Projection of current trends in maternal and neonatal mortality reduction shows that many countries will fall short of the UN Millennium Development Goal 4 and 5. Underutilization of maternal health services contributes to this poor progress toward reducing maternal and neonatal morbidity and mortality. Moreover, the quality of services continues to lag in many countries, with a negative effect on the health of women and their babies, including deterring women from seeking care. To enhance the use and provision of quality maternal care, countries and donors are increasingly using financial incentives. This paper introduces the JHPN Supplement, in which each paper reviews the evidence of the effectiveness of a specific financial incentive instrument with the aim of improving the use and quality of maternal healthcare and impact. The US Agency for International Development and the US National Institutes of Health convened a US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives on 24-25 April 2012 in Washington, DC. The Summit brought together leading global experts in finance, maternal health, and health systems from governments, academia, development organizations, and foundations to assess the evidence on whether financial incentives significantly and substantially increase provision, use and quality of maternal health services, and the contextual factors that impact the effectiveness of these incentives. Evidence review teams evaluated the multidisciplinary evidence of various financial mechanisms, including supply-side incentives  and demand-side incentives . At the Summit, the teams presented a synthesis of evidence and initial recommendations on practice, policy, and research for discussion. The Summit enabled structured feedback on recommendations which the teams included in their final papers appearing in this Supplement. Papers in this Supplement review the evidence for a specific financial incentive mechanism  to improve the use and quality of maternal healthcare and makes recommendations for programmes and future research. While data on programmes using financial incentives for improved use and indications of the quality of maternal health services support specific conclusions and recommendations, including those for future research, data linking the use of financial incentives with improved health outcomes are minimal. Globally, the UN estimates show that maternal mortality has fallen 47% between 1990 and 2010  with a high burden of maternal death often underutilize family planning and maternity services that facilitate healthy childbirths, save maternal and newborn lives, and ensure a healthy start for their young children. To address the lack of utilization and quality of maternal health services, many countries have recently used financial incentives (FIs). Evidence of the effectiveness of FIs for improved maternal healthcare was reviewed at the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives convened by the US Agency for International Development and the US National Institutes of Health on 24-25 April 2012 in Washington, DC. The papers in this JHPN Supplement provide an overview of each of the financial incentives, along with conclusions and recommendations based on the literature reviewed and presentations made at the Evidence Summit.Women's use of healthcare services that potentially reduce the risk of death due to pregnancy is very low in many parts of the world. For example, contraceptive prevalence is 24% in Africa and 58% in South-East Asia compared to the 71-80% coverage in countries with high and upper mid-level income , 48% of To focus the Evidence Summit on the critical barriers women face, which could prevent them from availing of services that could help them plan for and promote healthy pregnancy and birth, USAID carried out a scoping exercise in 2011. In this exercise, maternal health experts and teams from various international health organizations identified the following categories of barriers: family and community factors, health system constraints, poor quality of services, and governance issues leading to poor accountability at higher levels. Within these categories, important elements contributing to the low use and quality of services were identified .Lack of knowledge and awareness among women, families, and decision-makers may contribute to delays in recognizing the initiation of labour and the need for skilled birthing care, especially urgent in the event of an obstetric complication. Distance to facilities, poor road conditions, seasonal problems, and lack of transportation can lead to delays in the decision to travel to service facilities. The costs associated with transport, care, and medications as well as the opportunity costs of family members travelling with the woman may also affect decisions to seek care. Furthermore, village or facility ‘gatekeepers’, through ignorance or corruption, may delay or prevent women in labour or with complications from accessing the services that would save their lives. Fundamentally, the lack of agency that denies women the ability to make informed decisions independently can often lead to non-use of maternity services or delays in accessing care.On the supply side, there are also many factors that negatively effect provision of quality care. For example, poorly-designed and coordinated referral systems can prevent or slow access to emergency care. Inadequately-integrated and coordinated vertical programmes can also result in missed opportunities to provide essential maternal care. Services that should be available on a 24-hour basis may not be open or staffed at night or on weekends. Inferior medical infrastructure, including lack of water or electricity and essential drugs and equipment, may also affect the capacity to provide even the most basic level of care.Moreover, inadequate, poorly-trained and/or disempowered staff may provide substandard care. Dysfunctional incentives in the health system, such as low salary structures that do not vary based on performance, inadequate mechanisms to support, supervise, and hold health workers accountable, may result in low levels of motivation, absenteeism, and lack of innovation and quality. Healthcare providers may, in some cases, neglect or verbally or physically abuse women in outpatient clinics and even in childbirth in health facilities, thus discouraging the use of services and/or providing low quality of care that contributes to loss of life.At the policy level, poor political commitment and weak governance can lead to low standards, inadequate budget, lack of supervision, graft, and services that are simply not accountable to the women and communities they are supposed to serve.Among the many barriers that contribute to the underutilization of lifesaving services, financial barriers are significant, especially on the demand side. In 20 countries, with more than one recent Demographic and Health Survey (DHS), half (52%) of women surveyed, on average, identified lack of money as the biggest problem to using health services . Financiet al. in this Supplement.An important criterion for choice of inquiry through the Summit process was the importance of a barrier that could be improved through programmatic guidance based on available evidence. The importance of FIs and their evaluation is supported by the World Bank, its extensive experience in result-based financing for health , and by Many countries and donors have turned to financial incentives in the last decade as a solution to underutilization and poor quality of maternal services. Various financial instruments, including vouchers, performance-based incentives, conditional cash transfers, and others, are being implemented in a variety of settings with the broad goal of reducing maternal mortality and morbidity by enhancing the use and quality of maternal health services. The motivation for the Summit was the global demand to demonstrate linkages between financial incentive instruments and health outcomes.et al.in this Supplement.A systematic review of relevant English language publications since 1990 was undertaken, utilizing eight standard databases. There was a subsequent call for relevant additional papers from Expert Review Team members. In all, 139 references were provided to the Expert Review Teams to serve as the basis for a summary of findings and recommendations. The methodology for the literature review is described in the article by Higgs Prior to the Summit, three evidence review teams comprised 56 experts in finance, maternal health, and health systems, reviewed and analyzed the evidence of various financial mechanisms, including: (i) supply-side mechanisms, such as performance-based financing, user fees, and various insurance mechanisms; (ii) conditional cash transfers in which programmes condition cash payments to poor households on the use of maternal health services; and (iii) other demand-side incentives, such as vouchers for the use of services and of insecticide-treated bednets, user fee exemptions, and subsidies for such items as food and transport to the clinic. The analyses focused on two key questions to assess the effect of financial incentives on the provision and use of maternal health services:What financial incentives, if any, are linked positively or negatively to maternal and neonatal health outcomes, the provision and use of maternal health services, or to care-seeking behaviour by women?What are the contextual factors that impact the effectiveness of these financial incentives?At the Summit, the experts presented a synthesis of the evidence and analyses to a wider audience with the goal of formulating recommendations on practice, policy, and research. The Summit enabled structured feedback and dialogue on the conclusions and recommendations of the reviews. The Evidence Summit also explored cross-cutting issues and challenges that Summit participants advised the global community to address in future programming, research, and investment decisions.The success of programmes using financial incentives for maternity care depends, in part, on the context within which they are implemented and the design of the FI. To explore fully how the context and design of the incentive programme influence outcomes, key questions were identified during the initial evidence review and then during the Summit to identify factors that could influence FI programme results .Evidence review teams reviewed the available literature with these questions in mind, and Summit participants shared their experience and debated some of these issues.The reviews and discussions of the Summit concluded that the use of FIs, particularly conditional cash transfers, increases utilization of maternal health services, which has been typically slow over the two decades since the Millennium Development Goals were established .It is less apparent that such incentives improved the quality of maternal healthcare, primarily because of the lack of internationally agreed upon quality of care standards across the range of maternal health services. Metrics for measuring quality of care are needed both to determine the impact of incentive programmmes and what should be rewarded, particularly in the context of supply-side incentive programmes. The latter require indicators that can be routinely measured, collected, verified, and paid on, all without creating unintended negative consequences. Standardized quality of care criteria must be an immediate priority for maternal health experts.The evidence of impact of the financial incentives on health outcomes is weak and of poor quality. However, impact measures, especially of significant change in the reduction of maternal mortality, are typically not feasible in the short timeframe and limited study populations described in the literature reviewed. Long-term studies should be undertaken to assess the sustainability and the health impact of FIs for maternal healthcare.The Summit review also provided lessons for donors, researchers, programme implementers, and country-specific policy-makers to consider for future financial incentive programmes that are effective, ethical, and evidence-informed.et al. (in this Supplement) summarizes these findings and recommendations across all incentive instruments on coverage, quality of maternal care, impact, implications for research, programme design, and implementation.The specific findings of the evidence review on each of the supply- and demand-side mechanisms, including performance-based incentives, health insurance, user fee exemptions, conditional cash transfers, and vouchers, are presented in the papers of this Supplement. Morgan Financial incentives for maternal health inherently involve both health and financial sectors. Therefore, it was not surprising that the Evidence Summit identified a lack of a strategic alignment between maternal health and economic expertise in the design, implementation, and assessment of financial incentive schemes for maternal health. Increased collaboration between the economic and maternal health communities is required to better inform the design of research to assess effectiveness and understand the ‘hows’ of programmes. Furthermore, maternal health experts and programme designers need to be more conscious of the implications for health systems of incentive programmes they support. A closer collaboration between finance and health sectors can enhance programmes and policy to deliver informative data and conclusions to governments of the low- and middle-income countries and donors on what the most sustainable, equitable, and effective incentive programmes are to improve maternal and neonatal survival.Very few studies considered, evaluated, and reported on the effect of incentives on both supply and demand sides. Whether designed as supply- or demand-side programmes, it is useful to measure effects on both supply and demand sides.There is also a need for prioritized research agenda to develop more evidence. This agendum needs to be developed among key partners, including governments, development banks, donors, and universities, with the balanced input of economists and public health specialists knowledgeable about maternal health. Duration of initiatives and appropriate timing of measurement of results need to be specified to ensure that research documents both short- and long-term impacts of financial incentives.There is an urgent need for action, as we approach 2015, for evaluation of the progress towards MDG 5 and planning for the post-2015 world where ending the preventable maternal death needs to remain a priority , with anThis work was carried out by US Federal Government Employees and persons supported through contractual mechanisms by the federal government. This is an open-access article under the terms of the Creative Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided that the original authors and source are credited. The views and opinions in this paper are those of the authors and not necessarily of the United States Agency for International Development nor the National Institute of Allergy and Infectious Diseases. Among the authors, MES is paid by the United States Agency for International Development. ESH is paid by the National Institute of Allergy and Infectious Disease and was on assignment with the Bureau for Global Health at the United States Agency for International Development during the planning of the Evidence Summit. MK is currently paid by the United States Agency for International Development through an Intergovernmental Personnel Act Assignment Agreement with Johns Hopkins University School of Public Health and, during the summit planning, was paid by John Snow, Inc.


