Variations in an individual’s electronic health  literacy may influence the degree to which health consumers can benefit from eHealth. The eHealth Literacy Scale (eHEALS) is a common measure of eHealth literacy. However, the lack of guidelines for the standardized interpretation of eHEALS scores limits its research and clinical utility. Cut points are often arbitrarily applied at the eHEALS item or global level, which assumes a dichotomy of high and low eHealth literacy. This approach disregards scale constructs and results in inaccurate and inconsistent conclusions. Cluster analysis is an exploratory technique, which can be used to overcome these issues, by identifying classes of patients reporting similar eHealth literacy without imposing data cut points.The aim of this cross-sectional study was to identify classes of patients reporting similar eHealth literacy and assess characteristics associated with class membership.Medical imaging outpatients were recruited consecutively in the waiting room of one major public hospital in New South Wales, Australia. Participants completed a self-report questionnaire assessing their sociodemographic characteristics and eHealth literacy, using the eHEALS. Latent class analysis was used to explore eHealth literacy clusters identified by a distance-based cluster analysis, and to identify characteristics associated with class membership.P=.02), and those who used the internet at least daily reported significantly higher odds of high eHealth literacy .Of the 268 eligible and consenting participants, 256 (95.5%) completed the eHEALS. Consistent with distance-based findings, 4 latent classes were identified, which were labeled as low , moderate , high , and very high  eHealth literacy. Compared with the low class, participants who preferred to receive a lot of health information reported significantly higher odds of moderate eHealth literacy (odds ratio 16.67, 95% CI 1.67-100.00; The identification of multiple classes of eHealth literacy, using both distance-based and latent class analyses, highlights the limitations of using the eHEALS global score as a dichotomous measurement tool. The findings suggest that eHealth literacy support needs vary in this population. The identification of low and moderate eHealth literacy classes indicate that the design of eHealth resources should be tailored to patients’ varying levels of eHealth literacy. eHealth literacy improvement interventions are needed, and these should be targeted based on individuals’ internet use frequency and health information amount preferences. Web-based interventions have been reported to be consistently more effective than non-Web-based modalities in changing patient health behaviors and health-related knowledge . InformaApproaches used to assess eHealth literacy have included objective performance testing ,19 and sawareness as highest, whereas another subgroup self-rates their skills as highest. Finally, regression analyses can be completed to examine patient characteristics associated with assignment to each eHealth literacy class.Shortcomings in the interpretation of eHEALS scores highlight the need for a robust approach to analyzing and interpreting eHealth literacy data. In line with the principles of scale development ,32, measBy understanding the number and characteristics of groupings, it can be known whether a one size fits all approach to eHealth literacy improvement is appropriate, or whether more tailored interventions are required. If tailoring is needed, understanding how different classes scored across the eHEALS factors allows researchers and clinicians to ensure interventions are designed to specifically address the needs of that subgroup. Furthermore, understanding patient characteristics associated with class membership allows the identification of individuals who should be targeted for interventions, or who will require more intensive support throughout periods of eHealth delivery. A cluster analysis of eHEALS data is therefore an important next step to better understand the multicomponent nature of eHealth literacy and how these eHEALS factors coexist in subgroups of patients.This study aimed to determine (1) whether there are identifiable eHealth literacy classes among magnetic resonance imaging (MRI) and computed tomography (CT) medical imaging outpatients; and (2) sociodemographic and internet use characteristics associated with each eHealth literacy class.This cross-sectional study was completed with MRI and CT medical imaging outpatients attending the imaging department of a large, tertiary hospital, located within New South Wales, Australia. The results of this study have been reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology checklist  and the Eligible participants were: (1) attending for an outpatient MRI or CT scan; (2) 18 years or older; and (3) reported having access to the internet for personal use. Participants were excluded if they were: (1) non-English speaking; (2) deemed by reception staff to be cognitively or physically unable to consent or complete the survey; or (3) identified as having completed the survey previously. MRI and CT medical imaging outpatients were the focus of this research because they have high unmet information preferences, which could potentially be met by eHealth capabilities .Medical imaging department receptionists identified potentially eligible participants when they presented for their outpatient appointment. Potentially eligible participants were informed about the research and invited to speak with a trained research assistant. Interested patients were provided with a written information sheet and introduced to the research assistant, who gave an overview of the study and obtained the patient’s verbal consent to participate. During this overview, interested patients were told that the Web-based questionnaire would take approximately 10-15 mins to complete, participation was voluntary, and responses would remain confidential. The age, gender, and scan type of noninterested and nonconsenting patients were recorded. Consenting patients were provided with a tablet computer and asked to complete a Web-based questionnaire before their scan. Participants’ study identification number, assigned by the receptionist and entered by the research assistant, provided access to the questionnaire. Each participant could move freely through each screen using next and back buttons. The questionnaire was pilot tested with MRI and CT medical imaging outpatients 2 weeks before study commencement, which confirmed the acceptability and feasibility of electronic survey administration in this study setting. A paper-and-pen version of the questionnaire was available to participants who requested it. If the patient was called for their procedure before finishing the questionnaire, only those questions that had been completed were used for data analysis. Electronic responses were deidentified, collected using the QuON platform , and stoeHealth literacy was assessed using the 8-item eHEALS. All 8 eHEALS items were administered on 1 screen within the Web-based questionnaire, and the presentation of these items was not random. Respondents indicated their level of agreement with each statement on a 5-point Likert scale from 1 strongly disagree to 5 strongly agree. Responses were summed to give a final score ranging from 8 to 40, with higher scores indicating higher eHealth literacy. The tool has demonstrated test-retest reliability [iability , internaiability ,19,28, aiability . Previouiability ,19,20. Eiability ,31. ThisOn the basis of previous research indicating an association with eHealth literacy, standard self-report items assessed participant gender, age, marital status, education, internet use frequency, and overall health status ,13-17. RParticipant characteristics were summarized as frequencies and percentages or means and standard deviations. Consent bias was assessed for gender, scan type, and age group using Chi-square tests. Given the high completion rate , only complete eHEALS data were included in the analyses. Items relating to each eHEALS factor were summed to generate separate awareness, skill, and evaluate factor scores.2-statistic were computed to aid in determining the optimal number of classes (with plateauing indicating no improvements to model fit) [Cluster analysis was completed using a 2-phased approach. Distance-based unsupervised clustering was undertaken as an initial exploratory knowledge discovery technique, to identify natural clusters of patients according to their responses (refer del fit) , as weredel fit) . The maxdel fit) .P<.05) were included in the final multivariable LCA regression. Distance-based and latent class analyses were performed in R 3.4 [An LCA regression analysis was performed to identify participant sociodemographic and internet use characteristics associated with class membership. Given the exploratory nature of data analysis, all covariates were initially cross-tabulated with class membership (assigned according to maximum posterior probability) to identify model sparseness, and then analyzed using univariate LCA regression: gender; age (<65 years vs 65+ years); geographic location of residence ; marital status (married or living with partner vs not married); education (high school or less vs more than high school); overall health ; information amount preference (a lot of information vs not a lot of information); internet use for scan preparation; and internet use frequency (daily vs less than daily). Likelihood ratio tests (based on the univariate results) were performed to determine whether each predictor significantly improved the fit of the model. Covariates with a statistically significant likelihood ratio test  were interested in participating. Of 268 eligible participants, 261 (97.4%) started the eHEALS, 256 (95.5%) completed all eHEALS items, and 222 (82.8%) completed all eHEALS and study factor items. There were no significant differences between patients who were and were not interested in participating in the study based on gender, scan type, or age group. 