Procedures for priority setting need to incorporate both scientific evidence and public values. The aim of this study was to test out a model for priority setting which incorporates both scientific evidence and public values, and to explore use of evidence by a selection of stakeholders and to study reasons for the relative ranking of health care interventions in a setting of extreme resource scarcity.Systematic search for and assessment of relevant evidence for priority setting in a low-income country. Development of a balance sheet according to Eddy's explicit method. Eight group interviews (n-85), using a modified nominal group technique for eliciting individual and group rankings of a given set of health interventions.The study procedure made it possible to compare the groups' ranking before and after all the evidence was provided to participants. A rank deviation is significant if the rank order of the same intervention differed by two or more points on the ordinal scale. A comparison between the initial rank and the final rank (before deliberation) showed a rank deviation of 67%. The difference between the initial rank and the final rank after discussion and voting gave a rank deviation of 78%.Evidence-based and deliberative decision-making does change priorities significantly in an experimental setting. Our use of the balance sheet method was meant as a demonstration project, but could if properly developed be feasible for health planners, experts and health workers, although more work is needed before it can be used for laypersons. Tanzania, as many other countries in sub-Saharan Africa, needs to improve the way resources are allocated in health care. Around US$8 are spent per capita on health care per year, so hard policy decisions have to be made which affect millions of people . SeveralAt the international level, researchers, political decision-makers and organisations acknowledge the need to develop methods for using evidence in resource allocation which are efficient and seen as fair by the public -9. The gFrom a health policy perspective, much is known about the requirements of allocative efficiency. However, there is less agreement on how to develop political procedures which secure the requirements of fairness . The issThis study was motivated by these concerns. We aimed at testing out the balance sheet method as a model for incorporating scientific evidence and societal values in priority ranking of nine health care interventions in a setting of extreme resource scarcity.In collaboration with local experts in epidemiology and health planning, we identified six conditions and nine interventions relevant for an essential health care intervention package in Tanzania. These interventions included Integrated Management of Childhood Illness (IMCI), Safe Water , Highly Active Anti-Retroviral Therapy (AIDS), Voluntary Counselling and Testing (HIV), single dose Nevirapine (prevention of HIV from mother to child), Community Based DOTS (for patients with tuberculosis and HIV), Community Based DOTS (tuberculosis only), Intermittent Treatment of Pregnant Mothers , and Impregnated Bed Nets . Before conducting group interviews with key stakeholders, we collected several types of evidence in four steps , efficacy , cost-effectiveness, and equity . These cThe Global Burden of Disease Study and the East African Regional Study provided data on incidence and prevalence . A systeWe conducted a systematic search in Medline and the Cochrane database for studies on cost-effectiveness for all the identified health interventions. We used the search terms: 1) "condition/intervention", 2) "cost*effectiveness", and 3) "Tanzania" or "sub-Saharan Africa", for the period of 1995–2002. The search term for country was broadened if no records were found. Preference was given to studies where details of costs and benefits were clearly presented and where the outcome measures were either life years or disability adjusted life years saved – studies used: -43. We dFinally, we undertook a critical review of the literature on health policy and equity issues in the distribution of health benefits, from which we developed a list of group characteristics of the target population relevant to equitable health policy ,44,45. TThe information obtained was presented in an explicit and neutral manner to the respondents, in the form of a Balance Sheet, developed according to David Eddy's method . The criThrough the National Institute for Medical Research, we identified eight groups of stakeholders in priority setting in health, of which four were from an urban setting , and four from a rural setting (Moshi). These included representatives from the general population, health workers, national and district planners  and one patient group (people living with HIV/AIDS). We obtained informed consent from all participants. Each group comprised of eight to thirteen adult participants:i) Moshi District Health Management Team (DHMT) members (8 participants)ii) Mawenzi hospital health workers (doctors and nurses) (13 participants)iii) People living with HIV/AIDS (10 participants)iv) Lay people from Makuyuni village (10 participants)i) Temeke Municipal Health Management Team members (13 participants)ii) Lay people from Chamazi village (11 participants)iii) Muhimbili National Hospital health workers (doctors and nurses) (10 participants)iv) Ministry of Health officials (10 participants).We conducted an interview study using the nominal group technique . The oriEach group interview lasted about 3–4 hours. Each group session began with self-introductions, introduction of the purpose of the interview, as well as discussion of the selected conditions and their interventions to ensure a common understanding. After this, with the facilitation of the investigators, each group went through eight sessions:1. Participants were asked to rank the interventions without any evidence and prior to any discussions. The question asked: "Please rank the interventions according to your personal view of perceived importance. As more resources become available, they will be used according to the rank order given."2. After this, participants were requested to imagine they were health planners interested in the population health of their society. The question asked: "Imagine now that you are health planners: How would you rank the interventions?" The group discussed the interventions presented and came up with a priority ranking of the interventions by the whole group, through consensus, or if necessary through voting.3. Presentation of estimates of prevalence, burden of disease, and coverage  followed by individual ranking.4. Presentation of information on clinical effectiveness  followed by individual ranking.5. Presentation of information on cost- effectiveness of the interventions  followed by individual ranking.6. Presentation of group characteristics for each condition . The respondents were asked to discuss the validity of this information and its relevance for equity considerations. They were then asked to do the final individual ranking based on all the evidence given.7. Participants were asked to imagine they were health planners again. They discussed the interventions and came up with a priority ranking of the interventions by the whole group, through consensus or voting.8. Brief evaluation of the methodology and summing up.All group discussions were actively facilitated and participants had opportunities to ask for clarifications. Presentation of the evidence  varied according to the informant's level of expertise. Where appropriate, discussions were carried out in Kiswahili. All participants gave their written informed consent, and ethical and scientific clearance for this study was obtained from Medical Research Co-ordinating Committee of the National Institute for Medical Research of Tanzania.We collected each respondent's ranking before any evidence was given, and after introduction of the four kinds of evidence outlined above. All the individual rankings were tabulated into a spreadsheet, and we calculated mean rankings from each group and for all participants. Eight groups were convened with a total of 85 respondents, but three responses (two from the village group), had to be excluded because of obvious misunderstandings and inconsistencies. We present descriptive statistics for the remaining 82 respondents. The two rankings obtained through consensus or voting before and after all the evidence were tabulated separately, and the mean for all groups was calculated . While aggregation of the ranks masks the individual- and group-differences, the purpose of this paper was to test the application of the tool. Detailed discussion of the differences between individual groups will be presented elsewhere.For comparison of different rankings, we defined a rank deviation as significant if the rank order of the same intervention differed by two or more points on the ordinal scale. Difference in rank order is expressed as a ratio between the interventions with significant rank deviation over the total number of interventions.The main result from the sample of stakeholders in Tanzania, as expressed after all the evidence was received and discussed, is that Integrated Management of Childhood Illness (IMCI) should be considered the first priority, followed by Voluntary Counselling and Testing (VCT) and Prevention of Vertical Transmission of HIV from mother to child with single dose Nevirapine (both ranked as number two). The three interventions with the lowest priority were intermittent treatment of pregnant mothers with malaria (rank seven), followed by Directly Observed Treatment for tuberculosis (DOTS) for patients with the combined diagnosis of tuberculosis and HIV. Highly Active Anti-Retroviral Therapy (HAART) for HIV/AIDS was ranked lowest table .Our study procedure made it possible to compare the groups' ranking before and after all the evidence was given figure . Based oFrom our data, we were also able to explore how evidence and deliberation changed the rank order of various interventions. Three examples are given in figure Although ranking interventions according to data from different studies in a league table form is methodologically problematic, we wanted to test how the