Rx for Change, provide quick access to summaries of appraised systematic reviews of professional and consumer-oriented interventions to improve prescribing behaviour and appropriate medication use, and may help maximise the use of evidence to inform decisions. The present study aims to evaluate a training program to improve attitudes towards, confidence in skills, intentions to use, and use of systematic review evidence contained within Rx for Change.Suboptimal prescribing and medications use is a problem for health systems globally. Systematic reviews are a comprehensive resource that can help guide evidence-informed decision-making and implementation of interventions addressing such issues; however, a barrier to the use of systematic reviews is their inaccessibility . Publicly available databases, such as Knowledge to Action framework, a training program with content customised to local provider and consumer contexts was developed with knowledge user input. The training program consisted of a 6 minute information video, a 1 hour workshop with hands-on, interactive and didactic components, and two post-training reminders. Forty-nine people from five medicines-focused organisations in Canada and Australia attended one of six workshops. Participants were surveyed immediately pre and post and 3 months after training to evaluate their attitudes towards, confidence in skills, intentions to use, and use of Rx for Change, and attitudes towards and confidence in skills for using evidence for decision-making. Analyses for differences for each of the outcomes at three time points  was performed using a random effects model.Guided by the Rx for Change ; intention to use Rx for Change ; confidence in skills for using Rx for Change ; and confidence in skills for using evidence in policy decision-making  compared to pre-training. Confidence in skills for using both Rx for Change and evidence were maintained 3 months after training (both P < 0.005).Immediately post-training, there were higher respondent attitudes towards Participants of this training program reported sustained improvements in their confidence in skills for using evidence in policy decision-making. This may have important implications for uptake of systematic review evidence promoting improved prescribing and medication use. Health systems globally are focused on addressing inappropriate prescribing by healthcare professionals (providers) and inappropriate use of medications by patients (consumers) to maximise patient outcomes and minimise healthcare costs , 2. Sub-Systematic reviews comprehensively synthesise available evidence about potential policies and interventions to improve medication use but knowledge users find it difficult to access relevant systematic reviews and make sense of research evidence . KnowledIn response to these challenges, a range of innovative knowledge translation resources have been developed to facilitate the use of evidence to inform decision-making, including simplified frameworks developed with contribution from the policy sector to better understand how any given approach to increasing the use of evidence can be applied and understood , websiteRx for Change, an evidence-based resource of appraised and summarised evidence on the effectiveness of interventions targeting healthcare professionals and patients to improve prescribing and medication use [http://www.rxforchange.ca). Rx for Change is a collaboration between researchers at the Cochrane Effective Practice and Organisation of Care (EPOC) Group and the Cochrane Consumers and Communication Review Group (CC&CRG) primarily funded by the Canadian Agency for Drugs and Technologies in Health [The Cochrane Library, and EMBASE. Full text copies of potentially relevant reviews were retrieved and assessed for relevance [Rx for Change database is organised according to intervention type  and category  using taxonomies developed by EPOC and CC&CRG [Rx for Change contains more than 300 summarised reviews that synthesise findings from thousands of individual studies, spanning all conditions and diseases, and evaluating interventions targeting healthcare provider or consumer behaviours to improve medication prescribing or use.One such freely available online database is tion use  , anecdotal evidence suggests the need for further training to maximise use of the database for evidence-informed decisions.The primary objective of cymakers . HoweverRx for Change in collaboration with relevant knowledge users. The development of the training was guided by the Knowledge to Action framework [Rx for Change, as well as attitudes towards and confidence in skills for using evidence in general.The aim of this project was to develop and evaluate a training program for ramework . This frramework . The focRx for Change and a need for additional training. The three Canadian sites focused on evidence for organisational, professional and regulatory interventions, which are consistent with the primary interest (and expertise) of EPOC. Consistent with the primary interests (and expertise) of CC&CRG, the knowledge user organisations from the two Australian sites focus primarily on evidence for consumer-oriented interventions. The organisations were a mix of national (n = 2), provincial (n = 3), and government (n = 4) or non-government (n = 1) sites. All programs provided support and information that was needs driven, with the Canadian sites focusing on the ultimate goal to influence local provider behaviour, and the Australian sites focusing on consumer behaviour.This study used a pre–post design with a 3-month follow-up. Five knowledge user organisations responsible for the development of programs to improve prescribing and medication use contributed to this project, three from Canada (provider focused) and two from Australia (consumer focused). All five of these organisations expressed an interest in improving their use of Rx for Change database, and their needs and preferences for training. The interviews were transcribed and analysed using a directed content analysis [Rx for Change, and the need to address a variety of preferences for how the training should be delivered (tailoring). There was also an interest in including practical and locally important examples on incorporating evidence within their workplace context. In order to respond to this need and the desire to learn how to use evidence for policy decision-making, we developed a workshop that incorporated content from an existing framework for using evidence in policy decision-making – the SUPPORT Tool process [Rx for Change and encourage its use. Following the development of the training, a final feasibility check for the proposed training was completed with a manager from each of the five participating organisations. A more comprehensive presentation of the findings of the interviews and details of intervention design that resulted from this initial stage of the project is presented elsewhere [Key informants (n = 16) from each knowledge user organisation participated in interviews to shape the content and format for the training programs so that they were (1) tailored to their needs and (2) designed to address provider or consumer issues and barriers across the two countries. The semi-structured interviews included questions on their current use of evidence for decision-making, barriers and facilitators to using evidence as well as the analysis . The mai process . The SUPlsewhere .Rx for Change in the 3 months prior to the workshop and in the 3 months following the workshop (i.e. how many times in the past three months had they used Rx for Change), attitudes towards using evidence and Rx for Change for policy decision-making , confidence in skills , and intention to use Rx for Change . Surveys were developed for the study and were piloted in terms of relevancy, clarity and completeness.Participants were recruited from each of the knowledge user organisations via email invitations distributed to one key contact within each of the organisations and forwarded to potentially interested staff. The training was delivered to the five knowledge user organisations (training was provided twice to one organisation with a significant geographic range). Participants were surveyed immediately pre and post and 3 months after training. The surveys included questions on self-reported use of Rx for Change, (2) confidence in skills for using Rx for Change, (3) attitudes towards using evidence in decision-making, and (4) confidence in skills for using evidence for decision-making. Table Given the large number of variables in the survey (i.e. 24), the problems associated with multiple testing , and theP value of < 0.005 being considered as significant. All statistical analyses were undertaken using Stata .The survey responses were analysed descriptively and with frequencies and counts. Differences before and after training as well as between provider and consumer oriented organisations were analysed using a random effects model, with organisational unit used as a random effect and robust variance estimates used for each of the five outcome measures, each assessed on a scale from 1 to 5 time period  was the exposure variable, with the pre-training time point being used as the reference point. As participant responses were anonymised at the point of collection, repeated measures analyses could not be performed. To formally test if the effect of the intervention may vary between countries or organisations, interaction terms were fitted between time points and these clusters. A Bonferroni correction for multiple analyses  was used, resulting in a Rx for Change database.A total of 49 participants attended the workshops and submitted the pre-workshop survey (one with incomplete responses). For the post-training survey and 3-month follow-up, we had 47 and 28 participants submit the survey, respectively . Figure Rx for Change in the preceding 3 months. When asked to consider their use of Rx for Change in the 3 months since the training, only 39% (11/28) indicated that they never used Rx for Change. The number of people indicating that they used Rx for Change in the previous 3 months at least 2–3 times per month increased from 8% (4/49) during the 3 months prior to the training to 32% (9/28) during the 3 months after the training. Table Rx for Change.Prior to the training, 78% (38/49) of participants indicated that they never used y 39% 11/8 indicatRx for Change and confidence in skills to use evidence were statistically significantly greater than pre training at both the post and 3 month follow-up time points . Attitudes towards using evidence for decision-making were not significantly different from pre training at post training (P = 0.635) or at 3 months follow-up (P = 0.662). Both attitudes towards, and intentions to use, Rx for Change increased at post training (both P < 0.005), but not at follow-up . Table P values for interactions > 0.01), although there was limited power to detect such effects.Results indicated that confidence in skills to use Rx for Change) that policymakers could use to inform the design of programs to improve medication use. We tested this training for effects on attitudes towards, confidence in skills, intentions to use, and use of Rx for Change as well as attitudes towards and confidence in skills for using evidence for decision-making. We measured our outcomes pre and post the training workshop as well as at 3 months post training. Pre–post training effects were found for attitudes towards, and confidence in skills for using Rx for Change, as well as confidence in skills for using evidence for decision-making. More importantly, effects on confidence in skills for using Rx for Change and for using evidence for decision-making were maintained at 3 months post training. Therefore, the results indicate that this workshop, developed with input from knowledge users and using an evidence-based process of using evidence for policy decision-making as a guide, has potential to improve immediate and long-term confidence in skills in using this particular database, and in using research evidence in general.We developed user-informed training to increase the use of an online database of systematic reviews , there was either little room for improvement (suggesting a ceiling effect) or our scale was not able to detect differences. Attitudes towards using evidence tend to be positive, even if behaviour is not consistent with this attitude. Programs of this nature should probably not solely focus their efforts on changing attitudes towards using evidence but rather behaviours around the use of evidence. We did not observe any differences in intentions to use  culture . While aRx for Change since the training, yet there were fewer participants who indicated that they did not use Rx for Change in the 3 months after training than in the 3 months prior to training. We were unable to explore if participants had a need to use Rx for Change