The complex and seemingly overwhelming problems our world is facing today require equally complex and, for some, incomprehensible solutions. No single entity – and most definitely, no single individual – is capable of imagining the actions that must be taken to address geopolitical tensions, the climate crisis, economic instability, and general apprehension about the future .As always, recognition and definition of the problems themselves is a necessary first step to resolution. Getting to that point requires collective deliberation followed by consensus-based action. Looking to the Sustainable Development Goals, the consultation process that was globally inclusive  is a steRecognition and definition of the problems and evidence-based potential actions do exist for many critical problem areas. There is, however, a human reluctance to pursue the evidence further in order to connect the dots towards truly rooted solutions. An illustration of this is our reluctance at the international, national, and even personal levels to acknowledge that the present capitalist consumptive economic model is not really compatible with climate change salvage or reduction of some economic inequalities.Global leadership groups such as the G7 may achieve progress and consensus in areas such as trade and policies which promote the growth of capital. Yet these same groups are utterly unable to achieve any meaningful consensus towards areas involving the commons, the sustainable habitation of our planet, income inequality, human rights, and other issues which are emergently pressing. Clearly the process for high level recognition, examination of evidence, prioritization, and meaningful action is flawed, perhaps fatally so.Almost without exception, global political and business leadership is unable or unwilling to achieve consensus on an action plan that is commensurate with the urgency of these global challenges.Inspired, informed, selfless, civic leadership is needed to pressure and create the changes that may move the Doomsday clock away from midnight . These mOf course, the challenges are great. Those who consistently and vigorously defend the status quo have deep vested interests in industries that extract, market, and sell products that directly threaten global sustainability: in weapons of both personal and mass destruction, in outrageously pricing drugs in the global north and south, from Big Tobacco to Big Oil, to a Military Industrial Complex. These interests are well connected with our elected officials and have deep pockets and their own bodies of research and think tanks which are employed to defend the status quo.However, even these defenders of the status quo do not recognize the vested interest that they should have to address these issues for their very own children and grandchildren.As has been seen many times before, public opinion is ahead of effective policy-making . Polls cOne ongoing exercise that does seek to connect investigations and evidence in the areas of commerce, politics, economics, global health , environmental sustainability, and peace is the PEGASUS conference and process. By bringing together students, health practitioners, public health professionals, academics, activists, policy-makers, and public officials from diverse backgrounds involved formally or informally in these areas, the PEGASUS Conferences aims to identify the fundamental issues that are driving the current crises in all three and to bring this knowledge to a broader audience, such as through aiming to influence advocacy and policy making platforms.The name PEGASUS is inspired to connect the dots . Previous speakers have included activists such as Naomi Klein, peace advocates including Ziauddin Yousefzai, whose daughter Malala reached the Nobel stage, along with other past speakers such as Setsuko Thurlow and James Orbinski, political leaders such as Elizabeth May and Ryan Meili and Indigenous activists from Canada and abroad including Erica Violet Lee and Alfonso Morales.Hosted last year from April 27 to 29, 2018, at the University of Toronto, the third PEGASUS conference built on the immense wealth of knowledge to extend the platform for meaningful discussion from an impressive array of contributors. In considering how to address the pressing issues confronting contemporary society, PEGASUS III provided a venue to explore the space between thought and action (appropriately titled “from Thought to Action”).Each of our actions must stem from an idea or thought; one might even add inaction. This is true at the individual level as well as at the organizational level, be it a small non-governmental organization, interest group, academic organization, or government. The space between thought and action is often wide. How do we move from great thought across the divide to meaningful action, whether such action be research, policy, advocacy, activism, or education? Direct or indirect actions can be undertaken rooted in evidence, with the express purpose of changing the status quo.Given the role of evidence in igniting action, deliberate attention to what constitutes evidence is crucial. A discussion of what constitutes evidence was present in various plenary sessions. James Orbinski opened the conference with a keynote on “Climate Change and Global Health”, Vikram Patel, Charles Larson, Daisy Singla, and Janet Hatcher Roberts led the conference through a discussion on “Scaling Up Effective Interventions” with a session that was aware of the impact of interventions on existing systems and the possible unintended consequences of interventions.An example of the truly thought-provoking nature of the conference was the workshop session “Decolonizing Evidence”, a critical reflection on what constitutes evidence. This workshop drew on Indigenous ways of knowing and provided a humbling and interesting forum where participants actively discussed how some evidence is given preference over others, resulting in a lack of “cognitive justice”.Cognitive justice is the idea that all forms of evidence should be equally regarded, but not that all knowledge is equal – also referred to as ‘decolonizing knowledge’ . For exaIn her workshop titled “Promoting Cohesion in Families and Communities Through the Community Participatory Approach”, Miriam Were from Moi University in Kenya led participants on an exploration of the facets of women’s empowerment and community cohesion which included the thought that in order for women to become fully empowered, men must also become empowered to overcome their actions which may be rooted in self-doubt and lack of self-esteem.While these insights are being explored throughout the world, explicit acknowledgement is needed that the vision and leadership on these issues will come from: the global south and youth.In fact, some have opined that in considering knowledge, Africa remains colonized due to a lack of control over data, with particular reference to academic fieldwork . In thisWe must be open to the fact that “reverse innovation”, evidence that is specifically drawn from the global south, shapes practices in the global north. This includes: medical products (such as a low-cost electrocardiogram (ECG) that was developed to reach rural and low-income areas in India), health information (mapping of eyewitness reports of violence), and service delivery  . HoweverThe PEGASUS conference illustrates the importance of sharing insights through knowledge translation and exchange and crucially brings in views from both the global north and south. Similarly, the role and importance of youth is highlighted throughout the conferences, with speakers at PEGASUS IV including Dominique Souris, the co-founder and executive director of the Youth Climate Laboratory, and Nishin Nathwani, who is hosting a workshop on the arts with youth. When evidence from various sources are drawn on, and this knowledge is shared, effective policies may be developed. However, it is important to remain cognizant of the policy-making process and understand that evidence is not always drawn on during this process. We must expand our circles and through the open and honest platform of movements such as PEGASUS, play an active role in public policy development. This policy development should also provide justice to other ways of knowing.This is one of the main tenets of PEGASUS, which is why the conference is built on a foundation of four streams: peace, global health local, global health international, and sustainability. These streams ultimately bring together these unique perspectives to achieve shared goals around improving health for all by advancing awareness and understanding of peace, global health, and sustainability.PEGASUS clarifies and reminds us that small steps may lead to big change. It is through establishing common ground, strategizing together, and taking small steps, that we are engaging in “re-organized action” – coming together to reorganize by thinking through our preconceptions (such as those around what constitutes evidence) and clarifying next steps for action . Calling attention to the need to discuss, have open lines of communication, and engage in interdisciplinary collaboration is a way to re-organize action. These discussions can center around what works across different contexts and help us to determine what approaches may work and which may not. It is critical that we allow for mutual learning from one another to inform our actions.It is only then that we can overcome the key challenges of our time – a message of hope in a conflicted world.Topics examined previously at PEGASUS are cross-cutting by nature. Approaches to research that transcend conventional domains of inquiry are crucial. We invite you to join us in taking a step in this direction.The next PEGASUS conference, PEGASUS IV, is to be held at the Balsillie School of International Affairs in Waterloo, Canada in spring of 2021. COVID-19 has resulted in postponing the conference and will entail not only reconsidering the format in which it is delivered, but also highlights the need for collective interdisciplinary action involving researchers, educators, policy-makers, and civil society.As in previous PEGASUS conferences this conference seeks to engage participants in discussions around globally and locally critical problems with a particular focus on: climate change, migration, and sustainable development.One of the aims is to discuss these issues and their complexity.For example, are the sustainable development goals (SDGs) justified? Are there inherent flaws with their design? Are we excluding critical aspects through their development? What evidence (or lack thereof) is being used to justify success in this realm? Are the SDGs applicable to local contexts? These, among various other pertinent questions will be raised in the hopes of re-organizing action.We will be joined by numerous experts, ranging from: individuals in municipal government , federal government , those with multilateral organizations , researchers and knowledge creators  and the President of the Canadian Medical Association, Dr Sandy Buchman who also works in palliative care and homeless individuals in the inner city.www.pegasusconference.ca) to engage in critical, disruptive, visionary, visible, respected, and effective conversations and mobilize action, so that we can come one step closer to achieving a peaceful, sustainable, and healthy world for all.We hope you will join us at the next PEGASUS conference (


