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Complex interventions present unique challenges for systematic reviews. Current debates tend to center around describing complexity, rather than providing guidance on what to do about it. At a series of meetings during 2009-2012, we met to review the challenges and practical steps reviewer could take to incorporate a complexity perspective into systematic reviews. Based on this, we outline a pragmatic approach to dealing with complexity, beginning, as for any review, with clearly defining the research question(s). We argue that reviews of complex interventions can themselves be simple or complex, depending on the question to be answered. In systematic reviews and evaluations of complex interventions, it will be helpful to start by identifying the sources of complexity, then mapping aspects of complexity in the intervention onto the appropriate sources of evidence (such as specific types of quantitative or qualitative study). Although we focus on systematic reviews, the general approach is also applicable to primary research that is aimed at evaluating complex interventions. Although the examples are drawn from health care, the approach may also be applied to other sectors (e.g., social policy or international development). We end by concluding that systematic reviews should follow the principle of Occam's razor: explanations should be as complex as they need to be and no more.

Background Health interventions fall along a spectrum from simple to more complex. There is wide interest in methods for reviewing ‘complex interventions’, but few transparent approaches for assessing intervention complexity in systematic reviews. Such assessments may assist review authors in, for example, systematically describing interventions and developing logic models. This paper describes the development and application of the intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR), a new tool to assess and categorise levels of intervention complexity in systematic reviews. Methods We developed the iCAT_SR by adapting and extending an existing complexity assessment tool for randomized trials. We undertook this adaptation using a consensus approach in which possible complexity dimensions were circulated for feedback to a panel of methodologists with expertise in complex interventions and systematic reviews. Based on these inputs, we developed a draft version of the tool. We then invited a second round of feedback from the panel and a wider group of systematic reviewers. This informed further refinement of the tool. Results The tool comprises ten dimensions: (1) the number of active components in the intervention; (2) the number of behaviours of recipients to which the intervention is directed; (3) the range and number of organizational levels targeted by the intervention; (4) the degree of tailoring intended or flexibility permitted across sites or individuals in applying or implementing the intervention; (5) the level of skill required by those delivering the intervention; (6) the level of skill required by those receiving the intervention; (7) the degree of interaction between intervention components; (8) the degree to which the effects of the intervention are context dependent; (9) the degree to which the effects of the interventions are changed by recipient or provider factors; (10) and the nature of the causal pathway between intervention and outcome. Dimensions 1–6 are considered ‘core’ dimensions. Dimensions 7–10 are optional and may not be useful for all interventions. Conclusions The iCAT_SR tool facilitates more in-depth, systematic assessment of the complexity of interventions in systematic reviews and can assist in undertaking reviews and interpreting review findings. Further testing of the tool is now needed. Electronic supplementary material The online version of this article (doi:10.1186/s12874-017-0349-x) contains supplementary material, which is available to authorized users.

This article describes the relevance of systematic reviews to public health policy and practice. Systematic reviews synthesize the evidence on a clearly formulated question. Using systematic and (usually ideally prespecified) explicit methods to identify, select, and critically appraise relevant primary studies, review authors then extract, collate, and analyze data from the included studies. Although they have had a longer history in education and medicine, their production in public health is expanding as their application for public health decision-making is identified as increasingly important. Review methods continue to evolve to meet the needs of end users in a range of public health policy, practice, and research contexts. This article also highlights the importance of appropriate framing and dissemination of review findings as well as the infrastructure required to support researchers, practitioners, and health funders (governments and nongovernment agencies) to consider and incorporate implications of review findings into decision-making processes.

BACKGROUND: Although stroke is the second leading cause of death worldwide, no comprehensive and comparable assessment of incidence, prevalence, mortality, disability, and epidemiological trends has been estimated for most regions. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to estimate the global and regional burden of stroke during 1990-2010. METHODS: We searched Medline, Embase, LILACS, Scopus, PubMed, Science Direct, Global Health Database, the WHO library, and WHO regional databases from 1990 to 2012 to identify relevant studies published between 1990 and 2010.We applied the GBD 2010 analytical technique (DisMod-MR), based on disease-specific, pre-specified associations between incidence, prevalence, and mortality, to calculate regional and country-specific estimates of stroke incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) lost by age group (

