Purpose of this systematic review was to bring together studies of evidence-based practice among dentists in low- and middle-income countries, where its use has been reported to be limited. The protocol was registered in PROSPERO. Methodology: We searched the evidence (in English only) from medical databases including PubMed, EBSCO, The Cochrane Library, CINAHL, ScienceDirect, HINARI summon, and SCOPUS and Web of Science via Research4Life, grey literature, hand search from relevant articles, and augmented results on Google scholar. Published reports were retrieved from relevant websites and organizations. Studies included those that looked at key factors that facilitate or hinder Evidence Based Dentistry (EBD), as well as outcomes in terms of: knowledge, attitudes and skills of EB practice among dentists; and the methodology used and their relevance in future EBD strategies. Main focus was on dentists, as practitioners and faculty members. Studies on students and non-dental personnel were excluded. Findings: A total of 4568 records were retrieved and five potentially relevant articles were selected after title/abstract screening. Two articles were excluded after full text screening, and therefore Three papers were included in this review. The studies report limited knowledge, unsatisfactory attitude towards EBD and lowpractice of EBD and use of scientific evidence databases. None of the studies reported implementation of EBD nor evaluation thereof. The main barriers that constrained application of EBD ranged from lack of interest to infrastructural limitations. Originality: The current review showed that there is a need to strategised implementation of EBD in this region. It is recognised that healthcare is patient specific, constantly changing and involves uncertainties and probabilities.3 This process is applicable to all health fields, and dentistry included, which is termed as evidence-based dentistry (EBD).Globally, there is improvement in accessibility to internet and search engines, leading to an ‘explosion of information’ which is made available widely to both professionals and non-professionals (consumers). This makes the situation complex when it comes to selecting sound research evidence for optimal care, hence, the concept of evidence-based medicine (EBM) was introduced. EBM is defined as a “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”.4 (http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/policy-on-evidence-based-dentistry).The American Dental Association defines the evidence based dentistry (EBD) as “an approach to oral healthcare that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences”original research articles, i.e. what is often referred to as ‘primary sources of information’ or ‘primary literature articles'; 2) skills to directly allow them to knowledgeably read, interpret and assess clinically-relevant literature review articles. This might be either traditional literature review articles or systematic review articles, the latter either with or without meta-analysis (sometimes referred to as summary articles or the summative literature); and, 3) the building of Problem/population, Intervention, Comparison group, and Outcome (PICO) skills in students and dentists to generate an answerable question5. Ultimately, this will build on how they can incorporate the findings of either original research articles or literature review articles into their ‘evidence-based dentistry’ decision-making process to provide-‘evidence-based’ care for their patients. Hence, the basis for clinical decision in EBD, involves a triad of best available evidence, together with practitioners' expertise and patient characteristics or preferences.EBD refers to a broad set of three distinct skills: 1) the building of skills in students and dentists in assessing literature to directly allow them to knowledgeably read, interpret and assess clinically-relevant 7 EBD is useful when it comes to assisting in cost containment in health care and positively impacting on patient treatment outcome. EBD also makes practitioners more accountable in their practice; and allows incorporation of clinical research into practice. EBD, when included as an integral part in patient dental care, dental training and research was seen to improve skills and expertise and treatment outcome.Utilisation of evidence in patient care has a number of benefits including but not limited to support practitioner's decision-making process as well as enhance trust in treatment by the community.5. Due to the complexity of dental care, use of evidence in dental practice has been reported to be limited. The latter is reported to be due to scarcity of literature on high evidence research such as Randomised Control Trials (RCT)8. Models that specifically target dental profession are important due to the level of control a patient has concerning how, when and if it is necessary to treat dental problems in terms of personal desires and insurance benefits8. Building a research culture during undergraduate training is one of the basic strategies to inculcate utilisation of research evidence in patient care. In a study that assessed dental and medical students in Saudi Arabia, reported deficient knowledge and attitudes towards EBP and recommended changes that will enhance implementation of EBP.9 Studies have revealed marked improvement in students' knowledge, attitudes ands kills to practice EBP following EBP training. This has been observed among nurses, medical, as well as dental students.12Efforts have been done to integrate evidence-based practice (EBP) into clinical practice worldwide. These efforts have been evaluated across different health fields including general physicians, nurses, occupational therapy, physical therapists, western herbal medicine providers, dentists and the like. Strategies utilized to incorporate EBD included: promoting online knowledge transfer on rapid access to information on EBD among dentists; inclusion of summaries of systematic reviews and recommended treatment and guidelines; and in dental education13 On the same note, few studies done in LMICs on EBP showed limited use of scholarly electronic journals and the use of non-scholarly information (such as Google) was high.16 Due to the fact that, developments in dentistry do occur significantly, having good understanding andknowledge on acquiring accurate information is one of the key components that will assist in translating research evidence into clinical practice/community decision making.Most decision making on treating patients in most lowand middle-income countries (LMICs), has been based on what has taken place during normal undergraduate or postgraduate training. Hay and colleaguesalso reported that, most physicians rarely used scientific evidence, but rely on their own or colleagues' experience in patient care.There is a lot of primary research regarding EBD among dentists when it comes to their knowledge, practice and skills; as well as implementation strategies. The reported research has mostly been conducted in the upper middle-and high-income countries. The objective of this review, therefore, was to bring together adequate studies that assess the implementation of EBP among dentists in low and middle and income countries. We looked at the methodology used if they are adequate; and also, the key factors that facilitate or hinder EBD, as well as outcomes  of EB practice among dentists, to assist in recommendation of future strategies.The protocol for the current study was registered with PROSPERO databases in 2018, ID CRD42018090216.We included all cross-sectional survey studies, qualitative studies, case-control studies, randomised controlled trials, quasi-experimental studies, and cohort studies with or without comparison groups.We included studies that had focused on dentists, as practitioners and faculty members. We excluded dental students as well as other studies that had focused on both dentists and other medical practitioners such as medical doctors.We included studies that had the application of Evidence Based Dentistry (EBD) among dentists in terms of having knowledge and skills on acquiring accurate information and utilization of scientific evidence in patient care.The study assessed the improved levels of knowledge, skills, attitudes and practice of evidence-based dentistry among dentists from the low- and middle-income countries. The study compared the change of knowledge, skills and attitude and before and after the implementation of EBD. Additional outcomes included the following: Change of behavior towards EBD practice among dentists, formulation of guidelines, improved search strategies and discussions in meetings after implementation of EBDhttp://tinyurl.com/EBDappendix1).We searched evidence from medical databasesin November, 2018, and we updated the literature between October and January, 2020. These databases includedPubMed, EBSCO, The Cochrane Library, CINAHL, ScienceDirect, HINARI summon, and SCOPUS and Web of Science via Research4LIfe. Moreover, we conducted a grey literature search from respective databases and conducted a hand search from relevant articles in the subject matter. We also searched Google scholar to augment results from other databases. Relevant literature and published reports were retrieved from other websites and organizations. We searched literature published in English only and without restricting time period. The search terms that were used for each database are attached in Appendix 1 . The items that were not applicable to a particular study were scored as “N/A”18. Thus, they were not included from the summary score. Therefore, the “summary score for each paper was calculated by summing the total score obtained across the 14 items and dividing by 28 of the total possible score”18. The tool for qualitative studies had ten items, and the scores can be calculated in a similar fashion as for quantitative studies. The ‘not applicable’ option is not allowed for quantitative studies. Therefore, the “summary score for each paper was calculated by summing the total score obtained across the ten items and dividing by 20 of the total possible score”18. Two raters (authors) performed independently the risk of bias and then resolved differences.Structured narrative review of the studies is presented in this review. We used Excel to code and categorize data for qualitative data analysis.The search retrieved 4568 records, and 775 duplicated records were excluded see . About 3The risk of bias was further assessed for the two quantitative studies that were selected. The overall scores  assigned21 Two studies were conducted in Nigeria and one in Rwanda.21 Two of these studies involved assessment of knowledge, attitude and practice of dental practitioners and faculty on EBD.20 The third article aimed to determine the level of knowledge, attitude, and practice of