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1.  What do doctors really think about the relevance and impact of GP appraisal 3 years on? A survey of Scottish GPs 
The aim of appraisal is to provide an opportunity for individuals to reflect on their work to facilitate learning and development. Appraisal for GPs has been a contractual requirement since 2004 in Scotland, and is seen as an integral part of revalidation.
To investigate the outcomes of GP appraisal in terms of whether it has prompted change in medical practice, education and learning, career development, attitudes to health and probity, how GPs organise their work, and their perception of the overall value of the process.
Design of study
A cross-sectional postal questionnaire.
GP performers in Scotland who had undertaken appraisal.
The questionnaire was based on the seven principles outlined in Good Medical Practice, a literature review, and previous local research. The survey was conducted on a strictly anonymous basis with a random, representative sample of GPs.
Fifty-three per cent (671/1278) responded. Forty-seven per cent (308/661) thought that appraisal had altered their educational activity, 33% (217/660) reported undertaking further education or training as a result of appraisal, and 13% (89/660) felt that appraisal had influenced their career development. Opinion was evenly split on the overall value of appraisal.
Appraisal can have a significant impact on all aspects of a GP's professional life, and those who value the process report continuing benefit in how they manage their education and professional development. However, many perceive limited or no benefit. The renewed emphasis on appraisal requires examination of these findings and discussion of how appraisal can become more relevant.
PMCID: PMC2233956  PMID: 18307850
appraisal; continuing education; general practitioners; professional education; revalidation
2.  Understanding how appraisal of doctors produces its effects: a realist review protocol 
BMJ Open  2014;4(6):e005466.
UK doctors are now required to participate in revalidation to maintain their licence to practise. Appraisal is a fundamental component of revalidation. However, objective evidence of appraisal changing doctors’ behaviour and directly resulting in improved patient care is limited. In particular, it is not clear how the process of appraisal is supposed to change doctors’ behaviour and improve clinical performance. The aim of this research is to understand how and why appraisal of doctors is supposed to produce its effect.
Methods and analysis
Realist review is a theory-driven interpretive approach to evidence synthesis. It applies realist logic of inquiry to produce an explanatory analysis of an intervention that is, what works, for whom, in what circumstances, in what respects. Using a realist review approach, an initial programme theory of appraisal will be developed by consulting with key stakeholders in doctors’ appraisal in expert panels (ethical approval is not required), and by searching the literature to identify relevant existing theories. The search strategy will have a number of phases including a combination of: (1) electronic database searching, for example, EMBASE, MEDLINE, the Cochrane Library, ASSIA, (2) ‘cited by’ articles search, (3) citation searching, (4) contacting authors and (5) grey literature searching. The search for evidence will be iteratively extended and refocused as the review progresses. Studies will be included based on their ability to provide data that enable testing of the programme theory. Data extraction will be conducted, for example, by note taking and annotation at different review stages as is consistent with the realist approach. The evidence will be synthesised using realist logic to interrogate the final programme theory of the impact of appraisal on doctors’ performance. The synthesis results will be written up according to RAMESES guidelines and disseminated through peer-reviewed publication and presentations.
Trial registration number
The protocol is registered with PROSPERO 2014:CRD42014007092.
PMCID: PMC4067866  PMID: 24958211
3.  How to locate and appraise qualitative research in complementary and alternative medicine 
The aim of this publication is to present a case study of how to locate and appraise qualitative studies for the conduct of a meta-ethnography in the field of complementary and alternative medicine (CAM). CAM is commonly associated with individualized medicine. However, one established scientific approach to the individual, qualitative research, thus far has been explicitly used very rarely. This article demonstrates a case example of how qualitative research in the field of CAM studies was identified and critically appraised.
Several search terms and techniques were tested for the identification and appraisal of qualitative CAM research in the conduct of a meta-ethnography. Sixty-seven electronic databases were searched for the identification of qualitative CAM trials, including CAM databases, nursing, nutrition, psychological, social, medical databases, the Cochrane Library and DIMDI.
9578 citations were screened, 223 articles met the pre-specified inclusion criteria, 63 full text publications were reviewed, 38 articles were appraised qualitatively and 30 articles were included. The search began with PubMed, yielding 87% of the included publications of all databases with few additional relevant findings in the specific databases. CINHAL and DIMDI also revealed a high number of precise hits. Although CAMbase and CAM-QUEST® focus on CAM research only, almost no hits of qualitative trials were found there. Searching with broad text terms was the most effective search strategy in all databases.
This publication presents a case study on how to locate and appraise qualitative studies in the field of CAM. The example shows that the literature search for qualitative studies in the field of CAM is most effective when the search is begun in PubMed followed by CINHAL or DIMDI using broad text terms. Exclusive CAM databases delivered no additional findings to locate qualitative CAM studies.
PMCID: PMC3778880  PMID: 23731997
CAM; Qualitative studies; Meta-Ethnography; Quality appraisal
4.  A systematic review of the content of critical appraisal tools 
Consumers of research (researchers, administrators, educators and clinicians) frequently use standard critical appraisal tools to evaluate the quality of published research reports. However, there is no consensus regarding the most appropriate critical appraisal tool for allied health research. We summarized the content, intent, construction and psychometric properties of published, currently available critical appraisal tools to identify common elements and their relevance to allied health research.
