry of Health could contribute to the development of similar initiatives in other health systems. Decision makers use a number of different inputs to address a wide range of questions about the relevance and size of a policy issue, the impacts of different policy options, and the implementation of these options in their health systems. Research evidence is one of these key inputs in the policymaking process, and could contribute to making better decisions. Although efficient use of available resources has special relevance for Lowand Middle-Income Countries (LMICs), it also pertains to High-Income Countries (HICs) where policymakers strive to make the best use of resources.In this context, the World Health Organization (WHO) 2004 Annual Report included a chapter on the need for linking research to action . Later, Despite these global calls to use scientific knowledge in policymaking, research evidence has not been systematically used to make recommendations . AlthougEvidence Informed Health Policymaking (EIHPM) aims to ensure that the decision-making process is systematically and transparently informed by the best available scientific evidence . The comKnowledge Translation (KT), defined as “a dynamic and iterative process including synthesis, dissemination, exchange, and application of knowledge in order to improve population health, provide more effective health services and products, and strengthen health systems,” is closely related to EIHPM . In thisA number of experiences in LMIC countries—e.g., Evidence Informed Policy Network (EVIPNet) in Cameroon , RegionaChile has some experience using evidence in policymaking. The processes of formulating and evaluating the National Health Objectives for 2000–2010  and the Between 2010 and 2013, the Secretariat of EVIPNet Americas organized a number of training activities in this WHO Region, aiming to promote EIHPM and to build capacity on preparing evidence briefs for policy  and orgaDespite these initiatives, the scientific evidence was still not being used systematically in every policy decision in Chile. Moreover, research was not always an important input for decision makers and health policy. Finally, in 2014, the MoH opened a full-time position exclusively dedicated to establishing an EVIPNet working group in Chile.This paper describes the development and evolution of EVIPNet-Chile and identifies some of the lessons learned and challenges met after a year of experience. It describes the process of developing this initiative within the MoH, including objectives, organizational structure, strategy, activities, and main outputs during the period from October 2014 to October 2015.The structure of a KTP within a country could have an important impact for EIHPM. However, there is not a unique “organizational solution” to where the platform should be located in the national health system. There are examples of KTPs in universities, non-governmental organizations, government institutions, and public agencies .EVIPNet-Chile is coordinated by a Secretariat hosted by the Cabinet of the Minister at the MoH. This hosting enables a direct connection with the highest authorities of the MoH and other secretariats, with policymakers, local governments, public health care providers, civil society, and other stakeholders in health policymaking. In addition, EVIPNet-Chile Secretariat facilitates a fluid dialogue with universities and research groups .As a first step, in 2015, EVIPNet-Chile initiated a partnership with the Network of Schools and Departments of Public Health at a number of universities in Chile. This partnership—called the EVIPNet-Chile Network—is supported by the Country Office of the Pan American Health Organization (PAHO). It aims to expand the capacity of EVIPNet-Chile, to organize activities and prepare evidence syntheses to policymakers, and increase the numbers of those trained  in EIHPM concepts across the country.To use the best available evidence to produce outputs that can inform decisions in the health policymaking process.To promote the systematic use of evidence in the health policymaking process.To promote collaboration among policymakers, researchers, and civil society organizations.EVIPNet-Chile aims to support the health policymaking process, in order to improve public health and reduce health inequities in Chile. It has three main strategic objectives:Rapid Response Service for rapid evidence synthesisWebsite (one-stop shop)Capacity-building workshopsEvidence briefs for policyPolicy dialoguesIn order to accomplish these objectives, EVIPNet-Chile has outlined five main types of activities/products :Rapid RThe overall strategy of EVIPNet-Chile is organized in a matrix where each activity/product is aligned with each objective. The matrix shown in Although there is a variety of existing activities in which a KTP might engage, in Chile the aforementioned five were chosen as a good starting point, and a balanced combination that would address all the strategic objectives.Rapid Response Service (preparing rapid evidence syntheses). On a daily basis, decision makers require urgent evidence-informed answers to a number of policy questions. The Rapid Response Service aims to improve evidence accessibility to them by significantly reducing the time needed to summarize the existing research. The EVIPNet-Chile Secretariat prepares rapid evidence syntheses (summaries of the impact of specific interventions) in less than 20 working days, based mainly on relevant systematic reviews. The depth of the evidence