We examined the relation between home literacy environment (HLE) and early literacy development in a sample of children learning four alphabetic orthographies varying in orthographic consistency . Seven hundred and fourteen children were followed from Grade 1 to Grade 2 and tested on emergent literacy skills  at the beginning of Grade 1 and on word reading fluency and spelling at the end of Grade 1, the beginning of Grade 2, and the end of Grade 2. Their parents responded to a questionnaire assessing HLE  at the beginning of Grade 1. Results showed first that PT was associated with letter knowledge or phonological awareness in Dutch and Greek, while ALR was associated with emergent literacy skills in all languages. SBR did not predict any cognitive or early literacy skills in any language. Second, PT and ALR had indirect effects on literacy outcomes via different emergent literacy skills in all languages. These findings suggest that not all HLE components are equally important for emergent literacy skills, reading fluency, and spelling. No specific trend in the role of orthographic consistency in the aforementioned relations emerged, which suggests that other factors may account for the observed differences across languages when children start receiving formal reading instruction in Grade 1. To date, most studies on HLE have been guided by the Home Literacy Model , accordiPrevious longitudinal studies have consistently supported these predictions across a wide range of linguistic and cultural contexts e.g., . For exaExisting cross-linguistic studies have also provided evidence in support of the important role of HLE in literacy acquisition across languages . For exaDespite the consistent evidence of positive associations between HLE and children’s literacy development e.g., , the exiIn this study, we examined the developmental relations between HLE and literacy skills in a 2-year longitudinal study with children learning four European alphabetic orthographies varying in orthographic consistency: English, Dutch, German, and Greek. These languages were selected to vary widely in their orthographic consistency, namely, English being the most inconsistent, Greek being the most consistent, and Dutch, and German lying in between English and Greek in the orthographic consistency continuum . Guided Mage = 75.87 months at the first measurement point) were native speakers of English and were recruited from six public elementary schools in Edmonton, Canada; 120 children  were native speakers of Dutch and were recruited from five public elementary schools in Amsterdam, the Netherlands; 184 children  were native speakers of German and were recruited from five public elementary schools in Graz, Austria; and 238 children  were native speakers of Greek and were recruited from six public elementary schools in Heraklion, Greece. Our participants were recruited on a voluntary basis  and were tested four times: at the beginning and end of Grade 1, and at the beginning and end of Grade 2. By the end of Grade 2, our sample consisted of 157 English-speaking (9% attrition), 107 Dutch-speaking (11% attrition), 167 German-speaking (9% attrition), and 219 Greek-speaking (8% attrition) children. In all countries, children start school at 6 years of age. The children in each site came mostly from families of middle socioeconomic background (based on the location of the schools and parents’ education), and none were experiencing any intellectual, emotional, or sensory difficulties. Parental and school consent was obtained prior to testing.Our sample consisted of 714 children followed from the beginning of Grade 1 until the end of Grade 2. One hundred and seventy-two children  to Daily (4 points). The other question was worded similarly but replaced “to read words” with “to spell words.’’Two 5-point Likert scale questions were used to assess parent teaching. The first asked “When your child was in Kindergarten, how often did you (or someone else at home) teach him or her to read words?” and parents responded on a scale ranging from Less than 5 min a day (0 points) to 2 h or more (4 points). The other question was worded similarly but replaced “on a typical weeknight (Monday to Friday)” with “on the weekend (Saturday and Sunday).”Two 5-point Likert scale questions were used to assess shared book reading. The first asked “When your child was attending Kindergarten, how many hours did you (or someone else) read to your child on a typical weeknight (Monday to Friday)?” and parents responded on a scale ranging from To assess ALR, we first asked parents to report how many children’s books they had at home by using a 5-point scale . Second, we asked parents to report how many adult’s books they had at home by using a 5-point scale .Letter-Sound Knowledge task was administered in each language. Although we also assessed Letter-Name Knowledge, it was at the ceiling in English and for this reason, we only used Letter-Sound Knowledge in this study. Children were shown each of the uppercase letters on an A4 paper and asked to say what sound each made; short vowel sounds were accepted for vowel letters, and consonant sounds with the following vowel for consonants. The score was the number of correct letter-sounds produced. The maximum score was 26 in English, 24 in Dutch, 22 in German, and 24 in Greek. Reliability of this measure has been reported to be higher than 0.90 in each language.To assess PA, we used Phoneme Elision in each language. The task included four practice items and 24 experimental items designed so as to match items phonologically across languages , and word reading fluency and spelling were assessed at the end of Grade 1 (Time 2), the beginning of Grade 2 (Time 2), and the end of Grade 2 (Time 3). All testing took place in quiet rooms in the children’s school during school hours by trained research assistants. The tests were administered in one session lasting about 25 min. Administration and scoring were standardized across all children and languages.First, to test the measurement equivalence of the latent HLE constructs across languages, we evaluated a model of metric invariance , in whicAll analyses handled missing data by the full information maximum likelihood estimator implemented in Mplus , which h2 = 38.85, df = 33, p = 0.22, CFI = 0.99, TLI = 0.99, RMSEA = 0.04, 90% CI = 0.00 to 0.07, SRMR = 0.04, and the factor loadings were all substantial . These results indicate that our HLE questionnaire showed measurement equivalence across the four languages. The results of one-way ANOVAs with language as a factor showed that parent teaching was more frequent in English than in all other orthographies (Hedges’ gs ranged from 0.84 to 1.04). Shared book reading was less frequent in Dutch (Hedges’ gs ranged from 0.62 to 0.89), while ALR was greater in German (Hedges’ gs ranged from 0.44 to 0.79) than in all other orthographies. The descriptive statistics for child measures are shown in The descriptive statistics for parent measures are shown in 2 = 269.38, df = 178, p < 0.001, CFI = 0.98, TLI = 0.96, RMSEA = 0.06, 90% CI = 0.05 to 0.08, SRMR = 0.05. Neither parent teaching nor shared book reading was significantly associated with emergent literacy skills in English or German, but parent teaching was in Dutch and Greek. ALR, on the other hand, was significantly associated with emergent literacy skills in all languages. More specifically, parent teaching was uniquely associated with children’s phonological awareness in Dutch  and letter knowledge in Greek . ALR was uniquely associated with vocabulary in English , Dutch , and German . ALR was also associated with PA in German  and both PA and letter knowledge in Greek . In contrast, shared book reading did not have a unique association with any outcome measure.Next, a longitudinal structural model was constructed . The mod2 = 4.30, df = 1, p < 0.05). Similarly, when the association between ALR and vocabulary was constrained to be equal between German and Greek, the model fit deteriorated significantly . Taken together, these results indicate that parent teaching was more strongly associated with letter knowledge in Greek than in German, while ALR was more strongly associated with vocabulary in German than in Greek.The results of multigroup analyses showed that the fit of the multigroup model deteriorated significantly when the association between parent teaching and letter knowledge was constrained to be equal between German and Greek  can modulate the relation between HLE (microsystem) and literacy development . The results showed first that neither parent teaching nor shared book reading were uniquely associated with emergent literacy skills in English and German, while parent teaching was in Dutch and Greek. It should be