Aims and method To evaluate the feasibility of integrating a clinical librarian (CL) within four mental health teams. A CL was attached to three clinical teams and the Trustwide Psychology Research and Clinical Governance Structure for 12 months. Requests for evidence syntheses were recorded. The perceived impact of individual evidence summaries on staff activities was evaluated using a brief online questionnaire.Results Overall, 82 requests for evidence summaries were received: 50% related to evidence for individual patient care, 23% to generic clinical issues and 27% were on management/corporate topics. In the questionnaires 105 participants indicated that the most common impact on their practice was advice given to colleagues (51 respondents), closely followed by the evidence summaries stimulating new ideas for patient care or treatment (50 respondents).Clinical implications The integration of a CL into clinical and corporate teams is feasible and perceived as having an impact on staff activities. A CL may be able to collate ‘personalised evidence’ which may enhance individualised healthcare. In some cases the usual concept of a hierarchy of evidence may not easily apply, with case reports providing guidance which may be more applicable than population-based studies. One study5 reported that 65% of primary  psychiatric in-patient interventions were based on ‘high-level’ evidence. However, another study reported6 that more than 50% of primary care and community patients with depression do not receive adequate antidepressant dosages and less than 10% receive evidence-based psychotherapy. There is also evidence that psychiatry trainees who are aware of research findings that question the relative effectiveness of newer antipsychotics were more likely to prescribe them than those who were unaware of the research.7The challenges of translating research into clinical and managerial practice have long been recognised.3 thus the publication of journal articles alone is unlikely to result in behaviour change.8‘Passive’ knowledge translation (the synthesis and dissemination of research) is generally ineffective,9 and management/service delivery. It has been proposed10 that librarians should be transformed into ‘informationists’, meeting clinicians' need for synthesised evidence, as ‘There is no robust system to identify the information needs of today's psychiatrists in the UK’.11 However, there is one existing report on the potential benefits of embedding evidence in practice in community mental health teams.12 For this reason we evaluated the feasibility of routinely utilising a CL in order to facilitate knowledge exchange in a mental health setting. This intervention aimed to investigate whether evidence summaries produced by a multidisciplinary team integrated CL could meet a perceived need in a mental health trust and to report what enquiries would be raised.Clinical librarians (CLs) have received little attention in knowledge translation. They provide ‘information to... support clinical decision making’Three clinical teams  and the Trustwide Psychology Research and Clinical Governance Structure were recruited as initial pilot sites within Tees, Esk and Wear Valleys NHS Foundation Trust. This is a large trust which provides mental health and learning disability services to a region within north-east England. The CL aimed to embed knowledge of clinical evidence by attending clinical forums/consultations or supervisions/continuing professional development sessions to produce evidence summaries specific to individual patients, wider clinical problems or managerial work streams. To support the Psychology Research Structure, the CL completed literature reviews relating to organisational issues and provided training for psychology research assistants.13 All requests for evidence summaries were recorded by the CL and classified according to the broad category of request . Questions which could be classified as representing one of the four ‘classic’ types of clinical question  were also recorded as such by the CL.The approach used to produce the evidence summaries was the rapid review, which uses systematic review methods to search for and appraise research in a shorter time frame than would be needed to produce a systematic review.www.libraryservices.nhs.uk/forlibrarystaff/impactassessment/impact_toolkit.html). The questionnaire also contained a set of open questions in which participants were asked to assess the likely impact on their practice/patient care of not receiving the information synthesised in the evidence summary; and if possible to cite an example where the evidence summary had either changed previous views or where it had confirmed what they already knew, together with any further comments. The CL adapted two existing evaluation questionnaires to create a purpose-specific instrument, following input from the then library and information services manager. The questionnaire was delivered via Survey Monkey website (www.surveymonkey.com).Individual evidence summaries were evaluated via an online questionnaire. In the questionnaire, participants were first asked for basic details . They were then questioned on their views of the relevance, clarity and quality of evidence summaries via a set of subjective graded response options. Each graded response option question had five relevant levels; for example, for the question about clarity of the evidence summaries, options were from 1 (very unclear) to 5 (very clear). Participants were asked to indicate  whether they would have tried to find the information synthesised in the evidence summary themselves if the pilot CL service had not been available. They were also asked whether the evidence summary mainly confirmed their existing ideas, or whether it stimulated new ideas (or both). An important question asked participants toDuring the 1-year intervention period the CL received 82 requests for evidence summaries, in three broad categories of request. The first category related to the classic evidence-based practice conception of evidence being applied by the individual clinician to the individual patient (50% of summaries); the second to generic issues of concern to the whole multidisciplinary team/clinical service (23% of summaries); the third was for evidence summaries to be completed on management/strategic/corporate topics (27% of summaries).Fifty-seven evidence summary topics broadly represented one of the four ‘classic’ types of clinical question: aetiology (26%), diagnosis (5%), prognosis (9%) or treatment (60%). The most common type of clinical question was for evidence relating to treatments, but the large number of requests relating to other information needs, particularly aetiology, is novel.At the end of the pilot period (September 2012), 105 responses to the online questionnaire had been received .The impact of the evidence summaries cannot be easily quantified because the trajectory from research into practice is not always direct and immediate in a complex field such as mental health. Some evidence summaries may have more subtle or long-term impact; for example, when a consultant psychiatrist was asked whether their views had changed following receipt of an evidence summary on clients with intellectual disabilities being carers for parents, they indicated that, prior to receipt, they would have been ‘more inclined to advocate moves to separate accommodation for people with [intellectual disability] and aged parents’.Nevertheless, some striking examples of demonstrable effects on practice have emerged.Request 1 provides an example where the timely provision of information prevented delays in the initiation of appropriate treatment. In addition to influencing current treatment it can be seen that the evidence summary was also anticipated to have an effect on future treatment.Response from consultant psychiatrist, without receiving the CL evidence summary:‘It is likely [that] the proposed treatment [would either have been delayed] until I had time to complete the review myself or we would have gone ahead without the clinical confidence that the summary has provided.’‘I have never given ECT to someone with schizophrenia so it informed of the evidence in this area. I will now consider it as a potential option for treatment refractory clients in the future, particularly if they have neurological comorbidities.’See This request shows an example of clinical staff encountering an uncommon clinical problem and requiring information to ascertain the effects of the butane gas misuse on a patient's psychiatric presentation.Response from consultant psychiatrist:‘I think this one could be a good example of an “immediate response” to a difficult clinical question... [withdrawal from butane gas misuse] was something we had theorised about but had no knowledge of.’Request 3 shows an example of where a clinician's need for research to inform prescribing practice was clearly personalised and could not solely be met by sources such as the National Institute of Health and Care Excellence (NICE) guidelines, which provide general answers in the form of general guidelines.Response from consultant psychiatrist, without receiving the CL evidence summary:‘I would likely have tried a NICE-recommended medication that was not recommended for this patient's unique presentation.’This question was generated during a team discussion. Team members had previously hypothesised about the possible influence of menstruation on psychiatric presentations. The evidence summary has stimulated the multidisciplinary team to make changes in their clinical care, as the modern matron's response shows.‘The clinical ward team has used the evidence summary to influence care by producing action plans to implement the findings, e.g. ascertaining last menstrual period... on admission and encouraging patients to use a menstrual cycle diary.’Request 5 highlights an instance where an evidence summary informed complex managerial/organisational development issues with implications for a number of areas, including patient safety. A manager's response to the summary shows how the themes from the research literature highlighted by the CL changed previous ideas they had on the topic:‘Feedback is probably more effective when baseline performance is low, the person giving the feedback is a supervisor or colleague, when feedback is given in more than one format, and when it includes explicit targets and an action plan.’14Request 6 is a potent example which clearly demonstrates how research ‘can illuminate psychiatric practice in a more holistic way than purely by applying “scientific” evidence in the practice of “biological” psychiatry’.Responses from a consultant clinical psychologist and occupational therapist show that the topic of boredom among in-patients has clear global importance for mental health services.Consultant clinical psychologist: ‘The “boredom” in acute in-patients literature review has been extremely valuable to a variety of services across the trust including learning disability, forensic and older adult in-patient services. This has allowed these services to evaluate their current ward environments against the evidence and recommendations within the review. In my role as lead consultant clinical psychologist for research and clinical governance I have disseminated this review widely and the response has been extremely positive.’Occupational therapist: ‘This paper offered a thorough understanding of a topic which is identified as a problem at every15Demonstrable influence on the practice of a clinical ward team is also highlighted as the boredom evidence summary has resulted in the following developments in the clinical ward team which received the CL evidence summary:a morning handover between the nursing and intensive support teams making use of the patient's workbook so that intensive support staff are better briefed as to the activities/interventions likely to be most appropriate for the individual patient on that dayintensive support team assessing the uptake of activities and noting when an activity has been offered, but is not taken up, by the patientsince early 2012, multidisciplinary team meetings have been signposted to specific times each day to free up the nursing team for more one-to-one interactions with patients.14 A consultant clinical psychologist likewise perceived the CL role in the context of clinical governance and as integral to supporting research and development and issues core to the business of mental health trusts, commenting:One respondent, a consultant psychiatrist, considered the contribution of the CL within the wider context of Trust responses to clinical governance, commenting: ‘When compared with all the other aspects of clinical governance the [multidisciplinary team] practises, I have no doubt that the addition of the clinical librarian to the team has made the single largest improvement’.