To achieve Sustainable Development Goal (SDG) 3—healthy lives and well-being for all people—development interventions  are critically needed in addition to biomedical interventions .However, many development interventions, such as house screening for vector-borne disease control, remain neglected in global health policy today.A major reason for this neglect is a requirement for evidence from rigorous systematic reviews and randomised controlled trials, which were designed for biomedical interventions and are poorly-suited to most development interventions.A new framework for assessing the health benefits of development interventions is urgently needed for the health sector to support and fully leverage the potential of the SDGs.Biomedical interventions, such as therapeutics, vaccines and insecticides, are alone insufficient to achieve Sustainable Development Goal (SDG) 3—healthy lives and well-being for all ages. We also need development interventions to tackle the underlying determinants of ill-health by reducing deprivation and improving living conditions and the environment. This recognition formed the bedrock of early public health, from housing improvements and clean water provision in 19th century Europe and North America,https://www.cochrane.org/), WHO bases guidelines on ‘high-certainty’ evidence, largely derived from randomised control trials (RCTs) where there is confidence that the true effect of an intervention is similar to the estimated effect.Despite their importance, many development interventions remain neglected in global health policy. For example, the World Health Organization (WHO) recognises the need for multisectoral approaches to malaria,Unfortunately, biomedical evidence assessments are ill-suited for evaluating the health effects of development interventions for three reasons. First, prioritisation of evidence from RCTs is inappropriate. Unlike vaccines and therapeutics, with homogeneous characteristics, effect size and feasibility, development interventions  are context-specific, necessitating numerous iterations of RCTs to generate an equivalent evidence base. RCTs of development interventions are themselves more challenging and expensive. Development interventions are often implemented over large areas . Estimation of a statistically robust effect size necessitates randomisation of an unfeasibly large number of areas. The interventions themselves can be complex and multifaceted , complicating estimation of effect sizes. Blinding is impossible. Unlike biomedical interventions, development interventions have few financially viable pathways to scale-up. For all of these reasons, few RCTs of development interventions are done. This precludes meta-analyses, limits certainty of evidence and leads to calls for more RCTs or ‘paralysis by analysis’.Second, despite trends towards including other types of study, many systematic reviews still disregard historical, programmatic and observational evidence. The recent Cochrane review of housing improvements to prevent malaria, the oldest intervention against this disease, included only two studies of 4102 screened.Basing guideline development on biomedical evidence assessments alone is problematic for several reasons. First, taking a narrow view will impede global health goals by limiting our toolbox of interventions. Second, a system geared towards biomedical interventions will favour continued emphasis on vertical over horizontal health programmes among funders and decision-makers.Third, a focus on biomedical evidence assessments is a lost opportunity for wider development goals. For example, clean water and sanitation are the core goals of SDG6. Both are also human rights since ‘everyone has the right to (an adequate) standard of living…’.6We advocate the creation of a new approach to assess the health benefits of development interventions with three considerations. First, we must relax evidence criteria, accepting that RCTs may be logistically or ethically unfeasible. Non-randomised studies (including well-conducted before-and-after studies) must be considered, or systematic reviews will continue to find low-certainty evidence. Second, we must measure co-benefits of development interventions to avoid implementation delays from RCTs focused on single pathogens (figure). Third, we must consider the socioeconomic patterning of illness and opportunities to address these interlocking vulnerabilities. A step in the right direction is the new WHO INTEGRATE evidence-to-decision framework that, unlike GRADE, can evaluate complex interventions and assesses more criteria including human rights.15At this pivotal time, the health sector has a critical responsibility to leverage and support the potential of the SDGs, but cannot fulfil this within the current policy making framework. We urgently need a new framework for assessing the health benefits of development interventions to prevent further delays in their implementation and to maximise their impact.


Lactobacillus rhamnosus GG, given prenatally and postnatally, have not been shown to prevent AE in infants, although mixed strains of probiotics may decrease the risk of AE if given to the mother during pregnancy and to the infant for the first 6 months of life. In the postnatal period, there is no evidence that hydrolysed formula, compared with cow’s milk formula (CMF), reduces the risk of AE in partially breastfed infants. However, weak evidence suggests that a specific partially hydrolysed whey formula decreases the risk of AE compared with CMF. No specific skin practices can be recommended to reduce the eczema risk in healthy term babies. There is weak evidence of a low risk of reversible hypothalamic–pituitary–adrenal axis suppression following 2–4 weeks of treatment with low‐potency topical steroids, and conflicting evidence as to whether bleach bathing affects skin flora or AE severity. A single study demonstrated that the topical Janus kinase inhibitor tofacitinib at 2% significantly reduces the Eczema Area and Severity Index compared with vehicle. Topical naltrexone cream 1% improves pruritus  by 30% more than placebo. There is weak evidence that topical alternative therapies, including antioxidants, micronutrients and some herbal medicines, may improve AE.This review is part of a series of annual updates that summarize the evidence base for atopic eczema (AE). The aim is to provide a succinct guide for clinicians on the key findings from 14 systematic reviews on the prevention and topical treatment of AE published or indexed in 2018. Various supplements, including long‐chain polyunsaturated fatty acids, vitamin D and the probiotic  here for the corresponding questions to this CME article.Click  Part 2 will cover systemic therapies. The details of the search methods can be found at: A meta‐analysis of six randomized controlled trials (RCTs), involving 1861 infants, found no evidence supporting prenatal intake of long‐chain polyunsaturated fatty acids for the prevention of AE.Lactobacillus rhamnosus GG (LGG) given prenatally and/or postnatally did not reduce the risk of AE,In infants at high risk of allergy, the World Allergy Organization recommends probiotics for the mother during pregnancy and when breastfeeding and for the infants.Lactobacillus, Bifidobacterium and Propionibacterium strains, significantly decrease the risk of AE when supplementation starts during pregnancy and continues in the infant through the first 6 months postnatally .Another review looked at a larger number of studies  and concluded that mixtures of probiotics, including A review on vitamin D concluded there was no evidence to support supplementation during pregnancy, breastfeeding or early infant life for the prevention of allergic diseases.n = 90).n = 77) or prolonged (in the first months of life) (n = 2896) feeding with hydrolysed formula, compared with cow’s milk formula (CMF), for the prevention of AE in infants who were partially breastfed.A high‐quality Cochrane Review concluded that there was no evidence for early, short‐term (3–4 days) feeding of infants with hydrolysed formula compared with exclusive breastfeeding to prevent eczema (n = 13) were included and although they did not measure eczema directly, primary outcomes evaluated change in stratum corneum hydration, transepidermal water loss and skin surface pH within 6 months of birth. There was no evidence of significant differences between the tested wash products or wipes compared with water. Two RCTs examined the impact of daily application of an emollient in neonates at risk of AE (n = 118 and n = 124). Although both studies suggested that daily emollient application from birth reduced the risk of AE at 6 months, the evidence from one of these was weak, being a pilot trial assessing feasibility of the approach. Follow‐up in studies in this SR was variable and short , and many of the studies had a significant risk of bias.Skin‐care practices, such as bathing, cleansing, nappy care and the management of dry skin with emollients, used for healthy term babies were investigated in a review that included 26 studies and 16 RCTs.The likelihood of hypothalamic–pituitary–adrenal (HPA) axis suppression following 2–4 weeks of treatment with topical corticosteroid (TCS) for patients aged ≤ 18 years with AE was reviewed .A well‐designed SR intended to explore the risk of skin cancer with long‐term use of TCS (more than once a week for ≥ 1 month); however, the authors were unable to answer the question because no suitable studies were identified.A review of bleach baths assessed 14 studies (prospective cohort studies and RCTs) in adults and children.Two reviews from the same group in different years assessed the applications of Janus kinase inhibitors (JAK‐I) in skin diseases.A review of 22 articles included one RCT on topical naltrexone 1% with crossover of 40 adults with localized and generalized AE with severe pruritus, and showed that the treatment improved pruritus visual analogue scores by 30% more than a vehicle placebo.n = 40) compared furpalmate against topical steroids; the others were compared against vehicle or placebo, or had no comparison group. These limitations make it difficult to draw a valid conclusion from this SR.A drug company‐sponsored review of emollients containing furfuryl palmitate and furfuryl derivatives concluded that these compounds were safe and effective for mild to moderate AE.An SR summarized the current evidence for topical micronutrient application in AE. It reported that certain vitamins  and minerals  appeared to provide some benefit, although vitamin A was not effective and vitamin D may have exacerbated symptoms. The 16 studies had varied methodology, small sample sizes, and included five murine studies, a case report, a case–control study, cross‐sectional studies, split‐body comparison studies and RCTs in 571 participants with AE (including children and adults). The outcomes were mixed, and had time frames for treatment ranging from 3 days to 8 weeks, making comparison difficult. A standardized outcome such as SCORing Atopic Dermatitis (SCORAD) was used in only three studies. It is difficult to draw valid conclusions from this SR.Mahonia aquifolium (Oregon grape), a plant used in traditional Chinese medicine, for skin conditions.M. aquifolium. Although a statistically significant difference in EASI was observed at 12 weeks treatment compared with baseline (2.01 reduced down to 0.06), baseline severity was very low and the mean reduction failed to reach the minimum clinically important difference of 6.6.An SR evaluated  GG reduce the risk of AE when given during pregnancy, although probiotic mixtures may decrease the risk of AE if given in pregnancy and for the first 6 months of the infant’s life.There is no evidence that long chain polyunsaturated fatty acids, vitamin D and the probiotic LIn the postnatal period, there is no evidence for the use of hydrolysed formula compared with CMF for the prevention of eczema in infants who are not exclusively breastfed.There is conflicting evidence as to whether bleach baths, compared with water baths, have any effect on the skin flora and severity of AE.Topical tofacitinib 2% (a JAKi) improves the severity of AE compared with vehicle.M. aquifolium.There is weak evidence for the use of topical alternative therapies to improve AE, including antioxidants, micronutrients and To demonstrate up‐to‐date knowledge of prevention and treatment for atopic eczema.The World Allergy Organization does not recommend using probiotics in pregnant women at high risk for having an allergic child.Lactobacillus rhamnosus GG during the prenatal and/or postnatal period for reduces the risk of AE in infants.There is meta‐analysis evidence that administration of Lactobacillus, Bifidobacterium and Propionibacterium strains significantly decrease the risk of AE when started during the mother’s pregnancy and continued through the first 6 months of the infant’s life.There is some evidence to suggest that mixtures of Randomized controlled trials investigating the use of probiotics are consistent in their definition of AE.It is easy to compare studies of probiotics in AE owing to consistency in dose and strain.Which of the following statements regarding the use of probiotics in atopic eczema (AE) is true?in vivo measurement of water loss across the stratum corneum.Transepidermal water loss is an invasive Transepidermal water loss is a direct measure of AE.There is no meta‐analysis evidence that certain wash products or baby wipes increase the risk of AE compared with water.There is strong evidence that daily emollient application from birth prevents AE.One of the strengths of studies in skin care in AE is the length of follow‐up.Which of the following statements regarding skin care in the prevention of atopic eczema (AE) is true?A meta‐analysis showed evidence that intake of long‐chain polyunsaturated fatty acids in breastfeeding women was better than placebo for the prevention of AE in infants.A meta‐analysis showed no evidence that prenatal intake of long‐chain polyunsaturated fatty acids was better than placebo for the prevention of AE in infants, but there was moderate heterogeneity and high risk of bias in included studies.Lactobacillus rhamnosus GG reduced the risk of AE in infants when given during the mother’s pregnancy.A systematic review showed that the probiotic A systematic review outlined evidence to support that pregnant and breastfeeding women should take vitamin D supplements to reduce the risk of AE in their offspring.A systematic review outlines evidence to suggest infants should be given vitamin D supplements to reduce the risk of AE.Which of the following statements regarding the prevention of atopic eczema (AE) is correct?Skin cancer is associated with long‐term use of TCS.The adrenocorticotropic hormone stimulation test is a foolproof investigation for assessing hypothalamic–pituitary–adrenal (HPA) axis suppression.There is a high rate of HPA axis suppression following 2–4 weeks of treatment with TCS for patients aged ≤ 18 years with AE.There is a low risk of HPA axis suppression following 2–4 weeks of treatment with TCS for patients aged ≤ 18 years with AE.Children using low‐potency TCS have a high risk of reversible HPA axis suppression.Which of the following statements is correct regarding the potential adverse effects of topical corticosteroid (TCS) for patients aged ≤ 18 years or with atopic eczema (AE) ?The topical Janus kinase inhibitor (JAKi) tofacitinib given for AE has been shown to produce a significantly greater percentage change than vehicle in Eczema Area and Severity Index (EASI) after 4 weeks.A systemic review including studies of high quality showed evidence that furfuryl palmitate and furfuryl derivatives added to an emollient formulation in mild to moderate AE were effective.A systematic review including studies of high quality concluded that formulations of vitamins B, C and E and the minerals magnesium, zinc and iodine improve AE in children.A systematic review concluded that topical vitamin A and D improved AE in children and adults.Mahonia aquifolium significantly reduces EASI in AE.A systematic review including studies of high quality concluded that topical Which of the following statements regarding topical treatments for atopic eczema (AE) is true?http://www.wileyhealthlearning.com/cedThis learning activity is freely available online at Read the article in print or online, paying particular attention to the learning points and any author conflict of interest disclosuresReflect on the articlehttp://www.wileyhealthlearning.com/ced and answer the CPD questionsRegister or login online at Complete the required evaluation component of the activityUsers are encouraged toOnce the test is passed, you will receive a certificate and the learning activity can be added to your RCP CPD diary as a self‐certified entry.This activity will be available for CPD credit for 2 years following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional period.


Access to breast cancer genetic counseling is suboptimal for patients with limited health literacy or a migrant background due to ineffective communication and lack of healthcare professionals’ recommendation. This study examines the effect of a blended training program  for healthcare professionals on their awareness, knowledge, and self-efficacy towards communication about genetic counseling with patients with limited health literacy or a migrant background. In total, 59 breast surgeons and specialized nurses from 16 Dutch hospitals completed an online module and group training. Knowledge, self-assessed awareness, and self-efficacy were assessed before the training and 33 participants also completed a posttest questionnaire 6 months after the training program. We also assessed the perceived applicability and relevance of the training program from healthcare professionals’ perspectives. We found a significant increase in self-assessed awareness of the prevalence and impact of limited health literacy and in healthcare professionals’ self-efficacy to recognize limited health literacy and to communicate effectively with patients with limited health literacy or a migrant background. We did not find an increase in knowledge score. Almost all healthcare professionals reported that they use the techniques learned in the training, such as the teach-back method and plain language, and felt more confident discussing breast cancer genetic counseling. Our results suggest that a blended training program for healthcare professionals has potential to improve their ability to communicate effectively about breast cancer genetic counseling with patients with limited health literacy or a migrant background and offers a promising way to increase the referral rate for these groups of patients. Breast cancer, the most commonly diagnosed type of cancer, affects about 12% of women worldwide  based on healthcare professionals’ and patients’ needs and preferences, to increase healthcare professionals’ knowledge, awareness, and self-efficacy when communicating about breast cancer genetic counseling with communication-vulnerable patients, i.e., patients with limited health literacy or a migrant background  and a group training in one of the participating hospitals (2 h). The online module included information about the prevalence of low literacy and limited health literacy in the Netherlands, the relevance of health literacy in understanding and appraising information from healthcare professionals, and the way health literacy relates to socio-economic and background characteristics of patients. It also included information about how to communicate effectively with patients with a migrant background. In the group training, the teach-back method—a methodology used by healthcare providers to check whether a patient understands what has been discussed—was used as a technique to identify patients with limited health literacy and role-play was used as a strategy to acquire required communication skills and to practice the use of plain language  to get access to the online knowledge module. Within 2 weeks, they were invited to attend a group training on location. We used a pre-/posttest design to evaluate the effect of the Erfo4all intervention on knowledge, self-assessed awareness, and self-efficacy related to communication about breast cancer genetic counseling with patients with limited health literacy or a migrant background. Six months after the group training, the healthcare professionals were asked to fill out a second questionnaire (T1), again to assess knowledge, awareness, and self-efficacy. At T1, we added self-report questions concerning the applicability and relevance of the training program as well as healthcare professionals’ perceived awareness regarding the problem of health literacy in general and their confidence to adapt their communication effectively. Only healthcare professionals who completed the whole program and filled out the T0 and T1 questionnaire were considered in the pre- and post-intervention analysis. For the additional questions, all healthcare professionals who filled in the T1 questionnaire were included.Outcome variables were assessed with self-constructed online questionnaires, before (T0) and 6 months after the training (T1). The items in these questionnaires were based on the intervention mapping approach and the matrix of change used for the development of our training program  literacy among people with a migrant background, the prevalence of adults with limited health literacy in the Netherlands, the level of education in relation to the level of health literacy, and option of using of a professional interpreter (self-reported). Each item was rated as correct (1) or incorrect (0) and a total knowledge score was computed as the number of correct answers.Awareness was assessed by three items: prevalence and impact of health literacy in the Netherlands, impact of health literacy on medical communication, and the importance of taking into account cultural factors when communicating with patients with a migrant background.Items were scored on a 5-point Likert scale ranging from (1) hardly aware to (5) very highly aware.Self-efficacy was assessed by five statements on having confidence in recognizing limited health literacy in patients, communicating effectively about breast cancer genetic counseling with patients with limited health literacy, understanding which customs and habits from patients with a migrant background might influence communication, coping with cultural factors in communication with patients with a migrant background, and coping with a language barrier.Items were scored on a 5-point Likert scale ranging from (1) totally disagree to (5) totally agree.At T1, we also assessed healthcare professionals’ perceived awareness regarding the problem of limited health literacy in general and their confidence to tailor communication about breast cancer genetic counseling to the needs of communication-vulnerable patients. These additional items were scored on a 5-point Likert scale ranging from (1) totally disagree to (5) totally agree. The relevance of the training was assessed by asking whether the trained healthcare professionals shared information about the training with colleagues in multidisciplinary oncology meetings. Application of skills, such as the use of the teach-back method and plain language, was assessed with a 5-point Likert scale ranging from (1) never to (5) very regularly.Univariate analysis was used to describe the background characteristics of healthcare professionals.