It was chaired by Dr Beatriz Amendola, Professor Gordon McVie and Professor Umberto Veronesi. Specialists from Europe and America were invited as guest lecturers.The first international Over 300 people are attended the conference from all areas of oncology, doctors, physicists, medical technologists, nurses, residents, students, social workers, journalists, pharmaceutical chemists, from all over the country and abroad, including India. The success was achieved as a result of the multidisciplinary approach to the pathologies, which prompted significant interest from the audience.The ‘eContouring’ course (radio-oncologists) was taken by a large number of participants, the result of great interest in the subject, and the undoubtable merit of the guest instructors.ecancer, Dr Beatriz Amendola, President of the symposium and Dr Jorge Jimenez, President of Foro Nacional de Cancer Chile, and former Minister of Health.For the opening ceremony, we were honoured with the presence of Professor Gordon McVie, Founder of  Several scientific modules were carried out throughout the conference, with the aim of addressing and updating the community on radiotherapy indications, in cancers that are most prevalent in Latin America. The modules addressed the following topics: lung cancer, breast cancer, gynaecologic cancer, and cancer of the head and neck. The themes were presented in a multidisciplinary manner, in which all of the pillars involved in the treatment of cancer were included, such as surgery, radiotherapy, and medical oncology. We also used the opportunity to discuss, by means of satellite sessions, the current status of radiotherapy in Latin America, and giving participants the opportunity to interact and evaluate new emerging technologies with industry symposia.This conference constitutes An ‘eContouring’ course was conducted, supported by Varian Medical Systems and EduCase, as well as ASTRO (American Society for Radiation Oncology).ecancer are fundamental to the extinction of these barriers and the emergence of a more team-guided effort to research.This event was held in high regard by the community of oncology professionals in Chile, as it allowed for a multidisciplinary focus such as surgery, radiotherapy, and chemotherapy in the management of patients with cancer. It is important to highlight that in Latin American countries, the studies are carried out in a manner that are relatively isolated from the rest of the community, which is particularly different to what occurs in the rest of the world, specifically Europe, where research is carried out in a coordinated fashion within the different countries, experiences, and findings are shared and no boundaries are present to set back the medical progress in this part of the world. For this reason, contributions, such as the courses, provided by The principal objective of this conference was to demonstrate multidisciplinary cooperation in analysing the different pathologies. With the use of more modern technologies and equipment, considering the pros and cons of each specific one, the individual experiences of the correspondents, their case-by-case interpretation, the potential practical problems, and how to approach them.In the lung cancer module, Dr Andres Córdova, President of the Radiotherapy Society of Chile, emphasised the importance of tobacco consumption in the appearance of this cancer and called to attention the high prevalence of tobacco consumption in Chile. In addition, Dr Córdova demonstrated the superiority of pre-screening for prevention with low-dosage TAC in relation to radiography of the thorax in high-risk populations, emphasising the importance of prevention. Subsequently, Dr Claudio Suarez, thoracic surgeon of Santa Maria de Santiago Clinic, discussed the different types of surgical interventions, their advantages and disadvantages, as well as how a good programme for early detection can greatly improve the statistics for survival.Dr Beatriz Amendola of the ‘Innovative Cancer Institute’ Miami, EEUU, presented lectures in relation to radiosurgery in general and the management of metastasis in lung cancer. Dr Amendola emphasised the increase in the incidence and negative results of treatment in cases of late detection. It was demonstrated how stereotactic body radiation therapy (SBRT) has been gaining prevalence, specifically in elderly patients or those patients presenting comorbidities that present an impediment to surgical intervention. With regards to the treatment of metastasis, the importance of SBRT in vertebral, hepatic, and cerebral metastasis, and the associated subdivisions, was demonstrated.Dr Lus E Raez, of the Memorial Cancer Institute, discussed the systematic management of Lung Cancer, with particular focus on personalized therapies and the positive outcomes seen with the use of TKI, with ALK and ROS-1 inhibitors in selected patients. Dr Raez also discussed Immunotherapy and its results in cerebral and hepatic metastasis.Dr Marco Amendola of the ‘Innovative Cancer Institute’, discussed imaging techniques in lung cancer, referring to the staging, the follow-up and restaging, highlighting the importance of imaging for the organisation of radiotherapy, using the different techniques, particularly the use of positron emission tomography-computed tomography (PET-CT).ecancer, presented the following: Life After Protons, also referring to the successful evolution of ecancer since its foundation in 2007. In regards to protons, Professor McVie explained the characteristics and differences from photons, as well as their application in adults and children. Images of isodose were demonstrated throughout different locations, such as liver, head and neck, and breast.In the module discussing breast cancer and global radiotherapy, Dr Maria Laplana of the Catalan Institute of Oncology presented a conference on IORT (intraoperative radiotherapy), SBRT (stereotactic body radiation therapy), and HDR-IGBT (high-dose rate image-guided brachytherapy), comparing the different techniques and discussing the statistics regarding them. Subsequently, Professor Gordon McVie, of King’s College London, Founder of Dr Herbert Cardenas, radio-oncologist at the National Institute of Neoplastic Diseases (INEN) Peru, demonstrated his experience with V-MAT (volumetric modulated arc therapy), comparing this approach with fixed IMRT in different locations and its individual advantages.Dr Ana Maria Ciudad, of the Arturo Lopez Perez Foundation, Santiago de Chile, presented the Uterine Cancer module. Dr Ciudad discussed the integral management of cervical and uterine cancer in Chile, providing mortality rates and their evolution in time, as well as demonstrating a national research study, presenting figures from different stages and their treatment outcomes and results. Dr Clemente Arab, gynaecologist of the Arturo Lopez Perez Foundation and the hospital of Tisne de Santiago, discussed the topic of surgery in gynaecological cancers, indications with parametrectomy, types of surgery in low-risk tumours, the use of sentinel ganglions, and the use of radical abdominal trachelectomy.Dr Arno Mundt, radio-oncologist of Moffit Center, Florida, talked about radiotherapy in tumours of cervical cancer and the combination with surgery and/or chemotherapy, neoadjuvant chemotherapy with varied schemes, radio-chemotherapy and novel drugs. Dr Mundt also discussed the novel uses of radiotherapy in cancer of the vulva, endometrial cancer, and selected patients with ovarian cancer.In the international presentation, Dr Bernardo Vizcarra of Oncosalud Peru referred to radiotherapy and its evolution in time, as well as its applications in Peru, specifically in lesions of the central nervous system (CNS).The session presented by Dr Hugo Marsiglia, of the Arturo Lopez Perez Foundation, Santiago de Chile, discussed the 2016 consensus in radiotherapy for breast cancer. Dr Marsiglia demonstrated research studies carried out in patients were or were not treated with radiotherapy, in an elderly population of patients with breast cancer, and the clear advantage of treating with radiotherapy, the use of IOERT in young patients, various subdivisions and treatment of ganglionic areas.In the subsequent module, addressing cancer of the head and neck, Dr Adela Poitevin of Medica Sur, Mexico, discussed the general principles of the management and diagnosis of this type of pathology, as well as its prevalence in Latin America. Dr Poitevin demonstrated rates, risk factors, and treatment concepts.Dr Beatriz Amendola analysed radio-surgery (SBRT) in recurrent head and neck cancer, re-irradiation, as well as different techniques and dosage. Dr Amendola demonstrated different cases with their respective isodose curves, in different localisations and their encouraging results.Dr Gustavo Sarria, radio-oncologist of Oncosalud, Peru, discussed advanced techniques in regards to treatment of cancer of the head and neck, the results observed with IORT, brachytherapy, the evolution of different techniques of external radiotherapy and the comparison of V-MAT and fixed gantry IMRT.The following session was in the hands of Dr Beatriz Amendola. Dr Amendola discussed radiosurgery in the base of the skull and cervical vertebrae, particularly meningioma and vertebral metastasis, highlighting its promising results. Practical recommendations were given in regards to the delineation of volumes and potential risks of complications. Following this conference, Dr Luis E. Raz presented a discussion on the growth and evolution of the systemic management of head and neck cancer, particularly the use of immunotherapy, the importance of HPV, chemotherapy for induction and alternative schemes.The conference presented by Dr Arturo Madrid, surgeon of the Head and neck in the German Clinic of Santiago de Chile, discussed robotics, highlighting its advantages in lesions of the amygdala, the learning curve and potential use in other locations. Following this presentation, Dr Eugenio Vines, of the Service of Radiotherapy, Catholic University of Santiago, discussed re-irradiation in head and neck cancer. Dr Vines demonstrated cases of recurrent disease and the incidence of secondary primary malignancies with different re-irradiation techniques and their results.Dr Claudio Sole, radio-oncologist of the IRAM Oncology Clinic of Santiago, presented a session discussing the medical advances and novel trends in the treatment of prostate cancer. Dr Sole elaborated on different treatments for specific risk factors, dose escalation and varied fragmentation.Dr Sebastián Solé, also from the IRAM Oncology Clinic of Santiago, discussed novel strategies for the treatment of locally advanced rectal cancer, comparing specifically conventional radiotherapy versus shortened radiotherapy, and the importance of time periods in regards to treatment.To bring the conference to an end, Dr Arno Mundt discussed the medical advances in radiotherapy and its application to gynaecological cancer. Dr Mundt compared the varied techniques by means of their use, advantages, disadvantages, results and their complications.During the eContouring course, which attracted a large number of participants, themes regarding the use of eContouring in lung, cervical, uterine, endometrial, prostate, head, and neck cancer were analysed. The guest instructors Dr Adela Poitevin, Dr Arno Mundt, Dr Marco Amendola, and dosimetrist Alejandro Iglesias, provided a brief introduction, a review of the anatomy and volumes to embark upon, as well as potential constraints. It is worth noting that prior to this course, participants were tasked with several assignments, to be carried out in their homes. It was a complete success.In addition, the presence of satellite symposia allowed the participants to experience the latest projects and technologies of the industry: Elekta, Reich, Varian and Siemens were all participating.The meeting was valuable as the topics were very interesting and of current importance. Similar meetings are expected to be replicated in other Latin American countries.