2-statistic continued to decrease as the number of classes (K) increased, but the improvement was progressively smaller after 3 classes : when compared with other classes, class 1 had the highest probability of responding disagree and strongly disagree across all eHEALS items. The probability of this group responding either disagree or strongly disagree was highest for awareness items (0.88 and 0.89), followed by evaluate items  and skills items .Class 1—moderate eHealth literacy : when compared with other classes, class 2 had the highest probability of responding undecided across all eHEALS items, and the second highest probability of responding agree across awareness and skills items. This group was most likely to respond undecided to awareness items (0.56 and 0.59), either agree (0.54 and 0.58) or undecided (0.48) to skills items, and undecided to evaluate items .Class 2—high eHealth literacy : when compared with other classes, class 3 had the highest probability of responding agree across all eHEALS items. The probability of this class responding agree was greatest for skills items , followed by awareness (0.80 and 0.91), and evaluate items .Class 3—very high eHealth literacy : when compared with other classes, class 4 had the highest probability of responding strongly agree across all eHEALS items. The probability of this class responding strongly agree was greatest for skills items , followed by evaluate , and awareness items (0.53 and 0.61).Class 4—yes to internet use for scan preparation). Following univariate analyses, likelihood ratio difference tests indicated that age; education, marital status, overall health status, information amount preference, and internet use frequency all significantly improved the fit of the model  was selected as a reference class for multivariable regression. This was because these participants likely need additional support to engage with eHealth, making identification of the characteristics of participants in this subgroup a priority. As shown in This study was the first to identify classes of patients based on eHealth literacy, and to assess characteristics associated with class membership. The identification of multiple classes, using both distance-based and latent class analyses, highlights issues with using the eHEALS global score as a dichotomous measurement tool. In particular, these findings suggest that it may be important to account for multiple eHealth literacy subgroups when developing standardized guidance for the interpretation of eHEALS scores. Furthermore, the identification of multiple classes suggests that the design and delivery of eHealth resources may need to be tailored based on eHealth literacy. Patient characteristics, such as internet use frequency and health-related information amount preferences, may provide an indication of eHealth literacy, and related support needs.In total, 4 eHealth literacy classes were identified, and the probabilities of belonging to each of the 4 classes were similar . The finding that eHealth literacy varied substantially in this population suggests that MRI and CT medical imaging outpatients may have differing support needs relating to the use of eHealth technology. Subgroups of patients were characterized by having either very high, high, moderate, or low eHealth literacy. Within the very high eHealth literacy subgroup, awareness was the lowest scoring competency. This may be because consumers who are familiar with eHealth also understand the masses of Web-based information that is available and the common difficulty of locating valid and reliable information sources . Across In total, 2 out of 4 classes, comprising 52.7% of respondents, had the highest probability of responding either agree or strongly agree to eHEALS items, reflecting high and very high eHealth literacy. Despite this, there was room for improvement in awareness, skills, and evaluation competencies for the remaining 2 classes, comprising 47.3% of respondents and reflecting low and moderate eHealth literacy. This approximately even split in eHealth literacy capabilities is also apparent in other studies completed with cardiovascular disease patients  and chroThose who had used the internet less than daily had approximately 5 times the odds of belonging to the low eHealth literacy class compared with the high eHealth literacy class. Although mixed findings exist , an assoundecided response option resulted in imposter syndrome for those in the moderate class [Those with a preference not to receive a lot of information about their health had over 16 times the odds of belonging to the low eHealth literacy class, compared with the moderate eHealth literacy class. To the authors’ knowledge, this study is the first to explore the association between preferred amount of information and eHealth literacy. It is possible that the inclusion of an te class . In thiste class . It is tThe technology acceptance model provides a theoretical justification for the characteristics related to a subgroup assignment . Under tThe identification of low and moderate eHealth literacy classes suggests that eHealth literacy improvement interventions may be warranted within this population. However, there is minimal high-quality research investigating the effectiveness of such interventions, highlighting a need for continued research in this area . Given tTo aid in the interpretation of findings, labels  were arbitrarily assigned to eHealth literacy classes. It is therefore unclear whether, for example, those classified as very high eHealth literacy were indeed very high. As this study applied a novel approach to data analysis and interpretation, the generalizability of findings across medical imaging settings and to other patient groups is unknown. This class structure and the predictors of class membership should be studied and replicated in other populations. Furthermore, it is possible that the setting influenced responses as participants may have assumed that eHEALS questions related to scan-specific information on the internet rather than general eHealth resources.The eHEALS was selected because of its established psychometric properties, emerging research proposing a 3-factor structure, and wide application ,24,28,31This study used sophisticated analytical techniques to add to evidence about the nature of eHEALS scores within a clinical population. Cluster analyses were used to identify 4 classes of patients with differing eHealth literacy within this sample of MRI and CT medical imaging outpatients. The proportion of participants assigned to each latent class was similar, suggesting that eHealth literacy varies within this study setting. Across all classes, skills were perceived as the highest rated competency followed by either awareness or evaluation. The frequency of participants’ personal internet use and their health-related information preferences predicted class membership. Tools such as the eHEALS may need to be administered to identify class assignment, and inform eHealth literacy improvement interventions, as well as the design and delivery of eHealth resources. Findings from this study should also contribute to the development of guidance for eHEALS scoring interpretation, which is a necessary next step to improve scale utility . Study f


This study aimed to evaluate the mechanical, biological, and esthetic stability of a zirconium abutment according to evidence-based dentistry.An electronic search was performed. Domestic studies were found using the keywords “zirconia abutments” and “zirconium abutment” in KMbase, KoreaMed, and the National Assembly Library, and international studies were found using the same keywords in PubMed. All identified studies were divided by evidence level from the viewpoint of the research type utilizing the evidence-based review manual. A total of 102 domestic studies (with Korean language) were found, and 9 of these studies were selected. In these nine studies, 3 had evidence level 3 and 6 had evidence level 4. A total of 97 international studies (with English language) were found, and 19 were selected. Among these 19 studies, 5 had evidence level 2 and 7 had evidence level 3, whereas the remainder had evidence level 4. According to the studies, zirconium abutments are mechanically, biologically, and esthetically stable, but the evidence level of these studies is low, and the follow-up duration is no longer than 5 years.All examined studies verified the mechanical stability of zirconium abutments for a period no longer than 5 years. Therefore, a long-term clinical observation is needed. Zirconium abutments are thought to be biologically stable, but they are not superior to titanium abutments. As the esthetic stability of such abutments had a low evidence level in the studies that examined here, a much higher evidence level is needed. As the interest in the esthetic aspect of implant prosthesis increases, the importance of the esthetic element has been emphasized. It has been reported that ready-made titanium abutments leave a gray shade if the soft tissue is thin or if the gingival sulcus is shallow, and a non-esthetic outcome may be caused by the exposure of titanium in the gingival margin when a gingival recession occurs . AluminaZirconium abutments are widely used in South Korea, but it is not easy to find evidence of their clinical stability for long-term use by the Koreans. Glauser et al. reported that there was no fracture in the zirconium abutments in their study for an average of 49.2 months in single-tooth restoration . AdditioAccording to the Straumann report 2013, Korea is the country where dental implant treatment is most performed . The KorA key question was set. The significant element in determining the key question included the patient/problem (P), intervention (I), comparison (C), and outcome (O) (PICO). The combination of these four major elements is “PICO asking questions.” According to PICO asking questions, “Does the zirconium abutment (P and I) have mechanical, biological, and esthetic stability (O) compared to the titanium abutment (C)?” was set as a key question.Literature was searched, using the keywords “zirconia abutment,” or “zirconium abutment,” in KoreaMed, KMbase, and National Assembly Electronic Library, which were recommended as domestic literature search sites by 「Evidence Literature Utilization Guidelines」 published by the Health Insurance Review and Assessment Service of Republic of Korea (2013a). Literature was searched using keywords including “zirconia abutment” and “zirconium abutment” in PubMed to compare the evidence levels of the stability of zirconium abutments in the domestic and international literature. The searched literature was selected by determining the inclusion and exclusion criteria based on the concept of evidence-based dentistry. The domestic literature included studies with Korean subjects and literature written in Korean. The scope of this study was clinical literature. Studies with international subjects, animal experiments, laboratory studies, expert commentaries, and scholarly literature were excluded.In this literature, mechanical stability means that there are no problems of zirconium abutment fracture, abutment screw fracture, etc. To evaluate the biological stability, the conditions of the tissues around the zirconium abutments including the height of the bones, the plaque accumulation level in the soft tissue, the bleeding on probing, and the depth of the periodontal pocket were compared with the conditions of the tissues around the titanium abutments or around the healthy natural teeth. The esthetic stability was evaluated to be stable when the color and shape of the soft tissue surrounding the zirconium abutments were similar to those of the natural teeth.In this study, the grade criteria for clinical research literature suggested by the Health Insurance Review and Assessment Service were used. After the confirmation of the study type and contents that were selected based on Table As a result of the domestic literature search, a total of 102 kinds of literature were searched, including 28 kinds of literature at KoreaMed, 35 kinds of literature at KMbase, and 39 kinds of literature at the National Assembly Library. Of these 102 kinds of literature, 48 duplicate kinds of literature, 35 kinds of literature that fell under the exclusion criteria  based on a review of titles and abstracts, and three kinds of literature whose scope was not related to implant zirconium abutment were excluded. After a review of the full texts of the literature, six expert commentaries and one Master’s thesis that was published in an international journal with a different title were excluded. Finally, nine literature were selected (Fig. International literature was searched at the Refomax Electronic Library of Hallym University Medical Center by linking with PubMed using keywords including “zirconium abutment” and “zirconia abutment.” The literature type was set to review, clinical trial, and case report, and a total of 92 kinds of literature were selected: 13 reviews, 37 