α = 0.05. Statistical analyses were performed using SPSS version 24.0 .Categorical data, number of healthcare professionals, discipline, sex, and clinical setting are presented in numbers and percentages. Continuous data, like age and work experience, are presented as means and standard deviations. To analyze T0 and T1 data, we performed paired analysis or repeated measurement, since multiple responses from the same subject cannot be regarded as independent from each other. In this analysis, subjects were included only when data were available from both time points (T0 and T1). To check for potential selective drop-out, we compared the group that only completed the T0 (T0 only) with the group who completed both questionnaires (T0+T1) and looked for differences in demographics and outcome variables. To analyze pre-post differences in the outcome measures’ knowledge, awareness, and self-efficacy, we used the Wilcoxon signed-rank for related samples. Tests for statistical significance were two-sided with n = 59) and of those who completed both questionnaires (n = 33). Based on background characteristics, no statistical differences were found between both groups, indicating that drop-out between T0 and T1 was not selective.The baseline questionnaire (T0) was completed by 65 participants of whom 59 participants from 16 hospitals completed the whole training program (online module and group training). In total, 37 participants filled out the T1 questionnaire, of whom 33 participants from 14 hospitals filled out both questionnaires (T0 and T1). Table n = 33). At the posttest (after the training), there was a significant positive change on six outcome measures compared to the pretest (before the training). The largest increase was observed in participants’ self-efficacy. Understanding the customs and habits of patients with a migrant background, the ability to recognize limited health literacy, to communicate effectively about breast cancer genetic counseling, and to cope with cultural factors or a language barrier significantly increased from baseline to T1. Moreover, awareness of the prevalence and impact of limited health literacy in the Netherlands increased significantly. The total knowledge score did not increase over time.Table n = 37). More than 80% (n = 30) of the healthcare professionals reported having used plain language to explain genetic testing; of these, almost 41% (n = 12) reported using it (very) regularly. Even more, 92% (n = 34) reported applying the teach-back method to discover whether a patient understood information and to identify limited health literacy, while 62% (n = 23) reported using the teach-back method (very) regularly. More than 97% (n = 36) of the respondents felt more aware of health literacy problems and assessed their ability to recognize patients with limited health literacy higher and 86% (n = 32) reported that their ability to communicate effectively with these groups of patients had improved. Most healthcare professionals expected to benefit from a booster training session after 1 year and more than 41% (n = 15) reported sharing their experience with the training program in multidisciplinary oncology meetings with colleagues.In our prior study, we assessed acceptability and usefulness of the training program directly after the group training  aimed at increasing awareness, knowledge, and self-efficacy regarding limited health literacy and communication with patients with limited health literacy or a migrant background leads to significant improvement in awareness of the prevalence and impact of limited health literacy, and self-efficacy in communicating about breast cancer genetic counseling with these groups of patients. No significant differences were found in pre- and posttest knowledge scores, on awareness of the impact of health literacy on medical communication and the importance of taking into account cultural factors when communicating with patients with a migrant background. Almost half (41%) of the breast surgeons and specialized nurses who participated in the training reported to share their experience with colleagues and almost all reported to apply the techniques taught in the training in daily practice .Healthcare professionals experience several problems in discussing genetic counseling and testing with patients with limited health literacy or a migrant background. Low awareness of the problem of limited health literacy, difficulties in recognizing limited health literacy, coping with cultural factors and a language barrier in communication with patients with a migrant background, and a lack of the skills needed to discuss referral effectively with these patients are the main problems. This is often compounded by patients’ limited health literacy which has been shown to negatively affect their ability to play an active role in their own health care, by asking questions, participating in shared decision-making, and taking initiative  health literacy knowledge   apply certain communication skills. Although it is unknown whether the increased scores on awareness and self-efficacy in this case indeed led to sustainable changes in communication behavior in daily practice, feelings of self-efficacy have been linked previously with behavioral change (Mata et al. In conclusion, our study shows improvements in relevant outcome measures among a diverse group of healthcare professionals involved in surgical breast cancer care in different regions in the Netherlands. It is promising that the skills learned during the training seem applicable in daily practice, even in the long term, and that healthcare professionals reported gains in awareness and self-efficacy. We implemented the Erfo4all training program in three regions in the Netherlands in different clinical settings (academic and non-academic hospitals and among healthcare professionals from different disciplines. Our previous study showed that the acceptance and perceived usability of the program was high (van der Giessen et al.


Advice to a Young Scientist (1979) is a passage in his chapter on “Aspects of Scientific Life and Manners” where he discusses the techniques used in the hope of enlarging one’s reputation as a scientist or diminishing the reputation of others by nonscientific means.”The Brazilian–British biologist Peter Medawar won the Nobel Prize in 1960 for his study of acquired immune tolerance. Beyond his scientific work, he was also a gifted writer and expositor of scientific culture. One of the many treasures of his One such “trick,” Medawar writes, “is to affect the possession of a mind so finely critical that no evidence is ever quite good enough .” After all, as he writes in a different passage, “no hypothesis in science and no scientific theory ever achieves… a degree of certainty beyond the reach of criticism or the possibility of modification” .I share Medawar’s pragmatic vision of scientific reasoning. Scientists must resist the temptation to excessive skepticism: the kind that says no evidence is ever quite good enough. Instead they should keep their eyes open for any kind of information that can help them solve problems. Deciding, on principle, to reject some kinds of information outright, or to consider only particular kinds of studies, is counterproductive. Instead of succumbing to what Medawar calls “habitual disbelief,” the scientist should pursue all possible inputs that can sharpen one’s understanding, test one’s preconceptions, suggest novel hypotheses, and identify previously unrecognized inconsistencies and limitations in one’s view of a problem.This conception of science leads me to disagree with some elements of the philosopher of medicine Jonathan Fuller’s recent essay  about twscience or two philosophies of evidence so much as between two philosophies of action. In March, as health systems in Wuhan, Iran, and Northern Italy teetered under the weight of COVID-19 cases, Ioannidis cautioned that we really didn’t know enough to say whether a response was appropriate, warning of a “once-in a-century evidence fiasco” and suggesting that the epidemic might dissipate “on its own” [Fuller rightly points out that this distinction is only a rough approximation; indeed, there are many clinical epidemiologists who do not share the hardline skepticism associated with the most extreme wing of the evidence-based medicine community. But the distinction is also misleading in a subtle way. If the COVID-19 crisis has revealed two “competing” ways of thinking in distinct scientific traditions, it is not between two philosophies of its own” .. To my On the question of how we interpret evidence, Fuller concludes that to understand the scientific disagreements being aired about COVID-19, we need to blend the insights of each camp. “Cooperation in society should be matched by cooperation across disciplinary divides,” he writes. I don’t understand what this kind of bothsidesism means when one side is characterized as accepting many types of evidence, and the other as insisting on only certain kinds. On the question of how we should make decisions under uncertainty, of course more data are better. But decisions are urgent and must be made with the evidence we’ve got.This is not to deny that there are different and valuable perspectives on epidemiology. Like any other field, there are many specialties and subspecialties. They have different methods for how they study the world, how they analyze data, and how they filter new information. No one person can keep up with the flood of scientific information in even one field, and specialization is necessary for progress: different scientists need to use different approaches given their skills, interests, and resources. But specialization should not lead to sects—in this case, a group of scientists who accept only certain kinds of evidence and too rigidly adhere to a philosophy of non-interventionism.one type of disease—say, coronavirus diseases—requires drawing on a wide range of methodologies and disciplines.Infectious disease epidemiologists must embrace diverse forms of evidence by the very nature of their subject. We study a wide range of questions: how and under what conditions infectious diseases are transmitted, how pathogens change genetically as they spread among populations and across regions, how those changes affect our health, and how our immune systems protect us and, sometimes, make us vulnerable to severe illness when immune responses get out of control. We also seek to understand what kinds of control measures are most effective in limiting transmission. To understand