Privacy literacy is recognized as a crucial skill for safeguarding personal privacy online. However, self-assessed privacy literacy often diverges from actual literacy, revealing the presence of cognitive biases. The protection motivation theory (PMT) is widely used to explain privacy protection behavior, positing that whether individuals take defensive measures depends on their cognitive evaluation of threats and coping capabilities. However, the role of cognitive biases in this process has been understudied in previous research. This study focuses on Chinese digital natives and examines the differential impacts of subjective and objective privacy literacy on privacy protection behavior, as well as the role of cognitive biases in privacy decision-making. The results show that there is no significant correlation between subjective and objective privacy literacy, and a bias exists. When privacy concern is used as a mediating variable, there are significant differences in the paths through which subjective and objective privacy literacy influence privacy protection behavior. Furthermore, privacy literacy overconfidence moderates the relationship between privacy concern and privacy protection behavior. The findings confirm the influence of cognitive biases in privacy behavior decision-making and extend the PMT. This study also calls for the government to enhance privacy literacy training for digital natives to improve their privacy protection capabilities. It is cWe are highly interested in investigating whether there is a discrepancy between the self-assessed (subjective) privacy literacy and the actual (objective) privacy literacy of digital natives, and whether this cognitive bias would impact their privacy decision-making behavior. Specifically, our research question is as follows:Q1: Are digital natives overconfident in their privacy literacy? What is the relationship between subjective privacy literacy and objective privacy literacy?Q2: Can both subjective privacy literacy and objective privacy literacy promote privacy protection behavior? What are the differences in their impact?Q3: Does overconfidence affect privacy behavior decision-making?To answer the above questions, we conducted a survey among digital natives in China, collected data, and conducted analysis. The remaining sections of this paper are structured as follows: the next section provides a literature review, and the theoretical assumptions and research model are also presented in this section; the third section presents the research design, including data collection and measurement of variables; followed by the analysis of research results; finally, the conclusion and discussion are presented, along with the limitations of this study and future research directions.2.2.1.Initially, privacy literacy was commonly investigated as a cognitive ability by scholars. For instance, It is worth noting that H1: There is no significant correlation between subjective privacy literacy and objective privacy literacy.2.2.Privacy protection behavior can be defined as “computer-based actions taken by consumers to ensure information security” . IndividRegarding objective privacy literacy, studies have demonstrated that users with higher levels of privacy literacy knowledge are more likely to engage in information control compared to those with lower levels of knowledge . In the H2a: Subjective privacy literacy is positively correlated with privacy protection behavior.H2b: Objective privacy literacy is positively correlated with privacy protection behavior.2.3.Privacy concern is recognized as a significant factor in explaining online privacy behavior , and theH3a: Subjective privacy literacy is positively correlated with privacy concern.H3b: Objective privacy literacy is positively correlated with privacy concern.Previous research has established the significant impact of privacy concerns on privacy protective behaviors. For instance, H4: Privacy concerns are positively correlated with privacy protection behaviors.H5a: Privacy concerns mediate the relationship between subjective privacy literacy and privacy protection behaviors.H5b: Privacy concerns mediate the relationship between objective privacy literacy and privacy protection behaviors.2.4.Overconfidence is one of the most prominent biases in human decision-making . OverconH6a(b): Overconfidence negatively moderates the relationship between subjective (objective) privacy literacy and privacy concern.H7a(b): Overconfidence negatively moderates the relationship between subjective (objective) privacy literacy and privacy protection behavior.H8: Overconfidence negatively moderates the relationship between privacy concern and privacy protection behavior.Based on the above analysis, the research framework of this study is shown in 3.3.1.The study’s target population comprises digital natives, who are individuals that have grown up in the digital world and are proficient in using information and communication technologies . In Chin3.2.3.2.1.The SPL scale was adapted from three items by 3.2.2.The OPL scale consisted of 10 True/False/Do not know items , adapted3.2.3.The PC scale was adapted from 3.2.4.Drawing on the approach of 4.4.1.N = 21) scoring 0 on OPL, indicating that they did not answer any privacy knowledge questions correctly. Only 0.996% (N = 4) obtained a score of 10, indicating perfect accuracy in privacy knowledge. 18.70% of respondents (N = 75) scored 5, accurately answering half of the questions. To answer Q1, following the approach of N = 372) of respondents calibrated their privacy literacy incorrectly. Among them, 53.1% (N = 213) had calibration scores below zero, 39.7% (N = 159) had calibration scores above zero, and 7.2% (N = 29) had a complete calibration of privacy literacy. These results indicate that errors in privacy literacy calibration are evident. Overall, respondents tend to lack confidence in their privacy literacy, but the situation is not dire. Descriptive statistics of SPL indicate that respondents perceive their knowledge of online privacy to be neutral . Among the respondents, 35.9% have a lower SPL score (SPL score less than 3), 30.4% have a higher SPL score (SPL score greater than 3), and 33.7% have an SPL score of 3. These results suggest that the SPL is not high for the sample. Descriptive statistics of OPL show that the average score is M = 5.39 (SD = 2.304), with 5.24% of respondents , indicating a general sense of worry about privacy issues. Privacy protection behavior  shows a moderate level, but compared to privacy concern, it exhibits higher variability, suggesting significant differences in privacy protection behavior among respondents.4.2.Based on the calculations using AMOS, the fit indices of the structural model in this study are as follows: (CMIN/DF) = 1.084, GFI = 0.989, NFI = 0.989, IFI = 0.999, CFI = 0.999, RMSEA = 0.014. All the indices are within reasonable range, as they are much higher than the traditional threshold values suggested by 4.3.H1: B = 0.009, SE = 0.071, p > 0.05), indicating that there is no relationship between subjective privacy literacy and objective privacy literacy, thus supporting hypothesis H1. There is no significant correlation between subjective privacy literacy and privacy concerns , indicating that hypothesis H3a is not supported. There is a positive correlation between objective privacy literacy and privacy concerns , indicating that objective privacy literacy has a positive impact on privacy concerns, thus supporting hypothesis H3b. Privacy concerns are positively correlated with privacy protective behaviors , indicating that privacy concerns can predict privacy protective behaviors, thus supporting hypothesis H4. Subjective privacy literacy is positively correlated with privacy protective behaviors , indicating that subjective privacy literacy can directly influence privacy protective behaviors, thus supporting hypothesis H2a. However, there is no significant correlation between objective privacy literacy and privacy protective behaviors , indicating that hypothesis H2b is not supported. This suggests that objective privacy literacy may not directly influence privacy protective behaviors when privacy concerns are considered, and there may be an intermediate path that needs further analysis.The results of the path analysis of the SEM model constructed based on the theoretical framework were used to test the hypotheses. The results from 4.4.H5a. In contrast, the total effect and indirect effect of the second mediation path do not include 0 in the 95% CI, but the direct effect includes 0, indicating that the total effect and indirect effect are significant, but the direct effect is not significant. This suggests that privacy concerns mediate the relationship between objective privacy literacy and privacy protective behaviors, thus supporting hypothesis H5b.Bootstrap method was used in this study to test the mediation effect of privacy concerns. As bias-corrected percentile bootstrap method is superior to percentile bootstrap method , only th4.5.p < 0.05), indicating that overconfidence indeed played a moderating role. Furthermore, H6a(b) and H7a(b) are not supported, while H8 is supported.Based on the calibration variable of privacy literacy, samples with a calibration value of privacy literacy greater than 0 were defined as the “overconfidence” group, and samples with a corresponding calibration variable value less than 0 were defined as the “non-overconfidence” group. Then, multi-group analysis was conducted using Amos. The results showed that the unconstrained model and the constrained model were significantly different  their privacy literacy. Notably, this proportion was higher than the value reported in The findings of this study highlight that objective privacy literacy has a positive influence on privacy concerns, which differs from the results reported by Is there a distinction in the impact of subjective privacy literacy and objective privacy literacy on privacy protection behavior? The results of this research indicate that subjective privacy literacy can directly impact privacy protection behavior, but it does not exert an indirect impact through privacy concerns. On the other hand, when privacy concerns are taken into consideration, objective privacy literacy does not directly impact privacy protection behavior, but instead exerts influence through privacy concerns. One possible explanation is that individuals with higher subjective privacy literacy tend to have greater privacy self-efficacy, which directly influences privacy protection motivation and behavior. However, subjective privacy literacy may have little or no involvement in threat appraisal, and therefore, it does not directly trigger privacy concern. In contrast, objective privacy literacy exerts its impact on protection motivation and behavior through threat appraisal, and in this study, it demonstrated a full mediating effect on privacy concerns. This result can also be elucidated by the “cognition-attitude-behavior” model from cognitive psychology, which suggests that individuals’ attitudes towards a specific action depend on their cognition of the causes and effects, and attitudes strongly predict behavioral intentions . SubjectDoes overconfidence impact behavioral decision-making? The findings of this study reveal that overconfidence acts as a negative moderator in the relationship between privacy concerns and privacy protection behaviors. As discussed at the beginning of the article, how does the cognitive bias of overconfidence affect privacy decision-making? According to the PMT theory , privacyPrivacy literacy, being a malleable skill , can be There are several limitations to this study that warrant consideration. Firstly, the sample of this study was limited to undergraduate students from universities, who may not fully represent all digital natives in China, despite being an active and representative group. Future research could adopt a nationwide survey approach and consider factors such as education level in the analysis to enhance the generalizability of the findings. Secondly, although privacy concerns were selected as the mediator variable in this study, it is important to note that privacy literacy may impact privacy protection behaviors through other pathways as well. Future studies could explore alternative variables and pathways to further elucidate the complex relationship between privacy literacy and privacy behavior.Despite these limitations, this study has made significant academic contributions. Notably, it incorporated both subjective and objective privacy literacy into the research model, shedding light on their differential impacts on privacy behavior. Moreover, this study extended the protection motivation theory (PMT) by investigating the influence of cognitive biases, such as overconfidence, on privacy decision-making, thereby enriching the existing literature on privacy behavior.5.2.The issue of online privacy protection has long been a prominent topic of research and policy focus for scholars and governments worldwide. This study aimed to investigate the differential effects of subjective and objective privacy literacy among Chinese digital natives on privacy protection behavior, as well as the influence of overconfidence in privacy decision-making. The study findings revealed that there was no significant correlation between subjective and objective privacy literacy among Chinese digital natives, with a notable bias between the two. A substantial proportion of participants exhibited overconfidence in their privacy literacy. Furthermore, subjective privacy literacy was not significantly correlated with privacy concern, but positively correlated with privacy protection behavior. On the other hand, objective privacy literacy showed a positive correlation with privacy concern, and privacy concern acted as a mediator between objective privacy literacy and privacy protection behavior. Additionally, the relationship between privacy concern and privacy protection behavior was found to be moderated by overconfidence. Overall, the results of this study contribute to the existing literature on the complex relationship between privacy literacy and privacy protection behavior, and shed light on the influence of cognitive distortions and biases in privacy decision-making.