participants' rank order compared with such a league table figure . The leaThe most marked deviations were for Intermittent Treatment with sulfadoxine-pyrimethamine (SP) for pregnant women to prevent malaria, DOTS for patients with tuberculosis and HIV, and Insecticide-treated Bed Nets. In discussions, respondents gave various reasons for their ranking. For Intermittent Treatment with SP, many experts expressed concerns about the lack of evidence from randomised clinical trials on the assumed mortality reduction from this intervention . DOTS for patients with TB and HIV was given low priority since, as some said, life expectancy for these patients is shorter because of lack of access to anti-retroviral therapy in the country. Others supported the current TB policy in Tanzania . The Impregnated Bed-Nets strategy was given high priority by many because malaria is the major cause of under-five mortality, and participants felt that an intervention addressing this problem was important.Is the balance sheet method feasible for involving patients and the public? Our results from the patient group are somewhat discouraging in this respect figure . PatientThe interviews in the village groups (n = 21) gave valuable inputs, but in analysing the material we found that many participants found the ranking process difficult and we had to exclude two of the individual rankings because they were inconsistent. In the evaluation, many participants said that they found the information too technical to comprehend. Two of the participants could not read, and many had difficulties with numbers. We found the balance sheet approach more relevant and useful for health workers and planners.Our study suggests that evidence-based and deliberative decision-making does change priorities significantly in an experimental setting in a low-income country. This confirms findings from UK . InformeThere is partial overlap with the criteria our respondents found important and those found in a very interesting discrete choice experiment from Ghana . That stThere are several weaknesses to the study. We presented realistic choices in a hypothetical choice situation. The exercise is hypothetical in two ways: First, we did not present all available evidence to the participants. The amount of potentially relevant information is much larger than the selection we chose. In this sense, we limited the reasons participants could take into consideration. Second, policy makers must typically compare more than a few interventions at a time (the WHO-CHOICE database project aims to produce data for about 500 interventions). One of the major shortcomings of the balance sheet method is that its priority ranking results seem to be limited to the interventions included in the study design. Results will obviously change when other alternatives are introduced. However, all methods for priority setting that rely on evidence and comparisons of alternatives are incomplete if they do not include all relevant alternatives. Starting with a limited set of interventions and making the evidence explicit is only the first step for comprehensive priority setting. At a later stage more interventions and types of evidence can be included. What our study shows is that discussion of evidence and values may change priorities, and this way of making the process more transparent may be an advantage also in real-world situations where the alternatives are many and complex.Moreover, the choice situation we created was highly context sensitive. For example, we reported that coverage for treatment of smear positive patients with tuberculosis is almost 100 percent. This might have influenced the priority assigned to treatment for this condition .We did not ask respondents about re-allocations, and that this could be seen as a major drawback of the tool. However, there is nothing in the tool itself that prohibit rephrasing the question posed to the respondents – so that re-allocation is also considered.The search for evidence was restricted to the period 1995–2002. Especially for HAART, new evidence on cost-effectiveness has been published since, and this evidence might have changed the ranking of interventions. A less narrow search strategy could also have changed our results, i.e. we could have included studies from outside sub-Saharan Africa, and cost-effectiveness studies with other outcome measures than life years or DALYs. Moreover, we presented evidence on clinical outcomes based on results from meta-analyses and studies used in key cost-effectiveness studies. Performing a systematic search and full evaluation of all possibly relevant clinical studies for all nine interventions is extremely resource and time demanding, and we therefore assumed that key studies had already been identified in this way in the meta-analyses and the economic studies we used. However, our simplified approach could have introduced biases that the reader should be aware of.With regards to the composition of the respondent groups, we chose homogenous groups because given the cultural-, social- and gender- norms in this society; dominance of educated males may have been unavoidable. Homogeneous groups are typically considered better to avoid dominance from single individuals with expert status.Although the respondents gave reasons for their ranking and these would add understanding of the rankings, we do not report analysis of them here. This paper is the first exploration of this tool and its application. Details of the reasons and discussions during the deliberation will be presented elsewhere.In the evaluation, the respondents expressed that they did not have enough time to understand all the information. The balance sheet is difficult for laypersons and non-medical planners to understand, but even experts in the fields complained about the complexities of choice: four sets of evidence for nine interventions had to be balanced at the same time. On the other hand, it is hard to see how to reduce the complexities of this kind of decision-making. Many expressed the need for capacity building with respect to summarising the evidence base. Finally, some expressed concern that the discussion and voting procedure was easy to manipulate, eloquent rhetoricians tended to influence the consensus, or the open voting. We could have used secret ballots.Overall, the study suggests that many of the arguably most important decisions in priority setting – such as the assessment and interpretation of evidence – are so technical that they are not feasible for direct participation from the public. However, the balance sheet promotes what we will call internal accountability through explicitness, transparency and a commitment to scientific validity. This fits more easily into the deliberative framework advocated by among others Daniels and Sabin, focusing on accountability for reasonableness . RequireThe results from our exploratory study concerning ranking should not be generalized as an expression of all stakeholders' views for policy decisions in Tanzania. We do, however, think that the balance sheet method indicates some elements which are needed to improve resource allocation processes in Tanzania. As a first step, there is a need for institutional strengthening in terms of capacity building for the identification, assessment and interpretation of available evidence. The methods and tools of evidence-based medicine provide a useful starting point for such capacity building . In addiThe author(s) declare that they have no competing interests.LK and OFN conceived of the study, and EM, LK and OFN participated in its design and coordination and helped to draft the manuscript. All three authors participated in the group interviews and data analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Burden of Disease in Hai and Moshi distrcts.Click here for file


Despite wide distribution and promotion of clinical practice guidelines, adherence among Dutch general practitioners (GPs) is not optimal. To improve adherence to guidelines, an analysis of barriers to implementation is advocated. Because different recommendations within a guideline can have different barriers, in this study we focus on key recommendations rather than guidelines as a whole, and explore the barriers to implementation perceived by Dutch GPs.A qualitative study using six focus groups was conducted, in which 30 GPs participated, with an average of seven per session. Fifty-six key recommendations were derived from twelve national guidelines. In each focus group, barriers to the implementation of the key recommendations of two clinical practice guidelines were discussed. Focus group discussions were audiotaped and transcribed verbatim. Data was analysed by using an existing framework of barriers.The barriers varied largely within guidelines, with each key recommendation having a unique pattern of barriers. The most perceived barriers were lack of agreement with the recommendations due to lack of applicability or lack of evidence (68% of key recommendations), environmental factors such as organisational constraints (52%), lack of knowledge regarding the guideline recommendations (46%), and guideline factors such as unclear or ambiguous guideline recommendations (43%).Our study findings suggest a broad range of barriers. As the barriers largely differ within guidelines, tailored and barrier-driven implementation strategies focusing on key recommendations are needed to improve adherence in practice. In addition, guidelines should be more transparent concerning the underlying evidence and applicability, and further efforts are needed to address complex issues such as comorbidity in guidelines. Finally, it might be useful to include focus groups in continuing medical education as an innovative medium for guideline education and implementation. Clinical practice guidelines are commonly regarded as useful tools for quality improvement . HoweverTo improve adherence to guidelines in practice, an analysis of barriers to implementation of guidelines among target users is advocated ,11. A laFew studies have focussed on a set of guidelines considering the variety of barriers that should be addressed to improve guideline adherence . In addiThe aim of this study was to identify the perceived