International audience; BACKGROUND: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS: In 2010, there were 52*8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24*9% of deaths worldwide in 2010, down from 15*9 million (34*1%) of 46*5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2*5 to 1*4 million), lower respiratory infections (from 3*4 to 2*8 million), neonatal disorders (from 3*1 to 2*2 million), measles (from 0*63 to 0*13 million), and tetanus (from 0*27 to 0*06 million). Deaths from HIV/AIDS increased from 0*30 million in 1990 to 1*5 million in 2010, reaching a peak of 1*7 million in 2006. Malaria mortality also rose by an estimated 19*9% since 1990 to 1*17 million deaths in 2010. Tuberculosis killed 1*2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34*5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1*5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12*9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1*3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5*1 million deaths) was marginally higher in 2010 (9*6%) compared with two decades earlier (8*8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1*3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING: Bill & Melinda Gates Foundation.

Background Selective outcome and analysis reporting (SOR and SAR) occur when only a subset of outcomes measured and analyzed in a study is fully reported, and are an important source of potential bias. Key methodological issues We describe what is known about the prevalence and effects of SOR and SAR in both randomized controlled trials (RCTs) and non-randomized studies (NRS), and the effects of SOR and SAR on summary effect estimates and conclusions in systematic reviews of the effectiveness of healthcare interventions. Guidance Review authors should always suspect SOR and SAR in reviews that include NRS, assess primary studies for the risk of bias, and make reasonable attempts to retrieve study protocols or other documentation developed before study recruitment began. There are clues that may suggest SOR or SAR in NRS, including differences between the methods and results sections of the publication, study funder, and differences between study protocol or registration information and the study report. Conclusion Existing evidence about reporting biases in primary studies comes almost exclusively from methodological reviews of RCTs. The prevalence and impact of SOR and SAR in NRS are likely even greater than in RCTs but it is difficult to identify and confirm selective reporting in NRS. Copyright © 2012 John Wiley & Sons, Ltd.

nothing Refereed/Peer-reviewed

Logic models have long been used to understand complex programs to improve social and health outcomes. They illustrate how a program is designed to achieve its intended outcomes. They also can be used to describe connections between determinants of outcomes, for example, low high-school graduation rates or spiraling obesity rates, thus aiding the development of interventions that target causal factors. However, these models have not often been used in systematic reviews. This paper argues that logic models can be valuable in the systematic review process. First, they can aid in the conceptualization of the review focus and illustrate hypothesized causal links, identify effect mediators or moderators, specify intermediate outcomes and potential harms, and justify a priori subgroup analyses when differential effects are anticipated. Second, logic models can be used to direct the review process more specifically. They can help justify narrowing the scope of a review, identify the most relevant inclusion criteria, guide the literature search, and clarify interpretation of results when drawing policy-relevant conclusions about review findings. We present examples that explain how logic models have been used and how they can be applied at different stages in a systematic review. Copyright © 2011 John Wiley & Sons, Ltd.

This report presents the results of a systematic review of the effectiveness of worksite nutrition and physical activity programs to promote healthy weight among employees. These results form the basis for the recommendation by the Task Force on Community Preventive Services on the use of these interventions. Weight-related outcomes, including weight in pounds or kilograms, BMI, and percentage body fat were used to assess effectiveness of these programs. This review found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6 -12-month follow-up. A pooled effect estimate of 2.8 pounds (95% CI4.6, 1.0) was found based on nine RCTs, and a decrease in BMI of 0.5 (95% CI0.8, 0.2) was found based on six RCTs. The findings appear to be applicable to both male and female employees, across a range of worksite settings. Most of the studies combined informational and behavioral strategies to influence diet and physical activity; fewer studies modified the work environment (e.g., cafeteria, exercise facilities) to promote healthy choices. Information about other effects, barriers to implementation, cost and cost effectiveness of interventions, and research gaps are also presented in this article. The findings of this systematic review can help inform decisions of employers, planners, researchers, and other public health decision makers.

