Evidence-based policy (EBP), a concept modelled on the principles of evidence-based medicine (EBM), is widely used in different areas of policymaking. Systematic reviews (SRs) with meta-analyses gradually became the methods of choice for synthesizing research evidence about interventions and judgements about quality of evidence and strength of recommendations. Critics have argued that the relation between research evidence and service policies is weak, and that the notion of EBP rests on a misunderstanding of policy processes. Having explored EBM standards and knowledge requirements for health policy decision-making, we present an empirical point of departure for discussing the relationship between EBM and EBP.In a case study exploring the Norwegian Knowledge Centre for the Health Services (NOKC), an independent government unit, we first searched for information about the background and development of the NOKC to establish a research context. We then identified, selected and organized official NOKC publications as an empirical sample of typical top-of-the-line knowledge delivery adhering to EBM standards. Finally, we explored conclusions in this type of publication, specifically addressing their potential as policy decision tools.From a total sample of 151 SRs published by the NOKC in the period 2004–2013, a purposive subsample from 2012 (14 publications) advised major caution about their conclusions because of the quality or relevance of the underlying documentation. Although the case study did not include a systematic investigation of uptake and policy consequences, SRs were found to be inappropriate as universal tools for health policy decision-making.The case study demonstrates that EBM is not necessarily suited to knowledge provision for every kind of policy decision-making. Our analysis raises the question of whether the evidence-based movement, represented here by an independent government organization, undertakes too broad a range of commissions using strategies that seem too confined. Policymaking in healthcare should be based on relevant and transparent knowledge, taking due account of the context of the intervention. However, we do not share the belief that the complex and messy nature of policy processes in general is compatible with the standards of EBM. Knowledge is an essential foundation for informed decisions in healthcare policy, and there is broad agreement that best available research evidence should be used -3. Howevthe conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” [In 1971, the Scottish epidemiologist Archie Cochrane 1909–1988) ,5 raisedatients” . The aim8 ,5 raisSRs with meta-analyses gradually became the methods of choice for synthesizing research evidence, with further development of systematic approaches for judging quality of evidence and strength of recommendations beyond intervention studies ,9-11. StEBM and a broad range of SRs formed the basis for development and implementation of various guidelines for clinical practice . EBM hadIn Norway, the links between EBM and EBP were institutionalized in 2004 with the establishment of the Norwegian Knowledge Centre for the Health Services (NOKC). The details of the process are described in an anniversary monograph . This orTo begin, we will describe our overall research design and strategy , followeThe case study was conducted in three phases. First, we searched for information describing the background, tasks, organizational framework, establishment, values and development of the NOKC to define the study context. In the second phase, we identified, organized and selected official publications from the NOKC, establishing an empirical sample of typical top-of-the-line knowledge deliveries adhering to EBM principles and standards. In the third phase, we explored the conclusions drawn in this type of publication, specifically addressing their potential as policy decision-making tools. Our analysis provided arguments for a critical discussion of EBP and its underlying assumptions.a need to enhance the underpinning of decisions in ministries, directorate and regional health enterprises to improve achievement of aims within health policy and encounter future professional challenges” [In Norway, adoption of EBM was officially enacted in 2004 with the establishment of the NOKC, an independent government unit administered by the Norwegian Directorate of Health . The estllenges”   knowledge synthesis (different types of SRs) and (2) monitoring  . Other aIn October 2014, we conducted a systematic examination of all publications presented on NOKC’s website, reflecting the organization’s tasks, priorities and knowledge deliveries. SRs complying with EBM standards were the highest-ranked delivery format ,11,29.To identify SRs from NOKC’s website, we applied the organization’s own taxonomy of publication types. From our searches, it became clear that publications other than those classified as SR also contained elements of SR methodology. This overlap with well-defined SRs was noticed in publications classified as health technology assessments, brief reviews and reviews with sorted literature. The most consistent EBM-compatible methodology was identified in publications classified by NOKC as SRs. Publications in this category from the period 2004–2013 were therefore chosen as a purposive sample from which to explore links and relations between EBM and EBP.The sample was organized to reflect the number and type of NOKC-produced SRs, contextualized in terms of total output during these years. As the NOKC webpages offered no consistent thematic classification of SRs, we developed four categories to provide a rough overview of health areas covered by these publications: (1) screening/diagnosis; (2) treatment/medication/vaccination; (3) prevention/psychosocial interventions; and (4) initiatives within health and social services. In March 2015, we noted that the NOKC had totally revised their website, including their classification of publication types. While we found complete agreement for lists of SRs for the period 2007–2013, our lists for the years 2004–2006 had to be adjusted to reflect the new NOKC scheme. While still providing relevant information for our purposes, we concluded that the quantitative accuracy of this approach to data collection would be moderate, while still providing relevant information for our purpose. However, it was no longer possible to sort the full range of publications by type, as the original taxonomy had not been consistently applied by the NOKC.We then conducted a formative qualitative evaluation  of SRs fThe summary of quantitative results below displays the number, proportion and distribution  of SRs from the NOKC. We then report our findings on the potential of these SRs in support of health policy decision-making.During the period 2004–2013, the NOKC produced 1,570 publications in total, including SRs, systematic literature searches, sorted brief reviews, reports from the Knowledge Centre, reports from GRUK , reports from PasOpp (patient experiences), memorandums, health technology assessments and other published material , trade unions for health professionals (n = 4), hospitals (n = 3) and the Norwegian Cancer Society (n = 1).Altogether, 57,368 studies were screened to produce a total of 351 studies for synthesis in 2012. The average number of initial records identified for each SR was 4,098 , and the average number of included studies for each SR was 25 (range 3–91). While most of the included studies were SRs, some used RCTs or observational studies as their point of departure ) concluded that extensive and high quality documentation had been identified. While the report identified a range of effective interventions, the language of caution again appeared . Another related SR, dealing with interventions regarding nutrition, physical activity, obesity and sexual health in children and adolescents (06-2012), reported that substantial documentation allowed the authors to draw some conclusions. Nevertheless, they expressed some reservations about the broad scope of the documentation, which meant that the recommended interventions were at a rather general level. For the remaining 12 SRs, the authors’ conclusions are characterized in every case by an overarching caution.A major task for the NOKC as an independent government organization is to provide knowledge that will underpin health policy decisions . InstituEBM was developed as a strategy to inform patient care as well as health policy decisions. We are not the first to suggest that the evidence hierarchy of EBM, which gives precedence to quantifiable and supposedly universal knowledge, may be too confined to meet the needs of clinical decision-making in respect of the individual patient ,34. ResiPope described EBM as a contemporary social movement with a high profile, although not overly successful . After aWe find it plausible that EBM principles applied in SRs that synthesize current research knowledge in a standardized and transparent format may well enhance clinical decision-making. However, the tool seems most appropriate and capable of providing a clear answer when the research question fits the hierarchy of evidence and the PICO formula ,12. A tyIn clinical practice, however, such clear-cut decision spaces rarely exist, especially in the primary healthcare setting, where multimorbidity is commonplace . This isOur exploration of EBM indicates its shortcomings as a tool for clinical practice, in that its universal and standardized evidence base fails to address the particular question and context for decision-making. These concerns are no less valid in assessing EBM as a tool for policy decision-making  . Dobrow the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and advancing people’s health” [Even with better research studies and more solid conclusions than those of our sample from 2012, policy decision-making processes demand much more than knowledge translation, defined by WHO as “ health” . This co health” ,54. Our Knowledge deliveries that repeatedly communicate a broad lack of quality evidence across most tasks may indicate the inadequacy of standard tools for a government unit commissioned to enhance decision-making. One hypothesis arising from our empirical analysis is that the NOKC  addresses too broad a range of inquiries, using too confined a range of tools. The main problem with the EBM approach is its restricted and simplistic approach to scientific knowledge . The stathe policy process itself as a contested area of negotiation” and “the messy, complex, and serendipitous nature of policymaking” [In a critical analysis of evidence-based policy research, Oliver et al.  concludeymaking” . Compariymaking”  argue thymaking”  SR of thWe believe that current EBM-based NOKC studies seek to provide a legitimate basis for health policy decision-making in Norway, and we endorse the idea that certain domains of inquiry may be well suited to such approaches. However, given the large proportion of recent NOKC deliveries that lack substantial conclusions, we must also reflect on the potential policy consequences of ‘empty’ knowledge deliveries. As a broad range of complex interventions cannot be adequately evaluated by the EBM format, there will be limited availability of ‘authorized’ research documentation, and SRs will be unable to offer strong conclusions about positive effects. This is not the same as documentation of negative or zero intervention effects. Often, the issues leading to SR commissions are controversial, and the delivery is expected to recommend a direction or choice. The present findings highlight the possibility of policy decision-making in which political interests (as in “this government does not want to support such a reform”) may be legitimized by SRs that draw weak or deficient conclusions, which are then interpreted as evidence-based warnings against the intervention in question. In this way, the EBM evidence hierarchy may actually contribute to concealing the foundation of policy decision-making rather than providing transparency.In this case study exploring selected publications from the NOKC, we have demonstrated that EBM is not universally suited to knowledge provision for every kind of health policy decision-making. Our analysis raises the question of whether the EBM, represented here by an independent government organization, undertakes too broad a range of commissions using a range of strategies that seem too confined. As far as possible, healthcare policymaking should be based on relevant and transparent knowledge, taking account of the context of the intervention. However, we do not share a belief that the complex and messy nature of policy processes in general is compatible with the standards of EBM.