‘The clinical librarian role has been an extremely helpful resource in supporting the development of the psychology research and clinical governance framework and incredibly helpful in terms of supporting the national and regional quality and outcomes work relating to the payment by results agenda. I would fully support the continuation of this role and regard it as a critical component of the psychology research and clinical governance framework’.16 The nature of the requests for evidence was also illuminating; the large number of requests relating to information needs other than treatment strategies (e.g. aetiology) is a novel observation. This contrasts with findings from a previous study17 that the number of treatment-related questions outweighed those relating to other clinical areas (e.g. diagnosis). Additionally, a previous systematic review18 highlighted how previous discussions of the CL role have concentrated on clinician decision-making and patient care. However, the diversity of the information requests received in the present project suggests that the role of the CL extends beyond providing clinically oriented evidence summaries.This CL intervention demonstrated that there is perceived value in the local production of ‘evidence summaries’ to address practitioners' information needs. Interest in the CL role spread beyond the pilot areas and requests for summaries were received from Trust senior management and other corporate services. Our findings suggest that a CL can be an effective knowledge broker, facilitating the interaction between producers and users of research.19 Thus, we would speculate, it is senior staff that may most benefit from the role of the CL in this context. The primary reason why the clearest benefits from evidence summaries may be realised by senior staff is likely to be because the summaries were written on ‘foreground’ rather than ‘background’ topics/clinical questions. The distinction between background and foreground clinical questions is clearly elucidated in the literature.21 Background questions tend to be posed by students or trainee clinicians. They are about well-established facts/general knowledge and are usually answerable by textbooks or electronic ‘point of care’ summaries such as Clinical Evidence, DynaMed or UpToDate. In contrast, foreground questions require a synthesis of highly targeted evidence on treatment, diagnosis, prognosis or aetiology. Foreground questions are best answered by the research literature rather than by textbooks because they require current evidence (textbooks may be out of date) and they are often so specific that they will not be covered in general reference works. It is therefore usually more complex and time-consuming to search for an answer to a foreground, than a background, question.Our observation that it was predominantly senior staff who initiated the majority of requests  contrasts with a previous study that reported that the perceived need for evidence is primarily to be found among trainee clinicians.22 this alone is unlikely to influence practice. The present project has provided a suggestion as to how CLs may produce evidence syntheses which meet demonstrable information needs locally and individually. Our experience also challenges the traditional evidence-based practice paradigm. This model suggests provision of training, enabling clinicians to formulate clinical questions, search the literature, and appraise and apply the evidence. Clinicians are likely to benefit from education in literature reviewing, and use of secondary sources may be an especially efficient way of following evidence-based practice.23 Nevertheless, there is evidence to suggest that relying on the ‘knowledge users’ to find and implement research findings is problematic.24 Thus, alternatives such as the production of intermediate evidence syntheses may support both clinicians and managers in becoming competent ‘evidence users’.25 Training of end users must thus increasingly encompass an understanding of the role of CLs as evidence facilitators.26 Our present findings also highlight a potential reason why some evidence-based practice educational interventions have not produced substantive behaviour change.Although it is appropriate that ‘academic institutions and medical professional associations should contribute to collective efforts to summarise medical evidence and build... repositories of knowledge on the Internet’,19 These perceptions coincide with a mistaken view that evidence is synonymous with the RCT and therefore most applicable to ‘biological’ psychiatry.28 The fact that conventional ‘high-level’ evidence was available to illuminate issues relating to boredom  evidence from the highest levels available. Thus, it acknowledges a tension between two dimensions: salience (the extent to which the evidence is specific to the problem of focus) and level (the level in the hierarchy of evidence from which the information is drawn).  are likely to predict treatment response to a greater extent than pharmacogenetic factors (i.e. your hepatic enzyme expression is not relevant if you are not taking the tablets). Thus, we would promote a potential integration between the evidence-based practice paradigm and the personalised medicine paradigm with a widening in scope, taking account of patients' preferences and values – a central component of evidence-based practice.34We would view the concept of personalised evidence as complementing the evolving concept of personalised medicine. To date, the main focus of this movement has been to utilise information on individual differences (notably genetics) to predict response to pharmacological treatment. Such ideas have been applied to mental health to some extent.As well as evidence being personalised to patients' clinical presentations, needs and values, research can also be personalised to the needs of the clinician so that it can have an impact on the patient-clinician dyad. Arguably, clinicians' information needs are inherently ‘personal’ and require a personalised response from a CL. For example, a consultant psychiatrist and mental health nurse may both require evidence to care for the same patient but a CL can select information appropriate to each, even if their questions are expressed in a similar manner. Clinicians' need for personalised evidence not only relates to their professional group but many highly individual factors such as the clinician's level of experience in their role, whether or not they have previously encountered the clinical problem, their current theoretical and practical knowledge and their interest in, and skills and expertise towards, using research evidence. Evidence can therefore be selected and synthesised by a CL so that the research can be personalised to the patient, personalised to the clinician, and consequently personalised to the unique patient-clinician encounter.P<0.05). In contrast, Bayesians view even subjective information  as informative and such approaches have been widely implemented in, for example, business, where often high-stakes decisions must be made under uncertainty.35 Moreover, the Bayesian approach utilises prior knowledge, where available, to increase our confidence in making inferences from newly observed data.36 In theory, this means that lower levels of evidence can be combined with emerging higher levels of evidence to increase our certainty about the probable outcome of a course of action.It should be highlighted that the reliance on ‘lower’ levels of evidence to guide actions does not sit well with methodologists from a frequentist tradition , where the emphasis is on deriving certainty from establishing the unlikelihood of an event occurring through chance alone . Therefore future research should adopt a more robust prospective design, incorporating objective, as well as subjective, metrics of change and ideally also include data relating to patient experience. Future studies should also adopt a clustered (multilevel) design to account for possible differences between teams and services.


Here, we introduce SMs in detail using three recent case studies that demonstrate their utility for research and decision-making.Reviews of evidence are a vital means of summarising growing bodies of research. Systematic reviews (SRs) aim to reduce bias and increase reliability when summarising high priority and controversial topics. Similar to SRs, systematic maps (SMs) were developed in social sciences to reliably catalogue evidence on a specific subject. Rather than providing answers to specific questions of impacts, SMs aim to produce searchable databases of studies, along with detailed descriptive information. These maps  can prove highly useful for research, policy and practice communities, by providing assessments of The online version of this article (doi:10.1007/s13280-016-0773-x) contains supplementary material, which is available to authorized users. Synthesis of published research aims to build upon and go beyond primary studies to provide reliable answers to questions by formally summarising existing literature. Literature reviews are common in most research fields and, with an increasing use of statistical tools such as meta-analysis, these quantitative reviews provide a higher power for testing general predictions. Traditional literature reviews, including meta-analyses, however, are potentially susceptible to a range of possible biases, for example, selection bias, publication bias, and detection bias (Pullin and Stewart Systematic reviews (SRs) were established in the field of medicine in order to synthesise large bodies of primary research studies in a way that minimises bias, allowing for assessments of reliability, consensus and reasons for heterogeneity across the evidence base  (as of September 2015); an indication of the increasing attention paid to systematic mapping by commissioners and researchers alike. Here, we discuss the benefits of systematic mapping to research, policy and practice and provide two examples of recent SMs that demonstrate the high utility of the methods.Whilst SRs are useful in providing estimates of effect sizes associated with specific interventions or exposures, systematic reviewing methods have also been adapted for use in answering questions relating to the state of the evidence base itself. Such questions aim to assess what research has been undertaken, which study settings have been examined and what methods have been used across an evidence base. These methods have been termed ‘systematic maps’ (SMs) , and a CEE Methods Group concerned with SMs has been recently formed .Systematic maps were first developed and used to synthesise social science research  or test a hypothesis, but rather an overview of the evidence base, or more