oral health care providers toward the use of online medical databases for clinical decision-making processes.21 None of the studies reported presence of EBD implementation strategies nor evaluation thereof. The first article aimed to assess the state of EBD in the four fully accredited dental schools in Nigeria as an example of a developing economy.20There was a total of three articles that fulfilled the criteria and were qualified in qualitative synthesis and quality assessment.27 The second reviewed article conducted questionnaire survey among dentists registered with medical and dental council (N=114) in Nigeria19. While the third article involved oral health care providers (N=201) who are registered either with the Rwanda Allied Health Professional Council (RAHPC) or Rwanda Medical and Dental Council (RMDC)21. The latter also utilized self-administered questionnaires. See Appendix 2 for more details (http://tinyurl.com/EBDappendixII).This study involved, firstly, literature search on EBD that included six articles. Secondly, faculty members, dental specialists and resident doctors were interviewed over the phone. Among the six articles retrieved from literature search, three of themreported on steps by step procedures to follow on how to conduct EBD practice; while the other two reported on application of EBD for different dental procedures; the last one was a letter to the editor.21.The studies were ethically approved by their governing bodies and permission to conduct studies were reported as University of Rwanda College of Medicine and Health Sciences (CMHS) Institutional Review Board and permission to obtain contact details from RAHPC and RMDC; and the Senate Research University of Western Cape21 Similarly, on assessment of knowledge of different online databases, Adeoye reported thatthat slightly over 50% were not aware of the Cochrane collaboration while about 20% had minimal knowledge of the same19. In addition, whereas systematic review could be defined by 42% of participants, 25.4% of them were not aware of the systematic review terminology. Critical appraisal terminology was understood by about 50%, but more than a third of them were not aware of it19. Less than one third of the respondents could choose correct definitions of EBD related terms, including evidence-based practice, critical appraisal and systematic review . Among those who asserted to have knowledge on the three terminologies of EBP, systematic review and critical appraisal, only 32.5%, 40.4% and about half (54.4%) had truly answered correctly19. On the same note, Nzabonimana et al., reported that participants had low level of awareness of useful databases for clinical decision making such as PubMed (41%), Drug. com (29%), Medscape (16%), and MedlinePlus (14%).21All studies report that knowledge and awareness of EBD to be below averageor of low level.19 Additionally, the latter study stated that 46.9% of those with awareness on EBD concept feltthat it was important while 17.7% felt the EBD concept was not important.19 Similarly, Nzabonimana et al., reported that positive attitude towards the use of online medical databases and resources is important to support clinical decision21. Furthermore, the oral care providers in this study, also believed availability of online resources is beneficial for patient care.The reviewed studies indicated that poor attitude towards EBD was observed in most primary studies. Contrary to this, Adeoyereported that almost all (97.4%) the participating dental practitioners were interested in getting more informed on EBD with 42.1% desiring short courses as way to get the information.20 Nzabonimana and co-workersin their assessment of utilization of online resources for clinical decision making, reported that slightly less than half (49.7%) of the oral health care practitioners agreed that use of online databases was useful for clinical decision making while 20.4% disagreed and 29% where neutral.21The results indicate that there was low level of practicing EBD among dental professionals in the reviewed studies. EBD was not practiced by most dental practitioners, with majority utilizing clinical experience and expertise as the main basis for decision making during patient care at their centers.21 Adeoye reported that, majority of the dentists (68.4%) consulted either friends/colleagues opinion; 18.4% used textbooks and 7.9% electronic database when uncertain about choices of treatment19. The study among Rwandese oral health care provides reported information sought for was about clinical procedures (34.8%), drug prescription (24.8%) and drug interaction (5%).21The results indicate that electronic resources and person to person communication as the main sources of information for dental professional'spatient care services. For instance, Nzabonimana found that most dental professional relied on Google (81%) and 60% used YouTube videos for professional needs.None of the studies retrieved for this review reported structured implementation strategies on evidence-based dentistry by institutions or hospitals for students, postgraduates, faculty or dental/oral clinicians. All studies reported on knowledge, attitudes and practice of EBD. Therefore, evaluation of implementation was not applicable.19. The change was attributed to reading articles on EBD. The change in practice was also attributed to the quality of the journal articles read, the types of journals as well as the authors. Very few respondents (N=10) in the study reported to have participated in EBP courses.Adeoye reported that majority of the participants (82.3%) with awareness on EBD agreed to have changed their behavior to use the EB concept during practiceNone of the articles reviewed reported any formal and structured EBD training for clinicians or dental students.20. Fourthly, challenges in infrastructure such as unreliable electricity power supplies, limited access to web-based subscription medical databases, computers and internet services; and lastly, scarcity of mentors who are passionate about EBD. Additionally, Adeoyereported the most mentioned barriers being limited knowledge and awareness of EBP, inadequate finances, as well as equipment and materials19. Not having enough time for EBD practice was also cited as an obstacle due to high workload. Also stated was the fear related to slow rate of acceptance by dentists and limited opportunities for training EBP.Two of the studies reported barriers perceived by dental practitioners towards practicing EBD. Adeniyi and colleaguereported five barriers as outlined here: firstly, deficient practitioner interest; secondly, in dental health care, conventional model was more convenient, beneficial and effective than the EB model; thirdly, for most dental health conditions, reliable and high-level evidence is scarce, and that the retrievable evidence may not be applicable in local settings as they are from dissimilar culturesIn this review, there were three articles that fitted the criteria for inclusion into this review, showing the scarcity of EBD research in LMICs. Similarly, the current evidence on implementation strategies of EBD in LMICs is lacking. We expected to carryout meta-analysis and therefore to deploy meta-regression analysis by age, geographical location as well as other demographic characteristics. This analysis could not be performed due to a limited number of quantitative studies that are comparable. Despite the minimal number of articles included, systematic review can assist to identify that as a gap and form basis to suggest further work on the area of interest.Methodologically, the included studies mainly focused on the cross-sectional survey methods and qualitative interviews. Further, it is worth noting that the risk of bias assessment for qualitative studies was moderate, while the rating for the quantitative studies was above 0.9 percent. These findings indicate a good quality of the applied methods in the included studies. However, since the included studies only applied cross-sectional surveys, and minimal use of qualitative methods, there is a need for a more rigorous mixed method studies that will combine both quantitative and qualitative studies. Qualitative studies will assist to understand the context of EBD, while quantitative studies e.g., Randomized Controlled Trials (RCTs) will enable to ascertain the extent of the application of EBD, and areas for improvement.21 Significant number of dentists with limited levels of knowledge on EBD has been reported elsewhere in countries like Iran and Pakistan29. Studies reveal that having knowledge on issues pertaining to EBD, increases chances on uptake of EBD in patient care decision making12. Currently, access to internet has increased globally, this is true also for the LMICs. The improved access to information, necessitates the need to strategize implementation of EBD, particularly, to build capacity in utilization of appropriate online peer reviewed medical resourcesand tools for clinical decision making. Training in the form of continuing educational programs to clinicians and faculty; and incorporation of EBD modules into degree/certificate programs has been recommended.29The reviewed studies report low and below average knowledge and awareness of EBD and low use of EB databases.21. The negative attitudes stated were mostly related to lack of interest as well as unfavorableconditions for EBD practice, is a common phenomenon in most LMICs. This calls for interventions geared towards not only improved knowledge and attitudes but also making available the required tools to make EBD practical. The latter efforts are also applicable and may bring more effective outcomes, in situations where attitudes are positive among the dentists21.A positive attitude is essential for a change to occur towards a desired outcome. The current reviewed studies showed variation inreported attitudes of the dentists towards EBD. The dentists in the study byAdeniyi and colleague, reported negative attitudes towards utilization of EBD, unlike the other two studies that showed positive attitudes towards EBD19 As reported in a previous study in Kuwait, despite the high percentage of dentists reporting the use of EBD, fewer than fifty percent had reasonable understanding of fundamentals related to EBD.30 Majority of the dentists rely on experienceand obtaining information from colleagues or textbooks and non-peer reviewed information, which are convenient to them, but are considered not to have sufficient evidence for decision making. The study found that electronic resources and person to person communication as the main sources of information for dental professionals' patient care services. On electronic sources, the findings further showed that dental professionals relied on the Google (81%) and YouTube videos (60%) for professional needs. The high use of Google search has also been