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Based on the UN Convention on the Rights of the Child, children and young people have the right to participate in all matters and decisions that affect them. This applies in particular when they are patients in a children's hospital. In the international context, established formats for the participation of young patients regarding health issues already exist, for example "Children's Councils" or "Young Person's Advisory Groups". In Germany, such approaches are still mostly lacking. It thus remains important to develop suitable formats that enable meaningful and effective participation of young patients in the health system. These formats must be chosen in such a way that they can realistically be implemented in clinical settings as well as in pediatric research, and that they can be sustained in the long term. In order to strengthen the consideration of children's rights in the health system, the advancement of such participatory formats as well as their sustainable implementation and evaluation are desirable., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Während einer Pandemie muss Resilienz nicht nur als Eigenschaft des Gesundheitssystems, sondern auch des umgebenden Forschungsumfelds betrachtet werden. Um verlässliche, evidenzbasierte Empfehlungen aus der Universitätsmedizin an die Gesundheitspolitik und die Entscheidungsträger bereitstellen zu können, müssen wissenschaftliche Erkenntnisse schnell, integrativ und multidisziplinär generiert, synthetisiert und kommuniziert werden. Die Resilienz der öffentlichen Gesundheitssysteme und der Gesundheitsforschungssysteme sind somit eng verknüpft. Die Reaktion auf die SARS-CoV-2-Pandemie in Deutschland wurde jedoch durch das Fehlen einer adäquat vernetzten Gesundheitsforschungsinfrastruktur erschwert. Das Netzwerk Universitätsmedizin (NUM) wurde zu Beginn der Pandemie mit dem Ziel gegründet, Deutschland auf zukünftige Pandemien vorzubereiten. Ziel des Projektes "PREparedness and PAndemic REsponse in Deutschland (PREPARED)" ist es, ein ganzheitliches Konzept für eine kooperative, adaptierbare und nachhaltige Gesundheitsforschungsinfrastruktur innerhalb des NUM zu entwickeln und damit einen Beitrag zu einer umfassenden Pandemiebereitschaft zu leisten. Das vorgeschlagene Konzept dieser Infrastruktur vereint vier Kern- und drei Unterstützungsfunktionalitäten in vier verschiedenen Handlungsfeldern. Die Funktionalitäten gewährleisten im Falle zukünftiger Gesundheitskrisen ein effizientes Funktionieren des Gesundheitsforschungssystems und eine rasche Übertragung entsprechender Implikationen in andere Systeme. Die vier Handlungsfelder sind (a) Monitoring und Surveillance, (b) Synthese und Transfer, (c) Koordination und Organisation sowie (d) Kapazitäten und Ressourcen. Die sieben Funktionalitäten umfassen 1) eine Monitoring- und Surveillance-Einheit, 2) eine Pathogenkompetenz-Plattform, 3) Evidenzsynthese und vertrauenswürdige Empfehlungen, 4) eine Einheit zur regionalen Vernetzung und Implementierung, 5) eine Strategische Kommunikationseinheit, 6) Human Resources Management und 7) ein Rapid Reaction & Response (R 3 )-Cockpit. Die Governance wird als Kontroll- und Regulierungssystem eingerichtet, wobei agile Management-Methoden in interpandemischen Phasen trainiert werden, um die Reaktionsfähigkeit zu verbessern sowie die Eignung agiler Methoden für die wissenschaftliche Infrastruktur für die Pandemiebereitschaft zu untersuchen. Der Aufbau der PREPARED-Forschungsinfrastruktur muss vor der nächsten Pandemie erfolgen, da Training und regelmäßige Stresstests grundlegende Voraussetzungen für deren Funktionieren sind.During a pandemic, resilience must be considered not only as an attribute of the health care system, but also of the surrounding research environment. To provide reliable evidence-based advice from university medicine to health policy and decision makers, scientific evidence must be generated, synthesized and communicated in a rapid, integrative and multidisciplinary manner. The resilience of public health systems and the health research systems are thus closely linked. However, the response to the SARS-CoV-2 pandemic in Germany was hampered by the lack of an adequate health research infrastructure. The Network University Medicine (NUM) was founded at the beginning of the pandemic with the aim of preparing Germany for future pandemics. The aim of the project "PREparedness and PAndemic REsponse in Deutschland (PREPARED)" is to develop a holistic concept for a cooperative, adaptable and sustainable health research infrastructure within the NUM and thus contribute to pandemic preparedness and rapid response. The proposed concept for a health research infrastructure includes four core and three supporting functionalities in four different fields of action. The functionalities aim to ensure efficient functioning within the health research system and a rapid translation to other systems in future health crises. The four fields of action are (a) monitoring and surveillance, (b) synthesis and transfer, (c) coordination and organization, and (d) capacities and resources. The seven functionalities include 1) a monitoring and surveillance unit, 2) a pathogen competence platform, 3) evidence synthesis and trustworthy recommendations, 4) a regional networking and implementation unit, 5) a strategic communication unit, 6) human resources management, and 7) a rapid reaction and the response (R 3 )-cockpit. A governance will be established as a control and regulatory system for all structures and processes, testing agile management in non-pandemic times to improve responsiveness and flexibility and to investigate the suitability of the methods for scientific pandemic preparedness. The establishment of the PREPARED health research infrastructure must take place before the next pandemic, as training and regular stress tests are its fundamental prerequisites., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht. Jochen Schmitt erhielt unabhängig von dem vorliegenden Projekt institutionelle Zuwendungen für wissenschaftlich initiierte Forschung vom G-BA, BMG, BMBF, EU, Bundesland Sachsen, Novartis, Sanofi, ALK und Pfizer. Außerdem nahm er als Honorarberater für Sanofi, Lilly und ALK an Beiratssitzungen teil. Er ist Mitglied im Sachverständigenrat Gesundheit und Pflege des BMG und Mitglied der Regierungskommission für eine moderne und bedarfsgerechte Krankenhausversorgung der aktuellen deutschen Ampelkoalition. Julia Hoffmann und Lorenz Harst erhielten von der Volkswagen-Stiftung eine Förderung für die Teilnahme an einem Workshop zur Versorgungsforschung., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Problem: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, reliable, globally applicable recommendations for safe and continuous school operations were lacking., Approach: In October 2020, the German Association of Scientific Medical Societies' task force for COVID-19 guidelines and public health researchers at Ludwig-Maximilians-Universität München initiated the rapid development of a living evidence- and consensus-based guideline to reduce severe acute respiratory syndrome coronavirus 2 transmission in schools. To facilitate transparent, structured and comprehensive decision-making with a whole-of-society perspective, they applied the WHO-INTEGRATE evidence-to-decision framework. This framework supported a broad, multisectoral composition of the guideline panel. The panel used newly synthesized evidence on nine school measures. Participating medical societies or the guideline secretariat completed evidence-to-decision tables. They also drafted recommendations for the guideline panel, who discussed and revised them during moderated consensus conferences., Local Setting: In Germany, each state is responsible for organizing schooling. The German Association of Scientific Medical Societies coordinates development of evidence- and consensus-based guidelines., Relevant Changes: The first version of the guideline was published in February 2021, and the guideline dissemination created much media attention. Of the 16 state education ministries, almost all knew about the guideline, nine recognized it as a relevant source of information and five used it to check existing directives., Lessons Learnt: The WHO-INTEGRATE framework facilitated a comprehensive assessment of school measures from the start of guideline development, considering the broad societal impact of the measures. Using the framework in rapid mode was feasible, but it fell short of its potential., ((c) 2024 The authors; licensee World Health Organization.)

