In traditional fault diagnosis strategies, massive and disordered data cannot be utilized effectively. Furthermore, just a single parameter is used for fault diagnosis of a weapons fire control system, which might lead to uncertainty in the results. This paper proposes an information fusion method in which rough set theory (RST) is combined with an improved Dempster–Shafer (DS) evidence theory to identify various system operation states. First, the feature information of different faults is extracted from the original data, then this information is used as the evidence of the state for a diagnosis object. By introducing RST, the extracted fault information is reduced in terms of the number of attributes, and the basic probability value of the reduced fault information is obtained. Based on an analysis of conflicts in the existing DS evidence theory, an improved conflict evidence synthesis method is proposed, which combines the improved synthesis rule and the conflict evidence weight allocation methods. Then, an intelligent evaluation model for the fire control system operation state is established, which is based on the improved evidence theory and RST. The case of a power supply module in a fire control computer is analyzed. In this case, the state grade of the power supply module is evaluated by the proposed method, and the conclusion verifies the effectiveness of the proposed method in evaluating the operation state of a fire control system. Since the start of the 21st century, industrial manufacturing has gradually tended to become automated, large-scale, and systematic. In unmanned factories, the composition of industrial machinery and equipment is increasingly complex and functions increasingly well. Due to this, people are gradually paying more attention to the safety of equipment. The most commonly used method for traditional industrial equipment maintenance includes acquisition operation signal feature extraction and fault diagnosis. However, traditional fault diagnosis methods have been unable to adapt to the increasing tendency of industrial equipment to be: (1) modular; (2) generalized; (3) intelligent; and (4) modernized.A fire control system is a kind of complex electronic system which is responsible for controlling the aiming and firing of weaponry. Such systems play an important role in modern warfare, and their development is becoming more and more intelligent and modernized. If the system fails, it will greatly reduce the combat capability of weaponry. A general-purpose fire control system has the characteristics of randomness, susceptibility, concurrency, and communication. Traditional fault diagnosis methods cannot meet the demand of fault diagnosis for a fire control system. For example, the state evaluation of the fire control computer and sensor subsystem is massive . The staSince rough set theory (RST) contains a mechanism to deal with imprecise or uncertain problems, no prior information is needed to deal with uncertain information . RST canBased on the above research, this paper aims to tackle the problems in fault detection: the inability to synthesize conflicting evidence with the traditional synthesis rules and the combination explosion caused by excessive evidence dimensions. In this paper, a fire control system state evaluation method based on RST and improved evidence is proposed to solve the following problems: (1) the combination explosion; (2) the largely subjective nature of evidence acquisition; and (3) the inconsistency between the decision-making result and the actual result due to evidence conflicts.In this paper, RST is first introduced to preprocess and discretize the collected fire control system data. In order to retain the core attributes, attribute reduction is carried out and the basic probability assignment is determined . For theIn The Polish scholar Z. Pawlak proposed RST in 1982. RST is an effective tool for dealing with incomplete information. It does not require any prior information except for the set being processed. By analyzing the relationship between the studied objects, the potential rules for the set are obtained .V is the set of attribute values of the studied objects f: xth attribute for each object in U.The information system is the primary structure in RST. The information system  objects ; where C for a∈A ,10; and ∈Va  specifieD, that is, S is called the decision table [For on table .Ind(B) about B as:U into equivalence classes, where all objects in an equivalence class are indistinguishable from each other [Let ch other .Ind(A) is the equivalence relation over U; B, is defined as:X set. The definition of approximate mass represents the probability that can be accurately divided under the attribute set B.The information system Ind(R) = Ind(R − {r}), then R is independent, and P is independent [R is called the core of R. The equivalence relation family is defined via: If the discretized values of each sample under any n attributes correspond to the same value, then the value of these n attributes in the decision table is equal and they are referred to as equivalent attributes.Attribute reduction is performed to maintain the expressiveness of the information system and delete redundant attributes. Let ependent . The setThe discernibility matrix, also known as the discernible matrix or the distinct matrix, is a method of knowledge representation proposed by Skowron in 1991.CLet  of S is ,16:(3)miith row and jth column of The above definition indicates that the differential elements of the i = j and this Individuals with the same decision attribute value, whether or not the conditional attribute values are the same, cannot be distinguished. Therefore, when the decision attributes of individuals The discernibility function of the decision table S can be formally expressed as :(4)fM(S)In order to avoid a large number of redundant attributes in the actual system which affect the speed of operation and accuracy of decision-making, this paper simplifies the decision table. An instance in the decision table can be considered as a rule, which may contain redundant attribute values, so the reduction of instance attribute values is the reduction of the decision rule . The redM(S) for the decision table S according to the above Equation (3);Calculate the discernibility matrix fM(S) based on the discernibility matrix M(S);Calculate the discernibility function fM(S), where each disjunctive component is a reduction.Calculate the minimum disjunctive normal form of discernibility function Where DS evidence theory is an uncertain reasoning method which can integrate the evidence provided by multiple evidence sources ,20 and c(1) m is called the basic credibility distribution of the framework. Note, m(A) is the basic credibility distribution of A and A.then, A is any subset on the identification framework A is called the focal element of the belief function Bel. The relationship between the belief function Bel(A) and the basic credibility allocation function A—the sum of basic credibility—is expressed by Bel(A).Assuming that atisfies ,23:(5)Beion m is ,25,26:m(C){When applying evidence theory to practical situations, information with different degrees of conflict is often encountered. When dealing with different evidence bodies with low confidence and high conflict, the results are often not ideal and sometimes even contrary to common sense .K, which changes the basic probability distribution of the common focal element between the two evidences to The main reasons why evidence theory produces phenomena that are inconsistent with common sense when dealing with contradictory evidence ,32,33 ar● Conventional Conflict ProblemHigh Conflict: Take the identification framework The conflict factor for this example is thus, K = 0.0099 + 0.9801 + 0.0099 = 0.09999, and B; however, the synthesis result suggests that B is fully supported. Obviously, this is inconsistent with the actual situation.The support degree for the two pieces of evidence is extremely small for Total Conflict: assume the identification framework  follows :m1(A)=0 be used .