barriers towards the use of national guidelines for general practice by focusing on the key recommendations within the guidelines. By analysing multiple key recommendations from a set of guidelines, we aim to identify which barriers occur most frequently across the selection. These findings may be useful for guideline developers as well as for professional organisations in designing tailored implementation strategies.The Dutch College of General Practitioners (NHG) has developed a set of more than 80 national guidelines that cover the majority of conditions and diseases seen in general practice . The guiSix two-hour focus group sessions were conducted in which twelve NHG guidelines were discussed. Focus groups have proven to be a useful method of providing in-depth information and exploring cognitions and motivations underlying behaviour -25. ThisAn expert panel of GPs (n = 16) was asked to help selecting the guidelines for our study. The panel was recruited by the organisation responsible for CME for GPs in the Southwestern part of the Netherlands (Stichting KOEL) . We provThe panel suggested nineteen guidelines having high priority. From these nineteen, we selected twelve guidelines according to the equal distribution among prevalence and type of diseases, and the measurability of quality improvement on patient outcomes Table . Fifty-sGPs were recruited by Stichting KOEL through advertisement in their electronic newsletter and website. They could register for more than one focus group session and were offered CME accreditation (two hours per session). All 34 GPs that had registered for one or more focus group sessions were invited and 30 of them (88%) participated in the sessions . Nine of them participated in two sessions and one in all six sessions. One-half of the participants were male, and most of them were between 45 and 54 years of age (37%), practiced in a group setting (45%), and worked in a rural area or small town (39%). Compared to the total population of Dutch GPs , particiThe participants received a copy of the key recommendations of the guidelines one week in advance. In each focus group session, the GPs had a semi-structured discussion about the perceived barriers to the implementation of the key recommendations of two guidelines. The sessions were chaired by a GP with at least 15 years of experience in general practice and guideline development (JB), and co-chaired by a health services researcher (ML). A topic guide with open-ended questions was used to structure the discussion. The six sessions were held at Stichting KOEL from March to June 2008 and were audiotaped.et al.  five times, and I still did not understand it!'GUIDELINE RECOMMENDATION FACTORS – Incomplete/not up to dateGuideline cerebrovascular accident (KR1)'This recommendation is based on obsolete opinions. You cannot keep patients with stroke at home. All of them should be immediately admitted to hospital.'Examples of perceived barriers related to behaviour: environmental factorsENVIRONMENTAL FACTORS – Organisational constraints (outside organisation)Guideline urinary tract infection (KR1)'How to use a dipslide in out-of-hours services on Sunday? Then you need someone who reads the results on Monday. That is really bothersome.'ENVIRONMENTAL FACTORS – Organisational constraints (within own practice)Guideline eye inflammation (KR2)'I would like to reduce antibiotic prescriptions in patients with red eye, but the practice assistant often deals with these patients who ask for a prescription by telephone. The bottleneck is mainly in prescriptions requested over the telephone. There is an important improvement to make there, yes! As the assistant thinks that at any time a prescription is necessary.'ENVIRONMENTAL FACTORS – Organisational constraints (between organisations)Guideline cerebrovascular accident (KR 4/5)'It is unclear what the hospital arranges and what we need to do when stroke patients return to their homes. There should be a formal handoff between hospital and the GP.'ENVIRONMENTAL FACTORS – Lack of time/time pressureGuideline cardiovascular risk management (KR 1/2)'It's great what we could offer in cardiovascular risk management, but it would need full weekdays to realize this in practice.'ENVIRONMENTAL FACTORS – Lack of/unpractical resources/materialsGuideline sexually transmitted diseases (KR3)'There are different media, which is unpractical in use...and the media used in cervix streams can only be shortly preserved.'Key recommendations of guidelines (in Dutch). Description of the 56 key recommendations from the twelve included national guidelines (in Dutch).Click here for file


The Quality Enhancement Research Initiative (QUERI) is a unique quality improvement program designed to connect health services researchers to Veterans Health Administration (VHA) management and operations, as well as to provide the science and initiative for making change. Through this process, QUERI stakeholders have learned that success and impact in improving healthcare quality and outcomes largely depends on coordination and collaboration among numerous VHA programs and organizations working to develop and implement evidence-based clinical policies, practices, and quality improvement strategies. This Commentary discusses some of these collaborative efforts and perceived successes in achieving common goals from the viewpoints of two closely involved VHA Operations/Support stakeholders.Series of articles documenting implementation science frameworks and tools developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).The Commentary is part of a  In 1998, the U.S. Department of Veterans Affairs (VA) created the Quality Enhancement Research Initiative (QUERI)–a bold step into uncharted territory called "implementation research," representing a new path toward healthcare quality improvement (QI) , the most striking feature of TIDES was the assistance provided by the research team in implementing system changes. QUERI researchers took staff step-by-step through the process of developing this program and provided education, assistance in hiring people, as well as measurement tools. This resulted in a very effective demonstration of how to appropriately implement and successfully make what was literally a profound change in the culture of how best to treat depression among veterans. A national roll-out effort is now being planned, and involves development of the close type of collaboration between QUERI researchers and operational stakeholders recognized in this commentary as essential to success .In summary, from our viewpoint as VA managerial leaders closely aligned with QUERI, there are multiple examples of how QUERI has influenced the VA healthcare system, both directly and indirectly. In addition to those noted above:• Chronic Heart Failure (CHF) QUERI reduced readmission rates for veterans with chronic heart failure by up to 10% in one VA network.• IHD-QUERI improved lipid management for veterans with ischemic heart disease that translates into a commensurate reduction of about 75 coronary events over two years in one VA network.• MH-QUERI increased the appropriate use of antipsychotics for veterans with schizophrenia that has led to a 10% decrease in costs of these drugs in one VA network.• SUD-QUERI increased access to effective opioid agonist therapy for veterans with opioid dependence by 20%.The partnership between QUERI and other VA operational offices has resulted in successful development, implementation and evaluation of various evidence-based practices across the VA healthcare system. These efforts have helped to begin institutionalization of a cycle of quality improvement that can create a visible increase in the demonstrated quality of care through the effective implementation of evidence-based practice in routine care.Because of the collaborative efforts between research and operations, we can cite several such quality improvement efforts in the diverse QUERI disease areas. To date, QUERI Centers have identified the research evidence and developed quality improvement interventions that have been implemented at VA's facility level, regional level, and even across regions. The next phase – system-wide national rollout – will be more challenging but will continue to require the collaborative efforts of many VA healthcare stakeholders.QUERI has formed, and will continue to form the collaborative relationships necessary to address this challenge. The overarching goal remains the same: To systematically implement evidence-based practice across a large integrated healthcare systemTJC and RP participated in all phases of development and revision of this manuscript. Both authors read and approved the final manuscript. The views expressed in the article are those of the authors, who are responsible for its contents, and do not necessarily represent the views of the U.S. Department of Veterans Affairs.


Sir,“Exploring larger evidence-base for contemporary Ayurveda”, a guest editorial by Prof. Singh in IJAR April 2010 issue,[Referring to Ayurveda, however, the issue of applying evidence base needs to be redefined in reference to its unique propositions. There is a ubiquitous agreement upon the traditional evidences of Ayurveda of which experience, long-term use, and textual classical references form a large sum. This substantial evidence base of Ayurveda, however, is required to be brought in a format which can become retrievable to help with decision making in a clinical dilemma. A thorough documentation therefore comes as the foundation of evidence-based practice and it warrants an unfailing and untiring documentation of every evidence from Ayurveda, conventional or unconventional. Besides,The issue of evidence base in Ayurveda therefore requires to be dealt at various levels like documentation of existing evidences, designing diagnostic and clinical parameters which can act as evidence to help in decision making and generating more evidences in reference to the safety and efficacy pertinent to ayurvedic practice. This is the time when we need to understand that bringing evidence base to the practice of Ayurveda is mandatory if it is thought to be raised as a medical system where predictability and dependability are featured as key components.