since the training, making it difficult to fully interpret our Rx for Change use data. However, the results suggest that with no change in their intentions to use Rx for Change, a decrease in their attitudes towards it, and confidence in skills potentially declining, it is likely that use rates will revert to pre-training levels. This is often the case in knowledge translation interventions [Forty percent of the sample indicated that they had not used ventions , and metRx for Change, and this was maintained at 3 months. However, there is a trend towards declining confidence in skills. This might signal that additional skill development activities might be required to support the ongoing use of a database like Rx for Change.Confidence in skills for using evidence improved after the workshop, with the improvement being maintained 3 months later. This is an important result, particularly for a 1 hour workshop. Similar to confidence in skills for using evidence, the workshop improved perceptions of confidence in skills for using While consumer-based and provider-based organisations from different countries were used in the study, the staff within these organisations undertook similar duties – outreach to others to improve use of evidence. The ‘others’ were different but the people we targeted with the intervention were not that different. If, for example, physicians had been the targets of the education, differences would have been expected. This finding might improve the generalisability of our findings to a broad array of policy-based groups. However, caution in generalising is warranted given our context of only two countries and both being of high income.Rx for Change [Rx for Change training, three from Canada and two from Australia. By involving targeted user audiences we can better understand the needs of individuals or groups concerned with the identification and/or implementation of interventions used to change provider  and consumer (patient) behaviours as it specifically relates to medicines prescribing or practice. Limitations of this study include a relatively small number of sites and participants. In addition, the 3 month follow-up data only included 28 of the 49 participants who attended the workshop, resulting in an even smaller sample at the follow-up, thus increasing the potential for bias and reducing power to observe effects. While we did include a 3 month follow-up, the timing of this follow-up was short, and no further follow-up took place. The most significant limitations were the design of the study  and the use of a survey that was designed specifically for the study. While we did pilot test the survey for relevancy, clarity and completeness, we did not undertake additional measures of reliability and validity. Our conclusions are therefore tentative and additional experimental research is needed.We guided our research using the Knowledge to Action framework , which gr Change . AnotherRx for Change. Participants of this tailored training program reported sustained improvements in confidence in skills for using evidence in policy decision-making. This may have important implications for uptake of systematic review evidence to promote improved prescribing and medication use.The evaluation component aids understanding and future activities to optimise use of


Manual therapy is often used for patients with neck pain with or without radicular symptoms. There is sparse evidence on the effectiveness in cervical radiculopathy. The aim of this study was to assess current levels of evidence on the effectiveness of manual therapy interventions for patients with cervical radiculopathy.Electronic data bases were systematically searched for clinical guidelines, reviews and randomised clinical trials (RCTs) reporting on the effectiveness of manual therapy for patients with cervical radiculopathy. Eight relevant reviews, two guidelines and two recent RCTs, that had not yet been included in either, were retrieved. The overall quality of the evidence of included studies was evaluated using the GRADE method. Most interventions were only studied in one single RCT.There is low level evidence that cervical manipulation and mobilisation as unimodal interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of thoracic manipulation or mobilisation as unimodal interventions. There is low level evidence that a combination of spinal mobilisation and motor control exercises is more effective on pain and activity limitations than separate interventions or a wait-and-see policy. There is low level evidence of the effectiveness of cervical mobilisation with a neurodynamical intent as unimodal intervention, on the effectiveness of a multimodal intervention with neurodynamic intent on pain activity limitations and global perceived effect compared to a wait-and-see policy. There is also low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific exercises is effective on pain in patients with CR. There is low level evidence that traction is no more effective than placebo traction. Cervical radiculopathy (CR) is a term used to describe radiating pain in the arm with motor, reflex and/or sensory changes (such as paraesthesiae or numbness), provoked by neck posture(s) and/or movement(s) , 2. It ith and 6th decade in both genders has been reported , 3) indirectness , 4) imprecision  and 5) other considerations, such as reporting bias. The quality of the evidence was downgraded by one level when one of the factors described above was met [High quality: further research is very unlikely to change confidence in the estimate of effect.Moderate quality: further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.Low quality: further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.Very low quality: there is much uncertainty about the estimate.No evidence: no evidence from any RCTs.The overall quality of the evidence was evaluated using the GRADE method. The quality of the evidence was based upon five principal factors: 1) limitations in study design , 2) inconsistency of results [downgraded when there was statistical heterogeneity  reviews were retrieved, two guidelines on the effectiveness of manual therapy (either as a subgroup or as part of a population of non-specific neck pain) and two recent RCTs that had not yet been included in either see Fig. .Two reviews specifically looked at the manual therapy treatment of patients with CR (see Table One review included 4 studies –19 in whAnother review on chiropractic High Velocity Low Amplitude (HVLA) manipulations, reflecting on chiropractic treatment practices, included 1 RCT , a prospSix other reviews –28 assesTwo systematic reviews evaluated the effectiveness of conservative therapies specifically for patients with CR and included manual therapy as an intervention  concluded there is moderate evidence for the effectiveness of neurodynamic mobilisations and that, based on low-level evidence, thoracic manipulations and traction can be considered for patients with CR . A multiAll the above mentioned reviews included a total of 7 RCTs , 38, 39 Two recent RCTs had not yet been included in a review , 42. TheFive out of the nine included RCTs were of high methodological quality, as assessed using the PEDro scoring system  as a unimodal intervention with ultrasonography in patients with CR. They reported an increase in elbow extension during an Upper Limb Neural Tension test (ULNT) and a decrease in the area of symptom distribution, and pain intensity directly after treatment . No studManual therapy in RCTs of patients with CR is often an umbrella term encompassing multimodal interventions such as cervical manipulations and mobilisations combined with thoracic manipulations/mobilisation, traction, massage, neurodynamic mobilisation and specific exercises , 40, 41.Results from one study of high methodological quality suggested that, based on the size of the treatment effect on pain and activity limitations, a combination of manual therapy and motor control exercises was more effective at short term follow up (4 and 8 weeks) than a wait-and-see policy . One stuOne study of high methodological quality compared the effectiveness of traction or placebo traction added to a regime of cervical mobilisation, thoracic manipulation and exercises. At the 2 and 4 week follow up there were no significant differences on pain or activity limitations . In concOne study of high methodological quality s compared the effectiveness of cervical mobilisations with a neurodynamic intent combined with neurodynamic mobilisations using the shoulder and arm, to a wait-and-see policy . At the Two studies of low methodological quality compared the effectiveness of a multimodal intervention  to other conservative interventions in patients with CR , 30. OneIn conclusion, there is low level evidence from two studies of low methodological quality that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific exercises is effective on pain in patients with CR.This study aimed to assess the effectiveness of manual therapy interventions for patients with CR in comparison to other conservative treatments, placebo interventions or a wait-and-see policy. The overall level of evidence for any intervention is low. This is mainly due to the fact that most interventions have only been evaluated in one single study and some of these were of low quality, which seriously impedes the firm drawing of conclusions.There is a paucity of evidence for individual interventions or for combinations of interventions. From the few studies that were conducted, it would seem that multimodal management strategies are generally more effective than unimodal interventions. Several reviews and guidelines also conclude that a multimodal management strategy, comprising of spinal and neurodynamic mobilisation and specific exercises is the more effective conservative treatment for patients with CR , 45, 46.The preference of a multimodal approach is in agreement with recent publications on the effectiveness of conservative treatments of a variety of musculoskeletal disorders –54. It aIn general, conservative treatments are not aimed at the pathology itself (in case of CR degenerative spondylosis or disc herniation), but rather at the predictable ensuing consequences. As radiculopathy is a neurological state in which conduction is blocked along a spinal nerve or its roots, it is not defined by pain alone, but also by neurological signs which can consist of motor, reflex and/or sensory changes such as paraesthesiae or numbness , 57. MotChronic pain is also associated with CR. Specific dysfunctions in local muscles of patients with chronic pain have been documented, resulting in a loss of local motor control and direction specificity –62. ChanA limitation of this study is having only one rater, so that a ‘risk of bias’ assessment according to Cochrane Collaboration guidelines could not be executed. Instead, the PEDro scale of quality assessment was used. In defence, all trials on PEDro are independently assessed for quality and there is preliminary evidence of the convergent and construct validity of the PEDro total score and the construct validity of eight individual scale items . AnotherOnly two studies on cervical traction were included in this review as they were the only ones including manual therapy as an intervention , 29. Onethere is low level evidence that cervical manipulation as unimodal intervention is effective on pain directly after treatment but not at longer term follow up,there is no evidence on the effectiveness of thoracic manipulation or mobilisation as a unimodal intervention,there is very low level evidence that cervical mobilisation as a unimodal intervention is more effective at immediate follow up than a placebo or a wait-and-see policy on pain and ROM,there is low level evidence of the effectiveness of cervical mobilisation with a neurodynamic intent as unimodal intervention,there is low level evidence that a combination of spinal mobilisation and motor control exercises is more effective on pain and activity limitations than separate interventions or a wait-and-see policy,there is low level evidence that traction is no more effective than placebo traction,there is low level evidence on the effectiveness of a multimodal intervention with neurodynamic intent on pain activity limitations and GPE compared to a wait-and-see policy,there is low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific exercises is effective on pain in patients with CR.In patients with CR:There is a lack of evidence for the effectiveness of manual therapy in patients with CR. Nearly all interventions have only been studied once and even then some in a low quality study only. Just two manual therapy interventions have been studied twice and then as part of multimodal interventions. Clearly there is a need for repeated high quality studies to be able to give patients and health care providers evidence based advice on management choices.