specifically, what research has been undertaken, where and how.Procedurally, SMs and SRs share many similarities Table . The proTranslating systematic mapping and associated SR methodology from the social sciences and medicine, respectively, to environmental sciences requires some careful consideration of the relevant analogous systems that we deal with. However, these considerations are not as challenging as often perceived. For example, the PICO/PECO  model used in SRs and SMs translates well onto environmental subjects: population refers to the specific system investigated, rather than a human population (e.g. farms in boreo-temperate systems); intervention/exposure refers to either a management practice or some other environmental factor (e.g. soil tillage using mouldboard ploughing); comparator refers to the factor with which an intervention/exposure is compared (e.g. before tillage or untilled control group), although SMs may not always require the presence of a comparator; outcome refers to the variable being measured (e.g. soil carbon concentration). Not all review questions have a PICO/PECO structure, of course, but this is not particular to environmental science. There is a mistaken belief that SR methods are only appropriate for randomised control trials (RCTs) and quantitative, experimental research. In fact, SRs and SMs can be used to synthesise any form of research evidence, including observation and qualitative studies  general patterns in study methods and settings, (ii) knowledge gluts, where substantial numbers of studies have investigated a similar subtopic, (iii) knowledge gaps, where there is a significant lack of research on a subtopic, and (iv) deficiencies or best practices in research methodology . The SM database includes a range of descriptive information for all included studies, including: (i) citation information, (ii) study setting descriptors, (iii) methodology details, and (iv) summaries of the nature and location of quantitative or qualitative study findings . The SM database is intended to be a readily usable resource for researchers and decision-makers when looking for evidence, and usability is a main consideration when compiling the SM and building the database.In addition to the report and map database, reviewers may also produce other outputs from the systematic mapping process. In particular, geographical information systems (GISs) allow for information from within the SM database to be displayed across a cartographic map. This approach can be particularly useful for environmental topics that are global or wide scale in nature.Systematic maps have a variety of uses across research, policy and practice. Researchers, research funders and decision-makers can benefit from learning about knowledge gaps, subtopics that are underrepresented in the evidence base. Such gaps may warrant novel primary research in order to provide a future evidence base, particularly where prevailing policy or practice is controversial or perceived to require change. Researchers, research funders and decision-makers can also benefit from highlighted knowledge gluts that allow full synthesis in the form of SR. Furthermore, areas that have received substantial research effort may be deemed by research funders to be sufficiently well understood that research funding could be more effectively directed elsewhere. Researchers and research funders can also benefit from the identification of deficiencies and best practices across the evidence base, which may be used to increase consistency across studies. Environmental managers may also benefit from using the SM database as a library, from which they can identify a subset of studies that are most relevant to their situation. Finally, since SMs published with CEE are Gold Open Access , researchers, practitioners and policy-makers can use the database as a source of detailed descriptive information regarding studies that may not be individually accessible in full text. Practitioners and policy-makers often cite limited accessibility as a barrier to evidence use , other options exist for publication of SMs. However, since SRs and SMs are new methods, publishing them without using the expertise of a coordinating body  can have serious disadvantages. Firstly, no other formal academic publication as yet accepts SM or SR protocols. Secondly, other journals may not have the methodological expertise necessary to identify flaws or missing information within review reports. This is evident in a recent example, a SM on the subject of European agroforestry ecosystem services that was published in the journal Ecological Indicators  . One of the outputs of this SM was a map report, which described the background, methods and results of the mapping exercise, and discussed the range and nature of the evidence base. In addition, a SM database was published, providing details relating to the citation of the article describing the study, the study setting, the experiment studied, the methodology used to measure the experiment soil conditions, and the location, units and format of the quantitative findings of the study. Furthermore, a web-based GIS was produced based on the contents of the map. This GIS allows users to filter subsets of studies on a spatial map , forming a different and user-friendly interface to the database.The SM authors highlighted several knowledge gaps (e.g. a paucity of studies from Russia) and knowledge gluts (e.g. a multitude of studies investigating conservation tillage), and noted a lack of spatial and temporal replication and frequently missing information  within included articles. This information was detailed within the SM report and may prove useful for primary researchers , secondary researchers (knowledge gluts), research funders  and decision-makers  alike. Following on from the SM, the research team behind the review is currently undertaking two full SRs on subsets of the evidence identified in the map. One review will synthesise the findings of studies investigating the relative impacts of different tillage intensities on soil organic carbon. The second review will include all interventions, but will focus purely on studies with long-time series data . These two full reviews will involve an update to the original searches to ensure that recently published evidence is included. Both reviews will also include a full quantitative synthesis . Further knowledge gluts were identified in the SM that may also be synthesised by the review team if resources allow.Conservationists in Sweden and several other countries are currently involved in a discussion of the best means of preserving or restoring forest biodiversity in reserves and other areas that have been set aside from commercial forestry. One management option is non-intervention; other options include various forms of active management such as prescribed burning, thinning, partial harvesting, grazing or exclusion from grazing. Current practices and recommendations for the management of forest set-asides are often based on traditions (i.e. the “free-development” paradigm) rather than scientific evidence, however. Swedish stakeholders  therefore suggested a SR of all available evidence on the biodiversity effects of relevant forms of management in cool temperate and boreal forests.Since the evidence base was likely to be quite heterogeneous, including studies of a variety of interventions and many different aspects of biodiversity, it was recognised from the outset that systematic mapping might be useful as a first step towards full SR of specific management options. The review team searched not only for studies of interventions in actual forest set-asides, but also for appropriate evidence from commercially managed forests, since some practices applied there may equally be useful for conservation or restoration purposes.Around 800 relevant studies were found (16 484 search results > 6142 relevant titles > 1762 relevant abstracts > 798 relevant full texts), almost two-thirds of which had been conducted in North America. Most of the rest had been performed in Central or Northern Europe. These studies were presented much in the same way as those in the SOC SM described above, i.e. in a SM report, an associated database with details of each study, and a separate GIS which made it possible to plot and identify all included studies (or any selection of them) on a cartographic map. The details provided about the studies included descriptive data (meta-data) on locations, study design, forest stands, interventions, types of biodiversity outcomes and focal species.Knowledge gaps identified within the SM included a lack of studies on hydrological interventions (such as restoration of forested wetlands) and traditional silvicultural systems that are presently uncommon (such as coppicing and pollarding). As in the SOC SM, there was also a paucity of useful Russian studies.Based on the availability of relevant studies, the existence or absence of earlier reviews, and needs expressed by stakeholders, the authors of the SM finally identified four subtopics for which it would be feasible to complete full SRs: (1) What are the impacts of thinning, partial harvesting and understorey removal on the diversity of ground vegetation in mature temperate and boreal forest? (2) What are the impacts of temperate and boreal forest stand- and tree-scale interventions on dead wood and saproxylic species? (3) What is the effect of prescribed burning in temperate and boreal forest on biodiversity, beyond tree regeneration, pyrophilous and saproxylic species? and (4) What are the impacts of manipulating the pressure of grazing and browsing by livestock or wild ungulates on the diversity of temperate and boreal forest plants and invertebrates?Agriculture contributes high amounts of nitrogen, phosphorous, sediments, pesticides, and with livestock also potential human pathogens to waterways that all contribute to a decline in water quality . Buffer strips were the most frequently studied of the six interventions, with cover crops and slurry storage also commonly investigated. Very few/no studies had focused on woodland creation, controlled trafficking and subsoiling. In terms of measured outcomes, nitrogen was most frequently studied, followed by phosphorus, sediment, pesticides and bacterial pathogens.The majority of research in this area was found to focus on mitigating nitrogen pollution and on the use of buffer strips and catch crops. Knowledge gaps were therefore found for the remaining four mitigation interventions and outcomes other than nitrogen. Furthermore, the reviewers found relatively few robust studies: few used long-term datasets, measured across seasons, possessed well-matched controls, measured baseline data, or sampled within fields and watercourses. These research quality gaps identify the benefit that would come from adding more reliable research to the evidence base.SMs are becoming increasingly popular in environmental sciences and are likely to be as influential and prevalent as SRs. The outputs of SMs are useful for a range of stakeholders, but most importantly those that might benefit from highlighted knowledge gaps, knowledge gluts and suggested improvements and best practices in research methods. Thus, SMs are not only useful to researchers (primary and secondary) but also funders, policy-makers and practitioners. SRs will almost certainly always be more widely applicable in practice by stakeholders, since they aim to provide summary effect estimates of influential interventions or exposures. However, a strong need for systematic mapping remains, not least as a useful first step in the SR process, particularly where broad concerns are highlighted by commissioners and stakeholders.Supplementary material 1 (PDF 428 kb)Below is the link to the electronic supplementary material.