The pandemic of COVID-19 has rapidly spread to over 200 countries and territories in the past 4 months. To save lives and minimize transmission, millions of healthcare workers are working in front lines worldwide by putting themselves at high risk from the disease. All of them are working under extreme pressure and experiencing great psychological distress in such a challenging situation. In addition to the huge psychological pressure, healthcare workers around the world face morale and burnout issues as they have to make impossible decisions (Greenberg, Docherty, Gnanapragasam, & Wessely, However, it is important to ensure that evidence-based intervention strategies are employed so that already over-stretched resources can be maximized. Many barriers limit the implementation of conventional evidence-based interventions in this emergent setting. First, traditional face-to-face psychotherapy is hard to implement immediately because of the quarantine policy for minimizing transmission of the virus. Second, not all healthcare workers willingly participate in the group or individual psychological interventions, as evidenced by recent experiences from China (Chen et al., Given these challenges, urgent attention needs to be given to researching strategies to improve access to evidence-based psychological interventions for frontline workers, especially in LMICs. Self-help interventions offer a promising avenue because such interventions can be delivered through a variety of media, and self-help has been shown to be effective for a range of mental health problems (Scott, Webb, & Rowse, In summary, we see a grave need for the development of evidence-based self-help interventions for frontline healthcare workers to protect their mental health during the COVID-19 pandemic. They are the true heroes sacrificing a lot to save our lives today, it is our responsibility to ensure their current and future wellbeing.


Evidence-based health policy (EBHP) development is critical to the judicious use of public funds. EBHPs increase transparency, accountability, effectiveness, and efficiency of policies. Encouraging collaboration between researchers or knowledge producers and policy makers is important because both communities have distinct professional cultures, resulting in them working separately without understanding each other. Knowledge sharing is a complex process that requires understanding of cultural aspects that may reduce cultural differences and increase the use of common language. Health information technology (HIT) is a useful tool to increase knowledge translation, which may result in the transparent use of evidence and networking in developing EBHPs. Our vision is to leverage HIT tools for a better health system that includes digitalized, open source, evidence-based, and transparent ways for collaboration and development of robust mechanisms and for sharing of synthesized evidence with knowledge user–friendly forms.The aim of this study is to develop a conceptual framework on Knowledge translation and health Information Technology for Transparency (KhITT) in policy making and EBHPs . The framework will be informed by the views of four key stakeholder groups  toward EBHP. The informants may also describe practices that demonstrate the EBHP development process and suggest technology platforms to enable this process.We propose an exploratory, descriptive qualitative study to take place in British Columbia, Canada, using in-depth semistructured interviews. To ensure data saturation and trustworthiness, we will use a nonprobability, purposive snowball sample of up to 15 eligible participants in each of the four stakeholder groups. We will analyze the data using content analysis.The KhITT framework focuses on various stakeholders’ perspectives to better understand their perceived needs and priorities in identifying issues with EBHP, in order to make informed recommendations. Ethics approval has been obtained by the harmonized Behavioural Research Ethics Board at the University of British Columbia. We anticipate that we will complete data collection and analysis by December 2020. Preliminary results will be published in summer 2021.Our ultimate goal of this study is to develop a conceptual framework and describe the technology platforms that would enable the EBHP process. We anticipate that our rigorous content analysis will be able to produce insights and themes that are able to address our objectives, contribute to an in-depth understanding of the EBHP process within British Columbia, highlight all influential factors, explicitly disseminate and communicate the study results, identify issues with EBHP and provide informed recommendations to address them, and enhance efforts toward transparent EBHPs.PRR1-10.2196/16268 The New Yorker magazine as a cartoon: a policy maker handed a paper to an advisor saying, “Here is my policy; go find some evidence based on it.” Health policy makers have their own priorities and processes that influence and have implications on health outcomes.The movement for evidence-based health policy (EBHP) has made progress at all levels of government: local, provincial or state, and federal. Developing EBHPs is a critical way to ensure effective and efficient use of public funds and other scarce resources. In addition, using evidence-based methods in health policy development can increase transparency and accountability of these policies. Focus and efforts must align with innovative and effective products and services that will lead to stronger collaborations. Encouraging collaboration and innovative ways of policy making is important, especially when evidence is thin, research is limited, or when some public agencies lack the capacity, skills, knowledge, funding, commitment, and/or support of political leaders to integrate evidence into policy. A movement toward policy-based evidence, noted as found in Young , was depevidence [In the literature, there is an ongoing debate between researchers and policy makers about EBHP, mainly because of a misunderstanding or a lack of a common definition of evidence ,3 as welevidence . The comevidence  describeevidence , but choevidence , “collabevidence . Both knevidence ,9. For eevidence .In Australia, evidence-generation partnerships and levels of collaboration between researchers and policy makers vary widely from minimal to coproduction, which all partners considered as a worthy goal with many benefits . Furtherfacilitates understanding through three main ways. First, it effectively communicates data. Second, it provides people with the opportunity to explore, examine, analyze, and identify patterns within the data and to better understand large data sets. Finally, it encourages and affects user engagement via “consumption and production processes” [Researchers also need to make their studies transparent and available to the public, including to policy makers; help people make sense of the data; and develop and share their study results using visual means  for better understanding and uptake of key messages . Data viocesses”  of visuaocesses” .Despite important advances, rigorous evaluation requirements, and other evidence-based approaches in policy making, the majority of policies are rarely based on rigorous evidence . EvidencIn this environment, we developed a vision for an ideal health system where everything will be digitalized, open source, evidence based, and transparent. That health system may lead to fewer adverse events; better patient, provider, and system outcomes; greater innovation; and less ineffective use of resources . To achieve this ideal health system, we need to focus on three main principles:Collaboration between knowledge producers and policy makers for sharing the understanding of an issue and accepting each other’s knowledge, evidence base, and cultural manifestations.Development of robust mechanisms at an organizational level for synthesizing existing knowledge on a policy maker’s interesting topic.Communication and sharing of synthesized evidence in forms that are friendly to policy makers .Evidence-Based Health Policy. We argue that health care professionals need to be aware and contribute to the health policy–making process. We anticipate further development of the KhITT conceptual framework to provide insights and ways for improving collaboration between researchers and policy makers for the development of health policies that are transparent and evidence based. The KhITT framework builds upon the strong commitment of knowledge producers and policy makers to finding effective solutions and encourages the use of technology that supports the development of innovative health policies. For example, Tran and colleagues’ [To actualize this vision, we propose a conceptual framework called the Knowledge translation and health Information Technology for Transparency (KhITT) in policy making and EBHPs . A preliminary conceptual framework was recently developed and published . Our ideleagues’ ,23 work leagues’ . Collabosupport strong relationships between knowledge producers and policy makers and to inspire individuals and the public to commit to excellence in engaging communities and stakeholders toward transparent, system-based knowledge dissemination and EBHPs. The KhITT framework is comprised of recommendations that are organized within three domains: structure, reference and guide, and capacity building. Specifically, the goals of these domains are as follows:The KhITT framework aims to To provide a structure for understanding each other’s perspective, improving communication, and strengthening coordination efforts for effective solutions.To serve as a reference and guide for strategic choices and for setting priorities and strategies in incorporating evidence into health policy