Evidence‐based health care (EBHC), previously evidence‐based medicine (EBM), is considered by many to have modernized health care and brought it from an authority‐based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC.In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to “purify” clinical reality into a dichotomy of objective “evidence” from nature and subjective “preferences” from human society and culture.However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition—albeit implicit and undertheorized—that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a “situated practice” rather than as a sequence of research‐driven abstract decisions. Originally known as evidence‐based medicine (EBM) and now usually referred to as evidence‐based health care (EBHC) to embrace all health care professions, the movement has achieved much but also drawn criticism and concerns.the evidence based ‘quality mark’ has been misappropriated by vested interests; the volume of evidence, especially clinical guidelines, has become unmanageable; statistically significant benefits may be marginal in clinical practice; inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred; and evidence based guidelines often map poorly to complex multimorbidity.For instance, in 2014, a group of scholars questioned whether the EBHC movement was “in crisis” as a result of a number of unintended consequences of its earlier successWe have never been modern.Many authors consider that the emergence of EBM/EBHC (a movement that continues to evolve) marks the shift from the traditional “priestly authority” of doctors to a more modern, knowledge‐based—and hence rational and scientific—authority.1.1The term “modernity” is generally used to describe a historic period in European arts, politics, science, and the humanities that began in the 16th century with the rise of the new cosmology and experimental science and extended to the 20th century. It conveys the idea of a general progress towards the rejection of traditional and religious explanations as envisioned by enlightenment philosophers as well as early social theorists such as Max Weber, Emile Durkheim, and Auguste Comte. Their work culminated in a broad range of related theories and ideas still prevalent today. With modernity came increasing secularization, rational thought and rejection of tradition along with the firm belief that reality is based on empirically testable scientific laws.Bruno Latour wrote several classic books on the practices and nature of science that already inspired others to discuss relevant issues of the evidence‐based movement, such as the standardization of morals and patientsWe have never been modern, Latour acknowledges many versions of modernism, which is recognizable when society is engaged in 2 separate practices: purification, which means to make a distinction between nature  and human culture (which is man made), and translation/hybidrization, defined as efforts to combine elements of nature and culture in “hybrids networks”  entails that nature is always objectively knowable and never man made and human culture is always made up and never influenced by nature.According to this view, we would be “modern” when and to the extent that we could successfully separate nature and culture and subject the former to rational scientific analysis. However, argues Latour, despite the application of advanced scientific techniques and technological apparatus, modern society is struggling and failing to keep these 2 phenomena apart. Nature and culture remain inextricably linked, just as they were in the premodern era.To resolve this modernist problem, Latour does not argue for a return to premodern obscurantism, ie, deliberately precluding full understanding of anything. Instead, he introduces an alternative take on reality, which he calls a “middle kingdom.” In this view, the world, consisting of both nature and culture, is explained with reference to “hybrids” or the so‐called “quasi‐objects.” He offers a number of examples including soccer balls,1.2A new paradigm is emerging. EBM de‐emphasises intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research.The emergence of EBM in the early 1990s can be understood as a modernist movement. For instance, an article by the EBM Working Group in JAMA in 1992 opens as follows:[…] health information systems should be evaluated with the same rigour as a new drug or treatment programme, otherwise decisions about future deployments of ICT in the health sector may be determined by social, economic, and/or political circumstances, rather than by robust scientific evidence.In the above quote, real patients and conditions are understood as hybrids of 2 pure forms: objective nature and subjective culture. Clinical research is depicted as able to provide “facts” of biology and epidemiology, as far as possible void of human intuition or experience. Indeed, the programme of training that was to be offered to the early students consisted (more or less) of a menu of tools, techniques, and processes for separating objective  evidence from subjective (untrustworthy) opinions, biases, and perspectives. Thus, EBM began with explicit aspirations to modernism that still persevere today.Not all early protagonists of EBM rejected the value of clinical expertise. Indeed, Sackett et al famously defined EBM as an approach that integrates the best external evidence with individual clinical expertise and patients' choice.The moderns […] did not make quasi‐objects disappear by eradication and denial, as if they wanted to simply repress them. On the contrary, they recognized their existence but emptied it of any relevance […] The modern explanations consisted in splitting the mixtures apart in order to extract from them what came from the subject  and what came from the object. Next they multiplied the intermediaries in order to reconstruct the unity they had broken and wanted none the less to retrieve through blends of pure forms.Compare with Latour who writes:Thus, while Sackett and other early leaders of the EBM movement celebrated clinical expertise and the patent voice, they nevertheless insisted that evidence is developed in a secluded space outside the clinical encounter and only then translated through integration with expertise and preferences. In this way they reproduced the dichotomy between science and translation typical of modernism.…[a] Cartesian epistemology of differentiation—a reality of distinct subjects and objects—in which research evidence and clinical practice are seen as dualistically opposed. Evidence, in this context, is seen as a commodity, whose better, quicker, easier to access, and increasingly electronic transfer, from the research pole to that of practice will lead to the more effective clinical management of patients […]. Whilst the appeal of this dualist model is its maintenance of stable boundaries and firm divisions: objective/subjective, research/practice, facts/values, such thinking is almost always structured so as to privilege one side of the dualism over the other. This has made possible the hierarchical distinction between, for example, the objective ‘facts’ of biomedical research and the subjective ‘mere knowledge’ of clinical practice. Here, an analytic and disembodied (scientific) organisation of knowledge is privileged over more tacit and situated experiences: a body of evidence, separated from its social context, that can be unilaterally transmitted from the research setting—where it is known—to the world of practice—where it is not.By the late 1990s, critical social scientists were reflecting that EBM had succeeded in producingThe 1990s and 2000s saw an exponential expansion in the kind of research designated by the EBM community as “robust”—defined in terms of the methods used to reduce or eliminate bias in the collection and analysis of empirical data. The large RCT became the bread‐and‐butter type of research and in its trail rapidly followed increasingly sophisticated systematic reviews and meta‐analysis, instruments to appraise clinical practice guideline development, frameworks to guide and assess clinical care pathways, and the institutionalization of implementation as a science.1.3The original vision of the EBM movement was that within a generation, the evidence base for clinical decisions would have been collected, collated, and distributed for easy access by clinicians and policymakers. This knowledge base—“best evidence”—would be objectively verifiable and readily updated in real time as new research evidence from robust study designs accumulated.However, research evidence in many fields remains heavily contested. The scientists, clinicians, and guideline developers involved are usually EBM experts; they understand the rules for interpreting clinical trials and screening programmes perfectly well. Yet they each interpret the evidence differently. These disagreements between experts often originate not from the data but from a difference in values.Contrary to how knowledge was viewed in pre‐modern societies, knowledge now tends to be understood as information, that is as consisting of objectified, commodified, abstract, decontextualized representations. The overabundance of information in late modernity makes the information society full of temptations. It tempts us into thinking that knowledge‐as‐information is objective and exists independently of human beings; that everything can be reduced into information; and that generating ever more amounts of information will increase the transparency of society and, thus, lead to the rational management of social problems. However, … the information society is riddled with paradoxes that prevent it from satisfying the temptations it creates. More information may lead to less understanding; more information may undermine trust; and more