these issues for even epidemiological studies of transmission in households and other settings. We consider immunological studies that show us how markers of immunity develop, whether they protect us against future disease, and how particular markers (say a certain type of antibody directed at a certain part of the virus) change infection and mortality rates. We consider molecular genetics experiments, including those conducted in animal models, that tell us how changes in a virus’s genome affect the course of disease. We consider evolutionary patterns in the virus’s genetic code, seasonal patterns in its transmission and that of other related viruses, and observational studies of the risk factors and circumstances favoring transmission. And, of course, we also consider randomized trials of treatments and prevention measures, when they exist, as we seek to understand which interventions work and which ones may do more harm than good.We consider evidence from classical The upshot is that, done well, epidemiology synthesizes many branches of science using many methods, approaches, and forms of evidence. No one can be expert in all of these specialties, and few can even be conversant in all of them. But a scientist should be open to learning about all of these kinds of evidence and more.Thinking about evidence from diverse specialties is critical not only for weighing evidence and deciding how to act but also for developing hypotheses that, when tested, can shed light across specialties. Appropriate humility dictates that molecular virologists should not assume they are experts in social epidemiology, and vice versa. To say “I’m a virologist, so I’m not going to account for any findings from social epidemiology in my work” gives up the chance to understand the world better.Here’s an example. In the case of a new virus like SARS-CoV-2, the fact that socioeconomically disadvantaged people get sick more often than the wealthy gives clues, which we don’t yet know how to interpret, about the way the virus interacts with hosts. It would be informative to a virologist to distinguish the following two hypotheses (among others): (a) exposure to high doses of virus tends to cause severe disease, and disadvantaged people are often exposed to higher doses due to confined living and working conditions, or (b) comorbidities such as heart disease and obesity are higher among disadvantaged people, and lead to more severe outcomes. Of course, either, both, or neither of these hypotheses may turn out to be important explanations, but the canny virologist should wonder and think about how to distinguish them experimentally and test results against data from human populations. Reciprocally, a canny social epidemiologist should look to virological studies for clues about why COVID-19, like so many other illnesses, disproportionately harms the least advantaged in our society.In practice, virologists, immunologists, and epidemiologists are different specialists who often work far apart and almost never attend each other’s seminars. I do not think we should spend all our time learning each other’s disciplines. But I do think that a scientist who genuinely wants to solve an important problem should be open to evidence from many sources, should welcome the opportunity to expand their list of hypotheses, and should seek to increase their chances both of making a novel contribution to their field and of being right. Central to this effort is considering information from diverse kinds of studies performed by people with diverse job titles in diverse departments of the university—as well as their diverse forms of data and argumentation.When we move from the realm of understanding to the realm of intervention, the need for openness to different sources of evidence grows further. In some cases, like whether to use a drug to treat infection or whether to use a mask to prevent transmission, we can draw on evidence from experiments, sometimes even randomized, controlled, double-blind experiments. But in deciding whether to impose social distancing during an outbreak of a novel pathogen—and in thinking about how the course of the epidemic might play out—it would be crazy not to consider whatever data we can, including from mathematical models and from other epidemics throughout history. With infectious diseases, especially new and fast-spreading pandemics, action can’t wait for the degree of evidentiary purity we get from fully randomized and controlled experiments, or from the ideal observational study. At the same time, we must continue to improve our understanding while we act and change our actions as our knowledge changes—leaving both our beliefs and our actions open, as Medawar says, to the reach of criticism and the possibility of modification.Where does the skepticism so characteristic of the evidence-based tradition come from? One reason may be the habits and heuristics we absorb from textbooks, colleagues, and mentors.own work and that of one’s team: find all the flaws you can before someone else does; fix those you can and highlight as limitations those which are unfixable. Recently an advanced PhD student said to me: “I read your new idea that you shared on Slack this morning and I’ve been doing my best all afternoon to break it.” It made my day, and made me think I probably had very little left to teach her.In supervising students and postdocs, inculcating these habits is one of the most challenging, gratifying, and time-consuming parts of scientific training—far more than teaching technical skills. Some of these rules of thumb are well suited to science in general and serve us well throughout our careers, no matter the field. Among these are workaday but important heuristics like: consider alternative hypotheses; look at raw data whenever possible before looking at processed data; and repeat experiments, especially those whose results surprise you. Indeed, these heuristics can be summarized as a form of intense skepticism directed at one’s before prescribing drugs to prevent heart attacks or before performing a certain surgical operation may be a good rule of thumb in medicine . But randomized controlled trials are not available for huge swaths of scientific inquiry, and the narrow populations often studied in such trials can limit their applicability to real-world decision making. Nor are they always available when we need them: they require a lot of time and administrative resources to execute . Stumping for Evidence is thus useful in many parts of clinical medicine but impractical in many other aspects of science-informed decision making. Applying this doctrine indiscriminately across all areas of science turns the tools of a specialist into the weapons of a sectarian.Other heuristics, however, are more specific to a narrow field and may be ill suited to other contexts. Insisting on gold standard, randomized trial evidence https://twitter.com/trishgreenhalgh/status/1256487624346341376)This point was appreciated by David Sackett, one of the pioneers of evidence-based medicine. “Evidence-based medicine is not restricted to randomized trials and meta-analyses,” he wrote in 1996. “It involves tracking down the best external evidence with which to answer our clinical questions” . And in There is another lesson to be learned about the alarms that have been sounded about public health during the past few years. When the real or presumed risk involves communicable agents, such as the prions that cause bovine spongiform encephalopathy (mad cow disease), no precaution, however extreme, can be considered excessive. By contrast, for noncommunicable agents, such as radio-frequency energy, the lack of a theoretical foundation and the absence of empirical evidence of a substantial increase in risk legitimize cautious inaction, unless and until a small excess risk is firmly documented .I’d tone down the statement that “no precaution, however extreme, can be considered excessive,” which is either rhetorical or sectarian. But in my ideal public health world we’d have a lot more good sense like that proposed by Adami and Trichopoulos, acting not only on the strength of the evidence we have but on the relative harms of being wrong in each direction. And whether waiting or acting, we’d work hard to get the evidence to meet the challenges of skeptics and improve our decision-making, all with an eye to the possibility of criticism and modification Medawar describes.Indeed, on the question of how we ought to act during an outbreak, two leading epidemiologists in the clinical tradition, Hans-Olov Adami and the late Dimitrios Trichopoulos, argued that the non-interventionist rule of thumb is suitable for chronic, noncommunicable diseases but foolish for fast-moving infectious diseases. In an editorial accompanying an article that showed that the impact of cell phones in causing brain cancer was not large but might be larger than zero, they counseled “cautious inaction” in regulating cell phones. But they noted this is not how you would reason in the case of a transmissible disease:What does all this mean for the COVID-19 crisis? Scientists of all stripes should work together to improve public health, and none should mistake a professional tendency or a specialist’s rule of thumb for an unshakable epistemological principle. All should support rigorous evidence gathering, especially for the costliest and most disruptive interventions. And insofar as scientists identify with a philosophical school that predisposes them to write off certain forms of evidence entirely, they should, in short, get over it. Instead we should use every possible source of insight at our disposal to gain knowledge and inform decisions, which are always made under uncertainty—rarely more so than at present.