noted, however, that the correlation between parent teaching and letter knowledge was significant in English see , albeit Access to literacy resources, on the other hand, was significantly associated with emergent literacy skills in all languages and, as hypothesized, it was uniquely associated with children’s vocabulary knowledge in English, Dutch, and German. The strongest association between access to literacy resources and vocabulary was found in German see , 1989. TThe results further showed that parent teaching and access to literacy resources had indirect effects on literacy outcomes via emergent literacy skills in all languages, a finding that is consistent with those of previous studies with English-speaking participants e.g., . HoweverAn important educational implication of our findings would be to inform parents that increasing access to literacy resources at home may enhance children’s literacy development. However, our results that shared book reading was not uniquely associated with children’s literacy skills suggest that parents may not necessarily know how to effectively engage their children in shared reading activities. Given this, an implication of our findings would be to encourage researchers and educators to suggest the means by which the home literacy activities, shared book reading in particular, could be beneficial for their children’s literacy development  for each language. Second, home literacy activities were assessed retrospectively with a self-report questionnaire to the parents, and this may have resulted in inflated estimates of their literacy-related activities at home due to social-desirability bias . Third, we used observed variables instead of latent variables for HLE and the cognitive constructs in the models, and this might have resulted in the underestimation of the relations between HLE and literacy skills due to measurement error. Fourth, the possible influence of schooling on children’s performance across the testing points was not captured in this study partly because school-level variables were not our primary focus in the present study. Future studies should consider taking school-level variables into account to better understand how schooling, another microsystem affecting children’s literacy development, interact with the effect of HLE. Finally, because developing strictly comparable cognitive and literacy measures across such a diverse group of languages is extremely difficult given the unique features of each language, we decided to use existing measures of cognitive and literacy skills that follow the same administration and scoring procedures across languages. Although the observed differences in the relationships between HLE and literacy outcomes in our study might be partly due to the characteristics of the cognitive and literacy measures used in each language, we also acknowledge that fully controlling for the effect of item characteristics across four diverse languages is almost impossible.To conclude, the present study examined the developmental relations between HLE, emergent literacy skills, and literacy outcomes in a 2-year longitudinal study with children learning four alphabetic orthographies . The results indicated that parent teaching was associated more strongly with letter knowledge and PA in English, Dutch, and Greek, while access to literacy resources is associated more strongly with vocabulary knowledge in English, Dutch, and German. In contrast, the results did not provide evidence for a unique association of shared book reading with cognitive or early literacy skills in any language. Moreover, parent teaching and access to literacy resources had indirect effects on later literacy skills via different emergent literacy skills. These findings suggest that not all HLE components are equally important for specific facets of emergent literacy skills, reading fluency, and spelling across orthographies. The current findings add to the cross-linguistic literature on HLE as this is the first analysis directly comparing associations between HLE and literacy outcomes across different orthographies varying in orthographic consistency.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.This study was carried out in accordance with the recommendations of the University of Alberta Human Research Ethics Board with written informed consent from all subjects  in accordance with the Declaration of Helsinki. The protocol was approved by the University of Alberta Human Research Ethics Board.TI contributed to the conception and design of the work, ran the analyses, interpreted the findings, and took the lead on writing the manuscript. GM, PJ, and KL organized the data collection at each site, contributed to the interpretation of the findings, and revised the work critically. RP contributed to the conception and design of the work, the interpretation of the findings, and revised the work critically. GG conceptualized the research project, organized the data collection, contributed to the conception and design of the work, and supported the writing of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The term knowledge translation has been used to describe the process of applying research results to the real world, in order to enhance the quality and effectiveness of health care and services. The aim of this article is to discuss the incorporation of knowledge translation in the Brazilian public health. The article addresses the basic activities of knowledge translation and lists challenges and perspectives in Brazilian scenario. Brazil began to move towards understanding the process of translating scientific knowledge into practice. Investing in pilot studies to adapt the so-called effective interventions to the Brazilian scenario may be an alternative. Increasing the qualification of Brazilian researchers in the design and evaluation of implementation studies is relevant to improve this field in the country. Traditionally, the implementation of new knowledge takes many years, which makes it difficult to innovate in the provision of health services, results in inefficiency of health systems and impacts on the population’s quality of life2. Considering this difficulty, efforts have emerged to ensure that evidence is effectively understood and implemented in health practices3.The application of real-life search results is an old challenge that persists to this day4. Research utilization, implementation science, knowledge translation, knowledge transfer, and knowledge mobilization are expressions often employed6. Some also suggest the use of K* (knowledge star)7. In this article, we will use knowledge translation because it is the most used worldwide8.There is no consensus among the terms used to describe these efforts9. What about Brazil? What are the obstacles and advances of KT? Are research results used to formulate guidelines for practices, policies and programs? Are the guidelines for practice and options for policies and programs implemented? These questions motivated the elaboration of this article, which discusses concepts that describe some of the complexities that influence knowledge translation in the Brazilian public health.Some middle- and low-income countries have advanced in understanding and executing strategies for knowledge translation9.Knowledge translation is one of several terms used to describe the science of putting evidence into action and understanding how evidence-based practices work in the real world. It is an interactive process of knowledge that includes the synthesis, dissemination, exchange and use of knowledge in order to improve services and make effective products available to the population and, thus, strengthen the health system. 10. The common aspects among them focus on the suggestion of overcoming the traditional ways of disseminating a new discovery11. The Numerous models represent the components needed for knowledge translation11. Activities for knowledge translation may not be sequential and begin at any of the phases of the process, which will be listed below.Although knowledge translation interacts with a number of activities, including evidence-based health, continuing medical education, continuous professional development, and quality improvement, it is broader than all of them. It involves multiple factors present at different levels of the health system, which influence the way evidence is used by parties involved in decision-makingThis generation is represented by individual primary studies, i.e. first-hand reports of research results. In general, they are not ready to be transferred to practice yet, although they are essential to support future research. Randomized and observational controlled studies are examples of these first-generation studies.12.The synthesis consists of compiling the results of individual studies to determine what is known about the subject. In the health field, systematic reviews are very common, with or without meta-analyses13.The transfer concerns the transmission of knowledge to the potential user. Communication is fundamental and cultural and linguistic boundaries interfere in the process. At least two aspects can be identified, the diffusion and dissemination of evidence. Diffusion refers to the distribution of information, usually by traditional means such as journal publications, conference presentation, and various activities based on the web 13. It includes active and targeted methods such as art-based activities  and use of knowledge disseminators (people who appropriate evidence and promote it within their own organization or in other environments)14.Dissemination extends beyond information by packaging the message to a specific audience16. 