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/participants or patients/participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.SM is responsible for the overall research design, thesis writing, collation of the questionnaire, and data analysis. CC is responsible for the proofreading and article touch-up. All authors contributed to the article and approved the submitted version.This research was funded by Zhejiang Provincial Philosophy and Social Science Planning Project, grant number 22NDQN282YB.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Local evidence is important for contextualized knowledge translation. It can be used to adapt global recommendations, to identify future research priorities and inform local policy decisions. However, there are challenges in identifying local evidence in a systematic, comprehensive, and timely manner. There is limited guidance on how to map local evidence and provide it to users in an accessible and user-friendly way. In this study, we address these issues by describing the methods for the development of a centralized database of health research evidence for Cameroon and its applications for research prioritization and decision making.We searched 10 electronic health databases and hand-searched the archives of non-indexed African and Cameroonian journals. We screened titles, abstracts, and full texts of peer reviewed journal articles published between 1999 and 2019 in English or French that assess health related outcomes in Cameroonian populations. We extracted relevant study characteristics based on a pre-established guide. We developed a coding scheme or taxonomy of content areas so that local evidence is mapped to corresponding domains and subdomains. Pairs of reviewers coded articles independently and resolved discrepancies by consensus. Moreover, we developed guidance on how to search the database, use search results to create evidence maps and conduct knowledge gap analyses.The Cameroon Health Research and Evidence Database (CAMHRED) is a bilingual centralized online portal of local evidence on health in Cameroon from 1999 onwards. It currently includes 4384 studies categorized into content domains and study characteristics . The database is searchable by keywords or through a guided search. Results including abstracts, relevant study characteristics and bibliographic information are available for users to download. Upon request, guidance on how to optimize search results for applications like evidence maps and knowledge gap analyses is also available.https://camhred.org/) is a systematic, comprehensive, and centralized resource for local evidence about health in Cameroon. It is freely available to stakeholders and provides an additional resource to support their work at various levels in the research process.CAMHRED (The online version contains supplementary material available at 10.1186/s12961-023-01007-4. Research is an integral aspect of health systems and when used appropriately, it may inform optimal decision-making in health care and policy –3. In thSince its inception in 2016, the NHRS barometer has provided a comparable measure of African countries’ performance in general and within specific functional domains .One of tevidence that is available from the specific setting(s) in which a decision or action on an option will be taken.  'local' in this instance can refer to district, regional or national levels, depending on the nature of the policy issue being considered. Such evidence might include information on the presence of factors that modify the impacts of a policy [such as] the characteristics of an area and those who live or work in it; the need for services ; views and experiences; costs; political traditions; institutional capacity; and the availability of resources such as staff, equipment, and drugs .Research produced at a national level or targeting a specific setting feed into a type of evidence known as “local evidence” in the field of evidence-informed policymaking. The SUPPORT toolkit defines local evidence asEach of these factors lends itself to a different study design and methodology. For example, while observational studies can help to appraise and characterize the burden of a specific condition in a given population, they may not be the best type of evidence to support decisions about the choice of interventions required in a specific setting . In the In countries with developing NHRS like Cameroon, global evidence and recommendations often fill the gaps for local evidence needed to support decision-making , 18. HowA systematic approach to identifying and using local evidence is also important for contextualization . HoweverTo address the challenges listed above, we propose a local evidence mapping initiative. Evidence mapping has previously been used to scope broad topic areas using evidence from a variety of sources  –29. MoreThe objective of this study is to describe the methods for identifying and mapping local evidence through the development of a database for health research and evidence for Cameroon.We used evidence mapping design which combined systematic, scoping and bibliometric analysis methods to identify and categorize health literature from Cameroon to create an evidence map. Our methodology was guided by the mapping protocol established by the Global Evidence Mapping Initiative . EvidencWe included quantitative , qualitative, and mixed methods studies. We also included primary and secondary research focusing on health states, health outcomes, health systems, health policy, medicine, nursing and allied health professions, social determinants of health, health economics, human genetics.We included studies focused primarily on Cameroonian populations.From October 2018 to May 2019, we searched 10 electronic health databases , PSYCINFO, Base de Données de Santé Publique (BDSP), Archive ouverte en Sciences de l'Homme et de la Société (HAL-SHS), Base de données Persée and Erudit). We hand searched the archives of non-indexed African  and Cameroonian journals . Our search terms included Cameroon, Cameroun, Kamerun. We restricted searches to English and French articles published from 1999 to 2019. An example of our search strategy applied to EMBASE is available as a Additional file We screened all search results and excluded ineligible studies based on title and abstracts using the Rayyan application . We retrWe used DistillerSR to extract data on study characteristics presented in Table www.who.int/health-topics) and the Health Systems Evidence Database  at McMaster Health Forum , conducted in the Centre region ; with an observational study design  ; Medical Specialties ; Population  and Public Health . Within these domains, the most common subdomains were Infectious and parasitic diseases ; Infectiology ; Children ; Disease surveillance  respectively. Subdomains within the same domain were not mutually exclusive.The top four most coded domains in the CAMHRED were Diseases and conditions (https://camhred.org/) went live in December 2020 and provides a centralized and searchable online portal with studies categorized into content domains and study characteristics . This may have contributed to the large number of duplicates identified at the screening phase. We also included research published in peer reviewed journals which are currently not indexed in common electronic databases. Our experience confirmed findings from previous attempts at country-specific evidence synthesis for Cameroon which highlighted barriers to accessing local evidence housed in journals with non-searchable archives . We handThis study is a steppingstone for other local evidence mapping initiatives in Cameroon and countries with similar national health research systems. The applications of such initiatives are dependent on target user categories  and their objectives . For instance, knowledge brokering organizations active at the interface between research and decision making in Cameroon, have described using evidence mapping to provide context-specific policy options and inform priority setting exercises , 37–39. Our work also contributes to the growing literature on the methodology to guide evidence mapping which is currently marred by lack of consensus and the absence of guidelines such as those present for systematic reviews , 29. To Developing CAMHRED was not without challenges. As the first iteration of a country-specific database spanning 20 years; the breadth of health-related topics and research output to review, categorize and describe was large. Our approach and methods were both resource-intensive and time-intensive posing challenges for the first iterations of country-specific databases elsewhere. It took us a year from our last searches to coding completion and another 6 months before the database was ready for our first online launch. Other resource implications included software license purchases, staff time and IT costs. For instance, our initial search strategy resulted in thousands of articles which needed to be deduplicated prior to screening. Software such as Rayan and DistillerSR were instrumental in such de-duplication while research staff and volunteers contributed several hours to screening, data abstraction and coding. While the resulting product is comprehensive in content; feasibility and sustainability should be considered seriously prior to engaging in similar initiatives in other countries. In terms of sustainability, frequent updates to the database’s content are expected with a timeline model, based on our experiences with the first iteration. We anticipate that the process of updating the database should take anywhere between 3 and 6 months, provided there is commitment from at least two pairs of reviewers. Preparations for our next iteration of the database are currently underway with an updated search and new features. We will be revising our search strategy to reduce duplication from overlapping databases as seen in our first iteration. We are also exploring automation tools to reduce the burden of manual screening and classification .Most content categories in CAMHRED were based on existing taxonomies  and categories from one domain,  were inspired by stakeholder priorities. In other words, input from target users outside the research team was not included during the development of this taxonomy. This decision was based on time constraints and the assumption that these existing classification schemes were widely known and accepted. However, understanding of the domains and subdomains were expected to influence user experience and usefulness of the database. This was confirmed by preliminary user feedback following our first launch. To address these concerns, a thorough and detailed version of our user guide will be included in the next update as well as opportunities for training workshops with target users. We will also explore consensus and stakeholder engagement options for the addition of new topics to the database.The next update of CAMHRED’s content and user interface is scheduled for 2022. In this new version, we hope to address preliminary user feedback such as: keyword search sensitivity; user interface ; access to full text sources; and the availability of RIS file downloads. New features to expect include an expanded taxonomy (new COVID-19 domain) and a resources page . We are also working on establishing formal partnerships with research and policy platforms such as Cochrane Cameroon with the following objectives: increasing stakeholder buy-in; setting up a request and rapid response mechanism for evidence maps and gap maps; and formal evaluations.Our next steps include publishing guidance on how to use CAMHRED to create extensions of evidence mapping such as gap maps. We will be using a case study on local evidence mapping and gap analysis for sexual and reproductive health to describe how CAMHRED can inform decisions regarding future research and policy.Harnessing the increasing research output from Cameroon to help inform decisions made locally by clinicians, policymakers and patients is even more relevant now given rapidly changing global recommendations in a pandemic context. CAMHRED provides a one-stop shop for understanding what local evidence already available and existing gaps. However, it is not intended as a substitute for other evidence sources and comprehensive search strategies for systematic reviews, evidence briefs, rapid reviews, and responses. Instead, we suggest using the database as a tool to ease and support discussions surrounding problem definitions and implementation considerations for evidence-informed decision-making within a Cameroonian context. The methods we describe here can be tailored to settings with similar NHRS and beyond.Additional file 1. An example of our search strategy applied to EMBASE.