innovation.To nurture existing and emerging knowledge producers and policy makers who are interested in promoting EBHPs by exploring ways to use health information technology (HIT) .This framework emphasizes the important contribution of HIT as a useful tool to increase knowledge translation and transfer via communication among knowledge producers and policy makers that may result in the transparent use of evidence and networks in developing EBHPs . SharingThe purpose of this study is to develop a conceptual framework on KhITT in policy making and EBHPs . The specific objectives to achieve this aim are as follows:Explore and better understand key stakeholders’  different approaches on EBHPs.Capture those different approaches within three main categories—perceptions, perspectives, and experiences—to better understand participant expectations and insights from each stakeholder group and to incorporate them into the KhITT conceptual framework.Describe practices used for demonstrating the EBHP development.Describe the technology platforms that would enable the EBHP development process.For the purposes of this study, we define the relevant specific terms as follows:Knowledge translation, as defined by the Canadian Institutes of Health Research, is “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide effective health services and products and strengthen the health care system” . This prHIT is defined as the technology applied to the health sector that supports information management across computerized systems and improves all aspects of health care . Open access sources of information embody radical change, make HIT broadly available, and provide a forum for sharing information and knowledge toward software development and democratic action. This open communication model could start political discourse among knowledge producers and policy makers.Transparency is defined as openness, accountability, obligation, and honesty to share information and knowledge with the public.Policy making is defined as a messy iterative process with various opportunities to incorporate evidence and strengthen decisions .EBHP is defined as the integration of individual  professional expertise, experience, and practice with the best available research findings in the context of specific preferences and values. We adopted this description of EBHP by paraphrasing Sackett and associates’  definitiPerception is defined as a way of understanding, interpreting, or thinking about something through the fundamental senses. Perception depends on complex effortless functions of the nervous system and is influenced by experiences, feelings, and thoughts ,33.Perspective is defined as a point of view, a particular way of viewing things that depends on one’s attitude, experience, and personality.To achieve the aim and objectives of this study, we propose an exploratory, descriptive, qualitative study design to take place in British Columbia, Canada. We will collect data from policy-making centers , universities , public areas , and HIT workplaces  using a nonprobability, purposive snowball sample of four stakeholder groups: knowledge producers, policy makers, HIT professionals, and the public. Specifically, in Victoria and Vancouver, we will carefully target, invite for participation, recruit, and interview up to 15 participants from each of the following stakeholder groups:Researchers in academic institutions, whose work is relevant to health policies, including HIT researchers, to ensure that evidence from HIT research is introduced, due to the differences in how evidence is generated through research and how it is used in practice.Policy makers at all levels of governance  whose work focuses on health policies.HIT professionals, such as electronic health record managers, developers, or analysts. We hypothesize that there will be a disconnection between HIT researchers and HIT practitioners in terms of perspectives and the definition and use of evidence to drive policy and decision making.Citizens , regardless of gender, age, ethnicity, class, education, socioeconomic status, position, or other demographic characteristics. We will invite individuals older than 18 years of age who are interested in EBHP to participate in the research project.We will start recruiting study participants at the University of Victoria , the Vancouver Island Health Authority , and the provincial government located in Victoria . We are focusing on those stakeholder groups because we expect each group of participants to provide different perceptions, perspectives, and experiences relevant to EBHP and the EBHP development process, which we want to capture and incorporate into the KhITT conceptual framework for a better understanding of their expectations and insights.We estimate that the number of participants we plan to recruit will provide the needed data saturation ,35. DataTo ensure that data saturation has been reached in our study , we will construct a saturation grid, where major topics will be listed on the vertical axis and conducted interviews on the horizontal axis; at least two research team members will conduct coding of transcripts independently . In addiWe will collect the data using in-depth face-to-face or telephone-based semistructured interviews ; the intFor the interviews, we will develop and use our own semistructured instrument and guide .Main themes that explore participants’ knowledge, perceptions, perspectives, and experiences on methods and/or practices used to identify EBHPs.Follow-up questions, including prompts and stimuli aimed at following respondents’ answers and in-depth investigation of any issues raised.Prior to data collection, we will test and pilot the interview instrument and guide with several eligible participants, and we will revise and adapt it accordingly to ensure that the interview questions are meaningful to the respondents’ backgrounds . In addiTimes Colonist), and public places . Upon ethics approval, a recruitment posting will be sent to the social media accounts of all known British Columbia policy makers, knowledge producers, and HIT professionals, including links to the study materials. We will ask eligible participants  to pass our study information  to any other interested participants. Research assistants will approach potential eligible participants in all stakeholder groups, inform them about the study, and answer questions for clarification in person, via email, or via phone. Research assistants will also provide hard copies of the study materials to interested individuals and request their signed informed consent to participate in the study. Then, research assistants will arrange a face-to-face or telephone-based interview at a time and place that is convenient to each participant. At the beginning of the interview, research assistants will again request verbal consent and explain the interview process. During the audio-recorded interviews, pseudonyms or numerical identifiers will be used to protect the anonymity and confidentiality of the participants. In addition, research assistants will make field notes during and immediately after each interview about observations, thoughts, and ideas about the interview to help the data analysis process.We will recruit study participants through professional lists, email address listservs, personal contacts, and advertisements in social media accounts , local newspapers  the data for study participant anonymity and confidentiality. Then, we will transcribe verbatim the collected data . The lead researcher will transcribe two to three interviews to inform the analytic process; a professional transcription agency, or the research assistants themselves, will transcribe the remaining audio files. Finally, we will manage, process, and store the deidentified data files in a secure, digital, password-protected form in the principal investigator’s locked office using the University of Victoria’s technology and servers .According to Braun and Clarke’s  approachTranscription and review of transcripts for accuracy.Open coding by at least two researchers independently; themes to be checked against each other and against the original data for internal coherence, consistency, and distinctiveness.Development of an initial codebook in agreement with the research team.Analysis of the remaining interviews based on the initial codebook may follow, such as creating new codes or refining of existing ones, developing themes and subthemes to identify similarities and differences in the interviews, developing categories of meanings in order to group themes into broader  concepts, and establishing a good balance between analytic narrative and illustrative extracts.Thematic map to be developed based on the identified themes, subthemes, and categories as well as their relationships.During our thematic data analysis, which is guided by Lincoln and Guba , we willCredibility, which refers to the establishment of “confidence in the truth of the findings.”Transferability, which refers to the extent to which the study findings are applicable in other contexts .Dependability, which refers to whether the research question is clear and logically associated with the study purpose and design, as well as to the consistency of findings in a replicated study.Confirmability, which refers to objectivity or neutrality; that is, the degree to which the study findings are determined by the participants and clearly derived from the data and not by the researcher’s “biases, motivations, interests, or perspectives.”Reflexivity, which refers to the researcher’s own conceptual lens, explicit and implicit assumptions, preconceptions, and values that may affect research decisions during all phases of a study .Throughout data collection and analysis, we will ensure traceability and verification as part of the study quality using the following strategies to establish trustworthiness -48:Researcher triangulation, for credibility, transferability, and dependability. That is, engagement of multiple researchers, as well as graduate and undergraduate students, to incorporate their unique insights into the interpretation of findings; planned debriefing sessions among the research team members to provide a sound space on elaborating different study ideas and interpretations; and reporting the background and context descriptions of our study findings from the study participants.Participant validation, for credibility and confirmability, by seeking respondents’ reflections on the transcripts and interpretation of results.Reflexive journal to document researchers’ thoughts and reflections throughout the research