17.The implementation focuses on strategies used to adopt and integrate evidence-based interventions and on how they work in certain scenarios. It emphasizes the importance of external validity  and scalability (i.e. expansion of evidence-based practices to benefit more people and populations)18. There is also the restricted interaction between researchers and health decision-makers.The study of the theme in Brazil faces difficulties that are common to low- and middle-income countries. These difficulties are related to the local reality, characterized by low level of infrastructure and little engagement of people to translate evidence into practices, policies or programsThe health field has numerous impasses for the transfer and utilization of a new discovery. One of the major obstacles is the weakness of the research culture within the Brazilian Unified Health System (SUS). The interaction between knowledge producers and users should be increasingly stimulated from the identification of health problems, as it helps research agendas to be relevant to that context.19. It is relevant to systematize the process of defining health research priorities, in order to make it more transparent and stimulate the participation of public administrators, health professionals, politicians and the civil community in this construction19.Some initiatives aim at identifying national and regional health needs and increase selective induction for relevant knowledge production – for example, the development of the National Agenda of Priorities in Health Research (NAPHR)20. These are valuable local evidence to assist in decision-making. However, the use of these data is limited due to the restricted skills of critical analysis and interpretation of evidence by health decision-makers. Furthermore, understanding what the information does not respond to is as important as what it can elucidate when analyzing a database. And since the amount of information missing is, most of the time, greater than the information available, it is necessary to ask the right questions. Disseminators of knowledge could play a role of providers of evidence and, thus, assist evidence-informed decision-making in the clinical area or in the management of services 21. Some argue that national funding agencies need to be more supportive of evaluative studies for dissemination and implementation of the knowledge produced. This way, the advancement of the practice in the public health field could be promoted22.Brazil has secondary data collected in various forms by information systems and surveys23.The lack of institutionalization in the use of evidence is a difficulty to be overcome. The World Health Organization has encouraged the use of evidence in health decision-making processes. One of the initiatives was the creation of the Evidence-Informed Policy Network . This initiative had repercussions in Brazil. EVIPNet Brasil prepares evidence syntheses for policies and deliberative dialogues to discuss the results of the syntheses24. Political and economic interests can hinder this process25, and the presence of institutional leaders who value the use of evidence facilitates its adoption26. In Brazil, the applicability of knowledge translation differs due to the peculiarity of the management of the system in three decision-making spheres. With municipalization, each local administrator manages a local health system with discretion, that is, administrators have freedom of choice, based on convenience and opportunity, to base or not their decision on evidence. Another challenge to be overcome concerns knowledge transfer, that is, the packaging of the main message in products that are easily assimilated by different audiences. In this sense, some actions were developed in Brazil, for example: clinical protocols and therapeutic guidelines (http://www.saude.gov.br/protocolos-e-diretrizes), the primary health care portal (https://aps.saude.gov.br/), the community of primary care practices (https://novo.atencaobasica.org.br/), and the Brazilian Cochrane Center (https://brazil.cochrane.org/). However, most of these actions are focused on diffusion.The evidence synthesis is part of the process of knowledge translation that assists the decision-making process, but it is not enough to ensure evidence-informed decision making alonecordel chapbook, depending on the issue involved. In addition, researchers should be encouraged to submit plans for knowledge translation as part of their grant proposals and improve the communication of their research results to the general public or establish partnerships with communication professionals and graphic designers27.It is expected to advance in strategies for dissemination of evidence that consider the cultural differences of Brazil. For example, evidence transfer in the Northeast can be performed by means of a 28. Common characteristics for the success of these techniques include strong qualification, which considers the cultural, political and economic context and encourages a collaborative approach between researchers and decision-makers28.There are different strategies for knowledge translation, however, most were proposed and evaluated in developed countries29. A Brazilian initiative to sensitize and qualify administrators for the use of evidence is the specialization in evidence-informed policy (Espie), promoted by the Ministry of Health. This example could be expanded to benefit the whole country.It is easier to implement research after receiving qualification for the use of evidence30.The implementation of evidence in the Brazilian public health is advancing slowly, mainly because there is still not enough skilled scientists and professionals. It is necessary to qualify epidemiologists for knowledge translation, in order to contribute effectively to the integration of evidence in practice, as they are among the main evidence generators. Epidemiology can boost implementation by providing evidence on effective interventions, as well as informing methods, impact indicators and design of implementation studiesBrazil began to move towards the process of applying scientific knowledge to real life. Investing in pilot studies to adapt knowledge translation interventions to the Brazilian scenario may be an alternative. Qualifying Brazilian researchers in the design and evaluation of implementation studies is relevant to improve this field in the country. 1. Tradicionalmente, muitos anos decorrem para implementar um novo conhecimento, o que torna difícil a inovação na prestação de serviços de saúde, resulta em ineficiência dos sistemas de saúde e impacta na qualidade de vida da população2. Face a essa dificuldade, surgiram esforços para que as evidências sejam efetivamente compreendidas e implementadas nas práticas de saúde3.A aplicação de resultados de pesquisas na vida real é um desafio antigo que permanece no mundo contemporâneo4. Utilização da pesquisa (research utilization), ciência da implementação (implementation science), tradução do conhecimento (knowledge translation), transferência de conhecimento (knowledge transfer) e mobilização do conhecimento (knowledge mobilization) são expressões frequentemente empregadas6. Há ainda a sugestão de uso do K* (knowledge star)7. Neste artigo utilizaremos tradução do conhecimento por ser o mais utilizado mundialmente8.Não há consenso entre os termos usados para descrever esses esforços9. E no Brasil? Quais os obstáculos e avanços da tradução do conhecimento? Utilizam-se resultados das pesquisas para formular diretrizes para práticas, políticas e programas? As diretrizes para a prática e as opções para políticas e programas são implementadas? Tais indagações motivaram a elaboração deste artigo, que tem o intuito de discutir conceitos que contribuem para descrever algumas das complexidades que