A significant gap exists between the production of research evidence and its use in behavioral health policymaking. Organizations providing consulting and support activities for improving policy represent a promising source for strengthening the infrastructure to address this gap. Understanding the characteristics and activities of these evidence-to-policy intermediary (EPI) organizations can inform the development of capacity-building activities, leading to strengthened evidence-to-policy infrastructure and more widespread evidence-based policymaking.Online surveys were sent to 51 organizations from English-speaking countries involved in evidence-to-policy activities in behavioral health. The survey was grounded in a rapid evidence review of the academic literature regarding strategies used to influence research use in policymaking. The review identified 17 strategies, which were classified into four activity categories. We administered the surveys via Qualtrics and calculated the descriptive statistics, scales, and internal consistency statistics using R.α’s ranging from 0.67 to 0.85. Ratings of respondents’ willingness to pay for training in one of three evidence dissemination strategies revealed high interest in program and policy design.A total of 31 individuals completed the surveys from 27 organizations (53% response rate) in four English-speaking countries. EPIs were evenly split between university (49%) and non-university (51%) settings. Nearly all EPIs conducted direct program support (mean = 4.19/5 [sd = 1.25]) and knowledge-building (4.03 [1.17]) activities. However, engagement with traditionally marginalized and non-traditional partners (2.84 [1.39]) and development of evidence reviews using formal critical appraisal methods (2.81 [1.70]) were uncommon. EPIs tend to be specialized, focusing on a group of highly related strategies rather than incorporating multiple evidence-to-policy strategies in their portfolios. Inter-item consistency was moderate to high, with scale Our results suggest that evidence-to-policy strategies are frequently used by existing EPIs; however, organizations tend to specialize rather than engage in a breadth of strategies. Furthermore, few organizations reported consistently engaging with non-traditional or community partners. Focusing on building capacity for a network of new and existing EPIs could be a promising strategy for growing the infrastructure needed for evidence-informed behavioral health policymaking.The online version contains supplementary material available at 10.1186/s43058-023-00432-4. Contributions to the literatureA gap exists between the creation of research evidence and the use of that evidence in behavioral health policymaking. A number of organizations exist that could be well-suited to translate this evidence for decision-makers.Evidence-to-policy intermediaries (EPIs) are using evidence translation strategies found in the implementation science literature and are interested in learning about additional strategies.EPIs tend to specialize within limited subsets of strategies and may thus be missing opportunities to maximize translational impact.Existing EPIs report low engagement with community partners.The integration of evidence into health-related policymaking is a stated priority for multiple national and local governments and an articulated goal of researchers working to narrow the “evidence-to-practice gap.” A number of centers, collaboratives, and initiatives have emerged over the last decade with the aim of supporting evidence-informed policymaking, including the World Health Organization-supported European Advisory Committee on Health Research , Health In this paper, we investigate the distinct role that evidence-to-policy intermediaries (EPI) play compared to other types of intermediary organizations focused on mental and substance use services  as described in the field , 15 partA substantial gap remains between the production of research evidence and the inclusion of evidence in policymaking. This gap is particularly acute with regard to behavioral health research , 17, wheThe substantial time lag between when research is published and the uptake of findings into policy is well known . This laSeveral papers have explored and begun to catalog the competencies necessary to effectively translate research evidence , 26, butEPIs already play a critical role in the knowledge production-to-application ecology. A better understanding of how these organizations operate, their current capacities, and funding infrastructure is a step towards understanding how to support better evidence-informed policy with policymakers and community partners .The current study surveyed leaders of EPI organizations to identify common strategies used to integrate research evidence into behavioral health policy and system-level decision-making. The study sought to quantify the degree to which EPIs use any of seventeen specific strategies, identified in the knowledge translation literature. The authors were also interested in the perceptions of EPI leadership regarding whether the academic literature on evidence translation helps EPI organizations advance their translational work.Information from this study will help behavioral health policy researchers understand how EPIs provide support and guidance to policymakers and healthcare systems. Findings may elevate the role intermediary organizations play in influencing policy while highlighting the areas where targeted capacity building may enable such organizations to avoid overspecialization in a particular set of skills in favor of developing a suite of tools with which to engage policymakers to address complex needs.evidence-based, policy, center, support, implementation, mental health, and behavioral health. Organizations were included in the sample pool if descriptions of center activities included providing system leaders and policymakers with evidence syntheses, policy analyses, reports with policy/system recommendations, or stakeholder engagement activities for the purpose of informing policy. For eligible organizations, we sought contact information for individuals likely to be knowledgeable about policy-supporting activities within that organization. Individuals in leadership positions including executive leadership, program directors, and implementation specialists were intentionally selected. Conversely, when Internet searches returned information about specific individuals, additional searches were conducted to locate that individual’s academic or research “home base” to determine if that agency qualified as an EPI. Upon compiling the above list of organizations, up to two key leaders per center were identified based on Internet searches of the organization’s website. This approach yielded 83 individuals from 44 intermediary organizations. Snowball sampling identified leaders representing seven additional organizations, for a total of 51 organizations and 90 individuals. The majority of the centers identified may be characterized as “arms-length” intermediaries, which operate outside the realm of both national government infrastructure and existing service delivery systems . In the IS use section, participants were asked to provide an open-ended response to the question: What aspect(s) IS has/have been most useful to your practical work in influencing policymaking?Respondents were asked to provide additional comments and feedback regarding the three in-depth evidence-to-policy strategies : t-tests and chi-square tests were calculated to compare the results between U.S. and international-based organizations, as well as university-based versus non-university-based organizations.Descriptive statistics, scales, significance tests, and internal consistency statistics were calculated using R. Independent sample We used an open coding, inductive content analysis to extract themes from qualitative data . Two autThirty-one participants from 27 agencies responded to the survey . Half of all respondents (52%) represented directors or executive leadership of their agency. Nearly one-quarter (23%) were employed as managers or program directors, and one-quarter (26%) served as program officers, implementation specialists, or professors.Representation was evenly split between EPIs based at universities (48%) and those without a university affiliation (52%). More than two-thirds (71%) of agencies were based in the USA, with additional organizations representing Canada (13%), Australia (10%), and the UK (7%). Seven organizations (23%) identified as research centers, four (13%) identified as training or best practices support centers, and three agencies (10%) served as consultation and/or information management support centers. Two EPIs (6%) were identified as both research and training support centers, while four organizations (13%) served as both training and consultation support center. Five agencies (16%) identified as a combination of research, training, and consultation centers, while six EPIs (19%) self-identified outside of these categories .Funding mechanisms were diverse across EPIs. On average, government service contracts made up the largest share (29%) of EPI funding portfolios, followed by private fundraising 19%) and national government research grants (18%). Foundation research grants (7%) were the least frequently cited sources of funding. While funding was diverse between organizations (Table 9% and nap < 0.01). Non-university-based agencies reported more government and foundation service contracts than university-based centers, but this did not reach statistical significance. Non-U.S.-based organizations were funded by foundation service contracts at roughly double the rate of U.S.-based organizations (21.7% vs. 11.5%) and had a higher proportion of government research contracts . Private fundraising made up a greater share of non-U.S. organization budgets as well (22.5% vs. 16.9%). Meanwhile, university-based  and U.S.-based  organizations were more likely to be supported by national government research grants. U.S. agencies were more likely to be funded by non-national government service contracts . Foundation research grants, while comprising relatively small proportions of EPI budgets overall, made up a higher percentage of U.S.