analysis depends on the time available to deliver the product . One-stop shops are a useful strategy for improving accessibility to research evidence by health policymakers. There are a number of successful initiatives in this area, such as Health Systems Evidence in Canada  , Health There are important barriers that we addressed during this first year. For instance, although the EVIPNet-Chile Network has been positively evaluated to date, it is necessary to consolidate the relationships among KT, the policymaking process, and academic institutions. This network has been a major advance in terms of preparing evidence briefs for policy, but the work could be expanded into other new activities/products in the future.Secondly, as a new program inside a Ministry, it is necessary to make a cultural change for promoting the use of evidence in policymaking processes. This is generally a hard process, considering the existing different uses of evidence. In this sense, Rapid Response Service has been a useful tool, consolidating an important position within the MoH.Lastly, uses of evidence in the different stages of the policymaking process have also been challenging. The balanced combination of rapid evidence syntheses, evidence briefs for policy, and policy dialogues has successfully responded to the needs of policymakers and relevant stakeholders in a variety of scenarios and stages of the policymaking process.A number of challenges should be considered when implementing a KTP. First, as a part of the KT process, it is necessary to have a plan for incorporating new developments on EIHPM. For example, text mining  and liviA KTP can certainly be enriched by collaboration with international organizations, such as PAHO and WHO, but also by engaging with other countries of Latin America that are working on similar initiatives. Also, closer contact with non-governmental organizations working in this field, such as the Cochrane Collaboration, would be a major improvement, especially in terms of developing methodologies. The Rapid Response Service was the most challenging part of this effort because there is no standard method for producing the summaries; regardless, the service has been widely demanded within the MoH.Finally, in order to concretely evaluate the impact of EVIPNet-Chile on the policymaking process, it is necessary to conduct rigorous evaluations. A good starting point could be an analysis of the strategy matrix presented in RPSP/PAJPH and/or PAHO.Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the


The effectiveness of three types of plastic bags used by the New South Wales Police Force for the storage of clandestine drug evidence has been investigated through a comparison of mechanical properties. The tensile and tear properties of “as received” low-density polyethylene (LDPE) and poly(vinyl chloride) (PVC) bags do not show major differences such that one type would be favoured over the other. However, the mechanical properties of the bags once exposed to a range of chemicals routinely collected as drug evidence have been shown to be influenced as a result of different chemical interactions. Although an interaction of reagents/solvents with an additive within the LDPE bags is proposed to influence the mechanical properties of the bags, the change in properties has been shown to be less severe than that observed for the PVC bag, where softening and damage of the bags results due to absorption of reagents. Sealable plastic bags provide an effective means of transporting and storing a variety of types of police exhibits. This type of packaging has been widely adopted for evidence collection due to the ability to securely seal such bags, water resistance, transparency and the availability of a range of sizes ,2. Low-dA form of seized materials for which plastic bags are commonly employed is illegally manufactured drugs and their associated precursor chemicals. Evidence plastic bags are particularly practical for the efficient and safe collection of drug evidence from clandestine laboratories. Despite the apparent inertness of plastic bags, anecdotal evidence suggests that after storage of some types of chemicals, the physical properties of the bags may be compromised . It is aThis observation suggests that there is in addition of chemical interactions, some form of physical interaction between the stored chemical and evidence bag that potentially produces a deterioration in the properties of the bags.The aim of this study was to investigate the physical properties of the plastic bags currently used by the NSW Police Force to determine their effectiveness for the collection and storage of drug and related chemicals typically seized by the police. Both LDPE and PVC bags have been employed in the field and bags provided by different manufacturersIn order to determine the applicability of three types of evidence bags employed for the collection of drugs and their associated chemicals, a range of reagents and solvents frequently recovered from clandestine drug laboratories were stored in the bags under controlled environmental conditions. The physical properties of the plastic evidence bags have been investigated by measuring the mechanical properties via standard tensile and tear tests, to help the NSW Police force to get a better knowledge of evidence bags that are routinely used for the storage of drugs and related chemicals.Three types of plastic evidence bags were provided by the NSW Police Force: LDPE bags sourced from two different manufacturers (denoted