clinical trials, and 42 case reports. Based on the titles and abstracts, animal experiments, laboratory studies, and studies not related to implant zirconium abutment were excluded, and only the literature whose full texts could be obtained from the electronic library of the Hallym University Medical Center were selected. Finally, five reviews, eight clinical trials, and six case reports were selected (Fig. After the confirmation of the study types of the domestic and international literature, the evidence levels were classified. The classification results are presented in Table In the international literature search process, there was a function for setting a literature type; thus, it was easy to classify the evidence level compared to the domestic literature search. About the evidence levels of international literature, there were five systematic literature reviews with evidence level 2, four cohort studies, and three case-control studies with evidence level 3, and 1 case series and 6 case reports with evidence level 4.A summary of three domestic kinds of literature with evidence level 3 is presented in Table A summary of six domestic kinds of literature with evidence level 4 is presented in Table A summary of the outcomes of five international literature with evidence level 2 is presented in Table In Table First, zirconium abutments are mechanically stable within the 3- and 5-year follow-up periods. This study emphasized that the average 5-year follow-up period is longer than the follow-up periods of other studies. Second, zirconium abutments are stable for the restoration of a single tooth in the anterior and premolar regions. In the study of Glauser et al., single crowns using 54 zirconium abutments were observed for 4 years, and mechanical problems such as abutment fracture and abutment screw fracture, and marginal bone loss, were examined. During the average 49.2-month follow-up period, abutment fracture did not occur, and the mean marginal bone loss was reported to be 1.2 mm. Third, the esthetic stability of zirconium abutments cannot be determined . In the In Table The following three results were derived from international literature with evidence level 4. First, zirconium abutments are mechanically stable. In the study conducted by Lee et al., when nine patients were observed for 52 weeks after early loading, no abutment fracture or abutment screw loosening occurred . Second,In this study, the domestic and international literature on the stability of zirconium abutments were analyzed, with a focus on evidence-based dentistry. As a result, the following shortcomings were shown.First, the studies on the stability of zirconium abutments conducted for longer than 5 years are not sufficient. Considering that complications of zirconium prosthesis occur more than 5 years after, long-term studies lasting for more than 5 years are required. The analysis results of the domestic literature showed that zirconium abutments are mechanically, biologically, and esthetically stable, but most of the said literature have evidence level 4, meaning that the level of scientific evidence presented by them is low. Additionally, the stability of zirconium abutments is limited to the 5-year follow-up period. The evidence levels of international literature range from level 2 to level 4, and the scientific-evidence levels are higher and more varied compared to those of domestic literature. Like domestic literature, however, international literature reports the mechanical stability of zirconium abutments to last for 4 years; thus, the scientific evidence for the long-term stability of zirconium abutments is not sufficient. Further studies on the long-term survival rate of zirconium abutments are also required in other countries, and biological measurement values and esthetic outcomes need to be suggested using objective figures in long-term clinical practice.Second, the domestic and international literature supporting the esthetic stability of zirconium abutments are case reports with a low evidence level, and most of them report the analysis results in a subjective language and have a short follow-up period or do not report the follow-up period. Among the domestic literature, three literature (written by Byeon et al. , Lee et Zirconium abutments have a high survival rate regardless of implant location and prosthesis type within the 5-year follow-up period. Zirconium abutments are biologically stable. The evidence regarding the esthetic stability of zirconium abutments is not sufficient. Zirconium abutments are mechanically stable within the 5-year follow-up period. The long-term stability of zirconium abutments after 5 years cannot be determined. Therefore, clinical studies that investigate the long-term stability of zirconium abutments are required.


Hypertrophic cardiomyopathy (HCM) is a common genetic diseases with prevalence of 1 in 200-500 in general population, and it can result in sudden cardiac death (SCD) . FurtherIn our recent study, we sought to address this knowledge gap by evaluating cardiac Magnetic resonance (CMR) in 1423 HCM patients with preserved EF for presence and extent of scar in the LV by late gadolinium enhancement (LGE) . Our stuIn the current AHA/ACC guidelines, CMR carries a weak recommendation (class IIB) (Level of evidence C) for use to assess presence of LGE in case of patients with inconclusive SCD risk stratification by conventional factors . Several


Urinary incontinence is a common complaint in all parts of the world, cause of distress, as well as significant costs for both individuals and society. The aim of this study will be to evaluate the rigor of the development of clinical practice guidelines and to identify the recommendations of interventions for urinary incontinence in adult women.In this systematic review, clinical practice guidelines will be identified using a prospective protocol through a systematic search of: MEDLINE (via Ovid); EMBASE ; Web of Science and Virtual Health Library. Specific databases of guidelines for clinical practice will also be searched . Reviewers, independently and in duplicate, will assess the quality of the guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE II). The results will be checked for discrepancies. Differences between the scores equal to or greater than 2 will be considered as discrepant and the final result will be decided by consensus. A comparison of the recommendations of interventions and information about the level of evidence, the degree of recommendation, the level of agreement and the level of acceptance will be described. This step will also be done independently and in duplicate, and the result will be decided by consensus. The results will be presented in tables and the descriptive statistics will be calculated for all domains of the AGREE II instrument as mean (standard deviation) and median (interquartile range).The results derived from this study will increase the knowledge about the development of recommendations guidelines for urinary incontinence of high methodological rigor. This study may also identify key areas for future research.This study may guide health professionals, policy makers, and health policy managers in choosing the guidelines for recommendation in clinical practice.PROSPERO - CRD42018116517 Urge incontinence is present when there is a report of involuntary leakage associated or immediately preceded by a sudden need for emptying without the ability to delay.The prevalence among types of urinary incontinence varies among countries. It is estimated that women are more affected than men, and between 10% and 55% with ages between 15 and 64 years are affected, with the highest prevalence of stress urinary incontinence.The history of urinary incontinence is fundamental to the planning of the clinical process and should be the first step in the evaluation, informing details about the type, moment, severity, and other symptoms, allowing the categorization of the disease.,7,8 Due to numerous options of treatments, many professional organizations have developed guidelines to help clinicians treat patients with urinary incontinence.Treatment options for urinary incontinence may be surgical or conservative. In clinical practice, non-surgical therapies are the first line of treatment, including behavioral therapy with strategies for re-education of the bladder, training of pelvic muscle tone, biofeedback, electrical stimulation, vaginal cones, control of intake of caffeine, and pharmacological treatment, varying according to each case or type of urinary incontinence.Guidelines are important vehicles of influence for clinical practice. Local, national, and international societies adopt the process of identifying relevant clinical areas, formulating specific clinical issues, reviewing applicable evidence, and formulating recommendations that doctors and their patients should follow.,11,12To ensure reliability, clinical practice guidelines should be systematically developed by groups of people with skills, perspectives and knowledge based on the best available evidence.The Appraisal of Guidelines for Research & Evaluation (AGREE II) Instrument aims to address the variability in the quality of clinical practice guidelines, that is, assesses the methodological rigor and transparency with which the guideline is developed. Developed by an international group, first published in 2003 and updated in 2009, AGREE II has been widely used, offering a comprehensive, rapid, and consistent assessment of clinical practice guidelines.No systematic review performed the critical appraisal on the development of clinical practice guidelines for the treatment of urinary incontinence. Success in implementing recommendations should be related to the use of appropriate methodologies and rigorous strategies in the guideline development process.22.1This systematic review of clinical practice guidelines for adult urinary incontinence interventions will be undertaken to assess the methodological quality in their development and the recommendations of the interventions, available in those documents.2.2https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=116517). Ethical approval is not required because this is a literature-based study.This study will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-P).2.32.3.1Guidelines for clinical practice and consensus (if applicable) describing interventions for treatment of adults (age ≥ 18 years) with urgency, stress, or mixed urinary incontinence, even if the document reports 1 or more types of incontinence, will be included. We will consider the documents published from 2009 onwards (date of publication of the latest version of AGREE II), and restricted to English, Portuguese, Spanish, and French.2.3.2Specific clinical practice guidelines for the treatment of urinary incontinence due to neurological or oncological traumas will be excluded. If there is another more up-to-date version of the guideline; the available version is incomplete or contains only a summary of the information; the document is the translation of a guideline published in another language; and if there is a consensus guideline, evidence summary or algorithm; will be excluded.2.4The methodological quality of clinical practice guidelines for interventions for urinary incontinence in adults will be evaluated; the scores of each domain associated with the methodological quality of the guidelines will be identified; and the recommendations provided by the guidelines will be described and compared.2.52.5.1The following electronic databases will be