● Less RobustnessHigh Conflict: Take the identification framework After the synthesis of the two pieces of evidence, the result ● One Vote VetoSuppose the support degree of n pieces of evidence for A is as follows:The above n pieces of evidence are fused using the rule of evidence theory synthesis, and m(A) = 0. It can be seen from this example that, when one piece of evidence is inconsistent with or in complete conflict with multiple pieces of evidence, one negative vote will be obtained after the synthesis of the evidence, indicating that other evidence has no influence on the synthesis result.Synthesis problems, in view of evidence theory, have been analyzed by many scholars, who have presented a series of effective solutions. Some of these approaches adopt a view that does not tally with the actual result for the synthesis rule. Holders of this viewpoint attempt to improve the evidence combination rules by using modified conflict information. Another view holds that the inaccuracy of the synthesis results derives from the evidence source rather than the synthesis rules of traditional evidence theory ,37,38. AAt present, the weight distribution of conflicting evidence mainly adopts the conflict weight distribution method based on the distance between two pieces of evidence  or the sLet there be an identification frame Thus, the similarity coefficient of the two pieces of evidence ism, the evidence similarity number can be calculated by using the above formula, and the similarity matrix is thus:Assuming that the number of evidences obtained by the system is The degree of consistency between two evidences reflects the degree of mutual support between the two pieces of evidence ,46; ther follows :(13)Sup is normalized to calculate the credibility of the evidence, as shown inn pieces of evidence, which yields the corresponding basic probability assignment, the Deng entropy of the ith piece of evidence is defined as follows: m is a mass function defined on the frame of discernment m, and m, and the term In recent decades, various uncertainty measures have been proposed, e.g., Yager’s dissonance measure, Shannon entropy, and others derived from the Boltzmann–Gibbs (BG) entropy in thermodynamics and statistical mechanics, which have been used as an indicator to measure uncertainty associated with a probability density function (PDF). In this paper, a new entropy, called the Deng entropy, is proposed to handle the uncertain measure of Basic Probability Assignment (BPA). Deng entropy can be seen as a generalized Shannon entropy . When thDeng entropy can measure the uncertainty degree of some information. The higher the Deng entropy, the higher the degree of uncertainty. In a decision-making system, the more uncertain the information is (high Deng entropy), the lower its influence on decision making should be. Conversely, the more certain the information is (low Deng entropy), the higher the impact on decision making should be. Evidence consistency is used to reflect this idea in the overall decision-making process, as well as the degree of conflict with other evidence. The higher the consistency of evidence, the lower the degree of conflict with other evidence, and the more likely it will be to yield correct decisions. In the decision system, the average basic probability assignment of each subset (decision attribute) in the identification framework can reflect the correct trend of decision making in the evidence set. If there is a large distance between the basic probability assignment  of a subFor an identification framework fined as :(17)Con.Step 4: Considering the influence of evidence credibility and evidence validity on conflicting evidence, the weight of the piece of evidence is calculated according to Equation (19).f(A) to obtain a new conformity rule, via:Step 5: According to this new weight distribution for the conflict evidence, redefine the conflict distribution function In order to verify the effectiveness of the new conflict evidence synthesis rule designed in this paper, a comparative analysis was conducted with the basic probability assignment given by the high conflict evidence in Yager’s formula  removes By defining the concept of evidence credibility, Sun Quan et al.  set the  follows :(24)m(θ)K, the less the conflict between pieces of evidence will be. The fusion result is mainly determined by K is closer to 1, and the results of the approach average the credibility and the support degree Furthermore, the conflict between the distribution of the information is related to the evidence on the degree of the average support The smaller the conflict parameter In Li Bicheng’s opinion , conflicIn the literature , conflicm(A), m(B), m(C) respectively represents the basic probability distribution function of A, B, C. Where In this paper, the above synthesis method is adopted. To compare and illustrate the effectiveness of the evidence synthesis method and the rationality of the fusion result, we take four samples As can be seen from the results in For the state assessment and fault diagnosis of a weapon fire control system, rough set and DS evidence theory are introduced. The rough set restores the information system formed by the original data and extracts the classification rules so that the evidence theory can obtain the basic credibility. Then by allocating and using the synthesis rules, the final decision result is determined. The basic structure of the data fusion method based on rough set and evidence theory is shown in Take the power supply module for the core subsystem of a certain type of tank fire control, fire control computer, and sensor subsystem as an example. The power supply module primarily shows a 26 V main signal that is powered by an external 5 A fuse and is used for the fire control computer through a filter. The 26 V power supply(01) on the power board and the 26 V power supply(02) to the sighting system generate a ±15 V power signal on the power board. The application of a letter-following fusion method is used to construct and analyze the power supply module, and the validity and practicability of the algorithm are verified.This article has five training sample objects, 13 conditional attributes The set of conditional attribute codes is Where the corresponding pin is the aviation plug port number, where Power 15 V (a) and Power 15 V (b) are used to power supply ADA-5a board, Power-15V (a) and Power-15V (b) are used to power supply ADA-5b board.Set the research sample object as The conditions of the discretization according to the experience of experts are shown in Discretization of data is completed; the process of discretization involves the following equation:From the original data table, we find all the equivalent attributes in the decision table and perform reduction based on the defined equivalent attributes. The discovered equivalent attributes are as follows:According to the approximate mass equation by applying the above Equation (2), we next find the approximate quality of the conditional attributes in C:After further attribute reduction, the reduction set is improved . AttribuBased on According to Equation (21), for the conflict factor, a value of Thus, from eference  will assThus, the improved conflict evidence synthesis method presented in this paper is adopted to synthesize such high conflict evidence. The synthesis steps are as follows:Step 1: Calculate the similarity matrix by applying the above Equation (12):Step 2: Calculate the support degree between pieces of evidence by applying the above Equation (13):Step 3: Calculate the credibility of the evidence by applying the above Equation (14):Step 4: Calculate the Deng entropy of the evidence by applying the above Equation (15):Step 5: Calculate the weights of the conflict evidence by applying the above Equation (19):Thus, according to Equation (20), the following result is obtained:Since This article first introduced rough set theory and the related concepts of DS evidence theory. Then, we studied how the combination of rough set theory and DS evidence theory could play to the advantages of the two algorithms and avoid their disadvantages. An analysis of the classical theory of evidence conflict and evidence synthesis rules was performed. On the basis of an evidence weight allocation method, this paper proposed an evidence similarity calculation method using the fuzzy membership degree of reliability and the validity of the evidence. Furthermore, an improved conflict evidence synthesis method was proposed and studied with a comparative analysis. Finally, the improved method was applied to the intelligent evaluation model of a power supply module of a fire control computer. An example shows that this model can solve the paradoxical problem caused by the conflict of evidence theory synthesis rules to some extent and can accurately evaluate the running state.There is a large amount of running state data for a fire control computer. In the future, we suggest establishing an overall running state evaluation system according to the classification of incoming and outgoing signals. By gradually improving the study of state evaluation, one can meet the required standards for state evaluation of a fire control system and provide a favorable basis for the realization of situational maintenance.