There is an increasing interest worldwide to ensure evidence-informed health policymaking as a means to improve health systems performance. There is a need to engage policymakers in collaborative approaches to generate and use knowledge in real world settings. To address this gap, we implemented two interventions based on iterative exchanges between researchers and policymakers/implementers. This article aims to reflect on the implementation and impact of these multi-site evidence-to-policy approaches implemented in low-resource settings.The first approach was implemented in Mexico and Nicaragua and focused on implementation research facilitated by communities of practice (CoP) among maternal health stakeholders. We conducted a process evaluation of the CoPs and assessed the professionals’ abilities to acquire, analyse, adapt and apply research. The second approach, called the Policy BUilding Demand for evidence in Decision making through Interaction and Enhancing Skills (Policy BUDDIES), was implemented in South Africa and Cameroon. The intervention put forth a ‘buddying’ process to enhance demand and use of systematic reviews by sub-national policymakers. The Policy BUDDIES initiative was assessed using a mixed-methods realist evaluation design.In Mexico, the implementation research supported by CoPs triggered monitoring by local health organizations of the quality of maternal healthcare programs. Health programme personnel involved in CoPs in Mexico and Nicaragua reported improved capacities to identify and use evidence in solving implementation problems. In South Africa, Policy BUDDIES informed a policy framework for medication adherence for chronic diseases, including both HIV and non-communicable diseases. Policymakers engaged in the buddying process reported an enhanced recognition of the value of research, and greater demand for policy-relevant knowledge.The collaborative evidence-to-policy approaches underline the importance of iterations and continuity in the engagement of researchers and policymakers/programme managers, in order to account for swift evolutions in health policy planning and implementation. In developing and supporting evidence-to-policy interventions, due consideration should be given to fit-for-purpose approaches, as different needs in policymaking cycles require adapted processes and knowledge. Greater consideration should be provided to approaches embedding the use of research in real-world policymaking, better suited to the complex adaptive nature of health systems.The online version of this article (doi:10.1186/s12961-016-0089-0) contains supplementary material, which is available to authorized users. As the global health community is pushing for ambitious goals of universal health coverage and health equity in the post-2015 development era, there is an increasing interest worldwide to ensure evidence-informed health policymaking as a means to improve health systems performance . EvidencIn recent years, various strategies were developed and tested to bridge the gap between research and policy, largely focusing on knowledge translation (KT) . A numbePrevious research has shown that interactions between researchers and policymakers, timely access to quality evidence, and skills-building with policymakers increase the prospect of research findings being used in policy formulation , 19. Thewherein researchers pursue an area of interest and expect decision makers to readily alter policy in response to the results”  more confidence to address the claims of powerful experts in policy discussion” [In turn, the Policy BUDDIES initiative engaged sub-national policymakers working on chronic non-communicable diseases, nutrition and task shifting for antiretroviral therapy. In South Africa, provincial governments have constitutional obligations to respect laws passed at national level, yet sub-national policymakers can also develop their own context-specific policies within this framework . Provinccussion” , thus acIn Cameroon, the approach involved sub-national policymakers whose opportunities for evidence-informed decisions were hindered by long planning cycles and the concentration of authority at national level. Capacities of policymakers in finding and interpreting evidence were also identified as an important barrier to evidence-informed policymaking at sub-national level, in addition to lack of institutional support and incentives to use evidence . The difTacit knowledge corresponds to individual knowledge acquired by professionals throughout their everyday practice and experience and is distinct from explicit knowledge  as it is only occasionally shared in informal ways and contexts , 41. In As summarized in Table Both approaches also presented important commonalities in relation to collaborative processes, ownership of policymakers and continuity in the engagement between researchers and policymakers. The initial steps of the two approaches involved a mapping/scoping exercise as a means to assess the needs of policymakers. A strong participatory approach was also put forth in all settings, so as to foster equal partnerships and build a culture of trust among stakeholders. In addition, both approaches involved processes to ensure the robustness and validity of the evidence being used, including but not limited to concept mapping and assessment of scientific quality, as well as contextualisation of research findings. Due consideration was also provided to the relevance and adequacy of knowledge used in support of specific policy needs. Although the collaborative approaches were implemented in different settings and health systems across sub-Saharan Africa and Latin America, these similarities enabled the following cross-cutting lessons from common experiences at the interface between policy and research environments.perceived bias towards their findings” [a few big opinion formers, mostly professors, have their own research agendas” [In South Africa, policymakers mentioned that researcher buddies were perceived to be more neutral and objective than other internal and external academic and clinical experts involved in policymaking with a “indings” . The polagendas” . A similagendas” . The polThe positive outcomes identified in both the CoP and buddying approaches showed that the collaboration and iterative exchanges seemed better aligned to the evolving nature of policy planning and implementation. Traditional knowledge dissemination activities are mostly conceived as stand-alone endeavours, while complex and changing policymaking environments are more tailored to numerous interactions between research and policy stakeholders. The initiatives also made use of information and communication technologies to catalyse exchanges and collaborations among stakeholders, namely an online sharing platform (EZcollab) in South Africa and social media platforms in Mexico and Nicaragua. The use of information and communication technologies in intervention settings supported the synchronicity of policymakers’ demands with input provided by researchers. Such lessons learned about the usefulness of e-health technologies are crucial, as timely access to relevant research findings was reported as a compelling determinant of the use of evidence in health policymaking .The two pilot projects showed the crucial role of health systems champions and leaders, highlighting the importance of leadership development for both producers and users of research evidence to strengthen LMIC health systems. Motivated champions were key drivers of the ownership of policymakers and the engagement of parties in both the CoP and buddying approaches, and they played a pre-eminent role in stressing the value of science in policymaking. Hence, our findings are consistent with previous evidence underlining that engaged leadership is paramount to steward complex and pluralistic health systems .In addition to strengthening individual capacities in the policy arena, the two multi-site projects also highlight the importance of developing the researchers’ understanding of policy environments and their mindfulness of policymakers’ needs . StrengtBoth approaches showed that pathways through which research enters into policy are mediated by institutional arrangements that influence the interactions between policymakers and producers of research . In SoutThe evidence-informed policymaking approaches implemented in South Africa, Cameroon, Mexico and Nicaragua highlight the importance of cross-learning to integrate research into complex health systems policymaking. While the interventions were different in design, processes and, to some extent, target audiences and types of research evidence used, the commonalities in the multi-site experiences support cross-cutting lessons and conclusions, including the importance of trust- and relationship-building. Both approaches underline the need to develop an equal and continuous collaboration between policymakers and researchers in order to foster mutual understanding and benefits. In turn, such exchanges strengthen the capacities of policymakers to demand, appraise and use research evidence, while developing the researchers’ knowledge of policy realities and their ability to provide timely, appropriate support. In harnessing ongoing exchanges and collaborations between stakeholders, both the buddying and CoP approaches also challenge the vision of policymakers as passive recipients of ‘translated’ or synthesised research.The examined approaches stress the importance of developing fit-for-purpose interventions tailored to specific contexts and policy needs. In designing and implementing collaborative approaches to foster evidence uptake, due consideration should be provided to the type of evidence demanded by policymakers, the targeted steps in policymaking cycles, and the stakeholders’ competencies towards evidence-informed policymaking. In addition, this work highlights the need for an a priori mapping/scoping exercise, to understand the agency of the stakeholders in countering policy resistance and bringing about real changes in health policies and programmes. As such, interventions aiming to foster the use of research evidence should firstly engage in a thorough situational analysis to assess the capacities of policymakers to demand, appraise and use evidence in order to adopt and implement appropriate evidence-to-policy measures. The multi-site experiences also highlight the necessity to develop the capacities of both policymakers and researchers to engage on a continuous and timely basis.Although supporting evidence-informed policy by fostering peer-to-peer exchanges seems necessary, it also appears to be insufficient to continuously improve health policies and programmes. The two evidence-to-policy approaches suggest that adopting institutional rules and developing a supportive governance culture help incentivize evidence uptake. Due consideration should be provided to organisational and institutional arrangements to support evidence-informed policymaking, providing space to collaborative approaches such as buddying and CoPs. Health systems should also provide stronger incentives for dialogues between policymakers and researchers through formalised processes and enabling structures and environments. Formalised processes should include explicit incentives to demand and use evidence, as well as time and space for inter-linkages between policymakers.Research uptake does not follow a linear and deterministic pathway towards evidence-informed policy. Interventions implemented in real world policy-settings should be flexible so as to adapt to heterogeneous contexts and complex realities. Furthermore, approaches fostering the use of evidence should be embedded in continuous implementation cycles in order to account for the evolution of policymaking processes. Embedding the use of research would thus be more tailored to the complex adaptive nature of health systems, as put forth by the systems thinking literature applied to health systems strengthening –48. Fina