To fully assess the quality of the guidelines for the management of malignant pleural effusions (MPE) and ascites and reveal the heterogeneity of recommendations and possible reasons among guidelines.A systematic search was performed in the database to obtain guidelines for the management of MPE and ascites. The AGREE IIGtool was used to assess the quality of these guidelines. The Measurement Scale of Rate of Agreement (MSRA) was introduced to assess the scientific agreement of formulated recommendations for the management of MPE and ascites among guidelines, and evidence supporting these recommendations was extracted and analyzed.Nine guidelines were identified. Only 4 guidelines scored more than 60% and are worth recommending. Recommendations were also heterogeneous among guidelines for the management of MPE, and the main reasons were the different emphases of the recommendations for the treatment of MPE, the contradictions in recommendations, and the unreasonably cited evidence for MPE.The quality of the management guidelines for patients with MPE and malignant ascites was highly variable. Specific improvement of the factors leading to the heterogeneity of recommendations will be a reasonable and effective way for developers to upgrade the recommendations in the guidelines for MPE. Malignant pleural effusion and malignant ascites are common complications of malignant tumors, often indicating that malignant tumors have reached an advanced stage and thus leading to a shorter survival and lower quality of life. Malignant pleural effusion (MPE) refers to pleural effusion caused by the metastasis of malignant tumors from the pleura or other location to the pleura. The median survival is approximately 3 to 12 months. Most commonly, cases of MPE originate from lung cancer (37.5%), followed by breast cancer (16.8%) and lymphoma (11.5%) . HoweverThe Appraisal of Guidelines for Research and Evaluation II (AGREE II) is a reliable and useful tool for assessment of guidelines. This tool has been validated in guideline evaluation studies in critical care medicine, pain medicine, urinary system diseases, nutrition support, etc. –14. CurrTherefore, to provide some useful references for guideline makers, we decided to use the AGREE ertool to conduct a comprehensive evaluation of nearly 10 years of malignant pleural effusions and malignant ascites guidelines, analyze the key recommendations of the guidelines, identify heterogeneities, and find the reasons for these differences.This study was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). AGREE II instrument was introduced to conduct a comprehensive evaluation of the methodological quality of the guidelines for the management of malignant pleural effusions and malignant ascites and to evaluate the rigor and transparency of the management of malignant pleural effusions and malignant ascites.https://www.ncbi.nlm.nih.gov/pubmed/), Web of Science (http://apps.webofknowledge.com/), and CNKI (https://www.cnki.net). Furthermore, some relevant websites were also searched to prevent omitting guidelines, such as Baidu (www.baidu.com), NCCN , ATS journal , ERS journal , and BTS (https://brit-thoracic.org.uk). The search keywords were “malignant pleural effusion/malignant ascites”, and the limitations were “Title/Abstract” and “guideline/statement/consensus/recommendation”.A systematic search for guidelines on malignant pleural effusion and malignant ascites was performed from October to November 2019 without time and language limitations in our study. The databases we searched included PubMed (We applied a number of inclusion criteria to ensure that we screened the appropriate guidelines: (1) must be a guideline, recommendation, statement, or consensus; (2) must have a clear and detailed recommendation for the management of malignant pleural effusion and malignant ascites in sections or full text; (3) issued within the last decade; and (4) was the latest version. Moreover, the collected guidelines were excluded according to the following criteria: (1) duplicate publications; (2) old version of the guidelines; and (3) an interpretation or assessment of guidelines rather than guidelines itself.A total of two reviewers independently evaluated the search results  to determine whether to include or exclude each reference, in case of disagreement, a discussion with a third expert reviewer was conducted.http://www.agreetrust.org/), which covers 23 items in six domains. The score of each domain can be used to judge the merits and recommendation level of the guidelines [The tool we used to objectively assess the quality of the guidelines is the AGREE II tool  rated each of the 23 items and six domains on a scale of 1 to 7, with “1” indicating total noncompliance and “7” indicating total compliance. The higher the score is, the better the quality. Any difference in score of more than 2 to 3 points for an item was discussed to determine the final score, and then one of our members summarized and calculated the scores of each domain:(obtained score − minimum possible score)/(maximum possible score − minimum possible score) × 100%.Finally, the weighted mean of the six domains was taken to obtain the final score of the guidelines. We conventionally defined a score greater than 60% as a recommendation for the guidelines, a score of less than 30% as no recommendation, and a score between 30 and 60% as a recommendation, but the guideline needs to be revised.P < 0.05 indicates a significant difference.This is a descriptive study, and SPSS version 17.0  was used for two-way ANOVA to calculate the ICC . The ICC is normally between 0 and ~ 1, and the higher the value is, the better the reliability. Good consistency among 2~4 people can be considered when ICC > 0.75, and According to the above search strategy, a total of 66 articles were obtained from the database and manual search, among which 17 were duplicate articles. After removing the duplicate articles, only 49 articles were left, and then these articles were screened one by one according to the inclusion and exclusion criteria. A total of 9 articles were finally identified  and chemical pleurodesis were recommended by almost all the guidelines, and the most effective sclerosant for chemical pleurodesis is talc. In addition, treatment for special conditions and other complications were recommended in some guidelines but rarely mentioned in other guidelines. For example, the reference guidelines  makes a In patients with symptomatic MPE, most guidelines –6, 8 recP = 0.003) (heterogeneity test: I2 = 4.79%). In the last systematic review [P = 0.026) . Based on the above evidence, talc poudrage has a slight advantage over talc slurry; although the recommendations differ slightly in their wording, we tend to think the two statements are consistent. Furthermore, there are still unreasonable citations of evidence in the guidelines. The main evidence cited in one set of guidelines [Six guidelines –6, 8 clec review , the autidelines , and theidelines   in the process of formulating guidelines for the treatment of malignant pleural effusion, a systematic search strategy for evidence is recommended, and explicit items of recommendation should be set as comprehensively as possible. (2) Additionally, to help readers and users to locate the evidence, reliable evidence sources are required. (3) Controversial recommendations, for example, whether to recommend talc poudrage or talc slurry for patients with MPE and which treatment is better, should depend on the quality of evidence. A conservative recommendation tends to be suggested when the quality and quantity of evidence cited is very low. (4) There is a lack of guidelines for the management of malignant ascites at present; more evidence-based guidelines should be created to guide the management of malignant ascites in the future. (5) In the process of formulating guidelines, a uniform reference standard is required to reduce the heterogeneity among guidelines, and the AGREE , tool is worth recommending. (6) In addition, guidelines should also include the suggestions and feelings of the target patients and express concern and appreciation for these patients. (7) Preferably, future guidelines should reach an agreement for international cooperation, discuss the heterogeneity among guidelines written by different organizations and countries, and give a complete and universal version of the guidelines for MPE and malignant ascites.There are some advantages in our study: (1) we used the AGREE IIGREE dto objectively assess MPE and malignant ascites treatment guidelines, providing a great reference for the future formulation of guidelines, and (2) to analyze the heterogeneity among recommendations, the OCEBM grading system was used to reclassify relevant evidence, and we also found the reasons for such heterogeneity in the current guidelines. This study has some limitations: (1) we included only guidelines published in English and Chinese and did not provide a comprehensive evaluation of the guidelines published in other languages. (2) The guidelines we considered were from the last 10 years. Within 10 years, the updated evidence and treatment have contributed to the heterogeneity of the recommendations. (3) The guideline quality evaluation based on the AGREE based mainly focused on the methodology but lacked a content and evidence assessment; this led to low-quality guidelines scoring very high and being used as a reference. Even though the total score cannot fully reflect the true quality of the guidelines, we used the OCEBM grading system to analyze the strength of the recommendations and level of evidence; to some extent, this grading system remedied the defects of the AGREE s tool. (4) In this study, only the guidelines for the management of malignant pleural effusion and ascites were included, and the results can only show the problems and quality of the current guidelines for the diagnosis and treatment of malignant pleural effusion and ascites, but fail to represent the current quality and problems of the guidelines related to thoracic surgery.This quality assessment of guidelines for malignant pleural effusion and malignant ascites revealed the differences and problems among different guidelines. The quality of the guidelines was affected by the rigor of development, in which the level of evidence varied greatly among guidelines, and there was also a lack of an appropriate evidence grading system in some guidelines. Furthermore, the two domains of stakeholder involvement and applicability are insufficient and disappointing in most of the guidelines. Moreover, regarding the content of the recommendations, there is some argument and controversy regarding the choice between talc poudrage and talc slurry and between large-bore tubes and small-bore tubes. In addition, each set of guidelines includes some unique treatment in the management of malignant ascites. These heterogeneities may be due to the different preferences of the guideline makers, the poor quality of evidence, and the limited level of medical treatment at present. Hopefully, these issues will be better addressed in future guidelines and updates.


To compare reproducibility of aortic pulse wave velocity (PWV) measurements obtained from phase contrast magnetic resonance (PCMR) and cross-correlation analysis to applanation tonometry.Increased pulse wave velocity (PWV) results from arterial stiffening and is commonly seen with ageing and in patients with atherosclerosis and/or hypertension . CurrentPWV was measured in ten healthy volunteers (age: 32.9 ± 8.3 years) two times with each modality. To obtain PCMR measurements, subjects were scanned in a 1.5 T Philips Intera CV scanner . Oblique sagittal images in the plane of the aorta were acquired and velocity was encoded in the foot-head direction. After the first PCMR scan, subjects were removed from the scanner, repositioned, and the scan was repeated. After two PCMR scans, subjects remained in the supine position and underwent two measurements of the aortic  PWV by applanation tonometry using a Sphygmocor device  in an adjacent room.PCMR data were analyzed by examining the velocity waveforms at multiple points along the length of the thoracic and abdominal aorta throughout the cardiac cycle. Cross correlation between flow waveforms was then used to determine the transit time between two adjacent locations along the aorta . A robusAgreement and repeatability of PCMR and tonometry measurements were assessed by Bland-Altman statistics . Inter-sMean PWV values from PCMR and applanation tonometry were not statistically different  Figure . The avePWV was successfully measured by PCMR combined with cross-correlation analysis and by applanation tonometry. There was no significant difference in the PWV values; however, PCMR has a statistically significant lower inter-test CV compared to tonometry. It can be concluded that PCMR and cross-correlation analysis can be combined to accurately assess PWV as an estimate of aortic compliance.