process and for discussing any emerging issues.Other general strategies, such as storing raw data systematically, recording the rationale and justification of methodological and analytical choices, transparently describing all the study steps, documenting detailed notes about the development and hierarchies of themes, and establishing consensus on themes.Additionally, we may provide the opportunity to all interested stakeholders to have free access to the research process by developing the KhITT study website and data visualizations to better understand, and make better use of, our study findings.Our research team includes policy makers, researchers, HIT experts, and members of the public as key informants for better understanding their perceived needs and priorities in identifying issues with EBHP, in order to make informed recommendations. Together, we designed the proposed study and we will collaborate closely in the data collection and in the interpretation, dissemination, and diffusion of study findings. In addition, we will establish an advisory group of policy makers, HIT professionals and researchers, and citizens, who will support the research process, provide input and insights into the data analysis and interpretation of the findings, and contribute to the dissemination plan. The advisory group will meet on a regular basis during the study.We have already obtained ethics approval by the harmonized Behavioural Research Ethics Board at the University of British Columbia using their online research administration tool. For the duration of the study, we incorporated procedures that intended to protect participant anonymity and confidentiality.Supplementary and raw data will be placed online, made publicly available, and linked to the University of Victoria repository.At the completion of the study, we will present the findings at local, national, and international scientific conferences; professional events for stakeholder groups, including interviewees if they are interested in and willing to share their contact information, for better stakeholder engagement; and our professional websites, where we will provide data visualizations. Findings will be presented in a summarized form with no identifying information. We will also publish the results in peer-reviewed journals, professional and lay magazines, and the study website.The KhITT framework focuses on various stakeholders’ perspectives to better understand their perceived needs and priorities in identifying issues with EBHP, in order to make informed recommendations. Ethics approval has been obtained by the harmonized Behavioural Research Ethics Board at the University of British Columbia. Currently, we are recruiting study participants and collecting their consent forms. We anticipate that we will complete data collection and analysis by December 2020. Preliminary results will be published in summer 2021.The KhITT conceptual framework focuses on the routine enhancement of engagement, flexible accessibility, and strong relationships among knowledge producers and policy makers as key factors influencing transparent policy making ; the fraThe KhITT framework fills a gap in the literature, since there are not a lot of technology policy frameworks. There is a need to delineate policy to help guide implementations, as there have been issues with the success of health care information technology implementations worldwide. We hope that the developing conceptual framework, which includes an electronic platform, will be a useful tool for researchers and policy makers to practice closer collaboration and to influence each other’s world and work. In addition, we anticipate that the KhITT study findings will have an impact on changing behaviors and enhancing use of evidence in health policy. Specifically, we expect that the use of our research findings will serve as a tool that may help with the following ,52:Inform and enlighten policy making and change knowledge, awareness, attitudes, or opinions about the process of making decisions and health policies, but not necessarily action .Make specific decisions and policies or interventions by directly applying research in a useable form, such as a brief or a protocol .Legitimate a position, win an argument, make a case, or persuade those in decision-making positions, in order to change.The ultimate goal of the proposed KhITT framework is to develop a conceptual framework and describe the technology platforms that would enable the EBHP development process. We anticipate that our rigorous content analysis will be able to produce insights and themes that are able to address our objectives, contribute to an in-depth understanding of the EBHP process within British Columbia, highlight all influential factors, explicitly disseminate and communicate the study results, identify issues with EBHP and provide informed recommendations to address them, and enhance efforts toward transparent EBHPs.


Responsibility for public health in England transferred from the National Health Service to local authorities in 2013, representing a different decision-making environment. Systematic reviews are considered the gold standard of evidence for clinical decision-making but little is known about their use in local government public health. This study aimed to explore the extent to which public health decision-makers in local authorities engage with systematic reviews and how they do so.n = 14) in Yorkshire and the Humber local authorities. Sampling was purposive and involved contacting Directors of Public Health directly and snowballing through key contacts. Face-to-face or telephone interviews were digitally recorded, transcribed verbatim and analysed using the Framework Method.Semi-structured interviews were conducted with senior public health practitioners (Public health practitioners described using systematic reviews directly in decision-making and engaging with them more widely in a range of ways, often through a personal commitment to professional development. They saw themselves as having a role to advocate for the use of rigorous evidence, including systematic reviews, in the wider local authority. Systematic reviews were highly valued in principle and public health practitioners had relevant skills to find and appraise them. However, the extent of use varied by individual and local authority and was limited by the complexity of decision-making and various barriers. Barriers included that there were a limited number of systematic reviews available on certain public health topics, such as the wider determinants of health, and that the narrow focus of reviews was not reflective of complex public health decisions facing local authorities. Reviews were used alongside a range of other evidence types, including grey literature. The source of evidence was often considered an indicator of quality, with specific organisations, such as Public Health England, NICE and Cochrane, particularly trusted.Research use varies and should be considered within the specific decision-making and political context. There is a need for systematic reviews to be more reflective of the decisions facing local authority public health teams. In 2013 responsibility for public health decision-making in England transferred from National Health Service (NHS) primary care trusts to upper-tier and unitary local authorities (LAs) as part of the Health and Social Care Act 2012. LAs became responsible for commissioning a number of specific public health functions, such as sexual health services, smoking cessation, drugs and alcohol services and obesity programmes, with a ring-fenced budget provided to deliver these functions  actually is there a good financial reason for doing it?” (Registrar01)Participants from two LAs wanted better links with universities, in terms of input into research priorities, academics visiting LAs to explain their research or translation of systematic reviews into guidance for practice:“I suppose that's part of what we try to do locally is translate the systematic reviews into useful pieces but sometimes we don't have the connection with the academics that we could benefit from.” (DPH01)One DPH was interested in the potential for more secondments of academics to LAs and vice versa. Another issue raised was the need for systematic reviews to be disseminated so that PHPs were aware of new research. An online resource where all systematic reviews could be quickly found and accessed and email updates on newly published reviews were both suggested.Other than addressing the barriers above, participants were able to suggest several specific ways that systematic reviews could be improved to be more useful. It was suggested that good executive summaries were important, particularly due to time constraints. Several participants also spoke of the value of systematic reviews providing recommendations on implementation and practice. The inclusion of economic evidence, such as return on investment, in systematic reviews was also suggested:A key theme that emerged was that senior PHPs saw themselves as having a role advocating for the use of evidence within LA decisions.For some, this commitment to evidence use was clearly linked to their sense of identity as a public health professional. For example, a number of consultants and DsPH referred to their public health training or were self-reflective about their use of evidence. Some expressed feelings of regret or sadness that they no longer employed skills such as literature searching or critical appraisal, or kept up-to-date with research:“I feel like I've let that side of my discipline go away because I'm so busy just trying to do the day job … and some Directors of Public Health I know are much better at keeping up with evidence or … good at having like … an area of interest that they keep up to. I think I rely a lot on experts … or when I do go to kind of CPD events but … it's a failing of mine really that I should spend a bit more time keeping up with it” (DPH03)PHPs were involved in trying to influence decisions beyond the public health team, including those of elected members and other parts of the LA, such as social care and the wider determinants of health. Some participants also saw themselves as having a role to interpret and summarise evidence for decision-makers:“I see myself as a bit of a broker between kind of taking the academic information and presenting that in a way that's meaningful to kind of the audience that I'm working with, be it kind of planners or commissioners or clinical leads.” (Consultant03)As part of this influencing role, some teams used specific pieces