Landlord and Tenant Board hearing claims, counter-claims and defense by legal representation  as well as through mediation. Evidence in these hearings may include photographs, invoices for costs as well as testimony by tenants, landlords and “expert witnesses” who are most often pest control firms representing their landlord clients. A total of 44 Landlord and Tenant Board adjudicated cases available online were analyzed. The analysis included elements of the decisions such as adjudicator, claimant (landlord or tenant), basis of claim, review of evidence, amount of claim, amount awarded, and evaluation of the quality of the evidence. The results of the analysis of these findings are discussed. Recommendations for improvement of adjudicator decisions on the basis of knowledge of bed bug biology and Integrated Pest Management best practices are presented as well as the importance of education of tenants and landlords to a process of mutual trust, support and accountability.The resurgence of bed bugs in major urban centres in North America has resulted in conflict between landlords and tenants. This is commonly focused on attribution of blame for source of infestation, on responsibility, on costs for preparation, treatment and losses, and for compensation as rent abatement and/or alternative temporary housing. In Ontario, Canada, these issues are often decided by adjudicators at the  For example, in New York City it is reported that 83% of housing stock is rental housing . In ToroThe quality of multi-dwelling housing is often characterized in terms of quality of control of pests so that the terms “rat-infested” or “cockroach-infested” have been associated with poor quality and poor management of housing whether in the private or public sectors. Bed bugs are now on the top of the list in urgency as reflected in a survey published on the internet by Forbes showing the thirteen top infested cities in the U.S. based on number of service requests from data provided by the largest pest control firms . Prior tResolution of landlord/tenant conflicts in relation to bed bug infestations are addressed by various means including health department interventions, although some health departments considered bed bugs as a “nuisance pest” rather than a pest of public health concern and limited their involvement in addressing this issue . MunicipAlthough most landlord tenant regulation and bylaws as reflected in lease rental agreements do not speak to bed bugs specifically, the responsibilities of landlords and of tenants in these agreements are very similar across jurisdictions and nations . LandlorThe control of a pest is dependent on the behavior and actions of both the tenant and of the landlord. The tenant has accountability in terms of the upkeep of their home in a reasonable sanitary and housekeeping condition, and co-operation in treatment, and the landlord has a responsibility to all tenants to ensure that the site including the common elements is kept free of pests.The resurgence of bed bugs and the lack of understanding of society in general of management of bed bugs in various types of multi-housing dwellings including apartments, homeless shelters, hotels, motels, and university residences created a crisis that has manifested in an increase in litigation and claims due to bed bugs.In Ontario, Canada, Landlord tenant disputes are generally handled by an agency created for this purpose–the Landlord and Tenant Board (LTB). The purpose of the LTB is to streamline and facilitate resolutions ideally through a mediation/negotiation process and with the judgment of appointed adjudicators who hear claims and counter claims in cases in which mediation has failed. Not unlike other litigation processes, results of LTB decisions are based on presentation of claims with evidence and argument by lawyers or qualified paralegal agents. Some tenants qualify for legal aid, but many do not and may or may not be supported by a legal representative. The competence and the impartiality of the Adjudicator in reviewing evidence may also be a factor. The key participants in this process are not “expert” in pest management although “experts” may be called upon as witnesses in the dispute process. The purpose of this study was to review this process from available cases on the Internet. Each case comprised of the claims and defense and/or counterclaims of plaintiffs and the decision of the adjudicator. The initial motivation to undertake this study was the author's review of a small number of cases posted on the Ontario Non-Profit Housing Association website  in whichOntario Residential Tenancies Act, the Health Protection and Promotion Act, Ontario, and local municipal by-laws. These Acts and By-laws define responsibilities and requirements of landlords and tenants as well as of parameters by which the courts and boards render their decisions. The Acts do not generally relate specifically to the biology of one pest such as bed bugs, but function in a broader requirement relating to pests in general sometimes referred to as “vermin”.The purpose of this study was not to evaluate legal processes as this is beyond the scope of this analysis. The legal aspects of cases relate specifically to provincial and municipal legislation under the 2.Bed bug cases before the LTB  were rev2.1.Data was found by a search on the Canadian Legal Information Institute website  for case2.2.to condense extensive and varied raw text data into a brief, summary format;to establish clear links between the research objectives and the summary findings derived from the raw data and to ensure that these links are both transparent (able to be demonstrated to others) and defensible (justifiable given the objectives of the research); andto develop a model or theory about the underlying structure of experiences or processes that are evident in the text data.In order to evaluate these decisions in 44 cases, it was necessary to establish a qualitative evaluative process. Our approach followed the basic principles of Inductive Qualitative Analysis as outlined by Thomas  as folloWe evaluated the basis of adjudicator decisions in relation to the biology of bed bugs, and known factors of their spread, of detection, and of their control and prevention. As this study was not a field evaluation of specific cases, the evaluations were based on presented evidence documented in the cases, and on the decisions of adjudicators on the basis of this evidence. The evidence is described by most adjudicators within the summary of the case and includes a brief summary of presented evidence by claimant and defendant against claim as well as that of any “expert” witness. Outcomes of cases were analyzed simply in terms of outcomes for claimant or for defendant (sometimes as counter claims), or for both. The rating of the decisions was based on a number of evaluative factors. Six elements were selected for scoring. These were Cause, Detail Claim, Evidence, Expert Testimony, Missing, and Evaluation. Scoring was based on a simple pass, fail or neutral rating. . The scores were tallied. A score of 0 or less was rated as a fail. This was directly related to how evidence and expert witness testimony impacted decisions, and if the decisions were reasonable based on the evidence. In some cases, outcomes were not particularly useful to advance control, but adjudicators are not pest management professionals and are limited within the legal framework although decisions can influence subsequent actions by landlords and/or tenants especially through mediation.3.3.1.As shown in 3.2.Expert witnesses were utilized in 19 cases . In all 3.3.LTB decisions are based on the assessment of the facts by adjudicators. The LTB's purpose is to offer fair judgments based on the Residential Tenancy Act and the Health Protection and Promotion Act of Ontario. The intention of the LTB is to enable tenants and landlords to protect their interests through enforcement of the provisions of these laws without the need to resort to costly processes in the courts. Tenants may also call upon Municipal Property Standards or Public Health units; however, they are encouraged to use the LTB due to the ability to facilitate decisions that are binding, or to enable mediation that is also enforced by the board. Most of the issues facing the Board involve the key elements of maintenance, of enjoyment of the premises, and of the responsibilities of landlords and of tenants to one another, and to other tenants in their lease agreements. Pest control issues are more complex than most other maintenance issues as successful control in an individual apartment and in the entire building hinges on actions of tenants, of landlords, as well as of pest control firms, health units, and other agencies. The Adjudicator with a long docket of cases is under pressure to render a fair decision in a relatively short timeframe, and to present this on the basis of a fair evaluation of the evidence in relation to the appropriate statutes.It appears from these results that 71% of cases were well evaluated with reasonable decisions based on the entomological/pest management evidence, however, 12 of the decisions (27%) were adjudged not to pass on the factual bases as presented in the cases . In case“During cross-examination, Witness #3 gave a detailed explanation of the manner in which bedbug infestations occur. He advised that bedbugs do not exhibit the same travel patterns as cockroaches. Cockroaches will travel extensively throughout a building using electrical and plumbing conduits; however, bedbugs travel exclusively with a host and as a result are spread by people moving either themselves or their belongings from one lodging to another. Witness #3 was emphatic and unshakeable in his evidence that bedbugs do not generally move from one unit to another without a human carrier…”In another case (86704), the adjudicator considered that either the presence of infestation at some level as a pre-existing condition, or the failure of elimination were not sufficient grounds to terminate the lease as this was a common occurrence. In this case, the adjudicator considered that the unit was indeed infested prior to the tenant's move in. In spite of these findings the adjudicator stated in their analysis of the case that “Further, in my view, the steps taken by the Tenant were an over-reaction to a common and entirely resolvable problem. It was unnecessary for the Tenant to vacate the unit”. The landlord's agent indicated that all vacant units were fogged as a routine practice whether infested or not. This is an illegal action in the absence of infestation, and is considered a substandard practice by industry at large and Provincial Ministry of Environment Senior Scientist . Other aSpread of bed bugs between units in a building is a well known fact . UnfortuIt appeared even in this failed adjudication that the adjudicator did try to give a fair decision; however, the adjudicator did not understand the facts or what should be considered an acceptable state for a tenant at moving into a unit. This was based on an interpretation of “habitability”. The adjudicator noted that “The ‘fit for habitation’ standard does not mean that the premises is literally impossible to live in; rather, the test will be whether the premises meets current standards of decent accommodation”. I think most would agree that the presence of bed bugs does not comprise “current standards of decent accommodation”. These considerations are beyond scope of this study, however, knowledge of the impact of bed bugs, difficulty of control, and the expectation of a tenant to take possession of an un-infested premises were absent in this case.In another case (13390), the adjudicator supported landlord paying for accommodation for a pregnant tenant due to recommendation that they not be present in the unit after treatment for 24 h. This may set a precedent in future cases. In case 13393, the adjudicator adjudged the landlord's response to tenant concerns as “prompt, reasonable and professional” although there appeared to be chronic pest problems with mice, roaches and bed bugs. This was mitigated by the testimony that the tenant had not prepared the unit properly for treatment, however, the findings suggest that there were pre-existing infestation issues in the building. In addition, the female tenant was more than 8 months pregnant. This added concern and complexity and may have required accommodation. Some of the recommendations that the landlord made such as vacuuming for dead mice were not professional by any reasonable standard of pest management practices. The outcome of this case could have been different had the adjudicator been provided better evidence and facts, or had the tenant been represented by legal support.4.Most of the adjudicators in these cases were able to render fair decisions in a situation of conflict in which the majority of the expert witnesses represented the interests of landlords. The outcomes of cases were balanced between awards to tenants and validation of landlord claims, which were mostly about rent arrears and/or preparation issues. Unfortunately, 27% of adjudicator decisions were not rated as highly and were considered failures on the basis of the evidence in relation to the biology and pest management of bed bugs. In a workshop on bed bug management through Integrated Pest Management (IPM) held in Toronto , two legAs the cases focused on claims by specific tenants and landlords, there was little consideration given to the overall status in a site excepting evidence by the parties pertaining to the case, and in none of the cases was there any direction for follow-up at a housing site as this was out of scope of the LTB, nor were there any cases in which human rights in relation to accommodation were addressed. These are important issues which can influence abilities to control bed bugs. It is presumed that adjudicators will address such issues as in the case of a tenant who is unable to prepare for treatment and is under risk of eviction, so that the LTB can facilitate appropriate links to resources to assist in these cases, and that landlords will better understand reasonable accommodation in such instances. The Human Rights Code in Ontario requires reasonable accommodation for tenants who for reasons of health, or disability are unable to prepare. Pregnancy may fit into this category as well due to difficulty of preparation and health concerns. Landlords may need to act as facilitators in order that accommodation is provided.This review emphasizes the importance of a societal response to the bed bug resurgence as noted by the Joint Statement of EPA/CDC on the bed bug resurgence . Further