Introduction: Cinemeducation describes the use of film in medical education. The M23 Cinema (M23C) comprises a film screening and subsequent discussion with experts, affected persons and the audience. Previous research suggests that participating in cinemeducation may affect emotions and attitudes. This study aimed to establish a conceptual framework and explore when learning takes place, how learning occurs and what participants learn during the M23C., Methods: Informed by focused literature searches, discussions of the authors and the research results, a conceptual framework of the M23C was developed, comprising three dimensions (five distinct phases, learning methodology and potential impact). A mixed method study was undertaken, employing an exploratory sequential design. Initially, the qualitative component was conducted by interviewing everyone involved, comprising focus groups, expert interviews, a group interview and one narrative interview. All qualitative data were analysed using qualitative content analysis. The qualitative findings were used to inform the development of a survey among the participants of M23C evenings. The survey results were analysed descriptively. The findings generated by both data sets were integrated using the "following a thread" protocol and visualised by joint displays., Results: In total, 15 participants in M23C courses, six members of the current and two of the former organising committee, two experts, two affected persons and the initiator of the M23C were included in the qualitative component (n = 28). A total of 503 participants responded to the survey. The qualitative data confirmed the relevance of the five phases and participants described reflective thinking, perspective taking and emotional narratives as the three dimensions of how they learned during the M23C. Participants reported a change in attitudes, enriching their knowledge, experiencing empathy and learning about other health professions., Discussion: Our findings suggest that the M23C as a cinemeducation course provides a unique learning environment in the training of health professionals., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Exposure to marketing for foods high in sugar, salt, and fat is considered a key risk factor for childhood obesity. To support efforts to limit such marketing, the World Health Organization Regional Office for Europe has developed a nutrient profile model (WHO NPM). Germany's Federal Ministry of Food and Agriculture plans to use this model in proposed new food marketing legislation, but it has not yet been tested in Germany. The present study therefore assesses the feasibility and implications of implementing the WHO NPM in Germany., Methods: We applied the WHO NPM to a random sample of 660 food and beverage products across 22 product categories on the German market drawn from Open Food Facts, a publicly available product database. We calculated the share of products permitted for marketing to children based on the WHO NPM, both under current market conditions and for several hypothetical reformulation scenarios. We also assessed effects of adaptations to and practical challenges in applying the WHO NPM., Results: The median share of products permitted for marketing to children across the model's 22 product categories was 20% (interquartile range (IQR) 3-59%) and increased to 38% (IQR 11-73%) with model adaptations for fruit juice and milk proposed by the German government. With targeted reformulation (assuming a 30% reduction in fat, sugar, sodium, and/or energy), the share of products permitted for marketing to children increased substantially (defined as a relative increase by at least 50%) in several product categories (including bread, processed meat, yogurt and cream, ready-made and convenience foods, and savoury plant-based foods) but changed less in the remaining categories. Practical challenges included the ascertainment of the trans-fatty acid content of products, among others., Conclusion: The application of the WHO NPM in Germany was found to be feasible. Its use in the proposed legislation on food marketing in Germany seems likely to serve its intended public health objective of limiting marketing in a targeted manner specifically for less healthy products. It seems plausible that it may incentivise reformulation in some product categories. Practical challenges could be addressed with appropriate adaptations and procedural provisions., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Introduction: During the COVID-19 pandemic, decision-making on measures to reduce or prevent transmission of SARS-CoV-2 in schools was rendered difficult by a rapidly evolving and uncertain evidence base regarding their effectiveness and unintended consequences. To support decision-makers, an interdisciplinary panel of scientific experts, public health and school authorities as well as those directly affected by school measures, was convened in an unprecedented effort to develop an evidence- and consensus-based public health guideline for German schools. This study sought to assess whether and how this guideline impacted decision-making processes., Methods: This study comprised three components: (1) we sent inquiries according to the Freedom of Information Acts of each Federal State to ministries of education, family, and health. (2) We conducted semi-structured interviews with individuals involved in decision-making regarding school measures in two Federal States, and (3) we undertook semi-structured interviews with members of the guideline panel. The content of response letters in component 1 was analysed descriptively; data for components 2 and 3 were analysed using deductive-inductive thematic qualitative content analysis according to Kuckartz., Results: Responses to the Freedom of Information Act inquiries showed that the guideline was recognised as a relevant source of information by ministries of education in nine out of 16 Federal States and used as a reference to check existing directives for school measures in five Federal States. All participants (20 interviews) emphasised the value of the guideline given its evidence- and consensus-based development process but also noted limitations in its usability and usefulness, e.g., lack of context-specificity. It was consulted by participants who advised policy-makers (5 interviews) alongside other sources of evidence. Overall, perceptions regarding the guideline's impact were mixed., Conclusions: Our findings suggest that the guideline was relatively well-known in Federal States' decision-making bodies and that it was considered alongside other forms of evidence in some of these. We suggest that further research to evaluate the impact of public health guidelines on (political) decision-making is warranted. Guideline development processes may need to be adapted to account for the realities of decision-making during public health emergencies and beyond., (© 2023. The Author(s).)

Background: Integrated knowledge translation (IKT) through strategic, continuous engagement with decision-makers represents an approach to bridge research, policy and practice. The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA +), comprising research institutions in Ethiopia, Malawi, Rwanda, South Africa, Uganda and Germany, developed and implemented tailored IKT strategies as part of its multifaceted research on prevention and care of non-communicable diseases and road traffic injuries. The objective of this article is to describe the CEBHA + IKT approach and report on the development, implementation and monitoring of site-specific IKT strategies., Methods: We draw on findings derived from the mixed method IKT evaluation (conducted in 2020-2021), and undertook document analyses and a reflective survey among IKT implementers. Quantitative data were analysed descriptively and qualitative data were analysed using content analysis. The authors used the TIDieR checklist to report results in a structured manner., Results: Preliminary IKT evaluation data (33 interviews with researchers and stakeholders from policy and practice, and 31 survey responses), 49 documents, and eight responses to the reflective survey informed this article. In each of the five African CEBHA + countries, a site-specific IKT strategy guided IKT implementation, tailored to the respective national context, engagement aims, research tasks, and individuals involved. IKT implementers undertook a variety of IKT activities at varying levels of engagement that targeted a broad range of decision-makers and other stakeholders, particularly during project planning, data interpretation, and output dissemination. Throughout the project, the IKT teams continued to tailor IKT strategies informally and modified the IKT approach by responding to ad hoc engagements and involving non-governmental organisations, universities, and communities. Challenges to using systematic, formalised IKT strategies arose in particular with respect to the demand on time and resources, leading to the modification of monitoring processes., Conclusion: Tailoring of the CEBHA + IKT approach led to the inclusion of some atypical IKT partners and to greater responsiveness to unexpected opportunities for decision-maker engagement. Benefits of using systematic IKT strategies included clarity on engagement aims, balancing of existing and new strategic partnerships, and an enhanced understanding of research context, including site-specific structures for evidence-informed decision-making., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Child Life Specialists (CLSs) are psychosocial care professionals of child development and health who focus on the individual needs and rights of young patients. CLSs accompany sick children and focus on the children's perspective and their reality of life. CLS programs are already established in clinical settings in the United States and other Anglophone countries but have not yet been piloted in the German health care setting, neither has their implementation been evaluated in this context. This study aimed to explore the factors influencing the implementation of a pilot CLS program in pediatric inpatient care at the Dr. von Hauner Children's Hospital at the University Hospital of Munich, Germany., Methods: Building on methods commonly employed in the evaluation of complex interventions, we developed a logic model to guide the process evaluation of our program. Semi-structured interviews with four groups of stakeholders were conducted in person or via videoconferencing between June 2021 and January 2022. Data was analyzed collectively using the method of qualitative content analysis by Mayring., Results: Fifteen individual interviews were conducted with patients (children aged 5-17 years, n  = 4), parents ( n  = 4), CLSs ( n  = 4) and other health professionals ( n  = 3). Factors influencing the implementation were identified on three levels: system, staff and intervention. On the system level, a clearer definition of CLSs' tasks and responsibilities was perceived as important and would likely lead to a delineation from other (psychosocial) professions and a reduction of potential resistances. On the staff level, lacking training opportunities and feelings of being insufficiently skilled were limiting the CLSs professional self-confidence. On the intervention level, the emergence of a unique characteristic of the CLSs' work (i.e., preparation for medical procedures) supported the acceptance of the new program., Conclusions: The implementation of a CLS program into an established hospital system with existing psychosocial care services is challenging. Our results contribute to a better understanding of implementation processes of such an additional psychosocial care approach and provide recommendations for addressing upcoming challenges., Competing Interests: VV received travel support from the University Hospital of LMU Munich and the Care-For-Rare-Foundation for an internship at the Children’s Hospital in Seattle to get to know a CLS program. CK received funding from the Care-For-Rare-Foundation for implementing a CLS program at the Dr. von Hauner Children’s Hospital at the University Hospital of LMU Munich. The remaining 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., (© 2023 Hummel, Voss, Clark, Coenen, Klein, Rehfuess, Zu Rhein, Voigt-Blaurock and Jung-Sievers.)