information may make society less rationally governable.In the light of these examples, the warning offered in 1997 by Haridimos Tsoukas was remarkably prescient :The original goals of EBM to provide a methodology to generate independent truths and objectively assess the certainty of facts have so far proved elusive. Society's influence pervades. Despite the hopes and predictions of its forefathers, EBM has never become modern.1.4The discourse on EBHC displays a greater degree of reflexivity from within the community. Whereas the early protagonists of EBM saw the movement as part of the inevitable march of scientific progress, social scientists have always viewed EBM as historically—and politically—situated. Judith Greene,The EBHC movement has attracted critical comments from sociologist and policy analysts from a number of perspectives: that for instance, clinical epidemiology is not always the most appropriate framework for decision making in healthcare […] and that EBM can be deconstructed as a discourse which functions to maintain the ‘purity’ of medical practice in the face of threats to autonomy […]. [O]ne key problem within the EBM movement lies in its assumption of rationalistic behaviour and linear change: that evidence is stable and independent of social relationships.A number of recent developments suggest that the EBM/EBHC movement is gradually recognizing its rigid adherence to modernism while it tempts to get to grips with its stance towards nature on one side and human society on the other.The EBM/EBHC no longer views the result of a sample mean in an RCT as applicable unproblematically to the single case scenario. There is a more sophisticated understanding of the translational process from scientific evidence to a particular situation such as a complex intervention at the organizational and system level or an individual patient in a particular situation.But now the EBHC community too appears to embrace these criticisms as it tries to find solutions for the inability to fully be modern. For example, to deal with vested interests, the ALLTrials campaignFor example, inspired by the concepts of “shared decision making”What is new about these instruments is that they do not just prescribe what objective, purified nature says (does the drug work?), but also present arguments from human culture . True, as they still separate nature and human society in neat categories, they remain largely modernist. But nature and society are put on a more equal footing than ever before.a relational competence, where empathic perceptiveness and creativity render doctors capable of using their personal qualities, together with the scientific and technologic tools of medicine, to provide individualized help attuned to the particular circumstances of the patient.These developments are still somewhat removed from what it takes to care for an actual patient. That would be what philosopher Annemarie Mol calls a “logic of care”—a constant tinkering, while avoiding neglectThere is an increasing interest in less purified kinds of knowledge, research methods, and styles of reasoning.But they do reveal a growing interest in the EBHC discourse to start thinking from the standpoint of real patients in real encounters as with Latours quasi‐objects.For example, works by GigerenzerWe do not need to attach our explanations to the two pure forms known as the Object or Subject/Society, because these are, on the contrary, partial and purified results of the central practice that is our sole concern. The explanations we seek will indeed obtain Nature and Society, but only as a final outcome, not as a beginning.These examples show an understanding that the products of modernist practice of purification (resulting in explicit law like rules of medicine) need to be watered down to become applicable “in reality.” Latour writes:Purified findings from well‐designed RCTs and reviews are wonderful insights, but at the end of the day, they may prove useless in the face of an actual patient, in the here and now.Of course, consultations themselves have always been about translation and hybridization. In consultations, patients and health care professionals swiftly connect molecules, plaques, platelets, cells, average blood pressures, drugs, lifestyle, food, function, meaning, values, sense, and care. What is new is the growing acknowledgement in the discourse on EBHC that these are not clearly separable in objective nature or subjective culture .2In his book, Latour sought to eradicate the divide between science and culture. His middle kingdom implies a fundamental questioning of the modernist conception of science that extends beyond EBM.We have never been modern, EBHC cannot acknowledge this middle kingdom without ceasing to be modern and collapsing back into premodernism.While current initiatives in the EBHC movement may concede the existence of a middle kingdom—that is, they accept that research evidence cannot sit above history, culture, or politics but is recursively linkedThis creates an ambivalence: On the one hand, EBHC (at least as it has developed) depends on mediation, translation, or a “cultural supplement.” On the other hand, it still relies on the purification of science to be separate from, and more objective than, real‐world messiness. The whole concept of “best evidence” hinges upon such a divide. If not, it risks becoming “unscientific.” Inevitably, then, EBHC must move towards a middle kingdom to deal with the paradoxes it has already generated . But EBHC can never fully embrace this middle kingdom without effectively rejecting the very concept of evidence on which its central claims are based. Instead of resolving this paradox, the EBHC movement must coexist with it and “muddle through.”Latour argues that while modernity is built on a myth (the separability of nature and culture), it nevertheless produces benefits. Modernity generates the need for translation, hybridization, and cultural/technological supplements, a need that follows from the act of purification itself. The practice of purification also leads very efficiently to many new insights (smoking leads to cancer), concepts , and natural objects (DNA). All these quasi‐objects would not have existed in a premodern society, he argues. Indeed, it is hard to underestimate the impact EBHC has had with its renewed methods of induction as means to purify clinical reality into more or less stable rules and recommendations.The new EBHC should reflexively reject the science‐culture dichotomy. Especially in some circumstances . Rather, we suggest that a progressive, mature, “middle kingdom” EBHC would reframe the concepts of “evidence” and “medicine/health care” in EBM/EBHC in several different ways:against the clinical and economic data, which proves difficult.”The new EBHC recognizes that all evidence—whether derived from science on the one hand or from human culture  on the other—requires translation and interpretation. This is in contrast to a recent study where researchers found that guideline panel members differentiated between “objective evidence” from studies and “insights” from patients. They write: “There is a tendency to try to weigh‐up the patients' views The danger of the dominant discourse of rationality is that by marginalising and devaluing the role of individual judgement, it undermines rather than strengthens actors' capacity to act.The new EBHC acknowledges the need to reason not only from the individual to the general or from the general to the individual but from individual to individual casuistry. In the The new EBHC recognizes its own limitations in relation to decision support and inductive inference in health care.Rather, a mature EBHC will seek to incorporate the messiness of real‐world hybridization into a wider range of approaches and methodologies. Concepts of a “gold standard” and a “hierarchy of evidence” become highly problematic in such circumstances. Randomized controlled trials require “supplements” to create better inferences for a complex reality, be it pragmatic trials, pattern recognition modelling, participatory codesign, or other approaches.Latour's framework unveils EBHC as just one of the activities (practices) of everyday health care. It is the practice of purification in that realm: making inferences to produce new insights and good decisions.But as a result of the focus on purification practices of early EBM, the purpose of health care itself became skewed towards aiming for objective evidence from nature at the expense of care and equity. The concept of health care as caring, loving, and nurturing has largely been lost in the process.I see the NHS, rather crudely, as supplying on the one hand therapy, and on the other board and lodging and tender, loving, care.This was not intended. For Archie Cochrane, who the early EBM proponents often cited in support of their view, health care had 2 equality important dimensions:Purification and hybridization have their place, but not predominantly. Health care is about making good inferences (which is the role of EBHC), about equity, and about relationship‐based, loving care. Paraphrasing Latour, health care should once again be reinstated as broad concept that has both “science and society as its satellites.”3In this paper, we aimed to provide an understanding of the current position changes and the future of the evidence‐based movement by introducing Latour's views on modernity as a framework for discussion. An ongoing dialogue within the movement is needed about the role, the paradox, and benefits and harms of the modernist practice of purification. With Wood, we would argue for more interdisciplinary practices: “innovation is neither natural or inevitable, but constantly negotiated and aligned—a path forged within an assemblage of scientific and organisational and behavioural factors.”