The value placed on types of evidence within decision-making contexts is highly dependent on individuals, the organizations in which the work and the systems and sectors they operate in. Decision-making processes too are highly contextual. Understanding the values placed on evidence and processes guiding decision-making is crucial to designing strategies to support evidence-informed decision-making (EIDM). This paper describes how evidence is used to inform local government (LG) public health decisions.n = 175). To further explore definitions of evidence and generate experiential data on EIDM practice, key informant interviews were conducted with a range of LG employees working in areas relevant to public health.The study used mixed methods including a cross-sectional survey and interviews. The Evidence-Informed Decision-Making Tool (EvIDenT) survey was designed to assess three key domains likely to impact on EIDM: access, confidence, and organizational culture. Other elements included the usefulness and influence of sources of evidence (people/groups and resources), skills and barriers, and facilitators to EIDM. Forty-five LGs from Victoria, Australia agreed to participate in the survey and up to four people from each organization were invited to complete the survey  was deemed to be useful in public health decision-making.In total, 135 responses were received (75% response rate) and 13 interviews were conducted. Analysis revealed varying levels of access, confidence and organizational culture to support EIDM. Significant relationships were found between domains: confidence, culture and access to research evidence. Some forms of evidence (e.g. community views) appeared to be used more commonly and at the expense of others (e.g. research evidence). Overall, a mixture of evidence  was This study makes an important contribution to understanding how evidence is used within the public health LG context.ACTRN12609000953235.The online version of this article (doi:10.1186/s13012-014-0188-7) contains supplementary material, which is available to authorized users. As a concept, evidence-informed decision-making (EIDM) refers to the process of combining a range of sources of evidence to inform a decision -3. In prThree tiers of government operate in Australia: Commonwealth, State and Local. Local governments (LGs) operate locally meaning government of a town, city or region involving locally-elected officials. LGs are responsible for various local functions including planning and building approval (e.g. zoning of land), roads and parking, recreation and culture , community services , waste management and local laws. As such, LGs are similar to provincial public health departments in Canada and local authorities in the UK. Individuals working in LG public health teams come from very varied educational and professional backgrounds such as environmental science, sport and recreation, social planning, in addition to health promotion and public health specialists. This differs significantly from other jurisdictions dominated by medically trained public health practitioners (Canada and UK).The objectives of this study were to identify the types of evidence used within LGs and to explore their relative contribution to the process of EIDM. The information garnered contributes to global knowledge about EIDM and informed the design of an exploratory cluster RCT (Knowledge Translation for LG—KT4LG) to be implemented in Victorian LG .In order to explore the diverse research questions scientifically, a mixed-method design was applied; these are characterised by a series of projects complete in themselves but related to an overall project aim . Data arThe overall theoretical approach for this study was informed by the Evidence-Informed Policy and Practice Pathway (EIPPP)  which waDiffusion of innovations theory was used to help understand how EIDM might spread within these stages of the policy process and so informed Evidence-Informed Decision-Making Tool (EvIDenT) survey development and interview question design. It is increasingly used to help explore how ‘innovations’, which could be (depending on the perspective) research ideas or policy ideas, spread amongst individuals and organizations ,14,15. MInformed by previous work ,25, EvIDLG was chosen as the setting for this study having an increasing emphasis on preventive health . Given tpublic health planning, policy or programs and who represented diverse work areas. Follow-up phone calls were necessary to confirm participation and to ensure organizational consent and nomination forms were completed. Nominated employees within the LGs were emailed the plain language statement and a link to the online survey, which had an individual consent form built-in.All 79 LGs across the state of Victoria, Australia, were invited to participate in the EvIDenT survey. Chief executive officers (CEOs) were mailed an information kit, outlining the intent of the project, the requirements of participation, a plain language statement about the study and an organizational consent form. Participating councils were asked to nominate up to four employees who were involved in The sample for the interviews was drawn from survey participants who had nominated their interest in interview participation. During survey completion, all individual participants were asked to indicate their willingness to participate in an in-depth interview. Potential participants were invited by email within 2 weeks of survey completion.Ethical approval was granted by the University of Melbourne Human Ethics Sub Committee [722362].Survey data were entered online by participants directly between November 2008 and April 2009 . After tInterviews were conducted by phone (by RA) and lasted between 45–70 min. Interviews focused on the implementation of EIDM, including defining evidence, and practices and processes for evidence-informed public health. Probes were used to stimulate discussion and clarify previous responses, for example: How is evidence defined by you? Does this differ from how it is defined by your organization? Although there was a theoretical structure for the content of the interviews, they did aim to establish a sense of reciprocity with interviewees in order to uncover and construct meaning of EIDM in this context. All interviews were digitally recorded and professionally transcribed.Aligned with a concurrent triangulated research design, the overarching data analysis framework was parallel mixed analysis . The quaQuantitative data were analysed using Stata 10.1 . DescripAll analyses were adjusted for clustering effects due to nesting that may have been caused by individual respondents being located within organizations (LGs). Intra-cluster correlation coefficients were also used to examine the correlation of individual responses from the same organizations  to identThe tools psychometric properties were explored. The methods and result of this analysis is reported elsewhere .Regression models were used, including organization (LG) as a random effect to account for clustering, to test for a linear relationship between domain scores and key variables (e.g. culture and budget). Random effects regression models were used as the analysis was interested in the variance across both organizations and individuals.To ensure immersion in the qualitative data, each interview was reviewed three times (RA). Interviewees were also sent their transcripts for review, and any errors in the transcripts were amended. Qualitative data were then imported into spreadsheets for coding, sorting and organizing . Open con = 22, 49%) and metropolitan  LGs, representing most metropolitan LGs in the state  and nearly half of all regional LGs . As expected, sample characteristics such as budget, population size and geographic region size varied considerably . The sample included similar number of rural . Characteristics of individual respondents from all 45 participating LGs are shown in Table Ninety-eight people volunteered to be interviewed and 19 people were contacted using a sampling framework built previously using maximum variation sampling techniques to identify various decision-making experiences . Of thesThe EvIDenT survey did not ask participants to define evidence. Rather, it provided broad definitions as response options and focused on research evidence, which was defined for the purposes of clarity.Interviews provided insight into how evidence was defined by both individuals and their organizations. Analysis revealed a lack of consensus amongst interviewees about what constitutes ‘evidence’. Evidence was defined across a spectrum encompassing academic research, local research and evaluation, policy documents, population level or local data, community views, collegiate expertise and professional experience. In most cases, interviewees cited a combination of sources as forming an ‘evidence base’ to inform decision-making, for example community views plus academic research and local data. There was a strong focus on ‘evidence’ as defined by population-level data including census data and burden of disease data. Academic research was considered by many respondents as a crucial form of ‘evidence’. Interestingly, many participants struggled to provide a clear definition of evidence.Participants were asked to identify whether their own perceptions of evidence were shared by their organization. Whilst some felt that there was shared clarity around what constituted evidence across the organization, others felt the definition differed, depending on which department they worked in or on their level of seniority within the organization.Ultimately the consultation phase is the key, or what we are told by services or by community groups is where we focus our activities’ [KI11].Interviews also revealed the different types of evidence used to inform the development of priorities versus the development of strategies . Population-level data  were commonly used to inform priority setting, either sourced at the start of a planning process, simultaneously with or after community consultation. Strategy development appeared to be a more collaborative process, including consultation and data gathering. ‘Whilst the interviews explored experiences with evidence and the processes of EIDM in LGs, the survey aimed to determine levels of access to evidence, confidence in finding and using evidence, and LG culture for EIDM . Levels of reported confidence in searching for academic literature and assessing the quality or trustworthiness of sources of evidence varied. For example, whilst 26.0% reported high levels of confidence (scoring 6/7) in searching for academic literature more than a third (32.8%) had lower levels of confidence (scoring 1–3). Confidence was not discussed in the interviews.Some