This paper first discusses more generally the notion of evidence and then applies it to the field of health promotion. It is argued that health promotion has not yet reached the status of a fully recognised and recognisable discipline, borrowing many of its theoretical and methodological approaches from apparatuses to a wide variety of established other disciplines. Consequently, developing «evidence-based» practices in health promotion, as in biomedicine for example, is problematic on many counts and leaves three major issues unsolved. These issues areaddressed and the authors conclude on an optimistic note, despite the serious problems that still remain to be solved.

Lymphogranuloma venereum (LGV) is a sexually transmitted disease (STD) caused by infection with invasive Chlamydia trachomatis serovars L1-L3 (1). LGV is characterized by inguinal and/or femoral lymphadenopathy, typically following a transient, self-limited genital ulcer or papule that might go unnoticed. Rectal infection can result in proctocolitis that can present with mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and tenesmus, and signs of granulomas and/or ulcerations on anoscopy (1,2). LGV can be an invasive, systemic infection, and if it is not treated early, LGV proctocolitis can lead to chronic colorectal fistulas and strictures (2). In Europe, outbreaks of LGV have been reported among men who have sex with men (MSM), often in association with human immunodeficiency virus (HIV) coinfection (3-5). The prevalence of LGV in the United States is unknown (1), because diagnostic tests to differentiate LGV from non-LGV Chlamydia trachomatis are not widely available (6), and providers might not know that they should report cases that are presumptively treated.

The inadequate supply of affordable housing for low-income families and the increasing spatial segregation of some households by income, race, ethnicity, or social class into unsafe neighborhoods are among the most prevalent community health concerns related to family housing. When affordable housing is not available to low-income households, family resources needed for food, medical or dental care, and other necessities are diverted to housing costs. Two housing programs intended to provide affordable housing and, concurrently, reduce the residential segregation of low-income families into unsafe neighborhoods of concentrated poverty, are reviewed: the creation of mixed-income housing developments and the Department of Housing and Urban Development (HUD) Section 8 Rental Voucher Program. The effectiveness of mixed-income housing developments could not be ascertained by this systematic review because of a lack of comparative research. Scientific evidence was sufficient to conclude that rental voucher programs improve household safety as measured by reduced exposure to crimes against person and property and decreased neighborhood social disorder. Effectiveness of rental voucher programs on youth health risk behaviors, mental health status, and physical health status could not be determined because too few studies of adequate design and execution reported these outcomes.

Early childhood development is influenced by characteristics of the child, the family, and the broader social environment. Physical health, cognition, language, and social and emotional development underpin school readiness. Publicly funded, center-based, comprehensive early childhood development programs are a community resource that promotes the well-being of young children. Programs such as Head Start are designed to close the gap in readiness to learn between poor children and their more economically advantaged peers. Systematic reviews of the scientific literature demonstrate effectiveness of these programs in preventing developmental delay, as assessed by reductions in retention in grade and placement in special education.

Culturally competent healthcare systems—those that provide culturally and linguistically appropriate services—have the potential to reduce racial and ethnic health disparities. When clients do not understand what their healthcare providers are telling them, and providers either do not speak the client’s language or are insensitive to cultural differences, the quality of health care can be compromised. We reviewed five interventions to improve cultural competence in healthcare systems—programs to recruit and retain staff members who reflect the cultural diversity of the community served, use of interpreter services or bilingual providers for clients with limited English proficiency, cultural competency training for healthcare providers, use of linguistically and culturally appropriate health education materials, and culturally specific healthcare settings. We could not determine the effectiveness of any of these interventions, because there were either too few comparative studies, or studies did not examine the outcome measures evaluated in this review: client satisfaction with care, improvements in health status, and inappropriate racial or ethnic differences in use of health services or in received and recommended treatment.