A regional integrated cancer network has implemented a program  designed to support the uptake of evidence-informed interprofessional collaborative practices (referred to in this text as EIPCP) within cancer teams. This research project, which relates to the Registered Nurses' Association of Ontario (RNAO) Best Practice Guidelines and other sources of research evidence, represents a unique opportunity to learn more about the factors and processes involved in the translation of evidence-based recommendations into professional practices. The planned study seeks to address context-specific challenges and the concerns of nurses and other stakeholders regarding the uptake of evidence-based recommendations to effectively promote and support interprofessional collaborative practices.This study aims to examine the uptake of evidence-based recommendations from best practice guidelines intended to enhance interprofessional collaborative practices within cancer teams.et al. Ottawa Model of Research Use will serve to construct operational definitions of concepts, and to establish the initial coding labels to be used in the thematic analysis of the qualitative data. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interrelated contextual factors that enhance the uptake of EIPCP and changes in professional practices.The planned study constitutes a practical trial, defined as a trial designed to provide comprehensive information that is grounded in real-world healthcare dynamics. An exploratory mixed methods study design will be used. It will involve collecting quantitative data to assess professionals' knowledge and attitudes, as well as practice environment factors associated with effective uptake of evidence-based recommendations. Semi-structured interviews will be conducted concurrently with care providers to gather qualitative data for describing the processes involved in the translation of evidence into action from both the users' (n = 12) and providers' (n = 24) perspectives. The Graham The information obtained from the study will produce new knowledge on the interventions and sources of support most conducive to the uptake of evidence and building of capacity to sustain new interprofessional collaborative practice patterns. It will provide new information on strategies for overcoming barriers to evidence-informed interventions. The findings will also pinpoint critical determinants of 'what works and why' taking into account the interplay between evidence, operational, relational micro-processes of care, uniqueness of patients' needs and preferences, and the local context. Most cancer and palliative/end-of-life programs propose interprofessional collaboration as a key modality for improving quality of care -5. The n3) was a nurse-led interdisciplinary project that was funded by the Canadian Partnership against Cancer. A summary of the program components is presented in Table The development of the 'Psychosocial oncology: Building interprofessional capacity to improve cancer care across the continuum' program , the characteristics of the professionals involved  and the characteristics of the practice environment   . This mo) Figure .The literature on innovation and change in health services -29 and RThis study aims to examine the uptake of evidence-based recommendations from best practice guidelines intended to enhance interprofessional collaborative practices within cancer teams. In this study, care providers are those directly or indirectly  involved along the cancer trajectory, including community/home care, specialized hospital and ambulatory cancer services, as well as palliative/end-of-life care.More specifically, our study objectives are as follows: to assess how professional knowledge, beliefs and the practice environment support or impede the adoption of EIPCP; to assess how patients' knowledge, beliefs and needs influence this adoption process; and to describe the impact of an educational workshop and mentoring program on the uptake and sustainability of EIPCP over a six- to eight-month period.The planned study constitutes a practical trial, defined as a trial designed to provide comprehensive information that is grounded in real-world healthcare dynamics . An expl3 improvement initiative. The user group (UG) will consist of patients/caregivers using services at one of four care settings in the Montérégie cancer network that are involved in the POBC3. Inclusion criteria for the PG will include being: a key stakeholder knowledgeable about POBC3 planning, implementation and/or evaluation, and a participant in the workshop and/or mentoring activities of the POBC3. Inclusion criteria for the UG will include being 18 years of age or older, able to understand and communicate in French, and a current user of cancer services at one of the participating care settings. The potential PG participants will be recruited during the POBC3 workshop. They will be asked if they agree to be contacted for a study on EIPCP and to provide their contact information. For the UG group, field professionals will be asked to identify potential participants for interviews using a purposive sampling strategy aimed at maximum variability  [The participants will be selected from two groups. The care provider group (PG) will consist of professionals, managers, and decision-makers responsible for governance at the regional level who are directly or indirectly involved in the POBCjectory) . For use3 two-day workshop (T1) and six to eight months later after a period of mentoring (T2). This time frame was adopted first because the POBC3 is currently underway and pre/post-measurements are therefore not possible. Second, it was important to ensure a minimal sample size at T2 by taking potential workforce turnover into account.To meet objective one, quantitative data will be collected from professionals using an adapted cancer care version of the survey questionnaire from Davies' study on collaborative maternity care . This quConcurrently with T2, we will collect qualitative data to deepen our understanding of service users' perspectives (objective two), the contextual factors and the processes determining EIPCP patterns. In-depth interviews (60 minutes) will be conducted to gain understanding of the experience, the challenges, and the insights of both service users (n = 16) and care providers (n = 24). We will use a systematic interview guide adapted from Edwards'  and Pete3 activities. Based on our previous studies [a priori sample size of 80. The Power Analysis and Sample Size (PASS 2008) software was used to determine the sample size required for testing differences between groups. Assuming a type-one error rate of 5%, a minimal estimated sample size of 51 participants per group will give 80% power to detect a medium effect size using Cohen's guidelines [Approximately 100 professionals and managers are involved in POBC studies ,40, we aidelines . The samidelines , and takt-test and Mann-Whitney test) to identify PG (T1-T2) differences  [3, we will focus on operational processes (how team members provide care), relational processes (how team members communicate), and adaptive processes (how team members use evidence to enhance collaborative practice) [Quantitative data will be managed using the SPSS. We will conduct an assessment of the validity of the questionnaire with our sample using principal component analysis and analysis of internal consistency ,44. We w IC 95%) . Themati IC 95%) ,47. The y PG T1-T differenractice) .The trustworthiness of our research data and analysis will be ascertained using Miles and Huberman's criteria of credibility/validity, confirmability/objectivity, and transferability . Given tThe study has been approved by the Centre de Recherche de l'Hôpital Charles LeMoyne Ethics Board (ref. number AA-HCLM-09-034).3 planned educational workshops and mentoring activities will produce new knowledge on the interventions and sources of support most conducive to the uptake of evidence and building of capacity to sustain new interprofessional collaborative practice patterns. It will provide new information on strategies for overcoming barriers to the adoption of evidence-informed interventions. The findings will also pinpoint new determinants of 'what works and why,' given the interplay between the general application of evidence, uniqueness of cancer patient'/caregivers' needs and preferences, and the local context. It will provide new knowledge on strategies for making care providers aware of evidence-based recommendations from best practice guidelines and others sources of information. This knowledge will contribute to the refinement of continuing education programs, and will add new dimensions to existing survey instruments that assess knowledge, beliefs, and practices regarding evidence-informed interventions.This study will constitute a practical trial  that takThe authors declare that they have no competing interests.The study was initially conceived of by DT and DD. All contributing authors were involved in defining the study design and adapting both the questionnaire and interview grid. The manuscript was written by DT and DD, with all authors both contributing to its development and completion and approving the final version.


Low field strength (0.08 Tesla) magnetic resonance imaging (MRI) of the spleen with spin lattice relaxation time (T1) measurement was performed on a total of 79 healthy volunteers and 62 patients with lymphoma. Inhomogeneity was observed on the T1 images of the spleen from 25 volunteers. This was therefore considered a normal variant. The normal range of spleen T1 at 0.08 Tesla was established (362-420 msec). No influence of age on spleen T1 was detected. The range of T1 values observed in males and females was similar, although the mean spleen T1 for females was significantly longer than that for males. The sensitivity of T1 measurement for the detection of lymphoma in the spleen was poor, particularly for patients with Hodgkin's disease. In a minority of untreated patients, however, a spleen T1 value outside the normal range may indicate the presence of lymphoma in the spleen. A significant decrease in spleen T1 following treatment was observed in 9 patients who underwent serial scanning.