LDPE 1 and LDPE 2) and PVC bags sourced from a third manufacturer . The three types of bags are sealable bags with adhesive closure.2O), hydrochloric acid (37%), hydriodic acid (57% in H2O), hydrogen bromide (48% in H2O), methylamine (40% in H2O), methanol (99.8%), nitroethane (≥98%) and phosphoric acid (85% in H2O) (supplied by Sigma-Aldrich).Thirteen reagents regularly encountered in clandestine laboratories were examined at the request of the NSW Police based on the frequency of collection of such reagents: acetic acid (≥99.7%), acetone (≥99.9%), acetonitrile (≥99.9%), ethyl acetate (99.8%), formic acid (≥97%), hydrogen peroxide  of each bag was also determined to take into account the different thicknesses of the “as received” bags. UTS values of 26, 23 and 40 MPa were determined for LDPE 1, LDPE 2 and PVC bags, respectively. Although the “as received” PVC bag demonstrates a higher strength compared to the LDPE bags, the value is not significantly greater. The percentage of elongation values indicates that prior to storage of chemicals the LDPE bags are able to extend by 698.88% before breaking, while the PVC elongates by 185.41% under the same conditions. Thus, the LDPE appear to be the more ductile material.Tear testing of the bags enabled the tear force at break to be determined for each evidence bag and the values are listed in Tensile tests were also carried out on the three bag types after storage of chemicals for a period of three months. The obtained tensile force at break and percentage of elongation at break are provided in For both LDPE bag types a reduction in the tensile forces and percentage of elongation values is observed by comparison with the values reported for the unexposed bags . It is nThe consistent reduction in tensile properties when exposed to each reagent or solvent is unlikely to be associated with polymer solubility as polyethylene is known to be unreactive to the chemicals used in this experiment . HoweverThe tensile force at break for the PVC bags was reduced after exposure to most solvents, but with several chemicals showed a minimal change to this property . By compOverall, a small increase in tear force at break was observed when PVC was exposed to the chemicals .Table 4A combined reduction in tensile force and increase in elongation can be associated with a further softening (or plasticization) of the PVC film. The plasticizer used in the supplied PVC bags is a phthalate ester, predominantly dioctyl phthalate (DOP) (identified by infrared spectroscopy), and the concentration of plasticizer provided by the supplier was stated to be in the range of 10%–30%. The introduction of plasticizer molecules into the polymer structure provides more free volume and so more chain flexibility: when the polymer molecule becomes more flexible, better elongation is observed but the tensile strength is lowered compared to the unplasticized polymer . The addFurther evidence of the migration of reagent and solvent molecules into the system is provided by the changes to the bags observed on exposure to certain solvents investigated in the current study. For the PVC bags, more significant changes were observed and a “wrinkled” appearance was noted after removal from particular reagent/solvent systems . The observed wrinkling may result when the surface of the film becomes higher in viscosity while the bottom of the film is still relatively fluid . The proPrior to exposure to reagents or solvents both evidence bag types, LDPE and PVC, showed acceptable physical properties for use as storage bags. The PVC bags demonstrated a somewhat higher tensile strength than the LDPE bags studied. The polyethylene bags were more ductile that the PVC bags. All bags showed a similar tear resistance. When exposed to a range of chemicals for 3 months, the mechanical properties of the bags were differently affected. The LDPE bags showed a decreased tensile force and elongation at break when exposed to the reagents/solvents. The changes are attributed to the migration of a slip additive from the bag into the chemical in which it is immersed. The influence of chemical exposure on the mechanical properties of the PVC bags differed from that observed for LDPE: the elongation at break was notably increased while the tensile force decreased after exposure. The presence of plasticizer and the further softening of the material as a result of the migration of solvent molecules into the bags were responsible for the changed mechanical properties. Due to the nature of the interaction with a range of relevant chemicals, the LDPE bags appear to be the preferred option for the storage of drug related evidence. In addition to less visual changes to the polyethylene bags, the influence of chemical interaction on the physical properties was less prominent than in the case of the PVC bag. This study highlights the need to be aware of the potential reactions that may occur between stored chemicals and the additives present in otherwise chemically inert plastic bags. This can result in alteration of evidence bags and may be hazardous for end users. Nevertheless, it was already suggested with a previous study that chemicals should preferably be introduced in proper containers first, and these containers being placed in evidence bags afterwards. Further research may be conducted in this field, as there is potential to investigate tailored formulations for plastic bags that can minimize the potential for interaction with the chemicals most likely to be stored in drug evidence bags.