The growing burden of non-communicable diseases (NCDs) and an increase in the prevalence of the underlying risk factors are creating a challenge to health systems in low- and middle-income countries (LMICs). In Nepal, deaths attributable to NCDs have been increasing, as has life expectancy. This poses questions with regards to how age and various risk factors interact in affecting NCDs. We analyzed the effects of age on NCD risk factors, using data from the Nepalese STEPs survey 2019, a nationally representative cross-sectional study. Six sociodemographic determinants, four behavioral risk factors, and four biological risk factors were examined. Age effects were analyzed among three age groups: below 35 years (young), 35-59 years (middle aged) and 60 years and above (elderly). The prevalence of selected behavioral risk factors for NCDs, notably smoking, alcohol consumption and insufficient physical activity, and some biological risk factors (hypertension, hyperlipidemia) increases with age. The prevalence of most behavioral risk factors was highest among men and women aged 60 years and above. The prevalence of hypertension and hyperlipidemia was highest among the elderly, but the prevalence of diabetes and overweight/obesity was highest among the middle aged for both sexes. Age interactions in the association between behaviors and biological risk factors were surprisingly weak. However, age interactions were significant in the association between alcohol consumption and -hypertension, -overweight/obesity and -hyperlipidemia among women. While the prevalence of NCD risk factors tends to be higher among elders, the interaction between age and risk factors is complex. Most NCD risk factors are related to behaviors, which originate in young adulthood. It is necessary to diagnose and treat biological risk factors, in younger age groups before they manifest as NCDs. Similarly, behavior change interventions need to target these younger age groups to reduce the risk of NCDs later in life., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Sapkota et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The COVID-19 pandemic with its containment measures such as closures of schools and daycare facilities led to numerous restrictions in daily life, putting developmental opportunities and health-related quality of life in children at risk. However, studies show that not every family was impacted equally by the pandemic and that this exceptional health and societal situation reinforced pre-existing health inequalities among the vulnerable. Our study aimed at analyzing changes in behavior and health-related quality of life of children attending elementary schools and daycare facilities in Bavaria, Germany in spring 2021. We also sought to identify associated factors contributing to inequalities in quality of life., Methods: Data from a multi-center, open cohort study ("COVID Kids Bavaria") conducted in 101 childcare facilities and 69 elementary schools across all electoral districts of Bavaria were analyzed. Children attending these educational settings (aged 3-10 years) were eligible for participation in a survey on changes in behavior and health-related quality of life. The KINDL R questionnaire (based on children's self-report and parental report) was administered about one year after the onset of the pandemic (spring 2021). Descriptive and logistic regression analyses and comparisons to pre-pandemic KiGGS (German Health Interview and Examination Survey for Children and Adolescents) data were undertaken., Results: Among respondents, a high percentage of parents reported changes in their children's eating and sleeping behavior, sports and outdoor activities as well as altered screen time. Health-related quality of life in KINDL R analyses compared to pre-pandemic population averages were lower in all age groups (for 3-6-year-old KINDL R -total score: COVID Kids Bavaria MD 74.78 ± 10.57 vs KiGGS data 80.0 ± 8.1; 7-10 years-old KINDL R -total score: COVID Kids Bavaria MD 73.88 ± 12.03 vs KiGGS data 79.30 ± 9.0). No significant differences were detected with regard to associated factors, namely type of institution, sex of the child, migration background, household size and parental education., Conclusion: These findings suggest a relevant impact of the COVID-19 pandemic on children's behavior and health-related quality of life one year after the onset of the pandemic. Further analyses in large-scale longitudinal studies are needed to determine the effects of specific pandemic or crisis associated factors contributing to health inequalities., Competing Interests: The study COVID Kids Bavaria was financed by the Bavarian Ministry of Research and Art. CK reports support from the Care-for-Rare Foundation. CJS reports involvement with other COVID-19 related studies such as the COSMO study, COVerCHILD (NUM) and others. ER reports involvement with other COVID-19 related studies, notably COVerCHILD, and having co-coordinated the German evidence- and consensus-based S3 guideline on schooling during COVID-19 as well as being a member of the WHO Technical Advisory Group on Schooling during COVID-19. HS is a doctoral candidate in the Research Training Group “PrediktOren und Klinische Ergebnisse bei depressiven ErkrAnkungen in der hausärztLichen Versorgung (POKAL, DFG-GRK 2621)” (Predictors and Clinical Outcomes of Depressive Disorders in Primary Care) POKAL, a member of the German Research Foundation (DFG). UB is employed by the Department of Pediatrics, Kinderklinik München Schwabing, StKM GmbH und Klinikum Rechts der Isar, Technische Universität München, Germany. NM is employed by the Institute for Asthma- and Allergy Prevention (IAP), Helmholtz Center Munich, German Research Center for Environmental Health (GmbH), Munich, Germany. The remaining 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., (© 2023 Schillok, Coenen, Rehfuess, Kuhlmann, Matl, Kindermann, Maison, Eckert, von Both, Behrends, Früehwald, Neubert, Woelfle, Melter, Liese, Hübner, Klein, Kern and Jung-Sievers.)

Background: The City of Munich is planning and implementing a "Prevention Chain" as an integrated community-based prevention strategy in the new district of "Freiham" in Munich. This is taking place while the district is being built. The "Prevention Chain Freiham" aims to create an environment that enables a healthy upbringing of all children and adolescents right from the start. In order to guide this project, an interdepartmental working group was formed within the City of Munich's administration. This study analyses the working group's structures, processes and its collaboration with a variety of stakeholders., Methods: We conducted a multimethod study comprising qualitative interviews and social network analysis. Between March and April 2018, we conducted semi-structured interviews with members of the working group. The study participants also generated ego-centred social network maps. The transcripts were analysed using qualitative content analysis as described by Schreier. The network maps were also analysed using qualitative content analysis and the results were visualized. Our preliminary findings were interpreted, discussed and validated in a workshop in June 2018 with study participants., Results: Ten members of the working group participated in the study. The interdepartmental, multiprofessional collaboration in the working group was perceived as beneficial for the process of developing and implementing the Prevention Chain. The external coordination by MAGs and the scientific expertise provided by the LMU Munich were considered highly supportive. Barriers to the planning and implementation of the Prevention Chain were mainly located at administration level. Most facilitators were attributed to the collaborative processes within the working group. After having mapped all stakeholders currently involved in the Prevention Chain (mainly actors within the City of Munich's administration), additional relevant stakeholders were identified by the members of the working group., Conclusion: The organizational form of the working group as a formalized association of representatives of various departments that are jointly responsible for the Prevention Chain is considered beneficial for the success of the Prevention Chain. This is further supported by the external coordination and academic support. Advancing the development and implementation of the Prevention Chain will require support from all relevant departments across sectors and hierarchies., Competing Interests: Die Erstautorin arbeitet seit 01.03.19 bei MAGs – Münchner Aktionswerkstatt Gesundheit. Die Studiendurchführung und -auswertung waren zum Zeitpunkt der Bewerbung bereits abgeschlossen. Die Ko-Autor*innen waren (LMP, ER) oder sind (MC) nach wie vor in die Begleitgruppe der Präventionskette Freiham eingebunden., (Thieme. All rights reserved.)