Fellowships are a component of many professional education programs. They provide opportunities to develop skills and competencies in an environment where time is protected and resources and technical support are more readily available. The SEA-ORCHID fellowships program aimed to increase capacity for evidence-based practice and research synthesis, and to encourage fellows to become leaders in these areas.Fellows included doctors, nurses, midwives and librarians working in the maternal and neonatal areas of nine hospitals in South East Asia. Fellowships were undertaken in Australia and involved specific outputs related to evidence-based practice or research synthesis. Training and support was tailored according to the type of output and the fellow's experience and expertise. We evaluated the fellowships program quantitatively and qualitatively through written evaluations, interviews and follow-up of fellowship activities.During 2006-07, 23 fellows from Thailand, Indonesia, Malaysia and the Philippines undertook short-term fellowships (median four weeks) in Australia. The main outputs were drafts of Cochrane systematic reviews, clinical practice guidelines and protocols for randomised trials, and training materials to support evidence-based practice. Protocols for Cochrane systematic reviews were more likely to be completed than other outcomes. The fellows identified several components that were critical to the program's overall success; these included protected time, tailored training, and access to technical expertise and resources. On returning home, fellows identified a lack of time and limited access to the internet and evidence-based resources as barriers to completing their outputs. The support of colleagues and senior staff was noted as an important enabler of progress, and research collaborators from other institutions and countries were also important sources of support.The SEA-ORCHID fellowships program provided protected time to work on an output which would facilitate evidence-based practice. While the fellows faced substantial barriers to completing their fellowship outputs once they returned home, these fellowships resulted in a greater understanding, enthusiasm and skills for evidence-based practice. The experience of the SEA-ORCHID fellowships program may be useful for other initiatives aiming to build capacity in evidence-based practice. Healthcare organisations face considerable challenges in ensuring patient care is based on the best available evidence. Studies consistently demonstrate a failure to implement interventions that have been shown to be both effective and cost-effective . AlthougTo support evidence-based practice (EBP) change, clinicians need skills to acquire, appraise and interpret health research. There is arguably an even greater imperative for clinicians in developing country settings to have these skills as a result of the increased health burden and limited resources . CriticaFellowships are commonly used in high-income countries as a means of providing clinicians with professional training, including development of skills in research and EBP -12. FellThe SEA-ORCHID project  was a five-year collaborative project between four countries in South East Asia and Australia. At nine hospitals in Thailand, Malaysia, the Philippines and Indonesia, SEA-ORCHID investigated whether the health of mothers and babies can be improved through a multifaceted intervention to strengthen capacity for research synthesis, evidence-based care and knowledge implementation. The study protocol and baseline practices in perinatal health care have been published previously ,18.The fellowships program was one component of the intervention that also included training of clinical educators based at the nine study sites and support for a range of activities related to EBP locally and nationally. Through the fellowships, SEA-ORCHID aimed to increase capacity for EBP at participating hospitals and provide an opportunity for fellows to take time out from clinical work to gain skills and confidence to enable them to be leaders in EBP change in their professional roles.This paper presents an evaluation of the SEA-ORCHID fellowships program, including the key results of the program in producing outputs to support EBP and clinical practice change, and the experience of the fellows involved in the program.The fellowships program ran during the intervention phase of the project (2006 to 2007) and was designed to support clinicians and other professionals working at the nine SEA-ORCHID sites in South East Asia to undertake short-term EBP projects in Australia. The original research protocol specified a limited number of six-month fellowships. However, when it became clear that hospitals were reluctant to approve extended leave because of the difficulty of replacing staff and fellows themselves were often unable to be away from their families for this length of time, we decided to offer more fellowships of shorter duration.Fellowships were tailored according to the fellows' professional background and chosen projects, the needs of their hospital, and the duration, location and timing of the fellowship. Fellows were assigned to one of the three Australian SEA-ORCHID sites  depending on the type of support required for the fellowship and staff availability. In some cases, fellows divided their time between two Australian sites.The SEA-ORCHID investigators in Thailand, Malaysia, the Philippines and Indonesia selected fellows and fellowship projects on the basis of local needs for strengthening capacity in EBP. This process was pragmatic and based on subjective criteria and the availability of fellows, as well as recognising the importance of selecting fellows who were, or had the potential to be, leaders and champions for practice change .Fellows were chosen from the doctors, nurses and midwives working in the maternal and neonatal areas of the nine participating hospitals. Non-clinical professionals, such as medical librarians, were not considered for fellowships in the original project proposal but their critical role in facilitating knowledge transfer to clinicians led us to reassess this and include them.At a broad level, fellowships were designed to equip fellows with basic knowledge and skills to support and facilitate EBP and research synthesis. This involved learning about the components of EBP  and having the opportunity to put this knowledge into practice during the fellowship.There was a specific structured output for each fellowship. In the fellowship proposals, fellows nominated one or more outputs to focus on during their fellowship and to continue with on their return home. The outputs were determined by each site based on local needs and perceived barriers to evidence-based care , and agr• Cochrane systematic reviews• clinical practice guidelines• research protocols for randomised trials• teaching materials based on effective methods for teaching/supporting EBP and facilitating behaviour change.Fellowships were based on adult learning principles  of activStructured EBP education programs were provided which covered the concept of and need for EBP, and the skills required for EBP including asking answerable questions, database searching and critical appraisal. Training was also provided on methods of development of research protocols, systematic reviews and clinical practice guidelines as appropriate the fellowship output.The amount of tailored training and support each fellow received depended on the type of project, the fellow's previous experience and expertise, and the time available. We also encouraged fellows to join in the routine activities of the department hosting them, including ward rounds, journal clubs, staff meetings and seminars. Wherever possible we took advantage of pre-scheduled training opportunities and enrolled fellows in Cochrane review training and research protocol-writing workshops. We also organised periods of clinical observation for the clinical fellows as we wanted them to see how clinicians incorporated EBP principles in routine clinical care.The evaluation of the fellowships program included:• documenting the number and type of fellowships• assessing the outputs of the fellowships • investigating the experience of fellows and barriers to and enablers of the completion of fellowship outputs.The Australian SEA-ORCHID educators and project co-ordinator were responsible for collecting data from several sources for each fellow. These included written evaluations, face-to-face interviews and follow-up of fellowship activities.Fellows completed written evaluations of the fellowship program using a structured evaluation form at the end of their fellowship and again six months later.Fellows were encouraged to keep a learning portfolio during their fellowship to capture thoughts and reflections about significant experiences and future plans. Although the portfolios were personal documents, fellows provided reflective summaries of these portfolios for inclusion in the evaluation of the program.Each fellow gave an update on the status of their output six months after the completion of their fellowship. For some outputs, such as Cochrane reviews, the status of the output was verified through independent sources . Data collection on the progress of fellowship outputs continued until July 2008.Semi-structured, face-to-face interviews with the fellows were undertaken at the end of each fellowship and again after six months. The interviews were conducted by two of the Australian SEA-ORCHID educators (JS and TT) who had been closely involved in supporting the fellows. The interviews covered a range of topics, including experiences of the fellowship, how fellows had applied the knowledge and skills learned, progress with fellowship outputs, implementation plans and activities, and perceived barriers to and enablers of EBP.Data on the fellowship outputs were analysed quantitatively. Qualitative analysis included the six-month post-fellowship interviews, which were audio-recorded and transcribed by a transcription service. JS and TT reviewed and corrected the transcripts and JS analysed the data in emerging themes. NVivo software was used to store and manage the data. The written evaluations, notes from exit interviews and portfolio summaries were included in the qualitative thematic analysis.SEA-ORCHID supported 23 fellowships between August 2006 and September 2007 Table . There wThe main outputs of the fellowships were drafts of Cochrane systematic reviews, clinical