reported in other studies16. This finding indicates that the use of e-resources is discouraging as one would have expected probably due to lack of awareness and skills on how to use e-resources. Although Google is a good resource for retrieving large amount of results for dental professionals, concerns have been raised about how reliable is the information that it retrieves.16Practice of EBD and use of scientific evidence databases was low among the dentist in the current review. Moreover, even though a substantial number of dentists reporting EBD practice in the current review, a large number could not correctly respond to the EBD knowledge questions.The lack of studies, in this review, reporting implementation strategies for EBD in LMICs justifies why there was low or below average levels of knowledge on EBD. On the same note, EBD interventions, could improve dentists' attitudes towards the use of evidence in decision making and hence practice EBD. This underscores the need for EBD interventions among dentists in the region.31. Accessibility to dental literatures, insurance coverage to name the few, require plans that will be based on barriers and promoters specifically for EBD32There was a high number of literaturesthat assessed factors affecting uptake of EBP with more focus on medical profession. Despite the similarities in identified factors associated with EBP in other professions with those for dental profession, there is considerable differences in medical and dental practice due to differences in funding and organizational structures33As reported a systematic review previously, shortage of time and financial constraints featuring as barrier to EBD practiceIn our review similar barriers were noted, and in addition, cultural issues and non-supportive infrastructural were mentioned, requiring cultural and societal sensitive evidence to be obtained for effective implementation of evidence-based dentistry.The current systematic review revealed limited number of studies on EBD, and that none of the studies reported presence of EBD implementation strategies nor evaluation thereof. The dental professionals mainly relied on the electronic resources and person to person communication as the main sources of information for their patient care services.The study findings indicated a low and below average of knowledge and awareness of EBD and relevant databases for EBD. Poor attitude towards EBD was observed in most primary studies. Practice of EBD and use of scientific evidence databases was low among the dentist in current review. In terms of behavior change, one primary study reported that most of the respondents were aware of EBD concept and that reading a research/scientific article caused them to changetheir practice.None of the reviewed articles reported implementation of any formal and structured EBD training for clinicians or dental students. A number of barriers that constrained application of EBD were noted in the reviewed studies, which included: lack of interest, the traditional model for decision making is effective and more convenient than EBD, scarcity of reliable and high-level evidence in the world dental literature may require cautious application in our settings, infrastructural limitations , lack of mentors, lack of adequate knowledge and awareness of EBP, limited finance, lack of sufficient time for EBD, and a lack of adequate training opportunities on EBP.Methodologically, the included studies mainly focused on the cross-sectional survey methods and qualitative interviews. Given the fact that there is low application of EBD and poor use of EBD resources, the study had several implications to improve practice, policy and research methods, as shown below:Practically, the study recommends the following: Dental schools and hospitals need to build capacity to dental practitioners, faculty and students in the form of continuing educational programs and incorporation of EBD modules into degree/certificate programs. These training programs should inform them about evidence based online databases and resources to increase accuracy of their clinical decision making; Dental schools and hospitals libraries need to have promotion plan that will encourage the application of EBD to dental practitioners, faculty and students by using print and electronics means such as posters, leaflets, online videos on the websites etc.; Dental schools and hospitals need to form evidence-based study clubs between different specialties of healthcare in oral health to encourage adoption and use of EBD; Dental schools and hospitals need to ensure that libraries are kept up-to-date and relevant especially in healthcare as well as in the hospitals; Dental schools and hospitals need to improve the ICT infrastructure to ensure there is adequate access to computers, internet and electrical power for effective application of EBD; Responsible professional Council should give directives tothe dental practitioners to regularly attend courseson EBD and to include it into their daily clinical practice; Methodologically, the study recommends a need for a more rigorous mixed method studies that will combine both quantitative and qualitative studies; The study also recommends the need for allocation of funding for future research on evidence-based dentistry in the region; In terms of policy, dental schools and hospitals need to set up polices and guidelines that will encourage oral health care providers to refer to peer reviewed sources to ensure that they utilize reliable current and evidence-based information for patient management.


Industry self-regulation is the dominant approach to managing alcohol advertising in Australia and many other countries. There is a need to explore the barriers to government adoption of more effective regulatory approaches. This study examined relevance and quality features of evidence cited by industry and non-industry actors in their submissions to Australian alcohol advertising policy consultations.Submissions to two public consultations with a primary focus on alcohol advertising policy were analysed. Submissions (n = 71) were classified into their actor type (industry or non-industry) and according to their expressed support for, or opposition to, increased regulation of alcohol advertising. Details of cited evidence were extracted and coded against a framework adapted from previous research . Evidence was also classified as featuring indicators of higher quality if it was either published in a peer-reviewed journal or academic source, published within 10 years of the consultation, and/or had no apparent industry connection.Almost two-thirds of submissions were from industry actors . With few exceptions, industry actor submissions opposed increased regulation of alcohol advertising and non-industry actor submissions supported increased regulation. Industry actors cited substantially less evidence than non-industry actors, both per submission and in total. Only 27% of evidence cited by industry actors was highly relevant and featured at least two indicators of higher quality compared to 58% of evidence cited by non-industry actors.Evaluation of the value of the evidentiary contribution of industry actors to consultations on alcohol advertising policy appears to be limited. Modifications to consultation processes, such as exclusion of industry actors, quality requirements for submitted evidence, minimum standards for referencing evidence, and requirements to declare potential conflicts, may improve the public health outcomes of policy consultations. The sustained burden of alcohol-caused harm has required governments to consider regulatory options for reducing levels of harm and associated public costs , 2. StakWhere submissions are publicly accessible, they can provide a data source for evaluating the evidentiary contribution of different actors to policy consultations. To date, there has been limited work of this nature in the context of alcohol policy. In a study of alcohol industry submissions to a Scottish Parliamentary consultation on minimum unit pricing, Cullen et al. found that peer-reviewed evidence  accounted for only 15% of 115 items of evidence cited across 25 industry submissions methodp. 13 of the MS pdf.Q why would human subject ethics permission be sought to examine publicly available submissions?Perhaps other aspects of the research should be mentioned in this regard eg. Interviews or whatever necessitated human subject research.p. 13 of the MS pdf.the two inquiries that constitute the source of data are well described. However the authors could say why it was important. Eg was it to compare the two as justification that the results were not ideosyncratic to one inquiry? Was it to include both national and state inquiries etc.?p.16 of the MS pdf.Most of the codings are well explained and where relevant, the source in other relevant research. Regarding time since publication defined as up to 10 years or more than 10 years. Its there a rationale for this coding? Also, elsewhere in the text 15 years was mentioned. How does this fit the coding? [Also described on p.18 of the MS].p. 19 MS pdf.Line 276‘Where detected, analyses were re-run with extreme scores removed to determine whether results differed.’Q. isn’t it stated later that there were no cases of extreme scores?p. 27 of MS pdf.Principle findings brings together the most significant findings of the research.The authors give a very good succinct summation of the main findings.Final para‘Modifications to consultation processes, such as exclusion of industry actors, quality requirements for submitted evidence, minimum standards for referencing evidence, and requirements to declare potential conflicts, may improve the transparency and application of evidence and public health outcomes of policy consultations’.These are very reasonable recommendations that come out of this work with application more broadly to government inquiries. If submissions draw on evidence that is no publicly traceable for inspection/accuracy/bias, then this is a shortcoming that could seemingly be risk managed along lines suggested.Under acknowledgments, this reviewer is not sure of the relevance of the declarations that presumably apply to different authors’ contributions to submissions that would have been included in the inquiry. Acknowledgments usually refer to funding sources and the sort of statements made here should perhaps go in potential limitations and how/why bias is/not introduced and also discuss whether the reported research in this article was designed after or contemporaneously with these organisational submissions in which authors were involved.Alternatively, some of this may belong in declarations of interest. Since authors have contributed to some of the submissions to the inquires under analysis and in one case, to the final report. This does not mean to say the person should