Introduction: Different measures to prevent and control the spread of SARS-CoV-2 have been implemented in German schools. Decisions regarding such measures should be informed by evidence regarding their effectiveness, and their unintended consequences for health and society. A multi-stakeholder panel was convened to develop an evidence- and consensus-based guideline for school measures, using the novel WHO-INTEGRATE framework. Developing a guideline to inform decision-making outside of the clinical realm during a public health emergency was unprecedented in Germany. This study aims to identify lessons learnt for similar endeavours by addressing the following research question: What were the strengths and weaknesses of the guideline development process as perceived by the different groups involved?, Methods: Fifteen semi-structured interviews were conducted virtually. We recruited participants aiming to include the perspectives of all groups contributing to the guideline development, including both panel members (scientists, practitioners, school family and observers) and the guideline secretariat. For analysis, we carried out deductive-inductive thematic qualitative text analysis according to Kuckartz, structuring findings using a category system., Results: Due to time pressure, the guideline secretariat was heavily involved not only in synthesising the evidence but also in developing and drafting recommendations. Participants critically reflected on certain methods-related decisions, including the development of draft recommendations and application of the WHO-INTEGRATE framework by scientists only. The full potential of the framework might not have been harnessed. Participants' understanding of relevant and valid evidence varied, and the available evidence base was limited. Participants represented different types of expertise, notably expertise informed by scientific evidence and expertise grounded in lived experience, influencing their involvement in the guideline development process and discussions during meetings., Conclusion: Developing an evidence- and consensus-based public health guideline in only three months was challenging, notably because of the involvement of a broad range of stakeholders and the use of a novel Evidence-to-Decision framework, both unprecedented in Germany. Learning from this process with a view to "institutionalising" the development of public health guidelines and refining methods can contribute to more evidence-informed public health decision-making in Germany and beyond, in general and during a public health emergency., Competing Interests: EAR, BS, and LMP are members of the guideline secretariat as well as initiators of this process evaluation, which represents a conflict of interest (see Methods and Discussion with regard to how this research sought to minimise any undue influence as a result of this conflict of interest). The remaining 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., (Copyright © 2023 Wabnitz, Rueb, Pfadenhauer, Strahwald and Rehfuess.)

Background: Public health and social measures (PHSM) intend to reduce the transmission of infectious diseases and to reduce the burden on health systems, economies and societies. During the COVID-19 pandemic, PHSM have been selected, combined and implemented in a variable manner and inconsistently categorized in policy trackers. This paper presents an initial conceptual framework depicting how PHSM operate in a complex system, enabling a wide-reaching description of these measures and their intended and unintended outcomes., Methods: In a multi-stage development process, we combined (i) a complexity perspective and systems thinking; (ii) literature on existing COVID-19 PHSM frameworks, taxonomies and policy trackers; (iii) expert input and (iv) application to school and international travel measures., Results: The initial framework reflects our current understanding of how PHSM are intended to achieve transmission-related outcomes in a complex system, offering visualizations, definitions and worked examples. First, PHSM operate through two basic mechanisms, that is, reducing contacts and/or making contacts safer. Second, PHSM are defined not only by the measures themselves but by their stringency and application to specific populations and settings. Third, PHSM are critically influenced by contextual factors. The framework provides a tool for structured thinking and further development, rather than a ready-to-use tool for practice., Conclusions: This conceptual framework seeks to facilitate coordinated, interdisciplinary research on PHSM effectiveness, impact and implementation; enable consistent, coherent PHSM monitoring and evaluation; and contribute to evidence-informed decision-making on PHSM implementation, adaptation and de-implementation. We expect this framework to be modified and refined over time., Competing Interests: AM, LMP, JB, EAR and BS report having received institutional funding from the German Ministry for Education and Research towards the COVID‐19 Evidence Ecosystem (CEOsys) project, which facilitated systematic review work on school measures and international travel measures. EAR additionally reports being a member of the Scientific Advisory Board of the Robert Koch Institute, which offered guidance on PHSM during the pandemic in Germany, and of the WHO Regional Office for Europe's Technical Advisory Group on Schooling during COVID‐19; she also reports being a member of the methods working group of the WHO PHSM Initiative. RL reports being involved with setting up and implementing the WHO PHSM Initiative. SM reports being a member of the methods working group of the WHO PHSM Initiative, having participated in the UK Government's Scientific Advisory Group in Emergencies (SAGE) and in Independent SAGE, and being a member of the Lancet Covid‐19 Commission's Public Health Taskforce., (© 2023 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks are well-known tools that enable guideline panels to structure the process of developing recommendations and making decisions in healthcare and public health. To date, they have not regularly been used for health policy-making. This article aims to illustrate the application of the GRADE EtD frameworks in the process of nutrition-related policy-making for a European country., Methods: Based on methodological guidance by the GRADE Working Group and the findings of our recently published scoping review, we illustrate the process of moving from evidence to recommendations, by applying the EtD frameworks to a fictitious example. Sugar-sweetened beverage (SSB) taxation based on energy density was chosen as an example application., Results: A fictitious guideline panel was convened by a national nutrition association to develop a population-level recommendation on SSB taxation aiming to reduce the burden of overweight and obesity. Exemplary evidence was summarized for each EtD criterion and conclusions were drawn based on all judgements made in relation to each criterion. As a result of the high priority to reduce the burden of obesity and because of the moderate desirable effects on health outcomes, but considering scarce or varying research evidence for other EtD criteria, the panel made a conditional recommendation for SSB taxation. Decision-makers may opt for conducting a pilot study prior to implementing the policy on a national level., Conclusions: GRADE EtD frameworks can be used by guideline panels to make the process of developing recommendations in the field of health policy more systematic, transparent and comprehensible., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Public Health Association.)

In Nepal, deaths attributable to NCDs have increased in recent years. Although NCDs constitute a major public health problem, how best to address this has not received much attention. The objective of this study was to assess the readiness of the Nepalese health sector for the prevention and control of NCDs and their risk factors. The study followed a multi-method qualitative approach, using a review of policy documents, focus group discussions (FGDs), and in-depth interviews (IDIs) conducted between August and December 2020. The policy review was performed across four policy categories. FGDs were undertaken with different cadres of health workers and IDIs with policy makers, program managers and service providers. We performed content analysis using the WHO health system building blocks framework as the main categories. Policy documents were concerned with the growing NCD burden, but neglect the control of risk factors. FGDs and IDIs reveal significant perceived weaknesses in each of the six building blocks. According to study participants, existing services were focused on curative rather than preventive interventions. Poor retention of all health workers in rural locations, and of skilled health workers in urban locations led to the health workers across all levels being overburdened. Inadequate quantity and quality of health commodities for NCDs emerged as an important logistics issue. Monitoring and reporting for NCDs and their risk factors was found to be largely absent. Program decisions regarding NCDs did not use the available evidence. The limited budget dedicated to NCDs is being allocated to curative services. The engagement of non-health sectors with the prevention and control of NCDs remained largely neglected. There is a need to redirect health sector priorities towards NCD risk factors, notably to promote healthy diets and physical activity and to limit tobacco and alcohol consumption, at policy as well as community levels., Competing Interests: The authors have declared that no competing interests exist.