-based organization budgets (9.5%) than non-U.S. organizations .While national government research grants were the third most frequent source of revenue overall, they were present in the portfolios of university-based agencies at three times the rate of non-university agencies (27.3% vs. 9.1%), a statistically significant finding (p < 0.01) , although none of the categories exceeded “likely.” EPIs based outside of universities had higher mean scores for each category, but only one comparison reached statistical significance: compared to their university-based counterparts (2.40), non-university EPIs were more likely to believe that activities in the evidence synthesis category could be funded  facilitating co-design of new programs, systems, or processes, m = 4.03; (3) training and supporting leadership planning skills to acquire and implement new knowledge, m = 4.03; and (4) conducting interactive workshops designed for specific audiences to facilitate the use of evidence in planning, m = 4.00  in the reported frequency of use among the individual items. Four items scored at 4.0 or above (“very much—this is a core activity of ours”). These core strategies included (1) direct service improvement activities,  = 4.19;  facilitam = 2.40; (2) developing evidence reviews using formal critical appraisal methods, m = 2.68; (3) collaborating with traditionally marginalized and non-traditional partners to conduct research or translate evidence, m = 2.84; and (4) training and coaching policymakers to do a critical appraisal of the research literature, m = 2.87.Conversely, four strategies scored below a threshold of 3.0 (“somewhat—we do this a little”). These least employed strategies by EPIs were (1) maintaining a database of research-based information, r =  − 0.02–0.70), suggesting it was uncommon for organizations to be involved in all four types of evidence-to-policy translation. We observed nearly zero correlation (− 0.02) between the capacity building and evidence synthesis scales and between the capacity building and evidence dissemination categories (0.09). This suggests that organizations involved in predominately evidence synthesis and dissemination activities  are highly unlikely to be engaged in capacity-building activities . We observed a moderate correlation (0.37) between the connecting researchers to policymakers and evidence synthesis scales, as well as a moderate correlation between the capacity building and connecting researchers to policymakers scales (0.34). Evidence synthesis and evidence dissemination were also moderately correlated (0.64). The strongest correlation was observed between evidence dissemination and connecting researchers to policymakers (0.70) . However, university-based EPIs expressed a greater willingness to pay for training in request-driven evidence reviews (RDER) . U.S. organizations expressed a stronger interest in learning about RDERs  compared to their international counterparts. As will be reviewed below, the qualitative results suggest that this likely due to non-U.S. organizations having more expertise in conducting RDERs than U.S. organizations. Other comparisons did not reveal meaningfully or statistically significant differences between U.S. and non-U.S. or university and non-university organizations (see Table Non-university-based organizations viewed request-driven evidence reviews (RDERS) as more effective at influencing policy- than university-based organizations  familiarity with IS regarding the organization’s policy translation work, (2) relevance of IS to day-to-day policy translation activities, and (3) relevance of IS to overall policy translation work. Non-U.S. organizations held more positive views of IS compared to U.S. organizations on all four indicators. The lowest scored item in this Sect. (62.5/100) was the prompt rk Table .Qualitative analyses were viewed as exploratory prompts to guide the development of hypotheses for future studies about how evidence-to-policy strategies are currently used and viewed among real-world EPIs. As the prompts for the qualitative questions were neutral , we view comments about the value of these strategies or concerns to be meaningful signifiers of respondents’ experiences in the field. Eleven participants responded to the open-ended question about the value of RDERs. The timing of incorporating RDERs into an EPI strategy was a prominent theme among respondents. Three participants viewed RDERs as a valuable strategy for influencing policymaking in the immediate term, noting that RDERs represented a core function of their agency’s activities. Two participants noted that they were not currently conducting RDERs but thought they might adopt this strategy in the future.Funding was a concern raised by two participants, who noted that both current budgets and potential funders constrain the ability or willingness to center RDERs among an EPI’s core activities. Additionally, one respondent expressed a concern that RDERs are only one piece of a complex policymaking puzzle, limiting their independent effectiveness. Another respondent suggested that the impact of RDERs may only be relevant to policymakers who “have already bought into the idea of evidence-informed decision making and that are part of the process of the review.”Two participants expressed interest in comparing and improving the methods of producing RDERs, such as “staying on top of improvements and changes in these methods,” and mentioned that they “would be interested in learning how others field policymaker [RDER] requests in an efficient and rigorous manner.” A desire to meet with other organizations to share best practices and contrast RDER methods was also noted.n = 4), with one participant noting, “This is a key area for our business, as our customers  frequently find it difficult to communicate with academic researchers, but are motivated to understand and incorporate research findings into policy and practice.” Meanwhile, others noted that such connecting activities are engaged informally or might be something that “happens organically at events we organize on specific topics.”Ten participants provided comments about the connecting researchers to policymakers strategies. Multiple agencies reported this strategy as a core element of their work  provided comments regarding the most useful facets of IS to their practical work influencing policymaking. A core theme emerging from the responses was the strength of IS frameworks for facilitating knowledge translation. One respondent wrote, “implementation science…allows for a more thoughtful and successful translation of research into practice.” Another commented, “findings of implementation science have been helpful to us in prioritizing our [policy] recommendations.”n = 5), strategies for effective program implementation (n = 3), practical implementation studies and tools (n = 5), and the inclusion of multiple voices in the policymaking space (n = 3). In contrast, one participant saw IS as not sufficiently addressing real-world conditions, contending “research sometimes focuses more on describing characteristics of successful implementation efforts that are not necessarily highly changeable.”Additional comments highlighted the usefulness of systems thinking and systematic approaches to knowledge translation  . The ISFThe two least endorsed EPI activities in our study were evidence synthesis and collaborating with traditionally marginalized communities. Most EPIs in our survey appeared to be working in service improvement and capacity building and likely had a primary audience of policymakers and service providers. This has at least two implications for policy development. Increasingly, the field of health services research is concerned with the need to attend to equity in the processes of conducting research and translating research findings. The National Academy of Medicine, for example, recently published a white paper revisiting existing recommendations for improvement and calling for more community engagement and partnership . As arguThe need for interconnected supports and the limited value of any single evidence-to-policy activity was echoed by comments in the qualitative portion of the study. Respondents generally viewed responsive evidence reviews positively but felt that their impact was contingent on external conditions. Similarly, respondents felt that connecting researchers to policymakers had bidirectional benefits but could be problematic if used to support political positions. “Arms-length” EPIs may be more successfully positioned to maintain intellectual independence than other types of embedded or informal intermediary relationships .Funding availability is a key factor affecting which activities EPIs undertake. A topic not often addressed in the IS literature is the real-world market for behavioral health intermediaries in general, and policy intermediaries in particular. Franks and Bory’s  review oOverall, the findings provide a reason to be optimistic about the state of the “synthesis” and “capacity” building systems for behavioral health policymaking. We found that among our sample, the frequency of EPI activities was reasonably high. This provides a solid foundation for building a community of practice among entities doing IS-informed work. The high endorsement of IS in general suggests these organizations are active users of the research literature and are likely to adopt methods found to be effective for evidence-informed policymaking. However, respondents felt that IS could provide more meaningful guidance in this specific practice area.Finally, there is a business case to be made for EPIs to establish a diverse portfolio of evidence translation strategies. For example, both university-based and non-university agencies were willing to pay for training. EPIs incorporating these methods may open an untapped revenue stream that diversifies their funding portfolio while expanding their sphere of influence simultaneously.The study is limited to agencies identified through Internet searches, listserv dissemination, and snowball sampling. The sample almost certainly underrepresents organizations doing similar work. A post hoc estimate of respondents suggests about 70–80% came from direct requests following an Internet search or because the authors were already aware of the organization, and consequently, the results overrepresent “arms-length” intermediaries that are more likely to be connected to implementation science or health service research. We recognize that the definition of EPI is porous and future research might examine how these types of organizations differ and overlap with researcher-practice partnerships, university-community partnerships, and other similarly oriented efforts. Furthermore, as respondents exclusively came from Anglophone countries, we cannot generalize findings to the strategies or activities undertaken outside of these political environments. Other types of organizations may have different perspectives regarding what works to successfully integrate evidence-based information into policy and may have differing levels of interest in being part of a practice community.EPIs play a critical role in the knowledge production-to-application ecology of behavioral health policymaking. However, while EPIs are employing the research translation strategies found in the IS literature, such use remains highly specialized, as do the funding portfolios of these agencies. Polyspecialization is likely needed to harness translational impact. A particular need exists for EPIs to work with communities affected by policies, especially around behavioral health and social welfare. Additionally, EPIs use IS to translate research into policy; however, the perceived actionability of IS for agencies’ own policy translation methods was limited. Finally, there is a business case to be made for translating IS methods that could be income-generating for training organizations seeking to build the capacity of EPIs.Additional file 1.