Despite early predictions and rapid progress in research, the introduction of personal genomics into clinical practice has been slow. Several factors contribute to this translational gap between knowledge and clinical application. The evidence available to support genetic test use is often limited, and implementation of new testing programs can be challenging. In addition, the heterogeneity of genomic risk information points to the need for strategies to select and deliver the information most appropriate for particular clinical needs. Accomplishing these tasks also requires recognition that some expectations for personal genomics are unrealistic, notably expectations concerning the clinical utility of genomic risk assessment for common complex diseases. Efforts are needed to improve the body of evidence addressing clinical outcomes for genomics, apply implementation science to personal genomics, and develop realistic goals for genomic risk assessment. In addition, translational research should emphasize the broader benefits of genomic knowledge, including applications of genomic research that provide clinical benefit outside the context of personal genomic risk. Despite early predictions ,2, genomCYP450 testing to inform use of selective serotonin reuptake inhibitors (SSRIs) for depression found no evidence that testing assisted decisions about drug use or improved patient outcomes [CYP450 genotypes were not clearly correlated with drug levels in people using SSRIs [Many genetic tests have been marketed with scant evidence of clinical value. For example, a guidelines group evaluating outcomes . Furtherng SSRIs . CliniciBRCA mutations began within a few years of gene discovery, based on strong evidence of clinical validity—that is, evidence for a significant association between mutations in the BRCA1 and BRCA2 genes and risk of breast and ovarian cancer [But how much evidence is enough? The few tests that have moved rapidly into clinical practice suggest that evidence requirements vary. For example, clinical testing for n cancer —but withn cancer . The likn cancer .Gene expression profiling of breast tumors  offers aThe issue of adequate evidence is likely to become even more controversial as whole genome approaches are adopted. For example, success in the development of targeted therapies for some tumor mutations has led to increasing use of tumor genome analysis in oncology . Yet tumBRCA testing illustrates. Where the purpose of testing is less clear, or the results difficult to interpret, the evidence requirements are likely to be more stringent, and experts may disagree on the evidence threshold. Expediting genomic translation therefore requires two efforts related to evidence: more clinical research focused on health outcomes, and consensus development concerning acceptable evidence thresholds for different uses of genomic information [These examples indicate that the evidence needed to justify clinical use of a new genetic test varies. For tests that meet a defined clinical need, the evidence requirements are likely to be obvious, and often may not involve RCTs, as ormation . EvidencAlthough lack of evidence explains why some genetic tests are slow to enter clinical practice, it cannot explain the poor uptake of tests for which there is strong evidence of benefit. Documented barriers to appropriate genetic testing include lack of genetics knowledge among point-of-care physicians  and a deA case in point is universal tumor screening for Lynch Syndrome (LS) among patients with colorectal cancer. LS is a condition that confers a high lifetime risk of colorectal cancer and accounts for 2%–4% of colorectal cancers in the US . The EvaImplementation science, which focuses on identifying and overcoming barriers associated with deploying and tailoring new interventions, offers a means to address the gap between testing capability and practice. The Consolidated Framework for Implementation Research (CFIR), developed by health services researchers at the Veterans Administration, can be a particularly useful framework because it provides a model that can inform both the initial implementation approach and the subsequent analysis that identifies the barriers and facilitators of success that can be used to guide improvements . As summPlanning, buy-in, and execution will take different forms for different applications of genomic medicine, but the systematic approaches suggested by the CFIR framework will remain relevant. With the move from programs based on single gene conditions such as LS to genome sequencing approaches, a wide range of implementation challenges will need to be considered, including efficient identification and referral of patients, informed consent procedures, laboratory quality measures, and the scope of secondary findings, unrelated to the clinical problem for which testing was done, to be assessed and delivered. To address these challenges, investments in implementation science will be an important priority for genomics.As efforts to strengthen the evidence base and pursue implementation science are undertaken, there is a concurrent need to define realistic expectations for personal genomics. The health information incorporated in the human genome is complex and heterogeneous; its value varies according to both the nature of the information and the circumstances of the patient. Information about being a carrier for an X-linked or autosomal recessive disease, for example, is primarily of value for people of reproductive age, and only then if they choose to use such information in reproductive decision making. Similarly, cancer risk information may be highly valuable to a young adult but of little interest to an elderly patient with end stage heart disease. This heterogeneity points to a central challenge for genomic medicine: the need to define the genomic information that is useful in a particular clinical context.For example, pharmacogenetic testing can improve the safety of abacavir treatment for HIV-AIDS, and thiopurine treatment for acute lymphoblastic leukemia ,32. In bBRCA testing, suggest a different interpretation: genomic risk assessment identifies the minority of outliers who require a modification in treatment or prevention efforts. These successes of genomic medicine underscore, paradoxically, that one size often does fit most, if not all.Although personal genomics is touted as the means to move from one-size-fits-all to a more individualized approach to health care ,36, thesIn other words, the benefits of genomic risk assessment are important, but have little to do with the health care needs of most people, most of the time. Universal recommendations for vaccinations, Pap testing, and blood pressure evaluation still apply in the era of genomics, and all of us will benefit from well-balanced diets, regular exercise, and avoidance of cigarettes, no matter what genetic predispositions we have. When individual adjustments to care are needed, they most often relate to comorbidities or social circumstances —for examAs a corollary, genomic risk prediction is likely to be least effective in addressing the population health burdens that matter most—those deriving from common complex diseases such as diabetes, heart disease, stroke, and cancer. Genetics contributes to risk for all these conditions. Rare outliers have high risk due to inheritance of highly penetrant mutations such as those causing LS. More commonly, genetics is only a modest contributor to risk.For example, variation at over 40 loci is associated with likelihood of developing type 2 diabetes, but a few lifestyle factors account for the majority of risk –40. A reThe same general observation applies to virtually all other common diseases: although genetic variation contributes to differences in individual risk, lifestyle and other social determinants of health play a dominant role in health outcomes . VariancFurther, identifying risk for common diseases is generally not difficult: a variety of metrics, including weight, blood pressure, and biomarkers such as cholesterol and hemoglobin A1c, are available for this purpose. Assisting people to make behavioral changes to reduce their health risks is more difficult. Yet it has been estimated that hundreds of thousands of premature deaths could be avoided by reducing smoking, improving diet, and increasing activity levels . As a coTo be sure, genomic risk assessment is still of value, and opportunities to improve health outcomes through genomic screening are likely to increase over time. As the LS example illustrates, clinical translation of such discoveries will require both evidence for improved outcomes from screening and systematic efforts to implement screening programs. In addition to single gene conditions like LS, further research may point to ways in which genomic risk profiles can be used to identify outliers with high cumulative risk for complex diseases . As thisIt remains the case that genomic discovery related to the major disease burdens of the population will yield many variants of small effect. For most such findings, there is no translational gap in personalized medicine to overcome, because the information lacks clinical value. Instead, there will be an increasing need for analytic, technical, and clinical strategies that pull from the genome the information that can improve health care, while avoiding the introduction of large amounts of poorly predictive and distracting health information into the medical record.Although most gene variants associated with common complex diseases will be poorly predictive and lack clinical utility for individual health care, they nevertheless represent highly valuable research findings. Every gene causally associated with disease is a marker for a biological pathway, potentially revealing unexpected mechanisms of disease, connections between different pathological processes, and interactions between biological pathways and environmental risk factors. Promising examples are proliferating at a rapid rate. For instance, genome wide association studies (GWAS) have clarified the importance of autophagy in the pathogenesis of autoimmune disease, identified new loci associated with disease, and pointed to shared pathways between inflammatory bowel disease susceptibility and host responses to mycobacterial infection . In age-Genomics is a source of an expanding set of molecular tools for other avenues of health research as well . For exaGenomic research can also improve care by defining the genotypes of other organisms. In a recent widely publicized case, an infectious agent was identified and treated through the use of DNA-based diagnostics , pointinThese examples provide only a glimpse of the potential benefits of genomic health research. However, they offer an important insight about closing the gap between genomic knowledge and clinical care: the task is not solely, or even primarily, one of learning how to use individual genomes in clinical care . A perso