influenciam a tradução do conhecimento para a saúde pública no Brasil.Alguns países de média e baixa renda têm avançado na compreensão e na execução de estratégias para tradução do conhecimento9.Tradução do conhecimento é um dos vários termos usados para descrever a ciência de colocar a evidência em ação e de entender como as práticas baseadas em evidências funcionam no mundo real. Trata-se de um processo interativo do conhecimento que inclui a síntese, a disseminação, o intercâmbio e a utilização do conhecimento com a finalidade de melhorar serviços e colocar à disposição da população produtos eficazes e, assim, fortalecer o sistema de saúde. A 10. Os aspectos comuns entre eles se concentram na sugestão de ultrapassar os moldes tradicionais de divulgação da nova descoberta11. A Existem inúmeros modelos propostos para representar os componentes necessários para a tradução do conhecimento11. As atividades para tradução do conhecimento podem não ser sequenciais e se iniciar em qualquer uma das fases do processo, as quais serão listadas a seguir.Embora a tradução do conhecimento interaja com uma série de atividades, incluindo saúde baseada em evidências, educação médica continuada, desenvolvimento profissional contínuo e melhoria da qualidade, pode ser entendida como algo mais amplo que todas elas. Envolve múltiplos fatores presentes nos diferentes níveis do sistema de saúde, os quais influenciam a maneira como as evidências são usadas por partes envolvidas na tomada de decisãoEssa geração é representada pelos estudos individuais primários, ou seja, os relatos em primeira mão dos resultados de pesquisa. Em geral, eles ainda não estão prontos para serem transferidos para a prática, embora sejam imprescindíveis para apoiar pesquisas futuras. Estudos randomizados e observacionais controlados são exemplos desses estudos de primeira geração.12.A síntese consiste em compilar os resultados de pesquisas individuais para determinar o que é conhecido sobre o tema. Na área da saúde, os tipos mais comuns são as revisões sistemáticas com ou sem metanálises web 13.A transferência diz respeito à transmissão do conhecimento ao potencial usuário. A comunicação é fundamental e fronteiras culturais e linguísticas interferem no processo. Pelo menos dois aspectos podem ser identificados, a difusão e a disseminação da evidência. A difusão refere-se à distribuição da informação, geralmente por meios tradicionais como publicações em periódicos, apresentação em conferências e atividades diversas baseadas na 13. Inclui métodos ativos e direcionados como atividades baseadas em arte  e uso de disseminadores de conhecimento (pessoas que se apropriam das evidências e as promovem dentro de sua própria organização ou em outros ambientes)14.A disseminação amplia a comunicação da informação por empacotar a mensagem para um público-alvo específico16. A 17.A implementação concentra-se em estratégias utilizadas para adotar e integrar intervenções baseadas em evidências, e entender como elas funcionam em determinados cenários. Enfatiza a importância da validade externa  e da escalabilidade 18. Há também a restrita interação entre pesquisadores e tomadores de decisão em saúde.O estudo do tema no Brasil apresenta dificuldades que são comuns a países de baixa e média renda. Essas dificuldades se relacionam à realidade local, caracterizada por baixo nível de infraestrutura e pouco engajamento das pessoas para traduzir evidências em práticas, políticas ou programasHá numerosos impasses na área da saúde para a transferência e a utilização de uma nova descoberta. Um dos grandes obstáculos refere-se à debilidade da cultura de pesquisa no âmbito do Sistema Único de Saúde (SUS). A interação entre produtores e usuários do conhecimento deve ser cada vez mais estimulada a partir da identificação dos problemas de saúde, pois facilita que as agendas de pesquisa sejam relevantes para aquele contexto.19. É relevante sistematizar o processo de definição de prioridades de pesquisa em saúde, a fim de torná-lo mais transparente e de estimular a participação de gestores públicos, profissionais de saúde, políticos e comunidade civil nessa construção19.Existem iniciativas com intuito de identificar as necessidades nacionais e regionais de saúde e aumentar a indução seletiva para a produção relevante do conhecimento – por exemplo, o desenvolvimento da Agenda Nacional de Prioridades de Pesquisa em Saúde (ANPPS)20. São evidências locais valiosas para auxiliar na tomada de decisão. No entanto, o uso desses dados é limitado devido às habilidades restritas de análise crítica e interpretação das evidências pelos decisores em saúde. Além disso, ao analisar uma base de dados, compreender o que as informações não respondem é tão importante quanto o que elas podem elucidar. E como a quantidade de informação faltante é, na maioria das vezes, maior do que a informação a disponível, é necessário fazer as perguntas certas. Disseminadores do conhecimento poderiam exercer um papel de provedores de evidências, e assim, auxiliar a tomada de decisão informada por evidências, na área clínica ou na gestão de serviços 21. Argumenta-se que as agências nacionais financiadoras de pesquisas necessitam avançar no apoio a estudos avaliativos para disseminação e implementação do conhecimento produzido. Dessa maneira, poderiam promover o avanço da sua prática no campo da saúde pública22.O Brasil dispõe de dados secundários coletados de diversas formas por sistemas de informação e inquéritos Evidence-Informed Policy Network– EVIPNet, https://www.who.int/evidence/en/). Essa iniciativa repercutiu no Brasil. A EVIPNet Brasil elabora sínteses de evidências para políticas e diálogos deliberativos para discussão dos resultados das sínteses23.A falta da institucionalização do uso de evidências é uma dificuldade a ser superada. A Organização Mundial de Saúde tem estimulado o uso de evidências em processos decisórios de saúde. Uma das iniciativas foi o a criação da Rede de Políticas Informadas por Evidências , o portal da atenção primária à saúde (https://aps.saude.gov.br/), a comunidade de práticas da atenção básica (https://novo.atencaobasica.org.br/) e o Centro Cochrane Brasil (https://brazil.cochrane.org/). Contudo, a maioria dessas ações é voltada para a difusão.Usar síntese de evidências é parte do processo de tradução do conhecimento que auxilia o processo decisório, mas não é suficiente por si só para garantir a tomada de decisão informada por evidências27.Espera-se o avanço em estratégias de disseminação de evidências que considerem as diferenças culturais do Brasil. Por exemplo, a transferência de evidências no Nordeste pode ser realizada por meio de um cordel, a depender da questão envolvida. Além disso, os pesquisadores devem ser encorajados a apresentar planos para tradução do conhecimento como parte de suas propostas de subsídios e aperfeiçoar a comunicação dos resultados de suas pesquisas para o público em geral ou estabelecer parcerias com profissionais de comunicação e designers gráficos28. As características comuns para o sucesso dessas técnicas incluem um forte treinamento ou elemento de capacitação, que considere o contexto cultural, político e econômico e encoraje uma abordagem colaborativa entre pesquisadores e tomadores de decisão28.Existem diferentes estratégias para tradução do conhecimento, no entanto, a maioria foi proposta e avaliada em países desenvolvidos29. Uma iniciativa brasileira para sensibilizar e capacitar gestores sobre o uso de evidências é a especialização em política informada por evidências (Espie), promovido pelo Ministério da Saúde. Esse exemplo poderia ser expandido de modo a beneficiar todo o País.Há maior facilidade para implementar pesquisas quando se recebe treinamento sobre uso de evidências30.A implementação de evidências em saúde pública no Brasil está avançando lentamente, principalmente porque ainda não existe um quadro suficiente de cientistas e profissionais com a capacidade apropriada. Faz-se necessário aumentar a capacitação dos epidemiologistas sobre tradução do conhecimento, a fim de contribuir efetivamente para a integração das evidências na prática, pois estão entre os principais geradores de evidências. A epidemiologia pode impulsionar a implementação ao fornecer evidências sobre intervenções efetivas, bem como informar métodos, indicadores de impacto e delineamentos dos estudos de implementaçãoO Brasil começou a caminhar no processo de aplicar o conhecimento científico na vida real. Investir em estudos pilotos para adaptar ao cenário brasileiro intervenções de tradução do conhecimento efetivas em outros países pode ser uma alternativa. Aumentar a capacitação de pesquisadores brasileiros no delineamento e avaliação de estudos de implementação é relevante para a melhoria deste campo no País.