searched: MEDLINE (via Ovid); EMBASE ; Web of Science; and Virtual Health Library.www.guidelines.ecri.org) European Association of Urology (www.uroweb.org), NICE (www.nice.org.uk), American College of Physicians (www.acponline.org), American Urological Association (www.auanet.org), Brazilian Society of Urology (www.sbu-sp.org.br), Canadian Agency for Drugs and Technologies in Health (www.cadth.ca), Canadian Medical Association (www.cma.ca), and others.Specific databases for clinical guidelines will be searched, for example: ECRI Institute  to identify relevant studies. The isolated terms and their entry terms will be identified and will be crossed to perform the search, being adapted for each database. The terms used will be:  AND . The search strategy will be adapted to each database.2.6Duplicates will be removed by 1 of the reviewers. Reviewers , in pairs and independently, will assess whether abstracts and titles meet the eligibility criteria.The eligibility of the guidelines will be confirmed after reading the full text by the same reviewers and independently. Discrepancies will be solved by consensus and a third reviewer (CCB or LCL) will be able to assist in the final decision if necessary. In case of duplicate publication, the most up-to-date guideline will be used. All documents related to the guidelines  will be searched manually by 1 or 2 reviewers.2.7The information will be added to an Excel worksheet and the same reviewers, in pairs and independently, will be the extraction of the date. The discrepancies will be resolved by consensus. If cannot be resolved through discussion, will be referred to a third reviewer (CCB or LCL). Previously, the reviewers will be calibrated by extracting at least 3 documents of different levels of quality and will reach consensus. The results will be discussed with another reviewer, previously trained. This procedure should occur until the reviewers are able to extract the data.The following data will be extracted: number of authors, year of publication, update time, organizations , type of guideline , country of development, type , type of urinary incontinence, treatments described, target population, design of studies included , methods of recommendation formulation , and methods of classifying the quality of evidence .2.8The quality of each guideline will be evaluated using the Appraisal of Guidelines for Research and Evaluation - AGREE II. The translated and validated version of AGREE II for the Portuguese language (Brazil) will be used. The tool consists of 23 items covering 6 quality domains, scored with a Likert scale of 1  to 7  for each . The 6 areas are:1.scope and purpose2.stakeholder involvement3.rigour of development4.clarity of presentation5.applicability6.editorial independence.The same pairs of reviewers will conduct the quality assessment of the guidelines and the difference of 2 or more scores for each item will be considered as discrepant. The final score will be decided by consensus and if there is no consensus, another reviewer will help in the final decision.The quality of each guideline will be calculated for each domain, according to the AGREE II User Manual. The 6 domains are independents and the scores should therefore be calculated as the sum of the individual items in each domain. Then, the total obtained will be presented as a relation percentage to the maximum possible score for each domain. The evaluation will be conducted using the “My AGREE PLUS” platform.Previously, a training will be done to use the AGREE II instrument according to the following steps:1.study the AGREE II User Manual, the AGREE II validation article in Brazil and a guideline to choose;2.https://www.agreetrust.org);register on the “My AGREE PLUS” platform and complete the AGREE II Training Tools , and/or surgical using selected guidelines, respecting the particularities of the treatment of these diseases.For the recommendations of the description and comparison of the intervention, the level of evidence supporting them will be found. The information will be collected in relation to this level of evidence, the degree of recommendation, the level of agreement and the level of acceptance.This step will also be done in duplicate and independently by all reviewers. The information will be verified and, if there is no consensus, another reviewer will assist in the final decision.2.10The results will be presented in descriptive tables. Descriptive statistics will be calculated for all AGREE II domains as mean (standard deviation) and median (interquartile range). Graphs will be plotted when needed. The level of significance will be 5%. Statistical analysis will be conducted using the STATA software (version 14.2).3This study will identify guidelines of high-quality clinical practice describing interventions for urinary incontinence or the possible flaws observed in these articles. The results observed may guide the development of recommendations guidelines for urinary incontinence of high methodological rigor. Success in implementing recommendations should be related to the use of appropriate methodologies and rigorous strategies in the guideline development process.A description of the available recommendations on interventions and evidence supporting them contributes to the choice of treatment for urinary incontinence in adults. Thus, the results of this study can subsidize patients, health institutions, health policy makers, choose higher quality guidelines, inform on the existing recommendations of the different interventions and identify gaps in current evidence and make recommendations for future research.The method of this review includes explicit eligibility criteria, comprehensive and extensive database research, independent, and paired evaluation for study selection. Nevertheless, the fact of the present study will be limited to subjective analysis of the AGREE II instrument may be a limiting factor.The results of the research can be submitted for publication in scientific journals of high impact, peer reviewed, and also published in national and international conferences.Conceptualization: Flavia Blaseck Smiles, Cristiane Cássia Bergamaschi.Investigation: Luciane Cruz Lopes, Silvio Barberato-Filho.Methodology: Flavia Blaseck Smiles, Lauren Giustti Mazzei, Luciane Cruz Lopes, Silvio Barberato-Filho, Juliana Castro, Analaura Castro, Livia Luize Marengo, Cristiane Cássia Bergamaschi.Supervision: Cristiane Cássia Bergamaschi.Writing – original draft: Flavia Blaseck Smiles, Lauren Giustti Mazzei, Luciane Cruz Lopes, Silvio Barberato-Filho, Juliana Castro, Analaura Castro, Livia Luize Marengo, Cristiane Cássia Bergamaschi.Writing – review & editing: Lauren Giustti Mazzei, Luciane Cruz Lopes, Silvio Barberato-Filho, Juliana Castro, Analaura Castro, Livia Luize Marengo, Cristiane Cássia Bergamaschi.Cristiane Cássia Bergamaschi orcid: 0000-0002-6608-1806.


The National Health Service (NHS) in England planned a national diabetes prevention programme (NHS DPP) with phased implementation. Evidence-based guidelines and service specifications support efficient and effective translation of research into practice. We aimed to evaluate the use of a structured mapping exercise to appraise how evidence, service specification and early phase practice could inform recommendations to guide subsequent implementation of the NHS DPP.The mapping exercise facilitated comparison and appraisal of key components from different documentary sources . Key components were categorised into (A) pathways into programmes, (B) intervention content (C) inequalities and (D) quality assurance and staff training. We identified where key components were the same (accordance), where they varied (discrepancies) and where they were lacking (discontinuities), across the documentary sources. For example there was discrepancy in intervention duration and discontinuity in intervention enrolment procedures. This mapping exercise was useful to compare the fidelity in translation of evidence-based guidance into service specification and programme documents, thus identifying where future service implementation might be improved. This method may be applicable for use with other health conditions where research evidence requires translation into real world population programmes.The online version of this article (10.1186/s13104-018-3546-8) contains supplementary material, which is available to authorized users. The NHS 5 year forward view in England emphasised the need for ‘a radical upgrade in prevention and public health’ and included a plan for a national diabetes prevention programme (NHS DPP) .The NHS DPP in England, for individuals at high risk of developing type 2 diabetes (T2D), was planned to be rolled out in phases (i) demonstrator site phase (seven sites in England), (ii) wave 1  and (iii) wave 2 . The stated objectives were reduction in incidence of T2D, blood glucose parameters and weight [The NHS DPP service specification  was deveNational Institute for Health and Care Excellence (NICE) guidelines are created to improve outcomes for those using health services . HoweverTranslation of research into practice involves making sure research findings about effective treatments reach populations that can benefit and are implemented as intended . ReflectSummary of the process evaluation of the demonstrator and wave 1 phases of the NHS DPP are reported elsewhere .We aimed to appraise how evidence informed practice to guide subsequent implementation of the NHS DPP through a structured mapping exercise .NICE guidelines—PH38 preventing T2D guidance for individuals at high risk .The draft NHS DPP service specification (demonstrator site phase).The final NHS DPP service specification  (wave 1 All of the seven demonstrator site applications and Memoranda of Understanding (MoU) submitted to become part of the NHS DPP demonstrator site phase. Any provided baseline documentation from the seven sites.All of the four procurements and Memoranda of Understanding (MoU) submitted to become a provider for the NHS DPP wave 1 phase. Any provided baseline documentation from the four providers was reviewed.To conduct the mapping exercise we reviewed and extracted data from all the relevant evidence/documentary sources. The documentary sources used within the mapping method were:A.Pathways into the programmes B.Intervention content (intervention components using existing reporting frameworks and taxonomies –14)C.Inequalities using PROGRESS equality indicators  D.Quality assurance and staff training Data was extracted from the above documentary sources in relation to Key components. Components related to the whole of the programme were extracted to enable the complete T2D prevention pathway to be reviewed and synthesised. These included:Information was extracted on staff or health care professional involvement at each stage of the programme and also areas of responsibility, i.e. training of delivery staff.Structured mapping was used to collate the evidence and enable comparison of the findings across the different documentary sources. Initially we used a spreadsheet to facilitate the mapping process and we used recommendations in NICE guidance (PH38) to identify key components . The extAccordance—components that were common and reported across all documentary sources, e.g. the format of the intervention (face-to-face group sessions).Discrepancies—components that varied across documentary sources, e.g. duration or intensity of the intervention.Discontinuities—components that did not appear across all documentary sources, e.g. intervention enrolment procedures.The