Decision-making based on reliable evidence is more likely to lead to effective and efficient treatments. Evidence-based dentistry was developed, similarly to evidence-based medicine, to help clinicians apply current and valid research findings into their own clinical practice. Interpreting and appraising the literature is fundamental and involves the development of evidence-based dentistry (EBD) skills. Systematic reviews (SRs) of randomized controlled trials (RCTs) are considered to be evidence of the highest level in evaluating the effectiveness of interventions. Furthermore, the assessment of the report of a RCT, as well as a SR, can lead to an estimation of how the study was designed and conducted. We live in the age of information, innovation, and change. The number of published studies in the dental literature increases dramatically every year. Clinicians are required to base their decisions on the best available research evidence by critically appraising and incorporating sound scientific evidence into everyday clinical practice . The cliThe practice of evidence-based dentistry consists in dentists critically applying relevant research findings to the care of patients . The AmePracticing evidence-based dentistry reassures the quality improvement of health-care delivery by incorporating effective practices, while eliminating those that are ineffective or inappropriate . The maiDeveloping a clear, clinically focused questionIdentifying, summarizing, and synthesizing all relevant studies that directly answer the formulated questionAppraising evidence in terms of validity and applicabilityCombining research evidence with clinical expertise and patients characteristicsAssessing the successful implementation of previous stepsThe practice of EBD involves five essential steps ,7,8:DeveSome research designs are more effective than others in their ability to answer specific research questions. Rules of evidence have been established to grade evidence according to its strength, giving rise to the concept of ‘hierarchy of evidence.’ The hierarchy provides a framework for rating evidence and indicates which study types should be given more weight when assessing the same question . At the observational studies, the investigator observes patients at a point in time or over time, without intervening. They may be cross-sectional, providing a snapshot picture of a population at a particular point in time, or longitudinal, following the individuals over a period of time. Observational studies may also be prospective, when the data are collected forward in time from the beginning of the study, or retrospective, in which the information is obtained by going backwards in time .Fig.Fig23].Fsystematic review is a form of research that uses explicit methods to identify comprehensively all studies for a specific focused question, critically appraise them, and synthesize the world literature systematically [It is well recognized that health-care decisions should not be based merely on one or two studies but take into consideration all the scientific research available on a specific topic . Still, atically -28. The atically .Defining an appropriate health-care questionSearching the literatureAssessing the selected studiesSynthesizing the findingsPlacing the findings in contextDeveloping a systematic review requires a number of discrete steps :DefiningCochrane reviews are systematic reviews of primary research in human health care and health policy, undertaken by members of The Cochrane Collaboration [boration  adheringboration . The Cocboration .meta-analysis [Frequently, data from all studies included in a systematic review are pooled quantitatively and reanalyzed; this is called a analysis . This teanalysis . A meta-analysis .Critical appraisal is an essential skill of evidence-based dentistry which involves systematic assessment of research allowing, thus, clinicians to apply valid evidence in an efficient manner. When critically appraising research, there are three main areas that should be assessed: validity, importance, and applicability [For any clinician, the key to assessing the usefulness of a clinical study and interpreting the results to a particular subject is through the process of critical appraisal. cability .internal validity [External validity refers to whether the study is asking an appropriate research question, as well as whether the study results reflect what can be expected in the population of interest  [A study which is sufficiently free from bias is considered to have validity . Common validity . Externaability) .The validity of the trial methodologyClear, appropriate research questionThe clinical question should specify the type of participants, interventions, and outcomes that are of interest .RandomizationAllocation concealmentBlindingIntention-to-treat analysisThe concepts of randomization, allocation concealment, blinding, and ITT analysis were previously explained.Statistical powerstatistical power of a RCT as ‘the ability of the study to detect a difference between the groups when such a difference exists’. The size of the sample must be large enough to raise the trial's possibilities of answering the research question and, thus, enhancing the statistical power of the trial [McAlister et al. define the he trial .During the process of appraising a RCT, readers should evaluate the following:The magnitude and significance of treatment effectMagnitude refers to the size of the treatment effect. The effect size represents the degree to which the two interventions differ. Effect size in RCTs may be reported in various ways including mean difference, risk ratio, odds ratio, risk difference, rate and hazard ratio, and numbers needed to treat [to treat ,41.Statistical significance refers to the likelihood that a relationship is caused by something other than simple random chance. Probability (p) values and confidence intervals (CI) are used to assess statistical significance [Clinical significance refers to the practical meaning of the effect of an intervention to patients and health-care providers [ificance . A statiroviders .Generalizability of trial resultsThe fact that evidence addresses the effectiveness of a treatment does not mean that all patients will necessarily benefit from that. Thus, a clinician should always examine the similarities of the study participants with his own patients together with the proportion between the benefits and adverse events of the therapy .Randomized controlled trials are the standard for testing the efficacy of health-care interventions. The better a RCT is designed and conducted, the more likely it is to provide a true estimate of the effect of an intervention. When reading a RCT article, we should focus on certain issues in order to decide whether the results of the study are reliable and applicable to our patient .The valiRisk of Bias Tool, developed by The Cochrane Collaboration, which is based on a critical evaluation of six different domains [Critical Appraisal Skills Program (CASP), also, aims to help people develop the necessary skills to interpret scientific evidence. CASP has released critical appraisal checklists for different types of research studies that cover three main areas of a study: validity, results, and clinical relevance [Scottish Intercollegiate Guidelines Network (SIGN) has developed a methodology checklist in order to facilitate the assessment of a RCT. This checklist consists of three sections, each covering key topics of a trial [Many tools have been proposed for assessing the quality of studies. Most tools are scales in which various quality elements are scored or checklists in which specific questions are asked . One met domains . The Crielevance . Likewis a trial .To assess a trial accurately, readers need complete and transparent information on its methodology and findings. However, the reporting of RCTs is often incomplete -50 aggraMany clinicians base their assessment of a trial, or even their clinical decisions, on the information reported in the abstract, as they only read, or have access to, the abstracts of journal articles . A well-Did the review have a predetermined protocol?Was the question well formulated?Did the review include appropriate type of studies?Were all relevant studies identified using a comprehensive method?Were the included studies assessed in terms of their validity?Was the data abstracted appropriately from each study?How was the information synthesized and was the synthesis appropriate?Simply naming a review systematic does not imply that it is valid, even though systematic reviews are considered to be evidence of the highest level in the hierarchy of studies evaluating the effectiveness of interventions . ReadersAssessment of Multiple Systematic Reviews (AMSTAR) which consists of an 11-item questionnaire assessing the presence of key methodological issues [A tool commonly used to critically appraise the quality of a systematic review  is the l issues . SIGN hal issues .Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines were designed to promote the reporting quality in reviews of observational studies [Institute of Medicine (IOM) of the National Academies, also, has developed standards for conducting systematic reviews in order to help authors improve the reporting quality of their studies [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement focuses on ways in which authors can ensure the transparent and complete reporting of systematic reviews and meta-analyses. PRISMA consists of a checklist of 27 items indispensable in the reporting of SRs and meta-analyses and a flow diagram illustrating the flow of information through the four different phases of a systematic review [The  studies . The MOO studies . The Ins studies . The Prec review .The main function of an abstract of a systematic review is to signal its systematic methodology. However, despite the development of PRISMA, which gave some guidance for abstracts, the quality of abstracts of systematic reviews, as in RCTs, still remained poor . The PRIHealth-care professionals are urged to inform their clinical decisions with the best relevant evidence. Clinicians, thus, are expected not only to deliver a treatment but to choose the best treatment option based on their patients' needs and preferences while balancing all benefits and harms. However, translating research findings into clinical guidelines can often be challenging. Moreover, users of guidelines need to be confident that they can rely on existing recommendations. Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a system for grading the quality of evidence in order to develop recommendations that are as evidence-based as possible . The GRAClinical decisions guided by valid and reliable research findings are considered to be more focused and effective than others . Evidenc


Even the highest quality evidence will have little impact unless it is incorporated into decision-making for health. It is therefore critical to overcome the many barriers to using evidence in decision-making, including (1) missing the window of opportunity, (2) knowledge gaps and uncertainty, (3) controversy, irrelevant and conflicting evidence, as well as (4) vested interests and conflicts of interest. While this is certainly not a comprehensive list, it covers a number of main themes discussed in the knowledge translation literature on this topic, and better understanding these barriers can help readers of the evidence to be more savvy knowledge users and help researchers overcome challenges to getting their evidence into practice. Thus, the first step in being able to use research evidence for improving population health is ensuring that the evidence is available at the right time and in the right format and language so that knowledge users can take the evidence into consideration alongside a multitude of other factors that also influence decision-making. The sheer volume of scientific publications makes it difficult to find the evidence that can actually help inform decisions for health. Policymakers, especially in low- and middle-income countries, require context-specific evidence to ensure local relevance. Knowledge synthesis and dissemination of policy-relevant local evidence is important, but it is still not enough. There are times when the interpretation of the evidence leads to various controversies and disagreements, which act as barriers to the uptake of evidence. Research evidence can also be influenced and misused for various aims and agendas. It is therefore important to ensure that any new evidence comes from reliable sources and is interpreted in light of the overall body of scientific literature. It is not enough to simply produce evidence, nor even to synthesize and package evidence into a more user-friendly format. Particularly at the policy level, political savvy is also needed to ensure that vested interests do not undermine decisions that can impact the health of individuals and populations. Billions of dollars are spent each year on producing research, but to what extent does all this research actually serve to improve health outcomes? Notwithstanding the value of creating knowledge for its own sake, it is difficult to justify spending limited resources on countless research studies, especially where there is potential for causing harm to research subjects , if this does not contribute to a deeper understanding of the world we live in and how to make it a better place . Even thThere exists a large and growing literature on the barriers to using evidence in decision-making for health. Some of the key themes that are often discussed include (1) missing the window of opportunity – often due to the relatively long time-frame required to generate new evidence and synthesize existing evidence and the relatively short time-frame available for making