practice guidelines (CPGs) and protocols for randomised controlled trials (RCTs), and the development of training materials to support EBP , and an increase in evidence-based clinical practice change, journal clubs and Cochrane Library use.Most of the fellows were clinicians who, in addition to the research and education components of their fellowships, reflected on the implications of EBP for their clinical work. As a result, many of the fellows were keen to implement specific clinical practice changes which they had often observed in Australia. In this way the fellowships will directly contribute to the impact of the SEA-ORCHID project on healthcare processes and outcomes.Overall the fellows reported that they enjoyed the fellowships program and gained skills and experience in EBP and research use that were beneficial for them as well as their hospitals.I had an immensely beneficial time on this fellowship, obtaining invaluable hands-on experience in preparation of a systematic review and utilising available evidence to improve clinical care.After finishing my Cochrane systematic review, I also can apply the results into my clinical practice and be a role model and mentor for the residents and medical students to help them develop a Cochrane systematic review in the future.Fellows also reported gaining skills and confidence in areas beyond the confines of their specific fellowship output.Before I came to Australia, I only had some experience in conducting RCTs and Cochrane systemic review but no experience with CPG appraisal, adaptation and development with the AGREE tool. On this fellowship training program many perfect resources were provided to help with the topics above. This has made me more confident to conduct a quality RCT, develop or appraise a CPG and be more skilful in searching for evidence in the literature to resolve a clinical problem.Some fellows noted that the experience of the fellowship, even without completing their specific project, had enabled them to change clinical practice.The systematic review is still in the process of being completed. However, the information gained during the literature search performed has enabled certain changes be made with regards to management of folic acid supplementation in premature newborns.Other fellows reported making changes in a range of areas including encouraging mobility during first stage of labour, allowing fluid and food during early labour, prevention of neonatal infection and changes in use of birthing positions.Several fellows noted other career or personal benefits resulting from the fellowships program, such as gaining promotions.I think the [fellowship] helped getting my promotion. ... I have more confidence to speak up and to show my interest to the interviewer regarding my profession.The fellows identified that the components critical to the success of the fellowships program were having protected time, access to academic expertise and resources, tailored training, opportunities for clinically relevant research and opportunities to present and get feedback on their work.The Cochrane Library.Fellows identified several barriers to successfully completing their fellowship outputs once they returned home. These included lack of time, lack of equipment and lack of access to the internet and evidence-based resources such as Because for me when I went back to [my country], when I am trying to continue my fellowship, what I have done in the fellowship time is very difficult, because of the time; I have very, very tight time in here.Maybe first when we were [in Australia], the work is very easy because you were there and the things were there and the computer access is very good, but when we came here [home] the internet access ability is very low. When we can work in Australia for one day, maybe we have to do it here for three days to one week.Fellows identified a range of enablers of the completion of fellowship outputs. Access to computers and evidence-based internet sources to overcome the barriers identified above was regarded as an important enabler.Support from senior staff, colleagues and junior staff at their home institution was also noted as an important enabler of progress on the fellowship output. External research collaborators from other institutions and other countries were recognised as another important source of support.The support we get [from SEA-ORCHID] helps us get our researches finished and published.[SEA-ORCHID Investigator] has started research groups with membership from different institutions. The members may function as support groups to each other in conducting research and implementing evidence-based practice.Fellows recognised the importance of protected time in enabling completion of their fellowship outputs, but were not able to identify how this could be secured once they returned home.The SEA-ORCHID fellowships program resulted in 23 fellows, from a range of backgrounds and with diverse skills and experience, producing evidence-based training materials, drafts of Cochrane systematic reviews, clinical practice guidelines and trial protocols, plans for clinical practice change and a commentary for the WHO Reproductive Health Library. Six months after completing their fellowships there was some development in the drafting and submission process for Cochrane systematic reviews but little development of RCTs or CPGs. There was considerable activity in the delivery and dissemination of EBP training and materials, reported clinical practice changes, journal clubs and Cochrane Library use.The benefits of the SEA-ORCHID fellowships program to both fellows and the hospitals from which they were selected are similar to those reported from clinical fellowship programs in high-income countries like Australia and the United States ,11. MostOne of the main outputs of the fellowships program was the production of Cochrane systematic reviews, designed to be a practical way of introducing clinicians to the links between clinical practice and research. Systematic reviews and guidelines can take years to complete, so not surprisingly, busy clinicians returning home struggled to complete protocols for their reviews. Within six months of returning to busy clinical practices, and without protected time, it was not feasible for some fellows to complete even the protocol for their reviews.While we did not expect these outputs to be completed within the fellowship period or the six month follow-up, we hoped that the fellowships would enable greater understanding of, skill in and access to resources necessary for EBP, and this appears to have happened.The importance of selecting fellows who were practicing clinicians and librarians (and able to directly translate knowledge into practice change) cannot be overstated, and this has also been identified by other studies . While kThis study has some limitations. There were some difficulties with data collection which make definitive conclusions difficult to draw. It was not always possible to measure progress with fellowship outputs. For instance, in the case of some training workshops, it was not always clear what was being taught and how, with whom, for how many, how often and what the outcomes were . Sometimes it was unclear if the fellowship output was an entirely new activity or how it extended or enhanced existing EBP activities. It was also not always clear at what stage drafts of SRs, RCTs, and CPGs were up to or whether fellows still plan to complete them. Fellowship evaluation interviews were conducted by fellowship hosts which may have compromised impartiality, however data collection, analysis and interpretation were undertaken in awareness of this.Protected time, access to academic/technical expertise and resources, training, opportunities for clinically relevant research and opportunities for presentation of and feedback on work were all identified as critical components to the success of the fellowships program. Some suggestions for improving the program included: stronger support for links between fellows after their return from the fellowships; continuing to build and foster relationships with external collaborators; provision of access to well maintained computers, the internet and EBP resources in the fellows' work environments.The capacity of the fellows selected for the program is also a critical success factor. The motivation and commitment of fellows to spend time in another country (in some cases for the first time) and work on a project (often in a second language) took remarkable courage and perseverance. Acknowledging the achievements of the 23 fellows, in often very difficult circumstances, is vital to ensure the gains from these fellowships continue. During the six-month follow-up data collection, some fellows were embarrassed and apologetic about not having been able to complete outputs as they might have hoped. Despite significant environmental challenges, the personal and professional commitment of fellows to bring about change in their hospitals and universities is a tribute to the fellows.The results of this study highlight the potential value of fellowship programs as a method of increasing capacity in EBP. They also highlight key barriers that need to be addressed for fellowships to be ultimately successful and enablers that can be used to achieve this aim. These factors should, therefore, be considered when designing fellowship programs and selecting fellows for future capacity building initiatives.The SEA-ORCHID fellowships program provided protected time for fellows to work on individually selected, clinically relevant, projects which would produce specific outputs and lead to greater implementation of EBP. While the fellows faced substantial barriers to completing their project outputs once they returned to their clinical environments, these fellowships resulted in a greater understanding of, skill in, and enthusiasm for EBP. The experience of the SEA-ORCHID fellowships program may be useful for other initiatives aiming to build capacity in evidence-based practice.The authors declare that they have no competing interests.JS, SM, RM and TT implemented the fellowship program, and supported and trained the fellows. JS and TT undertook the interviews. JS collected and analysed the data and prepared the first draft of the article. SM and TT refined the draft. JS, SM, RM and TT approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/10/37/prepub