of evidence to persuade and influence decision-makers to support a certain position:“there's the more reactive stuff where something's happening or somebody says something and...I then have to go and look for evidence to either support or refute or we know that there's evidence that supports or refutes but having to sort of put it forward to change the direction of travel I suppose” (Consultant02)Some of this was akin to what has been described as political or symbolic evidence use, where evidence is used to justify a pre-determined position  can also help with changing thinking about something … they may help us think through a particular issue or they may help us commission a bit of research locally or they may help us have conversations with people. So I think they have a role but … I don’t think it’s that- and I don’t think to be fair I don’t think it’s ever been that really linear process” (Other03).position , 38:“Som“I suppose … the other thing that we might look at, the other way that we'd use evidence, whether systematic reviews or individual studies, would be what we do when they come out. So there might be significant ones published and then there’d be the question of we would then potentially look at our policy and how we might want to develop our policy based on those.” (DPH04)Another example of evidence use that was distinct to direct instrumental application to existing problems was the active response to new evidence as it was published:“I understand healthcare and social care through the research. That's just the way I've always done it.” (Consultant04)However, two consultants regarded it as an integral part of their job to keep up-to-date with new evidence:“we use evidence and systematic reviews and published evidence summaries from NICE and other national organisations … just as part of our day job really. We're always on the lookout for new evidence, new summaries, any changes … that might shift our knowledge and our thinking” (Consultant05)Research was encountered through a wide range of different routes, including dissemination from other organisations, Twitter, conferences, journal clubs, and professional networks.PHPs frequently engaged with systematic reviews and other research outside decision-making processes. The main reasons for this were maintaining knowledge, professional development and interest and it was sometimes expressed as a personal commitment. For example, one consultant had personal subscriptions to journals. Another consultant described themselves as a “big evidence person”, explaining that:“they definitely have a place, they're definitely very useful and we need to have them, even if they're not always acted on” (Consultant02)Their value was expressed by some participants as their ability to save them time by preventing the need to search for, appraise or summarise literature themselves. Relatively few participants explicitly stated that they valued them because they were high quality evidence but their perceived quality was often implicit when participants discussed their use. Some participants described a feeling of comfort or lack of worry when using systematic review evidence:“the sort of comfort of knowing … there’s somebody who’s done this really, really well” (Consultant04).Despite varying use, systematic reviews were highly valued in principle by most participants, particularly consultants, and seen as an important contribution to public health work:“it's only the start of the process to … build your case. The important thing is being able to argue your case and influence from that. So … for example you can design your service, you can start your policy on the basis of the evidence but you can't [be] quoting evidence to people indefinitely because it doesn't you don't come across well. You have to be able to put … everything into context and also have to reflect reality of funding, … political decisions” (Registrar01)However, some participants expressed limits to the value and impact of systematic reviews within LA decision-making. DsPH tended to talk more about the limits of reviews and the complex nature of decision-making. A theme emerged that published evidence was “only part of the puzzle” (DPH02) in decision-making:“I think there's a broader notion of what constitutes evidence and not quite so much the hierarchy of evidence that I'm used to from a more NHS, medical … gold standard systematic reviews through to observational stuff or whatever. Whereas … there's a hierarchy in that setting and I think in local government it's more horizontal so what a handful of people have said in a focus group is considered to be as important as a systematic review” (Consultant02)Trying to introduce research evidence to counter this was not always effective and could be received badly:“Sometimes the word ‘evidence’ or ‘this has come from the research’ doesn't always go down well with members and some of that is because local government really likes stuff that's relevant locally.” (Other03)In particular, international evidence and research from other parts of the UK could be disregarded or challenged by elected members:“whereas doctors, whereas health people I think will hold national evidence quite strongly, I think with when people work very locally, they're a bit like 'well that's all well and good but it doesn't apply to me' a bit more” (DPH03)Despite the contesting interpretations of evidence, the promotion of evidence within the LA was not always framed as PHPs working against an environment that was resistant to academic evidence. One participant said that, within a stakeholder group, public health would be seen as “the evidence guru” (Registrar01) and relied on to interpret the evidence base. Some other participants suggested that public health teams had the potential to increase skills and understanding of evidence within the wider LA.There were also contesting interpretations of evidence within LAs and a limited understanding of systematic reviews and other research outside of public health teams was highlighted. One consultant described how this could lead to difficult conversations when non-public health colleagues presented evidence that may be of limited quality or relevance. As previously discussed, a key theme that emerged was the power of local and anecdotal evidence within LAs:Interviews with PHPs demonstrated that systematic reviews are used directly in decision-making, as part of a culture of evidence use in the LA public health workforce. A wider engagement with systematic reviews and other research that is arguably intrinsic to senior public health roles, and sometimes expressed as a personal commitment to developing knowledge, was also noted. PHPs saw themselves as having a role advocating for the use of evidence within the LA and in some cases translating the academic evidence base. However, the extent of systematic review use varied between individuals and LAs. Use can be limited in the LA context, despite the fact systematic reviews are highly valued in principle and PHPs have a high level of exposure to research and appropriate skills to use it. Evidence is seen as only one factor in decision-making processes that can be complex and there are contesting interpretations of evidence. There are also a number of barriers to systematic review use in LAs, including time constraints, involvement of politicians and restricted access to journal articles. There are also barriers associated with the research available, including a lack of reviews published on topics relevant to LA public health. Systematic reviews can be seen as too narrow in their focus and not sufficiently reflective of the complex decisions facing PHPs. Other evidence is used alongside or instead of systematic reviews, with grey literature reports from specific trusted sources particularly valued. The source of evidence was important to participants and used as a quick way to judge quality and reliability.This study confirms findings from previous studies on public health decision-making which found that a wide range of evidence beyond academic research is used, local knowledge and evidence is particularly valued, and anecdotal evidence is powerful , 39, 40.However, this study raises questions over how easily examples of evidence use can be categorised as instrumental, symbolic or conceptual in political contexts. Although participants described research evidence being used in a ‘tactical’ manner, this did always equate to symbolic evidence use. In this context, even policies or positions that had been informed instrumentally by evidence still had to be sold politically to elected members, sometimes requiring the tactical use of specific pieces of evidence. A few participants also spoke about implementing new research findings as they were published, which is closer to the knowledge-driven model described by Weiss .Findings reiterate the complexity and heterogeneity of decision-making processes and evidence use , 26. TheThis study was based on a limited number of interviews in ten LAs. It was clear that many of the participants had a particular interest in evidence use so the findings may not reflect the full range of attitudes towards systematic reviews held by PHPs. Sampling focused on senior PHPs who had completed the public health speciality training programme and findings may not be generalisable to staff who have received less training in evidence use. As participants were working in one region of England only, some findings may not be generalisable to LAs in other regions. It has been suggested that there are specific drivers of health inequalities in the North of England and thus different priorities to other regions . As highThis study contributes to the understanding of the use of systematic reviews in decision-making, and more specifically the use of evidence in LA public health after the transfer of decision-making from the NHS. While it confirms a number of barriers and limitations to systematic review use found in previous studies, it also found differences with research undertaken in other public health settings. For example, some individuals used systematic reviews extensively, including direct use in decision-making processes and wider engagement, albeit alongside a range of other evidence. This reiterates the importance of considering evidence use with reference to the specific context and actors involved, in this case senior PHPs in LAs. Findings also highlight the complexity of decision-making and the fact that systematic reviews need to be more reflective of the decisions facing PHPs in LA public health.Additional file 1. Interview schedule.