The gaps observed between the use of research evidence and policy have been reported to be based on the different methods of using research evidence in policymaking by researchers and actual policymakers. Some policies and policymaking processes may therefore be particularly well informed by research evidence compared to others. The aims of the present article are to explore the use of research evidence in health-enhancing physical activity (HEPA) policies, identify when research evidence was used, and find what other types of evidence were employed in HEPA policymaking.Multidisciplinary teams from six EU member states analysed the use of research evidence and other kinds of evidence in 21 HEPA policies and interviewed 86 key policymakers involved in the policies. Qualitative content analysis was conducted on both policy documents and interview data.Research evidence was mostly used to justify the creation of HEPA policies and, generally, implicitly without citation. The policies analysed used many types of evidence other than citable research. The evidence used in HEPA policies was found to fall into the following categories: societal framework, media, everyday knowledge and intuition, research evidence, and other types of evidence.Research evidence seems to be the only type of evidence used in policymaking. Competition between the use of other types of evidence and research evidence is constant due to the various sources of information on the Internet and elsewhere. However, researchers need to understand their role in translating research evidence into policymaking processes. The health benefits of physical activity (PA) are supported by research evidence as well as the international public health community and its policies, including the World Health Organization (WHO) . RegularHowever, there are strong economic and moral, and occasionally political, arguments for making better use of research evidence in policymaking . EconomiPrevious international research on HEPA policies –22 has lInstitutions, interest groups, and networks interact with individuals and their ideas at different times and places during the policymaking process . In poliThis study is part of the EU-funded project Research into POlicy to enhance Physical Activity (REPOPA), with the overall aim of integrating scientific research knowledge, expertise, and real world policymaking processes. This could increase synergy and sustainability in promoting health and preventing disease, and promote physical activity in structural policymaking through different research and networking activities. The aims of the present article are to explore the use of research evidence in HEPA policies, identify when research evidence was used, and indicate which other types of evidence were used in HEPA policymaking. The study may be considered valuable in providing information on effective translation of research evidence into HEPA policymaking processes, which would ultimately lead to more effective HEPA policies.Each research team in the partner countries suggested relevant HEPA policies for consideration. Prior to the selection of HEPA policies for the study, the research team, e.g. principal researchers in each partner country, looked at the objectives, primary stakeholders involved, subpopulation specificity of policies, processes leading to release of the policies, and selection of documents used for the development of the policies. The policies were then categorised as national, regional, or local. Based on this primary inventory and in order to focus on the most recent developments, documents were selected according to the criteria of policies focusing on HEPA, being published by public authorities and representing HEPA policies in force at the beginning of 2012. The selected national, regional, and local HEPA policies ensured at least some variation in the scale and topic of the expected policy change: from major changes, such as governance structures and legislative perspective, to minor changes such as programmes, advice services, or building playgrounds. Some of the national, regional, and local policies belong to a ‘package’ of national, regional, or local policies created after elections for respective development purposes. They therefore also reflect wider policymaking processes and possibly the use of a wide base of research evidence. In the case of ‘package’ policies, the study concentrated on the specific policy documents for HEPA issues only. For the final set of HEPA policies, 21 policies from six European countries were selected with variation across the types of policies and policymaking processes. The topics of the sample of HEPA policies included in the analysis contained public health aspects , HEPA aspects , infrastructure , and places for PA  . The stuTo assess the use of research evidence in HEPA policies, content analyses of policy documents and semi-structured interviews were used. The content analyses of the policy documents and the interviews complemented each other to identify the various ways of using evidence in policymaking. The intention was to facilitate comparisons between countries in the use of research evidence in policymaking and take into consideration contextual differences through interviews. In each country, a policy was identified along with the content, stakeholders, and processes in relation to the relevant research. A series of questions was put to the stakeholders and policymakers to recall the use of research evidence. Further questions were allocated depending on the references to the use of research evidence in speeches, statements, guidelines, and similar background documents.The HEPA policy process was split into agenda-setting and policy development phases in order to identify the use of research evidence at different stages of the policymaking process on various topics and issues. The agenda-setting phase and the use of research evidence were mostly traced through interviews and the use of research evidence in the policymaking process through policies or other supporting documents. The agenda-setting phase and the use of research evidence were dependent on interviews, as most of the countries did not have records on the decisions made in the agenda-setting phase, whereas the policymaking phase was often described in policies or related background documents.Based on the literature review for the project proposal and its update upon acceptance of funding for the use of research evidence in policymaking, the study was undertaken using a qualitative descriptive approach inspired by political sciences , 31, pubThe content analysis of HEPA policy documents followed the ideas of Ritchie and Spencer  and consWhere appropriate, a published protocol and tool developed by Lavis et al.  and HannThe common guideline that was developed covered the criteria for the selection of policies, theoretical models of the policymaking phases based on Kingdon , the focDuring the HEPA policy document analysis, key informants for each policy were identified for face-to-face semi-structured interviews in order to verify the findings of the content analysis stage and gather information on any gaps in the uncited or implicit use of research evidence. The purposeful sampling of 87 informants in six countries was based on the selection criteria of the interviewees being directly involved in the policymaking process and able to report on the use of research evidence or other kinds of evidence in the policymaking process. In each policy, one of the interviewees was employed at the organisation responsible for the policy. The interviewees had been involved in policymaking processes of the policy on which they were interviewed and were policymakers, researchers, public sector officers, or other influential stakeholders. All the interviewees were contacted by email or phone by the research team in each country with basic information on the project and consent forms in the local language. The interviews were conducted by research team members with backgrounds in health and social sciences in the local language, recorded when accepted and transcribed for the analysis. An interview guide was developed by the REPOPA team led by the work package leader. In the guide, the questions for the policymaking process were split into agenda-setting and policy development phases. The questions followed the protocols , 15 withTo adapt the interviews for each context, each country team conducted between one and three pilot interviews to modify the questions, interview process, and language.The semi-structured interviews were selected as a method to gain complementary information and to facilitate the adaptation of questions to each policy and case. The stakeholder interviews for each policy verified facts identified during the content analysis of policy documents, gaps in the information gathered in the use of research evidence, and the needs of policymakers to use evidence in the policymaking process.In the semi-structured interviews, the interviewees were asked to recall the policymaking process period, review their files before the interview, and explain the policymaking process and the parties involved. The main issues in the interviews were how and why research evidence and other types of evidence did or did not enter into the policymaking, as well as the origin, influence, and characters of policymaking. The topics covered included policy changes, their significance, the use of research evidence and other types of evidence in bringing the content and change into the policy, the factors describing how and why the issues appeared on the policy agenda, and the factors influencing the way the policy developed.The selected HEPA policy documents and interviews were mapped, coded, and further analysed using the interview questions as guidance. Each HEPA policy and transcribed interview was reread, coded, sifted, charted, and sorted according to the key issues and themes, confirming the patterns of use of research and other evidence, and categorised into various topics and themes. The interviews were analysed by the country-based research teams using an interpretative approach derived from a content analysis of the policy . The codDemographic and statistical data (facts and reports used as a background or for prioritising policy areas)Non-systematically derived peer-reviewed scientific literature Systematically derived peer-reviewed scientific literature International, transnational, national, regional, or local standards and guidelinesKnowledge derived from community consultations, stakeholder workshops, and in-house consultationsNational reports Knowledge derived from expert consultations or policy briefs developed by research institutionsThe policies and interviews were further analysed to identify the use of evidence to support the policies. For the distinction between research evidence and other types of evidence, a list of evidence with modifications was developed based on Lavis, Ross, and Hurley . EvidencIn the content analysis stage, the policy documents were reviewed to identify the explicit use of research evidence. When research evidence was cited, the content was analysed to establish the way the citation supported the policy statements or position in addressing the issues. The