decisions, (2) knowledge gaps and uncertainty – especially the paucity of contextually-relevant evidence from local studies, (3) controversy, irrelevant and conflicting evidence – which act as smokescreens clouding the picture and making it difficult to decide how best to proceed, as well as (4) vested interests and conflicts of interest – which deliberately manipulate the evidence base to the detriment of the public’s health and wellbeing. These barriers often stem from the complexity inherent to producing knowledge, the disconnect between the worlds of researchers and policymakers, intentional subverting of the evidence for political or economic gain, or a combination of the above.The first step in being able to use research evidence is ensuring that it is available at the right time and in the right format , so thatUp-to-Date, JAMA Evidence and MD Consult, since these are quick and easy to use, as well as being clinically relevant, even if they come at a price. However, patients rarely have access to such tools, or even to information leaflets intended for patients which are not always distributed in practice, and therefore they must rely on what they can recall from the medical visit or else risk the information minefield which is the Internet. While ‘Googling’ for answers is certainly an option, there is a great deal of misleading information on the Internet. At the very least, it is important to use reputable websites and, ideally, sites that adhere to the HONcode principles, which is a code of ethics for quality health and medical information on the Internet  conflict-of-interest leading to more positive conclusions” [However, the tobacco industry is not the only culprit. A great deal has also been written in the medical literature about the pharmaceutical industry introducing bias which could have a favourable impact on medication sales and ultimately increase profits for shareholders. For instance, through “lusions” .Canadian Medical Association Journal [Canada is the only Western democracy to have consistently opposed international efforts to regulate the global trade in asbestos. And the government of Canada has done so with shameful political manipulation of science”. However, Canada is not alone when it comes to benefitting from ‘overlooking’ the evidence when it is inconvenient. Many countries, including Mexico, Indonesia and China, in spite of having ratified the Framework Convention on Tobacco Control, continue to receive so much income from the sale of these products through ‘sin taxes’ and other channels that they have difficulty implementing measures intended to reduce the use of tobacco products within their borders with the aim of improving the health of their own people [Additionally, cash-strapped universities are increasingly looking for alternative routes to fund-raising and attempt to capitalize on the production of intellectual property. Indeed, some universities have even developed venture capital teams to support the roll-out and marketing of scientific discoveries and technological innovations developed on their campuses. Yet, a commitment to open scientific inquiry and the pursuit of financial gains are two goals that can be very difficult to reconcile, often requiring a number of safeguards to be in place . Even be Journal , “Canadan people .a privatized, ‘American-style’ health financing and provision system is neither a feasible nor desirable model for developing countries” [In the past two decades, powerful international trends in market-oriented health-sector reforms have been sweeping around the world… advocated by agencies such as the World Bank to promote privatisation”. Thus, the authors call for an evidence-based approach to health sector reform, rather than promoting mass privatization of healthcare services and charging poor people user fees, which have been shown time and again to have negative impacts on health [suggests that an evidence-based approach to policy may finally be prevailing over an ideologically driven approach” [Even the ways in which health systems are organized and run are not immune to the misappropriation of evidence. Universal access to publicly-funded healthcare is an important determinant of health  and “a puntries” . Nonetheuntries” , “In then health ,35. Intepproach” . Thus, tReaders of the scientific literature should be aware of the ways in which the research evidence can be influenced and misused for various aims and agendas. That is not to say that we should throw out the whole ‘evidence-based’ enterprise, but simply that a healthy dose of scepticism and critical thinking is advisable. It is not enough to simply produce evidence, nor even to synthesize and package evidence into a more user-friendly format. New evidence needs to be critically appraised and considered in light of the larger body of existing scientific literature, both local and international. Particularly at the policy level, political savvy is also needed to ensure that vested interests do not undermine decisions that can impact the health of individuals and populations. Whether it is tobacco companies trying to flood the literature with contradicting evidence or pharmaceutical companies hiding research demonstrating that their products have no effect or lead to harm, these conflicts of interest can lead us to make erroneous conclusions and misinformed decisions. Ultimately, the public pays the price, whether through poor health or misspent money.In response to these challenges, a growing number of organisations, agencies, task forces and even global networks have been developed to synthesize, appraise and disseminate research evidence with the goal of improving health and reducing inequities. These include the Cochrane and Campbell Collaborations , Health Longer Lives/Healthier Lives website is another example that provides statistical data tools that allow people to see how their local area compares to the rest of the country in terms of specific health indicators and provides a route to existing evidence summaries produced by the UK’s National Institute for Health and Clinical Excellence [Many different models are being developed to increase the uptake and use of evidence in practice . These ocellence . Indeed,cellence .While it is important to be aware of the barriers and facilitators when using evidence in decision-making for health, at the end of the day, a decision must be made which takes into account the needs and concerns of the individual patients and local populations involved. In the next article in the series, a model for ensuring more participatory, transparent and evidence-informed decisions will be presented and discussed.


However, there are uncertainties about the best approaches/strategies to assess risk factors associated with oral cancer, effective components of preventive interventions for behaviour change and implementation strategies in primary care dental settings. Thus, in order to contribute to the prevention of oral cancer effectively, dental professionals need to assess patients on the major risk factors  and deliver appropriate prevention, taking into account the patient’s sociodemographic context.Tobacco and alcohol are recognised as the major risk factors for both oral cavity (mouth) and oropharyngeal (throat) cancers, with increasing acceptance of the role of human papillomavirus (HPV) in the aetiology of oropharyngeal cancers. In addition, there is a significant increased risk for oral cancer among lower socioeconomic groups, males and older age groups. There is a growing evidence for the potential role of The study aims to synthesise evidence on the best practice for undertaking an assessment of major behavioural risk factors associated with oral cancer and delivering effective behaviour change preventive interventions  by dental professionals in primary care dental settings.Cochrane Library, Ovid MEDLINE, EMBASE, Web of Science, PsychINFO, PubMed, TRIP and Google Scholar. We will also search websites of professional organisations/agencies and bibliographies/reference lists of selected papers. Quality will be assessed with the AGREE II  instrument for included clinical guidelines and the AMSTAR (A Measurement Tool to Assess Systematic Reviews) and ROBIS instruments for included systematic reviews. The best practice evidence will be assessed via a narrative synthesis of extracted data, considering publication quality.The study involves a systematic review and evidence appraisal. We will search for clinical guidelines and systematic reviews from the following databases: This systematic review will synthesise evidence on the best practice for oral cancer risk factor assessment and prevention and evaluate the relationship between available clinical guidelines and the review evidence base. This collation of evidence will be useful for making recommendations for future intervention, research and guideline development.CRD42015025289PROSPERO The online version of this article (doi:10.1186/s13643-015-0169-1) contains supplementary material, which is available to authorized users. The term oral cancer broadly includes oral cavity (mouth) and oropharyngeal (throat) cancers, and consensus on the definition is emerging . Based oThe World Cancer Report 2014 has oral cavity and oropharyngeal cancers combined as the seventh most commonly occurring cancer, and in terms of mortality, they rank 9th in the world . In 2012Oral cancer survival is linked to stage at diagnosis , and theOral cancer aetiology is multifactorial and the major risk factors can be categorised as modifiable  and non-modifiable (sociodemographic)  and especially HPV16 which is sexually transmitted , 18. An In addition to behavioural risk factors, the major non-modifiable risk factors include socioeconomic status, age and gender , 19. Accprimary care professionals and outlines the cost-effectiveness of these interventions, especially when combined with referral to specialist cessation services [Following the identification of risk, preventive interventions available to dental professionals include advice, behavioural counselling, adjusted patient recall intervals and/or signposting/referral to preventive services. The main current focus of preventive strategies is the delivery of a ‘brief intervention’ , which is defined as 5-15 min of motivational and/or supportive discussion akin to basic counselling . For exaservices , 24. Howservices .Given the growing acceptance of the role of HPV in the aetiology (and HPV testing in the management) of oropharyngeal cancers, the implications for patient/social history taking in oral health assessment and for patient counselling needs to be considered . For exaThe behavioural risk factors implicated in oral cancer risk are also associated with a wide range of diseases ; hence tobacco, alcohol and socioeconomic status in particular are known as common risk factors . The assmultiple risk factors in individuals, i.e. clustering of unhealthy behaviours and socioeconomic factors. Research has shown that risk factors  occur in combinations and show multiplicative interactions and are strongly associated with poorer socioeconomic environments [Consideration also needs to be given to focusing on the presence of ronments . This isronments .Communicating risks associated with oral cancer is a key challenge for dental professionals and can help in changing behaviour and/or improving patient decision-making . One of There is a plethora of guidance and recommendations available for dental professionals regarding the causes of oral cancer worldwide , 33 and This established a clear need to more clearly present details of evidence-based approaches for risk factor assessment and prevention for dental professionals for effective behaviour change to benefit those at the highest risk of oral cavity and oropharyngeal cancer . Thus, this systematic review involves identifying and appraising evidence for the best practice in oral cancer risk assessment and the delivering of preventive interventions for effective behaviour change. It does not cover screening and oral examination (e.g. for early detection).The study aims to synthesise evidence on the best practice for undertaking an assessment of major behavioural risk factors associated with oral cancer and delivering effective behaviour change preventive interventions  by dental professionals in primary care dental settings.What methods for assessing major