A systematic review was undertaken of 121 published critical appraisal tools sourced from 108 papers located on electronic databases and the Internet. The tools were classified according to the study design for which they were intended. Their items were then classified into one of 12 criteria based on their intent. Commonly occurring items were identified. The empirical basis for construction of the tool, the method by which overall quality of the study was established, the psychometric properties of the critical appraisal tools and whether guidelines were provided for their use were also recorded.
Eighty-seven percent of critical appraisal tools were specific to a research design, with most tools having been developed for experimental studies. There was considerable variability in items contained in the critical appraisal tools. Twelve percent of available tools were developed using specified empirical research. Forty-nine percent of the critical appraisal tools summarized the quality appraisal into a numeric summary score. Few critical appraisal tools had documented evidence of validity of their items, or reliability of use. Guidelines regarding administration of the tools were provided in 43% of cases.
There was considerable variability in intent, components, construction and psychometric properties of published critical appraisal tools for research reports. There is no "gold standard' critical appraisal tool for any study design, nor is there any widely accepted generic tool that can be applied equally well across study types. No tool was specific to allied health research requirements. Thus interpretation of critical appraisal of research reports currently needs to be considered in light of the properties and intent of the critical appraisal tool chosen for the task.
PMCID: PMC521688  PMID: 15369598
5.  Self-Rated Health Appraisal as Cultural and Identity Process: African American Elders’ Health and Evaluative Rationales 
The Gerontologist  2006;46(4):431-438.
We explored self-rated health by using a meaning-centered theoretical foundation. Self-appraisals, such as self-rated health, reflect a cultural process of identity formation, whereby identities are multiple, simultaneously individual and collective, and produced by specific historical formations. Anthropological research in Philadelphia determined (a) how African American elders appraise their health, and (b) how health evaluations reflect cultural and historical experiences within a community.
Design and Methods
We interviewed and observed 35 adults aged 65 to 80, stratified by gender and self-rated health. We validated theme analysis of focused interview questions against the larger data set of field notes and transcripts.
Health appraisal reflected a complex process of adaptation and identity. Criteria for health included: independent functioning, physical condition, control and responsibility for health, and overall feeling. Evaluative rationales that shaped health appraisals were comparisons, restricted possibilities for self-evaluation, and ways of handling adversity. Evaluative rationales mitigated undesirable health identities (including low self-reported health) and provided mechanisms for claiming desired health identities despite adversity.
Describing the criteria and evaluative rationales underlying self-appraisals of health extends current understandings of self-rated health and illustrates the sociohistorical context of individual assessments of well-being.
PMCID: PMC3199224  PMID: 16920996
Self-rated health; African Americans; Qualitative methods; Self-appraisal; Identity
6.  Towards evidence‐based medicine for paediatricians 
To give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence‐based” answers to common questions that are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format that has been successfully developed by Kevin Mackway‐Jones and the group at the Emergency Medicine Journal—“BestBets”.
A word of warning. The topic summaries are not systematic reviews, although they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor to search the grey, unpublished literature. What Archimedes offers is practical, best evidence‐based answers to practical, clinical questions.
The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching2 and obtaining answers.3) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best quality evidence to answer the question ( A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as the number needed to treat), books by Sackett4 and Moyer5 may help. To pull the information together, a commentary is provided, but to make it all much more accessible, a box provides the clinical bottom lines.
Electronics‐only topics that have been published on the BestBets site ( and may be of interest to paediatricians include the following.
Can steroids be used to reduce post tonsillectomy pain?
Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at If your question still hasn't been answered, feel free to submit your summary according to the instructions for authors at Three topics are covered in this issue of the journal:
Is teething the cause of minor ailments?
Should steroid creams be used in cases of labial fusion?
Does erythromycin cause pyloric stenosis?
1 Moyer VA, Ellior EJ. Preface. In: Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health. Issue 1. London: BMJ Books, 2000.
2 Richardson WS, Wilson MC, Nishikawa J, et al. The well‐built clinical question: a key to evidence‐based decisions. ACP J Club 1995;123:A12–13.
3 Bergus GR, Randall CS, Sinift SD, et al. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9:541–7.
4 Sackett DL, Starus S, Richardson WS, et al. Evidence‐based medicine. How to practice and teach EBM. San Diego: Harcourt‐Brace, 2000.
5 Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health. Issue 1. London: BMJ Books, 2000.
Can: doing, using and replicating evidence‐based child health
The practice of evidence‐based child health is said to be the five‐step way of asking questions, acquiring information, appraising the evidence, applying the results and assessing our performance.
If the truth be known, for the vast majority of the time, most of us perform our clinical practice replicating what we have done previously. Most of the time this is based on the combination of excellent education, skilled interpretation of clinical findings, and good discussions with children and families. We hope that the education we rely on was (and remains) based on the best available scientific evidence. If it is, we are practising a form of “micro‐evidence‐based healthcare (EBHC)” (doing just step 4).
Sometimes, we question our knowledge (or more uncomfortably, someone does this for us), and will head off to top up our understanding of an area. This “using” mode, if we use well‐appraised resources to supply our thirst for information, will also promote the practice of evidence‐based care. This midi‐EBHC asks us to go through steps 1, 2 and 4.
Occasionally, we also actually need to go through the entire process of getting “down and dirty” with the primary research and appraising it to influence our practice. Maxi‐EBHC is considerably more demanding in time, but largely more satisfying intellectually.