As many developed health systems grapple with the reorientation of their systems to those that are commissioning led, consumer engagement has emerged as an important theme. Despite many governments asserting the importance of consumer engagement in commissioning, an evidence base is yet to be developed to support this approach. This paper identifies the challenges and gaps in the literature relating to consumer engagement and commissioning, before setting out five potential solutions to these challenges. Ultimately, consumer engagement needs clarity of purpose and any approach should be tailored to context. Effective client involvement needs time and investment. To embark on such a process without this effort can be counterproductive. An ongoing challenge for many developed health systems is how to re-orient from a hospital-centric system to one that more effectively integrates primary and acute care . Across In this paper, we draw on a recent review of the international literature on consumer engagement in commissioning , settingthe process of planning, agreeing and monitoring services … Commissioning is not one action but many, ranging from the health-needs assessment for a population, through the clinically based design of patient pathways, to service specification and contract negotiation or procurement, with continuous quality assessment” [Commissioning has been taken up widely across a number of countries, including Australia, New Zealand, United Kingdom, Germany, the Netherlands and Finland. Although debate concerning the precise definition of commissioning continues, at its simplest commissioning is seen as “essment” . CommissWhile there is no single model of commissioning and no evidence that any single model achieves better outcomes than others , adoptinAs demonstrated by Dickinson et al. , there iAlthough attempts have been made to engage consumers in all parts of the commissioning process, the majority of evidence derives from the parts of the commissioning cycle that deal with making changes to relatively minor aspects of service provision, rather than engaging in strategic planning at a population level. This focus has left some commentators wondering whether consumers have been engaged with commissioning processes at all if we see commissioning as largely concerned with strategic planning and procurement . SchererLack of clarity about what consumer engagement means within the context of commissioning , 18.Lack of empirical evidence to demonstrate the most effective ways to engage consumers and describe the anticipated outcomes of that engagement .Lack of evidence of the skills and competencies that professionals and consumers require to engage with commissioning activities , 21.Limited number of established methods to engage representation of different groups and sectors in commissioning processes , 23.A range of challenges associated with conducting meaningful and effective engagement , 25.Our synthesis revealed five ongoing challenges to consumer engagement in commissioning processes that are commonly discussed in the literature :Lack of Most of the literature included in our review comprised some form of discussion of the abovementioned challenges. What was significantly less common, and typically absent all together, were any lessons, recommendations or solutions to these challenges, limiting opportunities for commissioners to be effective in their engagement activities. In response, we go beyond this literature to describe five broad solutions for consumer engagement in commissioning. These solutions do not individually correspond to the challenges set out above, but instead cut across them in an effort to help equip commissioners to become more effective in their approaches to consumer engagement.Getting local people on-board only to let them down, once again, acts as a further step towards disempowerment. Local people … can only feel less powerful through devoting their time, energy and enthusiasm into a project which is later abandoned … by the ultimately more powerful party” representation warrants greater attention, because when it comes to making decisions there will always be a few who decide on behalf of others” others” erment”  had written plans for public involvement, and four out of five (81%) had a public involvement committee or working group. However, only around a fifth of these committees or working groups (21%) had a designated budget and most budgets were £5000 or less” . staff” .long-term process and often is more challenging and takes more time than professionals initially anticipate” vement” vement” .Ultimately, consumer engagement needs clarity of purpose and any approach should be tailored accordingly. Effective client involvement needs time and investment. To embark on such a process without this effort can be counterproductive. A lack of evidence relating to commissioning and consumer engagement is challenging in terms of informing the development of these approaches. Few concrete examples are provided in the literature from which commissioners or providers can draw. In an attempt to provide greater guidance to those working in this space we have generated the principles that are set out in the paper to start to address this gap. This lack of evidence does, however, afford an exciting opportunity to build our knowledge around commissioning and consumer engagement processes. It continues to be important to invest in rigorous measurement that includes looking at what activities are effective in improving client outcomes. This work will require access to data and capacity-building to support the use of data in continuous improvement efforts as well as in the measurement and management of progress towards achieving outcomes. Development of data governance arrangements and system architecture may be needed to facilitate feedback processes that support continued engagement of consumers and improvement aims. Relationship building is critical to managing and supporting consumer engagement at different points in the commissioning cycle. New approaches to collaboration and the development of capacities to support these processes will be essential. It should be remembered that commissioning is a young field, as are attempts at widespread consumer engagement. Over the next few years it is likely that the field will develop and grow in terms of the evidence base, provided, in part, that we achieve consistency in terms of how engagement and commissioning processes are described and measured.


While there is an expectation to demonstrate evidence-informed public health there is an ongoing need for capacity development. The purpose of this paper is to provide a description of a tailored knowledge translation intervention implemented by knowledge brokers (KBs), and reflections on the factors that facilitated or hindered its implementation.The 22-month knowledge translation intervention, implemented by two KBs, sought to facilitate evidence-informed public health decision-making. Data on outcomes were collected using a knowledge, skills and behavioural assessment survey. In addition, the KBs maintained reflective journals noting which activities appeared successful or not, as well as factors related to the individual or the organisation that facilitated or hindered evidence-informed decision-making.Tailoring of the knowledge translation intervention to address the needs, preferences and structure of each organisation resulted in three unique interventions being implemented. A consistent finding across organisations was that each site needed to determine where evidence-informed decision-making ‘fit’ within pre-existing organisational processes. Components of the intervention consistent across the three organisations included one-to-one mentoring of teams through rapid evidence reviews, large group workshops and regular meetings with senior management. Components that varied included the frequency of the KB being physically onsite, the amount of time staff spent with the KB and proportion of time spent one-to-one with a KB versus in workshops. Key facilitating factors for implementation included strong leadership, influential power of champions, supportive infrastructure, committed resources and staff enthusiasm.The results of this study illustrate the importance of working collaboratively with organisations to tailor knowledge translation interventions to best meet unique needs, preferences, organisational structures and contexts. Organisational factors such as leadership, champions and supportive infrastructure play a key role in determining the impact of the knowledge translation interventions. Future studies should explore how these factors can be fostered and/or developed within organisations. While KBs implemented the knowledge translation intervention in this study, more research is needed to understand the impact of all change agent roles including KBs, as well as how these roles can be maintained in the long-term if proven effective. Public health professionals in Canada are expected to deliver effective and efficient programmes and services that protect and promote the health of the population . EvidencWhile the public health sector in Canada has been working toward EIDM for many years , knowledKnowledge brokers (KB) are one type of change agent that may be used to implement KT interventions. KBs work to promote, facilitate and support EIDM through one-to-one interaction with individuals, teams and organisations , 13. OneIn partnership with three Canadian public health departments, we used a case study design to conduct this study. The purpose of this study was to enhance individual capacity for EIDM and facilitate organisational contexts conducive towards it. Through the use of a case study methodology, we evaluated the impact of a KT intervention on EIDM knowledge, skills and behaviour, and identified contextual factors that facilitated or impeded impact. In this paper, we provide a thorough description of the KT intervention implemented by KBs in the three public health departments. Details related to the activities that were conducted and how they were implemented are provided such that others may replicate the intervention in other settings. The level of detail goes beyond what is generally included in publications reporting intervention outcomes. However, greater knowledge of what the intervention was comprised of and issues specifically related to implementation are needed in the KT literature. The primary focus of this paper is therefore to discuss important aspects related to intervention implementation and reflect on key factors that either facilitated or hindered its implementation.This case study was funded by the Canadian Institutes of Health Research as part of the Partnerships for Health System Improvement competition (FRN101867). Participants included front-line public health practitioners, managers, directors, and Medical and Associate Medical Officers of Health from three public health departments (cases). Ethics approval was received from the McMaster University Research Ethics Board.The three cases were situated in southwestern Ontario and differed with respect to the number of full-time staff, size of population served and organisational structure. They all served both urban and rural areas, as well as ethnically diverse populations, and were organised in discrete divisions or directorates such as communicable disease, chronic disease prevention and environmental health. Additional details related to the three cases are presented in Dobbins et al. 2018 .The KT intervention targeted six of the seven steps in the evidence-informed public health process described by the NCCMT . This inThe intervention was tailored for each case taking into account the philosophical stance, existing processes and supports, EIDM knowledge and skill of staff, and organisational goals. The intervention was implemented over 22 months. Each case was assigned a KB. While the KBs were employed by McMaster University, they spent a substantial amount of time located at the case sites. Given the time required to deliver the KT intervention, it was necessary to have two KBs, where one was assigned two of the cases and the other KB was assigned one case. Both KBs held a Masters degree and had several years’ experience working in KT and/or public health. In each case, the intervention began with an organisational assessment, followed by intervention implementation and ongoing monitoring and refinement of the intervention throughout the study. Additional details about the organisational assessment and results of this assessment have been published previously . A more The KBs, research team and senior management met regularly throughout the study to discuss intervention implementation and progress. During these discussions, ideas about how to continually modify the intervention arose and, in most instances, they were implemented. Case A identified new tools it wanted to use to support specific steps in the rapid evidence review process and revised existing tools. At the organisation level, Case A identified that additional strategies were needed to clarify staff roles and responsibilities with respect to EIDM. The KB also worked on developing workshop content and delivering EIDM