Public health and social measures (PHSM) have been central to the COVID-19 response. Consequently, there has been much pressure on decision-makers to make evidence-informed decisions and on researchers to synthesize the evidence regarding these measures. This article describes our experiences, responses and lessons learnt regarding key challenges when planning and conducting rapid reviews of PHSM during the COVID-19 pandemic. Stakeholder consultations and scoping reviews to obtain an overview of the evidence inform the scope of reviews that are policy-relevant and feasible. Multiple complementary reviews serve to examine the benefits and harms of PHSM across different populations and contexts. Conceiving reviews of effectiveness as adaptable living reviews helps to respond to evolving evidence needs and an expanding evidence base. An appropriately skilled review team and good planning, coordination and communication ensures smooth and rigorous processes and efficient use of resources. Scientific rigor, the practical implications of PHSM-related complexity and likely time savings should be carefully weighed in deciding on methodological shortcuts. Making the best possible use of modeling studies represents a particular challenge, and methods should be carefully chosen, piloted and implemented. Our experience raises questions regarding the nature of rapid reviews and regarding how different types of evidence should be considered in making decisions about PHSM during a global pandemic. We highlight the need for readily available protocols for conducting studies on the effectiveness, unintended consequences and implementation of PHSM in a timely manner, as well as the need for rapid review standards tailored to "rapid" versus "emergency" mode reviewing., (© 2022 The Authors. Research Synthesis Methods published by John Wiley & Sons Ltd.)

Objective: To systematically assess Germany's nutrition policies, to benchmark them against international best practices and to identify priority policy actions to improve population-level nutrition in Germany., Design: We applied the Food Environment Policy Index (Food-EPI), a methodological framework developed by the International Network for Food and Obesity/non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) network. Qualitative content analysis of laws, directives and other documents formed the basis of a multistaged, structured consultation process., Setting: Germany., Participants: The expert consultation process included fifty-five experts from academia, public administration and civil society., Results: Germany lags behind international best practices in several key policy areas. For eighteen policy indicators, the degree of implementation compared with international best practices was rated as very low, for twenty-one as low, for eight as intermediate and for none as high. In particular, indicators on food taxation, regulation of food marketing as well as retail and food service sector policies were rated as very low to low. Identified priority actions included the binding implementation of nutrition standards for schools and kindergartens, a reform of the value added tax on foods and beverages, a sugar-sweetened beverage tax and stricter regulation of food marketing directed at children., Conclusions: The results show that Germany makes insufficient use of the potential of evidence-informed health-promoting nutrition policies. Adopting international best practices in key policy areas could help to reduce the burden of nutrition-related chronic disease and related inequalities in nutrition and health in Germany. Implementation of relevant policies requires political leadership, a broad societal dialogue and evidence-informed advocacy by civil society, including the scientific community.

Background: Decision-making on matters of public health and health policy is a deeply value-laden process. The World Health Organization (WHO)-INTEGRATE framework was proposed as a new evidence-to-decision (EtD) framework to support guideline development from a complexity perspective, notably in relation to public health and health system interventions, and with a foundation in WHO norms and values. This study was conducted as part of the development of the framework to assess its comprehensiveness and usefulness for public health and health policy decision-making., Methods: We conducted a qualitative study comprising nine key informant interviews (KIIs) with experts involved in WHO guideline development and four focus group discussions (FGDs) with a total of forty health decision-makers from Brazil, Germany, Nepal and Uganda. Transcripts were analyzed using MAXQDA12 and qualitative content analysis., Results: Most key informants and participants in the FGDs appreciated the framework for its relevance to real-world decision-making on four widely differing health topics. They praised its broad perspective and comprehensiveness with respect to new or expanded criteria, notably regarding societal implications, equity considerations, and acceptability. Some guideline developers questioned the value of the framework beyond current practice and were concerned with the complexity of applying such a broad range of criteria in guideline development processes. Participants made concrete suggestions for improving the wording and definitions of criteria as well as their grouping, for covering missing aspects, and for addressing overlap between criteria., Conclusion: The framework was well-received by health decision-makers as well as the developers of WHO guidelines and appears to capture all relevant considerations discussed in four distinct real-world decision processes that took place on four different continents. Guidance is needed on how to apply the framework in guideline processes that are both transparent and participatory. A set of suggestions for improvement provides a valuable starting point for advancing the framework towards version 2.0., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Cinemeducation courses are used to supplement more standard teaching formats at medical schools and tend to emphasise biopsychosocial aspects of health. The purpose of this paper is to explore why medical students attend the cinemeducation course M23 Cinema (M23C) at LMU Munich and whether a film screening with a subsequent expert and peer discussion benefits their studies and their future careers as medical doctors., Methods: An exploratory sequential mixed methods study design was used. Qualitative research, i.e. three focus groups, four expert interviews, one group interview and one narrative interview, was conducted to inform a subsequent quantitative survey. Qualitative data was analysed using qualitative content analysis and quantitative data was analysed descriptively. The findings were integrated using the "following a thread" protocol., Results: In total, 28 people were interviewed and 503 participants responded to the survey distributed at seven M23C screenings. Participants perceive the M23C as informal teaching where they learn about perspectives on certain health topics through the combination of film and discussion while spending time with peers. The reasons for and reported benefits of participation varied with educational background, participation frequency and gender. On average, participants gave 5.7 reasons for attending the M23C. The main reasons for participating were the film, the topic and the ability to discuss these afterwards as well as to spend an evening with peers. Attending the M23C was reported to support the students' memory with regards to certain topics addressed in the M23C when the issues resurface at a later stage, such as during university courses, in the hospital, or in their private life., Conclusions: The M23C is characterised by its unique combination of film and discussion that encourages participants to reflect upon their opinions, perspectives and experiences. Participating in the M23C amplified the understanding of biopsychosocial aspects of health and illness in students. Thus, cinemeducative approaches such as the M23C may contribute to enabling health professionals to develop and apply humane, empathetic and relational skills., (© 2022. The Author(s).)

Background: Road traffic injuries are among the top ten causes of death globally, with the highest burden in low and middle-income countries, where over a third of deaths occur among pedestrians and cyclists. Several interventions to mitigate the burden among pedestrians have been widely implemented, however, the effectiveness has not been systematically examined., Objectives: To assess the effectiveness of interventions to reduce road traffic crashes, injuries, hospitalizations and deaths among pedestrians., Methods: We considered studies that evaluated interventions to reduce road traffic crashes, injuries, hospitalizations and/or deaths among pedestrians. We considered randomized controlled trials, interrupted time-series studies, and controlled before-after studies. We searched MEDLINE, EMBASE, Web of Science, WHO Global Health Index, Health Evidence, Transport Research International Documentation and ClinicalTrials.gov through 31 August 2020, and the reference lists of all included studies. Two reviewers independently screened titles and abstracts and full texts, extracted data and assessed the risk of bias. We summarized findings narratively with text and tables., Results: A total of 69123 unique records were identified through the searches, with 26 of these meeting our eligibility criteria. All except two of these were conducted in high-income countries and most were from urban settings. The majority of studies observed either a clear effect favoring the intervention or an unclear effect potentially favoring the intervention and these included: changes to the road environment (19/27); changes to legislation and enforcement (12/12); and road user behavior/education combined with either changes to the road environment (3/3) or with legislation and enforcement (1/1). A small number of studies observed either a null effect or an effect favoring the control., Conclusions: Although the highest burden of road traffic injuries exists in LMICs, very few studies have examined the effectiveness of available interventions in these settings. Studies indicate that road environment, legislation and enforcement interventions alone produce positive effects on pedestrian safety. In combination with or with road user behavior/education interventions they are particularly effective in improving pedestrian safety., Competing Interests: The authors have declared that no competing interests exist.