A better understanding of population-level factors related to measles case fatality is needed to estimate measles mortality burden and impact of interventions such as vaccination. This study aimed to develop a conceptual framework of mechanisms associated with measles case fatality ratios (CFRs) and assess the scope of evidence available for related indicators. Using expert consultation, we developed a conceptual framework of mechanisms associated with measles CFR and identified population-level indicators potentially associated with each mechanism. We conducted a literature review by searching PubMed on 31 October 2021 to determine the scope of evidence for the expert-identified indicators. Studies were included if they contained evidence of an association between an indicator and CFR and were excluded if they were from non-human studies or reported non-original data. Included studies were assessed for study quality. Expert consultation identified five mechanisms in a conceptual framework of factors related to measles CFR. We identified 3772 studies for review and found 49 studies showing at least one significant association with CFR for 15 indicators  and only non-significant associations for five indicators . Our study used expert consultation and a literature review to provide additional insights and a summary of the available evidence of these underlying mechanisms and indicators that could inform future measles CFR estimations. While measles mortality has decreased over the last several decades, an estimated 60,700 people died from measles in 2020 . HoweverThere is evidence that various plausible risk factors contribute to systematically higher individual-level measles case fatality, such as nutritional or vaccination status, overcrowding at home, and overall health system access or quality ,9,10. HoA clear framework of possible mechanisms related to CFR provides a means to organize the compiled evidence on risk factors associated with measles case fatality. Improved CFR estimates could help to assess health gains achieved through vaccination and other interventions such as nutrition supplementation, identify remaining gaps, understand likely drivers behind increased CFR, and support targeted efforts to reduce the disease burden in particularly vulnerable communities. Therefore, we used expert consultation to develop a conceptual framework of mechanisms related to measles CFR and identify population-level indicators related to these underlying mechanisms. We used expert consultation because the underlying mechanisms related to measles case fatality are multifactorial, complex, and challenging to establish casual pathways of to describe systematic changes in CFR. Then, we conducted a literature review to assess the evidence of association between these indicators and case fatality.We consulted with a group of experts who are co-authors on this paper  to deterTo adequately represent these underlying mechanisms via population-level factors, we identified a list of 58 indicators typically available at the population level  that couTo assess the level of evidence of association between measles case fatality and the final list of identified indicators, we conducted a review of the available literature . We sear(indicator-specific search terms)AND “measles”AND A full list of indicator-specific search terms can be found in Following the search, each indicator was assigned to one of the following categories: indicator has at least one published randomized controlled trial supporting a significant relationship with CFR, indicator has at least one published quantitative observational study supporting a significant association with CFR, indicator has at least one published qualitative study supporting an association with CFR, indicator has published evidence of a non-significant relationship between indicator and CFR, and indicator had no published evidence investigating the relationship with CFR, depending on the highest category of evidence found.For each study presenting any evidence of an association between an indicator and CFR, we assessed the overall quality of evidence presented in each study using the GRADE working group framework as a model . Each stFive underlying mechanisms were identified by the expert group: health system access and care-seeking behaviors, health system quality, measles control and epidemiology, nutritional status, and risk of secondary infection. Each mechanism was hypothesized by the expert group to have a direct association to either systematic increases or decreases in measles CFR, as well as interdependently with one another . For exaThe search yielded 3772 articles; the full text was reviewed for 857 of these articles meeting inclusion and exclusion criteria . Each inAmong these 49 studies, the following 26 countries were represented: Afghanistan, Bangladesh, Chad, Costa Rica, Democratic Republic of the Congo, Ethiopia, France, Ghana, Guinea-Bissau, India, Indonesia, Kenya, Malawi, Mexico, Mongolia, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Senegal, South Africa, Sweden, Tanzania, Turkey, and Zambia. There were 9 studies published in the period 1980–1989, 14 in the period 1990–1999, 14 in the period 2000–2009, 7 in the period 2010–2019, and 5 in the period 2020–2021. All studies with significant and non-significant evidence of an association between an indicator and measles CFR, along with their quality scores, are presented in In 1980, Bhuiya and colleagues  showed tSalama and colleagues  noted thIn 2013, in the Democratic Republic of the Congo, Gignoux and colleagues  showed cWith regard to the percent living in urban settings, published evidence of a non-significant relationship with CFR was found. There was no published evidence examining the association between CFR and time to care seeking.Rey and colleagues  noted thMultiple studies ,25,26,27There was no published evidence examining the association between CFR and access to intensive care units or health expenditure per capita.Joshi and colleagues  showed tp = 0.01). In South Africa from 2009 to 2010, le Roux and colleagues [Barclay and colleagues  showed tlleagues  showed tlleagues  noted thlleagues  showed tp = 0.0156). In hospitalized measles patients from 1994 to 2004 in Nigeria, Fetuga and colleagues [In addition to the biometric indicators of stunting and underweight identified by the expert group, multiple studies reported on the association between non-specific malnutrition and measles case-fatality; as such, the evidence associating non-specific malnutrition with measles case fatality are presented here. In Ghana, from 1973 to 1982, Commey and colleagues  showed tlleagues  estimatelleagues  also notAmong hospitalized measles patients in Malawi from 1992 to 1993, Courtright and colleagues  showed tWhile evidence was collected from various studies on vitamin A supplementation, a recent meta-analysis  pooling p < 0.01). Also, Aaby and colleagues [Burström and colleagues  showed tlleagues  showed tlleagues  noted thAmong hospitalized measles patients in Zambia from 1993 to 1995, Oshitani and colleagues  found thPublished evidence of non-significant relationships between each indicator and CFR were found for the following indicators: antibiotic use for measles-related pneumonia, malaria prevalence, and pneumococcal conjugate vaccination coverage. There was no published evidence examining the association with CFR and the following indicators: ambient air pollution, human immunodeficiency virus (HIV) treatment/antiretroviral therapy (ART) prevalence, de-worming frequency, oral rehydration solution for measles-related diarrhea, population density, and total fertility rate. For the association between pre-term birth prevalence and increased measles case fatality, evidence of an association  was founp = 0.038). Oshitani and colleagues [p = 0.033). Dollimore and colleagues [p = 0.0423) among patients hospitalized with measles.Nayir and colleagues  noted a lleagues  showed tlleagues  noted anlleagues  noted thlleagues  noted anAmong hospitalized measles patients in Pakistan from 2003 to 2004, Aurangzeb and colleagues  showed tDuring an outbreak in the Democratic Republic of the Congo in 2013, Gignoux and colleagues  noted a p = 0.0351).In a randomized trial in South Africa in 1987, Hussey and colleagues  showed tWe did not find any studies examining the relationship between CFR and the following indicators: maternal measles vaccination coverage, maternal antibody dynamics, vaccination efficacy, vaccination schedule, and vaccine coverage equity.Our conceptual framework of mechanisms related to measles CFR, based on expert consultation, and a literature review of indicators associated with these mechanisms strengthen the understanding of measles CFR and mortality estimation. We categorized potential risk factors for measles CFR into five mechanisms related to either systematic increases or decreases in measles CFR and searched for evidence of an association with measles CFR across 37 population-level indicators that are representative of these mechanisms. Among indicators included in our search, 15 indicators had evidence of an association with measles CFR.Overall, 26 countries were represented in 49 studies published from 1983 to 2021 that included quantitative or qualitative evidence of an association with CFR. Most locations were from low- or middle-income countries. Relative to other mechanisms, nutritional status had the greatest number of studies available across its group indicators. Only one indicator, vitamin A supplementation, had a previously conducted systematic review with meta-analysis pooling results across studies. For multiple indicators, results of various studies showed both statistically significant and non-significant associations with CFR. In the absence of a meta-analysis, we considered indicators with studies presenting evidence of a statistically significant association with CFR and studies presenting evidence of a non-significant association to be plausibly associated with CFR if there was at least one study with significant evidence.Most indicators could likely be classified under multiple underlying mechanisms. For example, MCV1 coverage could be related to measles control and epidemiology, but also to general health system access, health system quality, and risk of secondary infection. However, because indicators were used to represent mechanisms at large, the assignment of each indicator to a single mechanism for illustrative purposes did not influence the determination as to whether an association with CFR existed. These classifications, though, might have implications for future use cases of this work, such as for mathematical or statistical modelling, and users will need to consider these assumptions in the specific context in which they are working.While they may be associated with measles CFR, we identified 17 indicators for which no evidence had any significant association. For