This study sought to summarize the findings of the GBD 2010 (Global Burden of Diseases, Injuries, and Risk Factors) study for ischemic stroke (IS) and to report the impact of tobacco smoking on IS burden in specific countries. The GBD 2010 searched multiple databases to identify relevant studies published between 1990 and 2010. The GBD 2010 analytical tools were used to calculate region-specific IS incidence, mortality, mortality-to-incidence ratio, and disability-adjusted life years (DALY) lost, including 95% uncertainty intervals (UI). In 2010, there were approximately 11,569,000 incident IS events (63% in low- and middle-income countries [LMIC]), approximately 2,835,000 deaths from IS (57% in LMIC), and approximately 39,389,000 DALY lost due to IS (64% in LMIC). From 1990 to 2010, there was a significant increase in global IS burden in terms of absolute number of people with incident IS (37% increase), deaths from IS (21% increase), and DALY lost due to IS (18% increase). Age-standardized IS incidence, DALY lost, mortality, and mortality-to-incidence ratios in high-income countries declined by about 13% (95% UI: 6% to 18%), 34% (95% UI: 16% to 36%), and 37% (95% UI: 19% to 39%), 21% (95% UI: 10% to 27%), respectively. However, in LMIC there was a modest 6% increase in the age-standardized incidence of IS (95% UI: -7% to 18%) despite modest reductions in mortality rates, DALY lost, and mortality-to-incidence ratios. There was considerable variability among country-specific estimates within broad GBD regions. China, Russia, and India were ranked highest in both 1990 and 2010 for IS deaths attributable to tobacco consumption. Although age-standardized IS mortality rates have declined over the last 2 decades, the absolute global burden of IS is increasing, with the bulk of DALY lost in LMIC. Tobacco consumption is an important modifiable risk factor for IS, and in both 1990 and 2010, the top ranked countries for IS deaths that could be attributed to tobacco consumption were China, Russia, and India. Tobacco control policies that target both smoking initiation and smoking cessation can play an important role in the prevention of IS. In China, Russia, and India, even modest reductions in the number of current smokers could see millions of lives saved due to prevention of IS alone.

Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence. The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommenda- tions (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide's process to systemati- cally review evidence and translate that evidence into recommendations. The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention's other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions. The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps. Systematic reviews of and evidence-based recommendations for population-health interven- tions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users' ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation. Medical Subject Headings (MeSH): community health services, decision making; evidence- based medicine; systematic reviews; methods; population-based interventions; practice guidelines; preventive health services; public health practice; task force (Am J Prev Med

Systematic reviews framed by PICOS (Populations, Interventions, Comparisons, Outcomes, and Study designs) have been valuable for synthesizing evidence about the effects of interventions. However, this framework is limited in its utility for exploring the influence of variations within populations or interventions, or about the mechanisms of action or causal pathways thought to mediate outcomes, other contextual factors that might similarly moderate outcomes, or how and when these mechanisms and elements interact. Valuable insights into these issues come from configurative as well as aggregative methods of synthesis. This article considers the range of evidence that can be used in systematic reviews of interventions to investigate complexity in terms of potential sources of variation in interventions and their effects, and presents a continuum of purposes for, and approaches to, evidence synthesis. Choosing an appropriate synthesis method takes into account whether the purpose of the synthesis is to generate, explore, or test theories. Taking complexity into account in a synthesis of economic evidence similarly shifts emphasis from evidence synthesis strategies focused on aggregation toward configurative strategies that aim to develop, explore, and refine (in advance of testing) theories or explanations of how and why interventions are more or less resource intensive, costly or cost-effective in different settings, or when implemented in different ways.

The success of NCD prevention initiatives relies on a number of important factors, but one of the non-negotiables is an understanding of what strategies or programs have been implemented and evaluated before, and what contemporary epidemiological, qualitative, and contextual knowledge is available and reliable to inform. The method for finding and assessing the quality and relevance of contributing evidence requires tools that are useful to support policy and practice decision making. This chapter begins by outlining suggested essential components of systematic reviews that may be most useful in informing decisions about NCD prevention and health promotion, including theoretical frameworks or logic models, information on program implementation, outcomes, equity and ethics, and sustainability. The chapter also explores the realities of applying evidence to decisions in policy and practice settings, by discussing aspects of applicability and transferability of research evidence and outlining key questions often asked in policy and practice together with options for combining different types of evidence to inform decisions. Also provided are examples of processes that may assist with evidence-informed decision making. Refereed/Peer-reviewed