Introduction: Father-infant interactions are important for optimal offspring outcomes. Moreover, paternal perinatal psychopathology is associated with psychological and developmental disturbances in the offspring, and this risk may increase when both parents are unwell. While, the father-offspring relationship is a plausible mechanism of risk transmission, there is presently no “gold standard” tool for assessing the father-offspring relationship. Therefore, we systematically searched and reviewed the application and performance of tools used to assess the father-offspring relationship from pregnancy to 24-months postnatal.Methods: Four electronic databases  were searched. Selected articles included evidence of father-offspring relationship assessment in relation to parental perinatal psychopathology and/or offspring outcomes. Data was extracted and synthesized according to the following: (i) evidence supporting the performance of tools in terms of their psychometric properties when applied in the context of fathers, (ii) tool specific characteristics, and (iii) study specific methodological aspects in which the tool was embedded.Results: Of the 30,500 records eligible for screening, 38 unique tools used to assess the father-offspring relationship were identified, from 61 studies. Ten tools were employed in the context of paternal psychopathology, three in the context of maternal psychopathology, and seven in the context of both maternal and paternal psychopathology, while nine tools were applied in the context of offspring outcomes only. The remaining nine tools were used in the context of both parental psychopathology  and offspring outcomes. Evidence supporting the psychometric robustness of the extracted observational, self-report and interview-based tools was generally limited. Most tools were originally developed in maternal samples—with few tools demonstrating evidence of content validation specific to fathers. Furthermore, various elements influencing tool performance were recognized—including variation in tool characteristics  and study specific methodological aspects, .Conclusion: Given the strengths and limitations of each mode of assessment, future studies may benefit from a multimethod approach to assessing the father-offspring relationship, which may provide a more accurate assessment than one method alone. The antenatal period and 1st year postpartum  are associated with significant adjustments to fathers that pose risks for mental health difficulties. Among the various disorders that manifest perinatally, depression is one of the most common with incidence rates ranging between 8.4 and 10% in fathers —this risThere is emerging evidence in support of each link of this mechanism—i.e., between paternal perinatal mental health disorders and the father-offspring relationship, as well as between the father-infant relationship and subsequent offspring development. In general, less optimal parenting and reduced paternal involvement have been reported in the context of both diagnostic and symptom-level difficulties, experienced by fathers, in the perinatal period . Comparspill over” hypothesis ; as well as the “compensatory/buffering” model (such that fathers may try to compensate for (or buffer against) depression experienced by their partner by becoming more involved with the infant)  .Yet, inconsistencies in the reported evidence exist, with studies reporting no significant links between father-offspring relationship indices and either paternal or maternal psychopathology during the antenatal period , the 1squality of the father-infant relationship—such as fathers attachment relationship with the fetus . MoreovThe four interview tools assessed two domains of the father-infant relationship: (i) father-infant relationship quality and (ii) paternal involvement. Father-infant relationship quality was assessed by one tool and paternal involvement in child-care was assessed by the remaining three interview tools.p < 0.05 across the validity domains). Data supporting evidence of the tool's validity is presented below , extracted from all of the included studies using observational tools in this review.All 16 observational tools demonstrated evidence of internal structure primarily through the measurement of inter-rater reliability using intraclass correlation coefficients (ICC) or Cohen's kappa coefficients —with authors typically establishing moderate to good levels of agreement between raters, when applied to paternal samples in the included studies.Moreover, five of the 16 observational tools demonstrated additional evidence of internal structure in the remaining three sub-domains. This was demonstrated through evidence of dimensional structure with inter-scale correlations , factorial validity  and test re-test reliability .Two of the seven observational tools developed in paternal and parental samples  demonstrated evidence of content validity—through theoretically driven items specific to the measurement of paternal parenting. However, none of the observational tools demonstrated evidence of content validity, through the expert review of interactive domains or item development supported through interviews with fathers subject to content analysis.There was no reported evidence of response process validation across any of the observational tools developed in parental or paternal samples, included in this review.The majority of observational tools (12/16) excluding the AMSS, Behavior-State System; Competing demands task ; EAS; anSeven of the 16 observational tools demonstrated evidence of convergence with related constructs. Five observational tools  demonstConvergence With the same construct—i.e., With a measure of paternal parentingThe NICHD extracted from Brown and Cox  was the Convergence With related constructs—i.e., With a measure of maternal parentingFive of the 16 observational tools  demonstConvergence With related constructs—i.e., With the severity of paternal and/or maternal psychological symptomsFour of the 16 observational tools  demonstrated evidence of convergence with paternal symptom level difficulties —with paternal psychological assessments conducted antenatally and during the 1st year postnatal (2-12-months). This was primarily demonstrated through weak-to-moderate convergent associations with paternal interactive behaviors  speech  and affect , as well as infant interactive behaviors .In addition, three of the four tools  demonstrated evidence of convergence with maternal symptom level difficulties symptoms (i.e. depression)—with maternal psychological assessments conducted 2-3-months postnatal. This was primarily demonstrated through weak-to-moderate associations with paternal interactive behaviors  and affect .In general, increased levels of both paternal and maternal symptom level difficulties were associated with less optimal father-infant interactions—with most father-infant interaction assessments conducted during the 1st year postnatal (2- to-12-months).Four observational tools  demonstrated evidence of group discrimination between clinical diagnostic groups; while two tools  demonstrated evidence of discrimination between symptom-levels groups—in some, but not all paternal and/or infant behaviors assessed across the tools.Discrimination Between Parent Clinical Diagnostic GroupsFour of the 16 observational tools  demonstrated evidence of discriminant validity between paternal clinical diagnostic groups only —with the majority of clinical diagnostic assessments conducted at 2-3-months postnatal.This was demonstrated through evidence of clinical group discrimination across paternal interactive behaviors , speech , and affect , as well as infant interactive behaviors .In general, fathers with diagnosed psychopathology displayed less optimal father-infant interactions, compared to fathers with no diagnosis—with most father-infant interaction assessments conducted during the 1st year postnatal (~2-to-12-months).Discrimination between parent symptom-level groupsTwo of the 16 observational tools  demonstrated evidence of discriminant validity between maternal symptom level groups only—i.e., high v low maternal depressive symptom groups (based on EPDS cut-off scores). This was demonstrated through evidence of group discrimination across paternal interactive behaviors , affect , as well as infant interactive behaviors , as well as infant affect .Evidence from these two studies utilizing the two tools was mixed. While some evidence suggests that fathers whose partner reported symptom level difficulties scoring above the cut-off  displayed less optimal overall father-infant interactions at the same time-point, other research indicates that fathers whose partner reported symptom level difficulties above the cut-off  displayed increased levels of positive affect during father-infant interactions at 15–18 months.Six of the 16 observational tools  demonstrated evidence of predictive criterion validity with offspring outcomes—in some, but not all paternal and/or infant behaviors assessed across the tools.This was demonstrated through mostly moderate predictive associations between paternal interactive behaviors , speech  and paternal and infant affect  examined in relation to offspring outcomes—i.e., infant attachment security externalizing behavioral problems, language development, executive functioning and mental development.In general, higher quality father-infant relationships characterized by more sensitive and responsive interactions are associated with more optimal offspring outcomes. The majority of evidence was based on interaction assessments conducted at 3-6-months and at 24-months and offspring outcome measures assessed between 12 and-36-months (follow-up period ranging from 7-to-17-months)—with the exception of two tools  examined in relation to child outcomes after an 8-to-11-years follow-up period.All 18 self-report tools used to assess father-offspring relationship quality or paternal involvement demonstrated evidence of validity in at least one validity sub-domain , extracted from the included studies using self-report tools in this review.The majority of self-report tools (13/18) excluding the PAQ; PBQ; and three unnamed tools demonstrated evidence of internal structure through the measurement of internal consistency, primarily using Cronbach alpha—with authors typically establishing acceptable to good levels of internal consistency, when applied to paternal samples in the included studies in this review.Furthermore, three self-report tools  demonstrated evidence of internal structure in the remaining three sub-domains of internal structure , while one tool (PBQ) demonstrated evidence in two of these sub-domains . A further 10 tools demonstrated additional evidence of internal structure in only one of the remaining three sub-domains—i.e., dimensional structure (PAAS), factorial validity  and tesSix of the 10 self-report tools developed in paternal or parental samples  demonstThree of the 14 self-report tools  demonstrated evidence of response process validity specific to paternal samples, with modifications made based on fathers' responses during pilot testing.Most self-report tools (17/18—excluding the CRQ) extracted across 27 studies demonstrated evidence of relations with other variables—in at least one validity sub-domain .Fourteen of the 18 self-report tools demonstrated evidence of convergence with either the same construct  and/or related constructs .This included 10 self-report tools  which dSix of the 18 self-report tools  demThis was demonstrated through mostly moderate-large convergent associations between father-offspring relationship sub-scales  and another measure of either fathers attachment relationship to the fetus/infant, paternal involvement, or relations with paternal perceived skill/competence—with the majority of evidence based on interaction assessments conducted antenatally and across the 1st year postnatal.Five of the 18 self-report tools  demonstrated evidence of convergence with a measure of maternal parenting.This included mostly moderate-large convergent associations between measures of the father-offspring and mother-offspring relationship, across the same behavioral sub-scales, including parents attachment relationship to the fetus/infant, parent-infant bonding and involvement—with the majority of evidence based on interaction assessments conducted antenatally and across the 1st year postnatal.Nine of the 18 self-report tools  demonstIn addition, two of the nine tools  demonstrated evidence of convergence with maternal symptom level difficulties symptoms —with maternal psychological assessments conducted antenatally and at 6-weeks, respectively. This was demonstrated through weak associations with father-offspring relationship sub-scales—i.e., fathers attachment relationship to the fetus and father-infant bonding difficulties.In general, evidence from tools examined in relation to paternal psychopathology suggests that increased symptom level difficulties were associated with less optimal father-infant interactions—with most father-infant interaction assessments conducted antenatally and across the first postnatal year.In contrast, the two tools which demonstrated evidence of convergence with maternal symptom level difficulties was mixed. While some evidence suggests that fathers whose partner reported increased depressive symptom level difficulties antenatally had more optimal attachment relationships to the fetus, other evidence indicates that fathers whose partner reported increased anxiety and depressive symptom level difficulties  had less optimal attachment relationships to the fetus and more bonding difficulties with their infant at 6-months.Two of the 18 self-report tools  demonstThere was no reported evidence of discrimination between clinical diagnostic groups across the self-report tools included in this review.Two of the 