mapping exercise drew on Structured Mapping Theory, which describes the use of mapping and how evaluation of the analogy gives a measure of the quality of match between the base and a target . CriticaWe used the Accordance, Discrepancies, Discontinuities (ADD) ‘ADD-Fuse’ method outlined above, which was developed during the NHS DPP demonstrator and wave 1 phase evaluation projects, to facilitate critical appraisal. Critical appraisal identified where programmes or specifications consistently met the desired criteria or where differences or gaps were present and therefore where improvements could be recommended. Recommendations were formulated from the appraisal process and provided to the NHS DPP management team to inform subsequent phases , which was used to highlight the key commonalities, differences and gaps between the documentary sources Table .Table 2UTable In both the demonstrator and wave 1 phases, the format of the intervention was in accordance with the NHS DPP service specification (in person group sessions).The reporting of the content of the face-to-face sessions, the level of detail on outcomes, mechanisms of action and techniques used varied greatly between providers. As outlined in Tables A gap (discontinuity) in the draft NHS DPP service specification was identified at the demonstrator phase for the description of behaviour change techniques (BCTs) when compared with recommendation s in NICE guidelines Table . HoweverEvidence-based documentary sources were used to examine incorporation of evidence in the planned context of the NHS DPP programme. Comparison identified accordance, discrepancies and discontinuities (ADD-Fuse method). Different components, actors and responsibilities that may impact the implementation and evaluability of the NHS DPP were revealed. This process identified recommendations  made it possible to trace the progression of a new service as the phases were rolled out in England and observe changes in the NHS DPP service specification over time. The mapping exercise evaluated the programme as a whole, informing on wider aspects of a health improvement programme that could be improved, which would not be assessed if focused solely on the intervention.Variance in delivered programmes is likely to have an impact on the assessed outcomes. This structured mapping exercise has utility for implementation science and real-world programmes in explaining differences in outcomes based on specific components of the interventions and how each programme is implemented in relation to the service specification. This method could also enable the identification of key areas that require improvement. The mapping exercise examined the progression of a national programme rollout, identifying how the service specification developed from a draft to a final document . This mapping exercise could be utilised in further rollout of the NHS DPP. This process could be used for the development of future service specifications and in the reporting of behaviour change programmes. Fidelity measures need to be established in order to judge whether implementation of a programme meets the required standards.A mapping exercise was applied in the context of the NHS DPP in England. Using NICE guidelines allowed the service specification and provider documents to be examined in relation to the evidence base. This enabled identification of whether the implementation of a new health care programme may experience problems owing to shortcomings in the service specification or whether problems lie within the transition from evidence into practice. We suggest the method may be applicable for use within other disease or health conditions where research evidence requires translation into real world population programmes.The strength of the evidence base varies across different health conditions and therefore using a mapping exercise like this may not be applicable to programmes that do not have existing evidence-based guidelines and where the evidence is minimal or of poor quality.The NHS DPP explicitly entered other sources of evidence into the specification development  and this has implications for how closely the programme tracks the research evidence. There are of course reasons for doing this, for example practicality and funding can impact greatly, but this brings risks that the key components that make an intervention effective become diluted.Since the mapping exercise additional evidence has become available, in particular the 2017 update to the NICE PH38 guidelines . Data exAdditional file 1. Recommendations provided to the NHS DPP Management team and responses received from the NHS DPPManagement team.


In the era of eHealth, eHealth literacy is emerging as a key concept to promote self-management of chronic conditions such as HIV. However, there is a paucity of research focused on eHealth literacy for people living with HIV (PLWH) as a means of improving their adherence to HIV care and health outcome.The objective of this study was to critically appraise the types, scope, and nature of studies addressing eHealth literacy as a study variable in PLWH.This systematic review used comprehensive database searches, such as PubMed, EMBASE, CINAHL, Web of Science, and Cochrane, to identify quantitative studies targeting PLWH published in English before May 2017 with eHealth literacy as a study variable.We identified 56 unique records, and 7 papers met the eligibility criteria. The types of study designs varied  and often involved community-based settings (n=5), with sample sizes ranging from 18 to 895. In regards to instruments used, 3 studies measured eHealth literacy with validated instruments such as the eHealth Literacy Scale (eHEALS); 2 studies used full or short versions of Test of Functional Health Literacy in Adults, whereas the remaining 2 studies used study-developed questions. The majority of studies included in the review reported high eHealth literacy among the samples. The associations between eHealth literacy and health outcomes in PLWH were not consistent. In the areas of HIV transmission risk, retention in care, treatment adherence, and virological suppression, the role of eHealth literacy is still not fully understood. Furthermore, the implications for future research are discussed.Understanding the role of eHealth literacy is an essential step to encourage PLWH to be actively engaged in their health care. Avenues to pursue in the role of eHealth literacy and PLWH should consider the development and use of standardized eHealth literacy definitions and measures. HIV is a major global health issue with an estimated 36.7 million people living with HIV (PLWH) worldwide . In the eHealth, “a medical and public health practice supported by a Web-based platform,” is a popular innovation in self-management of chronic conditions and includes mobile phones, tablet computers, and personal computers . Web-baseHealth literacy refers to one’s ability “to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to address or solve a health problem” . In thisTo the best of our knowledge, this is the first systematic review to address eHealth literacy in PLWH. Although previous systematic reviews have addressed eHealth literacy in college students , underseWe conducted a systematic review of quantitative evidence designed to assess eHealth literacy as a study variable in PLWH. Owing to the heterogeneity relative to study designs and statistical analysis approaches among the included studies, we synthesized the study findings rather than conducting a meta-analysis.Studies were screened to assess their relevance for our review. Specifically, the following inclusion criteria were used papers that used a quantitative study design ; papers including eHealth literacy as a study variable; and papers including participants with HIV or AIDS. Our initial search was not limited by the age of study participants or sex to maximize the breadth of the study findings. In addition, we included any study that reported quantitative findings relevant to the review question. Studies from around the globe were included, as were studies conducted in various settings, including community or health system settings.Notably, only studies written in English were included. Studies were excluded if full-texts were unavailable , they were not quantitative designs, or they reported protocol only with no measured outcomes.In consultation with a medical librarian, peer-reviewed journal papers were searched systematically in PubMed, EMBASE, CINAHL, Scopus, Web of Science, and Cochrane databases using variations of MeSH terms—methodological interest , population of interest , and study design of interest  to identify relevant papers published in English before April 27, 2017. In addition, a manual search of reference lists in selected papers was completed. At the conclusion of the study selection process, 1 reviewing author extracted data from the studies using a standard template. The initial data extraction captured both the study characteristics  and key findings from each study. In addition, other team members reviewed the studies and extracted data relating to key findings. Extracted findings were compared and discussed until all discrepancies were resolved.We assessed the rigor of the underlying evidence base for the review by developing an overview of key methodological characteristics, including the study design, sample size and strategy, study setting, and year of publication. No studies were excluded on the basis of the quality assessment. Rather, the quality assessment process was conducted independently by 2 raters using the Joanna Briggs Institute quality appraisal tools based specifically on study designs, randomized controlled trials (RCTs) , quasi-eOverall, the studies appraised in this review achieved, at least, the assessment criteria, but the quality varied across individual studies. Although 1 RCT scored 8 of 13  and 1 ofFurthermore, an interrater agreement rate was calculated . The res+ [cluster of differentiation 4] T-cell count <350 cells/mm3 and taking ARTs for, at least, 4 years) [Study participants were recruited from a variety of settings as follows: community-based HIV/AIDS organizations ,28-30, H4 years) , 1 incluAmong studies that included women, most had a majority of female participants (56%-100%) but 2 ,26 incluIn this review, 5 of 7 studies defined eHealth literacy. Most studies -28 definIn addition, 3 studies conducted in the United States ,27,28 meMoreover, Ownby et al  used theOverall, varying scales with differing scoring systems were used to determine the level of eHealth literacy. High eHealth literacy scores among PLWH ranged from 52.4% to 87% in study samples with the majority of studies finding high eHealth literacy among 65%-80% of participants. Such a wide variance arose because high literacy was defined differently in each study, ranging from the ability to read a complete sentence  to a TOFP<.001) [P<.05 and P<.01, respectively) [The acceptability of eHealth interventions was measured in 3 studies ,29,30. Nctively) .In this review, 6 of 7 studies examined the associations between eHealth literacy and a variety of health outcomes in PLWH. The 2 studies that measured the relationship between eHealth literacy and HIV-related behavior reported conflicting results. In Blackstock et al , higher P=.02) as well as adherence behavioral skills, including using reminders, scheduling medications with other daily activities, and soliciting social support (P=.02). Data were collected 3 months apart; however, no control group was included