Making informed choices about the use of resources and the likely success of proposed NCD prevention and health promotion initiatives requires knowledge of what strategies have been previously evaluated. This information can be openly and curiously sought through the process of a systematic appraisal of the research evidence. This chapter provides a brief overview of the evidence synthesis process for those who are likely to draw upon evidence reviews to inform their practice. Subcomponents discussed include planning an evidence review, formulating answerable questions about health issues and inequalities, searching for relevant research, including evidence from nonhealth sectors, and appraising its strength and trustworthiness. An understanding of these processes, forming the basic steps of systematic review methodology, and the links between the steps provides a framework for those who need to engage with the evidence as part of an evidence-informed decision-making process. Refereed/Peer-reviewed

BACKGROUND Ischemic heart disease (IHD) is the leading cause of death worldwide. The GBD (Global Burden of Disease, Injuries, and Risk Factors) study (GBD 2010 Study) conducted a systematic review of IHD epidemiology literature from 1980 to 2008 to inform estimates of the burden on IHD in 21 world regions in 1990 and 2010. METHODS The disease model of IHD for the GBD 2010 Study included IHD death and 3 sequelae: myocardial infarction, heart failure, and angina pectoris. Medline, EMBASE, and LILACS were searched for IHD epidemiology studies in GBD high-income and low- and middle-income regions published between 1980 and 2008 using a systematic protocol validated by regional IHD experts. Data from included studies were supplemented with unpublished data from selected high-quality surveillance and survey studies. The epidemiologic parameters of interest were incidence, prevalence, case fatality, and mortality. RESULTS Literature searches yielded 40,205 unique papers, of which 1,801 met initial screening criteria. Upon detailed review of full text papers, 137 published studies were included. Unpublished data were obtained from 24 additional studies. Data were sufficient for high-income regions, but missing or sparse in many low- and middle-income regions, particularly Sub-Saharan Africa. CONCLUSIONS A systematic review for the GBD 2010 Study provided IHD epidemiology estimates for most world regions, but highlighted the lack of information about IHD in Sub-Saharan Africa and other low-income regions. More complete knowledge of the global burden of IHD will require improved IHD surveillance programs in all world regions.

Background: Globally 15 million people have an acute stroke every year and one third of them die secondary to stroke events. Most research on stroke prevention and treatment is done in developed countries, yet more than 85% of strokes occur in developing countries. In particular, stroke remains an underrecognized cause of death and disability in South Asia. Methods: We conducted a systematic review to identify reliable and comparable epidemiological evidence on stroke in South Asia from 1980 to 2010. Publications were screened for eligibility to identify only population-based stroke studies. Results: Of the 71 studies retrieved, only 6 studies from South Asia gave us acceptable estimates of the burden of stroke. Population-based studies from South Asia have stroke prevalence in the range of 45–471 per 100,000. The age-adjusted incidence rate varied from approximately 145 per 100,000 to 262 per 100,000. Rural parts of South Asia have a lower stroke prevalence compared with urban areas. Conclusions: Our review highlights the paucity of research data in South Asia. This must be addressed in order to accurately determine the burden of stroke in South Asia, so that specific policy recommendations can be formulated to combat the stroke epidemic in this region.

Background Childhood overweight and obesity is the most prevalent and, arguably, politically complex child health problem internationally. Governments, communities and industry have important roles to play, and are increasingly expected to deliver an evidence-informed system-wide prevention program. However, efforts are impeded by a lack of organisational access to and use of research evidence. This study aims to identify feasible, acceptable and ideally, effective knowledge translation (KT) strategies to increase evidence-informed decision-making in local governments, within the context of childhood obesity prevention as a national policy priority. Methods/Design This paper describes the methods for KT4LG, a cluster randomised controlled trial which is exploratory in nature, given the limited evidence base and methodological advances. KT4LG aims to examine a program of KT strategies to increase the use of research evidence in informing public health decisions in local governments. KT4LG will also assess the feasibility and acceptability of the intervention. The intervention program comprises a facilitated program of evidence awareness, access to tailored research evidence, critical appraisal skills development, networking and evidence summaries and will be compared to provision of evidence summaries alone in the control program. 28 local governments were randomised to intervention or control, using computer generated numbers, stratified by budget tertile (high, medium or low). Questionnaires will be used to measure impact, costs, and outcomes, and key informant interviews will be used to examine processes, feasibility, and experiences. Policy tracer studies will be included to examine impact of intervention on policies within relevant government policy documents. Discussion Knowledge translation intervention studies with a focus on public health and prevention are very few in number. Thus, this study will provide essential data on the experience of program implementation and evaluation of a system-integrated intervention program employed within the local government public health context. Standardised programs of system, organisational and individual KT strategies have not been described or rigorously evaluated. As such, the findings will make a significant contribution to understanding whether a facilitated program of KT strategies hold promise for facilitating evidence-informed public health decision making within complex multisectoral government organisations. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000953235