The need for evidence-based decision-making in the health sector is well understood in the global health community. Yet, gaps persist between the availability of evidence and the use of that evidence. Most research on evidence-based decision-making has been carried out in higher-income countries, and most studies look at policy-making rather than decision-making more broadly. We conducted this study to address these gaps and to identify challenges and facilitators to evidence-based decision-making in Maternal, Newborn and Child Health and Nutrition (MNCH&N) at the municipality, district, and national levels in Mozambique.We used a case study design to capture the experiences of decision-makers and analysts (n = 24) who participated in evidence-based decision-making processes related to health policies and interventions to improve MNCH&N in diverse decision-making contexts  in 2014–2017, in Mozambique. We examined six case studies, at the national level, in Maputo City and in two districts of Sofala Province and two of Zambézia Province, using individual in-depth interviews with key informants and a document review, for three weeks, in July 2018.Our analysis highlighted various challenges for evidence-based decision-making for MNCH&N, at national, district, and municipality levels in Mozambique, including limited demand for evidence, limited capacity to use evidence, and lack of trust in the available evidence. By contrast, access to evidence, and availability of evidence were viewed positively and seen as potential facilitators. Organizational capacity for the demand and use of evidence appears to be the greatest challenge; while individual capacity is also a barrier.Evidence-based decision-making requires that actors have access to evidence and are empowered to act on that evidence. This, in turn, requires alignment between those who collect data, those who analyze and interpret data, and those who make and implement decisions. Investments in individual, organizational, and systems capacity to use evidence are needed to foster practices of evidence-based decision-making for improved maternal and child health in Mozambique. The need for evidence-based decision-making in the health sector is well understood in the global health community , 2. SuchMuch research already exists on evidence uptake. A 2014 systematic review looking at facilitators and barriers to uptake of evidence in policymaking, describes an “explosion of research in the area” , and inc, and more have been developed since then. Of particular interest for our study, Rodriguez et al.’s conceptual model  implemented in Ghana, Mozambique, Tanzania, Rwanda and Zambia , 14 was We undertook this study to identify persisting challenges and facilitators to evidence-based decision-making in MNCH&N at the local  and national levels in Mozambique. The study can contribute to broader discussions within global health, about health systems strengthening in resource-limited countries , such asThis study is based on a combination of case studies that capture the diversity of experiences of evidence-based decision-making processes about MNCH&N at different levels where decisions about health policy and interventions are made in Mozambique , and at different performance levels on select maternal and child health indicators over time. The indicators were maternal and under-five mortality ratios between 1997 and 2011, because those were used in the most recent analysis published by the NEP in Mozambique . We seleWe sampled key informants who had participated in the generation of evidence and decision-making for planning and implementation of interventions aimed to improve reproductive maternal and under-five survival in each of the case studies, between 2014 and 2017, and continued in their institutions or were still associated with NEP activities at the time of interview. Although NEP activities were formally concluded in 2016 when the National Health Observatory was created . The. The6]. The framework breaks-up demand and use of evidence into seven sequential steps, namely, “recognition, acquisition, cognition, discussion, reference, adaptation, and influence”. Recognition refers to “individual motivation to use evidence and [ability] to identify questions that can be answered by [ …] evidence”. Acquisition describes individual knowledge about where and how to search for evidence. Cognition refers to the ability to “assess the quality of evidence and understand results”. Discussion relates to sharing and discussing “evidence with colleagues, researchers and others”. Reference describes the “ability to interpret and synthesise [ …] evidence”. Adaptation is the “ability to adapt results to local context or current questions”. Influence describes people having “sufficient latitude within their role to use evidence to influence decisions” . Demand This thematic analysis process, followed a case-oriented approach  that focThe study was approved by Mozambique’s National Bioethics Committee for Health (CNBS) and the Ministry of Health, after endorsement from the Directorates of Health of Maputo City, Maputo Municipality, and Sofala and Zambézia Provinces. Interviews were conducted after obtaining written informed consent from key informants. They consented separately for documenting the interviews using field notes and audio-recording. Audio-recordings and fieldnotes were protected using alphanumeric individual codes that replaced the identification of each key informant. Before preparing this manuscript, study investigators obtained key informants’ feedback on preliminary study findings, and that feedback was incorporated into the current manuscript.We interviewed 24 key informants, including 10 from the NEP , two from Maputo Municipal Directorate of Health, and three from each of the two districts of Sofala and Zambézia Provinces (Table At the NEP we included two key informants from the steering committee (decision-makers) representing the home institution (INS) and the National Directorate of Public Health (DNSP). The remainder eight key informants from the Technical Working Group (TWG) were from the home institution, the National Directorate of Public Health and the National Directorate of Planning and Cooperation of the Ministry of Health, and from the National Institute of Statistics and the Ministry of Economics and Finance. We also interviewed a technical assistant from the NEP donor (Canada Department of Foreign Affairs Trade and Development) and another one from Universidade Eduardo Mondlane (UEM) a local public university. The two key informants from Maputo Municipality were the Council member responsible for the health portfolio (a decision-maker) and the statistics and planning supervisor .At each district of Sofala and Zambézia we interviewed all key informants we had planned for, namely, a district government official, a decision-maker and a statistics and planning supervisor from the District Health, Women and Child Welfare Service. Because of time constraints, we could not interview two additional decision-makers from either the National Institute of Statistics, the Ministry of Education or of Economy and Finance, or from the Technical Secretariat for Food Security. In Maputo City, we could not interview a decision-maker at the municipal government, and at the provincial level we could not interview a government decision-maker, a health directorate decision-maker and a health analyst.At the district and municipal level and the national levels, the most salient domain was a high-quality organizational capacity to support the demand and use of evidence from routine HIS data and population-based surveys to inform decision-making. In Fig. For instance, the involvement of the [local] government in decision-making. Here we plan for the [maternal and child lifesaving] interventions. Another example is the building of a new health facility, where different actors were involved, and we had to be based on evidence to justify building that health facility. [The district] had a low coverage of family planning consultation, and we had to include more actors and we trained several technicians and teachers to increase the coverage of family planning .At the district and municipal levels, organizational capacity was more vocalized than systems capacity, while individual capacity was not visible in any step of the evidence-based decision-making process. Organizational capacity manifested mostly in the form of resources to access evidence from routine HIS data and population-based surveys (acquisition). In Maputo City, these investments in acquisition were also made on research studies. Regular health sector and local government meetings were cited as forums for sharing and discussing (discussing) and for collaborative decision-making (adaptation) in which actors outside the health sector, particularly representatives of local communities and international NGOs participated. This was more prominent in the two districts of Sofala, as a key informant noted:The use of routine HIS data  and of research (Maputo City) to make decisions, during local government and health-sector meetings, about building health facilities, improving training or allocating human resources to specific areas, were incentives for decisions to be informed by evidence (influence). Maputo City stood out for investment in prioritizing and institutionalizing research and providing incentives for its demand (recognition). This site was an exception in taking advantage of investments in resources for assessing the quality of evidence and understanding it (cognition), which a key informant explained that results from the city being better endowed with resources than the rest of the country. Specifically, Maputo City has higher qualified personnel, health facilities are located within a shorter radius from each other and have computers and better telecommunications network infrastructures, which ensures connection to the electronic-based HIS.Across all local level cases, organizational capacity did not translate into individual abilities for demand and use of evidence. However, systems interactions were mentioned, especially local government and health authorities inviting representatives of other government sectors, community leaders, and international NGOs to bi-annual and annual meetings, for consultations (discussion), during which they obtained support to implement decisions (influence).At the national level, organizational capacity was the most cited capacity, similarly to the local level, followed by individual capability and some systems capacity. NEP’s steering committee, by following a process of defining questions that the TWG had to answer by evaluating evidence from population-based surveys and routine HIS data, successfully institutionalized demand for research evidence (recognition). The NEP also invested in building the capacity of TWG members to assess evidence (cognition), to discuss their findings through regular meetings  and to share and discuss them with steering committee members (discussion), and to interpret and synthesize evidence. All this was supported by high-quality training provided by national and international experts, both in Mozambique and abroad, and by steering committee members’ insistence on the need for research excellence rather than on using evidence to inform