of the bigger—bigger strategies, you know, the health and well-being plan, broad service strategies …All of those things definitely have to delve into the research. You have to have it well referenced’ [KI18]. However, this did not often appear to be written down or formally enforced. In other LGs, there was limited imperative to use research evidence: ‘So there is no real need to produce rigorous, you know, peer reviewed programs and services …I like that in some ways. In other ways it’s a bit of a shame that there is no-one really monitoring this stuff’ [KI8]. For some interviewees, a lack of organizational culture supporting EIDM did not appear to stop them using evidence in internal decision-making.Respondents generally reported a moderate to high organizational culture for supporting EIDM. However, when asked for overall ratings of organizational culture, a quarter of respondents provided low ratings  suggesting some variation in responses between LGs. The culture of EIDM was discussed extensively in the interviews. The interviews revealed that there appeared to be an expectation in some LGs, or within some teams, that evidence be used to inform decisions. For example: ‘Evidence-based stuff is certainly bandied around in the health area. Less so in other areas. But I don’t know that it’s well understood what that means. You understand the words but you don’t understand the implications… [so] the understanding is that it’s valuable and it’s needed but the link between how it actually informs the policy or the outcome, there’s a real gap’ [KI11]. Organizational support was also linked to time and ‘so whilst it is certainly important, it is the first thing to fall off the list of things to do’ [KI11].Whilst many of the interviewees noted increasing acknowledgement of the need to practice EIDM within LGs, there did appear to be rhetoric associated with its use. As one interviewee noted: ‘If you understood why you have evidence, there wouldn't be a question of you practicing it’ [KI3].Interestingly, the culture associated with conducting and using internally generated evaluation findings to facilitate EIDM in councils appeared to be limited. Interviewees were asked more specifically about this relationship, and there was general agreement about the link between a culture of evidence and EIDM: ‘p = <0.01); where culture was rated highly, confidence was also likely to be rated highly (p = <0.05); and where culture was rated highly, levels of access were also likely to be rated more highly (p = <0.01).Linear regression, where LG was fit as a random effect, was also used to test for relationships between composite scores within each of the key domain areas . This analysis revealed significant linear relationships between key domain areas  = 1.023, −.631) and access . There was however no statistically significant relationship between skills and standardized organizational culture scores .Survey respondents were asked to identify whether they had participated in training that helped them to make judgments about the quality of research evidence. Half of respondents (50%) had participated in training program/s; however, many had not (41%) or were unsure (9%). Those who had undertaken critical appraisal training had a higher mean confidence summary score compared to those who had not. Regression analysis revealed a statistically significant linear relationship between skills and standardized scores for confidence (Skills (or a lack thereof) and skills development were a core theme of the interviews. Limited opportunities for professional development around EIDM for council staff and executive were apparent. Only one interviewee described having undertaken any relevant training. To address this lack of skill, consultants were often used to develop LG plans. A need for further professional development and accreditation or standard of skills was discussed.Survey respondents were asked to rate the influence and usefulness of a range of people/groups and resources in informing public health decision-making.greatest influence were councilors, CEO, public health managers  and the community. Academics were rated as having the least influence. Public health managers were rated the most useful people/groups in public health decision-making, and personal experience and the community were also highly rated. Least useful were councilors and advocacy/lobby groups. For nearly all people/groups rated, there were statistically significant linear relationships between the way influence and usefulness was rated. The exception was for councilors, who appeared to be more influential than useful in decision-making.People or groups with the influential resource in public health decision-making. Government reports were also highly rated. Similarly, the most useful resources were government reports, LG policy by-laws, and non-government reports. The least influential resources were academic reports and journal articles, and general published literature. The least useful resources were general published literature and newsletters/bulletins or online alerts.LG policy, plans and by-laws were the most most influential on public health planning decisions (93.9%). Of these, 55.7% favoured a mixture of evidence with ‘more internal than external’ evidence. There was no impact of clustering (measured by intracluster correlation coefficient (ICC)) upon the variability in the views of respondents within LGs (ICC = 0.00). That is, individuals within LGs were differentially influenced by internal, external, or a mix of influences.To summarize views on ‘influence’ and ‘usefulness’, respondents were asked to identify the types of evidence that have the greatest influence or those of most use in decisions. A ‘mixture of evidence’ was commonly reported as being most useful for informing public health planning decisions (94.6%). Of these, 56.1% favoured a mixture of evidence with ‘more external than internal’ evidence. Again, there was no impact of clustering on the identified variability in the views of respondents within the same LG (ICC = 0.00). The individual variation in responses to this question within LGs suggests that individuals may find evidence more or less useful than others within the organization.Similarly, a mixture of evidence was commonly reported as being The interviews also revealed a number of influences on decision-making, which were categorized as direct and indirect influences  and barriers and facilitators (dependent variable) to EIDM. A number of significant relationships were identified  and so increasing awareness of these resources may alter these perceived levels of access. Survey results revealed strong correlations between access, confidence and organizational culture. This suggests that interventions to support EIDM may be strongest when each of these elements is collectively addressed. Given that a lack of training was a barrier to EIDM, workforce development should be considered for LG staff particularly those in management, which may help create a stronger culture for EIDM within teams. Activities that promote meaningful exchange between researchers and decision-makers may also assist in expanding EIDM culture within organizations ,48,49.Culture emerged as an important issue in supporting EIDM. This is an ongoing challenge for organizations where clear processes are not in place to guide staff on how to source, appraise and combine different sources of evidence to decide on interventions . This laand useful included council policy, plans and by-laws and government reports; whilst academic reports, journal articles and general published literature were reported to be the least influential when making decisions about decision-making within their LG. Public health managers and the community were identified as both useful and influential.This paper presents an emerging picture of decision-making within LG. The EvIDenT survey identified the degree to which different forms of evidence are useful and influential. Influence is well described in the literature and can emanate from both internal and external sources ,20,51. Winternal than external evidence, was influential in public health decision-making in LGs. By comparison, a mixture of evidence, but more external than internal evidence, was deemed to be useful in public health decision-making. This suggests that internal evidence, which may not be tested for rigour, may be more influential in LGs. Participants recognized the usefulness or importance of external evidence in guiding decision-making. Research using these concepts is not available in comparable populations [We also chose to differentiate between internal and external evidence, defining internal evidence for participants as organizationally derived evidence, including organizational data and community opinions. External evidence was defined as peer-reviewed research or policy frameworks from other contexts. Overall, a mixture of evidence, but more ulations . Interviulations , but theulations . This liThe barriers to EIDM have been well documented and include time, access to resources, organizational culture, political influences, and skill in finding and using research evidence ,19,53,54This study benefited from the use of mixed methods design and analysis. The concurrent studies presented a detailed overview of the decision-making processes undertaken in LG. The survey revealed new data about access to evidence, confidence in using evidence and organizational culture for EIDM in LG. The interviews helped to explore the influences on these domains.This study involved 135 participants drawn from 45 LGs . Even so, this presents issues for broader generalisability of these findings. Those who completed the EvIDenT survey may have had more interest in EIDM processes, which could account for moderate to high levels seen in scores. Despite the small sample, the commonalities identified in responses across LGs indicate that those outside of the study sample may share many of the issues described in this study. Further research with a larger sample may provide a more complete picture of how EIDM operates . Given tWhilst the EvIDenT survey was not tested for reliability, it was extensively piloted. Given the complexity of decision-making in policy contexts, the use of survey methodology presented some challenges in terms of gaining a complete picture of current activity. This was resolved by incorporating a qualitative component.The findings from this study describe how evidence is defined and used in a multi-sectoral LG setting. Government policy has articulated the need for evidence to inform local policy and planning, and the importance of EIDM in public health is acknowledged as important to improve population health. However, the results demonstrate that there is much to be done to build organizational culture to support EIDM practice.The EvIDenT survey is one of few tools developed to enable exploration of EIDM in a community-based public health setting. It was designed to help explore how evidence is used within LG; to summarize the usefulness and influence of a range of sources of evidence and provide insight into how research is accessed, the level of confidence associated with research use, and the extent of an underlying organizational culture of EIDM. Given the breadth of the questions, it is likely to have broader application beyond LG.The findings presented in this paper provide a unique picture of how LGs make public health decisions. The results highlight the influence of some forms of evidence (e.g. community views) at the expense of others (e.g. research evidence). This suggests the need for enhanced organizational and system-level support to improve levels of access and confidence in using research evidence. Increased transparency requirements may encourage the consideration of various sources of evidence. Stronger organizational culture may result from such measures but may require more targeted interventions at either a state or regional level.Redressing the challenges to the use of evidence in LG decision-making identified in this paper is complex. The decision-making process will always be political and the time pressures for staff will always be significant. Building a stronger normative culture for EIDM is needed to ensure that decisions relevant to population health outcomes are adequately informed by research evidence, an expectation that would be considered standard in any other contexts where health outcomes are affected.