Logic models have long been used to understand complex programs to improve social and health outcomes. They illustrate how a program is designed to achieve its intended outcomes. They also can be used to describe connections between determinants of outcomes, for example, low high-school graduation rates or spiraling obesity rates, thus aiding the development of interventions that target causal factors. However, these models have not often been used in systematic reviews. This paper argues that logic models can be valuable in the systematic review process. First, they can aid in the conceptualization of the review focus and illustrate hypothesized causal links, identify effect mediators or moderators, specify intermediate outcomes and potential harms, and justify a priori subgroup analyses when differential effects are anticipated. Second, logic models can be used to direct the review process more specifically. They can help justify narrowing the scope of a review, identify the most relevant inclusion criteria, guide the literature search, and clarify interpretation of results when drawing policy-relevant conclusions about review findings. We present examples that explain how logic models have been used and how they can be applied at different stages in a systematic review. Copyright © 2011 John WileySons, Ltd.

Stroke is the second leading cause of death in the world. In the Middle East and North Africa stroke is increasingly becoming a major health problem, with projections that deaths from it will nearly double by 2030. This systematic review aims to bring together age-adjusted epidemiological data of stroke in this region. A literature review of five databases was conducted. Twenty-three papers met the criteria. The incidence of stroke varied extensively among studies. Studies reported rates from 29.8 per 100 000 people in Saudi Arabia to 57 per 100 000 people in Bahrain. Furthermore, the 28-day case mortality rate also differed among studies, ranging from 10% in Kuwait to 31.5% in Iran. The rates are comparable with those in the Western world; however, the population of the region is younger. The Middle East and North Africa are lacking in data on the epidemiology of stroke. There is an urgent need to develop strategies to prevent and better care for stroke patients in the Middle East and North Africa.

This report presents the results of a systematic review of the effectiveness of worksite nutrition and physical activity programs to promote healthy weight among employees. These results form the basis for the recommendation by the Task Force on Community Preventive Services on the use of these interventions. Weight-related outcomes, including weight in pounds or kilograms, BMI, and percentage body fat were used to assess effectiveness of these programs. This review found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6-12-month follow-up. A pooled effect estimate of -2.8 pounds (95% CI=-4.6, -1.0) was found based on nine RCTs, and a decrease in BMI of -0.5 (95% CI=-0.8, -0.2) was found based on six RCTs. The findings appear to be applicable to both male and female employees, across a range of worksite settings. Most of the studies combined informational and behavioral strategies to influence diet and physical activity; fewer studies modified the work environment (e.g., cafeteria, exercise facilities) to promote healthy choices. Information about other effects, barriers to implementation, cost and cost effectiveness of interventions, and research gaps are also presented in this article. The findings of this systematic review can help inform decisions of employers, planners, researchers, and other public health decision makers.

Reducing morbidity and mortality related to overweight and obesity is a public health priority. Various interventions in school and worksite settings aim to maintain or achieve healthy weight. To identify effective strategies for weight control that can be implemented in these settings, the Task Force on Community Preventive Services (Task Force) has conducted systematic reviews of the evidence on nutrition, physical activity, combinations of these interventions, and other behavioral interventions (e.g., cognitive techniques such as self-awareness and cue recognition). Task Force recommendations are based on evidence of effectiveness, which is defined in this report as achieving a mean weight loss ofor =4 pounds, measuredor =6 months after initiation of the intervention program. The Task Force recommends multicomponent interventions that include nutrition and physical activity (including strategies such as providing nutrition education or dietary prescription, physical activity prescription or group activity, and behavioral skills development and training) to control overweight and obesity among adults in worksite settings. The Task Force determined that insufficient evidence existed to determine the effectiveness of combination nutrition and physical activity interventions to prevent or reduce overweight and obesity in school settings because of the limited number of qualifying studies reporting noncomparable outcomes. This report describes the methods used in these systematic reviews; provides additional information regarding these recommendations; and cites sources for full reviews containing details regarding applicability, other benefits and harms, barriers to implementation, research gaps, and economic data (when available) regarding interventions.