The spleen is an organ that filters the blood and is responsible for generating blood-borne immune responses. It is also an organ with a remarkable capacity to regenerate. Techniques for splenic auto-transplantation have emerged to take advantage of this characteristic and rebuild spleen tissue in individuals undergoing splenectomy. While this procedure has been performed for decades, the underlying mechanisms controlling spleen regeneration have remained elusive. Insights into secondary lymphoid organogenesis and the roles of stromal organiser cells and lymphotoxin signalling in lymph node development have helped reveal similar requirements for spleen regeneration. These factors are now considered in the regulation of embryonic and postnatal spleen formation, and in the establishment of mature white pulp and marginal zone compartments which are essential for spleen-mediated immunity. A greater understanding of the cellular and molecular mechanisms which control spleen development will assist in the design of more precise and efficient tissue grafting methods for spleen regeneration on demand. Regeneration of organs which harbour functional white pulp tissue will also offer novel opportunities for effective immunotherapy against cancer as well as infectious diseases. This intervention is essential to maintain blood–borne immunity against encapsulated bacteria such as Streptococcus pneumoniae, which is the leading cause of overwhelming post-splenectomy infection (OPSI), and is associated with a 50–70% mortality rate.3 Various surgical approaches have been developed to re-implant whole or dissociated spleen fragments into the body,1 and these spleen auto-transplantation techniques continue to undergo constant refinement.4Spleen is an organ with the innate capacity to regenerate.6 However, the rationale for transplanting fragmented spleen cubes or slices, the events surrounding graft survival and tissue regeneration, and more precisely the cells controlling de novo spleen formation, are not well defined or understood. Indeed, it is accepted that most graft tissue does not even survive the initial transplantation period, and instead undergoes rapid and almost complete necrosis.7 When examined in animal models, mostly non-hematopoietic cells have been observed to survive the primary necrotic phase,7 raising the possibility that spleen stroma instigates or provides a foundation for new tissue growth. This has been supported by studies transplanting neonatal spleen stromal tissue grafts, prepared by mechanically separating hematopoietic cells from the stromal component of murine spleen tissue.8 Transplantation of these grafts have demonstrated that spleen stroma is sufficient to initiate new tissue development.8Fragments of spleen tissue are typically used for both clinical and experimental spleen auto-transplantation.+ICAM-1+MAdCAM-1+ lymphoid tissue organiser (LTo) cells, and hematopoietic CD3−CD4+IL-7Rα+ lymphoid tissue inducer (LTi) cells.10 Lymphotoxin-α1β2 (LTα1β2) is also an essential molecule for lymphoid tissue development, and in the absence of a functional lymphotoxin signalling pathway, both lymph node and Peyer’s patch formation is abolished.13 Intriguingly, embryonic spleen develops in the absence of lymphotoxin signalling. Lymphoid tissue inducer cells are similarly dispensable, since RORγ gene knockout which is critical for LTi development leads to the cessation of embryonic lymph node, but not spleen organogenesis.14An underlying contribution of stromal cells to lymphoid tissue organogenesis has been recognised during embryonic development. The formation of lymph nodes and Peyer’s patches is heavily dependent on early interactions between stromal VCAM-1-/- neonatal mice were grafted into wild-type recipients.8 Here, the formation of gross spleen tissue was unimpeded, consistent with LTi-independent spleen embryogenesis as previously reported.14 However, the transplantation of lymphotoxin-deficient LTα-/- neonatal spleen stromal grafts did not induce tissue regeneration.8 This contradicted reports that embryonic spleen develops in the absence of lymphotoxin, as well as transplantation studies involving embryonic day (E)15 LTα-/- spleen grafts which retained the capacity for full tissue development.15 Thus, in contrast to spleen development during early embryogenesis, spleen tissue regeneration after birth requires functional lymphotoxin signalling.To understand these relationships in the context of neonatal spleen regeneration, spleen stromal tissues derived from LTi-deficient RORγt16 Only recently have the equivalent stromal cell subsets controlling neonatal spleen regeneration been functionally defined. Using cell-aggregated grafts constructs, manipulation and transplantation of various CD45− stromal cell subsets enabled the identification of MAdCAM-1+CD31 (PECAM-1)+ spleen organiser (SPo) cells, which were indispensable for neonatal spleen regeneration.17 In common with LTo cells,18 organiser cells in spleen expressed high levels of lymphotoxin β receptor (LTβR), as well as ICAM-1 and MAdCAM-1 adhesion molecules. The localisation of MAdCAM-1+CD31+ cells around the marginal zone of neonatal spleen also supported an organiser cell identity,17 indicating a close relationship with CD4+CD3− LTi and migratory B220+ B cells which simultaneously cluster around the central arteriole during development.20 Notably, MAdCAM-1+CD31+ cells are also present in human foetal spleen from 14 weeks gestation,21 representing a potential spleen organiser cell type in humans.Specialised subsets of lymphoid tissue organiser cells guide lymph node and Peyer’s patch development.+MAdCAM-1lo/+CD31− cells was also found essential for tissue regeneration.17 In humans, these cells may correspond to a population of MAdCAM-1+CD31− cells that can be detected in foetal spleen from 18 weeks.21 At this stage, the precise identity of PDGFRβ+MAdCAM-1lo/+CD31− cells is unclear and may encompass a range of mesenchymal stromal cell subsets in spleen.22 Further examination of the phenotypic profile and spatial localisation will better inform the identity of this cell type, and any potential interactions with MAdCAM-1+CD31+ organiser cells, LTi, or B cells. Nevertheless, a combination of distinct endothelial and mesenchymal lymphoid tissue organiser subsets is required for lymph node development,16 giving precedence for the action of dual organiser populations in spleen tissue regeneration.Rather than a single spleen organiser cell subset controlling tissue formation, a second population of mesenchymal PDGFRβ14 However, the spleen is also structurally and functionally unique, exerting dual functions in red blood cell filtration that is carried out in the red pulp, and in adaptive immune responses which are generated in the white pulp.23 Contrary to embryonic spleen organogenesis, both MAdCAM-1+ marginal zone maturation and white pulp compartmentalisation of T and B lymphocytes occurs postnatally, and both structures are severely compromised in lymphotoxin-deficient mouse models.12 Therefore, spleen organogenesis can be divided into two separate stages. The initial phase of primitive red pulp formation begins during embryonic spleen development. This occurs independently of lymphotoxin signalling and is instead reliant on the expression of homeobox transcription factors including Tlx1 and Pbx1.24 Subsequently, full white pulp and marginal zone formation ensues during postnatal spleen development, and similar to lymph node organogenesis, occurs in a lymphotoxin-dependent manner.7Recent advances have elucidated the cellular components and molecular signalling events driving postnatal spleen regeneration. Yet, how do these findings integrate into a paradigm for secondary lymphoid organogenesis? The regulation of spleen organogenesis is considered distinctive because compared to other secondary lymphoid organs, embryonic spleen develops in the absence of lymphotoxin signalling.24 Spleen Nkx2-5+Islet1+ mesenchymal progenitors contribute to early tissue development and give rise to the majority of mesenchymal stromal lineages in spleen including gp38+ fibroblastic reticular cells, CD35+ follicular dendritic cells and NG2+ pericytes.22 It has also been shown that lymphoid tissue organiser cells can derive from this pool of multipotent mesenchymal stromal cells.22 Since LTo are typically defined as PDGFRβ+ cells,25 early spleen development may in part be regulated by mesenchymal PDGFRβ+ organiser cells, but any activity at this stage would not involve lymphotoxin signalling. From E12-E13, LTi or their precursors emerge in foetal spleen.20 At E16.5, these cells can be observed surrounding CD31+ or VE-Cadherin (CD144)+ central arterioles in close proximity to MAdCAM-1+VE-Cadherin+ endothelial cells,26 thus localising in areas of future white pulp development.28 At least up to E15, LTi co-localisation with organiser cells in the vicinity of spleen central arterioles occurs independently of lymphotoxin, and these interactions are dispensable for normal spleen development.15Thus, distinct spleen stromal cell types may exist which independently regulate embryonic and postnatal spleen development. During embryogenesis, specification of spleen mesenchymal cells and formation of splenic anlage commences at E10.5.29 and in spleen this signalling begins at E17.5.30 This may herald the first lymphotoxin-binding events, which trigger NFκB activation through the ligation of LTβR expressed on spleen organiser cells. However, most LTβR-mediated signalling is presumed to occur after birth, when larger numbers of LTi begin to express LTα1β2.19 Even then, LTβR signalling is likely to be augmented by a combination of LTi and mature B cells, which co-localise around central arterioles and functionally express lymphotoxin.19 Transgenic animals that selectively delete or express B cell LTα1β2 further support their involvement in lymphotoxin-mediated white pulp maturation.32 In addition to white pulp development, lymphotoxin signalling during this specific time window is essential for uptake of neonatal spleen grafts and full tissue regeneration.8At a time-point between late embryonic and early postnatal development, lymphotoxin becomes essential for spleen tissue regeneration and organisation of white pulp compartments. Nuclear factor kappa B (NFκB) signalling is critical for lymphoid tissue organiser cell maturation and function,27 In lymph nodes, a positive feedback loop generated by initial LTi engagement leads to the maturation of stromal organiser cells and the upregulation of homoeostatic chemokines such as CXCL13, and VCAM-1, ICAM-1 and MAdCAM-1 adhesion molecules.34 Consistent with this, upregulation of VCAM-1 and ICAM-1 is observed in stromal cells surrounding the central arteriole in spleen post-birth,20 at a time when mature B cells influx into the nascent white pulp region.19 Both of these events do not occur in LTα-/- mice.20 From this point on, three key reports help shape our understanding of spleen organiser cell maturation and marginal zone formation.Following elevated lymphotoxin cues in the spleen, formation of the marginal zone becomes a critical stage in white pulp formation and ultimately the establishment of immune competence. Between early spleen development and adult marginal