The aim of the study is to conduct an overview of systematic reviews (SRs) to provide a contemporary review of the evidence for delivery of Traditional Chinese Patent Medicine (TCPMs) for patients with acute ischemic stroke.SRs were assessed for quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Oxman-Guyatt Overview Quality Assessment Questionnaire (OQAQ). We assessed the quality of the evidence of high methodological quality (an AMSTAR score ≥9 or an OQAQ score ≥7) for reported outcomes using the GRADE  approach.(1) Dan Shen agents: tiny trends toward the improvement in different neurological outcomes ; (2) Mailuoning: a tiny trend toward improvement in the neurological outcome (RR = 1.18); (3) Ginkgo biloba: tiny trends toward improvement in the neurological outcome ; (4) Dengzhanhua: a tiny trend toward an improvement in neurological (RR = 1.23); (5) Acanthopanax: a small positive  result on neurological improvement reported; (6) Chuanxiong-type preparations: neurological functional improved (MD = 2.90);(7) Puerarin: no better effect on the rate of death or disability ; (8) Milk vetch: no better effect on the rate of death ;(9) Qingkailing: rate of death reduced . Limitations in the methodological quality of the RCTs, inconsistency and imprecision led to downgrading of the quality of the evidence, which varied by review and by outcome. Consequently, there are currently only weak evidences to support those TCPMs.The 9 TCPMs may be effective in the treatment of acute ischemic stroke, as the GRADE approach indicated a weak recommendation for those TCPMs’ usage. The Chinese National Essential Drug (CNED) , the Pharmacopoeia of the People's Republic of China (PPRC) (2010 edition), and the China Food and Drug Administration  list a variety of TCM preparations (mixtures of multi-herbs) subjected to a relatively strict drug evaluation process and widely used in current clinical practice for stroke in China. These TCM preparations are defined as TCPMs. TCPMs in CNED and PPRC represent the most important therapies listed by the China government, that may ameliorate the microcirculation are regularly used in acute ischemic stroke patients for >30 years. Nowadays, apart from aspirin and thrombolytic treatment with recombinant tissue plasminogen activator, no routine effective, generally accepted, specific treatment was applied for acute ischemic stroke. Assessment and confirmation of the effectiveness and safety of TCPMs, therefore, could have a significant impact on stroke management all over the world.Stroke is the second most common cause of death in the world and the third most common cause of disability.8 The portfolio of SRs has played an important role in informing evidence-base policy for Traditional Chinese Medicine (TCM) nationally and internationally.5 In spite of the availability of numerous publications regarding the use of TCPMs in stroke, the evidence from these SRs has not been evaluated systematically. Overview of SRs is designed to compile evidence from multiple SRs  of interventions into 1 accessible and usable document, allowing the reader a quick overview of reviews relevant to a specific decision.9 Overviews can also help inform the strategic direction of conduct and structuring of future SRs and provide an opportunity to identify potential ’evidence gaps’. Typically, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approah10 is applied to rate the quality of a body of evidence in SRs and to determine the strength of recommendations during the overview process.13 The GRADE system clearly distinguishes between the quality of evidence and the strength of the recommendations and takes into account factors in addition to evidence to suggest appropriate therapeutic approaches,11 resulting in recommendations for or against an intervention based on whether the potential benefits of said intervention outweigh the potential harm caused or burden imposed by the intervention, as well as patient values and preferences.In the hierarchy of evidence-based medicine (EBM), systematic reviews (SRs) of high-quality randomized controlled trials (RCTs) are considered the best evidence regarding specific healthcare interventions.To summarize evidence from >1 SR of different TCPMs in acute ischemic stroke, we conduct an overview in the first time that can be used by clinicians and policy makers in making decisions about the TCPMs.14 Ethical approval is not necessary for this overview research design.This overview was conducted on the basis of the recommendations for Cochrane overviews.Cochrane or non-Cochrane SRs of RCTs reporting outcomes with quantitative analyses were included. Data from original RCTs presented in >1 included SR were only analyzed once in this overview.15 regardless of gender, age for severity of neurological deficit.Ischemic stroke patients at acute stage (onset within 2 weeks) with any severity, either (1) diagnosed by brain magnetic resonance imaging (MRI) or brain computed tomography (CT) scan or (2) diagnosed corresponding to the World Health Organization definition,http://www.sda.gov.cn), and approved by the China Food and Drug Administration  were included in our research. Either (1) comparison of a TCPM with placebo or routine treatment (2) or comparison of a TCPM plus routine treatments versus routine treatments alone was included.TCPMs (mixtures of multi-herbs) listed in the PPRC (2010 edition), the CNED . The 2 categories of outcomes, critical, and important were included in the evidence profile.10A panel of 12 experts from our hospital specialized in neurosurgery, neurology, cardiovascular disease, and TCM was convened. This panel collected a priori as many important outcomes related to stroke as they can. Subsequently, they assessed numerically from 1 to 9 points to each outcome on the basis of their clinical importance  and recorded their judgments privately. In general, these outcomes of patient interest, long-term direct outcomes, as well as specific measures related to TCPMs, were considered as important or crucial outcomes. We statistically aggregated the individual judgments to derive the median score of each outcome. Subsequently, the importance of each outcome was classified. On the basis of their importance regarding clinical decision making, outcomes were specified as 3 categories: limited importance (median score = 1 to 3), important but not critical (median score = 4 to 6) and critical (median score = 7 to 9)16 (from inception until September 2014); the resources are showed in the supplemental material.We searched the “preappraised” evidence resources We also searched the following databases from their inception until September 2014 (both MeSH and free-text terms were used): Ovid Medline, Ovid Embase, the Cochrane Database of Systematic Reviews, Psych-info, ScienceDirect, Wanfang Database, the Chinese Biomedical Literature Database (CBM), the China National Knowledge Infrastructure/China Academic Journals Full-text Database (CNKI), the TCM Database and the Chinese Scientific Journals Database (VIP). Search terms were incorporated to target stroke and SRs but intervention-specific search terms were not included since we wished to identify and include SRs of any of the TCPMs. No language restriction in the process of study search. The Medline (Ovid) search strategies are listed in Appendix 1 and were appropriately modified for both the Chinese databases using Chinese terms and other databases.We hand-searched the lists of references for all eligible SRs and relevant clinical guidelines. We also contacted the authors if the data were not reported sufficiently in the SR.http://www.strokengine.ca/best_practice/acupuncture-best-practices/), Open-SIGLE (http://www.opengrey.eu/), PsycEXTRA (http://www.apa.org/psycextra/), and the National Technical Information Service .Grey literature resources were also researched: Stroke Engine (Two authors (Zhang X and Liu XT) independently screened the search results. Initially, the titles and abstracts of identified studies were reviewed so that irrelevant studies were excluded.Then the full texts were searched and checked to confirm their eligibility. Kang DY, the third author, reviewed the full text to determine eligibility in cases of disagreement.17 and the Oxman-Guyatt Overview Quality Assessment Questionnaire (OQAQ),18 were used by 2 authors (ZX and LXT) independently to rate the methodological quality of those included SRs. The quality scores were calculated in keeping with the methods and principles applied in previous researches21 for both these 2 tools as follows: 1 point was awarded when the answer was “Yes”; otherwise, 0 points were awarded. The total scores were obtained. Moreover, the reporting quality was rated by utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).22 To screen the SRs of high methodological quality in accordance with the “Canadian Agency for Drugs and Technologies in Health” (CADTH),23 we rated the SRs as “high” (range 9–11), “moderate” (range 5–8), or “low” (range 0–4) quality on the basis of overall score of AMSTAR. Studies were also assessed as being high-quality if their OQAQ overall score were ≥7. The SRs with high methodological quality were filtered into the process of data collection. Any questions occurred throughout the rating process were resolved by frequent discussions. We described the agreement validation and reliability our previous research.24Two tools, “A measurement tool to assess the methodological quality of systematic reviews” (AMSTAR)Standardized data collecting forms, which were piloted on 2 SRs included in this overview, were utilized to extract data