behavioural risk factors associated with oral cancer delivered by dental professionals on patients visiting primary care dental settings are considered the best practice and what are recommendations for associated preventive interventions, including advice, counselling, patient recall and signposting/referral to preventive services?What methods for delivering preventive interventions for major behavioural risk factors associated with oral cancer by dental professionals on patients visiting primary care dental settings are considered the best practice for effective behaviour change?Specific research questions for this systematic review in accordance with the PICOS  format are , 38 the Dental professionals here includes dentists, dental therapists, dental hygienists, dental nurses and oral health educators in primary care dental settings . Identifying the best practice means appraising approaches/strategies that are best supported in terms of evidence for their effectiveness and efficiency .This systematic review is registered with PROSPERO (registration number CRD42015025289). The PRISMA-P 2015 statement for systematic review protocols has been consulted for writing this protocol , 38. TheClinical guidelines (published/e-learning) and systematic reviews or meta-analyses (of randomised and non-randomised studies) available worldwide will be included in this systematic review. The included clinical guidelines, recognised by a national governmental or provider organisation, will comprise recommendations or the best practice related to risk factors associated with oral cancer, history taking, patient recall and delivery of preventive interventions in the primary care  setting. The included systematic reviews will contain evidence for the effectiveness of interventions for addressing risk factors associated with oral cancer and/or for preventive interventions (delivered in the primary care setting).We will not apply any language restrictions for identifying clinical guidelines and systematic reviews. The non-English papers will be translated to English with the help of the University Translation Services department. Clinical guidelines will be limited to the last 10 years. There will be no date restrictions for systematic reviews. Narrative/literature reviews and systematic review protocols will be excluded.Study participants/target groups include patients or subjects of any age attending primary care who are at risk of developing oral cavity or oropharyngeal cancers, i.e. tobacco users, alcohol drinkers and those at risk of developing HPV .The review covers interventions by primary care professionals to assess risk and/or promote behaviour change. Interventions could include advice, brief interventions, behavioural counselling, patient recall and referral to preventive services or any combination of these. We will exclude screening interventions for the detection of oral cancer .The best practice in oral cancer risk factor assessment (e.g. how best to ask about behaviour/assess risk/communicate risk)The best practice in preventive interventions:Description of evidence-based preventive interventions Evidence for effectiveness of interventions, i.e. changes in behaviours Role of specific aspects such as combination interventions (addressing multiple risks)The main outcomes of interest will be the following:The study includes primary care  settings; secondary or tertiary care are not included in this study.Cochrane Library, Ovid MEDLINE, EMBASE, Web of Science, PsychINFO, PubMed, TRIP and Google Scholar. An internet search of the websites of health boards and relevant  organisations/agencies will also be carried out. A list of organisations/databases for searching clinical guidelines has been provided in Additional file The literature search for clinical guidelines and systematic reviews will be carried out in health and psychological electronic databases: The University Librarian (HW-A) has helped develop the search strategy for identifying clinical guidelines and systematic reviews. The initial search terms were identified from a scoping of literature and from MeSH subject headings. In order to find all relevant data, the initial search terms included are broad, drawing from across primary care . Evidence will only be restricted to dental practice setting if sufficient quality and quantity can be identified. Key terms are prevention ; primary care  and risk factors . Various truncation symbols  and Boolean operators  will be used to refine the search. We decided not to limit the search to oral cancer, because of not wanting to rule out good guidelines and/or evidence on how to assess risk and deliver oral cancer prevention that can be extrapolated from guidelines and/or reviews aimed at another clinical condition  .Ovid MEDLINE and EMBASE, the SIGN search filter will be used; whereas to retrieve clinical guidelines in Ovid MEDLINE, the University of Texas School of Public Health search filter will be used [Cochrane Library, PsychINFO, PubMed and TRIP. In the Web of Science database, the search will be limited to ‘Reviews’ (including literature reviews and systematic reviews), as there is no filter for systematic review only. Using search filters will help in reducing the number of articles to be screened whilst identifying higher quality evidence and maximising specificity [The InterTASC Information Specialists’ Sub-Group (ISSG) search filter resource provides easy access to published and unpublished search filters designed to retrieve records by study design or focus . Thus, i be used . The seacificity .Ovid MEDLINE search strategy is provided in Additional file MEDLINE search strategy will be finalised first and then it will be adapted for other databases. The SIGN search filters and the University of Texas School of Public Health search filters have been provided in Additional file An example of the In accordance with the Cochrane review group guideline, all steps in data management  will be carried out independently by at least two members of the multidisciplinary review team and discrepancies discussed with the wider team . If, aftEndNote bibliographic software and duplicate records will be removed. Two investigators will independently review the title and abstract of all records against the inclusion/exclusion criteria to select for full text review. Disputed papers will be included at this stage. Full text copies of selected clinical guidelines and systematic reviews will be obtained and used to assess the eligibility of the records to be included in the final systematic review. Reasons for exclusion will be recorded and reported. Where more than one eligible clinical guideline or systematic review of the same research data exists, we will include the most recent publication.Records from all searches will be combined, imported into To summarise, a PRISMA four-phase flow diagram will be completed at the end of the study selection process. The next steps will be to extract data from the clinical guideline and systematic review strands for separate synthesis and systematic quality assessment/risk of bias exercises and finally to compare and contrast to give an overview across the two streams.Cochrane Collaboration [Centre for Reviews and Dissemination (CRD) at the University of York [The data extraction template will be adapted from the boration  and the  of York  data extDetails of information to be extracted from reviews and guidelines, respectively, are provided in Additional file Quality assessment of the included clinical guidelines will be carried out using the AGREE II  instrument. This consists of 23 key items in six domains and will be used to assess the methodological rigour and transparency in the development of the included clinical guidelines . Each doIn order to assess the methodological quality of included systematic reviews, the AMSTAR (A Measurement Tool to Assess Systematic Reviews) instrument will be used . The AMSWe will first keep the clinical guidelines and systematic reviews as separate ‘streams’, and each will be synthesised rigorously according to guidance on conducting systematic reviews . BecauseThe main steps in synthesis will be extraction and organisation of data, analysis between and within risk factors and professional groups and assessing robustness of evidence and recommendations , 52, 53.Tables including a full description of included studies  will be presented to summarise the evidence. This will be followed by a narrative description of the study characteristics presented in the tables, considering the methodological biases and other problems affecting the interpretation of study outcomes. Heterogeneity or sources of variability among study populations, settings, or outcomes will be explored as an integral part of data synthesis, but as this work is not meta-analytic, we will use the narrative synthesis to address the applicability of findings across, for example, professional groups and/or patient behaviours. A list of excluded studies will also be presented with the reasons for exclusion.We will follow the general framework for conducting narrative synthesis developed by Popay et al. i.e. Economic and Social Research Council (ESRC) Methods Programme , CRD 4848 and PeAfter this within-stream synthesis, we then want to ask specific questions about whether evidence from reviews is reflected in current guidance or whether collated guidance shows areas where better evidence is required. Whilst our appraisal and extraction methods follow validated protocols, the ‘higher level’ synthesis of these two streams in this way is innovative, and we believe will be a good contribution to knowledge. We will establish the best evidence for risk assessment and/or preventive interventions and then examine carefully the link between this review evidence and clinical guidelines. This will allow us to make recommendations where (a) gaps in guidance are identified or (b) guidance shows areas where more evidence is required.This systematic review will identify the best practice for oral cancer risk factor assessment and preventive interventions for dental professionals in primary care dental settings. This study will consider preventive interventions around common behavioural risk factors , recognising the role of sociodemographic factors. The collation of this evidence will help to identify gaps in the available clinical guidelines and the evidence base and gaps in evidence overall. The study will form the basis for informing the profession in this important field, by helping design future interventions, research and guidelines where necessary.This study is novel in synthesising evidence from both clinical guidelines and systematic reviews. After conventional synthesis of each stream, we will develop methods for evidence synthesis across these information sources. Another strength of this study is that the systematic search is not limited to oral cancer, thus we do not rule out good guidelines and/or evidence on how to assess risk and deliver prevention for these risk factors that may be aimed at another clinical condition  . Whilst Findings will be reported using the PRISMA statement for reporting of systematic reviews and meta-analyses . The fin