not be an author but to explain why these contributions do/not bias the research.Reviewer #2: Many thanks for the opportunity to review this well written and important manuscript. The authors have conducted a thorough analysis of responses to two public consultations focusing on alcohol advertising policy using previously published methods. In this way the study is an important contribution to the growing body of literature on industry use and representation of evidence in the consultation process and adds a novel dimension by analysing and comparing industry with non-industry submissions.I have only minor comments for the authors to consider addressing:Page 5 – paragraph from lines 91-103 – the authors could extend this further by making reference to additional studies that show that similar tactics are employed by the ultra-process food industry and the sugar sweetend beverage industry e.g.Fooks GJ, Williams S, Box G, Sacks G. Corporations’ use and misuse of evidence to influence health policy: a case study of sugar-sweetened beverage taxation. Globalization and Health 2019; 15(1): 56.Lauber K, McGee D, Gilmore AB. Commercial use of evidence in public health policy: a critical assessment of food industry submissions to global-level consultations on non-communicable disease prevention. BMJ Global Health 2021; 6(8): e006176.This could help to further demonstrate the cross-industry nature of these tactics.Page 8 lines 167-172 – the authors describe who was classified as industry – where their other commercial actors e.g. those from the tourism/entertainment industry or bars/clubs (where these considered “retailers”) and where these included as industry or non-industry? This may be helpful in thinking though some of the wider partnership and allies that can be built by the industry and whose interests are served or threatened by different policy outcomes as the authors have shown for the advertising industry.Page 22: “In both studies, significantly lower proportions of evidence cited by industry actors were highly relevant and featured indicators of higher quality compared to the points of comparison ”The authors may want to add some addition text to clarify that industry submissions have lower levels of features indicating high quality.Discussion/conclusion – the authors make several well-considered recommendations on how the consultation process may be strengthened. They may wish to highlight to the reader that similar recommendations have been made in other studies in the context of other policies and industries, which may strengthen the case for calling for such adjustments given other research groups in other locations and time points have also demonstrated the need for such measures if policy-making is to serve the public interest and draw on the best available evidence.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  20 Nov 2021Please see attached Response to Reviewers.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 29 Nov 2021An evaluation of the evidence submitted to Australian alcohol advertising policy consultationsPONE-D-21-26197R1Dear Dr. Stafford,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Quinn Grundy, PhD, RNAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 3 Dec 2021PONE-D-21-26197R1 An evaluation of the evidence submitted to Australian alcohol advertising policy consultations  Dear Dr. Stafford:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Quinn Grundy Academic EditorPLOS ONE


Do clinical practice guidelines (CPGs) that report on pharmacologic treatments of hospitalized patients with COVID-19 meet the National Academy of Medicine standards for trustworthiness?In this systematic review of 32 CPGs of predominantly low quality, few reported funding sources or conflicts of interest, included a methodologist, described a search strategy or study selection process, or synthesized evidence. Although 14 CPGs (43.8%) made recommendations or suggestions for or against treatments, they infrequently rated the confidence in the quality of the evidence (6 [18.8%]), described potential benefits and harms (6 [18.8%]), or graded the strength of recommendations (5 [15.6%]).The findings of this study suggest that few COVID-19 CPGs meet National Academy of Medicine standards for trustworthy guidelines. This systematic review evaluates the quality and trustworthiness of clinical practice guidelines for pharmacologic treatment of hospitalized patients with COVID-19 using the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards instrument. The COVID-19 pandemic created the need for rapid and urgent guidance for clinicians to manage COVID-19 among patients and prevent transmission.To appraise the quality of clinical practice guidelines (CPGs) using the National Academy of Medicine (NAM) criteria.A search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials to December 14, 2020, and a search of related articles to February 28, 2021, that included CPGs developed by societies or by government or nongovernment organizations that reported pharmacologic treatments of hospitalized patients with COVID-19. Teams of 2 reviewers independently abstracted data and assessed CPG quality using the 15-item National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) instrument.Thirty-two CPGs were included in the review. Of these, 25 (78.1%) were developed by professional societies and emanated from a single World Health Organization (WHO) region. Overall, the CPGs were of low quality. Only 7 CPGs (21.9%) reported funding sources, and 12 (37.5%) reported conflicts of interest. Only 5 CPGs (15.6%) included a methodologist, described a search strategy or study selection process, or synthesized the evidence. Although 14 CPGs (43.8%) made recommendations or suggestions for or against treatments, they infrequently rated confidence in the quality of the evidence (6 of 32 [18.8%]), described potential benefits and harms (6 of 32 [18.8%]), or graded the strength of the recommendations (5 of 32 [15.6%]). External review, patient or public perspectives, or a process for updating were rare. High-quality CPGs included a methodologist and multidisciplinary collaborations involving investigators from 2 or more WHO regions.In this review, few COVID-19 CPGs met NAM standards for trustworthy guidelines. Approaches that prioritize engagement of a methodologist and multidisciplinary collaborators from at least 2 WHO regions may lead to the production of fewer, high-quality CPGs that are poised for updates as new evidence emerges.CRD42021245239PROSPERO Identifier:  The process for creating guidelines affects CPG quality. In turn, CPG quality affects patient care, safety, and health care equality. In 2011, the National Academy of Medicine (NAM) (formerly known as the Institute of Medicine)11 The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool8 is the most widely used CPG appraisal tool. The scope of the AGREE II tool targets all components of a CPG report, emphasizing features that enhance its internal validity. The AGREE Recommendation Excellence tool,9 a supplement to the AGREE II tool, highlights 9 items in 3 themes that focus on the quality of the CPG recommendations and the justifications that underpin them. The AGREE Recommendation Excellence tool ascertains whether CPGs are credible and implementable by assessing their internal consistency. Notwithstanding, the AGREE II and AGREE Recommendation Excellence appraisal tools do not directly address the NAM criteria for trustworthy CPGs or consider the perspectives of different stakeholder groups involved in CPG development. More recently, the US Agency for Healthcare Research and Quality developed the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) instrument 11  and conducted a search of related articles  to identify updates. Two reviewers (M.L. and J.S.) independently screened all titles and abstracts of citations for eligibility. Disagreements were resolved by consensus or in discussion with a third reviewer (K.E.A.B.).Eligible CPGs were investigator led, sponsored or produced by a national or international scientific organization or government or nongovernment organization related to global health, and reported on pharmacologic treatments of hospitalized patients with COVID-19 and its complications. Pharmacologic interventions referred to treatments dispensed by hospital pharmacies, with an identifiable molecular structure. We included all versions of published CPGs. We did not apply language restrictions. We excluded CPGs produced for regional or local use , nonpharmacologic interventions, medications not dispensed by a hospital pharmacy , and CPGs that focused on treatments for specific populations .Fifteen reviewers , working independently and in duplicate, abstracted data pertaining to CPG publications , geographical representation of collaborators using World Health Organization (WHO) regions, CPG sponsorship , funding (monetary or nonmonetary), and scope . Reviewers recorded the patient populations addressed  and assessed whether CPGs had a formal conflict of interest (COI) policy and declared COIs . They noted whether patient and/or public perspectives were sought or incorporated. For each pharmacologic intervention, appraisers documented outcomes of interest and the direction of the recommendation statement (for or against or no recommendation), the strength of the recommendation, and the certainty of the evidence.11 , to characterize CPGs, NEATS scores, and the direction of recommendation or suggestion statements  for each pharmacologic treatment described in included CPGs. The NEATS instrument includes 3 binary or categorical items reflecting adherence to the NAM standard: assessing disclosure of funding (yes or no), multidisciplinary representation , and inclusion of a methodologist on the guideline panel  in CPG panels and 12 Likert scales. Reviewers rated adherence  to 12 NAM standards reflecting disclosure/management of COIs, inclusion of patient and public perspectives, use of systematic review of the evidence , a process for making recommendations , generation of specific and unambiguous recommendations, procurement of external reviews, and inclusion of a prespecified process to update the CPG.We tabulated results to highlight the evolution of evidence over time for each pharmacologic intervention addressed by 3 or more CPGs. We characterized and compared recommendations for use of each specific pharmacologic intervention by assessing whether a recommendation or suggestion was made for or against its use or whether no recommendation for its use was made. In assessing the consistency between CPGs for each pharmacologic treatment, we prioritized the direction of the recommendation over the strength of the recommendation.We depicted quality scores for each element of the NEATS instrument for each included CPG using a Coxcomb chart . We illu44 We excluded 19 CPGs 40 