If we reframe the practice of EBHC as using the family and child values, the best evidence, and our clinical expertise, then we can do it by micro‐methods, midi‐methods or maxi‐methods, and choose the most appropriate approach for the situation we confront.
I thank Dr Sharon Straus, Director of the Center for Evidence‐based Medicine, University of Toronto, Toronto, Ontario, Canada.
PMCID: PMC2083440
7.  A randomized trial to evaluate e-learning interventions designed to improve learner's performance, satisfaction, and self-efficacy with the AGREE II 
Practice guidelines (PGs) are systematically developed statements intended to assist in patient, practitioner, and policy decisions. The AGREE II is the revised and updated standard tool for guideline development, reporting and evaluation. It is comprised of 23 items and a user's Manual. The AGREE II is ready for use.
To develop, execute, and evaluate the impact of two internet-based educational interventions designed to accelerate the capacity of stakeholders to use the AGREE II: a multimedia didactic tutorial with a virtual coach, and a higher intensity training program including both the didactic tutorial and an interactive practice exercise component.
Participants (clinicians, developers, and policy makers) will be randomly assigned to one of three conditions. Condition one, didactic tutorial -- participants will go through the on-line AGREE II tutorial supported by a virtual coach and review of the AGREE II prior to appraising the test PG. Condition two, tutorial + practice -- following the multimedia didactic tutorial with a virtual coach, participants will review the on-line AGREE II independently and use it to appraise a practice PG. Upon entering their AGREE II score for the practice PG, participants will be given immediate feedback on how their score compares to expert norms. If their score falls outside a predefined range, the participant will receive a series of hints to guide the appraisal process. Participants will receive an overall summary of their performance appraising the PG compared to expert norms. Condition three, control arm -- participants will receive a PDF copy of the AGREE II for review and to appraise the test PG on-line. All participants will then rate one of ten test PGs with the AGREE II. The outcomes of interest are learners' performance, satisfaction, self-efficacy, mental effort, and time-on-task; comparisons will be made across each of the test groups.
Our research will test innovative educational interventions of various intensities and instructional design to promote the adoption of AGREE II and to identify those strategies that are most effective for training. The results will facilitate international capacity to apply the AGREE II accurately and with confidence and to enhance the overall guideline enterprise.
PMCID: PMC2868048  PMID: 20403188
8.  Appraisal patterns of envy and related emotions 
Motivation and Emotion  2011;36(2):195-204.
Envy is a frustrating emotion that arises from upward social comparison. Two studies investigated the appraisals that distinguish benign envy (aimed at improving one’s own situation) from malicious envy (aimed at pulling down the superior other). Study 1 found that appraisals of deservingness and control potential differentiated both types of envy. We manipulated these appraisals in Study 2 and found that while both did not influence the intensity of envy, they did determine the type of envy that resulted. The more a situation was appraised as undeserved, the more participants experienced malicious envy. Benign envy was experienced more when the situation was not undeserved, and the most when the situation was appraised as both deserved and controllable. The current research also clarifies how the types of envy differ from the related emotions admiration and resentment.
PMCID: PMC3356518  PMID: 22661793
Envy; Appraisals; Deservingness; Control potential; Social comparisons; Admiration; Resentment
9.  Men’s Appraisals of Their Military Experiences in World War II: A 40-Year Perspective 
Research in human development  2012;9(3):248-271.
Using data on veterans from the longitudinal Harvard Study of Adult Development (N=241), we focused on subjective aspects of military service. We examined how veterans of World War II appraised specific dimensions of military service directly after the war and over 40 years later, as well as the role of military service in their life course. In addition to examining change in appraisals, we examined how postwar appraisals of service mediated the effects of objective aspects of service, and how postwar psychological adjustment and health mediated the effects of postwar appraisals, on later-life appraisals. Men’s appraisals at both time points were generally, but not highly, positive, and revealed remarkable consistency over four decades. Postwar appraisals strongly predicted later-life appraisals and mediated the effects of objective service variables. The effects of postwar appraisals were not carried forward through psychological adjustment or midlife health. Better adjustment, however, was negatively related to later-life appraisals. Results reinforce the idea that how men perceive their military experiences may be more important in predicting outcomes than the experiences themselves. Results are discussed in light of the sample characteristics, the historical context of World War II, and the complexities of appraisal and retrospection.
PMCID: PMC3532891  PMID: 23284272
lifespan; aging; history; meaning-making; coping
10.  Improving the use of research evidence in guideline development: 8. Synthesis and presentation of evidence 
The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the eighth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.
We reviewed the literature on the synthesis and presentation of research evidence, focusing on four key questions.
We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments.
Key questions and answers
We found two reviews of instruments for critically appraising systematic reviews, several studies of the importance of using extensive searches for reviews and determining when it is important to update reviews, and consensus statements about the reporting of reviews that informed our answers to the following questions.
How should existing systematic reviews be critically appraised?
• Because preparing systematic reviews can take over a year and require capacity and resources, existing reviews should be used when possible and updated, if needed.
• Standard criteria, such as A MeaSurement Tool to Assess Reviews (AMSTAR), should be used to critically appraise existing systematic reviews, together with an assessment of the relevance of the review to the questions being asked.
When and how should WHO undertake or commission new reviews?
• Consideration should be given to undertaking or commissioning a new review whenever a relevant, up-to-date review of good quality is not available.