Designing a safety promotion programs that have significant impact on the wellbeing of your community is about finding creative solutions for the tension between visionary dreams and practical, evidence-informed solutions: • Nothing will be achieved unless you have the vision to imagine a better reality for ourselves, our family, our friends and our community • Nothing can be achieved unless you have the pragmatism and commitment to seek out achievable evidence informed effective solutions1. To achieve population level reductions in injury you need to GET REAL!The ISCCC commissioned a guideline to assist communities addressing Indicator 4 - Programs that are based on available evidence - in their designation application.Review of the international literature on translation of research into practice.Millions of lives could be saved if we just applied what is already known. This is the business of Indicator 4. Effective public health programs are the logical consequence of sound evidence. To implement an effective community-based safety promotion and injury prevention program three types of experts are required 1. Researchers (experts in what to do) 2. Politicians, administrators and practitioners (experts in how to do it) 3. Members of the target community (experts in what will work for them) four types of knowledge / evidence are required: 1. Evidence from a community’s own research and surveillance systems (Indicator 6) 2. Evidence about common types of injury and their causes 3. Evidence-based practice – evidence about what has been shown to work under research conditions 4. Practice based evidence – evidence about what has been shown to work in real world conditions. Accessing, interpreting and applying sound evidence is critical to the success of a safe community program.Safe Communities, Designation, Evidence-based practice, Practice-based evidence, Knowledge Translation


Lipid rafts are functional membrane microdomains containing sphingolipids, including gangliosides, and cholesterol. These regions are characterized by highly ordered and tightly packed lipid molecules. Several studies revealed that lipid rafts are involved in life cycle of different viruses, including coronaviruses. Among these recently emerged the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The main receptor for SARS-CoV-2 is represented by the angiotensin-converting enzyme-2 (ACE-2), although it also binds to sialic acids linked to host cell surface gangliosides. A new type of ganglioside-binding domain within the N-terminal portion of the SARS-CoV-2 spike protein was identified. Lipid rafts provide a suitable platform able to concentrate ACE-2 receptor on host cell membranes where they may interact with the spike protein on viral envelope. This review is focused on selective targeting lipid rafts components as a strategy against coronavirus. Indeed, cholesterol-binding agents, including statins or methyl-β-cyclodextrin (MβCD), can affect cholesterol, causing disruption of lipid rafts, consequently impairing coronavirus adhesion and binding. Moreover, these compounds can block downstream key molecules in virus infectivity, reducing the levels of proinflammatory molecules , and/or affecting the autophagic process involved in both viral replication and clearance. Furthermore, cyclodextrins can assemble into complexes with various drugs to form host–guest inclusions and may be used as pharmaceutical excipients of antiviral compounds, such as lopinavir and remdesivir, by improving bioavailability and solubility. In conclusion, the role of lipid rafts-affecting drugs in the process of coronavirus entry into the host cells prompts to introduce a new potential task in the pharmacological approach against coronavirus. Coronaviridae family is morphologically characterized by a crown shape deriving from the presence on the envelope of a 20-nm long protein called “spike” , contains the spike glycoprotein involved in the process of recognizing the host cell. Spike protein differs for point mutation in coronaviruses  declared pandemic the viral disease caused by this virus. SARS-CoV-2 virus has been isolated from nasopharyngeal and oropharyngeal samples from patients affected with a flu-like disease  are able to cause severe respiratory disease like pneumonia and death  triggering and T-cell activation   and mevastatin-induced disruption of lipid rafts inhibited infectious bronchitis virus infection, suggesting that lipid rafts are involved in viral attachment  alpha-cyclodextrin, (β-CD) beta-cyclodextrin, and (γ-CD) gamma-cyclodextrin. Cyclodextrins can assemble into complexes with various drugs to form host–guest inclusions and have therefore been accepted as pharmaceutical excipients. Cyclodextrins were found attractive for a variety of applications because they could protect sensitive organic guest molecules from oxidation and from volatilization and could make more soluble apolar guests, too. The synthetic derivatives of native cyclodextrins are divided into three groups: ionizable, such as sulfobutylether β-CD (SBE-β-CD); hydrophobic, such as 2,6-di-O-ethyl-β-CD; and hydrophilic, such as 2-hydroxypropyl-β-CD (HP-β-CD). Modified beta-cyclodextrin owns antiviral activities Braga, . For exaHowever, the use of cyclodextrins or statins as active drugs against coronaviruses has some limitations. Indeed, they have a pleiotropic effect in cultured cells by affecting many different signaling pathways. Moreover, in addition to cholesterol, MβCD also extracts other lipids, such as fatty acids and ceramides from cell membranes. Finally, MβCD depolymerizes the actin meshwork, drastically affecting whole cellular architecture.Antiviral drugs targeting Ebola and HIV have demonstrated encouraging results in SARS-CoV-2 patients, and cyclodextrin seems to be the best excipient to enhance the properties of these drugs, including the antiviral drug Kaletra, a combination of lopinavir and ritonavir, a protease inhibitor for HIV, which demonstrates a benefit in treatment of viral pneumonia , offer alternative candidate drugs for SARS-CoV-2 (Zhou et al., Further applications for the use of lipid raft affecting drugs are derived from the observations of Zhou and Simmons , who poiIt is conceivable that the first contact between coronavirus and host cells occurs into lipid rafts, specialized regions of cell plasma membrane, which provide a suitable platform able of concentrating ACE-2 receptor, thus representing a port of cell entry for viruses.This review is focused on targeting lipid rafts as a strategy against coronavirus. We report that agents, such as statins or cyclodextrins, can deplete cholesterol and cause disruption of lipid rafts, consequently affecting coronavirus adhesion and binding. Furthermore, these compounds can assemble into complexes with various drugs to form host–guest inclusions and may be used as pharmaceutical excipients of antiviral drugs, such as lopinavir and remdesivir, by improving bioavailability and solubility. Thus, the possible use of drugs affecting lipid rafts in the process of coronavirus entry into the cells introduces a potential new task in the pharmacological strategy against coronavirus.MS, RM, GR, VMan, SM, AL, TG, and VMat wrote the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Pragmatic, Rapid, and Iterative D&I (PRIDI) Cycle: The PRIDI Cycle is based on a “double-loop” learning process, reflecting the iterative and adaptive D&I, along with iterative re-consideration of goals and priorities, interventions and corresponding D&I strategies, and needs and capacities of individuals and contexts. Stakeholder engagement is essential- which itself is an evolving activity. The results of iterative evaluations should be communicated with local implementers and stakeholders through customized feedbacks.Public health emergencies – such as the 2020 COVID19 pandemic –accelerate the need for both evidence generation and rapid dissemination and implementation (D&I) of evidence where it is most needed. In this paper, we reflect on how D&I frameworks and methods can be pragmatic  tools for rapid and iterative planning, implementation, evaluation, and dissemination of evidence to address public health emergencies. Even when the health system priority is provision of the best care to the individuals in need, and scientists are focused on development of effective diagnostic and therapeutic technologies, planning for D&I is critical. Without a flexible and adapting process of D&I, which is responsive to emerging evidence generation cycles, and is closely connected to stakeholders and target users through engagement and feedback, the interventions to mitigate public health emergencies – such as the COVID19 pandemic - will have limited reach and impact on populations that would most benefit. The PRIDI cycle is intended to provide a pragmatic approach to support planning for D&I throughout the evidence generation process. Public health emergencies – such as the current COVID19 pandemic – dramatically accelerate the need for evidence generation and synthesis, as well as the rapid dissemination and implementation of evidence-based practices and interventions.  In a matDissemination and implementation (D&I) science has emerged as an evolving field to address the well-documented gap between research and practice.  Disseminhealth problem itself may be dynamic and rapidly changing. In February 2020, the main concern of many health systems was implementing case finding and quarantine strategies, while in March 2020, it was allocating ICU beds and ventilators, and in May 2020, safe strategies to gradually lifting lock downs. (The haustion) and outehaustion), 22 are Key stakeholders  within systems and broader communities have evolving concerns, needs, and values. Their readiness, knowledge, and capabilities are evolving based on changing circumstances and contexts, and their trust of medical institutions and perceptions of the importance of scientific evidence varies.redundancy and parallelism within systems, which positively and negatively affects the implementation of evidence-based processes and practices. On the positive side, we can learn from the experience of other hospitals who deal with similar situations and challenges . .  