reported on pharmacologic treatments for critically ill patients specifically, and the remainder reported on treatments for hospitalized patients with COVID-19. Fifteen CPGs (46.9%) were international44 and 17 (53.1%) were national.42 Most CPGs (25 [78.1%]) had sponsorship from 1 or more national societies, and few CPGs (3 [9.4%])34 had sponsorship from government, nongovernment, or not-for-profit agencies (4 [12.5%]).44 Seven CPGs (21.9%)34 explicitly reported their funding sources 44 included multidisciplinary guideline panels, and 5 guideline panels (15.6%)44 included a methodologist.Eighteen CPGs (56.3%) explicitly disclosed funding information.44 with high adherence (score of 4 or 5) to the NAM standard to disclose actual or potential financial COIs and report how COIs were incorporated or managed in the CPG development process. Eight CPGs (25.0%)43 had intermediate adherence (score of 3) and 12 CPGs (37.5%)41 had low adherence (score of 1 or 2) to this NAM standard.We identified 12 CPGs (37.5%)44 adhered (both with a score of 5) to the requirement to seek the views of patients, surrogates, advocates, and/or the public who represent those that have experience with the disease, its treatment, or its complications or those who could be affected by the CPG. These individuals could be integrated into the CPG development group or engaged in other ways or at various points in CPG development.Only 2 CPGs (6.3%)44 adhered (score of 4 or 5) to the requirement to describe their search strategy in detail, including a listing of the databases searched, summary of the search terms used, and the start and end date covered by the search. Five CPGs (15.6%)44 adhered (score of 4 or 5) to the requirement to describe the study selection, including the number of studies identified and a summary of inclusion and exclusion criteria. Five CPGs (15.6%)44 adhered (score of 4 or 5) to the requirement to provide a synthesis of the evidence from the selected studies in the form of a detailed description of the body of evidence or as evidence tables or both.Six CPGs (18.8%)44 adhered (score of 4 or 5) to the requirement to provide a grade or rating of the level of confidence or certainty in the quality or strength of the evidence underpinning each recommendation. Similarly, 6 CPGs (18.8%)44 adhered  to the requirement to provide a clear description of the potential benefits and harms and link this information to specific recommendations. The same 6 CPGs44 adhered (score of 4 or 5) to the requirement to have an explicit link to a summary of the relevant evidence and link this information directly to recommendations. Five CPGs (15.6%)44 adhered (score of 4 or 5) to the standard to rate the strength of the recommendations  based on a clear and well-described evidence-to-recommendation scheme that took into account the balance between benefits and harms, available evidence, and their confidence in the underlying evidence . Fourteen CPGs (43.8%)44 adhered (score of 4 or 5) to the requirement to make specific and unambiguous recommendations that stated which actions should or should not be taken in specific situations or populations, and, where recommendations were vague or underspecified, clearly described the rationale for making recommendations.Six CPGs (18.8%)44 adhered (score of 4 or 5) to the requirement to describe an external review process by specifying (name and description) relevant stakeholders  and a process for external review. Only 2 CPGs 44 had a prespecified procedure to update the CPG that included the time frame for updating, the process by which a decision would be made to update the CPG, and a description of how the update would be conducted.Only 3 CPGs (9.4%)44 were that they were multidisciplinary and included collaborators from at least 2 WHO regions. Four of these 5 highest-quality CPGs44 included a methodologist in their guideline panel.We depict the total NEATS score for each included CPG in a heat map in Clinical practice guideline recommendations evolved during the period of our review to recommend or suggest the use of corticosteroids for hospitalized patients with COVID-19 . Convers11 Although nearly two-thirds of CPGs included multidisciplinary guideline panels, fewer than 20% of CPG panels included a methodologist. Only 37.5% of CPGs had a detailed disclosure of actual or potential COIs. Few CPGs (6.3%) included patient and public perspectives. Fewer than 20% of included COVID-19–related CPGs described their search strategy, a process for study selection, or provided a synthesis of the evidence. Although nearly half of CPGs made suggestions or recommendations for or against treatments, fewer than 20% of CPGs provided a grade or rating of the level of confidence in or certainty with the quality or strength of the evidence, offered a clear description of the potential benefits and harms with links to specific recommendations, or rated the strength of the recommendations using a clear grading scheme. Fewer than 10% of CPGs underwent external review and even fewer described a process for updating. The overall quality of CPGs, as assessed by the NEATS score, was low. Multidisciplinary panels that included a methodologist and collaborators from at least 2 WHO regions were features of high-quality COVID-19 CPGs.In this systematic review of CPGs evaluating pharmacologic treatments for hospitalized patients with COVID-19, we found that few CPGs met the NAM standards for trustworthiness as assessed by the NEATS instrument.64 Overall, most included CPGs in our study failed to meet NAM standards and consequently were at increased risk of bias. Although producing high-quality guidelines may be viewed as impractical during a pandemic, this review identified features of high-quality COVID-19–related CPGs using the NEATS instrument. Although most high-quality CPGs tended to be published later in the pandemic, a high-quality CPG in our review was published in March 2020.15 Moreover, we noted that updates of CPGs published earlier in the pandemic tended to be of higher quality than the parent documents  have been published is unprecedented. During a pandemic specifically, there is a high demand for early, systematically developed statements that reflect best practices based on available evidence to guide the practice of health care professionals. Nonetheless, strong methodologic standards for CPGs are essential to avoid promulgating useless or potentially harmful treatments and wasting health care resources.ocuments . Improve66 From 130 randomly selected CPGs from the National Guideline Clearinghouse, Kung et al65 found that the median number of NAM standards satisfied was 8 of 18 . The authors noted that fewer than half of their included CPGs and one-third of CPGs produced by subspecialty societies met more than 50% of the NAM standards.65 Similar to our study, others have shown that fewer than half of CPGs provided information regarding COIs,65 few CPGs included patients or patient representatives,66 and the CPGs rarely included a process for updating.66 The present review adds to the literature by documenting that fewer than 20% of CPGs included a systematic review or adhered to the International Organization for Standardization to generate recommendations for care. Although several CPGs in our review (14 of 32 [43.8%]) made suggestions or recommendations for or against treatments, they infrequently provided a grade or rating of the level of confidence or certainty regarding the quality or strength of the evidence (6 of 32 [18.8%]), offered a clear description of the potential benefits and harms (6 of 32 [18.8%]), or rated the strength of the recommendations using a clear grading scheme (5 of 32 [15.6%]). As such, the guidance statements from most CPGs included in our review were not optimally informed by the key dimensions of evidence on pharmacologic interventions for COVID-19. Contrary to a review of oncology CPGs,66 most CPGs in our review did not undergo external peer review. Similar to our study, an earlier review of 19 COVID-19–specific CPGs12 found that the overall quality of CPGs was poor; lacked detail; had inconsistent recommendations, even for the same intervention; and did not provide explicit linkage between the evidence and generating recommendations. Recently, Stamm et al64 evaluated the quality of 188 general COVID-19 CPGs published from February 1 to April 27, 2020, using the AGREE II tool. The CPGs in this review were largely (83%) based on informal consensus without clear evidence summaries and scored highest for scope and purpose (89%) and lowest (25%) for rigor of development. The latter finding may relate to the paucity of evidence available early in the pandemic. Unlike previous COVID-19 CPG reviews,64 we limited our review to pharmacologic treatments for COVID-19, included CPGs with broad potential reach (authored by societies and government or nongovernment organizations), and appraised quality using the NEATS (vs AGREE II) instrument. Taken together, systematic reviews of CPG quality have identified that most CPGs were of low overall methodologic quality and tended to make recommendations that promoted more interventions as opposed to more effective interventions.Our findings align with other assessments of nonpandemic and pandemic CPG quality.11 To ensure consistency and reliability of judgments, 2 trained personnel assess each CPG using the NEATS tool at the National Guideline Clearinghouse. Subsequently, these assessments are shared with CPG developers to enhance the accuracy and completeness of NEATS quality summaries. This feedback loop provides guideline developers with a benchmark to compare their processes against the NAM standards and an opportunity to clarify their methods.67 Several authors68 have noted that the additional rigor required to adhere to these standards may come at the cost of increased complexity, expertise, money, and time to CPG completion, most of which are in short supply during a pandemic. Future research is needed to compare appraisal tools, understand how to create CPGs that are ready for implementation, and aid stakeholders  to be informed CPG consumers.Instruments that appraise CPG quality provide stakeholders with a metric to evaluate and select the most rigorously developed CPGs with the goal of improving patient care, safety, and outcomes. The AGREE II checklist focuses on assessment of the quality and reporting of CPGs in 6 domains  but does not address the clinical validity of CPG recommendations. By contrast, the 15-item NEATS instrument assesses adherence to NAM standards. The NEATS tool has been shown to have high interrater reliability (weighted κ = 0.73) and external validity.11 Second, approaches that prioritize broad collaborations that engage multidisciplinary stakeholders who work together and share expertise and resources and are from at least 2 WHO regions may be optimal and lead