The use of scientificknowledge for policymaking has since grown in impor-tance, fueled by the growth in information, increasingreliance on technologies, and the need to balancebenefits and harms in decision processes.The complexity and potential utility of informationnow available for guiding policy and practice decisionshave led to methods for synthesis of research informa-tion.

This paper first discusses more generally the notion of "evidence" and then applies it to the field of health promotion. It is argued that health promotion has not yet reached the status of a fully recognised and recognisable discipline, borrowing many of its theoretical and methodological approaches from apparatuses to a wide variety of established other disciplines. Consequently, developing "evidence-based" practices in health promotion, as in biomedicine for example, is problematic on many counts and leaves three major issues unsolved. These issues are addressed and the authors conclude on an optimistic note, despite the serious problems that still remain to be solved.

In the mid-1990s, the independent national Task Force on Community Preventive Services (the Task Force) was created under the auspices of the Department of Health and Human Services to summarize what is known about the effectiveness of community-based interventions to improve population health outcomes. The Task Force wanted to examine broad social determinants of health from an ecologic perspective—one that recognized the connection between health and sustainable human, cultural, economic, and social activities. Communities interact with resources in the social and physical environments over broad periods of time. Understanding patterns of health or disease requires a focus not only on personal behaviors and biologic traits but also on characteristics of the social and physical environments that shape human experience and offer or limit opportunities for health. Social Determinants of Health

The inadequate supply of affordable housing for low-income families and the increasing spatial segregation of some households by income, race, ethnicity, or social class into unsafe neighborhoods are among the most prevalent community health concerns related to family housing. When affordable housing is not available to low-income households, family resources needed for food, medical or dental care, and other necessities are diverted to housing costs. Two housing programs intended to provide affordable housing and, concurrently, reduce the residential segregation of low-income families into unsafe neighborhoods of concentrated poverty, are reviewed: the creation of mixed-income housing developments and the Department of Housing and Urban Development (HUD) Section 8 Rental Voucher Program. The effectiveness of mixed-income housing developments could not be ascertained by this systematic review because of a lack of comparative research. Scientific evidence was sufficient to conclude that rental voucher programs improve household safety as measured by reduced exposure to crimes against person and property and decreased neighborhood social disorder. Effectiveness of rental voucher programs on youth health risk behaviors, mental health status, and physical health status could not be determined because too few studies of adequate design and execution reported these outcomes.

Early childhood development is influenced by characteristics of the child, the family, and the broader social environment. Physical health, cognition, language, and social and emotional development underpin school readiness. Publicly funded, center-based, comprehensive early childhood development programs are a community resource that promotes the well-being of young children. Programs such as Head Start are designed to close the gap in readiness to learn between poor children and their more economically advantaged peers. Systematic reviews of the scientific literature demonstrate effectiveness of these programs in preventing developmental delay, as assessed by reductions in retention in grade and placement in special education.

OBJECTIVES: This study examined the relationship between acculturation levels of poor Latina women in Los Angeles and their children's immunization status. Receipt of three doses of diphtheriatetanus-pertussis vaccine and two doses of oral polio vaccine by the age of 12 months was considered adequate immunization. METHODS: Household interviews were conducted in East Los Angeles and South Central Los Angeles with mothers (n = 688) about one randomly selected child aged 12 to 36 months. RESULTS: One fourth of the children were inadequately immunized. Less-acculturated mothers were more likely to have adequately immunized children. Inadequate prenatal care, absence of close family members, the child's birth position as other than firstborn, and more than one family relocation during the child's lifetime were associated with inadequate immunization. CONCLUSIONS: The findings challenge the notion that children of recent immigrants bear a higher risk of underimmunization.