some indicators, the type of data available did not allow us to reliably assess the association with CFR, despite the availability of published evidence. For lower respiratory infection and diarrheal disease prevalence, high rates of community prevalence of related pathogens may theoretically increase the risk of secondary infection in measles cases and subsequently increase case fatality. There was substantial evidence to suggest that the development of pneumonia or diarrhea following acute measles infection was associated with increased case fatality. However, it was not possible to distinguish whether the development of pneumonia or diarrhea represented the progression of primary measles or reflected secondary infection with an additional pathogen. Without routine specimen testing when additional clinical symptoms arise, we are unable to distinguish whether these are population-level factors related to increased measles CFR or markers of disease severity. Thus, it was not possible to determine the nature of these specific associations.Given the heterogeneity of underlying studies and their varying quality scores, we were unable to perform any quantitative synthesis to combine the evidence found in the published literature. Additionally, the objective of our review was to generate supportive evidence for the conceptual framework and related indicators via identifying any evidence suggesting an association with measles CFR rather than generating a single effect size per indicator.We assessed only associations with acute measles case fatality as our end point. However, it is known that since health facilities experience higher patient loads  and secoWe did not explicitly re-examine the relationship between age or measles incidence, given their known importance regarding case fatality. It has been shown previously that as age increases, CFR decreases ,10. ThesThis work has several limitations. First, the evidence presented in this study is heterogeneous and includes both population-level and individual-level relationships. Next, we did not identify the reasons for studies showing non-significant associations, such as having an underpowered sample size to assess significance. We only used one database during our literature search. Additionally, due to limitations in available data, we were unable to assess causality of associations between indicators and CFR. For example, as with nutritional status, few studies had information on anthropometry prior to measles onset, and since measles infection commonly leads to weight loss, reverse causality cannot always be excluded. Nonetheless, some large prospective studies confirmed increased CFR in malnourished children. Additionally, we did not consider evidence specific to populations that are at particularly high risk of measles infection and mortality, such as refugees or internally displaced persons. While these subgroups of the overall population are likely at higher risk of both measles infection and mortality given underlying concerns related to access to health services and other increased risk of infection, there is a scarcity of population-specific indicators and underlying data regarding measles CFR. Although data in these populations are likely challenging to collect, we support the investigation of these critical questions to better understand how to assess burden among these high-risk groups. Additionally, we considered only acute fatality from a measles case . Additional consideration should be given to which indicators and mechanisms contribute to longer-term impacts of measles on overall mortality . FinallyOverall, this study addresses some of the knowledge gaps around factors influencing measles CFR and, moreover, may be valuable for decision making and programmatic targeting among disease control programs. More work as well as primary data collection is needed to continue expanding what is known about these associations, to close important knowledge gaps, and to better estimate measles CFR across settings and populations.


Dirofilaria immitis, the causative agent of heartworm disease, characterized by respiratory signs, airway hyperreactivity, remodelling and inflammation. Allergy is a multifactorial pathology, and the role of a number of helminth parasites in the development of allergies in humans and other species has been demonstrated in many studies. The aim of the present study was to verify whether cats seropositive for D. immitis present hypersensitivity to some environmental allergens.Cats can be infected by D. immitis and for hypersensitivity to 20 allergens, using commercial allergen test kits.Blood samples were collected from 120 cats and tested for the presence of specific immunoglobulin G antibodies against D. immitis IgG and 55 (45.8%) showed clinical signs of heartworm disease of a respiratory nature. The results of testing with the allergen kits showed that 50.8% of cats were seropositive for ≥ 1 allergens, with the most common allergens being Dermatophagoides farinae (25.8%), Dermatophagoides pteronyssinus (20.0%), Malassezia (17.5%) and Ctenocephalides felis (14.2%). The prevalence of allergies was significantly higher—by almost threefold—in cats seropositive for D. immitis (68.1% vs. 25%). There were no significant differences between the prevalence of allergic cats and presence/absence of symptoms, and the results confirmed that symptoms were not a decisive factor for the presence of allergies. The risk for developing allergies was 6.3-fold higher in cats seropositive for D. immitis than in cats that were seronegative, confirming that seropositivity for D. immitis is a risk factor.Of the 120 cats tested, 72 (60.0%) were seropositive for anti-D. immitis and Wolbachia is related to the presence of bronchoconstriction and bronchospasm in the affected cat. The results support the suspicion that contact with D. immitis may be a risk factor for the presence of allergies.Cats with confirmed heartworm can develop serious respiratory signs, potentially leading to progression to permanent lung injury and predisposing cats to hyperresponsive airway disease. Previous studies have shown that seropositivity for  Dirofilaria immitis, a vector-borne nematode that causes heartworm disease .Based on the ELISA results, 72 (60.0%) were seropositive to anti-Dermatophagoides farinae (25.8%), Dermatophagoides pteronyssinus (20.0%), Malassezia (17.5%) and flea (14.2%) = 2.326, P = 0.130]. While 49.2% of the cats were not seropositive to any allergen, 18.3% showed increased IgE for one allergen, 11.7% for two allergens and 20.7% for > 2 allergens. The mean number of allergies per cat was 1.483 , with no significant differences found between seropositive and seronegative cats for D. immitis , with the incidence of allergies being almost threefold higher than that in D. immitis-negative cats (68.1% vs 25%). Cats seropositive to D. immitis showed higher prevalence of IgE against all of the most common allergens. There were no significant differences in the prevalence of allergic cats and presence/absence of symptoms between D. immitis-seropositive and -seronegative cats.The percentage of cats with allergies was significantly higher in the group of cats seropositive for D. immitis seropositivity/symptom combination . For asymptomatic cats, the mean number of allergies per cat  was higher in seropositive cats . Similarly, the mean number of allergies was higher in symptomatic seropositive cats than in asymptomatic seronegative cats . For seronegative cats, the mean number of allergies tended to be higher in symptomatic cats than in asymptomatic ones   revealed a relationship between the number of allergies per cat and 46) Fig. .Fig. 2EsP = 0.000, Cramer’s V = 0.430) between the four groups. Post-hoc comparisons adjusted by the Bonferroni test indicated that the incidence of allergies was two- to threefold higher in seropositive cats (both asymptomatic and symptomatic) than in the two seronegative (symptomatic/asymptomatic) subgroups  and the presence of allergies, the results indicated an overall significant relationship [GML; F3.35)= 7.650, .35= 7.65D. immitis and respiratory symptoms.A logistics regression was applied with a dichotomous dependent variable that coded whether the cat was allergic or not, with “being allergic” the event studied. The multivariate logistics model or logit expressed the probability that a cat may be allergic depending on the different factors considered. Thus, the analysis detected which aspects significantly increased the probability of being allergic. The prognostic factors considered were sex, age, breed, serology to  P-value of 0.923. The model had a moderate area under the curve value of 0.707 .For the final model, the Hosmer and Lemeshow test had a chi-square value of 1.947 and aD. immitis ELISA result; the other factors were not included because Exp(b) was < 1, which indicated a reduction in the probability of allergy. We used the logistic equation to estimate different values of the independent factors. The interpretation of the impact on the risk of the predictors was 6.391 for the result in the D. immitis ELISA test, meaning that the risk of being allergic was multiplied by a factor of 6.3 in cats seropositive for D. immitis compared to those which were seronegative.The model included only one predictor, namely the D. immitis result and the symptoms separately, the quality of the model was similar: 0.727 , with a chi-square for the Hosmer–Lemeshow test = 15.398 and P-value = 0.062. These results showed that being seropositive and asymptomatic multiplied the risk of allergy by 8.7 (compared to being seronegative asymptomatic), being seropositive with symptoms multiplied the risk by 5.6 (compared to being seronegative asymptomatic), while being seronegative with symptoms did not vary the risk of allergy compared to asymptomatic seronegatives. These results confirmed that being seropositive for D. immitis was a risk factor for allergy, but that the presence/absence of symptoms was not a risk factor for allergy.When the variable of the four subgroups was introduced instead of the Several studies have shown that various parasitic molecules are involved in the modulation of the immune and allergic response of hosts infected by helminths and have described that parasitic infections can evoke a strong response and high levels of IgE in allergic patients , 27.Toxocara spp. and Ascaris lumbricoides have been reported to cause allergic reactions  in adults and children, with seropositivity to those parasites being a strong risk factor for allergic outcomes in younger generations [Toxocara spp. and A. lumbricoides was found in children with allergic rhinitis [Previous studies in humans have shown a relationship between helminthic infections and the development of atopy, asthma, or rhinitis, but this relationship is still open to controversy. For example, infections caused by erations , 27. In rhinitis , 27, 28.rhinitis , 29, 30.Toxocara