• When time or resources are limited it may be necessary to undertake rapid assessments. The methods that are used to do these assessments should be reported, including important limitations and uncertainties and explicit consideration of the need and urgency of undertaking a full systematic review.
• Because WHO has limited capacity for undertaking systematic reviews, reviews will often need to be commissioned when a new review is needed. Consideration should be given to establishing collaborating centres to undertake or support this work, similar to what some national organisations have done.
How should the findings of systematic reviews be summarised and presented to committees responsible for making recommendations?
• Concise summaries (evidence tables) of the best available evidence for each important outcome, including benefits, harms and costs, should be presented to the groups responsible for making recommendations. These should include an assessment of the quality of the evidence and a summary of the findings for each outcome.
• The full systematic reviews, on which the summaries are based, should also be available to both those making recommendations and users of the recommendations.
What additional information is needed to inform recommendations and how should this information be synthesised with information about effects and presented to committees?
• Additional information that is needed to inform recommendations includes factors that might modify the expected effects, need (prevalence, baseline risk or status), values (the relative importance of key outcomes), costs and the availability of resources.
• Any assumptions that are made about values or other factors that may vary from setting to setting should be made explicit.
• For global guidelines that are intended to inform decisions in different settings, consideration should be given to using a template to assist the synthesis of information specific to a setting with the global evidence of the effects of the relevant interventions.
PMCID: PMC1702353  PMID: 17147809
11.  The Dynamic Interplay between Appraisal and Core Affect in Daily Life 
Appraisals and core affect are both considered central to the experience of emotion. In this study we examine the bidirectional relationships between these two components of emotional experience by examining how core affect changes following how people appraise events and how appraisals in turn change following how they feel in daily life. In an experience sampling study, participants recorded their core affect and appraisals of ongoing events; data were analyzed using cross-lagged multilevel modeling. Valence-appraisal relationships were found to be characterized by congruency: the same appraisals that were associated with a change in pleasure-displeasure (motivational congruency, other-agency, coping potential, and future expectancy), changed themselves as a function of pleasure-displeasure. In turn, mainly secondary appraisals of who is responsible and how one is able to cope with events were associated with changes in arousal, which itself is followed by changes in the future appraised relevance of events. These results integrate core affect and appraisal approaches to emotion by demonstrating the dynamic interplay of how appraisals are followed by changes in core affect which in turn change our basis for judging future events.
PMCID: PMC3466066  PMID: 23060842
cognition-emotion; core affect; appraisal; experience sampling; daily life
12.  Guidelines for guideline developers: a systematic review of grading systems for medical tests 
A variety of systems have been developed to grade evidence and develop recommendations based on the available evidence. However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent. We compared grading systems for medical tests on how they use evidence in guideline development.
We used a systematic strategy to look for grading systems specific to medical tests in PubMed, professional guideline websites, via personal correspondence, and handsearching back references of key articles. Using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument as a starting point, we defined two sets of characteristics to describe these systems: methodological and process ones. Methodological characteristics are features relating to how evidence is gathered, appraised, and used in recommendations. Process characteristics are those relating to the guideline development process. Data were extracted in duplicate and differences resolved through discussion.
Twelve grading systems could be included. All varied in the degree to which methodological and process characteristics were addressed. Having a clinical scenario, identifying the care pathway and/or developing an analytical framework, having explicit criteria for appraising and linking indirect evidence, and having explicit methodologies for translating evidence into recommendations were least frequently addressed. Five systems at most addressed these, to varying degrees of explicitness and completeness. Process wise, features most frequently addressed included involvement of relevant professional groups (8/12), external peer review of completed guidelines (9/12), and recommendations on methods for dissemination (8/12). Characteristics least often addressed were whether the system was piloted (3/12) and funder information (3/12).
Five systems for grading evidence about medical tests in guideline development addressed to differing degrees of explicitness the need for and appraisal of different bodies of evidence, the linking of such evidence, and its translation into recommendations. At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.
PMCID: PMC3716938  PMID: 23842037
Grading systems; Quality of evidence; Diagnostic; Medical tests; Grade; Guideline development
13.  Self-perceived competence correlates poorly with objectively measured competence in Evidence Based Medicine among medical students 
BMC Medical Education  2011;11:25.
Previous studies report various degrees of agreement between self-perceived competence and objectively measured competence in medical students. There is still a paucity of evidence on how the two correlate in the field of Evidence Based Medicine (EBM). We undertook a cross-sectional study to evaluate the self-perceived competence in EBM of senior medical students in Malaysia, and assessed its correlation to their objectively measured competence in EBM.
We recruited a group of medical students in their final six months of training between March and August 2006. The students were receiving a clinically-integrated EBM training program within their curriculum. We evaluated the students' self-perceived competence in two EBM domains ("searching for evidence" and "appraising the evidence") by piloting a questionnaire containing 16 relevant items, and objectively assessed their competence in EBM using an adapted version of the Fresno test, a validated tool. We correlated the matching components between our questionnaire and the Fresno test using Pearson's product-moment correlation.
Forty-five out of 72 students in the cohort (62.5%) participated by completing the questionnaire and the adapted Fresno test concurrently. In general, our students perceived themselves as moderately competent in most items of the questionnaire. They rated themselves on average 6.34 out of 10 (63.4%) in "searching" and 44.41 out of 57 (77.9%) in "appraising". They scored on average 26.15 out of 60 (43.6%) in the "searching" domain and 57.02 out of 116 (49.2%) in the "appraising" domain in the Fresno test. The correlations between the students' self-rating and their performance in the Fresno test were poor in both the "searching" domain (r = 0.13, p = 0.4) and the "appraising" domain (r = 0.24, p = 0.1).