research evidence was published as journal articles, book chapters, working papers, or reports typically produced by research institutes, universities, or other independent research units. Other types of evidence referred to readings, information from media, and interaction with peers or stakeholders. Involvement of people in hearings, working groups, meetings, and the like was also looked for in the policy documents and interviews.Finding patterns when research was used required a framework for determining the contexts in which policymaking occurred , 27, 40.The interviews complemented the understanding of the use of research evidence in the agenda-setting and actual policymaking phases of HEPA policies. Policy documents  providedBy contrasting and searching for internal patterns, connections, and explanations for themes, categories, or issues in the content analysis, it was possible to describe the HEPA policymaking process, involvement of stakeholders and use of research evidence, and other types of evidence for judging HEPA policies for, for example, various subgroups. Sometimes, research evidence on health determinants and efficacy of interventions was used to legitimise actions, with other types of evidence used to accommodate contextually salient factors such as culture, community and organisational values, resources, and political priorities, which defined the usefulness of evidence for HEPA policymaking and implementation.Explicit citable use of research evidence was mostly found in the justification of HEPA policies and when stating a specific study or publication as a trigger for a policy. It seemed that the visions and goals of the policies were not validated by research evidence but by other types of evidence. For the justification of the policies, instead of using peer-reviewed scientific articles, the policymakers used various types of secondary publications, such as national and international reports and recommendations. In other parts of the policy, such as target setting or actions for target groups, explicit research evidence was rarely used.Neither policy document analysis nor interviews provided information on whether explicit or implicit evidence or citable research evidence was really influencing policies or whether implicit evidence was informed by research evidence.The study found that most countries did not have routine reporting mechanisms for policy decisions during policymaking processes that would have been accessible for this study. Some countries had records available in the form of media communications, lists of members of the various committees, working groups or legislative commissions, and report databases. Theoretically, in the agenda-setting phase, priorities are set out for the policymaking process and in the actual policymaking development phase the research evidence should support the issues to be considered, chosen, and selected as part of the policy. Nevertheless, in the studied HEPA policies, the decisions made in the agenda-setting and policymaking phases were not recorded and therefore the information on the use of research evidence was based on what was found in the documents and their references and in the recall of interviewees.Where research evidence was used, it was identified in an ad hoc manner in the policymaking phase and consisted of epidemiological research, population studies or statistics, and case studies. Peer-reviewed research articles and research based on surveys, as well as monitoring, evaluation, and implementation studies were rarely used. When the HEPA policies used citable research evidence, it was not necessarily peer-reviewed scientific articles. Instead, various types of national and international reports and recommendations were used. In most cases, when paragraphs in the policy documents suggested being informed by scientific knowledge, explicit research evidence was seldom referenced.According to the interviews, the research evidence used in HEPA policymaking was based on previous strategies, programmes, recommendations, guidelines, alignments, traditions, political support, trends, legislation, or economics Figure . In the Policymakers obtained other types of evidence from experiences, such as earlier national or international good practices, projects or programmes, or information gathered from personal networks Figure . MeetingThe most challenging part of the different types of evidence used in the policymaking was the use of the Internet and media information for policymaking. The challenge was even stronger when the policymaking process had occurred some years ago, which was the case for most of the policies. According to the interviews, for the political level of policymaking, the media and its attention to certain topics during the policymaking process seemed to be an important source and legitimation of information and concern for taking up the issue in the policy.Based on the content analysis of policy documents and interviews, the types of evidence used were listed, the items from which were classified and categorised; these five broad categories, namely research evidence, other types of evidence, societal frameworks, media, and everyday knowledge and intuition, are depicted in Figure The aims of the study were to assess how, to what extent, and where research evidence and other evidence were used in HEPA policymaking. In this qualitative study of the content analysis of 21 policy documents and 86 stakeholder interviews from six European countries, it was found that most countries did not have routine reporting mechanisms for policy decisions using research evidence during the policymaking processes. This can be considered a weakness in the transparency of the policymaking processes. Other related reports were available, but they were not necessarily related to policies or policymaking processes as such, they did not reflect the chosen policies, or particularly explain, describe, or confirm the use of specific research evidence in policymaking. Overall, from the content analysis of the policy documents, it was established that there was a lack of citable research evidence use in policy documents as it was rarely explicitly expressed. This was also confirmed by the interviews with stakeholders involved in policymaking. It was found that implicit evidence, such as common knowledge, facts, and practices, were primarily used in the policies.However, when investigated in more depth, the study proved that the use of other types of evidence and broader societal framework information (both of which may or may not have been informed by citable research) was common. The use of non-citable research evidence was difficult to define, as many guidelines, standards, and recommendations by international and national organisations are based on citable research but without explicitly showing the citations used. In addition, public hearings and experiences from other sectors and colleagues from networks as other types of evidence confirmed the expectation that various types of evidence were used in policymaking. As shown in a previous study , 42, theThe content analysis approach showed that research evidence seems to be only one type of information used in policymaking, and competition between the use of other types of information and research evidence is constant due to various sources of information on the Internet and elsewhere. To navigate the use of evidence in policy and practice, it is therefore necessary to understand how ideas spread through systems, how decisions and policies are made, and how capacity is required to use evidence in policymaking . The useEvidence-informed policymaking is a contingent, complex system-like, non-linear, and emergent process of producing, managing, and implementing new knowledge. Most authors appear to agree with at least the possibility that evidence-informed policymaking can work as a virtuous cycle in order to improve policymaking, even if there are widely divergent ideas about what constitutes the component parts of the evidence-informed policymaking process, how this can and should be done, and what it should achieve . PolicymThe aim of the study, based on successive phases of policy analysis and stakeholder interviews, was to allow more in-depth identification of evidence use for HEPA policymaking and of the pattern of evidence use. One major limitation of this study was that the interviewees did not recall the policymaking process in detail, even if the policies were still in force. The evidence used in the policymaking process also remained unclear to some extent despite selection of the most recent HEPA policies to minimise recall bias. However, this study clearly shows that there is a need for future policy research to take into account the various types of evidence used in policymaking and to choose a study design that can minimise recall bias. A further study area is the use of the Internet and its sources of research evidence and other types of evidence in policymaking. Additional countries would have increased the validity of the results and a variety of approaches to HEPA and the use of research evidence. However, the selected policies were not necessarily from the same levels due to the non-existence or unavailability of similar policies across the six countries.The use of research evidence identified through this study will be relevant to other researchers and research units working with policymakers at national, regional, and local levels. Similarly, the findings yield useful approaches for consideration by policymakers who work with researchers in academic institutions. These research-policy nexuses are clearly intended for practical applications in policymaking. Not all research is meant for this purpose. Research evidence seems to be only one type of information used in policymaking. Competition between the use of other types of information and research evidence is constant due to various sources of information on the Internet and elsewhere. In addition to the research evidence, other types of evidence from good practices, experiences from networks, work-related knowledge, and public hearings were used in policymaking; for example, values, traditions, interests, and opinions also influence everyday knowledge for policymaking. Moreover, past policies, regulations, and other policies influence and are used to frame policies. However, the use of research evidence seems to depend on close contacts between policymakers and researchers as well as on easy availability of and access to information. Making better use of research evidence in developing HEPA policies requires researchers to understand their role in policymaking and in translating research into policymaking .Consolidating and revising HEPA policies to be more informed by research evidence at national, regional, or local level would strengthen systematic assessment of structures and institutional arrangements of HEPA policies and make them more effective. HEPA policies are embedded within a wider socio-economic context, and HEPA policies should therefore target wider determinants of physical activity and its impact on health. Using more explicit research evidence in policymaking could also offer alternatives and options for research evidence in more transparent ways.