decision-making.That capacity [to conduct modeling and develop analysis to inform decision-making] continues there [at the Ministry of Health]. The National Health Institute is highly motivated to lead the process. To lead research .This investment translated into TWG members’ individual capacity to assess the quality of evidence  and understand the results of routine and population-based survey data (cognition). TWG members also developed abilities to discuss evidence among themselves, during their meetings  and to present them to the steering committee, usually once to twice a year (discussion). TWG members’ ability to interpret and synthesize evidence (reference), is partially obvious in a summary the National Health Observatory published in 2017, which “identified patterns of seasonality in routine data to inform health policy and programs” . As a study participant noted, this individual capacity was also beneficial to their organization, the Ministry of Health:What motivated me the most in NEP was its multisectoral composition  and people in different professional positions […]. It was a united class, which had no silos .Albeit to a lesser extent, systems capacity for recognition and discussion, was expressed in the NEP. The multisectoral composition of the NEP’s steering committee and TWG helped raise awareness about questions the project addressed among government actors outside the MOH (recognition). Meetings of both bodies of the NEP were excellent forums for multisectoral consultation and learning (discussion) that particularly motivated TWG members, as one of them described:More facilitators than challenges for evidence-based decision-making were mentioned at the district and municipal level. Conversely, more challenges were mentioned at the national level.At the district and municipal level, both facilitators and challenges were for evidence use, rather than for demand Table . FacilitAccess to evidence of quality, collaborative participation, development of planning and implementation capabilities […]. It is through these means that correct decisions are made, i.e., evidence is needed, collaboration of all involved in the decision-making process, those involved in the process of develop capabilities for better decision-making, which are then planned and implemented .The most prominent organizational level facilitators were access to electronic-based routine HIS data; collaborative decision-making at health-sector regular meetings in which non-health actors from the local government, community and NGO representatives were often invited; and linkages between planning of activities based on the available evidence and the ability to implement decisions made in those meetings. Systems level facilitators to use and demand of evidence were international NGOs’ funding and logistical support, and local government assistance, especially by allocating human resources and building health facilities.Look at how Maputo City looks likes from 7 am though 3:30 pm. It has nearly two million people. However, the planning was designed for the nearly 1.2 million inhabitants that the national census found. Another problem is how to reach Maputo City’s population. The greatest challenge here lies in looking at Maputo City as an exception to the rule. We need services appropriate to this reality. We have presented our concerns to the Ministry of Health, because this is the ministry that has to take adequate measures .We make central level decisions. In reality, we are more implementers than decision-makers. All decisions that are or were made are based on the five-year [central] government plan, which is the guiding document from which we create the Economic and Social Plan and the Health Sector Strategic Plan .The main challenges to the use of evidence were systemic. To a small extent, the lack of national government funding prevents the implementation of decisions at the local level. To a larger extent, however, a top-down approach to decision-making that relies on the central government and health sector planning documents, hinders decision-making sensitive to local specificities. This was noted by key informants in both Maputo City and a district in Zambézia Province.At the national level, key challenges were for use of evidence, and were found at the individual, organizational, and systemic levels, while the main facilitators were for demand of evidence and were at the organizational level alone Table .Table 3There is an informal NEP that influences decision-making at the Ministry [of health]. Such NEP is made up of [international] NGO technical staff who influence the Ministry’s programs and operational plans. That creates an important challenge to an evidence-based decision-making process, since it fragments priorities based on the influence of [international] NGOs and other partners of the Ministry of Health .The main individual challenge was limited qualified human resources in the public health sector and a training model focused on short-term sessions (week-long at most) that participants perceived to focus on building TWG members’ capacity to address the questions raised at the NEP, instead of capacities that could be applied to other questions and health issues they face in their everyday work. At the organizational level, participants perceived that dissemination of the results produced by the NEP was relatively later than needed and was not assertive enough. That the report published out of the work of the NEP did not include evidence from routine data made some participants perceive it as confirmation of the mistrust of quality of routine data that discourages its use in decision-making. Participants also perceived the influence of international NGOs and donors over the Ministry of Health as perpetuating decision-making practices that promote global priorities over national ones and prevent the institutionalization of evidence-based decision-making at the Ministry. A point made as follows:At the systemic level, key informants regarded the limited central government funding as a key challenge to countering the influence of international organizations and priorities. They also noted that the lack of participation of non-health actors  in the NEP was a challenge to promoting decision-making based on evidence the NEP had produced.Finally, the good work environment created by the good relationships among the institutions involved and the search for regular collaboration, along with the strategic vision of the steering committee was very helpful .Key facilitators were institutional investments in resources for capacity building of NEP’s TWG members in assessing the quality of evidence, analysing and synthesizing evidence, which was possible given the leadership of the steering committee, and creative communication and team building strategies that the project coordinators employed. This partially reflected in the following remarks:Our research into challenges and facilitators to evidence-based decision-making in MNCH&N at the municipality, district, and national levels in Mozambique suggests limited demand for evidence to inform decision-making. This may reflect local health officials not feeling empowered to make decisions, given a top-down approach in which decisions are made at the central level, while implementation occurs at the local level. The little mention of individual capacity for demand and use of evidence is consistent with this top-down approach because it reduces local level officers to implementers of plans and decisions that have been made elsewhere. It is also consistent with previous studies, which show that disengagement from the research process can lead to health officers feeling that policies designed centrally are not relevant to local realities , 23, 24.At the national level, it seems that all steps within the domains of demand and use of evidence identified in Rodriguez and colleagues’ framework were occurring at the organizational level. Conversely, none of those steps were present around the individual competences at the district and municipality levels, which echoes local concerns about the lack of individual research capacity. A key facilitator for developing data-use capacity that fosters multi-institutional collaboration is the positive feedback loop that occurs when individuals can see an immediate benefit to themselves or their institutions. This was the case of capacity building in the NEP, where the audience for findings was the steering committee . DespiteThis resonates with lack of trust in evidence having also been identified as a barrier to evidence-based decision-making , at the Study participants reported that the influence of international actors weakens the capacity of the Ministry of Health to set its own priorities. Previous studies conducted in Mozambique also suggest that, if not carefully coordinated, external NGOs – who are often well-funded and equipped to implement their programs, but who operate with their own agendas – may foment fragmentation of the national primary health care system and undermine the country’s ability to set its own priorities , 28. ConThe study missed perspectives from key informants who were not available for interview during the data collection period, especially some from the NEP’s steering committee and Maputo City’s provincial government. Because decision-making about health in Maputo City is under the responsibility of the municipality, this limitation has likely little influence over the study findings regarding Maputo City. Secondly, we did not have access to several documents, because they were not readily available or key informants did not feel comfortable sharing them without authorization from their supervisors. This challenge is ubiquitous in Mozambique  and can Notwithstanding these limitations, this study has ethical and methodological strengths. Specifically, the ethical approach we used, allowed us to fulfil the ethical obligation of reporting preliminary findings to study participants, and incorporate their feedback in this manuscript. The study design allowed us to describe facilitators and challenges that cover diverse contexts  where evidence-based decision-making processes for maternal and child health occur in Mozambique.We undertook this study to identify persisting challenges and facilitators to evidence-based decision-making in MNCH&N at the district, municipal and national levels in Mozambique, in 2014–2017. Evidence-based decision-making requires that actors have access to evidence and are empowered to act on that evidence. This requires alignment between those who collect data, those who analyse and interpret data, and those who make and implement decisions. Such alignment is still absent in the cases we studied in Mozambique. Additionally, institutionalizing practices of evidence-use for decision-making requires engagement and empowerment at individual, organizational, and systems levels that still face challenges at various levels in Mozambique. Those challenges are related to the lack of balance between centralized decision-making and decentralized action, between national level goals and local level specificities, and between global priorities and national needs. Addressing those challenges is important to achieving maternal and child health outcomes grounded on reliable evidence-based decision-making in Mozambique.