canis had increased IgE levels and allergic reactions to house dust mites (D. farinae). Similar results were found in the present study, with D. farinae, which is one of the most frequent allergens reported in cats [Toxocara cati infection and asthma [Ascaris suum can cause immediate hypersensitivity in the lungs of pigs when the larvae migrated through the alveolar spaces. In cats, only experimental studies have been carried out to determine the clinicopathological characteristics of asthma after sensitization to ovalbumin [A. suum antigens [This relationship between parasites and the development of hypersensitivity has also been studied in species other than humans. Fischer et al.  showed t in cats , 31, 32,d asthma . Dawson d asthma , showed valbumin  and A. santigens , with thD. immitis, it has been observed that people who come into contact with this parasite (seropositive to specific IgG) showed the presence of total IgE and specific anti-D. immitis IgE more frequently [D. immitis, which may be a factor contributing to the development of allergies in inhabitants of hyperendemic regions [D. immitis was found to be more frequent in children with asthma [Regarding equently , indicat regions , 15. In h asthma .D. immitis and Wolbachia surface protein (WSP) is related to the presence of bronchoconstriction and bronchospasm in the cat [D. immitis may be a risk factor for the presence of allergies, as suggested by the results of this study.Cats with heartworm show the clinical signs of endarteritis, fibrosis of the vascular intima and hypertrophy of the walls of pulmonary arteries happens, similar to the clinical signs in dogs –4. Moreo the cat , 34. AltD. immitis seropositivity. In the cat, it is common to find asymptomatic infections at the time of diagnosis; however, the cats in this study were also at risk of having a fatal outcome and the risk of complications was also present [Analysis of the results showed that the presence of symptoms was not a risk factor for the presence of allergies, nor were there significant differences between the presence/absence of symptoms and  present –4. Moreo present , 36.The scientific evidence obtained to date in other parasites and the results obtained from the present study suggest the possibility that the symptoms and pathophysiology of feline heartworm disease may be complicated by allergic pathologies in this species. Consequently, the study of allergen panels could be relevant in infected cats, whether or not they are symptomatic at the time of diagnosis.D. immitis infection is a causative agent for the development of allergies. Furthermore, cats were studied according to whether or not they were seropositive to IgG against D. immitis. The presence of antibodies indicates exposure, but not necessarily current infection. However, those cats with the presence of specific IgG are considered to be in contact with the parasite and are therefore at risk of infection. Also, to exclude other diseases , all cats were mainly subjected to anamnesis, physical exam, thoracic X-ray, echocardiographic exam and blood tests. To detect IgE against several common allergens, only a diagnostic test was performed, with no additional confirmatory examinations. Moreover, only 20 allergens were evaluated, so the possible involvement of other allergens was not studied. Furthermore, the sensitivity and specificity of these tests were not specified by the manufacturer, so these are also important limiting factors to take into account. Finally, all cats were from an area where heartworm is hyperendemic, but the variability of the allergic antigenic load to which the study cats may have been exposed is unknown. Nevertheless, the selected cats came from very similar climatic areas. Further studies to determine the possible relationship between D. immitis infection and the development of allergies need to be carried out.There are a number of limitations to this study. The results are not indicative of causation but, rather, correlation, and therefore do not demonstrate that D. immitis are more likely to exhibit an immune response against environmental allergens. We also found that being seropositive was a risk factor for the development of hypersensitivity in cats. Given the limitations of the study, the results should be interpreted with caution, although they do provide interesting information which should encourage future studies focused on determining whether there is a causal relationship between the development/exacerbation of allergies and D. immitis infection.The results of the present study support the suspicion that cats which have been in contact with


School-based interventions for the prevention of dating and relationship violence (DRV) and gender-based violence (GBV) take advantage of universal opportunities for intervention. Information on differential effectiveness of interventions is important to assess if they ameliorate or worsen social gradients in specific outcomes. This is especially important in DRV and GBV prevention given the gendered context of these behaviours and their common aetiologies in patriarchal gender norms, and social acceptance in school contexts of sexual harassment, such as catcalling or unwanted groping. We undertook a systematic review of moderation analyses in randomised trials of school-based interventions for DRV and GBV prevention. We searched 21 databases and used supplementary search methods without regard to publication type, language or year of publication, and synthesised moderation tests relating to equity-relevant characteristics  for DRV and GBV perpetration and victimisation. Across 23 included outcome evaluations, programme effects on DRV victimisation were not moderated by gender or prior experience of DRV victimisation, but DRV perpetration outcomes were greater for boys, particularly for emotional and physical DRV perpetration. Findings for GBV outcomes were counterintuitive. Our findings suggest that practitioners should carefully monitor local intervention effectiveness and equity to ensure that interventions are working as intended. However, one of the most surprising findings from our analysis—with clear relevance for uncertainties in practice—was that differential impacts by sexuality or sexual minority status were not frequently evaluated. This synthesis examines whether such interventions contribute to reducing health inequalities arising from these outcomes. DRV refers to physical, sexual and emotional violence in relationships between young people. GBV refers to violence rooted in gender and sexuality inequality . Common Impacts of DRV and GBV are disproportionately experienced by girls . Sexual DRV and GBV are amenable to intervention in schools via various approaches ranging from educational (e.g. classroom teaching) to structural (e.g. school policy changes) . Systema2This systematic review was part of a larger evidence synthesis project with a protocol registered on PROSPERO (CRD42020190463). As this was a systematic review, it did not require ethics approval.2.1Randomised-controlled trials that evaluated moderating factors of intervention effectiveness were included, including both parallel and cluster designs. Trial populations were children of compulsory school-age (5- to 18-years of age). Interventions were included if they were implemented within school settings and were partially or wholly targeted at reducing DRV or GBV outcomes. No restriction was placed on the content of interventions or the method of delivery. Comparisons with a control intervention  were included. Analyses that investigated the moderation of DRV or GBV perpetration or victimisation outcomes were included, regardless of the moderating factor or the findings. Data from formal moderation tests as well as raw event rate data for moderator subgroups, where available, were extracted.2.2A literature search was conducted in July 2020 across a broad range of bibliographic databases including Ovid MEDLINE, Embase, APA PsycINFO; EBSCO CINAHL, Education Research Complete, ERIC; ProQuest ASSIA, Sociological Abstracts, Dissertations and Theses; Web of Science Social Science Citation Index, and the Cochrane Central Register of Controlled Trials. Searches were not limited by date, language or publication type. Database searches used a combination of free-text terms and subject headings for schools and DRV/GBV. The search was updated in June 2021 with additional free-text search terms for interventions identified in the original search.Forwards and backwards citation searching on included studies was also used, and the reference lists of relevant systematic reviews and reports were reviewed. Supplementary searches were also conducted, including targeted author name searches in Web of Science and Scopus, and searches of key websites, trial registries and Google Scholar. Search results were downloaded into EndNote X9  for deduplication. Full details of the literature search strategy and sources are provided in Records identified in the search were screened for inclusion by two reviewers at both title/abstract and full text. Publications were not excluded at title/abstract on the basis of outcome. Disagreements were resolved through discussion and with the involvement of a third reviewer as necessary. Data were extracted into a piloted data extraction form and checked by a second reviewer.2.3Box 1. Interpretation of harvest plotsBars vary by height, colour and shading, and have a number that represents the number of relevant interaction tests for that moderator and outcome.height of bars represents the significance and direction of moderation presented by a trial. Full height bars represent significant moderation for a given outcome demonstrating greater intervention impact for one group. Three-quarters height bars represent a pattern of moderation estimates including some, but not consistent, significant evidence of greater intervention impact for one group. Half-height bars represent consistently non-significant estimates of moderation trending in one direction, and quarter-height bars are used for studies that only present non-significance as opposed to moderation estimates.The colour of bars represents the timeframe of outcomes analysed. Blue bars represent moderation evidence from long-term outcomes, red bars represent moderation evidence from short-term outcomes, and purple bars represent moderation evidence from both short-term and long-term outcomes.The shading of bars represents the nature of the moderation analysis. Dark shaded bars represent formal interaction tests, whereas light shaded bars represent outcome evaluations where formal interaction tests were not presented.Finally, the We synthesised evidence narratively, considering each test of effect modification within an outcome evaluation as a data point. We first considered whether enough studies were presented to construct a harvest plot for overall outcomes and then, where possible, explored