To develop a synthesis within a Bayesian probability framework of previously established evidence, in order to derive an overall conclusion about the hypothesis (H1): ‘High-viscosity glass-ionomer cements (HVGIC) are inferior to silver amalgam as (load bearing) restorative materials for permanent posterior teeth’.Following Bayesian method, the prior Odds that H1 is true , the Likelihood Ratio incorporating new evidence , as well as the posterior hypothesis Odds in view of the new evidence, were calculated.The prior Odds that HVGICs are clinically inferior to amalgam as restorative materials in posterior permanent teeth in relation to the hypothesis that this is not so was 1.12 to 1. The Likelihood Ratio based on new evidence in favor the hypothesis was zero and the subsequent posterior Odds 0 to 1. Therefore, based on the new evidence, the Odds that HVGICs are clinically inferior to amalgam as restorative materials in posterior permanent teeth degreased from 1.12 to zero.The current evidence suggests lack of support for the hypothesis that high-viscosity glass-ionomer cements are inferior to silver amalgam as restorative materials for permanent posterior teeth. Should future research to this topic uphold the current findings, a wider range of clinical benefits for both patient and care provider, beyond appropriate restoration longevity for placing HVGIC based restorations may apply.The online version of this article (doi:10.1186/s12903-015-0108-5) contains supplementary material, which is available to authorized users. The term ‘high-viscosity’ or ‘high-viscous glass-ionomer cement’ (HVGIC) has emerged within the scientific dental literature and is related in clinical studies specifically to the products Fuji IX  or Ketac Molar  . A definGlass ionomers, such as HVGICs, are reported to adhere primarily via calcium bonds to the mineral content of teeth  and thusDuring a systematic review of clinical controlled trials, the survival rate of HVGIC restorations, placed using the atraumatic restorative treatment approach, in permanent posterior teeth in comparison to conventionally placed silver amalgam has been established . This syThe systematic review findings are in disagreement with results from one comprehensive, non-systematic literature review by Manhart et al. . The conAgainst this background, an empirical meta-epidemiological study was conducted in order to investigate whether trends and performance differences between conventional amalgam and direct HVGIC restorations in posterior teeth can be correctly inferred through naïve-indirect comparison of failure rates from uncontrolled longitudinal clinical studies . Based oIn addition to uncontrolled longitudinal clinical studies, laboratory trial results are sometimes used as basis for clinical inference and recommendations for daily dental practice. Based on laboratory evidence, glass-ionomers are traditionally considered as unsuitable for clinical use as a permanent filling material in the posterior dentition due to in-vitro measured poor mechanical properties , 13. SpeA meta-epidemiological study was conducted in order to test the null-hypotheses whether the results from laboratory trials concerning HVGICs versus amalgam indicate similar effect direction and magnitude as results from clinical controlled trials concerning HVGICs versus amalgam restorations placed in permanent posterior teeth . The resAfter the conduct and reporting of systematic review , 9 and m(i)H1: HVGICs are clinically inferior to amalgam as restorative materials in posterior permanent teeth;(ii)H2: HVGICs are clinically not inferior to amalgam as restorative materials in posterior permanent teeth.Two hypotheses were generated:Following Bayesian method, the prior Odds of hypothesis H1 (relative to H2) based on previous evidence, the Likelihood Ratio incorporating new evidence, as well as the posterior Odds of hypothesis H1 (relative to H2) in view of the new evidence, were calculated.Pre) was calculated from the ratio of the probability that H1 is correct, P(H1), to the probability that H2 is correct, P(H2), i.e.: OddsPre = P(H1)/P(H2); with P(H2) = 1 – P(H1). All probabilities were calculated as the ratio of the number of hypothesis supporting events (n) to the total number of evaluated events (N) based on previous evidence from naïve-indirect-indirect comparison of results from clinical uncontrolled longitudinal trials and from laboratory trials.The prior Odds (Oddsn(E|H1)/Pn(E|H2) × Pn+1(E|H1)/Pn+1(E|H2). The new evidence (E) was established from empirical study results (labelled as ‘Evidence 1’) /(P2 – P1)2} x ƒ, with:1 = P2 + 10 %PControl group event rate = n/Nƒ = ƒ = 7.9 NThe assumption of 10-percentage point difference in the failure rate was chosen in line with the work by Taifour et al.  concerniy Pocock :NP = { AND "Dental Restoration, Permanent"[Mesh] for longitudinal studies investigating amalgam. The search period was limited to publications from 2002/01/01 to 2012/09/25. Trial inclusion criteria were: (i) Prospective clinical one-arm study  or quasi-one-arm study ; (ii) Minimum 12-month follow-up period; (iii) Investigated cavity type Class I or II in permanent posterior teeth (Tunnel restorations not included); (iv) Publication language: English; (v) Study outcome: restoration failure [Events observed from non-clinical, laboratory investigations originated from trials that established the material characteristics of HVGICs with silver amalgam as control. The trials were identified on basis of a systematic literature search , comprising a search of the databases: CENTRAL accessed via Cochrane Library; MEDLINE accessed via PubMed; Biomed Central; Database of Open Access Journals (DOAJ); IndMed; OpenSIGLE and Google Scholar. Trial inclusion criteria were: (i) Articles published in English; (ii) Full reports of prospective clinical controlled  and laboratory trials ; (iii) Head-to-head comparison of high-viscosity glass-ionomers (HVGIC) versus amalgam; (iv) Longest follow-up period reported per trial; (v) Relevance to tooth restorations in posterior teeth of the permanent dentition; (vi) Computable data reported . FurtherH1) and events whose 95 % Confidence intervals indicated no statistically significant difference between HVGICs and amalgam, as well as events that indicated a statistically significant higher effect size in favour of HVGIC were considered as evidence in support of hypothesis H2 (nH2). All events are presented in Additional file (2)H1/N and P(H2) = nH2/N [PH1) = n = nH1/N  = nH2/N (3)Pre = P(H1)/P(H2)OddsEvents with 95 % Confidence intervals that indicated a statistically significant higher effect size in favour of amalgam were considered as evidence in support of hypothesis H1  and events whose 95 % Confidence intervals indicated no statistically significant difference between HVGICs and amalgam or indicated a statistically significant higher effect size in favour of HVGIC were considered as evidence in support of hypothesis H2 (nH2). The Likelihood Ratio of strength of evidence in support of hypothesis H1 relative to hypothesis H2 was calculated using the following steps:(4)1(E1|H1) =  assumed to be 0.50P(5)2(E2|H1) = nH1/N2and P2(E2|H2) = nH2/N2P(6)1(E1|H1)/P1(E1|H2) × P2(E2|H1)/P2(E2|H2)LR = PA total of three events related to restorations placed in posterior permanent teeth  that HVGICs are clinically inferior to amalgam as restorative materials in posterior permanent teeth (H1) in relation to the hypothesis that this is not so (H2) was 1.12  lead to the posterior Odds (OddsPost) that hypothesis H1 is true (relative to H2) to be zero. Therefore, based on the new evidence [Multiplication of the Likelihood Ratio (LR) with the prior Odds , which is used for calculation of the final analysis result (OddsPost = OddsPre × LR). Within the context of this study, no subjective assumptions were utilized, thus the objection to the use of Bayesian analysis in this study does not apply. Instead of subjective assumptions, prior probabilities were established from evidence that was identified through systematic literature search [The main objection to Bayesian analysis is that prior probabilities of hypotheses, i.e. before consideration of any evidence, were traditionally established from pure subjective assumptions . Such ase search , 10. TheIn addition, the results are further limited by the internal validity of all clinical trials that were included in the meta-epidemiological studies , 10 and p = 0.011) than that of results published in English [The language restriction was justified on basis that treatment effect estimates from non-English studies are shown to be 16 % more beneficial /Pn(H2) x Pn+1(H1)/Pn+1(H2), from different evidence sources is based on the assumption that these sources are independent from each other. Evidence 1 [1(E1|H1) / P1(E1|H1) x P2(E2|H1) / P2(E2|H1) as 1.00, thus did not affect mathematically the calculation of the Likelihood Ratio  xidence 1  may not idence 1 , 9, as tidence 1 . HoweverPre - value but in turn will also have increased the validity of the prior Odds, as it may have reduced the level of bias risk and subjectivity that these types of study methods carry.Neither the results from possible naïve-indirect comparisons of uncontrolled laboratory trials nor the results from case reports or conclusions from non-systematic literature reviews  were included in the Bayesian analysis. This may have reduced the Odds2(E2|H1)/ P2(E2|H2) quotient is derived by division of zero, thus rendering all subsequent multiplications with that quotient zero, as well.The Bayesian analysis results suggest that the posterior Odds for the hypothesis that HVGICs are inferior to silver amalgam as restorative materials for permanent posterior teeth are zero H1). Such results remain subject to revision on basis of future evidence that may or may not corroborate the current evidence. However, the current results from new evidence (E), identified through several systematic literature searches . Such re–10 and uIf HVGIC restorations placed in permanent posterior teeth exhibit indeed no inferior clinical efficacy than silver amalgam (as still current gold standard for posterior tooth restorations) then their use as valid restorative treatment option may be justified. Such treatment option may have additional clinical benefit, besides its apparent lack of any higher restoration failure rates –9: It haAgainst the background of such potential benefits and the Minamata Convention on Mercury’s call for a phase-down approach to dental amalgam , HVGICs While the current evidence suggests lack of support for the hypothesis that high-viscosity glass-ionomer cements are inferior to silver amalgam as restorative materials for permanent posterior teeth, further studies are needed. Should further research uphold the current findings, a wider range of clinical benefits for both patient and care provider, beyond appropriate restoration longevity for placing HVGIC based restorations may apply.


A decade after physicians (including psychiatrists) endorsed the shift toward evidence-based medicine, the world's largest association of psychologists, the American Psychological Association (APA), belatedly but officially embraced the tenets of evidence-based practice (EBP) [American Psychological Association (APA), Why does EBP matter for the ethical practice of psychological treatments? Evidence carries ethical imperatives. Both the decision about what is considered to be beneficial in psychotherapy, and the current paucity of research regarding the potential negative effects of psychological treatments, carry ethical implications. We argue that the failure to pay attention to psychotherapy research effectively risks undermining key requisites included in professional codes of practice for clinical psychology, psychiatry, social work, and allied fields. First, EBP bears repercussions for the clinician's duty of professional competence, or what O'Donohue and Henderson  have colEvidence shows that there are divergent views about the importance, and feasibility, of informed consent among practicing psychotherapists , The duty to be professionally competent carries significant additional implications for the duty to respect patient autonomy. Historically, paternalism was the largely unquestioned bedrock of healthcare practice. Paternalism is defined as “the interference of a state or an individual by another person, against their will, and defended or motivated by the claim that the person interfered with will be better off or protected from harm” Dworkin, ; it was Evidence suggests that psychotherapists may be routinely failing to provide adequate informed consent to patients  have a right to know that exposure and response prevention is the best-supported intervention for their condition—and hence a first-line treatment  somehow carries a different moral valence for psychotherapy than for biomedical treatments. Legally and morally, licensed clinical and counseling psychologists, psychiatrists, and other psychotherapists are duty-bound to eschew healthcare paternalism. Patients deserve to be fully informed if they are to make autonomous choices regarding psychological treatment modalities. Psychotherapy must incorporate best evidence into training and practice if it is to establish and maintain high ethical standards of care. The discussion about how best to accomplish this crucial goal must now begin in earnest.CB devised and structured the paper. CB, SL and JK jointly co-authored the content.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer LF and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.