Background/objective: International travel measures to contain the coronavirus disease of 2019 (COVID-19) pandemic represent a relatively intrusive form of non-pharmaceutical intervention. To inform decision-making on the (re)implementation, adaptation, relaxation or suspension of such measures, it is essential to not only assess their effectiveness but also their unintended effects., Methods: This scoping review maps existing empirical studies on the unintended consequences, both predicted and unforeseen, and beneficial or harmful, of international travel measures. We searched multiple health, non-health and COVID-19-specific databases. The evidence was charted in a map in relation to the study design, intervention and outcome categories identified and discussed narratively., Results: Twenty-three studies met our inclusion criteria-nine quasi-experimental, two observational, two mathematical modelling, six qualitative and four mixed-methods studies. Studies addressed different population groups across various countries worldwide. Seven studies provided information on unintended consequences of the closure of national borders, six looked at international travel restrictions and three investigated mandatory quarantine of international travellers. No studies looked at entry and/or exit screening at national borders exclusively, however six studies considered this intervention in combination with other international travel measures. In total, 11 studies assessed various combinations of the aforementioned interventions. The outcomes were mostly referred to by the authors as harmful. Fifteen studies identified a variety of economic consequences, six reported on aspects related to quality of life, well-being, and mental health and five on social consequences. One study each provided information on equity, equality, and the fair distribution of benefits and burdens, environmental consequences and health system consequences., Conclusion: This scoping review represents the first step towards a systematic assessment of the unintended benefits and harms of international travel measures during COVID-19. The key research gaps identified might be filled with targeted primary research, as well as the additional consideration of gray literature and non-empirical studies., (© International Society of Travel Medicine 2021. Published by Oxford University Press.)

Simulation modeling can be useful to estimate the long-term health and economic impacts of population-based dietary policies. We conducted a systematic scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guideline to map and critically appraise economic evaluations of population-based dietary policies using simulation models. We searched Medline, Embase, and EconLit for studies published in English after 2005. Modeling studies were mapped based on model type, dietary policy, and nutritional target, and modeled risk factor-outcome pathways were analyzed. We included 56 studies comprising 136 model applications evaluating dietary policies in 21 countries. The policies most often assessed were reformulation (34/136), taxation (27/136), and labeling (20/136); the most common targets were salt/sodium (60/136), sugar-sweetened beverages (31/136), and fruit and vegetables (15/136). Model types included Markov-type (35/56), microsimulation (11/56), and comparative risk assessment (7/56) models. Overall, the key diet-related risk factors and health outcomes were modeled, but only 1 study included overall diet quality as a risk factor. Information about validation was only reported in 19 of 56 studies and few studies (14/56) analyzed the equity impacts of policies. Commonly included cost components were health sector (52/56) and public sector implementation costs (35/56), as opposed to private sector (18/56), lost productivity (11/56), and informal care costs (3/56). Most dietary policies (103/136) were evaluated as cost-saving independent of the applied costing perspective. An analysis of the main limitations reported by authors revealed that model validity, uncertainty of dietary effect estimates, and long-term intervention assumptions necessitate a careful interpretation of results. In conclusion, simulation modeling is widely applied in the economic evaluation of population-based dietary policies but rarely takes dietary complexity and the equity dimensions of policies into account. To increase relevance for policymakers and support diet-related disease prevention, economic effects beyond the health sector should be considered, and transparent conduct and reporting of model validation should be improved., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: The effectiveness of the Munich Breathlessness Service (MBS), integrating palliative care, respiratory medicine and physiotherapy, was tested in the BreathEase trial in patients with chronic breathlessness in advanced disease and their carers., Methods: BreathEase was a single-blinded randomised controlled fast-track trial. The MBS was attended for 5-6 weeks; the control group started the MBS after 8 weeks of standard care. Randomisation was stratified by cancer and the presence of a carer. Primary outcomes were patients' mastery of breathlessness (Chronic Respiratory Disease Questionnaire (CRQ) Mastery), quality of life (CRQ QoL), symptom burden (Integrated Palliative care Outcome Scale (IPOS)) and carer burden (Zarit Burden Interview (ZBI)). Intention-to-treat (ITT) analyses were conducted with hierarchical testing. Effectiveness was investigated by linear regression on change scores, adjusting for baseline scores and stratification variables. Missing values were handled with multiple imputation., Results: 92 patients were randomised to the intervention group and 91 patients were randomised to the control group. Before the follow-up assessment after 8 weeks (T1), 17 and five patients dropped out from the intervention and control groups, respectively. Significant improvements in CRQ Mastery of 0.367 (95% CI 0.065-0.669) and CRQ QoL of 0.226 (95% CI 0.012-0.440) score units at T1 in favour of the intervention group were seen in the ITT analyses (n=183), but not in IPOS. Exploratory testing showed nonsignificant improvements in ZBI., Conclusions: These findings demonstrate positive effects of the MBS in reducing burden caused by chronic breathlessness in advanced illness across a wide range of patients. Further evaluation in subgroups of patients and with a longitudinal perspective is needed., Competing Interests: Conflict of interest: M. Schunk reports grants from BMBF (German Federal Ministry of Education and Research), during the conduct of the study. Conflict of interest: L. Le has nothing to disclose. Conflict of interest: Z. Syunyaeva has nothing to disclose. Conflict of interest: B. Haberland has nothing to disclose. Conflict of interest: S. Tänzler has nothing to disclose. Conflict of interest: U. Mansmann has nothing to disclose. Conflict of interest: L. Schwarzkopf has nothing to disclose. Conflict of interest: H. Seidl has nothing to disclose. Conflict of interest: S. Streitwieser has nothing to disclose. Conflict of interest: M. Hofmann has nothing to disclose. Conflict of interest: T. Müller has nothing to disclose. Conflict of interest: T. Weiß has nothing to disclose. Conflict of interest: P. Morawietz has nothing to disclose. Conflict of interest: E.A. Rehfuess has nothing to disclose. Conflict of interest: R.M. Huber reports grants from BMBF (German Federal Ministry of Education and Research), during the conduct of the study. Conflict of interest: U. Berger reports grants from BMBF (German Federal Ministry of Education and Research), during the conduct of the study. Conflict of interest: C. Bausewein reports grants from BMBF (German Federal Ministry of Education and Research), during the conduct of the study., (Copyright ©The authors 2021. For reproduction rights and permissions contact permissions@ersnet.org.)

An evidence-based approach is considered a central requirement in the public health system. Five general principles apply in evidence-based medicine as well as in evidence-based public health (EBPH). These comprise a systematic approach, transparency in relation to uncertainty, integration and participation, management of conflicts of interest, and a structured, reflective process. This article aims to promote a common understanding of what taking an evidence-based approach entails in the field of public health.We explored the international understanding of EBPH through systematic literature searches of definitions, concepts, and models regarding an evidence-based approach in public health. In this manner, 20 English sources and one German source were identified and examined using content analysis. Beyond the above-described general principles, characteristics of these perspectives are concerned with a population orientation, the underlying concept of evidence, disciplines, and stakeholder groups to be involved in the process, as well as relevant criteria and necessary competencies for implementing an evidence-based approach.Based on this, and taking into account methodological developments to address complexity, four specific implementation factors of EBPH can be derived. These include theory, interdisciplinarity, context-sensitivity, and complexity as well as general societal aspects.The practical implementation of EBPH requires human and financial resources as well as competencies - among others, for conducting systematic reviews of the effectiveness of measures, examining other relevant questions in a scientific manner, and establishing transparent processes to formulate recommendations.