training for all staff.In Case B, an ‘EIDM roadmap’ was developed to help support and sustain EIDM. Identified responsibilities included developing and implementing brokering strategies, recommending communication within or across directorates to help avoid duplication of rapid evidence reviews or supporting work, clarifying roles in EIDM broadly and for KB work specifically, helping the health department negotiate a selection of priority questions, and generating practical recommendations for internal consultants.Case C implemented an EIDM policy that was ultimately endorsed and adopted by the health department’s Executive Committee. With approval from senior management, the purpose of an existing committee was revised to include responsibility for developing and implementing strategies to sustain EIDM in the organisation. This health department also implemented voluntary basic EIDM training for all employees comprised of a full day EIDM introductory workshop and a subsequent half day workshop on critical appraisal of systematic reviews.An estimate of intervention dose  and intensity according to level  was tracked by the KBs in a reflective journal. KBs maintained a daily reflective journal of activities undertaken, as well as observations and reflections of the impact of these activities on EIDM. KBs also documented key factors that either facilitated or hindered implementation. Data from the KBs’ reflective journals were entered in NVIVO 8. The data were coded for emerging trends and themes by several members of the research team . Once agreement on major themes and codes were reached, and a coding scheme developed, the data were coded by one member of the research team (RT). The research team met to discuss interpretation of the themes..The KBs spent 2 days per week delivering the KT intervention in each case, although there were substantial differences in how the time was allocated. In Case A, the KB was physically onsite 2 days per week for the full 22 months. The KB spent the majority of time mentoring teams through rapid evidence reviews, and assessing the applicability of the research evidence to the local setting. The KB also participated in a monthly critical appraisal club with staff, provided workshops on EIDM, responded to questions posed by staff related to EIDM, and attended and presented at meetings with senior management and other health department staff. Presentations included an introduction to EIDM, interpreting statistics, and searching for and critically appraising public health practice guidelines. The total number of staff who were mentored, either individually or in small groups by the KB, was 48, whereas 33 staff participated in large group training such as presentations or workshopsIn Case B, the KB was initially physically onsite 2 days during 1 week of the month, but after approximately 6 months, at the request of the organisation, this was changed to half a day each week. The organisation indicated having the KB onsite more frequently would help maintain momentum for those engaged with the KB. The KB spent time onsite engaged in two specific activities, namely (1) building capacity for EIDM among staff who had responsibility for incorporating research evidence into practice decisions; and (2) conducting workshops with other staff about what EIDM is and why it is important. The KB also attended and presented at meetings with the senior management team and other health department staff. Twelve staff were mentored either individually or in small groups, by the KB; 76 participated in large group training such as presentations or workshops.In Case C, the KB also started out being physically onsite 2 days during 1 week of the month, but 6 months into the intervention, the case requested this be changed to 1 day every other week. The KB spent more time conducting large group training workshops, although small groups were also mentored through rapid evidence reviews. The KB also worked with the Research and Knowledge Exchange committee to develop policies, procedures and a guidebook for EIDM, and presented at senior management meetings and department-wide symposia. The total number of staff that engaged either individually or in small groups with the KB was 17, whereas 49 participated in large group training such as presentations or workshops.Overall, a statistically significant improvement in knowledge and skill was observed from baseline to follow-up in each case. Further details and discussion of these results have been reported elsewhere . The remThe following are the key factors – at the organisational, team and individual level – perceived by the KBs that either facilitated or hindered implementation of the KT intervention and, ultimately, EIDM.Particularly important factors in supporting EIDM at the organisational level were strong leadership and support for changing culture and practice to systematically incorporate research evidence into the decision-making process. Champions to communicate the value of EIDM supported ‘getting the word out’ and increased knowledge and understanding among staff about what EIDM is and is not. Existing infrastructure, such as a library and on-staff librarians, was identified as a key factor that enabled EIDM, as well as having particular roles identified in the organisation with responsibility for finding and using research evidence. Each case recognised the existence of committed financial and human resources, willingness to participate in the research study and support for staff to spend time engaged in the EIDM process as fundamental to the EIDM process. Existing EIDM processes and tools, such as those from the NCCMT and Health Evidence, helped the cases adopt or develop their own EIDM policies, procedures and tools. An important component of the KT interventions, observed by the KBs as contributing to successful EIDM, was regular contact between the KBs, and KBs and staff, research team, case key contact, and senior management.At the team level, the KBs identified meaningful interest in EIDM among teams and enthusiasm to improve knowledge and skills in finding and using research evidence in decision-making as important factors. This was observed especially among teams that were working on resolving important priority policy or programme decisions in their health department. The KBs noted that small teams working on rapid evidence reviews on topics of relevance and importance to the health department were seen among their peers as ‘taking small steps’, which enabled the health department to pilot EIDM processes and ‘test’ whether EIDM was feasible and valuable for making important practice decisions. In some cases, teams that were already skilled in finding and using research but who wanted to formalise their processes, were instrumental in demonstrating the feasibility and usefulness of EIDM. Sharing early experiences reassured and provided support for teams who later engaged in EIDM.At the individual level, the KBs noted that curiosity and enthusiasm among staff supported culture change and the creation of EIDM processes and practices. The KBs indicated that identifying staff with existing EIDM-related training and experience and getting them involved in the intervention was helpful, particularly in the early stages of implementing the KT intervention.The KBs observed that challenges to implementing the intervention mirrored facilitators to a large extent. For example, without leadership, champions, infrastructure and committed resources, the KBs noted that the cases struggled to achieve culture and practice changes that formally and systematically incorporated research evidence into decision-making. At the organisational level, KBs commented that limited engagement in and modelling of EIDM behaviours by senior management tended to result in similar behaviours by staff throughout the organisation. The KBs reflected that organisational change required active involvement of leadership that was consistently observable throughout the organisation. They also noted that verbal communication of the organisation’s commitment to EIDM was insufficient in facilitating organisational change.At the team level, the KBs observed how managers could act as barriers to staff development with EIDM. In instances where managers lacked understanding of the EIDM process or the time required to develop skills for EIDM and conduct activities consistent with EIDM, KBs observed staff did not have adequate time allocated to these tasks. As a result, staff struggled to make progress and/or experienced pressure to complete their work more quickly. Further, when teams reported their public health work as ‘mandated’ or externally prescribed, it was challenging to engage staff in EIDM as they did not perceive opportunities existed to change practice. This significantly reduced interest and motivation to learn EIDM-related skills across some teams and divisions/directorates.At the staff level, individuals varied greatly with respect to the amount of EIDM-related training they required to integrate EIDM in day-to-day work. This presented challenges with respect to developing multiple unique training programmes at the individual and team levels. Other challenges included occasional resistance to participation in EIDM and to changing practice status quo. A lack of confidence among staff regarding EIDM-related knowledge and skill was consistently identified. Most challenging was the reality of competing priorities and lack of time. This was sometimes characterised as staff not seeing EIDM as part of ‘core work’, but rather an ‘add-on’ to their already full workloads.Each case involved in this study featured a unique combination of individual, team and organisational characteristics and circumstances relating to their communities, political contexts and available resources. Furthermore, they were involved, to varying extents, in supporting EIDM prior to this study and therefore may have been more amenable to EIDM adoption in comparison to other public health departments in Ontario and Canada. Each case was involved in designing its own KT intervention, which has been shown in other studies to be associated with a higher degree of uptake of research evidence .As part of the KT intervention, KBs actively helped public health professionals identify, appraise and interpret best available research evidence as well as assess its applicability to the local context and determine if practice changes were needed based on review of the evidence. Previous evidence has shown that active engagement of decision-makers in applying evidence to practice improves uptake of research evidence .The findings of this study are supported by others who have reported that KT interventions need to be tailored to the specific context of organisations and the health professionals working within them , 28. FurA variety of change agents have been used to implement KT interventions, including facilitators , 35, opiIn this case study, particular activities were highly important at the outset of the intervention in setting the stage for intervention implementation; specifically, plans to draft a policy and procedures guidebook, with subsequent rapid evidence review experience that informed the tools for a guidebook, meetings with the Medical Officers of Health, and development of a document outlining a process for change at both the team and organisation levels. These activities acted as catalysts in each of the health departments. KBs have been shown previously to be catalysts for systems change , as wellThe KBs in this study supported participants to gain capacity in locating, appraising, translating and assessing applicability and applying evidence to practice, as well as assisting each case to improve its EIDM processes. The KBs identified librarians in two of the cases as champions for EIDM, while the third case identified library services as a barrier to EIDM . Other fThe findings of this study demonstrate an increase in EIDM knowledge and skills among staff and improvement in EIDM behaviours, particularly among staff who interacted closely with the KBs. Findings also highlight the importance of infrastructure and policies aimed at maintaining and sustaining a culture of EIDM, which has also been reported in the literature . TangiblThe results of this study illustrate the importance of working collaboratively with organisations to tailor KT interventions to best meet unique needs, preferences, organisational structures and contexts. Organisational factors, such as leadership, commitment to culture change, available resources and infrastructure, are critical in supporting the change process. Public health departments considering embarking on a process to embed EIDM into routine practice should first identify organisational strengths for EIDM, and work to optimise organisational supports where they exist and develop them where they do not. Once these are in place, organisations are more likely to be ready for change and to engage actively in developing and implementing KT strategies. While KBs implemented the KT intervention in this study, more research is needed to understand the impact of all change-agent roles, including KBs, as well as how these roles can be maintained in the long-term if proven effective.