On the nAdditional complexities that need to be addressed include the striking racial/ethnic inequities that have been apparent with respect to COVID19 morbidity and mortality, related in part to embedded systems that create and reinforce structural and interpersonal forms of discrimination and racism. , 24However, classical D&I frameworks and approaches may need some rapid adaptations to be pragmatic and of most use in rapidly evolving emergency situations. An important feature of emergencies is the quick, dynamic, and unpredictable course of events,  which maTo align both the science of D&I with the practice of D&I in real-world settings, it is important to explicate how health systems can apply D&I frameworks and methods rapidly, effectively, equitably, and with few resources to guide local adoption of evidence-based interventions or emerging best practices/protocols (informed by the best available evidence at the time). In this paper, we reflect on widely adopted D&I frameworks and tools and how they should be adapted to address dynamic trajectories of emergency situations.Figure 1 shows the PRIDI model for D&I. It depicts the dynamic connection between the cyclical process of executing and evaluating D&I (center), the intervention and strategies (left side), the multi-level nature of the context (upper side), and goals and outcomes of D&I (right side). Consistent with recent emphasis on iterative and pragmatic nature of D&I, , 26 its As shown in Fig. 1, we incorporated this cyclical process to the center of the PRIDI model. The cycle of D&I itself activates lateral cycles , which involve revisiting the mental models, goals and outcomes, interventions and D&I strategies, and individuals and contexts, through the course of D&I cycles. It resembles a double-loop learning model. , 29 ThisTo the extent possible, monitoring and evaluation should be prioritized, and results should be regularly communicated with stakeholders, and meaningfully and consistently incorporated in any re-design or planned adaptations/modifications within the system.  If an inThe engagement of stakeholders within these dynamic contexts is critical throughout this process to understand what is working or not and why, where inequities are emerging, and the feasibility and acceptability of the programs and practices. The double loop nature of the process also has implications for engagement of diverse stakeholders in the context of psychological safety where people feel free to express contrarian views thus fostering opportunities to challenge conventional assumptions. For example, suppose we assume that African Americans by virtue of higher SARS-CoV-2 infection rates and worse outcomes will have higher demand for COVID-19 testing and vaccines in development. This would be a reasonable assumption from which we could develop cyclical PDSAs for messaging. This assumption would suggest that finding ways to promote awareness in the African American community regarding where to get tested and where to receive the future vaccine will reduce disparities in infection. Yet, if the African American community were at the table and divergent views were encouraged based on recognition of second order learning, members might express reservations about COVID-19 testing including risk for family separation, forced quarantine with pay, and greater stigma. Similarly, members might voice deep skepticism towards receiving future vaccines including mistrust of government statements, concerns about being guinea pigs for a vaccine that has been rushed to market, and/or concerns about the vaccine containing virus. This second order learning might suggest a fundamentally different approach rather than incremental changes in content, dose or frequency in messages.In intervention  to be disseminated and implemented  (e.g. the ‘what’)The D&I strategies involve the processes, approaches, or interventions that facilitate and enhance the proactive dissemination and implementation of the interventions. Examples include tailored email/online communication for the self-assessment platform, literacy appropriate instructional packages for patients about the COVID19 call center, staff training/education to learn about the new workflow, motivational incentives to enhance staff participation in grand rounds. See Consistent with RE-AIM/PRISM model , the intInterventions generally include a core (the essence or function of the intervention that is responsible for its impact), and an adaptable periphery (that could be modified to adapt to various contexts and situations).  IgnoringD&I adaptation models may be useful to help guide planned adaptations (e.g. ADAPT-ITT), to helpEvaluation is not a one-time post-intervention process in D&I; it is an iterative, ongoing process that can enhance and inform the evolvability of evidence-based interventions and strategies, including their design, adaptation, refinement, and delivery throughout the process of D&I. Consequently, intended goals and outcomes of D&I should ideally be incorporated from the beginning . In emergency planning, the value of learning from continuous evaluation is even more essential, as the path forward can be more uncertain, the interventions are more experimental and their evidence-base evolving, and the clinical situation and healthcare contexts can change quickly. As such, it may be useful for decision-makers to have a compass to guide them as to whether they are moving in the right direction or need to re-assess and re-design and challenge existing models that might not fit with such a dynamic context.RE-AIM provides a systematic conceptual framework to guide the planning, adaptation, and evaluation of the D&I activities, programs, practices or policies., 40 An iThe upper side of Figure 1 shows the multi-layer and complex nature of contextual factors and their role in determining the success or failure of D&I efforts. It is critical to consciously consider the complexity of personal, inter-personal, organizational, social, economic, policy, community, and cultural contexts at the design phase, and across the continuous process of re-evaluation and adaptations throughout implementation phases. A seemingly useful intervention may fail to implement, since patients may find it irrelevant to their needs and characteristics, or may face certain financial and structural/logistical barriers to access and use it, or may not trust the source of the intervention; staff or administrators may find it burdensome ; at the organizational level, infrastructure needed to deliver the program may have geographical, demographic, and structural limitations. External environment factors, such as policies, economic challenges, and cultures and social norms are also rapidly changing. For example, adherence to long-term physical/social distancing may vary based on demographics and cultural backgrounds;  Country-Feel more invested to help disseminate, implement, and sustain itAre prepared cognitively and operationally and are more committed to execute itMay identify setting or culturally specific barriers that may have been have missedProvide real time feedback on whether strategies are working and inform important refinements or adaptations of interventions and strategiesEnhance relevance and fit, and may propose innovative solutions that haven’t been consideredIt may seem like an inappropriate time to engage stakeholders in the context of emergency situations. However, even brief engagement of stakeholders has immense benefits that make it worth considering, at the design phase and through the cyclical process of re-evaluation and re-design.  StakeholStakeholder engagement may be applied at different degrees along the spectrum of implementation, depending on the availability of time and resources, and the nature of the intervention and D&I strategies.  Even at All mentioned processes are only possible under the context of strong organizational commitment,  as well Reach, Effectiveness, Adoption, Implementation, Maintenance. Recent extensions of this model can also inform more explicit consideration of understanding and addressing health equity and equitable implementation over time and in dynamic contexts. (In this paper, we reflected on the cyclical model of ‘Assess > Plan > Do > Evaluate > Report’ , RE-AIM/ontexts.  IntervenThe cyclical process of D&I informs double loop learning processes, that may result in revisiting mental models, goals and outcomes, interventions and D&I strategies, and individuals and contexts. The results of cyclical evaluations should also be communicated with local implementers and stakeholders through customized, and actionable feedback. Stakeholder engagement is a key solution to understand and address contextual variations and barriers. It is a continuum ranging from informing the stakeholders to co-ownership, and will be critical to addressing some of the striking racial/ethnic and setting inequities evidence for COVID19, including redistribution of decision-making and resources with the community. The iterative process also accommodates for emergent evidence-generation and potential revisions in the evidence base of the interventions that are being implemented.Even though the health system priority at this moment is provision of best care to the individuals in need and development of effective diagnostic and therapeutic technologies,  flexibleThis paper calls for dynamic and adaptive D&I models that are responsive to rapid and unpredictable nature of emergencies through rapid and iterative cycles, continuous engagement of stakeholders, and incorporating the evolution of goals, interventions, and contexts. We also call for more dynamic and two-way translational dialogue between D&I and evidence generation research.