Background: The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA+) is a research consortium concerned with the prevention, diagnosis and treatment of non-communicable diseases. CEBHA+ seeks to engage policymakers and practitioners throughout the research process in order to build lasting relationships, enhance evidence uptake, and create long-term capacity among partner institutions in Ethiopia, Malawi, Rwanda, South Africa and Uganda in collaboration with two German universities. This integrated knowledge translation (IKT) approach includes the formal development, implementation and evaluation of country specific IKT strategies., Methods: We have conceptualised the CEBHA+ IKT approach as a complex intervention in a complex system. We will employ a comparative case study (CCS) design and mixed methods to facilitate an in-depth evaluation. We will use quantitative surveys, qualitative interviews, quarterly updates, and a policy document analysis to capture the process and outcomes of IKT across the African CEBHA+ partner sites. We will conduct an early stage (early 2020) and a late-stage evaluation (early 2022), triangulate the data collected with various methods at each site and subsequently compare our findings across the five sites., Discussion: Evaluating a complex intervention such as the CEBHA+ IKT approach is complicated, even more so when undertaken across five diverse countries. Despite conceptual, methodological and practical challenges, our comparative case study addresses important evidence gaps: While involving decision-makers in the research process is gaining traction worldwide, we still know very little regarding (i) whether this approach really makes a difference to evidence uptake, (ii) the mechanisms that make IKT successful, and (iii) relevant differences across socio-cultural contexts. The evaluation described here is intended to provide relevant insights on all of these aspects, notably in countries in Sub-Saharan Africa, and is expected to contribute to the science of IKT overall.

Competing Interests: Conflicts of interest The author declared no conflicts of interest.

Background: Decision-making in public health and health policy is complex and requires careful deliberation of many and sometimes conflicting normative and technical criteria. Several approaches and tools, such as multi-criteria decision analysis, health technology assessments and evidence-to-decision (EtD) frameworks, have been proposed to guide decision-makers in selecting the criteria most relevant and appropriate for a transparent decision-making process. This study forms part of the development of the WHO-INTEGRATE EtD framework, a framework rooted in global health norms and values as reflected in key documents of the World Health Organization and the United Nations system. The objective of this study was to provide a comprehensive overview of criteria used in or proposed for real-world decision-making processes, including guideline development, health technology assessment, resource allocation and others., Methods: We conducted an overview of systematic reviews through a combination of systematic literature searches and extensive reference searches. Systematic reviews reporting criteria used for real-world health decision-making by governmental or non-governmental organization on a supranational, national, or programme level were included and their quality assessed through a bespoke critical appraisal tool. The criteria reported in the reviews were extracted, de-duplicated and sorted into first-level (i.e. criteria ), second-level (i.e. sub - criteria ) and third-level (i.e. decision aspects ) categories. First-level categories were developed a priori using a normative approach; second- and third-level categories were developed inductively., Results: We included 36 systematic reviews providing criteria, of which one met all and another eleven met at least five of the items of our critical appraisal tool. The criteria were subsumed into 8 criteria, 45 sub - criteria and 200 decision aspects . The first-level of the category system comprised the following seven substantive criteria: "Health-related balance of benefits and harms"; "Human and individual rights"; "Acceptability considerations"; "Societal considerations"; "Considerations of equity, equality and fairness"; "Cost and financial considerations"; and "Feasibility and health system considerations". In addition, we identified an eight criterion "Evidence"., Conclusion: This overview of systematic reviews provides a comprehensive overview of criteria used or suggested for real-world health decision-making. It also discusses key challenges in the selection of the most appropriate criteria and in seeking to implement a fair decision-making process., Competing Interests: Competing interestsThis research was conducted within a research project initiated by the World Health Organization in which the WHO-INTEGRATE EtD Framework V1.0 was first developed and published by the authors. The authors declare that they have no competing interests. The funding organizations, in particular the USAID, the Bavarian Health and Food Safety Authority and Norad had no influence on the research process or content of this manuscript., (© The Author(s) 2020.)

Background: A broad range of interventions have been implemented to improve ambient air quality, and many of these have been evaluated. Yet to date no systematic review has been conducted to identify and synthesize these studies. In this systematic review, we assess the effectiveness of interventions in reducing ambient particulate matter air pollution and improving adverse health outcomes., Methods: We searched a range of electronic databases across multiple disciplines, as well as grey literature databases, trial registries, reference lists of included studies and the contents of relevant journals, through August 2016. Eligible for inclusion were randomized and cluster randomized controlled trials, as well as several non-randomized study designs often used for evaluating air quality interventions. We included studies that evaluated interventions targeting industrial, residential, vehicular and multiple sources, with respect to their effect on mortality, morbidity and the concentrations of particulate matter (PM - including PM 10 , PM 2.5 , coarse particulate matter and combustion-related PM), as well as several criteria pollutants, including ozone, carbon monoxide, nitrogen oxides, nitrogen dioxide, nitric oxide and sulphur dioxide. We did not restrict studies based on the population, setting or comparison. Two authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We assessed risk of bias using the Graphic Appraisal Tool for Epidemiological studies (GATE) for correlation studies, as modified and employed by the UK National Institute for Health and Care Excellence. We synthesized evidence narratively, as well as graphically using harvest plots. We assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system., Results: We included 42 studies assessing 38 unique interventions. These comprised a heterogeneous mix of interventions, including those aiming to address industrial sources (n = 5; e.g. the closure of a factory), residential sources (n = 7; e.g. coal ban), vehicular sources (n = 22; e.g. low emission zones), and multiple sources (n = 4; e.g. tailored measures that target both local traffic and industrial polluters). Evidence for effectiveness was mixed. Most included studies observed either no significant association or an association favoring the intervention, with little evidence that the assessed interventions might be harmful., Conclusions: Given the heterogeneity across interventions, outcomes, and methods, it was difficult to derive overall conclusions regarding the effectiveness of interventions in terms of improved air quality or health. Some evidence suggests that interventions are associated with improvements in air quality and human health, with very little evidence suggesting interventions were harmful. The evidence base highlights the challenges related to establishing the effectiveness of specific air pollution interventions on outcomes. It also points to the need for improved study design and analysis methods, as well as more uniform evaluations. The prospective planning of evaluations and an evaluation component built into the design and implementation of interventions may also be particularly beneficial., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Regular consumption of sugar-sweetened beverages (SSB) can increase the risk for obesity, type 2 diabetes, cardiovascular disease, and dental caries. Interventions that alter the physical or social environment in which individuals make beverage choices have been proposed to reduce the consumption of SSB., Methods: We included randomised controlled, non-randomised controlled, and interrupted time series studies on environmental interventions, with or without behavioural co-interventions, implemented in real-world settings, lasting at least 12 weeks, and including at least 40 individuals. Studies on the taxation of SSB were not included, as these are subject of a separate Cochrane review. We used standard Cochrane methods for data extraction, risk of bias assessment, and evidence grading and synthesis. Searches were updated to January 24, 2018., Results: We identified 14,488 unique records and assessed 1,030 full texts for eligibility. We included 58 studies comprising a total of 1,180,096 participants and a median length of follow-up of 10 months. We found moderate-certainty evidence for consistent associations with decreases in SSB consumption or sales for the following interventions: traffic light labelling, price increases on SSB, in-store promotion of healthier beverages in supermarkets, government food benefit programs with incentives for purchasing fruits and vegetables and restrictions on SSB purchases, multi-component community campaigns focused on SSB, and interventions improving the availability of low-calorie beverages in the home environment. For the remaining interventions we found low- to very-low-certainty evidence for associations showing varying degrees of consistency., Conclusions: With observed benefits outweighing observed harms, we suggest that environmental interventions to reduce the consumption of SSB be considered as part of a wider set of measures to improve population-level nutrition. Implementation should be accompanied by evaluations using appropriate methods. Future studies should examine population-level effects of interventions suitable for large-scale implementation, and interventions and settings not yet studied thoroughly., (© 2020 The Author(s) Published by S. Karger AG, Basel.)