Tobacco control is an area where the translation of evidence into policy would seem to be straightforward, given the wealth of epidemiological, behavioural and other types of research available. Yet, even here challenges exist. These include information overload, concealment of key (industry-funded) evidence, contextualization, assessment of population impact, and the changing nature of the threat.In the context of Israel's health targeting initiative, Healthy Israel 2020, we describe the steps taken to develop a comprehensive tobacco control strategy. We elaborate on the following: a) scientific issues influencing the choice of tobacco control strategies; b) organization of existing evidence of effectiveness of interventions into a manageable form, and c) consideration of relevant philosophical and political issues. We propose a framework for developing a plan and illustrate this process with a case study in Israel.Broad consensus exists regarding the effectiveness of most interventions, but current recommendations differ in the emphasis they place on different strategies. Scientific challenges include integration of complex and sometimes conflicting information from authoritative sources, and lack of estimates of population impact of interventions. Philosophical and political challenges include the use of evidence-based versus innovative policymaking, the importance of individual versus governmental responsibility, and whether and how interventions should be prioritized.The proposed framework includes: 1) compilation of a list of potential interventions 2) modification of that list based on local needs and political constraints; 3) streamlining the list by categorizing interventions into broad groupings of related interventions; together these groupings form the basis of a comprehensive plan; and 4) refinement of the plan by comparing it to existing comprehensive plans.Development of a comprehensive tobacco control plan is a complex endeavour, involving crucial decisions regarding intervention components. "Off the shelf" plans, which need to be adapted to local settings, are available from a variety of sources, and a multitude of individual recommendations are available. The proposed framework for adapting existing approaches to the local social and political climate may assist others planning for smoke-free societies. Additionally, this experience has implications for development of evidence-based health plans addressing other risk factors. Controlling tobacco use, the leading preventable cause of death in the world today , remainsBecause individual measures have limited effectiveness, and groups of strategies implemented together seem to offer greater promise than individual strategies , comprehWhich strategies and interventions should be included in the plan? To answer this, policy makers must address both scientific and philosophical issues in the context of the local political constraints. Recommendations with a strong evidence base may not be politically feasible. For example, subsidizing cessation services has been proven to increase cessation, yet, a society with a strong emphasis on individual responsibility may oppose such a move. Likewise, increasing the excise tax on cigarettes and earmarking percentages of the increased revenue for tobacco control activities will inevitably provide an important resource for tobacco control, but some finance ministries oppose earmarking of funds as it restricts their freedom to set budgets. Proposed measures must also be adapted to the ability of states to enforce measures.Faced with these myriad sources of information, the salient question facing policy makers is: Extensive scientific evidence and related recommendations for practice are available. These include interventions at both the individual level, as well as those geared for entire communities, for large organizations, and comprehensive programs at the national and international levels. Philosophical and political issues such as the degree of reliance on pure scientific evidence, the desirability of, and best method to prioritization interventions, and the best strategy to designate ultimate responsibility for tobacco control, have been less well addressed.In this paper we propose a framework for developing comprehensive tobacco control plans. We address scientific issues affecting choice of strategies and interventions; suggest a system to organize the existing evidence into a manageable form; discuss the philosophical and political issues that arise in the course of such an endeavour; and present a systematic means of adapting scientific knowledge, philosophic principles, and policy recommendations to the local setting. As a case study, we report the Israeli experience in developing a national plan relevant to local needs, aspirations, and means.The Healthy Israel 2020 initiative was created in 2005 with a mandate to develop national health targets and recommend evidence-based interventions necessary to achieve them . The HeaFrom 2005-2008, the Committee met regularly to develop health objectives, set quantitative targets for each objective, and develop a set of strategies and specific interventions to achieve them. Concomitantly, members collaborated to produce a summary of the existing evidence to serve as the backbone for writing recommendations for interventions.Initially, the leadership of Healthy Israel 2020 envisioned the following multi-stage process for selecting a set of interventions necessary to reach the health targets:1 - Evidence-based interventions were to be selected from various sources, including the Cochrane Collaboration, the US Preventive Services Task Force, the US Task Force on Community Preventive Services, and other literature reviews and original studies, ranked by level of evidence.2 - Interventions were to be selected from the resultant list based on current patterns of tobacco use in Israel, feasibility of implementation, and the existing political constraints.3 - The items were to be prioritized on the basis of their potential future impact, quality of the evidence of effectiveness, and their generalizability as gleaned from the scientific literature. The information from the scientific literature was to be complimented by local evidence and the Committee's expert opinion on feasibility of implementation. Cost, cost-effectiveness, and issues of inequality were also to be considered.The final product was to be a prioritized list of interventions.Challenges in developing evidence-based tobacco control policy are summarized below.Information overload is a problem common to guideline development in many areas of medicine and public health . ThousanConventionally, public health professionals seek evidence from the published literature. However, in the case of tobacco, much research was done by the industry with the explicit intention that it not be published. Furthermore, some research that has been published was undertaken with the explicit aim of confusing the picture, as part of a process of denialism, used not only by the tobacco industry but also others in, for example, the oil and alcohol industry . A wealtThe strength of scientific evidence for interventions varies , and polThe situation is more complicated when deciding about specific interventions. Measures that, intuitively, seem worthwhile may turn out to be ineffective or even harmful: for example, the youth anti-smoking campaigns sponsored by the tobacco industry portrayed smoking as adult behaviour, but in doing so may have actually increased the probability of initiation .The classical hierarchy of evidence  forming Most research papers and many systematic reviews provide estimates of effectiveness of interventions. However, in the policy setting, a point estimate of effectiveness provides insufficient information on which to base policy. The important outcome is population impact: How much will implementing this particular strategy affect tobacco use in the population as a whole?As an example of the difference between these parameters, consider brief physician-based counselling for cessation. This has been shown to increase quit rates by 74%, corresponding to an absolute increase of 1%-3% in quit rates . Yet, thNotwithstanding the limitations of the available evidence, there is a clear imperative that public health policy should draw on what does exist to the extent possible. Since the tobacco industry is constantly seeking to stay one step ahead of the tobacco control community, there is a continuing need for innovation. One contemporary example is the need to address the marketing of smokeless tobacco ,31, incrAnother is action against product placement in films . AlthougThese examples are important because none of them are addressed in existing recommendations. Thus, those involved in tobacco control must constantly keep up to date with the tactics adopted by the tobacco industry to circumvent controls and the evidence for new approaches to control. This involves familiarity with the medical and social research literature, the industry's trade media, and research using the industry's internal documents.th quarter 2008) [The evidence related to specific interventions is summarized in Additional File er 2008) , the US er 2008) , and theer 2008) . A similer 2008) . Interveer 2008)  and is nTax increases, legislation and enforcement of smoking bans and restrictions, mass media campaigns, workplace interventions, and quitlines are effective strategies in community settings. In the clinical setting, screening and brief advice by health professionals, pharmacotherapy, and counselling  are effective. Subsidizing the cost of cessation and provider reminder systems is effective at the health system level. School-based approaches have limited effectiveness.Comprehensive strategies have been proposed by authoritative bodies including the WHO  , and preDeciding what to prioritize involves philosophical and scientific considerations. Those who believe that the individual bears sole or primary responsibility for smoking will be less likely to advocate government expenditure on cessation medications and other aids. Protection of non-smokers in public places may be more acceptable to these fierce individualists.Advocates of prevention focus on the advantage of intervening before addiction occurs. Advocates of cessation point out the quicker impact on disease burden that cessation will bring, due to the long lag time for the development of many smoking-related illnesses , as wellA central question is whether information about effectiveness of interventions is transferrable between