Dr. Michael Tamilia is not included in the author byline. He should be listed as the third author and affiliated with Lady Davis Institute for Medical Research-Jewish General Hospital; Montreal, QC, Canada and Division of Endocrinology, Jewish General Hospital; Montreal, QC, Canada. The contributions of this author are as follows: Dr. Tamilia was involved in the very early process of the work describe in the paper, in both discussions and experimental design.


Effective delivery of drugs via liposomes in the treatment or prevention of disease is the aim of numerous researchers worldwide. Therapies include those for cancer, microbial infections, hormone and enzyme deficiencies, metal detoxification, gene deficiency or malfunction, as well as vaccines. Intimate knowledge of the structure and physical properties of liposomes, and of ways such properties influence their behaviour within the biological milieu, is central to their success.The discovery of liposomes in the mid-1960’s ,3,4.in vivo, namely its interaction with the biological milieu in the living animal and, as a result, the proposition of an array of therapeutic applications. Following a period of “disillusionment” of those (mainly in industry) with expectations unjustified by the degree to which liposomes had been developed at that time, the 1980s were a period of reflection and consolidation. This was also a period of advancements in improving liposomal stability in biological fluids such as blood [The use of liposomes in drug delivery and targeting is often discussed in the context of decades marked by significant milestones. Thus, the 1970s are noted for the initial understanding of the system’s behaviour as blood , in lipoas blood  in termsin vivo at the cellular and subcellular level, facts about the fate of intravenously injected liposomes and entrapped contents were easy to establish. We were able to show [My involvement with liposomes, described in more detail elsewhere  began wi to show ,4, that  to show . It was Being aware of the need for specific drug action in a multitude of therapies, exploration of the potential uses of liposomes was extended to cancer and antimicrobial (intracellular) therapy ,15,16, aet al. [A major potential disadvantage of the liposomal carrier is that, following intravenous injection, it is rapidly intercepted by the fixed macrophages of the liver and spleen. However, the involvement of the RES in vesicle uptake is the basis of the mode of action of several of the licensed liposome-based products, including vaccines against Hepatitis A and influenza. Added to this is the promise ,23 of liet al. , led to et al. . It turnet al. . Consequet al. ,32,33,34Such is the structural versatility of the liposomes, it renders the design of vesicle versions destined for specific needs practically limitless. In this respect, newer developments  include


Researchers and trialists face many uncertainties when designing and conducting research. Embedded methodology studies can help to resolve these. However, despite hundreds of thousands of trials, there are probably only a few hundred studies assessing the effects of different methods for doing this research. The concept of the SWAT  programme is to aid the development of such research by increasing awareness of, and stimulating interest in the need for this research and providing a framework and resource to inspire and generate ideas, and to store, disseminate and modify such research. The programme was established as part of the development of an All-Ireland Hub for Trials Methodology Research in collaboration with the Medical Research Council's Network of Hubs in the UK and the Global Health Network. It will facilitate this research into research. Each SWAT comprises of simple, one or two page protocols and, as of April 2015, 19 different SWAT outlines have been registered. This presentation will detail the SWAT concept, and describe the core outline which consists of the following sections: background, intervention, comparator, allocation, primary outcomes, secondary outcomes, analysis, possible problems, likely costs, publications, and version information. The SWAT website will be available to view, and examples of completed SWATs will be shown. The presentation should stimulate ideas for future SWAT, and encourage researchers to see how they might maximize the impact of embedding research into research, leading to improvements in the design of future clinical trials and other studies.


Balamuthia mandrillaris can cause a serious infection of the brain, other organs , and rarely, spinal cord. Originally isolated from the brain of a mandrill that died of meningoencephalitis at the San Diego Zoo, Balamuthia mandrillaris is named for the late professor William Balamuth of the University of California at Berkeley, for his contributions to the study of amebae. More recently, B. mandrillaris has been shown to be transmissible through organ transplantation.A free-living ameba naturally found in the environment,


Sickle cell disease is a life-long genetic disease that begins in childhood, affecting the structure of erythrocytes, altering the healthy biconcave shape to a crescent shape, leading to the blockage of veins, thereby resulting in organ damage . There iThe mortality rate associated with SCD has remained high in Africa, despite the use of appropriate interventions to manage the various forms of crises . In the There are five treatment approaches for SCD that are tailored to the clinical phenotype of a patient, namely supportive, symptomatic, preventative, abortive and curative approaches . The supBlood transfusion: Blood transfusions improve the oxygen-carrying capacity and oxygen-delivery efficiency of blood to the tissues and decrease the blood concentration of sickle cells and improve perfusion of tissue microvasculature. Transfusions are typically used to ameliorate chronic anaemia and pain episodes [episodes , and areepisodes , 18. Furepisodes , is one episodes  and blooepisodes . This evHydroxyurea: Hydroxyurea is an oral, cytotoxic, anti-metabolic and -neoplastic drug for principal haematological disorders. The first clinical application of HU was in 1984 [ in 1984  and sinc in 1984 , protect in 1984 , long te in 1984 , toddler in 1984  and infa in 1984 . The mos in 1984 . The tri in 1984 . However in 1984 , HU is s in 1984 . This wa in 1984  leading  in 1984 , 33. Sim in 1984  with the in 1984 . Similar in 1984 , 37, and in 1984 . Further in 1984 . This isHaematopoietic stem cell transplantation: Currently, allogeneic HSC transplantation is the most successful curative treatment for SCD [ for SCD . This me for SCD , 40. To  for SCD . Transpl for SCD . Althoug for SCD , immunos for SCD . Using t for SCD . The fin for SCD . Using a for SCD . As enco for SCD . The ave for SCD . The SCTEvery 2 years, Africa sees the birth of a number of SCD-affected children equal to the sum of the American and European populations affected by SCD, where most of these children die before age 5 . One of The data available on clinical trials and reports conducted outside of Africa is illustrative that a range of treatments are available and have been successful at curing SCD. What is required is the implementation of strategies to affordably avail these treatments in Africa, particularly HU and ultimately, HSC transplantation, through a collective effort from researchers, physicians, state departments of health and the private sector. This approach is likely to foster collaborative healthcare and research networks across the continent, ensuring the continued development of scientific and technological capacity in Africa to effectively manage the high disease burden of haematological disorders such as SCD.