This study provides supporting evidence that at the undergraduate level, self-perceived competence in EBM, as measured using our questionnaire, does not correlate well with objectively assessed EBM competence measured using the adapted Fresno test.
Study registration
International Medical University, Malaysia, research ID: IMU 110/06
PMCID: PMC3116466  PMID: 21619672
Evidence Based Medicine; assessment; undergraduate
14.  Understanding the Relative Importance of Positive and Negative Social Exchanges: Examining Specific Domains and Appraisals 
Negative social exchanges have been more reliably related to psychological health than have positive social exchanges. Little research, however, has sought to understand how underlying appraisal processes link such exchanges to psychological health. This study examined the frequencies of occurrence and appraisals of four parallel domains of positive and negative exchanges in relation to positive well-being and psychological distress in a national sample of 916 older adults. Structural equation analyses revealed that negative exchanges were related both to less well-being and greater psychological distress, whereas positive exchanges were related only to positive well-being. Furthermore, results supported a process in which appraisals mediated the link between social exchanges and psychological health. This social appraisal process helps explain the disproportionate impact of negative exchanges on psychological health.
PMCID: PMC3833824  PMID: 16260704
15.  Using consecutive Rapid Participatory Appraisal studies to assess, facilitate and evaluate health and social change in community settings 
BMC Public Health  2006;6:68.
To investigate how a relatively socio-economically deprived community's needs have changed over time, assess which recommendations from an earlier assessment were implemented and sustained, and consider whether serial Rapid Participatory Appraisal is an effective health research tool that can promote community development and has utility in assessing longitudinal change.
Rapid Participatory Appraisal involves communities in identifying and challenging their own health-related needs. Information on ten health and social aspects was collated from existing documentation, neighbourhood observations, and interviews with a range of residents and key informants, providing a composite picture of the community's structure, needs and services.
The perceived needs after 10 years encompassed a wide construct of health, principally the living environment, housing, and lack of finance. Most identified upstream determinants of health rather than specific medical conditions as primary concerns. After the initial Rapid Participatory Appraisal many interviewees took the recommendations forward, working to promote a healthier environment and advocate for local resources. Interventions requiring support from outwith the community were largely not sustained.
Rapid Participatory Appraisal proved valuable in assessing long-term change. The community's continuing needs were identified, but they could not facilitate and sustain change without the strategic support of key regional and national agencies. Many repeatedly voiced concerns lay outwith local control: local needs assessment must be supported at higher levels to be effective.
PMCID: PMC1435890  PMID: 16539712
16.  Assessment vs. appraisal of ethical aspects of health technology assessment: can the distinction be upheld? 
An essential component of health technology assessment (HTA) is the assessment of ethical aspects. In some healthcare contexts, tasks are strictly relegated to different expert groups: the HTA-agencies are limited to assessment of the technology and other actors within the health care sector are responsible for appraisal and recommendations. Ethical aspects of health technologies are considered with reference to values or norms in such a way that may be prescriptive, or offer guidance as to how to act or relate to the issue in question. Given this internal prescriptivity, the distinction between assessment and appraisal seems difficult to uphold, unless the scrutiny stops short of a full ethical analysis of the technology. In the present article we analyse the distinction between assessment and appraisal, using as an example ethical aspects of implementation of GPS-bracelets for people with dementia.
It is concluded that for HTA-agencies with a strictly delineated assessment role, the question of how to deal with the internal prescriptivity of ethics may be confusing. A full ethical analysis might result in a definite conclusion as to whether the technology in question is ethically acceptable or not, thereby limiting choices for decision-makers, who are required to uphold certain ethical values and norms.
At the same time, depending on the exact nature of such a conclusion, different action strategies can be supported. A positive appraisal within HTA could result in a decision on mandatory implementation, or funding of the technology, thereby making it available to patients, or decisions to allow and even encourage the use of the technology (even if someone else will have to fund it). A neutral appraisal, giving no definite answer as to whether implementation is recommended or not, could result in a laissez-faire attitude towards the technology. A negative appraisal could result in a decision to discourage or even prohibit implementation. This paper presents an overview of the implications of different outcomes of the ethical analysis on appraisal of the technology. It is considered important to uphold the distinction between assessment and appraisal, primarily to avoid the influence of preconceived values and political interests on the assessment. Hence, as long as it is not based on the subjective value judgments of the HTA-agency (or its representative), such an appraising conclusion would not seem to conflict with the rationale for the separation of these tasks. Moreover, it should be noted that if HTA agencies abstain from including full ethical analyses because of the risk of issuing an appraisal, they may fail to provide the best possible basis for decision-makers. Hence, we argue that as long as the ethical analysis and its conclusions are presented transparently, disclosing how well-founded the conclusions are and/or whether there are alternative conclusions, the HTA-agencies should not avoid taking the ethical analysis as close as possible to a definite conclusion.