Patient-reported outcome measures (PROM) or self-completed questionnaires have been used to report outcomes in osteoarthritis (OA) for over 35 years. Choices will always need to be made about what should be measured and, if relevant, what would be the most appropriate PROM to use. The current study aims to describe the available PROMs used in OA and their performance quality, so that informed choices can be made about the most appropriate PROM for a particular task.The study included a systematic search for PROMs that have been in use over 17 years (period 2000–2016), and to catalogue their psychometric properties, and to present the evidence in a user-friendly fashion.78 PROMs were identified with psychometric evidence available. The domains of pain, self-care, mobility and work dominated, whereas domains such as cleaning and laundry and leisure, together with psychological and contextual factors, were poorly served. The most frequently used PROMs included the Western Ontario McMaster Osteoarthritis Index, the Short Form 36 and the Knee Disability and Osteoarthritis Outcome Score which, between them, appeared in more than 4000 papers. Most domains had at least one PROM with the highest level of psychometric evidence.A broad range of PROMs are available for measuring OA outcomes. Some have good psychometric evidence, others not so. Some important psychological areas such as self-efficacy were poorly served. The study provides a current baseline for what is available, and identifies the shortfall in key domains if the full biopsychosocial model is to be explored. Patient-reported outcome measures (PROM) are commonly used for osteoarthritis (OA) outcomes.Some PROMs, for example, Western Ontario McMaster Osteoarthritis Index, are well known.This is the first comprehensive review of all PROMs used in published OA studies, including trials.This work provides a detailed analysis of the psychometric properties of all OA PROMs and highlights shortfalls in PROMS measuring several domains.This work provides a wide range of outcomes for domains that may not usually be considered by clinicians.Clinicians can make choices about tools based on their published robustness.Studies on the lived experience of those with osteoarthritis (OA) show that most facets of life can be affected by this long-term condition.Whether in the context of a clinical trial, or other intervention study, or to monitor the routine care of the patient, choices will need to be made about what should be measured and, if relevant, what would be the most appropriate PROM to use. Systematic reviews have been made on PROMs to help select the most appropriate PROM with the best evidence, but these are often conditional in some way, for example, joint specific, PROM specific or some particular kind of intervention.The study set out to identify the PROMs that have been in use over 17 years (period 2000–2016), and to systematically catalogue their psychometric properties, and to present the evidence in a user-friendly fashion.The search strategy was developed by the authors at a consensus meeting in early 2012, and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.10.1136/rmdopen-2018-000715.supp1Supplementary dataThe second search simply adds the name of the PROM using ‘AND’ as Boolean operator to the first part of the search, but without giving a specified period, as the psychometric evidence could arise from any period following the construction of the PROM. This was to identify the relevant psychometric evidence associated with the PROM. The third search removes the psychometric parameters to simply count the use of the PROM in OA during the period 2000–2016. Targeted hand-searching of reference lists and other supplementary sources, such as textbooks, was also performed.Potential papers with a candidate PROM identified in search 1 were then screened by two independent reviewers. This included independent screening of the titles and abstracts. For search 2, having added the name of the PROM to the search criteria, papers were included if they met the following criteria: (1) the subjects related to the evidence had OA and the evidence was (mostly) OA specific; (2) one or more of the chosen psychometric criteria specific to the PROM  in question  were reported in the article; (3) the article was in English; and (4) it was available in full text. These selected papers were again reviewed by two independent researchers and any disagreements were discussed and resolved with a third reviewer.The results are reported in a series of hierarchically structured tables: (1) overall summary table—main body; (2) PROM-specific summaries—10.1136/rmdopen-2018-000715.supp2Supplementary data10.1136/rmdopen-2018-000715.supp4Supplementary dataIt must be noted that the evidence presented here is condition specific; so while a generic PROM may have considerable evidence of validity in other conditions or in mixed samples, if there is no specific evidence within OA, it will be rated as such. Likewise, it is possible that subscales that have been reported may have no separate psychometric evidence for OA, but a total score may do so. Evidence from adaptations into different languages were accepted if some psychometric evidence was forthcoming. Consequently, for a PROM to be included in this review, psychometric evidence for OA from some aspect of the PROM must be evident.An independent full-text review of each paper identified the psychometric evidence. This was collated in accord with the domains of the COnsensus-based Standards for the selection of health Measurement INstruments COSMIN checklist10.1136/rmdopen-2018-000715.supp3Supplementary dataDiscrimination is evaluated by the magnitude of internal consistency reliability, and whether or not some form of Minimally Important Difference (MID)/Minimally Clinical Important Difference (MCID)/Standardised Response Mean(SRM) is presented. For validity, certain PROMs may have been developed originally in another condition  or generally for arthritis, and subsequently validated for OA. Where this is the case, and their additional validation is within OA, we designate them as a ‘hybrid’ disease-specific PROM . Pain, mobility, self-care and work dominated the measured domains, with physical functioning a major complex domain (in that it measures two or more underlying domains such as self-care and mobility). All these domains have a range of PROMs satisfying both ‘good’ and ‘moderate’ criteria on the OMERACT filter, including disease-specific instruments. Work, while well represented, had fewer PROMs rated as ‘good’ or ‘moderate’. In contrast, domains associated with instrumental activities of daily living such as cleaning or laundry, or for other aspects of participation such as leisure activities, were poorly served by available PROMs, as were psychological aspects such as ‘Self-efficacy’, and relevant environmental factors.The most frequently used PROMs are shown in Seventy-eight PROMs with some level of supporting psychometric evidence, available and assessed by the patient partner were catalogued according to a variety of commonly used domains. Found in published papers between 2000 and 2016, almost all domains had at least one PROM rated as ‘good’ or ‘moderate’ (green or yellow) on the OMERACT filter summary. The domains of pain (ICF-b280), mobility (d4) and self-care (d5) were dominant, along with work (d8451). This is unsurprising as these are those aspects of OA that are commonly reported, and include potentially modifying factors relevant for intervention.While some well-known PROMs appear to have no evidence of their reliability and/or validity, there are a number of reasons for this. For example, the original Arthritis Impact Measurement Scale (AIMS) paper involved 104 cases from a mixed rheumatology clinic sample, 31% of which had OA.On balance, any PROM that has a yellow or green indicator will be worth considering, conditional on the year of publication. Yellow may indicate a propriety status if the feasibility indicator is also yellow. As PROMs appear to be treated as a commodity by certain large-scale test companies, where the  rights to the PROM are bought from the original developers, and subsequently made propriety, it will be essential to check the status of any PROM to ascertain its current propriety status. Readers are also encouraged to view the relevant published papers listed in The lack of adequate PROMs used to ascertain aspects of participation such as leisure, together with psychological and environmental factors, is of concern, as this limits the available mediators and moderators for analysis of the more complete biopsychosocial model. For example, treatment focused on self-efficacy and psychological distress has been reported as most effective in improving the quality of well-being of those with OA aged 60 years and over.The information presented here arises from just one of several EULAR-funded initiatives to catalogue the available PROMs across several rheumatic diseases, leading to the EULAR Outcome Measures Library.Given the age-related prevalence of OA, and the ageing of the population in western societies, maintaining health status and quality of life among those with OA is likely to be a major public health issue. Currently, a rich catalogue of PROMs is available for measuring these domains, although some potentially important domains such as leisure and ‘self-efficacy’ are poorly served. Rheumatologists and other allied health professionals working with those with OA will need to keep in mind the wider biopsychosocial model, together with recent developments in the area of e-health informatics which prescribes the ICF as the basis of reporting health, defined as functioning.