Health policy and management decisions rarely reflect research evidence. As part of a broader randomized controlled study exploring implementation science strategies we examined how allied health managers respond to two distinct recommendations and the evidence that supports them.A qualitative study nested in a larger randomized controlled trial. Allied health managers across Australia and New Zealand who were responsible for weekend allied health resource allocation decisions towards the provision of inpatient service to acute general medical and surgical wards, and subacute rehabilitation wards were eligible for inclusion. Consenting participants were randomized to (1) control group or (2) implementation group 1, which received an evidence-based policy recommendation document guiding weekend allied health resource allocation decisions, or (3) implementation group 2, which received the same policy recommendation document guiding weekend allied health resource allocation decisions with support from a knowledge broker. As part of the trial, serial focus groups were conducted with a sample of over 80 allied health managers recruited to implementation group 2 only. A total 17 health services participated in serial focus groups according to their allocated randomization wave, over a 12-month study period. The primary outcome was participant perceptions and data were analysed using an inductive thematic approach with constant comparison. Thematic saturation was achieved.Five key themes emerged: (1) Local data is more influential than external evidence; (2) How good is the evidence and does it apply to us? (3) It is difficult to change things; (4) Historically that is how we have done things; and (5) What if we get complaints?This study explored implementation of strategies to bridge gaps in evidence-informed decision-making. Results provide insight into barriers, which prevent the implementation of evidence-based practice from fully and successfully occurring, such as attitudes towards evidence, limited skills in critical appraisal, and lack of authority to promote change. In addition, strategies are needed to manage the risk of confirmation biases in decision-making processes.Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12618000029291). Universal Trial Number (UTN): U1111-1205-2621. There is a global move towards the implementation of science-led healthcare practices, commonly referred to as evidence-based practice. Evidence-based practice is underpinned by research and guided by principles of safety, effectiveness, person-centred care, timeliness, efficiency, and equity  alongsidFailure to translate research findings into day-to-day healthcare practices results in evidence-based practice gaps . Bridginavailability heuristic bias has been described in medical decision-making and pertains to whether a person can retrieve information from their mind to make a decision … based on two factors, one favours the intervention, one favours the control. Overall, it just is non-systematically done. Specifically, there appeared to be limited understanding about statistical interpretation. One experienced researcher questioned the process used towards the systematic reviews.What we are saying is there is not a great number of studies. Yes, there is pooled results, but this is based on still a very limited number of studies. I guess we do not feel that there is enough evidence out there to make a change. Most participants reported to be more confident in results if there were a larger number of studies supporting an outcome, in contrast to the sample size, effect size, and confidence interval reported within a given study. As a result, participants reported there was “Insufficient data”  and quality of included studies, such as “Patchy evidence”  to support the research findings. This was closely linked with a reluctance to consider changing the status quo.Surgery is an interesting one, because there is evidence for it outside of the weekend service. There is actually evidence out there with regard to early mobilization, for a fractured knee, the knee replacement…. I am inclined to say we should stick with the protocols we have got with that regards. I would not be changing anything there. Most participants cited a preference for making decisions according to studies they had previously relied on to develop their current weekend clinical protocols. All these studies advocated for weekend allied health, such as early mobilization post surgery. However, these studies were not included in the systematic review (criteria cited elsewhere ).SurgeryThe lack of evidence [in the systematic reviews] does not mean that we should not be providing that service; we just do not have enough evidence… so we deal with our own [internal] evidence. We know what works in our site and have that information. After reviewing the results of the systematic review, participants reported an overwhelming response for the need to revisit internal, local health service data. Subsequent participant reports suggested that internal data was the primary source of information for consideration when making resource allocation decisions.I think for me, I need to go back, re-read the document. I need to also go back and look at some of the data [internal] that I have around… look at some of the files to see exactly what has happened. Other participants indicated that they preferred to verify the results for themselves before making decisions. This reportedly involved revisiting the papers in the systematic review, as well as reflecting on internal data.From my understanding, there is a very positive trial happening. I do not remember what they are looking at. But they think they have actually increased orthopaedic services [on the weekend], in response. Alternatively, participants reported hearing that there were studies currently in progress promoting weekend allied health services. As a result, some participants preferred to wait for these findings to be published. As such, participants appeared to place value in incomplete research over and above completed work.What about what other sites are doing?… is there benchmarking data? Closely linked with a reliance on descriptive local knowledge when making resources decisions, was a reliance on collective data, such as benchmarking.In regard to the research around the subacute setting, we would absolutely love to provide some sort of weekend service. An additional factor potentially driving respondents to prioritize local data and other forms of evidence, not included in the systematic review, was that the findings and recommendations were often not congruent with participants’ reported beliefs, values and wishes for their practice. Where the evidence conformed to their beliefs, the evidence was more enthusiastically accepted.To actually churn things through [move patients] is, I suspect, why we have the weekend staff at the end of the day. Participants also strongly relied upon anecdotal staff experiences. Participants indicated suggested that their colleagues felt that weekend allied health services facilitated flow of people through the healthcare service, discharge, and workload pressures, while ensuring care.We have moved services around and have a number of proposals [for weekend allied health services] ready to go. These are based on evidence so to speak—of the actual work that we have been doing. Overall participants readily stated that local context was a key factor informing decision-making and these were based on internal reviews of their weekend service.2.How good is the evidence and does it apply to us and our patients?Participant discussions often expressed the perception that patient experience was more important than the evidence, such as patient feedback or satisfaction reports from people receiving their healthcare services. At times, this appeared to be valued over and above published evidence. For example, participants stated that patient comfort, satisfaction and desire for regular contact with a therapist were integral to decision-making about what services were needed.Anecdotal data on patient comfort, you know things like that… that is what we rely on. You know, I have been in private heath now, our clients are, our customers are fairly demanding. I would argue more so than when I was in public health. Participants working in private settings most commonly cited the importance of patient feedback in decision-making.Now, I hear what you are saying, that things do not necessarily have to be done by a physiotherapist. But often there are barriers that come up if it [a service] is not instigated by allied health—depending on their local culture strength. Other frequently cited local contextual issues were the expectations of medical and nursing staff. Many participants reported that surgeon expectations influenced allied health service delivery and, as such, they felt curtailed in what they could change. Despite the availability of skilled nurses, many sites reported that there was an expectation of allied health providing key interventions, such as mobilizing or assisting with activities of daily living. In many health services, this informed nursing roles and staff rosters; thus, to make changes reportedly required a cultural shift underpinned by extensive consultation and education.I think the complexity for managers is that published evidence is one source of data, but it is not the only source of data in which we make decisions. We draw on a systems-based approach to thinking about how services are delivered, whom they are delivered to, how we have to manipulate and be flexible with resources. Both parts of the puzzle are not necessarily things that you will go to a formal piece of evidence to look at, because it is a dynamic decision-making process. Does that make sense? Overall, upper level managers’ cited data was only one of many components that informed decision-making, such as staff availability, managing resources and system processes.3.It is difficult to change thingsParticipant reports highlighted their hesitancy in responding to recommendations