Reporting guidelines, such as the Consolidated Standards of Reporting Trials (CONSORT) Statement, improve the reporting of research in the medical literature . Many such guidelines exist and the CONSORT Extension to Nonpharmacological Trials  provides suitable guidance for reporting between-groups intervention studies in the behavioral sciences. The CONSORT Extension for N-of-1 Trials (CENT 2015) was developed for multiple crossover trials with single individuals in the medical sciences , but there is no reporting guideline in the CONSORT tradition for single case research used in the behavioral sciences. We developed the Single Case Reporting guideline In BEhavioural interventions (SCRIBE) 2016 to meet this need. This statement article describes the methodology of the development of the SCRIBE 2016, along with the outcome of 2 Delphi surveys and a consensus meeting of experts. We present the resulting 26-item SCRIBE 2016 checklist. The article complements the more detailed SCRIBE 2016 explanation and elaboration article  that provides a rationale for each of the items and examples of adequate reporting from the literature. Both these resources will assist authors to prepare reports of single case research with clarity, completeness, accuracy, and transparency. They will also provide journal reviewers and editors with a practical checklist against which such reports may be critically evaluated. University courses generally prepare students of the behavioral sciences very well for research using parallel, between-groups designs. By contrast, single-case methodology is “rarely taught in undergraduate, graduate and postdoctoral training” Kazdin, , p. vii.To address these issues we developed a reporting guideline, entitled the Single-Case Reporting guideline In BEhavioural interventions (SCRIBE) 2016, to assist authors, journal reviewers and editors to improve the reporting of single-case research. This Statement provides the methodology and development of the SCRIBE 2016. The companion SCRIBE 2016 Explanation and Elaboration (E&E) article . None of the designs below the solid horizontal line meets these criteria and they are not considered single-case experiments: The B-phase training study comprises only a single (intervention) phase; the so-called “pre–post” study does not take repeated measurements during the intervention (B) phase. In the Figure, we place the A-B design in an intermediate position between the nonexperimental single-case designs  and the four experimental designs above the dotted horizontal line because it has weak internal validity, there being no control for history or maturation, among other variables. As a result, it is regarded as a quasiexperimental design  in a single participant who serves as his or her own control, often incorporating randomization and blinding.The medical Journal of Behavioral Education in 2012, Remedial and Special Education in 2013, the Journal of School Psychology and Neuropsychological Rehabilitation in 2014, Aphasiology in 2015) and methodological quality recommendations . In order to ensure representation from experts in areas of single-case investigations in clinical psychology, special education and single-case methodology and data analysis, another five experts were invited to the steering committee . Of course, other content experts exist who would have been eligible for the steering committee, but a guiding consideration was to keep the number of members to a reasonable size so that the project was manageable. In the early stages of the project, steering committee members were instrumental in item development and refinement for the Delphi survey.A 13-member steering committee for the SCRIBE project was formed comprising a Sydney, Australia, executive . An additional three members who had spearheaded the CENT initiative  were invited because of their experience and expertise in developing a CONSORT-type reporting guideline in a closely related field  those identified in a systematic review previously conducted by the CENT group . We examined the quality of authors’ work, as described in their reports, using our methodological quality scale , and an additional three experts recommended by steering committee members. Graphed results were provided to respondents, along with anonymous comments on the items from the other panel members. A complete data set of responses for Round 2 was collected from 45 participants. Again, the ratings of importance for each item were mostly very high, all items having median importance ratings of at least 8/10, but the range of responses decreased. According to the criteria of von der Gracht (2012) consensus was achieved for 82% of items (36/44) which had IQRs of 2 or less on the 10-point scale. The remaining eight items had IQRs from 2.25 to 4 and were discussed in detail at the consensus meeting.As depicted in Figure Sixteen world experts in single-case methodology and reporting guideline development attended a 2-day consensus meeting, along with the Sydney executive and two research staff. Representation included clinical-research content experts in clinical and neuropsychology, educational psychology and special education, medicine, occupational therapy, and speech pathology; as well as single-case methodologists and statisticians; journal editors and a medical librarian; and guideline developers. Delegates met in Sydney on December 8 and 9, 2011. Each participant received a folder which contained reference material pertinent to the SCRIBE project, and results from both rounds of the Delphi survey. Each of the Delphi items contained a graph of the distribution of scores, the mean and median scores of each round of the survey, along with the delegate’s own scores when s/he completed the Delphi surveys.The meeting commenced with a series of brief presentations from steering committee members on the topics of reporting guideline development, single-case methods and terminology, evolution of the SCRIBE project, and description of the CENT. Results of the Delphi survey were then presented. Delegates had their folder of materials to consult and a PowerPoint presentation that projected onto a screen to facilitate discussion. A primary aim of the consensus meeting was to develop the final set of items for the SCRIBE checklist. The final stages of the meeting discussed the documents to be published, authorship, and knowledge dissemination strategy.During the meeting the 44 Delphi items were discussed, item by item, over the course of four sessions, each led by two facilitators. The guiding principles for discussion were twofold. First, item content was scrutinized to ensure that (a) it captured the essence of the intended issue under consideration and (b) the scope of the item covered the necessary and sufficient information to be reported. Second, the relevance of the item was examined in terms of its capacity to ensure clarity and accuracy of reporting.Three delegates at the consensus meeting  took notes about the amalgamation and merging of items where applicable and refinements to wording of items. Final wording of items was typed, live-time, into a computer that projected onto a screen so that delegates could see the changes, engage in further discussion, give approval, and commit to the group decision. In addition, the meeting was audiotaped for the purpose of later transcription to have a record of the discussion of the items and inform the direction and points to describe in the E&E document.Figure By the end of the meeting, delegates reached consensus on endorsing 26 items that thus constitute the minimum set of reporting items comprising the SCRIBE 2016 checklist. The SCRIBE 2016 checklist consists of six sections in which the 26 aspects of report writing pertinent to single-case methodology are addressed. The first two sections focus on the title/abstract and introduction, each section containing two items. Section 3, method, consists of 14 items addressing various aspects of study methodology and procedure. Items include description of the design , participants, setting, ethics approval, measures and materials , interventions, and proposed analyses. The results (Section 4) and discussion (Section 5), each contains three items. Section 6 (documentation) contains two items pertaining to protocol availability and funding for the investigation.In total, 24 Delphi were merged into seven SCRIBE items because they referred to the same topics: (a) SCRIBE Item 5 (design) contained three Delphi items ; (b) Item 8 (randomization), two Delphi items (sequence and onset of randomization); (c) Item 11 (participant characteristics), two Delphi items (demographics and etiology); (d) Item 13 , two Delphi items ; (e) Item 14 (measures), nine Delphi items ; (f) Item 19 (results), two Delphi items (sequence completed and early stopping); and (g) Item 20 (raw data), four Delphi items . One of the Delphi items relating to meta-analysis, was considered not to represent a minimum standard of reporting for single-case experimental designs and accordingly was deleted.The audio recording of the 2-day consensus meeting was transcribed. The final guideline items were confirmed after close examination of the conference transcript and the SCRIBE 2016 checklist was developed  can use the checklist to evaluate whether the report meets the points outlined in the guideline. Users will find the detailed SCRIBE 2016 E&E document  and a SCRIBE website (www.sydney.edu.au/medicine/research/scribe) provides information and links to the SCRIBE 2016 publications. SCRIBE users are encouraged to access the website and provide feedback on their experiences using the SCRIBE and suggestions for future revisions of the guideline. Future research will evaluate the uptake and impact of the SCRIBE 2016.Following publication of this SCRIBE 2016 Statement and the E&E article  replication, which is of critical importance for establishing generality, (b) the coding of different aspects of the studies as potential moderators in meta-analysis, and (c) evaluation of the scientific quality of the research. All of these factors are relevant to the development of evidence-based practices.Robyn L. Tate, John Walsh Centre for Rehabilitation Research, The Kolling Institute of Medical Research, St Leonards, New South Wales, Australia, and Sydney Medical School Northern, The University of Sydney; Michael Perdices, Department of Neurology, Royal North Shore Hospital, New South Wales, Australia, and Discipline of Psychiatry, The University of Sydney; Ulrike Rosenkoetter, John Walsh Centre for Rehabilitation Research, The Kolling Institute of Medical Research, and Sydney Medical School Northern, The University of Sydney; William Shadish, School of Social Sciences, Humanities and Arts, University of California, Merced; Sunita Vohra, Department of Pediatrics, University of Alberta; David H. Barlow, Center for Anxiety & Related Disorders, Boston University; Robert Horner, Department of Special Education and Clinical Sciences, University of Oregon; Alan Kazdin, Department of Psychology, Yale University; Thomas Kratochwill, School of Educational Psychology, University of Wisconsin—Madison; Skye McDonald, School of Psychology, University of New South Wales; Margaret Sampson, Library and Media Services, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Larissa Shamseer, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Leanne Togher, Discipline of Speech Pathology, The University of Sydney; Richard Albin, Department of Special Eduction and Clinical Sciences, University of Oregon; Catherine Backman, Department of Occupational Science and Occupational Therapy, University of British Columbia; Jacinta Douglas, Department of Communication and Clinical Allied Health, La Trobe University; Jonathan J. Evans, Institute of Health and Wellbeing, University of Glasgow; David Gast, Department of Special Education, University of Georgia; Rumen Manolov, Department of Behavioural Sciences Methods, University of Barcelona; Geoffrey Mitchell, Discipline of General Practice, University of Queensland; Lyndsey Nickels, Department of Cognitive Sciences, Macquarie University; Jane Nikles, Centre for Clinical Research, University of Queensland; Tamara Ownsworth, School of Applied Psychology, Griffith University; Miranda Rose, Department of Communication and Clinical Allied Health, La Trobe University; Christopher H. Schmid, School of Public Health, Brown University; Barbara Wilson, Department of Neuropsychology, Oliver Zangwill Centre, Ely, Cambridgeshire, United Kingdom.The SCRIBE Group wishes to pay special tribute to our esteemed colleague Professor William Shadish (1949–2016) who passed away on the eve of publication of this article. His contribution at all stages of the SCRIBE project was seminal.http://arcblog.apa.org.Funding for the SCRIBE project was provided by the Lifetime Care and Support Authority of New South Wales, Australia. The funding body was not involved in the conduct, interpretation or writing of this work. We acknowledge the contribution of the responders to the Delphi surveys, as well as administrative assistance provided by Kali Godbee and Donna Wakim at the SCRIBE consensus meeting. Lyndsey Nickels was funded by an Australian Research Council Future Fellowship (FT120100102) and Australian Research Council Centre of Excellence in Cognition and Its Disorders (CE110001021). For further discussion on this topic, please visit the Archives of Scientific Psychology online public forum at In order to encourage dissemination of the SCRIBE Statement, this article is freely accessible through Archives of Scientific Psychology and will also be published in the American Journal of Occupational Therapy, Aphasiology, Canadian Journal of Occupational Therapy, Evidence-Based Communication Assessment and Intervention, Journal of Clinical Epidemiology, Journal of School Psychology, Neuropsychological Rehabilitation, Physical Therapy, and Remedial and Special Education. The authors jointly hold the copyright for this article.http://dx.doi.org/10.1037/arc0000026.supp]Supplemental data for this article can be accessed here. [