to the production of fewer but higher-quality CPGs that are poised for updates as new evidence emerges. This approach could not only limit duplication of efforts but also limit publication of inconsistent recommendations. As opposed to de novo CPG development, local and regional groups should consider appraising and adapting existing high-quality CPGs to their practice context using the ADAPTE process.69 This 3-stage process includes start-up (assessment of skills and resources required), adaptation , and end stage .69 Inherent to the ADAPTE process is access to CPGs and availability of local expertise in CPG appraisal. Adaptation to the clinical context is an important consideration, because most CPGs in our review were sponsored by societies with infrastructure and expertise and few were developed in low- and middle-income countries. Third, journal editors and peer reviewers should mandate use of 1 or more CPG appraisal tools at the time of manuscript submission to ensure publication of high-quality and trustworthy CPGs.Several strategies might enhance the development of trustworthy CPGs, even in the setting of a pandemic. First, CPG panels should include participation of a methodologic expert . Their expertise adds to decisions regarding study design and the potential for bias and influence on study findings, methods to minimize bias in the conduct of systematic reviews, use of quantitative methods, conduct of qualitative synthesis, and issues related to data collection and management.Our review has several strengths. Unlike prior reviews of COVID-19–related CPGs, we limited our review to pharmacologic treatments for hospitalized patients with COVID-19, included CPGs with broad potential reach (sponsored by societies and government or nongovernment organizations), and appraised CPG quality using the NEATS (vs AGREE II) instrument. To our knowledge, this is the first report to use the NEATS instrument to appraise CPG quality outside of the National Guideline Clearinghouse. We prioritized use of the NEATS tool because it had undergone rigorous development and testing and is aligned with NAM standards for trustworthy CPGs. We performed a comprehensive search and reviewed citations, abstracted data, and assessed quality in duplicate to limit ascertainment bias.Our review also has some limitations. First, we limited our search to CPGs that were published in peer-reviewed journals. Second, we did not contact CPG authors to verify the methodologic aspects of their respective guidelines. Consequently, our assessment of methodologic expertise may be an underestimate, limited by reporting of this information in CPGs. Third, we did not have specific information pertaining to whether the included CPGs underwent peer review  or were appraised using a quality checklist or other tool by authors at the time of submission. Notwithstanding, these points highlight the need for high publication standards even in the unique circumstances posed by a pandemic.Few COVID-19 CPGs met NAM standards for trustworthy guidelines. Approaches that prioritize engagement of a methodologist and multidisciplinary collaborators from at least 2 WHO regions may lead to the production of fewer, high-quality CPGs that are poised for updates as new evidence emerges.


The overall aim of this special issue is to contribute to the international discourse around literacy, numeracy, adult education and basic education. It engages with numeracy and mathematical literacy, New Literacy Studies, adult education, and lifelong learning in the context of the United Nations Sustainable Development Goals (SDGs), both from theoretical perspectives and from an empirical viewpoint.Education affects people’s lives in ways that go far beyond what can be measured by labour market earnings and economic growth. Education contributes to a wide range of social outcomes such as better health, higher levels of civic and social engagement, as well as addressing other socially relevant domains of concern, such as crime, anti-social behaviour and poverty (Schuller and Desjardins 2007).By 2030, ensure that all youth and a substantial proportion of adults, both men and women, achieve literacy and numeracy .Despite the collective efforts among various stakeholders to achieve progress in working towards the targets of SDG 4, several problematic issues remain, even as we are already five years into implementing the United Nations 2030 Agenda for Sustainable Development. The current pandemic arrived on top of these. The challenges involved in developing indicators to monitor progress were already well-acknowledged at the start of the SDG agenda in 2015. In 2016, led by the UNESCO Institute for Statistics (UIS), the Global Alliance to Monitor Learning (GAML) was established (UIS 2017).The broader approach towards education and learning and the concept of sustainability are already embedded in the history of the United Nations Educational, Scientific and Cultural Organization (UNESCO). They are reflected in the instrumental role UNESCO has played since the end of the Second World War in expanding the right to education to include adults. The call within the fourth Sustainable Development Goal SDG 4) to “ensure inclusive and equitable quality education and promote lifelong learning opportunities for all” UN 2015)0152 has  to “ensud UIS 201.7The challenges pertaining to SDG target 4.6 include the complexity of measuring functional literacy and numeracy, the feasibility of reporting adults’ literacy and numeracy against a global common measurement scale, and the difficulty of increasing data coverage among those UNESCO Member States that do not currently have direct assessments in place. GAML’s task force on SDG target 4.6, chaired by the UNESCO Institute for Lifelong Learning (UIL) and the Organisation for Economic Co-operation and Development (OECD), recommended the use of specific skills levels associated with the OECD Programme for the International Assessment of Adult Competencies (PIAAC) as benchmarks.9These recommendations were based on results of a global consultation as well as analyses of existing population data on skills such as PIAAC and the World Bank’s Skills Towards Employment and Productivity (STEP) study. Empirical data have revealed that approximately 50 per cent of adult populations living in middle-income countries, such as, for example, Turkey and Chile, are at or below PIAAC Level 1 on the literacy scale (OECD 2017).12International Review of Education – Journal of Lifelong Learning (IRE) to take stock and gather perspectives from various research fields in order to support a more comprehensive understanding of key issues and challenges surrounding SDG target 4.6 on adult literacy and numeracy.Notwithstanding these challenges, five years into the SDG agenda, the research community has produced methodological advancements that can help measure adult literacy and numeracy at the lower end of the proficiency scale. It has also produced useful knowledge towards understanding literacy and numeracy competences and practices among men and women, albeit mostly in high-income countries. Moreover, scholars have provided important critical perspectives for better understanding the diversity and contextualisation of literacy and numeracy practices. With ten years remaining until the deadline of the United Nations 2030 Agenda for Sustainable Development, it is timely for the The first part of this special issue contains two articles that provide critiques of the monitoring and measurement of adult literacy and numeracy as well as three others that add to the critiques by discussing methodological advancements.Several scholars have warned that the time pressure and lack of scientific reflection associated with large-scale assessments bear the potential danger of leading to monopolist effects of a handful of education assessment companies or institutions on low- and middle-income countries .normality.In particular, the test items developed for IALSBrandt LineEven though the SDGs explicitly try to overcome the Sotiria Grek investigates the SDG 4-related monitoring procedures carried out by supranational organisations. Her purpose is to offer insights into the labour and infrastructure involved in the joint production of metrics. Drawing on declarations, agreements and reports as well as empirical findings from a series of interviews she conducted with key actors from major international organisations and civil society, Grek suggests that quantification has facilitated symbolic governance of the education policy field. As a result, the joint effort towards achieving the targets of SDG 4 represents the rise, and to a large degree the dominance, of the influence of the transnational field of measurement in education.The first article we present in this special issue is entitled “Prophets, saviours and saints: Symbolic governance and the rise of a transnational metrological field”. Arguing from the Bourdieusian perspective of a “sociology of numbers”, Lisanne Heilmann looks at literacy and numeracy from a post-structuralist perspective. This perspective relies on theories of a relational subject, as introduced by Judith Butler from a feminist standpoint (Butler 2004).constructed through how they are actively performed  and referred to (e.g. when someone is pronounced “literate” or “competent”). She points out that measuring competences implies an individual that “has” competences. What if we are “doing competences”? Emphasising discourse analysis, e.g. by Michel Foucault and Judith Butler, Heilmann elaborates a shift from the New Literacy Studies, which questioned the individualised understanding of literacy as an abstract competence, to a post-structuralist literacy theory.In our second article, entitled “Doing competence: On the performativity of literacy and numeracy from a post-structural viewpoint”, numeracy shifts towards a more holistic approach and asks for criticality. This seems highly relevant in times of infection statistics and disastrous financial markets, and thus in times where statistics and infection rates inform policymakers and the public on whether to cut back fundamental rights. Therefore, it is most important to discuss how we conceptualise “numeracy” in large scale assessments.Challenges from discourse theory and sociology of numbers do not only apply to literacy research, but also to numeracy. Slowly, but steadily, numeracy research is becoming more visible, but adult numeracy can still be seen as a neglected field .Dave Tout, explains the most recent concept underpinning the ongoing PIAAC cycle, in which relevant changes include the aforementioned critical approach. Data collection is scheduled for 2021–2022 and the results are due to be published in 2023. Tout points out that the development and ongoing refinement of the theoretical frameworks and constructs that shape programmes such as PIAAC