zone formation, there is no clear connection surrounding the events leading to marginal zone maturation. Outstanding questions include the origins of the marginal zone, and whether marginal zone reticular cells (MRC) in fact represent adult spleen organiser cells.27 first presented striking images detailing the expression of MAdCAM-1 in murine spleen from birth to adulthood. At day 0, MAdCAM-1 expression was dispersed throughout spleen tissue, which by day 6 coalesced into foci surrounding central arterioles. The final expansion of characteristic ring-shaped marginal zone structures was observed from 2 weeks of age. In 2009, work by Zindl et al. showed that adult marginal zone sinus-lining vessels, which express both MAdCAM-1 and the arterial endothelial marker ephrinB2,35 branched directly from the central arteriole. Not only were ephrinB2+ cells in the marginal zone a physical continuum of the central arteriole, but cells in this region also expressed markers including CD31, Flk-1 (VEGFR-2) and VE-Cadherin. These reports suggest that after birth, MAdCAM-1+ cells in the marginal zone extend directly from and closely encompass the central arteriole, and share the expression of several endothelial cell markers.36Katakai and colleagues+CD31+ stromal cells are organiser cells functioning in neonatal spleen tissue regeneration17 now consolidates these previous reports. Moreover, it supports an ontogenetic relationship between embryonic/neonatal SPo and adult marginal zone reticular cells, which share co-expression of MAdCAM-1 and CD31, and require LTβR signalling to maintain normal architecture.36 It is therefore proposed that MAdCAM-1+VE-Cadherin+/CD31+ cells which are distributed around central arterioles shortly before and after birth represent SPo (Fig. 19 Postnatally, these cells are in spatial alignment with LTi and incoming B cells and upon LTα1β2 ligation, serve as functional spleen organisers. Lymphotoxin signalling during this developmental window is required to enforce MAdCAM-1 upregulation in the marginal zone, which leads to the remodelling of the marginal sinus vascular network and the organisation of adult white pulp structures.The finding that MAdCAM-137 A reduction in grafting efficiency leads to the development of spleen tissue with poor structural and functional qualities, evidenced by large fibrotic regions and irregular white pulp areas.39 Similarly, ageing is associated with a general loss of lymphoid tissue organisation and the development of immunosenescence.40 Since MAdCAM-1+CD31+ cells are essential for driving the regeneration of spleen tissue and regulating white pulp organisation, it will be of interest to determine whether numerical or functional changes in this population manifest with age. Answers to these questions may inform better approaches to engineer immune-competent spleen grafts, or may stimulate the development of therapies aimed at directly repairing or rejuvenating aged spleen tissue in situ.Spleen auto-transplantations have been performed clinically for decades, yet the organiser cells controlling tissue regeneration are only starting to be understood. Defining the cellular and molecular events which drive tissue regeneration will be important for addressing limitations in spleen graft functionality, such as the age-related decline in successful spleen auto-transplantations that regenerate full tissue immunoarchitecture.


We identified 5 observational audit tools for review: Bedimo-Rung Assessment Tool–Direct Observation (BRAT-DO), Community Park Audit Tool (CPAT), Environmental Assessment of Public Recreation Spaces (EAPRS) tool, Physical Activity Resource Assessment (PARA), and Quality of Public Open Space Tool (POST). All 5 tools have established inter-rater reliability estimates ranging from moderate to good. However, BRAT-DO is the only tool with published validity. We found substantial heterogeneity among the 5 in length, format, intended users, and specific items assessed. Researchers, practitioners, or community coalition members should review the goal of their specific project and match their goal with the most appropriate tool and the people who will be using it.We reviewed prominent audit tools used to assess the physical environment of parks and their potential to promote physical activity. To accomplish this, we manually searched the Active Living Research website ( The relationship between physical activity and health is well established –3; howevResearchers have developed various observational audit tools to examine the physical environment of parks and their potential to promote physical activity. However, the format, length , assessment methods, literacy required to complete assessments, and characteristics and features of these tools vary widely. We reviewed 5 prominent audit tools for assessing the physical environment of parks to assist public health practitioners, researchers, and community members in determining which audit tool is best for them to use for a specific research project or evaluation.http://www.activelivingresearch.com) for published observational audit tools that evaluate the physical environment of park-based settings, and we reviewed tools used by researchers in studies included in a systematic review of observational studies of park-based physical activity , eating and drinking features, access and neighborhood characteristics, signage, safety-related features, incivilities , and the park’s condition and maintenance. We placed items not fitting into these categories in a category called “other items assessed.” In comparing the measures, our first level of review was to evaluate the following characteristics: length, intended users, data collection method, reliability, and validity. The second level of review was a more detailed analysis of each tool based on specific features assessed. Last, we compared the 5 tools on the basis of the outcomes assessed in the first 2 levels of review.http://www.activelivingresearch.com) comprises 28 items and is divided into 4 sections: park information, access and surrounding neighborhood, park activity areas, and park quality and safety. CPAT was designed for community members, stakeholders, and researchers to easily assess community parks with an emphasis on the physical activity of youths. Inter-rater reliability of the CPAT is generally moderate to high; most items have agreement ranging from 80% to 90%  is a pencil-and-paper tool designed to identify and evaluate the physical structures and characteristics of parks. BRAT-DO is intended for use by researchers, consists of 181 items (16 pages), and assesses the following domains: access, condition, aesthetics, features, and safety. The tool has established inter-rater reliability among people trained in the assessment protocol; inter-rater agreement across domains ranged from 67.6% to 100%  is the most comprehensive observational audit measure available. It is in its sixth revision and is available in pencil-and-paper format. EAPRS contains 751 items in 16 sections and is 59 pages long. Inter-rater reliability varies by section or domain assessed; however, most items in the tool demonstrate moderate-to-high reliability estimates  (EAPRS  (http://κ ≥ .60) . http://grants.hhp.coe.uh.edu/undo/?page_id=21) is a brief, 1-page (49 items) instrument that assesses park type, features, amenities, qualities, and incivilities. It was originally developed to assess resources in low-income, urban communities that surround public housing developments (PARA  (http://lopments . Use of http://www.see.uwa.edu.au/research/cbeh/projects/post) is a pencil-and-paper–based tool designed to evaluate physical attributes of public open spaces, including parks, that may influence physical activity. POST is 2.5 pages in length and consists of 88 items. Inter-rater agreement for the items ranges from 50% to 98%, with most items demonstrating greater than 85% agreement .Courts. All 5 tools assess the presence of courts; however, the type of court varies. All 5 assess basketball and tennis courts. Three  also assess volleyball courts. Only EAPRS assesses the presence of handball courts, and only POST assesses netball courts..Fields and open green spaces All 5 measures evaluate the presence of soccer and softball or baseball fields. Other field types evaluated by measures were football or rugby  and cricket (POST). CPAT, BRAT-DO, and EAPRS also included items to assess the presence of open green spaces and fields for general play.Golf courses. EAPRS and BRAT-DO are the only 2 measures that assess the presence of golf courses. The EAPRS was the most detailed, because it assessed the presence of regular (9- or 18-hole), miniature, and Frisbee golf courses. BRAT-DO evaluated the presence of a regular golf course..Running and walking features All 5 measures assess the presence of unpaved trails or paths for running and/or walking activities. Two measures, PARA and EAPRS, also evaluate the presence of sidewalks..Water features Four measures, CPAT, BRAT-DO, EAPRS, and POST, evaluate the presence of ponds and lakes and creeks and streams within parks. CPAT, BRAT-DO, EAPRS, and PARA also include items to evaluate the presence of swimming and wading pools. CPAT is the only measure assessing splash pads. Only BRAT-DO and EAPRS assess whether the park is located on a beach or riverfront..Other types of activity areas The audit tools reviewed also assess the presence of other activity areas. For example, CPAT and PARA assess the presence of exercise stations or exercise equipment. Likewise, CPAT and EAPRS assess the presence of dedicated dog parks. EAPRS provides the most comprehensive assessment, because it is the only measure to assess batting cages, BMX (bicycle motocross) tracks, driving ranges, horseshoe pits, shuffleboards, and other features..Sitting and resting features All 5 tools evaluate the presence of picnic tables. All except PARA assess the presence of benches. EAPRS also assesses the presence of other types of sitting or resting features, including seat walls and bleachers..Landscaping features All measures include items to assess landscape features. Common items assessed are trees, flower and garden areas, fountains, and areas with shade..Facilities All 5 measures include items that evaluate the presence of restrooms and trash cans. BRAT-DO was the only measure to assess if play or athletic equipment is available for rent. PARA was the only measure to assess the presence of showers or changing rooms, and POST was the only measure to evaluate the presence of meeting rooms. EAPRS and POST also assessed the presence of event venues or stages.Eating and drinking features. All five tools assess the presence of water fountains. BRAT-DO, EAPRS, and POST also evaluate the presence of grills or barbeques. All measures except PARA assess the presence of other food sources ..Access and neighbor characteristics All measures include items to evaluate park access and environmental supports for transit to parks. Common items include the presence of sidewalks or paths connecting to the park, adjacent roadways and parking lots, and the presence of bike racks. CPAT was the only measure to assess presence of a nearby public transit stop. Only 2 measures, CPAT and BRAT-DO, assess whether a park can be locked or is