from SRs and original RCTs. One author (ZX) extracted data and a second author (LXT) examined the all extracted.We extracted the following information from SRs: the sample sizes of each group, assessment of methodological quality, inclusion and/or exclusion criteria  and TCM syndrome classification. The risk of bias of RCTs within included SRs was not reassessed, but instead reported keeping to the SR authors’ judgment. One researcher (ZX) rated the original RCT publication when any “Risk of bias” items were not reported in the SR and then a researcher (LXT) reassessed and checked. The following data of original RCTs were extracted: characteristics of the participants, interventions, comparisons performed and outcomes and total duration of study.We contacted the authors of the SRs or the original study reports in the event that the required information could not be extracted from the reports. We resolved disagreements through consensus with a third author (Kang DY).10 was used to rate the evidence quality for each type of TCPMs, and each outcome.The results related to the critical or important outcomes of the SRs initially recognized to being high-quality (an AMSTAR score ≥9 or an OQAQ score ≥7) evidence were used to construct the whole body of evidence. The GRADE approach10For each SR, Zhang X  and Kang DY  learned using the GRADE approach during the 22nd Cochrane Colloquium . These authors utilized the GRADE tool independently to evaluate the evidence pertaining to key outcomes. The quantitative data were analyzed to determine the whole quality of the evidence determining specific recommendations in the GRADE approach. The criteria by which evidence may be downgraded or upgraded depend on 5 methodological domains referring to risk of bias, consistency, directness, precision, and publication bias and the overall quality of the whole evidence  as well.10 The strengths of the recommendations were classified as strong recommendations and weak recommendations . The following 3 key factors determine the strength of the recommendations: best estimates of the effective magnitudes on both positive and negative outcomes, importance of the outcomes, and confidence in the magnitudes of estimates of the effects of the TCPM on the crucial or important outcomes.10The second component of the GRADE approach entailed the determination of the strength of the recommendations, that is, the extent to which we were confident that the positive effects of the TCPM outweighed its negative effects or vice versa.25 and both assessment of the evidence quality and strength of the recommendations was conducted on the GRADE pro.26 We planned the calculation of the inter-rater reliability (Kappa coefficients)for each GRADE domain and the overall quality of evidence if sufficient SRs were included.We defined the analyzed unit for our research is the SRs . For continuous outcomes, we summarized data using the mean difference (MD) with 95% confidence interval (CI). For dichotomous outcomes, we presented the risk ratio (RR) or odds ratio (OR) and its 95% CI as appropriate. For the clinical heterogeneity among the included SRs, we did not seek to compare results across RCTs applying indirect methods such as network meta-analysis. The data were entered into EpiData 3.1The detailed literature search process and the reasons for exclusion of the studies are included in Figure The 9 included SRs covered 83 RCTs . The following 9 TCPMs were overviewed in the SRs and varied in, frequency, duration, intensity, and comparisons: Dan Shen agents, Mailuoning, Ginkgo biloba, Dengzhanhua, Acanthopanax, Chuanxiong-type preparations, Puerarin, Huangqi, and Qing Kai Ling (Qingkailing). The characteristics including outcome measures, the effects of the interventions, the risk of bias assessment of the included RCTs and SRs are summarized in Table 10 of Dan Shen and the low or very low overall quality of evidence regarding outcomes were more likely to warrant weak recommendations of Dan Shen agents as combined therapies for acute ischemic stroke , outcomes pointing in different directions (toward both favors Mailuoning and controls) and the very low overall quality of evidence were more likely to warrant weak recommendations of Mailuoning for acute ischemic stroke  was randomized, placebo controlled and double blind. An envelope used for keeping secret of the drug coed was utilized, which satisfied adequate concealment of randomization. However, 4 and 3 patients were lost to follow up in the Ginkgo biloba and control group respectively; these 7 patients were not excluded. Moreover, this RCT did not use ITT analysis. As a result, the quality was downgraded for this outcome. Moreover, we downgraded the quality of the evidence of this outcome for imprecision because of the small number (<400) of participants. Eventually, the evidence pertaining to these 2 outcomes was judged to be very low or low respectively (Table 10 (RR < 2) of Ginkgo biloba and the low or very low overall quality of evidence regarding outcomes were more likely to warrant weak recommendations of Ginkgo biloba for acute ischemic stroke , the 9 original RCTs did not report whether they applied a blinded outcome assessment or intention-to-treat (ITT) analysis and the follow-up period was relatively short (14 to 35 days). Therefore, the quality of the evidence for this outcome was downgrade (Table 10 (RR<2) of Dengzhanhua, the low overall evidence quality and the uncertainty in the effects of other outcomes (such as long-term harm) were more likely to warrant weak recommendations of Dengzhanhua for acute ischemic stroke  compared Acanthopanax plus routine therapy with routine therapy alone, of which 8 RCTs with methodological limitations reported a small positive (RR = 1.17) result on neurological improvement (MESSS) and the other 5 also reported a small positive effect (RR = 1.31) on neurological improvement . Low-quality evidence  was demonstrated that Acanthopanax be superior to controls improving neurological function (MESSS). Additionally, very low-quality evidence  was concluded that Acanthopanax be superior to controls in neurological improvement  . Before-after treatment neurological functional deficit scores were also evaluated indicating that Chuanxiong plus routine therapy had a superior effect than routine therapy alone MD = -3.11). There were very-low- to low-quality evidences  (Table 1. There 10 (RR<2) and the uncertain of balance between benefits and harms were more likely to warrant weak recommendations of Puerarin for acute ischemic stroke . This, however, requires further investigation because the quality evidences were low  (Table ke Table .10 (RR < 2) and the uncertain of balance between benefits and harms were more likely to warrant weak recommendations of Milk vetch for acute ischemic stroke . However, this requires further investigation because the quality evidences were low  (Table The rate of death (for any cause) was reduced in the Qingkailing group . This, however, requires further investigation because the quality evidences were very low . The very low overall quality of the evidence and the uncertain of balance between benefits and harms were more likely to warrant weak recommendations of Qingkailing (Qing Kai Ling) for acute ischemic stroke . In this overview, there was very limited evidence from SRs on the effect of TCPM on the important or critical outcomes. The quality of the evidence reported by the included SRs was rated using GRADE methods and ranged from very low to low. The main reasons for the quality of the evidence being downgraded include bias in the primary studies , inconsistency and imprecision. The evidence was frequently restricted to a single small trial. We finally concluded that the strength of the recommendation for all the 9 TCPMs in acute ischemic stroke was weak. These weak recommendations imply that the decision to prescribe a TCPM from the 9 TCPMs for a patient suffering from acute ischemic stroke should be approached with caution. In this study, recommendations of the domains of values and preferences or resource use were not assessed, as relevant data were unavailable.Firstly, the inclusion of both “preappraised” and non-“preappraised” evidence resources ensures that our overview serve as a comprehensive summary of all current high-quality SRs. Secondly, Our results may have been biased, as our selection process missed TCPMs with no clinical data. We can only draw conclusions regarding treatments based on available evidence. The clinical practicality of this study may be impacted by including these TCPMs and the recommendations should be revised when clinical data for these TCPMs is available. Thirdly, some included RCTs and SRs predate the last diagnostic guidelines for stroke. This increases the risk that RCTs and SRs may have included participants who would not be identified as stroke according to current diagnostic criteria and so leads a source of likely clinical heterogeneity across the evidences. Similarly, some included SRs and primary studies do not clearly report the details of their routine therapies. Critically, we identified that the consistent definition to the outcome of neurologic improvement was lack in some of the included studies. Fourthly, very little data on relatively long term (> 6 months) outcomes were identified for any TCPMs except Puerarin, which leads an important limitation of the evidence base given the chronic nature of the condition. Additionally, most of the included SRs and studies considered neurologic improvement as the primary outcome, but adverse events were often incomplete