The IWGDF 2019 Updated Guidelines for prevention of foot ulcers in diabetes advise that nerve decompression surgery not be considered. This nerve decompression option has similar scientific supporting evidence to other surgeries which are recommended. The sanction ignores a large body of non‐Level 1 evidence demonstrating various beneficial outcomes of ND including pain relief, DFU prevention, and protection from recurrence and amputation. Diabetes/Metabolism and Related Research has published the updated IWGDF 2019 Guidelines on the prevention of foot ulcers in persons with diabetes. This advisory includes as Recommendation #13, ‘We suggest not to use a nerve decompression procedure, in preference to accepted standards of good quality care, to help prevent a foot ulcer in a person with diabetes who is at moderate or high risk of foot ulceration (IWGDF risk 2‐3) and who is experiencing neuropathic pain’.Guidelines, to seek further evidence of relative value of ND versus current standard treatments.We are struck by the inconsistency of this adverse advice with other guidelines, particularly the immediately preceding #11 and #12 recommendations addressing surgical tendon lengthening and flexor tenotomy procedures. Here, the expert panel authors present supportive opinions for tendon surgery despite an identical Weak/Low recommendation, again noting weakness of supporting evidence. Why the differing recommendation despite similar levels of evidence? No data are presented suggesting greater putative risk to ND compared to tendon procedures. And there is no specific call, as in the prior not use ND, be viewed? Is there evidence that ND carries increased risks of continued pain, repeat ulceration, sepsis, amputation or mortality? Are there published data that show the accepted standards of good quality care show superior outcomes? Sadly, there is neither. While evidence for ND may not be of Level 1 EBM quality, the evidence against its use does not exist above the level of persistent sceptical opinion.So how should this negative recommendation, to Now consider that the apparent bias against the nerve decompression procedure might be owing to a lack of appreciation of the dual nature of diabetic peripheral neuropathy (DPN) and a differing rationale and target for ND neurolysis in contrast to current standard treatment or the surgical tendon procedures. DPN has long been deemed to have a solely metabolic aetiology labelled length‐dependent axonopathy, and to be both progressive and irreversible. Only recently has come attention to the common presence of secondary, metabolically induced, peripheral nerve compressions in diabetes. This important entrapment component of neuropathy is due to physical nerve trunk enlargement within constrained spaces like fibro‐osseous tunnels and is substantiated by clinical observation, ultrasonography and MRI imaging studies.Integration of an anatomic compression understanding into the DFU aetiology and therapy paradigm has encountered persistent opposition.2, arterial flow pulsatility, balance, protection from initial DFU, lowest described ulcer recurrence risk and hospitalization for foot infections and amputation.We now know that in DPN, local nerve compression and its sequelae need not be permanent nor irremediable. Although ND evidence is mostly Level 2 or 3, clinical, uncontrolled and often retrospective, it is hardly meagre and compares favourably with contrary Level 5 expert opinion. Surgical site infection has been shown to be linked not to a diabetes diagnosis but to the neuropathy.Aside from improvements in these many outcome measures, another rarely mentioned phenomenon may be an important DFU correlate which is also responsive to ND. This is the circulation phenomenon called pressure‐induced vasodilatation (PIV). Zwanenburg et al have reviewed the concept and the evidence that local circulation, as measured by cutaneous laser Doppler flowmetry, is normally increased by gradual application of moderate pressure as might exist on pedal skin while standing and walking.Acute pain is also known to block PIV in animals. The relevance to chronic human DPN pain is unknown. We do know that chronic DPN pain has been responsive to ND in most cases,Neurologists have been reluctant to credit the decompression surgery for comfort restoration in DPN, citing potentials for bias or placebo effects and an unexpected bilateral benefit of unilateral ND.In DFU recurrence, overall expectations from 19 studies are that annual recurrence risk approximates 40%.Still, it is an attractive hypothesis, supported by much published literature, to propose that ND effects on pain relief, restoration of protective sensation, and recovery of PIV in combination can explain these patients' observed resistance to initial or recurrent DFU. We may well find that attacking the secondary compression neuropathy will be more successful and cost effective than current measures emphasizing surveillance and pressure management of DPN patients at high risk. But this remains speculation until academia is willing to participate in designing and joining ND research projects. Should ND prove an effective protection from DFU recurrence as proponents have reported, possibilities exist that the minimized DPN, restored protective sensation, and PIV recovery can be engaged to also prevent initial ulcerations, minimize amputations and avoid early mortality.Evidence for use of ND in DSP is not yet as scientifically compelling as would be ideal, coming from studies which are not EBM Level 1. Yet it would be our hope that a more open‐minded and informed IWGDF recommendation could be proffered than, ‘We suggest not to use a nerve decompression procedure’. At the very least, no adverse advisory opposing ND surgery should be made absent reports of actual harm or demonstrated superiority of standard care. Otherwise, DPN patients who may be ideal candidates for ND surgical treatment are denied this option to improve their comfort, prevent complications, and extend their life.This article represents the opinions of the authors on a topic of international clinical import and as such does not require any institutional committee or IRB approval.This essay reflects the opinion of the authors based upon personal experience as a diabetic neuropathy patient who has undergone nerve decompression surgery (DSN), a decade of study and review of the pertinent literature , and over 10 years of research and experience with ND and its results in treating diabetic neuropathy complications .