findings by type of DRV or GBV. Harvest plots are an imaging tool used to depict the cumulative evidence of effect modification across included studies with individual bars representing trials organised by rows defined by outcomes and placed according to the moderation evidence . Further details are presented in Box 1. To minimise double-counting, the number of relevant interaction tests for each study and each outcome is the number of tests for non-overlapping outcome constructs; i.e. where tests are undertaken for multiple types of violence and for a violence construct that is the sum of all of these types, overall tests are not reflected in the harvest plots.A common issue in included analyses was the lack of a formal test for moderation, either by significance of an interaction term, a Wald test or a likelihood ratio test comparing nested models. Where possible, we were able to construct statistical estimates of effect modification by using estimates from subgroups with a standard z-test for equality of means, using log-transformed estimates where necessary (e.g for effect estimates expressed as odds ratios). Failing this, we were able to approximate direction and likely significance of interaction estimates based on additional within-trial information .Given the lack of an agreed appraisal tool for moderation analyses, we did not specifically appraise moderation analyses, instead highlighting where these were imputed as a key marker of quality.3A total of 26 reports of 23 outcome evaluations comparing active vs control were included in our synthesis of moderation evidence see .The largest category of moderator analyses covered sex, comparing boys versus girls as a binary variable . These moderator analyses were reported in 20 outcome evaluations. Six outcome evaluations considered prior history of the outcome as a moderator (e.g. whether prior history of DRV perpetration moderates intervention impacts in reducing DRV perpetration).Five outcome evaluations considered ethnicity as a moderator, contrasting majority populations against ethnic minority populations. A further moderator analysis  from an Formal moderation tests were not presented in nine outcome evaluations  comparin3.1Moderation of intervention impacts on DRV victimisation was tested in 13 outcome evaluations .3.1.1In total, 12 outcome evaluations  reportedThe resultant harvest plot for this outcome and moderator is shown in 3.1.2Five outcome evaluations  reportedThe resultant harvest plot for this outcome and moderator is shown in 3.2Moderation of intervention impacts on DRV perpetration was tested in 14 outcome evaluations .3.2.1Sex was considered as a moderator of DRV perpetration outcomes in 13 outcome evaluations . Four evThe resultant harvest plot for this outcome and moderator is shown in 3.2.2Four outcome evaluations  consider3.3Moderation of intervention impacts on GBV victimisation was tested in 13 outcome evaluations .3.3.1Sex as a moderator of GBV victimisation outcomes was considered in 11 outcome evaluations . Four ouA further five evaluations  did not Finally, two evaluations suggested a greater impact on girls. One outcome evaluation  suggesteThe resultant harvest plot for this outcome and moderator can be seen in 3.3.2Three evaluations  consider3.4Moderation of intervention impacts on GBV perpetration was tested in 10 outcome evaluations .3.4.1Ten outcome evaluations  considerThe resultant harvest plot is displayed in 3.4.2Two evaluations  consider3.5Moderators pertaining to dating history, age, ethnicity, acculturation, sexuality, and poverty status are presented in 4The majority of equity-relevant analyses reported moderation related to sex and prior history of the outcome. All other evidence for equity-relevant moderators, including age, ethnicity, sexuality and poverty, were sparse and did not present conclusive indication of moderation within outcome. Our syntheses suggested that programme effects on DRV victimisation were not moderated by gender or prior experience of DRV victimisation. However, there was evidence from multiple studies for gender moderating programme effects on DRV perpetration with greater benefits for boys, particularly for emotional and physical DRV perpetration. There was weaker evidence that programme effects were greater for those with prior experience of DRV perpetration.In contrast to DRV victimisation, there was some evidence that programmes had greater effects reducing GBV victimisation among boys than girls, driven primarily by longer-term evidence. Two studies examined prior experience of GBV victimisation finding little evidence of moderation. The finding of a larger effect for male than female GBV victimisation is surprising and hard to interpret. Similarly, there was some, albeit patchy, evidence that programmes were more effective in reducing GBV perpetration for girls than for boys, and some evidence that programmes were more effective for those with prior experience of GBV perpetration.4.1The finding that, for some DRV perpetration outcomes, effects were larger for boys suggests that these programmes were not gender-neutral in their impacts and, possibly, in their delivery and mechanisms of impact. The programmes may have been interpreted by students as programmes aiming to reduce male perpetration of DRV and, also informed by the above findings on mediation, might have achieved these effects via changes in male attitudes to violence. There was weak evidence that such mechanisms might have been slightly stronger among those who had previously engaged in perpetration. The finding that programmes may have been more effective in reducing GBV perpetration among girls more than boys is unexpected and not easily interpreted. It might possibly be that programmes encouraging girls not to perpetrate GBV were more novel and therefore impactful than similar messages concerning male perpetration, or that interventions may be more effective when targeting audiences regarding GBV as a less acceptable behaviour. However, this is speculative and this finding adds to the overall picture that GBV programmes may not work as theorised; i.e. with respect to gendered theories of violence.From a practice perspective, our findings suggest that interventions are just as, if not more, effective as secondary prevention compared to primary prevention. Our findings also suggest that practitioners should carefully monitor local intervention effectiveness and equity to ensure that interventions are working as intended. However, one of the most surprising findings from our analysis—with clear relevance for uncertainties in practice—was that differential impacts by sexuality or sexual minority status were not frequently evaluated. This is despite the substantial burden of GBV that sexual minority young people experience, including as regards homophobic and transphobic violence. In addition, age-related moderation analyses were scant, despite their potential value in identifying a ‘critical period’ for DRV and GBV prevention, ideally building on early years learning about healthy relationships and social skills.4.2meta-analysis even non-significant estimates can contribute towards the overall magnitude of the effect. Finally, understanding of DRV and GBV has evolved considerably over the last decade. While this may have been reflected in changes to measuring effect modification, we did not find that removing studies reporting over a decade prior to the search affected our conclusions.A strength of this analysis is the extensive search and the comprehensive presentation of included moderator analyses. This is the first review of its kind in this area. However, as with any review, it is possible that some relevant studies were missed. In addition, as noted above, not all studies presented complete information on moderation analyses; and it is possible, if not likely, that some exploratory analyses were not reported. This is especially the case if findings were not significant or otherwise judged uninteresting. These possibilities cannot be excluded, nor their impact on the findings estimated. Indeed, a challenge with harvest plots is that their ability to depict studies with moderation analyses described as ‘not significant’ is limited, given that in standard 5Our systematic review has suggested that while intervention effects for DRV perpetration are not gender-neutral, intervention effects for GBV outcomes are counterintuitive. To ensure interventions are equity-promoting, future triallists and developers should consider where and why equity effects may arise.This study is funded by the NIHR Public Health Research Programme (NIHR130144). In addition, Vashti Berry and G.J. Melendez-Torres are part-supported by the NIHR Applied Research Collaboration South West Peninsula (NIHR PenARC) and Chris Bonell is part-funded by an NIHR senior investigator award. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in the design and conduct of the study.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The principles were developed by internationally‐renowned surgical experts within the Balliol Collaboration who have gone on to promote these within their respective local and national jurisdictions. The resultant engagement with these recommendations is reflected by the primary paper within the Lancet SeriesEvidence‐based surgery is the practice of using reliable scientific data to deliver surgical care for optimal patient and system outcomes and to advance surgical care at an individual, community, and population level. Global engagement with evidence‐based surgery has followed the rapid progress of the evidence‐based medicine paradigm,ANZ Journal of Surgery, have reflected this, by reducing physically‐printed information and moving towards the dispersion of data via digital media alone.To be effective, marketing needs to adapt methodologies to incorporate modern technologies. Electronic data and information technology are now firmly integrated within the foundation of modern healthcare systems.The philosophy fundamental to evidence‐based surgery is adaptable to the digitalisation movement, and can even be employed to enhance the utilization of electronic data and information technology within surgical systems of care. To optimize the potential for information dispersion that accompanies the use of digital data, surgical groups and institutions should look to harness technology to market evidence‐based principles wherever possible. As seen with the success of the Balliol Collaboration in communicating a reliable structure for surgical innovation to the global surgical community,Joshua G. Kovoor: Conceptualization; investigation; writing – original draft; writing – review and editing. Jacob Cherini: Conceptualization; investigation; writing – review and editing. Stephen Bacchi: Conceptualization; investigation; writing – review and editing. Guy J. Maddern: Conceptualization; investigation; supervision; writing – review and editing.