18 self-report tools  demonstThis evidence suggests that fathers reporting symptom level difficulties scoring above the cut-off  displayed less optimal attachment relationships with their infant at 1- and 4-months and lower levels of involvement at 9-months.Four of the 18 self-report tools  demonstThis was primarily demonstrated through mostly moderate predictive and concurrent associations between father-infant relationship sub-scales  and offspring outcomes .In general, this evidence suggests that higher quality father-infant relationships are associated with more optimal offspring outcomes—with the majority of father-infant interactions assessments conducted across the 1st-year postnatal and offspring outcome measures assessed at 6-to-12-months (follow-up period for predictive associations ranging from 3-to-12-months)—with the exception of one tool (CRPR) assessing outcomes at pre-school age.All four interview tools used to assess father-offspring relationship quality or paternal involvement demonstrated evidence of validity in at least one validity sub-domain , extracted from the included studies using interview tools in this review.One of the four interview tools (WMCI) extracted from one study demonstrated evidence of internal structure through the measurement of inter-rater reliability using Cohen's kappa coefficients (ϰ); indicating good levels of agreement between raters when applied to a paternal sample. However, there was no reported evidence of factorial validity or test re-test reliability, across the interview tools included in this review.One of the four interview tools [an unnamed tool ] developThere was no reported evidence of response process validation across the interview tools developed in parental or paternal samples included in this review.Three of the four interview tools  eThree of the 14 self-report tools demonstrated evidence of convergence with either the same construct  and/or related constructs . This included one interview tool (WMCI) which demonstrated evidence of convergence with another measure of paternal parenting; while two tools  demonstThe WMCI extracted from Hall et al.  was the There was no reported evidence of convergence with a related measure of maternal parenting across the self-report tools, included in this review.One of the four interview tools [Parental Involvement Time Diary ] demonstIn addition, two of the four interview tools  demonstEvidence from the Parental Involvement Time Diary suggests that increased paternal antenatal and postnatal symptom level difficulties were associated with lower levels of paternal involvement at 3-to-9-months. In relation to maternal symptom level difficulties, evidence was somewhat mixed. Findings from both tools suggest that fathers whose partner reported increased anxiety and depression symptom level difficulties had increased levels of involvement in child-care related activities antenatally and across the first 6-months. In contrast, there was some indication from the CDS suggesting that partners increased symptom level difficulties from 7-to-12-months were associated with lower levels of involvement.The CDS extracted Goodman et al.  was the Note, mean values for each group were not reported since this relationship was examined to test for potential control variables, and was not a main focus of the study).Evidence from the CDS demonstrated evidence of discrimination between paternal clinical diagnostic groups —fathers lifetime history of depression was associated with their level of accessibility to the child and involvement in child-care related activities at 3, 6, and 12-months  and offspring outcomes.Evidence is discussed in relation to three key themes: (1) the tools' psychometric robustness across four validity domains ; (2) the tools' characteristics; and (3) methodological study features in which the tool was utilized. Considerations and recommendations are drawn from the synthesized evidence to help guide tool selection, as well as areas of future research.The synthesized validity evidence demonstrates that most tools included in this review were originally developed in maternal samples. Of the tools developed in parental and paternal samples, nine tools demonstrated evidence of content validation specific to paternal samples—i.e., two observational , six self-report tools  and oneNonetheless, the majority of observational and self-report tools, as well as one interview-based tool (WMCI), regardless of the sample they were initially developed in, did demonstrate evidence of internal structure—with authors typically establishing adequate levels of inter-rater reliability or internal consistency, when applied to paternal samples in the included studies. However, there was a general lack of evidence across all tools to support their factor and dimensional structure, test re-test reliability, as well as the processes underlying item response and performance in the context of fathers. Only two self-report tools  demonstrated additional evidence of internal structure across these three sub-domains, whereas only evidence across two domains  was demonstrated in one observational tool (NICHD). There was no such evidence in any of the four interview tools included in this review.While it is encouraging that some research over the last few years has focused on the development of tools with a theoretical focus on the father-offspring relationship, the synthesized evidence suggest that the majority of father-offspring relationship assessments were based on tools originally intended to assess the mother-offspring relationship. Given evidence from some studies suggesting that mothers and fathers differ in the way they understand and interact with their offspring , future With regards to the tools' relations to other variables, tools were generally applied in the context of paternal psychopathology—with evidence generally suggesting that the presence of paternal psychopathology  was associated with less optimal father-offspring relationships. This was based on evidence from 14 tools demonstrating evidence of convergence with paternal symptom level difficulties, as well as some evidence discriminating between paternal symptom-level groups—i.e., four observational , nine self-report  and oneIn contrast, far fewer tools used to assess father-offspring relationship were utilized in the context of maternal psychopathology, and overall, the extracted evidence utilizing these tools was mixed—i.e., supporting both the “spill over”  andNonetheless, the father-offspring relationship is not only shaped by, for example, the family environment and exposure to psychopathology, but also the degree of coordination between specific parenting behaviors. For example, there is some evidence to suggest that parents who consider themselves as competent and skilled parents are more likely to be involved in child-care , 121. HeSimilarly, evidence supporting the predictive value of tools utilized in the context of offspring outcomes was generally limited across the tools included in this review. This included six observational  and four self-report tools  which dSeveral important variations potentially influencing tools' performance were identified. These are: (i) differences in the behaviors assessed across tools, (ii) the conceptualization of father-offspring relationship constructs, and (iii) diverse scoring formats applied to these constructs.The tools included in this review assessed a broad range of behaviors within the father-offspring relationship. While self-report and interview tools generally evaluated overall measures of the father-offspring relationship , observational tools assessed more discrete domains of behaviors on a broader spectrum . However, there was considerable variability across the tools in how behaviors within the father-offspring relationship were associated with either offspring outcomes or parental psychopathology—especially in relation to observational tools.via. the GRS were higher in fathers in the depressed group (defined in this study as fathers with a positive SCID and/or BDI/EPDS depressive symptoms above the cut-off), compared to non-depressed, at 2–16 weeks ]—via. the Categorical System for Micro-Analysis of the Early Mother–Child Interaction using frequencies and time-durations for a composite of behaviors   , whereasalizing) , 125 havTherefore, decisions surrounding the selection of a tool should be guided by the behavior intended to be assessed, the rationale of the study, and should consider the strengths and weakness of the coding frameworks utilized. For example, global ratings are useful for capturing the quality of interactive behaviors and are more time-efficient in comparison to frequency coding , 126. OnLikewise, there is variation regarding scoring formats applied to the construct of paternal involvement. For example, self-report tools included in this review primarily assessed “relative” measures of father involvement , whereas interview measures most often assessed “absolute” values of paternal involvement .While adopting “relative” measures to assess paternal involvement may, in part, reduce social desirability bias  and indicate levels of involvement within a family, “absolute” measures also need consideration. Hence, adopting both relative and absolute measures may be beneficial, given their potentially differential links with measures of parental psychopathology and offspring outcomes.Several methodological aspects potentially influencing tools' performance were identified. These include: (i) study setting and sample characteristics, (ii) study design, (iii) interaction setting, and (iv) timing and nature of correlates  examined in relation to assessments of the father-offspring relationship.Most tools used to assess the father-offspring relationship were applied to homogeneous samples—comprising mainly Caucasian fathers from largely high-income settings, well-educated fathers residing in the family home and from two-parent families of middle to high SES. More diverse samples have been relatively unexplored, despite differences in paternal interactive styles across cultures. For example, physical play as an essential hallmark of paternal interactive style is less often evident in non-western samples . SimilaImportantly, the majority of tools included in this review were applied to relatively small to modest sample sizes of <200 participants recruited from samples across single hospital or clinic sites —with up to one third of included tools in this review applied to samples of <100 participants. Only two observational (NICHD) and six self-report tools  were apMost of the tools used to assess the father-offspring relationship included in this review were applied to cross-sectional data analyses. Those tools which were utilized in the context of prospective analyses had relatively short follow-up periods—on average around 10-months. In addition, assessments of the father-offspring relationship and their correlates  were mostly assessed at one time-point—especially across studies employing observational tools. Thus, in choosing a particular tool the stage of offspring development should be given careful consideration—given the infants rapid development over the 1st year post-partum and high susceptibility to the quality of the parent-offspring relationship , 129.It is also likely that the tool's performance may depend on the interaction setting. For example, there is some suggestion that free-play sessions may allow more depressive behaviors to emerge, leading to increased displays of parental withdrawal, whereas other settings, such as infant-seat and structured task-based play, require greater involvement from the parent , 130. YeMoreover, most tools used to assess the father-offspring relationship included in this review were examined in relation to paternal psychopathology during the antenatal period and within the first 3-6-months following birth. Yet, there is evidence to suggest that, in comparison to mothers, father's vulnerability to psychopathology may peak later on toward the second half of the 1st year postpartum —with potSimilarly, the performance of tools used to assess the father-offspring relationship likely depends on the onset and duration of maternal psychopathology. For example, in one study utilizing the CDS to assess paternal levels of involvement, higher levels of maternal depressive symptoms from 4 to 6-months predicted increased levels of paternal-reported weekend engagement and accessibility in child-care at 12-months. In contrast, depressive symptoms from 7 to 12-months predicted lower levels of paternal reported weekend accessibility at 12-months . This suMany tools used to assess the father-offspring relationship included in this review were also examined in relation to parental depression, and to a lesser extent, anxiety, and alcohol dependence. In addition, paternal anxiety and depression symptoms may have differential influences on the father-offspring relationship . HoweveTaken together evidence from this study points toward the validity of tools in relation to depression (i.e. symptom level difficulties). Hence, the application of these tools in the context of other mental health conditions, requires further testing, before they can be reliably applied to different populations.Finally, the tools included in this review were examined in relation to a range of offspring outcomes domains. This primarily included behavioral problems, attachment security, difficult temperament—and to a lesser extent, infant sleep quality, psychological difficulties, and indices of social and cognitive development. However, most tools assessed the father-offspring relationship at one point in time, around the 1st-year postpartum—with relatively short follow-up periods for infant outcomes (mostly between 2 and 12-months). Hence, further research focused on different developmental