PMCID: PMC4260058  PMID: 25493102
assessment; appraisal; ethical analysis; prescriptiveness; surveillance technology; persons with dementia
17.  Perceived Role of the Journal Clubs in Teaching Critical Appraisal Skills: A Survey of Surgical Trainees in Nigeria 
Critical appraisal skills allow surgeons to evaluate the literature in an objective and structured manner, with emphasis on the validity of the evidence. The development of skills in critical acquisition and appraisal of the literature is crucial to delivering quality surgical care. It is also widely accepted that journal clubs are a time-honored educational paradigm for teaching and development of critical appraisal skills. The aim of this study is to determine the perceived role of journal clubs in teaching critical appraisal skills amongst the surgical trainees in Nigeria.
Materials and Methods:
The West African College of Surgeons and the National Postgraduate College of Nigeria have mandated that all residency programs teach and assess the ability to develop critical appraisal skills when reviewing the scientific literature. Residents at the revision course of the West African College of Surgeons in September 2012 evaluated the role of journal clubs in teaching critical appraisal skills using a 17-item questionnaire. The questionnaire addressed four areas: Format, teaching and development of critical appraisal s kills, and evaluation.
Most of the journal clubs meet weekly [39 (59%)] or monthly [25 (38%)]. Thirty-nine residents (59%) perceived the teaching model employed in the development of critical appraisal skills in their institutions was best characterized by “iscussion/summary by consultants” and “emphasis on formal suggestion for improvement in research.” Rating the importance of development of critical appraisal skills to the objectives of the residency program and practice of evidence-based medicine, majority of the residents [65 (98%)] felt it was “very important.” The commonest form of feedback was verbal from the consultants and residents [50 (76%)].
The perceived importance of journal clubs to the development of critical appraisal skills was rated as very important by the residents. However, residents indicated a need for a formal evaluation of the journal clubs. It is our hope that the results of this survey will encourage postgraduate coordinators to evaluate the quality of their journal clubs in the development of skills in critical appraisal of the literature.
PMCID: PMC4141447  PMID: 25191095
Critical appraisal skills; evaluation; journal club; literature; research; surgical trainees
18.  What potential research participants want to know about research: a systematic review 
BMJ Open  2012;2(3):e000509.
To establish the empirical evidence base for the information that participants want to know about medical research and to assess how this relates to current guidance from the National Research Ethics Service (NRES).
Data sources
Medline, Web of Science, Applied Social Sciences Index and Abstracts, Sociological abstracts, Health Management Information Consortium, Cochrane Library, thesis index's, grey literature databases, reference and cited article lists, key journals, Google Scholar and correspondence with expert authors.
Study selection
Original research studies published between 1950 and October 2010 that asked potential participants to indicate how much or what types of information they wanted to be told about a research study or asked them to rate the importance of a specific piece of information were included.
Study appraisal and synthesis methods
Studies were appraised based on the generalisability of results to the UK potential research participant population. A metadata analysis using basic thematic analysis was used to split results from papers into themes based on the sections of information that NRES recommends should be included in a participant information sheet.
14 studies were included. Of the 20 pieces of information that NRES recommend should be included in patient information sheets for research pooled proportions could be calculated for seven themes. Results showed that potential participants wanted to be offered information about result dissemination (91% (95% CI 85% to 95%)), investigator conflicts of interest (48% (95% CI 27% to 69%)), the purpose of the study (76% (95% CI 27% to 100%)), voluntariness (39% (95% CI 2% to 100%)), how long the research would last (61% (95% CI 16% to 97%)), potential benefits (57% (95% CI 7% to 98%)) and confidentiality (44% (95% CI 10% to 82%)). The level of detail participants wanted to know was not explored comprehensively in the studies. There was no empirical evidence to support the level of information provision required by participants on the remaining seven items.
There is limited empirical evidence on what potential participants want to know about research. The existing empirical evidence suggests that individuals may have very different needs and a more tailored evidence-based approach may be necessary.
Article summary
Article focus
What information do potential participants want to know when they are deciding whether to take part in research?
What is the established empirical evidence base?
How does the current empirical evidence base relate to current guidance from the NRES?
Key messages
There is little empirical evidence of what information potential participants want to know about research when they are making the decision to take part.
The limited empirical evidence available suggests that potential participants may have very different information needs.
Further research is required to determine what potential participants really want to know about research and how this can be delivered in a way that takes into account their different informational needs.
Strengths and limitations of this study
An extensive search strategy ensured that the review was systematic in capturing all available empirical evidence.
Papers included in the review differed in their methodologies and presentation of results, making comparisons between papers extremely difficult.
PMCID: PMC3367142  PMID: 22649171
19.  Enabling Psychiatrists to be Mobile Phone App Developers: Insights Into App Development Methodologies 
JMIR mHealth and uHealth  2014;2(4):e53.
The use of mobile phones, and specifically smartphones, in the last decade has become more and more prevalent. The latest mobile phones are equipped with comprehensive features that can be used in health care, such as providing rapid access to up-to-date evidence-based information, provision of instant communications, and improvements in organization. The estimated number of health care apps for mobile phones is increasing tremendously, but previous research has highlighted the lack of critical appraisal of new apps. This lack of appraisal of apps has largely been due to the lack of clinicians with technical knowledge of how to create an evidence-based app.
We discuss two freely available methodologies for developing Web-based mobile phone apps: a website builder and an app builder. With these, users can program not just a Web-based app, but also integrate multimedia features within their app, without needing to know any programming language.