and deciding. A key reported barrier towards implementing evidence was that participants anticipated that additional, future conflicting evidence would emerge in support of weekend allied health service delivery.Because I don’t need to find out later that someone comes out with a really fantastic control trial in two years… proving equivocally that occupational therapists and physiotherapists get people out much quicker if they see them on a weekend. Out of all of those, I think most clinicians probably say function and quality of life is what they are hoping to change. I do not think people go into health so they can reduce length of stay. Another challenge expressed by participants was balancing the research evidence with what they believed to be high quality, individualized care, even if data was not available to support these beliefs.Yeah, just without the evidence, we are going to rely on our own reasoning, I guess, and that is what we have done. In the absence of sufficient evidence, participants placed significant value in their clinical reasoning and the perceived effectiveness of services provided by their profession.It is not public, but I tell you what, you really encouraged me to publish. This has really lit a fire in my belly to do some research and publish [local data] on this stuff. Given that most studies in the systematic review pertained to occupational therapy and physiotherapy services on the weekend, participants from other allied health disciplines expressed an interest in undertaking research or publishing existing, local research in order to advocate for their profession.I think our sense is probably we will be looking at the physiotherapy and occupational therapy recommendations where there are sort of more evidence taken. Overall, where there was more evidence, there was more willingness to act on the recommendation.We could move the staff… but the difficulty comes when you have been allocated specific funding by a specific part of the organization. I am not saying that it cannot be done, but certain parts of the service do allocate the funds. We provide professional supervision for them; so, we can still influence [service provision] but we cannot actually make the decisions to change weekend staffing. Participants reported that components of their weekend services were often funded by different divisions whereby there was the expectation to provide weekend allied health. While making a change was not considered insurmountable, it was perceived to be difficult. As such, there was a preference among participants to continue meeting the expectations of their funders.We do not have a very good understanding of models of care across Australia and how they are similar or different. Yet we are being asked to make decisions on evidence from some studies, not looking at the whole picture. Likewise, some participants reported confusion about the perceived variances in models of care across the Australian states and this impacted decision-making towards making a service change. For example, there was a perceived lack of subacute services in New South Wales providing the impetus for more acute services, including weekend allied health. As a result, important local contextual differences influenced allied health manager decision-making.Interestingly for rural and regional services, the lack of allied health on the weekend was routine practice. By default, they aligned with the recommendations but also explored other options such as “Giving iPads to our patients so they can do self-directed therapy on the weekends” . However, metropolitan sites appeared reluctant to reflect on this variance, despite consistency with study recommendations. Instead, metropolitan participants remained silent at this point in the focus group.4.Historically that is how we have done thingsParticipants who were reluctant to change weekend allied health service delivery cited a belief in the perceived benefit of historical weekend allied practice, particularly when considering the need for allied health to respond to the timing of orthopaedic surgery.I mean it [the recommendations] goes against the physiotherapist. And obviously we have a long tradition of providing quite extensive services to acute medical and surgical wards. We have acute care cover for the elective surgical patients on the weekend so that we can meet their requirements with most surgeries done on Thursday and Friday. .It will take us more than 10 years to try and find that funding again—you know what I mean? We are going to shoot ourselves in the foot. When considering relocating staff in response to the recommendations, many participants reportedly feared that any weekend allied funding would be lost and redistributed to services other than allied health.We worked so hard across disciplines—to actually get allied health as a recognized part of care over the weekend. Participants also reflected on the past time and effort required to successfully advocate for a weekend allied service delivery on the weekend. As a result, considering making changes was difficult and participants feared that a change in service would reflect poorly on the allied health service reputation.5.What if we get complaints?The majority of participants reported that the fear of receiving complaints was a major barrier to modifying their weekend allied health service model. The most commonly cited reason was the long-standing expectation in providing a weekend service.I think we have a lot of pushbacks from our facility if we even stop to talk about stopping weekend services that we currently provide. Enormous amount of noise [complaints]. You will also potentially get complaints from patient and patient’s family. As a dietitian, it is just appalling that someone would be left [nil by mouth] for 72 h [over the weekend]. What you are going to have to do is put in a drip, and all the cost associated with that. So, even though there may not be evidence, I think that’s a pretty big, common-sense element that comes in to have an assessment from a speech pathologist, rather than having to wait…. A lot of our joint replacement patients are going home day two and if day two falls on a weekend—we are going to miss them. We need to see and review them and make sure everything is in place for when they go home. Participant reports also suggested that some recommendations placed patients at risk of complication if they were not seen on the weekend. This had the potential to create additional costs for the organization.Dealing with complaints was perceived to be a time-consuming process and therefore efforts were made to pre-empt and avoid complaints wherever possible. As such, when participants anticipated complaints in response to toward making staff change to a well-established service delivery model, they cited that they needed to “Do our homework”  to be certain before making a change.It is becoming almost archaic now: the notion of a weekend and will definitely be so in 10 years’ time. Perceived changes in society towards a 7-day workweek was another commonly cited variance towards the need to maintain weekend allied health service delivery. Indeed, having 7-day allied health was viewed as favourable considering society expectations, such as those observed in the retail industry.Where the evidence aligned with prior expectations and previous decisions, allied health managers appeared agreeable to the recommendations, with only local contextual factors and resourcing appearing to stand in the way of adoption. Where the evidence did not align, there were several themes identified describing what would likely be barriers to implementation of the recommendation.Our results add valuable information towards resource allocation decision-making in allied health. Extensive literature highlights the presence of bias in clinical decision-making in allied health practice and the likelihood of inconsistencies and potential for suboptimal outcomes , 26, 45.A second barrier existed when evidence was lacking for specific allied health disciplines. Recent research suggests that resource allocation decisions are made difficult by a paucity of research evidence  and the This study highlights that implementing an evidence-based public health service is complex. While some proponents of evidence-based practice adopt greater specificity, such as GRADE components, others are less clear, which means it is difficult to make decisions especially when local contextual factors exist. Driving change in healthcare commonly encounters resistance and scepticism. Providing leadership development skills has the potential to equip allied health leaders and reduce feelings of disempowerment and frustration. Overall, changing the status quo can be timely and costly process due to the need to identify where resistance exists, create awareness and address any cognitive bias. Further, this may involve incorporating psychological indicators to help overcome barriers and carefully plan proposed changes .The strength of this study lies in the longitudinal, qualitative methodology and tracking of changes over time. A broad range of experiences were identified, and we achieved thematic saturation; however, we did not explore issues affecting allied health decision in the other implementation groups and such understandings would provide further insight into how changes are made. However, our results provide emerging insights into allied decision-making. This is important since allied health is often arranged in discipline-specific departments that need to service multiple clinical areas  and makeResults from this study provide insight into barriers, which prevent the implementation of evidence-based practice from fully and successfully occurring, such as attitudes towards evidence, limited skills in critical appraisal, and lack of authority to promote change. Although there is a growing body of knowledge, there remain many unanswered questions towards translational science. What works in one context of care may or may not work in another setting, suggesting that context variables matter in implementation.