Splenic nodules and heterogeneous parenchyma are seen frequently in abdominal ultrasound examinations of dogs, but the clinical importance of these lesions remains unclear.To determine whether specific ultrasonographic findings correlate with clinically relevant cytologic diagnoses and determine what sonographic features are correlated with these diagnoses. Another objective was to develop a scoring rubric to help clinicians make decisions on whether or not certain ultasonographic findings of the spleen warrant evaluation by fine‐needle cytology.One‐hundred twenty‐five adult client‐owned dogs with ultrasonographically identified splenic nodules, heterogeneous parenchyma, or both.Medical records were retrospectively searched for ultrasound‐guided splenic fine‐needle cytology reports. Ultrasonographic images were assessed for nodule number, size, echogenicity and distal enhancement, degree of splenic heterogeneity, and peritoneal fluid. Dogs were divided into 2 groups: those with clinically important or clinically irrelevant cytologic findings. Potentially useful and discriminatory ultrasonographic findings were identified by statistical analysis, and the most useful findings were used to generate the scoring rubric.The clinically important group included 25 of 125 dogs . Splenic nodules 1‐2 cm in diameter, peritoneal fluid, and >1 targetoid nodule were associated with clinically important cytologic findings. Receiver operator characteristic analysis showed that the scoring rubric was useful for identifying dogs in the clinically important group.Splenic fine‐needle cytologic findings identified a clinically relevant diagnosis in 20% of dogs, and larger nodule size, number of targetoid lesions, and presence of peritoneal fluid increase the likelihood of detection of clinically important disease. AUCarea under the curveCIconfidence intervalROCreceiver operator characteristic1Sonographically detected splenic parenchymal changes can be found during abdominal ultrasound examination in asymptomatic patients or patients with unrelated disorders. Splenic nodules without associated splenomegaly are a relatively common finding in older dogs,Fine‐needle cytology is commonly performed in patients with splenic nodules, and fine‐needle sample collection is considered safe even in the presence of coagulopathies or thrombocytopenia.The clinical relevance of small, nodular lesions in the spleen and the optimal clinical approach to patients with these lesions remains unclear. This is in contrast to patients with larger splenic masses (>2 cm diameter) or known underlying disease with a high rate of splenic involvement , in which it is generally accepted that fine‐needle aspirates of the splenic tissue are indicated.Our objective was to determine whether specific ultrasonographic findings correlate with a clinically relevant cytologic diagnosis and determine what sonographic features were correlated with these diagnoses. A further objective was to develop a scoring rubric to help clinicians make decisions on whether or not certain ultasonographic findings of the spleen warrant fine‐needle cytology.22.1The medical records database of the Oregon State University Veterinary Teaching Hospital was retrospectively searched to identify dogs in which ultrasound‐guided splenic sample cytology was performed between July 2011 and June 2015. Criteria for inclusion were ultrasonographic examination of the spleen in which splenic nodules or heterogeneous splenic parenchyma were identified followed by splenic fine‐needle sample cytology on the same day. Nodules were defined as being <2 cm, whereas masses were defined as being >2 cm. In patients with splenic nodules identified on multiple visits, the ultrasound examination and cytology results from the first visit only were used in the study. The following criteria were used for exclusion: presence of a splenic mass (>2 cm), dogs known to have mast cell neoplasia or lymphoma before ultrasound examination, absence of a cytology report or ultrasonographic images, and dogs with homogenous splenic parenchyma without any nodules. Dogs with a diagnosis of lymphoma or mast cell neoplasia made during the first visit to the veterinary teaching hospital were not excluded from the retrospective analysis.Information collected from medical records included signalment, date of imaging and sampling, presenting complaint, and cytologic diagnosis.2.2Cytologic specimens were obtained by ultrasound‐guided fine‐needle sample collection performed by board‐certified veterinary radiologists. All ultrasonographic examinations and ultrasound‐guided sample collection was performed using an 8 MHz curvilinear transducer. Fine‐needle sample collection was performed using 22‐gauge, 1.5‐inch‐long needles using a nonaspiration technique.Static images of ultrasound examinations and radiology reports were reviewed by 2 authors , an intern and a board‐certified veterinary radiologist to determine the ultrasonographic appearance of the splenic parenchyma and nodules. Observers were blinded to the clinical presentation, history, and cytology results. Information collected from ultrasonographic images and radiology reports included the number and size of the largest nodules, presence of distal acoustic enhancement of the nodules, echogenicity of nodules, margination of the nodules (ill‐ or well‐defined), heterogeneity of the splenic parenchyma, and presence of peritoneal fluid.Targetoid lesions were defined as nodules with a hypoechoic rim and a hyperechoic or isoechoic center.Board‐certified clinical pathologists reviewed all cytologic slides for diagnostic interpretation. The retrospective review of the cytologic slides was performed by an independent board‐certified clinical pathologist (E.G.) in a blinded fashion without knowing the size and characteristics of the nodules and without knowledge of the initial diagnostic interpretation. Lesions were interpreted based on the predominating cellular constituents present. Nodules considered to represent a benign or normal process included extramedullary hematopoiesis , lymphoid and plasma cell hyperplasia or reactivity, or no abnormalities based on the presence of normal blood constituents with no cellular proliferation. These findings were classified as clinically irrelevant because they did not affect case management. Cytologic diagnoses of malignant neoplasia were based on the presence of abnormal cellular infiltrates  or proliferation of monomorphic populations of atypical round cells including lymphocytes, histiocytes, or mast cells. Interpretation of inflammation was based on increased numbers of leukocytes in excess of expected numbers based on known peripheral blood results. Neoplastic and inflammatory lesions were