countries. Social norms and political climates differ substantially, so a strategy which is feasible or effective in one country or region or society may be impossible to implement or ineffective in another setting. Much of the available evidence is produced in the developed nations, which have the resources to both deliver the interventions and assess their effectiveness.Some of the evidence base is built on research performed in a variety of countries, such as that on the effects of smoke-free air laws. Yet, even that literature is mostly limited to research performed in Western nations, and generalization to countries with deficient public compliance to governmental regulation is problematic.Hence, transferring evidence which can be found in the literature from other countries, societies, or cultures may not represent the effectiveness or feasibility of an intervention in another place or time. On the other hand, evidence is likely to be sparse from smaller or less developed countries. Dismissing evidence, and in particular, robust, multi-national evidence simply because it comes from elsewhere, would not benefit countries without the resources to perform their own research.Policy makers must decide whether to recommend a comprehensive package or a prioritized list of interventions. Some public health bodies, such as the Partnership for Prevention, produce prioritized lists of preventive interventions under the assumption that policy makers seek such guidance to maximize the impact of their limited health budgets. Current recommendations from organizations reviewed here recommend comprehensive policies as opposed to prioritized lists, largely because of mounting evidence that interventions work better in combination than separately . HoweverThe actual process used by the Committee was substantially modified during the course of deliberations. The first change came about because some Committee members were interested in submitting proposals for innovative interventions, which did not have the advantage of supporting evidence. On the one hand, this went against the grain of a truly evidence-based plan; on the other, innovation in tobacco control is crucial to counter the continually-changing tactics of the tobacco industry. So it was decided to allow innovative interventions. Like the evidence-based interventions, these had to undergo approval by the full Committee. Further, the innovative nature of these interventions was duly noted, in the context of the transparent rankings of the evidence base which were provided for all interventions.A further issue which arose was the fact that there was little local evidence regarding effectiveness of interventions. We found and used what little local evidence we could. For the most part, however, we were forced to choose between using the available evidence, even though it came from outside of Israel, or having almost no evidence to use. We chose the former, but considered local cultural, social, and political norms when making our plan.The most significant change to the program occurred when we reached what was to be the final stage of the work: prioritization of the various interventions. Like all the Healthy Israel 2020 Committees, we were tasked with not simply providing a list of interventions, but with providing a prioritized list of interventions. The details of how to prioritize were to be determined by the Committee and based on a combination of potential future impact on disease burden, quality of the evidence of effectiveness, generalizability, equity, cost, cost-effectiveness, and feasibility.As we began to consider different options for prioritization, we were confronted with three serious problems:i. We could not find a single measure on which to prioritize which was acceptable to the committee. Balancing the needs of future population impact, equity, strength of evidence, and cost did not lend itself to any kind of straightforward prioritization; further, estimates for most of these measures were not easily available, and estimation was beyond the scope of the 2020 initiative.ii. The list which we had developed included 76 interventions. This was unwieldy and also had many interventions which were similar.iii. As we delved farther into the literature on tobacco control policy and comprehensive tobacco control plans, we found evidence that the most effective policies were not based on single strategies or prioritized lists of interventions, but on multi-component plans in which the different components complimented one another.We grappled with these three issues in a full Committee meeting. In a breakthrough decision, we decided to move away from the concept of a long, prioritized list of interventions and, instead, adopted the concept of a comprehensive plan based on a much smaller number of grouped interventions. These broad categorizations would include multiple individually-related items, but would be unprioritized: the idea was that they would be recommended as a set of strategies instead of as a prioritized list. We considered categorizations based on various factors  or targeted outcome ); before deciding on the groupings listed below.Once we had created the main strategic groupings, we sorted the individual interventions into the groups and then compared our categories with existing comprehensive plans. We made some revisions on the basis of these existing plans before finalizing our plan.The final framework for developing the plan is illustrated in Figure 1 - Compilation of a list of potential interventions based on• Comprehensive review of interventions reviewed by the Cochrane Collaboration, and/or recommended by the US Preventive Services Task Forces, and the US Task Force for Community Preventive Services.• Ad hoc review of interventions examined by other reviewing agencies, particularly the UK's National Institute for Clinical Excellence, The US Public Health Service Clinical practice guideline: Treating Tobacco Use and Dependence: 2008 Update, and the scientific literature• Innovative ideas suggested by Committee members.2 - Modification of that list based on local needs and the prevailing political climateWe qualitatively considered relevance to the Israeli situation, practicability, the current political climate, and potential population impact (to the extent possible). Exclusions were primarily based on lack of political feasibility. Thus, for example, legislating decreased nicotine content was not considered feasible, as most Israeli cigarettes are imported. While a call for increased excise taxes was included, a call for earmarking part of that income for tobacco control activities was not, due to the known opposition of the Treasury to earmarking of funds.3 - On the basis of the list, creation of broad groupings of interventional strategies to form the basis of a comprehensive planThe broad categories were to cover all the main elements of tobacco control. In many cases, similar strategies are important for different goals. For example, mass media is important for prevention of smoking initiation, cessation, and reduction of second hand smoke exposure. Constructing the categories was influenced by the existing evidence for effectiveness. School interventions, for example, were not defined as a separate category because of the dearth of evidence for effectiveness from these interventions. Interventions were categorized into eight broad strategies , to be coordinated by a central organizing body. Because of the politically sensitive nature of the structure of the central organizing body, we did not include a recommendation for the structure of that body.4 - Refinement of the plan by comparing it to existing comprehensive plansWe added a category for monitoring which included monitoring of tobacco industry activities and monitoring of effects of implemented interventions. Neither of those elements had previously been included in the plan.The final set of strategies and interventions, representing a comprehensive plan for national tobacco control, is presented in Table A summary of the Healthy Israel 2020 Committee's report was presented to the Knesset (Israeli Parliament) as part of the Health Minister's 2008 report on smoking. The plan has an impact on tobacco control activities of the Ministries of Health and Education. It is expected to gain cachet when the full Healthy Israel 2020 Initiative report is published later this year.Development of a comprehensive tobacco control plan is a complex endeavour, involving crucial decisions regarding intervention components. "Off the shelf" plans, which need to be adapted to local settings, are available from a variety of sources, and a multitude of individual recommendations are available. The proposed framework is based on the following steps: 1: compilation of a list of potential interventions based on current evidence, augmented with innovative suggestions; 2: modification of that list based on local needs, philosophical principles, and the prevailing political climate; 3: streamlining the list by categorizing interventions into broad groupings of related interventions; together these groupings form the basis of a comprehensive plan, and 4: refinement of the plan by comparing it to existing comprehensive plans.This framework may assist others planning for smoke-free societies. Additionally, this experience has implications for development of evidence-based health plans addressing other risk factors.CDC: Centers for Disease Control (US); FCTC: Framework Convention for Tobacco Control; HMO: Health Maintenance Organization; IOM: Institute of Medicine (US); NICE: National Institute for Clinical Excellence (UK); NIH: National Institute of Health (US); USPSTF: US Preventive Services Task Force; WHO: World Health Organization; USPHS: US Public Health ServiceThe authors declare that they have no competing interests.LJR is Chair of the Healthy Israel 2020 Tobacco Control Subcommittee. She initiated this paper and wrote the initial draft. MM contributed to the writing. ER and JB assisted in preparing the tables and additional files. All authors participated in the process of developing the plan, critically edited the paper, and reviewed the final manuscript.Table S1. Tobacco control interventions reviewed by the Cochrane Collaboration, the US Preventive Services Task Force, and the Task Force for Community Preventive ServicesClick here for fileTable S2. Strategies and interventions recommended by the Tobacco Control 2020 Committee (Explicit evidence base included)Click here for file