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021-2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries., Competing Interests: Competing interests: RvL is also chief executive officer and founder of Madam Therapeutics, a private entity that is pursuing the development of new antibiotics. All other authors declare no known conflict of interest., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Extensive exposure to solar ultraviolet radiation (UVR) is the main risk factor for keratinocyte carcinoma (KC), making outdoor workers, including farmers, a high-risk population for KC. The use of sun protection is crucial for KC prevention but is not typically implemented by outdoor workers during their daily tasks., Objectives: To explore the attitudes of Bavarian farmers regarding sun-protective measures in their daily work and to understand perceived barriers and unmet needs., Methods: Farmers were recruited through the Bavarian Farmers Association in Bavaria, Southern Germany. Qualitative semi structured interviews were conducted with participants between December 2017 and March 2018. Interviews were recorded, transcribed verbatim and analysed using qualitative content analysis., Results: Twenty farmers (11 women, nine men; nine aged 18-30 years, 11 aged > 60 years) participated. Knowledge and awareness of UVR exposure and KC, perceived individual barriers to implementing sun-protective measures, individual experiences and farm life-specific circumstances emerged as key areas influencing the perspectives of farmers regarding the primary prevention of KC. Female farmers tended to take a more positive stance on sun protection, whereas male farmers showed a lower overall interest., Conclusions: Knowledge and awareness of KC and UVR exposure is very limited in Bavarian farmers with serious perceived barriers due to the demands of daily agricultural work. Further qualitative studies are needed to identify intervention options that can increase skin cancer awareness and that can successfully overcome real barriers to implementing sun protection., (© 2019 British Association of Dermatologists.)

Introduction: Evidence-to-decision (EtD) frameworks intend to ensure that all criteria of relevance to a health decision are systematically considered. This paper, part of a series commissioned by the WHO, reports on the development of an EtD framework that is rooted in WHO norms and values, reflective of the changing global health landscape, and suitable for a range of interventions and complexity features. We also sought to assess the value of this framework to decision-makers at global and national levels, and to facilitate uptake through suggestions on how to prioritise criteria and methods to collect evidence., Methods: In an iterative, principles-based approach, we developed the framework structure from WHO norms and values. Preliminary criteria were derived from key documents and supplemented with comprehensive subcriteria obtained through an overview of systematic reviews of criteria employed in health decision-making. We assessed to what extent the framework can accommodate features of complexity, and conducted key informant interviews among WHO guideline developers. Suggestions on methods were drawn from the literature and expert consultation., Results: The new WHO-INTEGRATE (INTEGRATe Evidence) framework comprises six substantive criteria- balance of health benefits and harms , human rights and sociocultural acceptability , health equity , equality and non-discrimination , societal implications , financial and economic considerations , and feasibility and health system considerations -and the meta-criterion quality of evidence . It is intended to facilitate a structured process of reflection and discussion in a problem-specific and context-specific manner from the start of a guideline development or other health decision-making process. For each criterion, the framework offers a definition, subcriteria and example questions; it also suggests relevant primary research and evidence synthesis methods and approaches to assessing quality of evidence., Conclusion: The framework is deliberately labelled version 1.0. We expect further modifications based on focus group discussions in four countries, example applications and input across concerned disciplines., Competing Interests: Competing interests: SLN helps oversee the quality of WHO guidelines and reports being a member of the RIGHT Working Group and the GRADE Working Group. EAR is a member of the GRADE Working Group.

There is growing interest in the potential for complex systems perspectives in evaluation. This reflects a move away from interest in linear chains of cause-and-effect, towards considering health as an outcome of interlinked elements within a connected whole. Although systems-based approaches have a long history, their concrete implications for health decisions are still being assessed. Similarly, the implications of systems perspectives for the conduct of systematic reviews require further consideration. Such reviews underpin decisions about the implementation of effective interventions, and are a crucial part of the development of guidelines. Although they are tried and tested as a means of synthesising evidence on the effectiveness of interventions, their applicability to the synthesis of evidence about complex interventions and complex systems requires further investigation. This paper, one of a series of papers commissioned by the WHO, sets out the concrete methodological implications of a complexity perspective for the conduct of systematic reviews. It focuses on how review questions can be framed within a complexity perspective, and on the implications for the evidence that is reviewed. It proposes criteria which can be used to determine whether or not a complexity perspective will add value to a review or an evidence-based guideline, and describes how to operationalise key aspects of complexity as concrete research questions. Finally, it shows how these questions map onto specific types of evidence, with a focus on the role of qualitative and quantitative evidence, and other types of information., Competing Interests: Competing interests: None declared.

Public health interventions and health technologies are commonly described as 'complex', as they involve multiple interacting components and outcomes, and their effects are largely influenced by contextual interactions and system-level processes. Systematic reviewers and guideline developers evaluating the effects of these complex interventions and technologies report difficulties in using existing methods and frameworks, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE). As part of a special series of papers on implications of complexity in the WHO guideline development, this paper serves as a primer on how to consider sources of complexity when using the GRADE approach to rate certainty of evidence. Relevant sources of complexity in systematic reviews, health technology assessments and guidelines of public health are outlined and mapped onto the reported difficulties in rating the estimates of the effect of these interventions. Recommendations on how to address these difficulties are further outlined, and the need for an integrated use of GRADE from the beginning of the review or guideline development is emphasised. The content of this paper is informed by the existing GRADE guidance, an ongoing research project on considering sources of complexity when applying the GRADE approach to rate certainty of evidence in systematic reviews and the review authors' own experiences with using GRADE., Competing Interests: Competing interests: All authors are current members of the GRADE Working Group. SPG’s spouse is a salaried employee of Eli Lilly and Company and owns stock. SPG has accompanied his spouse on company-sponsored travels.

Public health and health service interventions are typically complex: they are multifaceted, with impacts at multiple levels and on multiple stakeholders. Systematic reviews evaluating the effects of complex health interventions can be challenging to conduct. This paper is part of a special series of papers considering these challenges particularly in the context of WHO guideline development. We outline established and innovative methods for synthesising quantitative evidence within a systematic review of a complex intervention, including considerations of the complexity of the system into which the intervention is introduced. We describe methods in three broad areas: non-quantitative approaches, including tabulation, narrative and graphical approaches; standard meta-analysis methods, including meta-regression to investigate study-level moderators of effect; and advanced synthesis methods, in which models allow exploration of intervention components, investigation of both moderators and mediators, examination of mechanisms, and exploration of complexities of the system. We offer guidance on the choice of approach that might be taken by people collating evidence in support of guideline development, and emphasise that the appropriate methods will depend on the purpose of the synthesis, the similarity of the studies included in the review, the level of detail available from the studies, the nature of the results reported in the studies, the expertise of the synthesis team and the resources available., Competing Interests: Competing interests: JMG reports personal fees from the Campbell Collaboration. EAR reports being a Methods Editor with Cochrane Public Health.