locked at the time of audit. All measures except PARA assess the quality of the neighborhood surrounding the park..Signage CPAT and BRAT-DO are the most detailed measures of signage, because they evaluate the presence of posted park rules and regulations, hours, event programming, dog and pet user rules, and information on how to reserve areas and other types of signage. PARA and POST are the least detailed. EAPRS assesses the presence of signs for rules and regulations, maps, and event programming..Safety-related features All measures assessed lighting. CPAT, BRAT-DO, and EAPRS also assess the presence of telephones and emergency call boxes and onsite park staff. CPAT was the only measure to assess threatening behavior among park users . PARA and POST are the least detailed in assessing park safety features; they assess only presence of lighting..Incivilities All measures assessed the presence of incivilities. CPAT, BRAT-DO, PARA, and POST are the most detailed. Example items assessed were litter, graffiti, and loud noise. EAPRS included only a few items to assess incivilities.Condition and maintenance. All measures except POST evaluate the condition and maintenance of parks. However, the method in which the measures assess these aspects differs. CPAT, BRAT-DO, and EAPRS first assess the presence of a specific park feature or amenity and then use a separate additional item to assess its condition and maintenance. PARA uses a combined scale to assess both the presence and condition of the features.Dogs. All measures except the BRAT-DO include items to assess the presence of dogs. CPAT and POST further expand on this topic by including an item to assess if waste litter bags for dogs are present.Because of the heterogeneity of the 5 audit tools reviewed, practical guidance on the usefulness of a tool for specific research projects is warranted. Our comparative analysis showed heterogeneity in the length of the audit tools. Two tools, PARA and CPAT, were designed for researchers, public health practitioners, and community members, where BRAT-DO, EAPRS, and POST were designed for researchers and public health practitioners only. A positive finding of our review was that all 5 audit tools have inter-rater reliability estimates that range from moderate to good. This finding is encouraging and speaks to the organization and clarity of the tools and their training manuals. In reference to validity, BRAT-DO is the only tool to report validity outcomes. Studies are needed to establish the validity of the other audit tools.Choice of an audit measure for a project should be based on various factors, which include the level of detail needed, education and skill level of the people performing the assessment, time needed to complete the assessment, target population of park users , and resources available to train assessors and to conduct the assessment. When choosing a tool, researchers will often face a trade-off among these factors, because each tool will not perfectly address all project specifications. Despite this trade-off, all 5 measures reviewed show promise for evaluating the built environment of parks for the support of physical activity.Although comprehensive, our review has limitations. We limited our selection to audit tools used in studies included in our systematic review of park-based physical activity studies  and thosDespite these limitations, this review has several strengths. To our knowledge, this is the first review of observational audit tools to evaluate the physical environment of parks in relation to physical activity. Findings are designed to help researchers, public health practitioners, and community coalitions identify an appropriate tool for a particular project. Another strength was the high level of detail used to evaluate the 5 measures. We compared various aspects of each tool, including length, assessment method, intended users, reliability, validity, and specific park features assessed. This level of detail strengthens the quality and usefulness of the review.Our review was intended to provide guidance in selecting the best audit tool for a proposed park evaluation project. When selecting an appropriate tool, researchers should review the goal of their project and match their goal with the most appropriate tool, because the method of assessment will have a direct relationship with validity and usefulness of the outcomes. Likewise, researchers may find it necessary to use multiple audit tools or to combine sections of different audit tools to evaluate the specific features of a park environment.


The GRADE-CERQual  approach provides guidance for assessing how much confidence to place in findings from systematic reviews of qualitative research . The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. Confidence in the evidence from qualitative evidence syntheses is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. CERQual provides a systematic and transparent framework for assessing confidence in individual review findings, based on consideration of four components: (1) methodological limitations, (2) coherence, (3) adequacy of data, and (4) relevance. A fifth component, dissemination (or publication) bias, may also be important and is being explored. As with the GRADE  approach for effectiveness evidence, CERQual suggests summarising evidence in succinct, transparent, and informative Summary of Qualitative Findings tables. These tables are designed to communicate the review findings and the CERQual assessment of confidence in each finding. This article is the first of a seven-part series providing guidance on how to apply the CERQual approach. In this paper, we describe the rationale and conceptual basis for CERQual, the aims of the approach, how the approach was developed, and its main components. We also outline the purpose and structure of this series and discuss the growing role for qualitative evidence in decision-making. Papers 3, 4, 5, 6, and 7 in this series discuss each CERQual component, including the rationale for including the component in the approach, how the component is conceptualised, and how it should be assessed. Paper 2 discusses how to make an overall assessment of confidence in a review finding and how to create a Summary of Qualitative Findings table. The series is intended primarily for those undertaking qualitative evidence syntheses or using their findings in decision-making processes but is also relevant to guideline development agencies, primary qualitative researchers, and implementation scientists and practitioners.The online version of this article (10.1186/s13012-017-0688-3) contains supplementary material, which is available to authorized users. Decisions on health, social care, and other interventions, programmes, and policies need to be based on the best available evidence . While dQualitative research aims to explore people’s perceptions and experiences of the world around them, including their perspectives on health and illness, health and social care services, and wider health and social system policies and processes. In recent years, systematic reviews of qualitative research  have become more common and the methods for undertaking these reviews are now well developed –12. Evidwww.gradeworkinggroup.org).The ‘Confidence in the Evidence from Reviews of Qualitative research’  approach provides guidance for assessing how much confidence to place in findings from qualitative evidence syntheses. It complements other ‘Grading of Recommendations Assessment, Development, and Evaluation’ (GRADE) tools for assessing how much confidence to place in evidence on the effectiveness and harms of interventions and their resource use and in evidence about diagnostic tests , 18. TheThe GRADE-CERQual approach  has been developed to support people using findings from qualitative evidence syntheses in decision-making processes. CERQual allows the user to make a transparent assessment of how much confidence decision-makers and other users can place in individual review findings from syntheses of qualitative evidence. We define a review finding as an analytic output from a qualitative evidence synthesis that, based on data from primary studies, describes a phenomenon or an aspect of a phenomenon . Many inIn developing CERQual, we were informed by the principles and methods of qualitative research and have also sought to apply lessons learned from the GRADE Working Group’s development of similar tools for other types of evidence. Table We acknowledge that some within the qualitative research community have argued that synthesising data across multiple qualitative studies challenges the integrity of the contributing primary studies and that findings from this synthesis process may therefore not be trustworthy e.g., –21). How. How21])how a synthesis is undertaken  rather than being seen as a complete barrier to conducting syntheses or to the practical usefulness of qualitative synthesis findings to decision-makers [We acknowledge debates on the most appropriate methods for synthesis but argue that concerns regarding the synthesis process and its outputs should be addressed in n-makers .CERQual assumes that qualitative research, in addition to its more interpretative and exploratory functions, has an instrumental role to play in informing decisions. In other words, qualitative research holds the potential to produce knowledge that can directly inform decision-making processes.CERQual acknowledges that a well-conducted qualitative evidence synthesis does not automatically produce useful findings applicable to a range of contexts. As with primary qualitative research, sophisticated processes of analysis and interpretation are required. CERQual aims to accommodate the interpretivist nature of qualitative synthesis by, for example, encouraging the review authors to examine possible theoretical contributions and to be sensitive to the importance of context when assessing confidence in the evidenceThe CERQual approach is intended to be applied to well-conducted syntheses that report their methods and limitations in a transparent way. We believe that applying CERQual to the findings of a poorly conducted or poorly reported synthesis would be challenging and would not yield useful results. Paper 2 in the series provides guidance on assessing how well a review was conducted .As a pragmatic approach, CERQual makes several assumptions and acknowledgements regarding ongoing methodological debates in the field of qualitative research:Additional file Overall, we used a pragmatic and iterative approach to develop each CERQual component by brainstorming concepts within the development team, undertaking formal and informal searching of the literature for definitions, following up relevant citations, talking to experts in the field of qualitative evidence synthesis, developing consensus through multiple face-to-face meetings and teleconferences, and seeking feedback from ongoing engagement with the qualitative evidence synthesis community, the GRADE Working Group and organisations that commission, produce, or use systematic reviews.The initial stages of the process for developing CERQual, which started in 2010, are outlined elsewhere   as a potential fifth component in assessing how much confidence to place in qualitative