and the assessments themselves, alongside the research based on the rich data of empirical and background information emerging from these surveys, have contributed significantly to our knowledge and understanding of numeracy in people’s lives.The next article, “Evolution of adult numeracy from quantitative literacy to numeracy: Lessons learned from international assessments” by lower end of the hierarchically arranged skills levels. Even if many consider a hierarchical model as problematic ,Tabea Durda, Cordula Artelt, Clemens M. Lechner, Beatrice Rammstedt and Alexandra Wicht provide a process model based on reader-related, text-related and task-related factors along different stages of the reading process that can cause reading difficulties. Their model enables the identification of difficulty-generating factors, in particular task and text characteristics. This model is also suitable for developing proficiency level descriptors by differentiating between a low reading proficiency level and a functional reading proficiency level among adolescents and adults.However, measurement and monitoring on a global level produce a need for scholarly knowledge on testing especially at the PIAAC has five hierarchically organised proficiency levels for literacy. A sixth category, labelled “below Level 1”, lumps together low proficiencies at the bottom end of the proficiency continuum. While PIAAC Levels are already broadly suitable for international comparison, the in-depth assessment of “Level 1” and “below Level 1” has so far only been focused on by individual countries  using instruments developed nationally. Focusing on the reading aspect of literacy, the article which concludes the first part of this special issue investigates how these nationally developed low proficiency assessment instruments might be adjusted to facilitate international comparability.Anke Grotlüschen, Barbara Nienkemper and Caroline Duncker-Euringer discuss two competing approaches. One is the reading components approach, and the other is the lower-rungs approach. Reading components test sets are well-known and widespread. Some of them have been administered in national surveys, some were applied under LAMP in several languages, and many countries opt to run the reading components module of the PIAAC programme. However, starting from IALS in the 1990s, the concept of a hierarchical ladder of proficiency levels has emerged and since been applied with a focus on the lower rungs in the Skills for Life surveys  and the two German Level-One (LEO) surveys conducted by the University of Hamburg. Based on the German PIAAC Reading Components dataset, Grotlüschen et al. investigate whether the existing component items can be arranged hierarchically (as lower rungs of the ladder) in a similar way as PIAAC and LAMP items to facilitate global reporting and comparison. They conclude that that it is indeed technically possible to integrate the full set of PIAAC reading component test items into hierarchical “rungs”.In “International assessment of low reading proficiency in the adult population: A question of components or lower rungs?”, In the second part of this special issue, we present five articles that relate to findings from qualitative and quantitative literacy and numeracy research, and help to reveal several insights and nuances relevant to measurement and monitoring of literacy and numeracy.grande dame of numeracy research, showed the importance of practices in 1988 with her work on “cognition in practice” (Lave 1988).29Several major theoretical approaches have shown that the discussion of “competences” is shifting towards the notion of “practices”. Social anthropologist Jean Lave, Stephen Reder, Britta Gauly and Clemens Lechner present more recent findings generated by PIAAC-L, a longitudinal national follow-up survey conducted in Germany, and discuss the influences of practices on competences and vice versa.practice engagement theory (PET) Reder et al. suggest that literacy training which increases engagement in meaningful practices might generate proficiency growth. The authors’ comparisons of how various practice engagement indexes predict growth of literacy and numeracy proficiencies indicate that reading engagement is the strongest predictor of literacy growth, and maths engagement is the strongest predictor of numeracy growth. They conclude their article by considering their findings’ implications for sustainable development, lifelong learning policy and future research into the development of adult literacy and numeracy proficiency.We begin this second part with an article entitled “Practice makes perfect: Practice engagement theory and the development of adult literacy and numeracy proficiency”. Richard Desjardins offers a retrospective of thirty years of assessment with a particular focus on the trend data made available from IALS and PIAAC. The aim of his research is to understand the determinants of literacy proficiency in terms of (1) how they may be affecting the development of literacy from an individual lifecycle (micro-level) perspective, and (2) how they may be affecting the development of national (macro-level) profiles of literacy proficiency as countries’ sociodemographic compositions, sociocultural practices and economies change over time. He discerns an interesting decline of literacy practices in work-related contexts. Possible reasons for this may be that early measurement parameters do not fit any more, or that earlier practices (like looking up something in a printed dictionary) no longer apply in a digital world, but it may also be due to less practical use of skills in everyday contexts, which in the long run can affect skills levels as well. Overall, the decline of literacy practices may be a reason for stagnation in literacy competences (Desjardins 2017).31In our next article, entitled “Micro and macro drivers affecting adult literacy proficiency profiles across countries”, Sabina Lissitsa and Svetlana Chachashvili-Bolotin investigated the association between cognitive skills and job autonomy among Israeli-born Jews, Arabs and immigrants from the former Soviet Union (FSU) living in Israel. Job autonomy – employees’ freedom to schedule and organise their work independently according to their own experience and preferences – is a major factor in job satisfaction. However, it is not granted to many employees in Israel, and the authors’ close examination of the Israeli labour market reveals that while cognitive skills are positively correlated with job autonomy among Israeli-born Jews and partially among Arabs, these effects are insignificant among FSU immigrants. Lissitsa and Chachasvili-Bolotin analyse their findings through social homophily theory, which explains bonding tendencies among socially and culturally similar people.The eighth article we present in this special issue is entitled “It’s not what you know but where you come from: Cognitive skills, job autonomy and latent discrimination of ethnic minorities in Israel”. Based on PIAAC data, Doria Daniels looks at how adult education and training (AET) learners navigate second-chance education. In her article entitled “Exploring adult education and training as a transformative learning space for alienated out-of-school youth in South Africa”, she investigates what facilitates these learners’ educational success. Education policies in South Africa recently introduced a shift in the function of AET from providing opportunities for the acquisition of literacy to offering a formal qualification. This changed status of AET created a second-chance educational opportunity for youthful, non-traditional “new-generation” adult learners with a troubled history of formal schooling both to complete their general education and/or to further their education and their chances of entering the workforce. Daniels shows how vulnerable second-chance learners slowly, but steadily find ways to advance their quest for an education as energies within AET contexts and their personal worlds come together. Daniels’ narrative interviews also demonstrate how desperate the situation is in South Africa for adults with low literacy skills. Moreover, migration and globalisation call for basic education and pathways to vocational education for immigrants and people with learning disabilities. Adults with learning disabilities – a problematic terminology anyway – are often excluded and overlooked by large-scale assessments and by educational policies.Outside the PIAAC measurement industry, questions and findings on literacy and numeracy research extend beyond the question of predictors and outcomes of competences. Based on her narrative interviews with vulnerable adult learners, Wiebke Curdt and Silke Schreiber-Barsch entitled “Abilities in the blind spot of testing regimes: Eliciting the benefits and the limitations of participatory research approaches for numeracy in adult basic education”. The article argues that adults with learning difficulties  and their numeracy-related abilities are still hidden in the blind spot of large-scale testing regimes. Based on rich qualitative data, Curdt and Schreiber-Barsch discuss how participatory research designs can work out in exploring how these learners apply numeracy practices in everyday life contexts, and what challenges occur. This allows both a methodological perspective as well as a focus on vulnerable subpopulations We conclude this special issue with an article by In sum, the authors who have contributed to this special issue reflect on the complexity of literacy and numeracy assessments, focus on the need for a contextualisation of literacy and numeracy practices, and present us with the knowledge that we can gain from analysing existing data generated through large-scale skills assessments over the past 30 years. In particular, they provide critical considerations regarding monitoring and measuring literacy and numeracy, and remind us of those learners who might have been excluded in the policy debates around literacy and numeracy improvement. Between them, these ten articles cover a rich and controversial set of approaches, a set that avoids easy answers or recipes, and instead offers a critical discourse that matches the aims of the United Nations Agenda 2030 SDGs.Children who do not learn to read early enough often fail later in school or when they enter the labour market: Close a school today and you will end up with an increased share of illiterate adults (Magnusson 2020).33As countries and the international community are joining efforts to fight the pandemic and ensure that learning does not stop for children, young people and adults alike, we are hoping to see sound research on the impacts on adult learning and basic education. We would do well to advance the common goal set by SDG target 4.6.Yet, as editors and authors, we are aware of many gaps we could not possibly fill. In particular, it is worth noting that these articles were written before the outbreak of the COVID-19 pandemic. Thus, the timing of this special issue did not allow us to reflect upon the impact of the pandemic on adult learning and education in general, and the monitoring and reporting for SDG target 4.6 in particular. For instance, the short-term impact of school closures when it comes to the ability to read and write, may, in the long run, have a more severe impact on lifelong learning. As commented by Per Magnusson in his blog post published by UIL on 22 May 2020,