We present techniques for creating a mobile Web-based app using two well-established online mobile app websites. We illustrate how to integrate text-based content within the app, as well as integration of interactive videos and rich site summary (RSS) feed information. We will also briefly discuss how to integrate a simple questionnaire survey into the mobile-based app. A questionnaire survey was administered to students to collate their perceptions towards the app.
These two methodologies for developing apps have been used to convert an online electronic psychiatry textbook into two Web-based mobile phone apps for medical students rotating through psychiatry in Singapore. Since the inception of our mobile Web-based app, a total of 21,991 unique users have used the mobile app and online portal provided by WordPress, and another 717 users have accessed the app via a Web-based link. The user perspective survey results (n=185) showed that a high proportion of students valued the textbook and objective structured clinical examination videos featured in the app. A high proportion of students concurred that a self-designed mobile phone app would be helpful for psychiatry education.
These methodologies can enable busy clinicians to develop simple mobile Web-based apps for academic, educational, and research purposes, without any prior knowledge of programming. This will be beneficial for both clinicians and users at large, as there will then be more evidence-based mobile phone apps, or at least apps that have been appraised by a clinician.
PMCID: PMC4285745  PMID: 25486985
smartphone application; mobile application; creation
20.  Towards evidence based medicine for paediatricians 
In order to give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence based” answers to common questions which are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format which has been successfully developed by Kevin Macaway‐Jones and the group at the Emergency Medicine Journal—“BestBets”.
A word of warning. The topic summaries are not systematic reviews, through they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence based answers to practical, clinical questions.
The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching,2 and gaining answers.3) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best quality evidence to answer the question.4 A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as number needed to treat, NNT) books by Sackett5 and Moyer6 may help. To pull the information together, a commentary is provided. But to make it all much more accessible, a box provides the clinical bottom lines.
Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at If your question still hasn't been answered, feel free to submit your summary according to the Instructions for Authors at Three topics are covered in this issue of the journal:
Does neonatal BCG vaccination protect against tuberculous meningitis?
Does dexamethasone reduce the risk of extubation failure in ventilated children?
Should metformin be prescribed to overweight adolescents in whom dietary/behavioural modifications have not helped?
1. Moyer VA, Ellior EJ. Preface. In: Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.
2. Richardson WS, Wilson MC, Nishikawa J, et al. The well‐built clinical question: a key to evidence‐based decisions. ACP J Club 1995;123:A12–13.
3. Bergus GR, Randall CS, Sinift SD, et al. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9:541–7.
4. (accessed July 2002).
5. Sackett DL, Starus S, Richardson WS, et al. Evidence‐based medicine. How to practice and teach EBM. San Diego: Harcourt‐Brace, 2000.
6. Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.
How to read your journals
Most people have their journals land, monthly, weekly, or quarterly, on their desk, courtesy of their professional associations. Then they sit, gathering dust and guilt, for a period of time. When the layer of either is too great for comfort (or the desk space is needed for some proper work), the wrapper is removed and the journal scanned. But does how people read reflect their information needs or their entertainment requirements?
It is not uncommon to find people straying from the editorial introduction to the value added sections (like obituaries, Lucina‐like summary pages, and end‐of‐article fillers) rather than face the impenetrable science that sits between them. I think that this is probably unhelpful, and would urge readers to do one more thing before placing the journal in the recycling. Scan the table of contents; if it mentions a systematic review or a randomised trial, then read at least the title and the abstract's conclusions. If you agree, pat yourself warmly on the back for being evidence based and up‐to‐date. If you disagree, ask if it will make any impact on your clinical (or personal) life. If it might, run through the methods and quickly appraise them. Does it supply higher quality evidence than that you already possess? If it does, it's worth reading. If it doesn't, don't bother too much.
There are new innovations which might aid the tedious task of consuming research effort. The on‐line Précis section of the Archives provides a highly readable version of the contents page to whet one's appetite. Finally, it's worth mentioning that evidence based summary materials (like Archimedes, or Journal Watch) are always worth reading—and if you didn't think that you wouldn't be here, would you?
PMCID: PMC2082933
Archimedes; evidence based medicine
21.  Rating the Quality of Trials in Systematic Reviews of Physical Therapy Interventions 
Physical therapists seeking to use evidence to guide their practice may have limited time to read research reports. One way to reduce the time required to identify and read about the research that is relevant to a particular clinical question is to read a systematic review that summarizes multiple studies. This paper explains the process that is used to conduct systematic reviews, which includes the establishment of a protocol, comprehensive searching, appraisal of the quality of the included studies, data extraction and metaanalysis, and consideration of the clinical and research implications of the findings. We also consider how the reader of a systematic review can determine whether the review is likely to provide an unbiased (believable) estimate of the treatment effect. A systematic review of randomized trials of a cardiopulmonary physical therapy intervention is used as an example. The issue of appraisal of quality is then discussed further, with a demonstration of how one validated tool for quality appraisal–the PEDro scale–can be used to evaluate a randomized trial in cardiopulmonary physical therapy.
PMCID: PMC2941354  PMID: 20957075
systematic review; physical therapy
22.  The effectiveness of health appraisal processes currently in addressing health and wellbeing during spatial plan appraisal: a systematic review 
BMC Public Health  2011;11:889.
Spatial planning affects the built environment, which in turn has the potential to have a significant impact on health, for good or ill. One way of ensuring that spatial plans take due account of health is through the inclusion of health considerations in the statutory and non statutory appraisal processes linked to plan-making processes.