reporting. Consequently, in many assessing processes the balance between benefits and harms remains unclear. Finally, data relating to hemorrhagic stroke were not collected and analyzed; the results and conclusions of this overview should not be extended to hemorrhagic patient group. None of the studies recruited stroke patients in subacute (onset within 2–28 days) or recovery stage (onset after 28 days), so we have no effectiveness and safety information for the TCPMs in patients with stroke who onset after 2 weeks. We also have not included SRs of any TCPM as a monotherapy to treat stroke patients.While all eligible and high-quality SRs have been attempted to identify using a highly sensitive strategy, there is a possibility that some key literatures may have been overlooked, which may have impacted on our conclusions regarding some TCPMs. Moreover, an SR including low-quality RCTs may produce a misleading GRADE result, for example, yielding a narrow confidence interval (means good precision) around the incorrect intervention effect estimate. For this reason, SRs included for our study were restricted to those with high quality. Furthermore, the aim of this overview was to summary the evidence from SRs; therefore, we did not include the missing original RCTs in the SRs with lesser quality.28 published clinical guidelines on the TCM treatments of people with ischemic stroke , which used many of our SRs and trials. They concluded that Chinese herbal medicine may be beneficial following stroke. As the most recent search was conducted in September 2014, our overview can be considered the most up-to-date evidence on the TCPMs.There are no reviews comparable with this overview. However, the Evidence-Based Review of Stroke Rehabilitation (EBRSR)The evidence compiled by this overview weakly supports using TCPMs for acute ischemic stroke. Compared with usual care alone, the addition of Dan Shen, Mailuoning, Ginkgo biloba, Dengzhanhua, Acanthopanax and Chuanxiong-type preparations in patients with acute ischemic stroke appeared to have beneficial impact on neurological improvement, and adding Dan Shen injection or not were unclear in decreasing the rate of death and small effective in reducing disability. Mailuoning appeared to have no impact on health-related quality of life and activity of daily life. Chuanxiong-type preparations were not effective in the reduction of adverse effects, but did reduce risk of death. Puerarin, Milk vetch, Qingkailing can mildly decrease the mortality too. Well-designed and conducted SRs and RCTs are warranted to support the utilization of the 9 TCPMs on acute ischemic stroke patients.To facilitate comparison across TCPMs SRs and the efficient future update of this overview, the following SRs of TCPMs need to standardize and unify their methods as well as reporting, such as the reporting of included RCT characteristics, risk of bias assessment criteria for both SRs and RCTs, outcomes and evidence synthesis methods.Given that TCPM is a complex intervention and stroke is a disease treated with complex interventions, a significant challenge of SRs of TCPM is treating the potential heterogeneity among interventions (such as composition of TCPMs and methods of delivery) and outcomes . Potentially effective approaches to explore this complexity include stratification ('splitting’) of outcome results or intervention types, subgroup analyses and meta-regression.The current SRs of the RCTs described the potential benefits of the 9 TCPMs ; however, the overall bodies of evidence were found to be of low quality. Our critical appraisal of the evidence using the GRADE approach resulted in the formulation of weak recommendation.


Public health decision making can be a complicated process because of the complex nature of inputs and the need for group decision making. Nevertheless, public health research and practice during the last century gained many notable achievements and contributed to the 30-year gain in life expectancy. Despite these accomplishments, a greater attention to evidence-based approaches may be helpful. In its most straightforward definition, evidence-based public health (EBPH) means applying the principles of evidence-based medicine (EBM) to the field of public health . HoweverIn this special issue we collect several contributions to the emerging field of evidence-based public health, covering different aspects of the EBPH policy cycle, that is, from evidence generation and evidence synthesis to evidence communication and policy recommendation . We are Systematic reviews and meta-analysis are a workhorse of evidence-based medicine and two studies in our special issue demonstrate clearly that this is also the case for evidence-based public health. G. A. Kelley et al. conducted a systematic review titled “Exercise and BMI in Overweight and Obese Children and Adolescents: A Systematic Review and Trial Sequential Meta-Analysis” utilizing a trial sequential meta-analysis approach. This approach combines conventional meta-analysis methodology with meta-analytic sample size considerations; inferences derived from this method may potentially improve reliability of estimates. The systematic review “Sexual Risk Behaviors and HIV Infection among Men Who Have Sex with Men and Women in China: Evidence from a Systematic Review and Meta-Analysis” by H.-Y. Wang et al. sheds light on potential transmission mechanism of HIV/AIDS in China, indicating that more emphasis must be put on prevention measures for men who have sex with men and women.A crucial, but at times overlooked, factor for a successful public health policy is the availability of trained medical staff. In our special issue two articles study this important topic. Interestingly enough, both are from Sub-Saharan Africa, a region that constantly faces the challenge of brain drain, that is, the outmigration of well-trained individuals. The study from Ethiopia titled “The Prevalence of Skilled Birth Attendant Utilization and Its Correlates in North West Ethiopia” by M. Alemayehu and W. Mekonnen looks at the prevalence of skilled birth attendants demonstrating that both social and technical factors must be addressed if this prevalence should be improved in the future. The study titled “Working Atmosphere and Job Satisfaction of Health Care Staff in Kenya: An Exploratory Study” by K. Goetz et al. investigates the factors that influence job satisfaction for health care works in Kenya. Clearly, improving job satisfaction may prove to be a very cost-effective tool in increasing retention rates among health care staff in Africa.The contribution “Intervention Mapping to Adapt Evidence-Based Interventions for Use in Practice: Increasing Mammography among African American Women” by L. Highfield et al. uses the topic of mammography among African American women to demonstrate the use of intervention mapping as a tool for a systematic planning process. Their use of a simplified framework (IM Adapt) allowed adapting and implementing an evidence-based intervention to help underserved African American women to keep appointments for mammography screening. A separate paper titled “Evaluation of the Effectiveness and Implementation of an Adapted Evidence-Based Mammography Intervention for African American Women” by L. Highfield et al. evaluated the effectiveness of the identified intervention and added evidence to the finding that sequentially measuring efficacy and effectiveness of an evidence-based intervention, followed by implementation, may be missing important contextual information.A paper from Croatia titled “Perinatal Health Statistics as the Basis for Perinatal Quality Assessment in Croatia” by U. Rodin et al. describes how the national perinatal health audit improved after introducing reporting criteria as recommended by WHO and PERISTAT. This database now allows comparison in perinatal outcome with other countries and targeting areas of improvement in a more evidence-based fashion. The contribution “Health Impacts of Increased Physical Activity from Changes in Transportation Infrastructure: Quantitative Estimates for Three Communities” by T. J. Mansfield and J. M. Gibson utilizes the approach of quantitative health impact assessment to assess the implications of increased physical activity from changes in transportation infrastructure. To this end they use a simulation tool (DYNAMO-HIA) that was specifically developed for such applications.An Australian paper titled “Public Concern about the Sale of High-Caffeine Drinks to Children 12 Years or Younger: An Australian Regulatory Perspective” by C. M. Pollard et al. presents a study connected to the epidemiology of caffeine intake. Usually this is attributed mostly to coffee consumption. However, this paper demonstrates that growing concerns regarding the consumption of caffeinated beverages such as energy drinks by children and adolescents exist in communities in Western Australia, in particular by females and those living with children. These concerns increase with age. The final paper of this special issue titled “Smoke-Free Workplaces Are Associated with Protection from Second-Hand Smoke at Homes in Nigeria: Evidence for Population-Level Decisions” by D. Kaleta et al. aims to support decision making at the population level. These authors find evidence that smoke-free workplaces have the important additional effect of stimulating smoke-free homes in Nigeria and in turn reduce second hand smoking exposure of children.In summary such collection of papers covering different issues relevant to EBPH will provide evidence for decision makers and will contribute to the development of this field.