classified as clinically relevant if they changed case management. Based on the clinical importance of the cytologic diagnoses, dogs were divided into 2 groups , and ultrasound findings were compared between groups. Group 1 was comprised of dogs with clinically important cytological diagnoses, whereas group 2 included dogs with clinically irrelevant cytologic diagnoses.A “clinical importance score” rubric (Table 2) was created based on the ultrasonographic findings and their statistical relevance Table . For eac2.3P < .05. After univariate analysis, a multiple factor “clinical importance score” rubric was created. Briefly, variables from the univariate analysis that showed a calculated P value < .1 were identified, and numeric scores assigned for each finding. Scores were weighted by relative risk identified in the contingency analysis, with findings that had a high relative risk for the presence of clinically relevant disease given a higher score. For variables that were stratifiable, increasingly more severe findings were given higher weightings in the scoring system. The scoring system was applied to the ultrasonographic data, and the diagnostic performance of the scoring system assessed using receiver operator characteristic (ROC) analysis  were analyzed using Fisher's Exact Test, whereas variables that were stratified  were analyzed using the chi‐squared test for trend. For the initial univariate analyses, statistical significance was set at All statistical analyses were performed using GraphPad Prism 6.0 for the Macintosh operating system .3The medical records search identified 245 dogs meeting the initial inclusion criteria. One‐hundred sixteen dogs were excluded from the study: 64 dogs were diagnosed with mast cell tumor or lymphoma before splenic fine‐needle sample cytology, 45 dogs had a mass ≥ 2 cm in diameter, 6 dogs did not have cytology reports or ultrasound images available, 1 dog had homogenous splenic parenchyma without any nodules, and 1 dog had a nondiagnostic sample. These excluded cases resulted in a sample size of 125 dogs that met the final criteria for assessment.Group 1 included 25 of 125 (20%) dogs with clinically important cytologic diagnoses including lymphoma (n = 10/25), sarcoma (spindle cell) tumor (n = 4/25), malignant histiocytosis (n = 3/25), suppurative inflammation (n = 3/25), epithelial neoplasm , melanoma (n = 1/25), and hemangiosarcoma (n = 1/25). Group 2 included 100 of 125 dogs (80%) with cytologic diagnoses not impacting the diagnostic or therapeutic plan, including extramedullary hematopoiesis (n = 79/100), lymphoid reactivity or hyperplasia (n = 12/100), and normal spleen (n = 9/100).P = .62). The most common breeds of dogs in group 1 were mixed breed dogs (6/25), Golden Retriever (4/25), and Labrador Retriever (4/25). The most common breeds of dogs in group 2 were mixed breed dogs (25/100), Golden Retriever (9/100), Labrador Retriever (7/100), Dachshund (5/100), Flat‐Coated Retriever (3/100), Heeler (3/100), Boxer (3/100), and German Shepherd Dog (3/100). Of the 25 dogs in group 1, 17 were neutered males, 7 were spayed females, and 1 was a sexually intact female. Of the 100 dogs in group 2, 38 were neutered males, 2 were sexually intact males, 55 were spayed females, and 5 were sexually intact females. No statistical difference in breed or sex was found between the groups.The mean age of dogs in group 1 was 9.0 years , whereas the mean age of dogs in group 2 was 9.4 years ; no significant difference was found in age between the 2 groups (P = .01). A higher prevalence of peritoneal fluid was found in dogs with clinically important splenic lesions (12/25) when compared to dogs with clinically irrelevant lesions . Three of 25 dogs in group 1 had multiple targetoid nodules, and no dogs in group 2 had multiple targetoid nodules, but 4 of 100 dogs in group 2 had singular targetoid nodules (P = .01). The presence of multiple nodules was not different between groups (P = .07). Other findings are summarized in Table The presence of splenic nodules with diameter 1‐2 cm was significantly more common in dogs with clinically important splenic lesions  indicates that this scoring system is significantly better than random chance (AUC of 0.5) at detecting clinically important disease in the spleen (Figure As with most retrospective studies, our study had some limitations. The first limitation was the absence of histopathologic confirmation of the cytologic diagnosis. Although cytologic diagnoses often reflect histologic results, if incorrect or inadequate sampling occurs or cytology is unable to distinguish between reactive and neoplastic conditions, accurate diagnosis with fine‐needle sample cytology may not be possible.A second limitation also is related to the retrospective nature of the study. It was not definitively documented that the splenic fine‐needle cytology sample was obtained from the nodules or surrounding parenchyma. It is our general procedure to sample nodules as well as some non‐nodular parenchyma, but we cannot be sure that this was always the case.A third limitation relates to the retrospective evaluation of the static ultrasonographic images of the spleen and radiology reports because only saved images could be evaluated and images may not have been acquired of all nodules. All ultrasound examinations were performed by 1 of 2 board‐certified radiologists, and multiple images of the spleen were available for all animals. The combination of this consistency combined with a radiology report written within 24 hours of the ultrasound examination and the presence of static images documenting the appearance of the spleen decreases the possibility that the ultrasonographic data incorrectly represented the disease of the patient.In conclusion, splenic fine‐needle sample cytology is a minimally invasive diagnostic modality that identified a clinically important diagnosis in approximately 20% of adult dogs with splenic nodules or heterogeneous splenic parenchyma. Specific ultrasonographic findings, such as the size and number of splenic nodules as well as the presence of peritoneal fluid, may increase the index of suspicion for the presence of malignant neoplasm or suppurative inflammation. Use of the proposed scoring method and a cutoff score of either 4 or 5 may help identify which animals in this population of patients may benefit the most from splenic fine‐needle sample cytology after ultrasound examination.Journal of Veterinary Internal Medicine. He was not involved in review of this manuscript.Helio de Morais serves as Associate Editor for the Authors declare no off‐label use of antimicrobials.Authors declare no IACUC or other approval was needed.Authors declare human ethics approval was not needed for this study.