A systematic review to identify evaluation studies of appraisals or assessments of plans where health issues were considered from 1987 to 2010.
A total of 6161 citations were identified: 6069 from electronic databases, 57 fromwebsite searches, with a further 35 citations from grey literature, of which 20 met the inclusion criteria. These 20 citations reported on a total of 135 different case studies: 11 UK HIA; 11 non UK high income countries HIA, 5 UK SEA or other integrated appraisal; 108 non UK high income SEA or other integrated appraisal. All studies were in English. No relevant studies were identified reporting on low or middle income countries.
The studies were limited by potential bias (no independent evaluation, with those undertaking the appraisal also responsible for reporting outcomes), lack of detail and a lack of triangulation of results. Health impact assessments generally covered the four specified health domains (physical activity, mental health and wellbeing, environmental health issues such as pollution and noise, injury) more comprehensively than SEA or other integrated appraisals, although mental health and wellbeing was an underdeveloped area. There was no evidence available on the incorporation of health in Sustainability Appraisal, limited evidence that the recommendations from any type of appraisal were implemented, and almost no evidence that the recommendations had led to the anticipated outcomes or improvements in health postulated.
Research is needed to assess (i) the degree to which statutory plan appraisal processes (SA in the UK) incorporate health; (ii) whether recommendations arising from health appraisal translate into the development process and (iii) whether outcomes are as anticipated.
PMCID: PMC3276579  PMID: 22115419
23.  Toward a theoretical model of quality-of-life appraisal: Implications of findings from studies of response shift 
Mounting evidence for response shifts in quality of life (QOL) appraisal indicates the need to include direct measurement of the appraisal process itself as a necessary part of QOL assessment. We propose that directly assessing QOL appraisal processes will not only improve our ability to interpret QOL scores in the traditional sense, but will also yield a deeper understanding of the appraisal process in the attribution of and divergence in meaning. The published evidence for response shift is reviewed, and an assessment paradigm is proposed that includes the explicit measurement of QOL appraisal process parameters: 1) induction of a frame of reference; 2) recall and sampling of salient experiences; 3) standards of comparison used to appraise experiences; and 4) subjective algorithm used to prioritize and combine appraisals to arrive at a QOL rating. A QOL Appraisal Profile, which measures key appraisal processes, is introduced as an adjunct to existing QOL scales. The proposed theoretical model, building on the Sprangers and Schwartz (1999) model and highlighting appraisal processes, provides a fully testable theoretical treatment of QOL and change in QOL, suggesting hypothesized causal relationships and explanatory pathways for both cross-sectional and longitudinal QOL research.
PMCID: PMC408464  PMID: 15023229
quality of life assessment; appraisal; response shift theory; individual differences.
24.  How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research 
Physicians, nurses, and other clinicians readily acknowledge being troubled by encounters with patients who trigger moral judgments. For decades social scientists have noted that moral judgment of patients is pervasive, occurring not only in egregious and criminal cases but also in everyday situations in which appraisals of patients' social worth and culpability are routine. There is scant literature, however, on the actual prevalence and dynamics of moral judgment in healthcare. The indirect evidence available suggests that moral appraisals function via a complex calculus that reflects variation in patient characteristics, clinician characteristics, task, and organizational factors. The full impact of moral judgment on healthcare relationships, patient outcomes, and clinicians' own well-being is yet unknown. The paucity of attention to moral judgment, despite its significance for patient-centered care, communication, empathy, professionalism, healthcare education, stereotyping, and outcome disparities, represents a blind spot that merits explanation and repair. New methodologies in social psychology and neuroscience have yielded models for how moral judgment operates in healthcare and how research in this area should proceed. Clinicians, educators, and researchers would do well to recognize both the legitimate and illegitimate moral appraisals that are apt to occur in healthcare settings.
PMCID: PMC2914676  PMID: 20618947
25.  The biopsychosocial model of stress in adolescence: self-awareness of performance versus stress reactivity 
Stress (Amsterdam, Netherlands)  2014;17(2):193-203.
Extensive research among adults supports the biopsychosocial (BPS) model of challenge and threat, which describes relationships among stress appraisals, physiological stress reactivity, and performance; however, no previous studies have examined these relationships in adolescents. Perceptions of stressors as well as physiological reactivity to stress increase during adolescence, highlighting the importance of understanding the relationships among stress appraisals, physiological reactivity, and performance during this developmental period. In this study, 79 adolescent participants reported on stress appraisals before and after a Trier Social Stress Test in which they performed a speech task. Physiological stress reactivity was defined by changes in cardiac output and total peripheral resistance from a baseline rest period to the speech task, and performance on the speech was coded using an objective rating system. We observed in adolescents only two relationships found in past adult research on the BPS model variables: (1) pre-task stress appraisal predicted post-task stress appraisal and (2) performance predicted post-task stress appraisal. Physiological reactivity during the speech was unrelated to pre- and post-task stress appraisals and to performance. We conclude that the lack of association between post-task stress appraisal and physiological stress reactivity suggests that adolescents might have low self-awareness of physiological emotional arousal. Our findings further suggest that adolescent stress appraisals are based largely on their performance during stressful situations. Developmental implications of this potential lack of awareness of one’s physiological and emotional state during adolescence are discussed.
PMCID: PMC4096124  PMID: 24491123
Appraisal; cardiovascular; challenge; physiology; speech; Trier social stress test; threat

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