in this study.In contrast, following an electronically delivered health literacy intervention targeting HIV-related health literacy on medication adherence, participants in Ownby et al  self-repP=.01), and return to the clinic within 7 days of the first transmitted SMS text message, AOR 3.81  [P=.04) [Siedner et al  examined P=.002) . In addi [P=.04) .P=.007). Krishnan et al [P<.01); for example, participants with poor adherence were less likely to be interested in anonymous internet interaction with a health professional to discuss HIV-related issues compared with participants with optimal adherence (P<.001) [P=.01,.009,.04, respectively) but not among those in adherence categories of ≤75% [The relationship between eHealth literacy and HIV treatment adherence was mixed. Literacy was inversely associated with ART adherence, which was measured by Kim et al  as the san et al  found no(P<.001) . Ownby e(P<.001)  attempte of ≤75% . These cP=.003), higher plasma HIV viral load , less frequent computer and internet use (P<.05), not owning a smartphone (P<.05), and higher anxiety related to using a computer (P<.05). According to Kim et al [P=.09).Because only 2 studies assessed participants’ HIV viral load under dissimilar study settings, we were unable to determine the association between eHealth literacy and HIV viral suppression ,29. WoodAlthough there has been limited reporting on eHealth literacy targeting PLWH, available studies addressing eHealth literacy in PLWH varied in their scope, methodology, and outcomes. The studies included in the systematic review provide some evidence for the role of eHealth literacy in relation to diverse HIV-related health outcomes, including HIV transmission risk, retention in care, treatment adherence, and virological suppression. Even though eHealth literacy was generally high and majority of those individuals included in the samples were receptive to the use of SMS text messaging communication , findingIn descriptive studies, eHealth literacy was either inversely associated with HIV transmission prevention behaviors, ART adherence, or viral load ,28,29 orNegative outcomes in retention in care and treatment adherence may be attributed to general literacy challenges and access to phones, laptops, and desktop devices ,30. In aThis review has revealed several gaps in the existing evidence base; gaps that collectively point to what we argue should be key parts of the eHealth literacy research agenda going forward. The most important gap and a critical focus of future research is the use of validated instruments to measure eHealth literacy, which do not appear in these studies. Much of the research we reviewed used some form of eHealth literacy assessment but with no evidence of validity and reliability or proxy measures for eHealth literacy. Future eHealth literacy research should adopt more rigorous instrumental approaches to addressing eHealth literacy as a new way of promoting and facilitating self-management in PLWH. In addition, there exists a limited explanation of definitions of eHealth literacy used in the literature. Hence, the selection of study instruments was minimally justified within the reviewed studies, highlighting the need for adopting a validated eHealth literacy framework to better understand and promote healthy behaviors and outcomes of PLWH. Finally, this review highlighted a critical methodological gap and area for future improvement—the need for ensuring a rigorous study design with adequate sample size, use of validated eHealth literacy measures and theoretical framework, and the use of diverse study samples of PLWH; for example, because >90% of adolescents and young adults use the internet daily , youth nAlthough the strengths of this review’s design included its inclusive search strategy that ensured extensive coverage, standardized data extraction, and iterative analysis, there are several limitations. First, despite our expanded search criteria, only a small number of studies met the inclusion criteria because of a lack of published studies. Second, the heterogeneity in the quality and quantity of data reported in the studies included in the review. Finally, we were unable to include studies in languages other than English, thereby limiting the generalizability of our findings.In conclusion, the importance of eHealth literacy among PLWH has only recently begun to be addressed. In the areas of HIV transmission risk, retention in care, treatment adherence, and virological suppression, the role of eHealth literacy remains partially understood. Understanding the role of eHealth literacy among PLWH is an essential next step in self-management of HIV and AIDS. Avenues to pursue in the role of eHealth literacy and PLWH should include the development and use of standardized eHealth literacy measures. Additionally, examining the role of eHealth literacy longitudinally from prevention to viral suppression could yield knowledge regarding at what point, from diagnosis through management, are the best points to intervene with eHealth literacy strategies. Finally, elucidating the other factors that potentially contribute to eHealth literacy, such as access and general literacy, could yield valuable findings going forward.


There is often a discordance between health research evidence and public health policies implemented by the United States federal government. In the process of developing health policy, discordance can arise through subjective and objective factors that are unrelated to the value of the evidence itself, and can inhibit the use of research evidence. We explore two common types of discordance through four illustrative examples and then propose a potential means of addressing discordance.In Discordance 1, public health authorities make recommendations for policy action, yet these are not based on high quality, rigorously synthesised research evidence. In Discordance 2, evidence-based public health recommendations are ignored or discounted in developing United States federal government policy. Both types could lead to serious risks of public health and clinical patient harms.We suggest that, to mitigate risks associated with these discordances, public health practitioners, health policy-makers, health advocates and other key stakeholders should take the opportunity to learn or expand their knowledge regarding current research methods, as well as improve their skills for appropriately considering the strengths and limitations of research evidence. This could help stakeholders to adopt a more nuanced approach to developing health policy. Stakeholders should also have a more insightful contextual awareness of these discordances and understand their potential harms. In Discordance 1, public health organisations and authorities need to acknowledge their own historical roles in making public health recommendations with insufficient evidence for improving health outcomes. In Discordance 2, policy-makers should recognise the larger impact of their decision-making based on minimal or flawed evidence, including the potential for poor health outcomes at population level and the waste of huge sums. In both types of discordance, stakeholders need to consider the impact of their own unconscious biases in championing evidence that may not be valid or conclusive.Public health policy needs to provide evidence-based solutions to public health problems, but this is not always done. We discuss some of the factors inhibiting evidence-based decision-making in United States federal government public health policy and suggest ways these could be addressed. Rigorously synthesised health research evidence should inform clinical practice, guideline development and health policy . AlthougMany lifesaving medical practices across numerous disciplines have been established in recent years, based on evidence derived from rigorous syntheses of the scientific literature. Some noteworthy examples include the use of statins for preventing and treating cardiovascular disease , adult mHowever, many competing social values may drive public policy, and better health is only one of them. Health guideline methodologists have recognised that financial or other resource constraints, trade-offs between desirable and undesirable outcomes, feasibility of intervention implementation, variability in stakeholder values, and preferences and uncertainty about the stability of effect estimates are all important factors in determining whether research evidence is translated to health policy , 19. AddThe policy-making process may require judgment calls by a variety of stakeholders. Although their intentions may be good, the judgment of health policy stakeholders can be influenced by several unconscious biases, which may not be obvious or apparent to them. These may include ‘irrational escalation’  , ‘statusAs one of its core functions, government is charged with improving the nation’s health and protecting its citizens from harms caused by natural disasters, environmental threats, and people motivated by self-serving interests. In many circumstances, the government is the only entity with the authority and capacity to protect the public good against competing ideological, economic and other interests . AlthougWe provide four examples to illustrate these discordances and then discuss some reasons (i.e. barriers or interrupting factors) for why research evidence may not end up being reflected in health policy recommendations or in United States federal health policy. We also propose a way to resolve these discordances. We wish to emphasise that this paper is not meant to be a comprehensive review of interventions related to the public health areas discussed here, nor does it provide an exhaustive list of factors and barriers that could interfere with the process of translating the best research evidence into health policy.The following working definitions and conceptual framework Fig.  help to the process of integrating science-based interventions with community preferences to improve the health of populations”  to be effective in reducing teen pregnancy, and the other 25% for “innovative” programmes .Tab.Tab82].TScreening for a disease at the population level may be appropriate when, among other conditions, the disease burden is very high, screening tests are reasonably accurate , the risk of adverse events is low and costs are low; it may not be appropriate in other contexts. Breast cancer screening is associated with several common and important adverse effects, as follows: (1) a 5–50% risk over a 20-year period of receiving false positive results, leading to more tests that are costly, time-consuming and may cause anxiety , 84; (2)the specific expertise and competing interests of the authors influenced the conclusions of systematic reviews” [A systematic review of 59 reviews published between 2000 to 2015 about benefits and harms of the mammography concluded that “reviews” . The autWomen should begin scheduling their annual mammograms at the age of 40” and “Mammography can help to reduce the number of deaths from breast cancer among women ages 40–70”, referencing to the CDC surveillance SEER in 2002–2008 [The American Breast Cancer Foundation seemingly ignores these risks and harms, instead making such recommendations as the following: “002–2008 . Other bThe two examples presented above for Discordance 1 serve to illustrate how lack of knowledge, unconscious biases, vested interests and other factors can have an impact on the validity and reliability of synthesised research evidence underpinning public health recommendations. With