Interventional procedures around the knee are widely adopted for treating different musculoskeletal conditions. A panel of experts from the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the existing literature to assess the evidence on image-guided musculoskeletal interventional procedures around the knee, with the goal of highlighting some controversies associated with these procedures, specifically the role of imaging guidance, as well as the efficacy of the medications routinely injected.We report the results of a Delphi-based consensus of 53 experts in musculoskeletal radiology, who reviewed the published literature for evidence on image-guided interventional procedures around the knee to derive a list of pertinent clinical indications.A list of 10 statements about clinical indications of image-guided procedures around the knee was created by a Delphi-based consensus. Only two of them had the highest level of evidence; all of them received 100% consensus.Ultrasonography guidance is strongly recommended for intra-articular and patellar tendinopathy procedures to ensure the precision and efficacy of these treatments. Prospective randomized studies remain warranted to better understand the role of imaging guidance and assess some of the medications used for interventional procedures around the knee.• A list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the knee was produced by an expert panel of the ESSR.• Strong consensus with 100% agreement was obtained for all statements.• Two statements reached the highest level of evidence, allowing us to strongly recommend the use of ultrasonography to guide intra-articular and patellar tendon procedures to ensure higher accuracy and efficacy of these treatments.The online version contains supplementary material available at 10.1007/s00330-021-08258-1. Interventional procedures around the knee are widely utilized to treat different musculoskeletal conditions. Some of these interventions  are often performed without image guidance, particularly by orthopedists. However, image guidance ensures correct needle position for optimal medication delivery, avoiding injuries to adjacent neurovascular bundles –5. CurreInstitutional review board approval was not needed as no patient-specific data were involved. This paper concludes the task carried on by an expert panel of the ESSR which reviewed the evidence of image-guided musculoskeletal interventional procedures in the lower limb. Here, we report the results focusing on tendon, joint, and bursal interventions around the knee. As previously done –12, we uIntra-articular US-guided procedures around the knee joint, such as arthrocentesis and intra-articular injections, are more accurate than palpation-guided procedures, resulting in improved fluid aspiration and injection therapeutic outcome(s).Level of evidence, 1n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, 2.US-guided knee joint injections of corticosteroid-anesthetic give short-to-midterm pain relief and functional improvement in inflammatory arthritis. Although similar outcomes may be observed in osteoarthritis, efficacy is controversial, and alternative analgesic therapies (such as oxygen-ozone) have been proposed, but evidence supporting their use remains limited.A systematic review reported that image-guided and particularly US-guided knee injections are more accurate than palpation-guided procedures . A randoLevel of evidence, 2n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, In a randomized study, US-guided injections of corticosteroid-anesthetic demonstrated pain relief and improved function at 2 and 6 weeks in patients with inflammatory arthritis . In knee3.US-guided HA intra-articular injections are safe and improve pain scores and function in knee osteoarthritis, showing greater efficacy than steroids in the long term.Regarding other US-guided intra-articular analgesic treatments, a randomized controlled study compared oxygen-ozone efficacy with that of corticosteroid at 1 week, 1 month, and 3 months . Both thLevel of evidence, 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, 4.US-guided injections of regenerative medications have been reported to show clinical benefit by relieving pain and enhancing function in patients with knee osteoarthritis but lack randomized controlled trial evidence.Systematic reviews of overlapping meta-analyses found that HA injections are effective in treating knee osteoarthritis with no increased risk of adverse events , with poLevel of evidence, 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Regenerative therapies have emerged as alternative strategies to treat knee osteoarthritis. Among them, blood derivatives such as PRP , autolog5.US-guided procedures around the menisci are promising for short-term pain management, but evidence supporting their use is limited.US-guided injections of other regenerative substances, such as adipose-derived stem cells  and amniLevel of evidence, 4n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, 6.In fat pad–related anterior knee pain syndromes, US-guided corticosteroid-anesthetic injection and fat pad alcohol ablation might be safe and effective in short-term pain reduction, although no randomized studies are available.In patients with knee osteoarthritis and meniscal extrusion , tear, oLevel of evidence, 4n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, 7.US-guided dry needling is effective in improving function and pain in patellar tendinopathy (PT), especially if associated with PRP. Conflicting results about the clinical effectiveness of PRP in PT do not allow supporting the use of this treatment as a first-line approach.Anterior knee pain may be associated with inflammation, hypertrophy, or edema of fat pads resulting in impingement syndromes , 46. US-Level of evidence, 1n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, 8.Other US-guided treatments have been shown to be safe for treating PT . However, no studies compared them; thus clinical superiority of one treatment over another still needs clarification.A meta-analysis on nonsurgical approaches for PT confirmed that dry needling was one of the non-invasive treatments demonstrating clinical improvement . RetrospLevel of evidence, 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, Peritendinous corticosteroid injection for PT has been shown to be more effective than placebo at 3 months. However, it caused reversible short-term skin atrophy in 37% . FurtherUS-guided high-volume injection has shown good short-term results in athletes and nonathletes , 59. US-Hyperosmolar dextrose prolotherapy can be safely used to treat intractable Osgood-Schlatter’s disease and chronic PT in young adolescents and adults. Some evidence suggests greater symptom improvement after prolotherapy than the usual conservative treatment , 62. HowSmall-cohort randomized controlled studies on sclerosing injections on groups of athletes and nonathletes reported improvement in knee function with short-term pain reduction , 65. Mor9.US-guided aspiration, wall fenestration, and corticosteroid injection of Baker’s cysts are safe and effective procedures in relieving pain and reducing cyst volume in patients with Baker’s cysts secondary to internal knee derangement.US-guided HA injection is a safe and feasible treatment for PT pain . US-guidLevel of evidence, 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, 10.US-guided corticosteroid injections are more effective than blind injections to treat pes anserinus bursitis, but the added value of imaging to guide other periarticular injections (excluding patellar tendon and Baker’s cyst) has not been demonstrated.Although Baker’s cyst therapy depends on the primary cause, percutaneous interventions can be safely performed under US guidance –73. In pLevel of evidence, 3n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100%Agree, A prospective randomized cadaveric study has shown that US-guided injections in the pes anserinus bursa are feasible and more accurate than palpation-guided injections . A prospWe found some evidence concerning image-guided procedures around the knee. In all statements, US guidance has been established as pivotal, as accuracy and clinical outcome are generally higher compared to palpation-guided procedures with the highest level of evidence (statement #1). Moreover, US-guided injection of corticosteroid-anesthetic has proven to be effective in the short-to-midterm follow-up for treating inflammatory arthritis with a level of evidence 2 (statement #2). Conversely, despite being seemingly safe and effective in treating osteoarthritis, strong evidence is still lacking for US-guided injections of HA (statement #3) and regenerative medications (statement #4). Furthermore, only small case series are available for US-guided procedures around the menisci and injections and alcohol ablation in knee anterior fat pad–related syndromes, reporting promising results that require to be further confirmed by larger series.Regarding periarticular treatments, PT is the most investigated topic. According to our results, US-guided dry needling is highly effective in PT with a higher level of evidence (statement #7). Notably, although the association of PRP to dry needling seems to improve the outcome, there are still conflicting results concerning the value of PRP alone for PT, leading us to recommend avoiding this treatment as a first-line strategy. Although different safe and effective US-guided treatment options exist, no randomized prospective studies have effectively clarified which one should be preferred as the best choice (statement #8). Last, US-guided treatments of Baker’s cyst (statement #9) and pes anserinus bursitis (statement #10) are both safe and effective, but the level of evidence of these procedures is still too low to strongly recommend these treatments.In summary, ten statements regarding US-guided musculoskeletal interventions around the knee have been provided by a working group of experts from the ESSR. US guidance is strongly recommended for intra-articular and PT procedures to ensure higher accuracy and efficacy. Prospective randomized studies remain warranted, especially for knee procedures with low levels of evidence.Supplementary file1 (DOCX 21 KB)Below is the link to the electronic supplementary material.