This report describes trends in reported breast, cervical, and colorectal cancer screening within the US population from 1987 to 1992. Data from the 1987 and 1992 Cancer Control Supplements of the National Health Interview Survey were analyzed to determine use of Pap smears by women aged 18+; of mammography and clinical breast examination by women aged 50+; and of proctoscopy, digital rectal examination, and fecal occult blood testing among men and women aged 50+. Use of mammography doubled between 1987 and 1992 while Pap smear use changed very little. Use of the three colorectal cancer screening modalities increased but levels remained low. Usage trends were also assessed in relation to several sociodemographic factors. Disparities in screening reported in 1987 according to income and education persisted in 1992.

International audience; BACKGROUND: Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time. METHODS: We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights. FINDINGS: Global DALYs remained stable from 1990 (2*503 billion) to 2010 (2*490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions. INTERPRETATION: Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results. FUNDING: Bill & Melinda Gates Foundation.

Background\ud Knowledge translation strategies are an approach to increase the use of evidence within policy and practice decision-making contexts. In clinical and health service contexts, knowledge translation strategies have focused on individual behavior change, however the multi-system context of public health requires a multi-level, multi-strategy approach. This paper describes the design of and implementation plan for a knowledge translation intervention for public health decision making in local government.\ud \ud Methods\ud Four preliminary research studies contributed findings to the design of the intervention: a systematic review of knowledge translation intervention effectiveness research, a scoping study of knowledge translation perspectives and relevant theory literature, a survey of the local government public health workforce, and a study of the use of evidence-informed decision-making for public health in local government. A logic model was then developed to represent the putative pathways between intervention inputs, processes, and outcomes operating between individual-, organizational-, and system-level strategies. This formed the basis of the intervention plan.\ud \ud Results\ud The systematic and scoping reviews identified that effective and promising strategies to increase access to research evidence require an integrated intervention of skill development, access to a knowledge broker, resources and tools for evidence-informed decision making, and networking for information sharing. Interviews and survey analysis suggested that the intervention needs to operate at individual and organizational levels, comprising workforce development, access to evidence, and regular contact with a knowledge broker to increase access to intervention evidence; develop skills in appraisal and integration of evidence; strengthen networks; and explore organizational factors to build organizational cultures receptive to embedding evidence in practice. The logic model incorporated these inputs and strategies with a set of outcomes to measure the intervention’s effectiveness based on the theoretical frameworks, evaluation studies, and decision-maker experiences.\ud \ud Conclusion\ud Documenting the design of and implementation plan for this knowledge translation intervention provides a transparent, theoretical, and practical approach to a complex intervention. It provides significant insights into how practitioners might engage with evidence in public health decision making. While this intervention model was designed for the local government context, it is likely to be applicable and generalizable across sectors and settings.

Background The value placed on types of evidence within decision-making contexts is highly dependent on individuals, the organizations in which the work and the systems and sectors they operate in. Decision-making processes too are highly contextual. Understanding the values placed on evidence and processes guiding decision-making is crucial to designing strategies to support evidence-informed decision-making (EIDM). This paper describes how evidence is used to inform local government (LG) public health decisions. Methods The study used mixed methods including a cross-sectional survey and interviews. The Evidence-Informed Decision-Making Tool (EvIDenT) survey was designed to assess three key domains likely to impact on EIDM: access, confidence, and organizational culture. Other elements included the usefulness and influence of sources of evidence (people/groups and resources), skills and barriers, and facilitators to EIDM. Forty-five LGs from Victoria, Australia agreed to participate in the survey and up to four people from each organization were invited to complete the survey (n = 175). To further explore definitions of evidence and generate experiential data on EIDM practice, key informant interviews were conducted with a range of LG employees working in areas relevant to public health. Results In total, 135 responses were received (75% response rate) and 13 interviews were conducted. Analysis revealed varying levels of access, confidence and organizational culture to support EIDM. Significant relationships were found between domains: confidence, culture and access to research evidence. Some forms of evidence (e.g. community views) appeared to be used more commonly and at the expense of others (e.g. research evidence). Overall, a mixture of evidence (but more internal than external evidence) was influential in public health decision-making in councils. By comparison, a mixture of evidence (but more external than internal evidence) was deemed to be useful in public health decision-making. Conclusions This study makes an important contribution to understanding how evidence is used within the public health LG context. Trial registration ACTRN12609000953235. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0188-7) contains supplementary material, which is available to authorized users.