There is an error in the spelling of the affiliation for all of the authors. All authors are affiliated with: Department of Neuroscience, Mayo Clinic, Jacksonville, Florida, United States of America.


An incorrect grant number is in the funding statement. The correct funding statement is as follows: This work was partly supported by a Grant-in-Aid for Young Scientists (B) 25750042 from the Ministry of Education, Science, Sports and Culture, a grant for the special scientific research program aimed at the improvement of QOL  via oral function in collaboration with universities from the Ministry of Education, Culture, Sports, Science, and Technology, and a research grant supported by Kojinkai Foundation, and the President discretion research budget of the University of Tokushima. No additional external funding received for this study. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.


Department of Health and Human Services, the Task Force is an independent, nonfederal, unpaid panel of public health and prevention experts whose members are appointed by the Director of CDC. The Task Force provides information for a wide range of decision makers on programs, services, and policies aimed at improving population health. Although CDC provides administrative, research, and technical support for the Task Force, the recommendations developed are those of the Task Force and do not undergo review or approval by CDC.


Ying Huang is not included in the author byline. She should be listed as the eighth author and affiliated with Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, United States. The contributions of this author are as follows: Analyzed the data.


To describe the profile of morbidities and expenses related to hospitalization of the elderly compared to the adult population (20 to 59 years).A descriptive, cross-sectional investigation of hospitalizations of the elderly (60 years or older) in Brazil during the period from 2002 to 2011, with data from DATASUS and based on ICD-10.Although the highest number of hospitalizations were in the adult age range, the expenses were greater with the elderly, and in this case especially with mental and behavioral disorders, musculoskeletal and connective tissue diseases, followed by circulatory diseases and external causes.The results suggest the adoption of more comprehensive policies and increased investment in health promotion, disease prevention, and appropriate and suitable treatment for the most prevalent diseases in the elderly, particularly in primary care. However, in addition to these demographic changes, there are simultaneous alterations in the epidemiological profile, both in morbidity and mortality of the population, especially due to reduced incidence of infectious parasitic diseases and increase in non-communicable diseases.In a current context of health sciences, similar to various developing countries, Brazil is rapidly aging. This is a reflection of a process called demographic transition, resulting from the reduction in mortality and fertility rates. As a consequence of this change in age profile of the population, greater fiscal pressures are expected on public healthcare services and social security, generating a great demand for health services which will in turn lead to an increase in expenditures with medical costs and hospital admissions.It is estimated that the population over 60 years in age will go from less than 20 million in 2010, to approximately 65 million in 2050,5. In this way, an outline of the profile and statistics of hospitalization rates of the elderly may serve as a model for drawing up more effective strategies of health promotion and disease prevention.If, on the one hand the elderly display a greater burden of diseases and disabilities, and therefore, use a large portion of the health services, on the other hand, inefficiency and high costs related to the current models of elderly healthcare stand out.In this regard, the Unified Healthcare System Hospital Information Services  provides a database that accounts for 80% of hospital admissions in the country, enabling not only profiling of hospitalizations, but also allowing an assessment of their economic impactBased on questions as to the true proportions of hospitalization costs of the elderly in Brazil, this investigation had the objective of describing the profile of morbidities and expenses related to hospital admissions of the elderly compared to those of the adult population (20 to 59 years).. For comparison purposes, the adult age range was also presented, considered from 20 to 59 years.A descriptive cross-sectional study of hospital admissions of the elderly (60 years or more) in Brazil during the period from 2002 to 2011.This population was grouped into three categories: 60 to 69 years, 70 to 79, and 80 years or more, considering the stages specified by Fletcher & Fletcher. The run chart studied is based on official and secondary data on hospital admissions obtained from the SIH-SUS. The variables analyzed were gender, age, type of Hospital Admission Authorization , cost of hospitalization, days of stay, and working diagnosis, as per chapters of the International Classification of Diseases and Health-Related Problems – Tenth Revision (ICD-10). For the working diagnosis, all the chapters of ICD-10 were used except Chapter XV, which refers to admissions for natural deliveries and caesarean sections (codes 080 to 084.9), maintaining disorders related to pregnancy and puerperium.The resident population during the period (2002 to 2011), used to calculate some of the coefficients, was made available by the SUS Information Technology Department (DATASUS) and the primary causes of hospital admissions among elderly Americans.The major groups of causes were considered, as well as diagnoses due to selected causes including circulatory system diseases; respiratory system diseases; digestive system diseases; infectious and parasitic diseases; genitourinary diseases; external causes; endocrine, nutritional, and metabolic diseases; nervous system diseases; mental and behavioral disorders; neoplasms; musculoskeletal system and connective tissue diseases; and other diseases. This list was partially set up, for comparison purposes, based on the major causes of hospital admissions among the elderly Brazilian populationThe analyses were performed based on absolute numbers, percentages, and a few indicators, namely: The data from hospitalization records are not subject to sampling error, since they cover the totality of events occurred. However, they suffer the effects of random error in the registration process and population estimate. Since it is a study that uses secondary data from an electronic database that makes such information available for access to the general public (DATASUS), this investigation was not submitted to a Committee on Research Ethics in Human Beings. The development of this investigation occurred during the period from August 2002 to December 2012.During the 10 years considered in this study, there were 20,590,599 hospital admissions among elderly Brazilians within the scope of SUS. Of these hospitalizations, 11,434,487 (55.5%) corresponded to the female gender, and the sum of values paid for all these hospitalizations was R$ 21,545,274,041, as displayed on The elderly represented 16.11% during the period, contributing towards 27.85% of hospitalizations and 36.47% of the resources paid for them. The ratio between the percentage of values paid for hospitalizations and the percentage of the population increases gradually with age in men and women. This ratio was equal to 3.55 for elderly men, 1.57 for elderly women, and 2.26 for the elderly of both genders. When these data are divided by age range, the cost/inhabitant ratio increases significantly with age: 0.76 in the range of 20–59 years; 1.85 in 60–69; 2.65 in 70–79; and 3.05 in the range of 80+ years.Still on As to regions, the Southeast Region showed higher mean values than the rest. The cost/day of hospitalization is the highest in the North (R$ 103.81) and South (R$ 103.07) Regions, and the latter one represents the highest daily values among the elderly (R$ 125.64). Both adults and the elderly remain in the hospital longer in the Southeast Region , while in the North Region the values are 5.9 days for the elderly and 4.4 days for adults.As can be seen, the daily values of hospitalizations show a similar distribution among adults and the elderly, especially for circulatory system problems. In the elderly population, external causes have a higher value than in the other age groups observed. As to length of stay, in general, those aged over 60 years spend more time hospitalized, except for infectious diseases and nervous system disorders. It is noteworthy mentioning that the length of stay for mental and behavioral disorders reaches 103 days among the elderly .The hospitalization rate  has a coThe hospitalization rates of the elderly, in general, were higher than in the population aged 20–59 years, being nine-fold higher regarding the circulatory system diseases; with the exception for mental and behavioral disorders, in the male population, and from the same cause besides genitourinary system diseases among women.On Considering the use of a secondary database coming from healthcare services, such as the SIH-SUS, a few limitations can be identified: the possibility of emitting more than one AIH  for the same individual , and the remunerative structure of the system that privileges financial logic in detriment of epidemiological logic, facts that can compromise information reliability and validity..Nevertheless, such data have been increasingly more used in epidemiological research, besides the fact that such a system offers an expressive volume of data that represents about 80% of admissions of the entire hospital network of the