that in mind, we now turn our attention to two additional illustrative examples for Discordance 2, which show the types of pressures that often compete with research evidence in health policy development.Approximately 30% of children and adolescents in the United States are clinically obese (body mass index ≥ 30%) or clinically overweight (body mass index ≥ 25% to < 30%). Children with obesity are at higher risk of developing asthma, type 2 diabetes, bone and joint problems, sleep apnoea, and of becoming obese as adults . This inphysical activity interventions in a school-based setting with a family component or diet and physical activity interventions in a school-based setting with home and community components have the most evidence for effectiveness” [Several recent systematic reviews provide compelling evidence about a growing number of interventions to prevent childhood obesity. Prevention interventions are diverse in terms of programming  and setting . A 2013 systematic review concluded that “iveness” . Anotheriveness” , 90. Howiveness”  approachPrevious policy recommendations, such as after-school physical activity programmes, taxation on SSB, and bans on fast-food TV advertising targeting children have been studied via microsimulation analysis. Of these, the single most effective strategy was increased taxation on SSB .Childhood obesity has received substantial public health attention in the past decade. By 2013, 30 states in the United States had enacted legislation to create or expand obesity-prevention efforts in children. Currently, the most important federal law with indirect implications for childhood obesity is the Healthy, Hunger-Free Kids Act (2010). This legislation includes six large nationwide programmes , but theto develop a national strategy to reduce childhood obesity that: (1) provides for the reduction of childhood obesity rates by 10% by the year 2020; (2) addresses short-term and long-term solutions; (3) identifies how the federal government can work effectively with entities to implement the strategy; and (4) includes measures to identify and overcome obstacles” [Children are directly targeted by the fast-food industry, which uses advertising and marketing strategies designed to capture children’s attention. Strategies include the use of cartoon characters, movie stars and sports figures in marketing as well as offering complementary toys with a child’s meal and special play areas at restaurants. Regulating advertisements directly targeting children could be a promising approach to preventing childhood obesity. There is compelling evidence that the food industry creates obesogenic environments to influence children’s preferences for and consumption of foods that contribute to obesity . In 2005stacles” . The lasThe HIV epidemic remains a major public health challenge in the United States and globally . People Along with methadone maintenance treatment, the use of syringe service programmes (SSPs) is an effective strategy to prevent the spread of blood-borne infections in PWID . ProvisiIn 1988, the Department of Health and Human Services forbade the use of any federal funds to support the SSP until it was proven to be safe and effective . Since aSocially conservative members of the United States Congress have disregarded evidence supporting the provision of SSP for PWID for over two decades. In the absence of randomised controlled trials, opponents of the intervention argue that there is no proof that it is effective and safe. They often referred to early studies in Canada , showing no difference in HIV incidence between needle exchange groups and control groups, and suggested that provision of free needles may increase drug use and injection . HoweverSome time lag between the production of science and its translation into policy and programmes is reasonable and should even be encouraged. In the context of public health programmes such as SSPs, potential harms of the intervention should be given just as much attention as the benefits. However, more than 20 years of research evidence shows that SSPs have minimal harms, while providing significant health and economic benefits.External considerations beyond the realm of scientific evidence have driven SSP policy decision-making , 115. ThFor simplicity and illustrative purposes, we designate each health policy example to demonstrate one of the discordance types and related interruptive factors or barriers. However, even among these examples, there could still be other interruptive factors that also interfere with the translation of evidence to the policy process, causing Discordance 1 and/or or Discordance 2. There are many other potential factors that we cannot explore here, however, we do suggest that perhaps the three most prominent barriers and interruptive factors in the context of our examples are the lack of knowledge about the principles of evidence-based medicine, unconscious biases, and vested interests and beliefs.Knowledge of the principles of evidence-based health policy is a cornerstone of evidence-to-policy translation. We have already discussed how the lack of such knowledge among stakeholders may lead to Discordance 1, wherein an intervention may be characterised as evidence based when, in fact, it is not, and even an intervention that results in net harms may be promoted. This may also lead to or facilitate Discordance 2 situations. For instance, we can safely assume that most legislative staffers involved in the process of policy development have not been trained in the principles of evidence-based medicine concepts to the extent that that they could properly understand, appraise and interpret health research evidence. Given the complexity of the evidence base in childhood obesity (second example), even well-trained persons might have difficulty in appreciating nuances of evidence quality. With the fourth example, one needs a relatively strong knowledge base of epidemiologic bias to proceed with good discernment in decision-making.Unconscious bias may inform our decisions in different ways to those we have already discussed to this point, and can lead to both Discordance 1 and Discordance 2. For example, it is plausible that some stakeholders involved at different stages of policy development might generally prefer to keep things the way they are (status quo bias). Perhaps unaware of global standards, those reviewing the evidence for OAH may prefer to continue using the same biased but familiar methodology. Advocacy groups promoting access to mammography for women may prefer the existing pro-mammography guidelines, given that women’s struggles to increase health coverage where especially relevant to women. Policy-makers may feel the issue of childhood obesity is too complex to tackle; they may feel less pressure to scale up SSPs, compared to current, urgent discussion about the prescription opioid epidemic. They also may not be willing to change their previous public positions, as constituents may see this as flip-flopping on a matter of moral importance. Other types of unconscious biases  can potentially be discerned in any number of health policy examples beyond those that we discuss.Finally, perhaps the most widely acknowledged interruptive factor in evidence-based policy-making is the influence of vested interests and beliefs. This can creep into every aspect of health policy development. Although decision-makers are typically required to disclose all potential financial conflicts of interest or to affirm that they have none, it is still fair to inquire about potential conflicts of interest, perhaps not strictly financial in nature, when cherry-picked data are used to suggest that a given behavioural intervention works, while evidence for alternative approaches is ignored. What would happen to a professional organisation if it intensively ran campaigns to enroll women over age 40 for mammograms because they purportedly save lives, if that same organisation later had to admit to these women that it had made a mistake? This professional call to action may only have saved lives in a small minority of women while it failed to inform women of potential harms such as the increased incidence of false positive results that likely led to overtreatment. In another controversial area, how could politicians whose constituents perceive injection drug use to be morally degenerate behaviour develop the political willpower to scale-up SSP in the United States? Careful consideration of the types of evidence and data that exist to support or refute existing arguments may be helpful to bring to the public for their education.We identified two types of discordances between evidence and policy implementation and illustrated their impact with examples. In addition to being wasteful of scarce financial resources, both Discordance 1 (the discordance between research evidence and policy recommendations) and Discordance 2  can lead to large negative impacts on human health and wellbeing.The first harm reflects missed opportunities to save lives by implementing policies driven by our core values and supported high-quality evidence. When there is discordance between policy recommendations and enacted policy, we fail to implement interventions that have been shown to work. Amid conflicts about best approaches and the pressure of other agendas competing against research evidence, important public health problems as prominent as the HIV/AIDS epidemic may be neglected . PolicieThe second type of harm is reflected in opportunity costs. Public funding is usually limited and there are always competing  and emerging  public health problems and crises. Thus, for instance, the $1.3 billion public funds spent annually for mammograms in younger (age 40–49) women with only an average risk for breast cancer is funding that might have been better spent on interventions that actually saved women’s lives. Far from competing over scant resources and debating which dreaded disease is more important, the bottom line is the urgent need to make policy decisions that consider policy options based on the best evidence available. Continuing failure to do so supports political narratives that government is the problem, as it is perceived, by some, not to make wise investments, while others perceive that government should not play a role in this type of societal investment.Physical or psychological harms are a third type of problem. Many medical procedures and public health interventions are accompanied by unintended negative consequences. Even procedures or interventions believed generally to be harmless may have an important negative impact, because the impact of these harms may be downplayed or ignored by investigators , 125. InFinally, the discordance between research evidence and policy recommendations can work to discredit scientific efforts and the research community as they are perceived by the general public and policy-makers. The scientific community has always had to fight against ideologies and anti-scientific dogma, especially in the context of public policy. In addition, special-interest groups may actively deploy tactics to discredit scientific findings that are counter to vested interests or beliefs –129. TheThere are many stakeholders in health policy development. Besides policy-makers, they may include healthcare providers, insurance companies, government and regulatory agencies, professional disease-specific associations (e.g. American Heart Association), community and grassroots organisations, individual patients and their families, national-level foundations (e.g. Robert Wood Johnson Foundation), lobbyists, product manufacturers, patent holders, the media, and other interest groups. If scientific evidence is used appropriately in the process of policy development, it can potentially have a large impact on population health. This may be seen reflected in laws and regulations that set standards for the quality and safety of our food, the water we drink and the air we breathe, as well as in the quality and quantity of healthcare services we receive.Within this milieu, health advocacy groups and those engaged in the development and translation of scientific evidence for policy recommendations have a critical role to play in advancing an agenda for improving health. Health advocates are expected to make positive changes by improving access to quality care and preserving patient’s rights at the structural level . Their role is even more crucial for underserved and marginalised communities  whose voices may not be heard in the absence of active advocacy, as well as for topics that may be stigmatised or be controversial, such as SSPs and abortion. However, as with other types of stakeholders, unconscious biases (e.g. confirmation bias) or natural human altruism may also play a role – we want an intervention to work, even when the evidence does not show this conclusively.Despite this important role, health advocacy has only recently been recognised as a distinct discipline within the domain of public health . HoweverSome policy-makers and other stakeholders may have training in epidemiology yet lack the sophistication to understand the nature of bias in research or to have an adequate understanding of how to interpret systematic review findings. This is important, since even systematic reviews may promote certain agendas , 131 or As a first overarching step, the research community should work with other stakeholders involved in health policy development to build a climate in which research evidence is highly valued but also tested rigorously. Often, efforts are made to discredit science or regulatory and public health safety agencies are pressured to downplay scientific evidence. Funding agencies, academic institutions, researchers, scientific journals and others directly engaged in producing and disseminating evidence can play a critical role in overcoming some of these challenges. Among other potential approaches, they could raise the bar in favour of quality versus quantity of research studies, improve the quality of the peer-review process on both ends of the evidence production pipeline , and train more experts in the field of evidence-based public health. For instance, in the example of behavioural interventions to prevent teen pregnancy, there are too many studies assessing small-size programmes with short-term follow-ups that only measured changes in knowledge and self-reported behaviours  of participants. Further, emphasis should be placed on the importance of change in actual pregnancy outcomes; the observed effect on self-reported sexual behaviour outcomes is unreliable and provides indirect evidence. Training of experts in the field of knowledge transfer may also narrow the gap in evidence to policy translation. Knowledge transfer is an emerging field aimed to optimise the transfer of the latest research evidence and stakeholder perspectives, with the goal of improving health outcomes . Health Further, the scientific community must do a better job in educating the public about the fact that science is an evolving process and is thus subject to change. Today’s best evidence may be tomorrow’s old news. Problem solving and policy development require an iterative process. Often, it requires several cycles of planned data gathering and evaluation in order to achieve increasingly better outcomes. Policy-makers often want to declare, ‘problem solved’. Scientists should be willing to say, ‘Let evidence indicate if we are on the right path, and let us be ready to learn and continue to improve upon our outcomes’, and continue to test the applicability of the evidence to the field.It can also be difficult to identify appropriate and applicable research evidence for policy development. For instance, in respect to childhood obesity, there is a mismatch between the complex and multi-factorial nature of the problem  and the existing evidence .Another overarching issue is the explosion of research production, making it even harder to differentiate high-quality and relevant evidence from the rest for decision-making. Thousands of new medical and public health articles are indexed in PubMed, alone, each week. Workers in the field of knowledge transfer use synthesised research findings from high-quality systematic reviews to deliver best evidence to policy-makers and other key stakeholders. This evidence may be packaged in the form of ‘evidence briefs’ or other approaches , 132, anTo minimise harms associated with the discordance between evidence and policy, we propose that those engaged in the policy-making process, in particular those who translate evidence for policy recommendations and who are health advocates, should learn to appraise the evidence informing their policy agenda , or work closely with those who do have those skills and can represent the public interest in the policy arena being debated. Health advocates often simplify research findings in order to communicate the essence of the analysis. Trusted advocates should work with the researchers involved to ensure that the statement of the findings is indeed accurate.We suggest that a minimum grounding of stakeholders in core principles of evidence-based public health, as well as in the science of communicating about research findings, may build a bridge between the latest scientific evidence and public health policy. This may be especially useful when the evidence is not clear-cut, as with pregnancy prevention interventions or mammography for breast cancer. A more nuanced understanding of the degree to which one may believe research findings, including consideration of epidemiologic biases, applicability to the policy question and the role of industry or interest group funding, could help to make United States health policy more evidence-based and improve health at the population level.In the end, enhanced training may only improve a subsection of the problem that is attributable to lack of adequate knowledge in evidence-based public health. We also need to recognise the importance of building competency in other areas, as outlined below.We propose more attention be given to improve the communication capacity of policy-makers in the manner that evidence is framed for different audiences, particularly segments that may discount the validity of evidence that may not support findings contrary to these groups’ belief systems or sense of morality, such as the SSPs for HIV prevention. It is particularly crucial that these groups be engaged, especially if they question the importance of making societal investments in particular issues, for example, segments who discount the role of government in developing and implementing programmes.Competencies should be built to identify common ground across different audience segments, framing results as a means of responding to concerns across different groups concerned with particular societal outcomes, or those who may be concerned with costs related to certain outcomes. They also have to face their own ‘unconscious bias’ in championing evidence that may not actually be valid. Regarding the example of mammography for breast cancer, for instance, different healthcare provider and patient advocacy groups perceive and act upon the same evidence to push their respective agendas forward in different ways.There are some limitations to our analysis. It is not a comprehensive analysis of all possibilities for discordance; indeed, we acknowledge that the types of discordance we examine here are only two very prominent ones. We selected our examples purposively, and there may have been better exemplars. A couple of other possibilities include screening for depression and primary care check-ups. Depression screening often leads to overdiagnosis and, in most cases, to diagnosed patients initiating antidepressant regimens –135, desThere are likely many other factors causing or mediating Discordance 1 and 2 in the context of our examples. To illustrate each example, we focused our analysis on a single Discordance that was most visible to us, and apparent in the literature. There may or may not also be the complementary Discordance in those contexts. For example, in the example of adolescent pregnancy prevention, we merely reflect on Discordance 1 . However, it is also likely that this Discordance exists because of the macro-level political and cultural climate in which the alternative approaches (i.e. promotion of contraceptives and abortion services that are truly evidence based) are morally unacceptable for some policy-makers and their constituents, and thus are removed or downplayed in the policy agenda (Discordance 2).Further, in the context of provided examples, there could be discordance between evidence and policy in respect to other interventions that stakeholders inappropriately promote or demote. For example, in addition to behavioural interventions, OAH has also been promoting certain abstinence-based programmes to prevent teen pregnancy , 139, deIn order to properly tease out the actual factors causing or mediating Discordance 1 and Discordance 2 in the context of our examples, we would need to conduct a survey of all stakeholders involved . Such a study would allow us to collect and analyse primary data about stakeholder knowledge of evidence-based medicine, their deeply held values and beliefs in the context of the subject area, subtle or indirect conflicts of interest that may have bearing on decisions, and other issues that may interfere with the process of rigorously translating evidence to policy. Without such data, we may not be able to get an accurate and comprehensive picture of the real issues from the existing published literature and our analysis may gravitate towards speculation.Public health policy should provide evidence-based solutions to public health problems. National and local policy-makers may face barriers in the use of research evidence when allocating resources . Their pIn both types of discordance that we discuss here, there is a risk of increased population morbidity and/or mortality. It may not be feasible or, indeed, possible to change many context-specific barriers in the use of health research evidence in public health policy and programming. However, we can still mitigate the risks to population health if all stakeholders involved in guiding, developing and implementing public health policy have at least foundational skills in assessing evidence quality, as well as in communicating about it in nuanced ways. This could help to increase the use of the best evidence, which could result in better population health. Even where research evidence and evidence-based recommendations are used only selectively, health policy decisions will at least be evidence informed, if not always evidence based. Given the intractable or systemic nature of many discordances, even this partial uptake could help to reduce harm and improve health at the population level.Research evidence is often shunted aside in health policy development, but it need not be this way. If research evidence were developed by scientists who followed global best practices in conducting and reporting their research , 141–144