stages may help identify and target specific patterns of paternal behavior which have a predive value in terms of developmental outcomes. This would also support the development of objective predictive tools which might be useful in early intervention programs to help fathers better interact with their children.The search strategy for this review was intentionally broad to capture relevant literature and its performance was tested to ensure optimal sensitivity. Furthermore, decisions regarding inclusion of potentially relevant literature were made by two reviewers, to promote the robustness of decision-making. Nonetheless, it is possible that some studies would have been missed—for example, where there was no indication in the abstract of the use of a tool used to assess the father-offspring relationship in relation to parental psychopathology and/or offspring outcomes, during the perinatal and up to 24-months postpartum. Moreover, this review focused specifically on the literature concerning the direct relationship between the father and the offspring—i.e., father's direct interactions with their offspring and their involvement in child-care related activities.However, other important aspects of the father-offspring relationship, such as offspring attachment security, fathers attitudes and beliefs which guide parenting and predict the future quality of the father-offspring relationship and level of involvement , 133, weIn addition, since one of the main aims of this review was to examine the performance of tools used to assess the father-offspring relationship in the context of parental psychopathology, other determinants which shape the father-offspring relationship were not examined—including, for example, marital satisfaction, parenting stress, and socioeconomic circumstances , 134. ThFinally, since there is currently no “gold standard” measurement to assess father-infant interactive processes, over the perinatal period, our eligibility criteria were focused on observational study designs. While future research could examine the effectiveness and robustness of tools used to assess the father-offspring relationship in the context of intervention studies, it is first necessary to conduct further research to assess the psychometric robustness of these tools when applied to the father-offspring relationship in specific contexts .Based on the synthesis of evidence in this review, recommendations, and clinical implications are outlined to help guide tool selection. This is discussed in relation to the applicability and performance of tools across clinical populations, as well as the feasibility of implementing such assessment tools for use in clinical practice.First, given the limited evidence of tools examined in the context of a clinical diagnosis in fathers—with most evidence on symptom level difficulties—caution should be taken in their application within a clinical setting. Similarly, based on the tools included in this review, there is no current evidence to support the application of father-infant interaction tools in families where the mother is clinically unwell.Hence, at present, it is not possible to recommend one specific tool type over another for use within a clinical setting. Moreover, there is limited evidence to assess the clinical relevance of interaction patterns since typical distributions of clinical data and clinically valid cut-off scores have not been widely established. Thus, before such clinical data is available, a multimethod approach utilizing a range of tool types may be beneficial in providing a more accurate assessment—with the potential to compare interaction patterns across the tool types.Second, these assessment tools may offer a potentially valuable resource in a variety of clinical settings—for example, for use in preventative screening to identify interactional difficulties, to support the formulation of risk assessments, and for the evaluation of treatment outcomes in parent-infant interventions. There are potentially important clinical applications for the identification of father-infant dyads which may benefit from early intervention programs, such as video-feedback interventions which have already provided encouraging results in non-clinical samples .Of note, the implementation of father-offspring relationship tools within routine clinical assessments may depend on feasibility and accessibility for use by health workers from a range of professional backgrounds. For instance, observational tools are often complex and lengthy for clinical use demanding considerable resources—including lengthy assessments, extensive training and experience, reliability maintenance and testing, as well as high training costs. Hence, services will need to consider the best ways to invest in staff training and the maintenance of these skills over time. This may include, for example, the development of standardized online training modules which include examples of interaction assessments , integrated video feedback clips and standardized self-assessment reliability tests. This could ease the burden on training and increase access in clinical practice. Crucially, the consideration of a multi method approach for the assessment of the father-offspring relationship would also be beneficial.The father-infant relationship is important for optimal offspring outcomes; hence we have reviewed the application and performance of tools used for their assessment. Evidence concerning the psychometric robustness of father-offspring relationship tools, in the context of parental psychopathology and/or offspring outcomes, was generally limited. Hence, tool selection should be guided by the research aims of the study, the intended purpose of the tool and should also consider the tools' performance in terms of its of psychometric properties, the characteristics of the tools and the study methodology within which the tool will be embedded. Furthermore, given the strengths and limitations of each mode of assessment, future studies may benefit from a multimethod approach to assessing the father-offspring relationship, which may provide a more accurate assessment. Future research is also needed, on a large scale, to replicate existing studies which have utilized tools to assess the father-offspring relationship, as well as meta-analytic studies, to validate existing findings. With particular attention on the application of these tools to diverse populations , larger sample sizes and longer follow-up periods. This will help to elucidate how behaviors within the context of the father-offspring relationship unfold overtime and relate to different offspring developmental stages, together with the influence of parental psychopathology at different stages during the perinatal period and up to 24-months postpartum.VS, ZD, JD, JI, and FB contributed to the conception and design of the study. All authors were involved with screening records for inclusion based on the title and abstract, with JS and VS responsible for deciding which full-text articles were included in the review. Data extraction was undertaken by JS and VS, who led the synthesis process. The synthesis was refined by team discussions . JS and VS drafted the paper. All authors critiqued the manuscript for important intellectual content.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although evidence-based practice (EBP) is largely supported across healthcare professions, its implementation in manual therapy professions such as osteopathy remains limited and debated. There is currently little knowledge of how Spanish osteopaths relate to EBP.The main aim of this study was to investigate the attitudes, skills and use of EBP among Spanish osteopaths. A secondary aim was to identify barriers and facilitators for the adoption of EBP in the Spanish osteopathic context.National cross-sectional survey of Spanish osteopaths registered and non-registered to an osteopathic association in Spain. Eligible participants were invited by a range of recruitment strategies including email and social media campaigns to complete the Spanish-translated Evidence-Based practice Attitude and utilization Survey (EBASE) anonymously online.A total of 567 osteopaths completed the survey which represents an approximate response rate of 9%. Participant’s attitudes toward EBP were largely positive. Most respondents agreed or strongly agreed that EBP was necessary in the practice of osteopathy (89.6%) and that professional literature and research findings were useful to their day-to-day practice (88.9%). Levels of perceived skill in EBP were reported as low to moderate with lowest levels for items related to ‘research conduct’. Except reading/reviewing professional literature and using online search engines to find practice-related literature, participant engagement in all other EBP-related activities was generally infrequent. The perceived proportion of clinical practice that was based on clinical research evidence was reported to be very small. Main barriers to EBP uptake included a lack of clinical evidence in osteopathy and insufficient skills for applying research findings. Main facilitators of EBP uptake included access to full-text articles, internet at the workplace and online databases.Spanish osteopaths were largely supportive of evidence-based practice, had low to moderate skills in EBP and engaged in EBP activities infrequently. Formal regulation of the profession in Spain and the inclusion of osteopathic programs into the university sector would potentially improve EBP skills and use.The online version contains supplementary material available at 10.1186/s12913-021-06128-6. Evidence-Based Practice (EBP) has been defined as the integration of knowledge provided by the best available evidence, with a practitioner’s clinical experience and judgement, and combined with an individual patient’s values and preferences . AlthougOsteopathy is considered a manual therapy discipline in which its therapeutic base has been traditionally embedded within a specific conceptual framework and principles –19. HoweOsteopathy is defined by The World Health Organisation (WHO) as a first-contact patient-centred health discipline . As oste“Scientific rigour and evidenced-informed practice as an important part of osteopathic treatment and patient management” and includes the “ability to appraise medical and scientific literature critically and the incorporation of relevant and contemporary information into practice” as essential competencies for osteopathic practice 26] and SNotwithstanding, there appear to be few differences in EBP use between these countries. Similar to our sample, the use of EBP among osteopaths in Australia, UK and Sweden is reported to be generally low , 30, 35,In terms of potential solutions to improving EBP uptake, education about EBP alone may not be sufficient . FindingPrevious surveys of osteopaths , 30, 35 Other important barriers related to lack of skills , showing the necessity to improve these abilities in order to encourage EBP uptake among new osteopaths. While education is important, there also needs to be a change in mindset, triggered by a comprehensive reflection that considers osteopathy as a healthcare profession that embraces science as a way to evolve and self-assess .Exactly how EBP and research culture should be promoted among healthcare practitioners remains controversial. Several recent scoping reviews in the field of physiotherapy suggests some ideas , 58. TheRegarding enablers, around 63% of participants considered free access to scientific evidence, access to the internet at work, access to free databases and online EBP education materials to be very useful enablers. This was in line with osteopath’s reports in other countries , 30, 35.But above all, we consider that it is necessary to change the way EBP is taught within osteopathic educational programs in Spain. Currently, for many OEIs, EBP is incorporated within the curriculum by teaching specific research techniques, methods and statistics in the final years of training. Instead, we propose that the philosophy of EBP should be promoted from the beginning and embedded along the whole programme. Such integration should be facilitated by the explicit inclusion of EBP as a core competency within professional standards and requirements in addition to accreditation processes . OEIs diAlthough the survey response rate exceeded the minimum sample size required, we noticed a high percentage of missing responses. As all responses were compulsory, this meant many respondents dropped out of the survey early, possibly due to survey fatigue. This was also a limitation that was discussed in a UK study of osteopaths . NonetheWhile the process of translating the questionnaire strictly followed standard methods reported by WHO , includiThis study furthers our understanding of Spanish osteopaths’ attitudes, skills and use of EBP. Our results showed that participant’s attitudes toward EBP were largely positive. At least four out of five participating osteopaths agreed that EBP was necessary in the practice of osteopathy and professional literature and research findings were useful to their day-to-day practice. However, the perceived skills, use and engagement in EBP activities was reported as moderate to low. Fortunately, there was general interest in learning and improving the skills necessary to incorporate EBP into clinical practice. Our findings, therefore, suggest that wider inclusion of osteopathic educational programmes into university environments along with a pedagogical shift towards the promotion of critical thinking and reflective practice may be helpful in assisting Spanish osteopaths to embrace EBP. Although, as discussed in this paper, the absence of osteopathy regulation in Spain could potentially continue to curtail efforts to improve EBP uptake in this professional group.Additional file 1.