country, factors that can reproduce such questioning,9,10.As to the data raised by the present investigation, hospitalizations in the adult population predominated, reaching 77% of hospitalizations among people of the female gender. As to the elderly population, one notes a prevalence of use of hospital services 1.6-fold greater in males, following the tendency of other studies.The value paid for hospitalizations is greater among the adult population, a reflection of the greater number of users of SUS at working age. However, the ratio of cost per inhabitant is expressively greater in the elderly population, especially among men, which enables stating that hospitalizations of the elderly are more costly than those that occur among individuals between 20 and 59 years of age. A study performed in 2004 found a cost ratio about four times higher among the elderly relative to the adultsTaking into consideration the differences between the genders, one must consider aspects inherent to the health culture of society, in which men, since early times, do not have the habit of caring for their health nor of seeking treatment at healthcare units. With time this fact leads to an increase of diseases in this population that are generally diagnosed at more advanced stages, requiring more specialized and expensive treatments. Whereas women tend to seek health care units more frequently, having treatments and investing in prevention and self-care, justifying less hospital expenses when they are aged. and genitourinary system diseases, described higher expenses with hospitalizations along the South-Southeast axis.The mean value of hospitalizations expressed the greatest cost in the Southeast Region, which was justified by longer hospital stay among its users, despite the fact that the daily cost of admissions in the North and South Regions has higher values. No references were found in literature covering the distribution of diseases with a national perspective, but other studies about specific disorders, such as suicideOne must consider that the most prevalent diseases up until the beginning of this decade, i.e., circulatory, neurologic, and neoplastic diseases, had their mean values decreased relative to mental and behavioral disorders, and musculoskeletal conditions. This is considered as a possible result of health-related actions performed by the Family Health Strategy , which has assisted the population in promoting health, control and prevention of diseases., in addition to specific approaches as to stroke, other cerebrovascular and cardiovascular events, and circulatory system diseases, which in this case have an extensive relation with vaccination of the elderly against the influenza virus, as a national strategy focused on the Primary Care services as from 1999.Such actions have been the focus of recent studies that considered the ESF a protective factor for the elderly as to chronic and degenerative diseasesdelirium, an acute organic ailment of which onset will initiate a series of events that can culminate with loss of independence, increased morbidity and mortality, besides elevating length and costs of hospitalization and care after hospital discharge.In considering the higher results of the mean value of hospitalization and hospital length of stay, there is an expressive amount of cases related to mental and behavioral disorders. One of the primary etiologies, which may be associated to this result, is .As to musculoskeletal and connective tissue diseases, those with greatest prevalence were osteoporosis, arthrosis, chronic spondylitis, arthritis, and rheumatism, with growing numbers and consolidating as a public health concern, a predominance of cardiovascular disorders was also observed, as well as in a study that analyzed national information during two specific periods: 1994 and 2005, with 32% and 28% of cardiovascular events, respectively.In calculations relative to the rate of hospital admission and cost indexes, the prevalence of circulatory system diseases was observed among adults. In a study that evaluated the diseases that most affected the elderly during the period from 1998 to 2005 in a city in the state of Paraná.A prospective study performed in Greece comparing hospital admissions in three distinct months of the same year identified similar results, especially regarding the greater prevalence of hospitalizations due to circulatory system diseases, followed by musculoskeletal and gastrointestinal diseases.As to hospitalizations of the elderly related to the respiratory system, a large part presents with a direct relation with the influenza virus, which in Brazil has a seasonal distribution and an approximate prevalence of 22 cases per thousand inhabitants, influenced by geographic density, age distribution of the population, and climate conditions. Complications of this virus may cause severe respiratory problems, such as pneumonia.In addition to a better perception and evaluation of the strategies of Primary Care, especially within the ESF context, the role of health professionals, especially nurses, overcomes difficulties, such as lack of human and material resources, training of professionals, and an adequate physical structure, prioritized by care aligned with human values, respect, and autonomy for the elderly person, which may contribute favorably towards reduction of the most common diseases in the aged.In a broader context of health promotion, the inclusion of the elderly in activities that favor their social interaction, life habits, etc, should be highlighted. Some initiatives, such as a group of elderly individuals linked to a hospital geriatrics service, identified improved overall quality of life in the individuals, resulting from the psychological and social support they received from peers and professionals, and the benefits from the group activities, as well as a tendency towards elevation observed in the social relation and general domainsAcademia da Cidade (City Gymnasium) implemented by the Ministry of Health, in 2011. This initiative seeks to create places where people can exercise, engage in sociocultural activities, receive orientation, and develop projects integrated with Primary Care, which could serve even as an entry into the health system. Some studies have already shown the effectiveness of this proposal, which is not only for the elderly, but they generally are the ones that participate in it, in addition to those who would not have the means of paying to go to a gymnasium.A public initiative that may be effective in most frequent diseases of the elderly and in longer hospital stays, is the As a consequence of an older population, health promotion (in the vastness of its practice), actions of health education, prevention of diseases, and retarding of diseases and fragilities, as well as maintenance of independence and autonomy, may guarantee better quality of life to the elderly.In the present investigation, distinct indicators were used to evaluate costs related to hospitalization of the elderly. Without going into the merit of the scope of each one, the results showed differences and similarities, composing a more complete picture for assessing of such health costs.The results presented here allow one to infer that admissions of the elderly population are more costly than those conditioned by the adult population, expressed by most of the indicators observed. Health complications related to the aging process itself are covered, such as chronic diseases, possible failures in health promotion actions and prevention of diseases, in addition to an increment in prevalence of diseases rarely investigated in literature to date, such as the primary causes of the expenses.These effects may be reduced with the adoption of more comprehensive policies and greater investment in actions of promotion, prevention, and opportune and adequate treatment for the most prevalent diseases in the aged. These policies may and should serve as subsidies for the preparation and implementation of actions capable of bringing favorable changes to the lives of the elderly and to the Unified Healthcare System, as the structure in charge of their care, among many other responsibilities.


Problem vs. recreational users may be segregated (to enable their comparison) using information available from each study's instruments, on key addiction phenotypes (e.g., craving, withdrawal, difficulties in controlling use, persistent use despite harmful consequences on mental health, and socio-occupational functioning, higher priority given to drug use than to other activities and obligations; APA., Finally, we propose the development of an agreed-upon instrument to objectively assess key features of cannabis addiction vs. non-problem use in neuroscientific settings, as most measures of cannabis related problems are borrowed from those used for other substances, the features of which may not fit those relevant to cannabis dependence (Lorenzetti et al., In conclusion, we call for a greater, systematic and coordinated research effort internationally, to identify pathways in and out of CUDs and fill the existing gap between the limited knowledge on CUDs and the increasing availability of cannabis products.VL and JC formulated the key concepts and led the writing of the commentary; NS, HG, CS, and MY contributed to the concepts and writing of the commentary. AV contributed to the key concepts and to the writing of the commentary.NS is supported by the Australian Research Council Future Fellowship FT110100752. MY is supported by the National Health and Medical Research Council of Australia, Senior Research Fellowship.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.


The affiliation for the third author is incorrect. Michal Ginter is not affiliated with the Paleontology Section but with the Faculty of Geology, University of Warsaw, Warsaw, Poland.