evidence synthesis findings. We initiated pilot work to explore how dissemination bias has been conceptualised in qualitative research, its perceived scope, and how it might be conceptualised. Some of this work is discussed in paper 7 in this series  and elseWe have defined confidence in the evidence as an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. This assessment communicates the extent to which the review finding is likely to be substantially different from the phenomenon of interest. By ‘substantially different’, we mean different enough that it might change how the finding influences a decision about health, social care, or other interventions . For insCERQual involves an assessment of each individual review finding in terms of four components: 1) methodological limitations, 2) coherence, (3) adequacy of data, and (4) relevance  as well as at different levels . We report confidence in each review finding as either high, moderate, low, or very low confidence Table .Table 3DA key product of a CERQual assessment, as with other GRADE approaches, is a succinct, transparent, and informative Summary of Qualitative Findings (SoQF) table. The SoQF table facilitates the use of review findings in decision-making processes and is purpose-designed to communicate to users both the overall confidence assessment for each review finding and an explanation of this assessment. In paper 2 in this series, we describe how synthesis authors proceed from a full review finding to a summary of a review finding, for inclusion in a SoQF table . The SoQAs noted in relation to GRADE for evidence of effectiveness, confidence in the evidence exists on a continuum. One limitation of a CERQual assessment is the discrete categorisation of confidence into levels , which inevitably involves a degree of arbitrariness. However, we would argue that the accessibility and transparency of this approach outweigh its limitations .An ever-expanding array of qualitative synthesis methods are available , 42. Ourhow to apply the GRADE-CERQual approach. The series takes the reader through all the stages involved in making an assessment of confidence in findings from qualitative evidence syntheses, including how we have conceptualised each component of CERQual and how these components relate to other concepts in the fields of primary qualitative research and qualitative evidence synthesis. Figure This series of papers aims to provide guidance to users on The second paper in the series discusses how to move from a full description of a review finding to a summary of a review finding—an important step in the process of applying CERQual; how to determine to which review findings to apply CERQual; how to make an overall CERQual assessment; and how to create a Summary of Qualitative Findings table . The nexThis series is the first to discuss in detail how to apply the GRADE-CERQual approach. The series has been developed primarily for those undertaking qualitative evidence syntheses or those supporting the use of the findings of such syntheses in decision-making processes. The series is also relevant to guideline development and health technology assessment agencies, decision-makers, and qualitative researchers. It will also be useful for those seeking to understand recommendations and other decisions to which qualitative evidence with CERQual assessments have contributed. We will provide further guidance on using CERQual within decision-making processes, including in guideline development and in additional papers planned within our publications strategy.Different readers will use this series in different ways Fig. . Those cIn writing this series, we have tried to draw on examples from published or ongoing syntheses addressing a disparate range of questions and contexts in order to show how CERQual should be applied. We also highlight key methodological issues to be considered at each stage or that arise from using CERQual. However, because CERQual is a relatively new approach, the pool of worked examples is not yet extensive and is drawn largely from the areas of health and social care. We believe, though, that CERQual can and should be applied to findings from qualitative evidence syntheses across all fields, including agriculture, crime and justice, education, the environment and international development. We encourage readers to share with us their applied examples from these domains.The increasing use of qualitative evidence within a range of decision-making processes, and the growing awareness of the roles that qualitative evidence can play in decision-making , suggestwww.cerqual.org), on which new developments will continue to be flagged.Many decision-makers acknowledge the need to widen the range of evidence that they examine, to address questions such as the acceptability of interventions and programmes as well as other factors that might impact on their implementation. Many are aware that qualitative research provides a valuable pool of knowledge from which they can draw. We believe that the CERQual approach will help to increase the usability of findings from qualitative evidence syntheses, including use by those who are implementing interventions across fields such as education, health, social care and justice. CERQual will evolve as we gain more experience in applying the approach across diverse review findings derived from different synthesis approaches. Table Peer review reports for this article are available in Additional file Additional file 1:The purpose of CERQual and what CERQual is not intended to address. (PDF 621 kb)Additional file 2:Methods used to develop the CERQual approach—2010 to 2015. (PDF 647 kb)Additional file 3:Questions included in the CERQual online feedback form and short individual discussions. (PDF 468 kb)Additional file 4:Minimum criteria for fidelity to the GRADE-CERQual approach in a qualitative evidence synthesis. (PDF 353 kb)Additional file 5:Open peer review reports. (PDF 142 kb)


Following calls for greater transparency in the use of evidence for decision-making,–Although the use of network meta-analysis for WHO guideline development is recent, the method is well established within national health technology assessment agencies. It has become essential to formulating recommendations on reimbursements by health care agencies around the world. The method has also recently been adopted by Cochrane, and we found that since 2015, 10% (23/230) of systematic reviews published by this organization used network meta-analysis. The method has numerous qualities that lend themselves to decision-making processes such as clinical guidelines development. In 2015, GRADE working groups published guidance on how to use GRADE in conjunction with network meta-analysis.Network meta-analysis offers several advantages to the process of developing guidelines. One advantage is the ability to make a quantitative comparison of interventions that have not been directly compared in studies. This is pivotal to guideline development because, in the absence of head-to-head evidence , guideline development groups will rely more strongly on expert opinion. Hence, they may make comparisons that do not adequately account for potential biases in study designs, intervention characteristics and study populations. Indirect comparisons connect treatments via a common control or comparator (e.g. a placebo or a standard of care) to establish comparative effects between treatments that have not been compared head-to-head in randomized controlled trials. The connection through this common comparator supports the adjustment for bias that would otherwise be introduced by differences in prognostic factors if the individual treatment arms were compared across trials directly. Admittedly, bias may still remain following the use of a common comparator if the prognostic factors are themselves an effect modifier to the interventions.A second advantage is that by analysing both direct and indirect evidence collectively, the evidence base is strengthened – often to an extent that could mean the difference between grading the strength of evidence as low versus moderate or high. The importance of being able to make indirect comparisons within a network of evidence was seen when the WHO guidelines development group reviewed the evidence about the choice of treatment for HIV-infected patients who were antiretroviral therapy (ART)-naïve. Two of the most promising new agents for first-line ART are dolutegravir and low-dose efavirenz. When the guidelines development group met, no study had compared these two options directly. However, both treatments had been compared to standard dose efavirenz, which continues to be a favoured first-line ART in most HIV programmes globally. Published results of randomized controlled trials suggested that both dolutegravir and low-dose efavirenz are comparable to efavirenz in terms of efficacy, but have more favourable tolerability. Using network meta-analysis, dolutegravir was shown to have lower levels of discontinuations due to adverse events than did low-dose efavirenz and this led to higher probabilities of viral suppression. Thus, by considering both alternatives simultaneously, the guidelines development group – composed of clinical experts, policy-makers and community members – was able to draw stronger conclusions on the choice of first-line regimens. Nonetheless, a network meta-analysis is not a substitute for a well conducted randomized controlled trial.A third advantage of network meta-analyses in guideline development is that it comprises a simultaneous analysis of all potential treatment options and makes full use of the available evidence within a single analysis. Doing so provides a more concise assessment of the clinical landscape that in turn lends itself better to decision-making. This was particularly important for the development of the WHO HCV guidelines.Finally, while network meta-analyses have traditionally been used to assess the comparative effectiveness of drugs, the approach can be applied more broadly. In the latest revision of the WHO HIV guidelines,Some challenges remain in the use of network meta-analysis in guideline development. As with pairwise meta-analysis, network meta-analysis methods are conventionally used to synthesize only evidence from randomized controlled trials. For the purpose of guideline development, large cohort studies may often depict an aspect of clinical practice that is not captured in randomized controlled trials. While this is not specifically a limitation of the network meta-analysis method , it limits the clinical research questions that can be answered through network meta-analysis. This is a particular challenge with rare adverse events that are not evaluated with randomized controlled trials, which are usually limited in size and duration.In conclusion, WHO clinical guidelines have become increasingly evidence-based through the use of rigorous methods of synthesizing the evidence. Over the past decade, high-quality, pairwise meta-analyses have been widely used in this context, but network meta-analysis methods are increasingly important for the optimal evaluation of competing interventions. We expect that network meta-analysis will increasingly be used and adapted for developing other guidelines.