To describe the steps involved in evidence-based decision making for the implementation of programs aimed at the promotion of physical activity. It is a descriptive, cross-sectional study with quali-quantitative approach, held with municipal health secretaries chosen deliberately by regional health representatives of the state of Paraná. A total of 27 secretaries participated in a telephone interview consisting of 17 open questions. Content analysis was conducted according to the categories of an evidence-based decision-making model consisting of seven steps. None of the participants employed every step of the evidence-based decision-making model. The steps that were most often mentioned included: evaluation of the program (33.3%), use of evidence from the literature (22.2%) and identification of the problem (22.2%). The steps that were reported the least included: quantification of the problem (14.8%), development and prioritization of actions (14.8%), development of the plan of action (14.8%) and evaluation of the community (3.7%). The use of evidence-based decision making in the context of the promotion of physical activity was shown to be incipient among the health secretaries of the state of Paraná. We suggest widening dissemination and training on the use of evidence-based decision making among municipal administrators to increase the effectiveness of actions for promotion of physical activity. Municipal administrators can understand more easily the demands and the needs of local communities and are therefore central people in the development of local actions for the promotion of health ,,,The use of EBDM is recent in the field of PA and occurs predominantly in high-income countries This study is part of the project Local practices and use of evidence in the prevention of chronic non-communicable diseases in the state of Paraná. It is a descriptive, cross-sectional study with quali-quantitative approach, held with municipal health secretaries of the state of Paraná. The study was approved by the Ethics Committee for Research with Human Beings of Pontifícia Universidade Católica do Paraná .The state of Paraná is located in the Southern region of Brazil, has 11,219,013 inhabitants distributed in 399 municipalities and occupies a land area corresponding to 199,880 km The selection of participants took place in two stages. In the first, the representatives of the state’s 22 regional administrations were contacted by telephone, since they are privileged actors in the localities for having access to the reality of each municipality, as well as to the actions that are carried out in them. Two representatives did not accept participating in or did not attend the interviews. The 20 representatives contacted indicated, according to the perception and knowledge of their location, the municipalities that had positive experiences and those that showed difficulties in the implementation of programs for the promotion of PA. In all, 33 municipalities were indicated, 17 with positive experiences and 16 with difficulties. In the second stage, the indicated MHS were invited to participate in the study. Among the 33 MHS invited, six  (18.2%) declined. Thus, the final sample was composed by 27 MHS: thirteen municipalities that had positive experiences and 14 that had difficulties in the implementation of actions for promotion of PA.The data were collected through telephone interviews between the months of July and August 2015. The secretaries’ contact information  was made available by the Council of Municipal Health Secretaries of Paraná (COSEMS-PR) The telephone interviews had an average 30-minute duration  and consisted of 17 open questions, organized into seven blocks: i) socio-demographic information; ii) health priorities in regional health administration; iii) knowledge of evidence-based interventions for prevention of chronic non-communicable diseases (NCD); iv) barriers to evidence-based decision making; v) evidence-based support for NCD prevention; vi) steps of evidence-based decision making for NCD prevention and vii) steps of evidence-based decision making for promotion of PA. The questionnaire was developed jointly by one international and three national researchers with experience and publications in the field of health, NCD and public management, and aimed to standardize the information pertaining to the decision-making process.The transcription of the interviews was carried out by two auxiliary researchers, having been verified by the study’s coordinator. The secretaries’ anonymity was maintained, because the data that could identify them were replaced by codes a priori , according to the model proposed by Brownson The data were analyzed using a descriptive approach and by carrying out content analysis Step 1 – Evaluating the community: identification of health priorities and comparison with the country’s surveillance data .Step 4 – Seeking evidence in the literature: mapping of scientific evidence about PA programs in scientific journals and databases , government documents and websites Step 5 – Developing and prioritizing actions: identification of the need for political support for the program’s implementation, as well as of the cost for implementation, maintenance and definition of the necessary structure.Step 6 – Developing a plan of action: use of a logical model for the program’s implementation Step 7 – Evaluating the program: identification of the program’s dissemination, adherence by the population and results in accordance with the proposed objectives .In all, 27 MHS of the state of Paraná participated in this study, 13 from municipalities with positive experiences and 14 from municipalities with difficulties in the implementation and execution of programs for promotion of PA. The participants were predominantly women (56.6%), between 41 and 59 years old (55.5%), with training in the field of health (48.1%), having occupied the position for a period between 13 and 36 months (51.8%) and acting in medium-sized municipalities (55.5%), with between 10,001 and 50,000 inhabitants   .In relation to the process of adoption of the EBDM steps for implementation of PA promotion programs, no secretary reported the application of all seven steps, and one in three secretaries did not apply any of the steps suggested by the literature. The steps most often employed by the secretaries were: evaluating the program (33.3%), using evidence from the literature (22.2%) and identifying the problem (22.2%). The steps that were applied the least in the municipalities investigated included: quantifying the problem (14.8%), developing and prioritizing actions (14.8%), developing a plan of action (14.8%) and evaluating the community (3.7%)   .The MHS of municipalities with positive experiences mentioned the use of more EBDM steps than those that acted in municipalities with difficulties in the implementation of actions for promotion of PA   . HoweveThe study’s results indicate that none of the MHS interviewed employed all the EBDM steps, and that one in every three MHS did not apply any of the steps in the implementation of programs for promotion of PA. The implementation of the EBDM steps was more frequent among the MHS of municipalities with positive experiences compared to those with difficulties. The steps most often employed by the secretaries were: evaluating the program, using evidence from the literature and identifying the problem.The results of this study indicate that the MHS have difficulty recognizing the local needs and including strategies to identify and quantify the problem, because these steps are fundamental for the application of EBDM “The identification of the problem is very simple, and all programs face this physical activity issue. We verified a large number of obese people in the population. A survey has been carried out to find out the percentage of the overweight portion of the population {indicates the physical activity program}” S12.,The main need indicated in the report was the fight against obesity, the practice of PA being recognized as an important aspect to reverse this situation, which is supported by the literature ,Another important result indicates a low rate of use of scientific evidence among the secretaries. The low rate of application of this step can be associated with little familiarity with the scientific language, difficulties of access to scientific evidence and lack of ability to develop a scientific evidence-based program Indeed, it is important to understand how the programs are implemented (practice-based evidence), because they have high external validity. The results of this study show that the secretaries have difficulties in the following steps: developing and prioritizing actions and developing a plan of action, this being the most frequent among the MHS with difficulties in the promotion of PA, according to the reports presented.“We discussed a couple of months ago that, during the Hiperdia meetings, it would be requested that nurses went for walks with the people from the group. So, this was the first idea we had. Next we will carry out an evaluation and see what else fits this profile” S4.,,,The difficulty in planning causes interventions to have little chance of being effective or sustainable, because, as identified in this study, the MHS have difficulties in assessing and identifying the community’s problems, since these steps are fundamental for the whole process of development of the plan of action. The actions often do not have well-defined goals and do not meet the population’s needs. In addition, many programs do not have sufficient funding or a qualified technical team The step that was most often mentioned by the participants was: evaluating the program. This result corroborates that of another study which shows that the assessment of the impact of the interventions and economic benefits are the main factors referred to by decision-makers in relation to the PA programs’ implementation Despite its importance, the evaluation reported by the participants refers only to the population’s health indicators, which corroborates the literature Generally speaking, although the analysis of the present study focused on the EBDM steps, the secretaries have no understanding of the process as a whole. It is necessary to train the MHS and the technical team so they may adopt EBDM as a process that will improve planning, cost-effectiveness, adherence and health indicators for the community.The results of this study provide important information about the process of planning, implementation and development of PA among the MHS of the state of Paraná. However, the sample was obtained through an indication of the regional coordinators and contrasted the counties with positive experiences and those with difficulties in the actions for promotion of PA. However, the comparison between municipalities with extremes of experience and success in the promotion of PA does not clarify all the complexity and diversity that exists in the state’s municipalities. Thus, we cannot generalize the results for municipalities with medium performance in PA promotion actions.The findings are based on reports of the administrators of each secretariat; it is possible that some response bias is present, as they could overestimate their knowledge of the subject. Considering that the results indicate low knowledge about the EBDM process, this bias would not change the conclusion of the study. Furthermore, no technical coordinators of the programs were interviewed to expand the possibilities of analysis and interpretation of the data.The results of the study indicate that the employment of the EBDM steps to implement the PA promotion programs in municipalities of the state of Paraná is infrequent and limited to a few steps only. In addition, municipalities with prominent actions for the promotion of PA use more EBDM steps than municipalities with difficulties in the promotion of PA. We suggest the expansion of the information about the EBDM process in Brazil, especially among municipal administrators of PA promotion programs, because the implementation of its steps is an important mechanism for the success of these initiatives in Brazilian municipalities. Promoting training courses, expanding the source of high-quality information and facilitating the exchange of experiences between municipalities with more experience in PA actions are strategies that can be tested in Brazil for greater use of the EBDM process in the promotion of PA.