Publications

2011
Hoffman, S.J. ed., 2011. Student Voices 2: Assessing Proposals for Global Health Governance Reform, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
Hoffman, S.J. ed., 2011. Student Voices 3: Advocating for Global Health through Evidence, Insight and Action, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
Hoffman, S.J., et al., 2011. Assessing Healthcare Providers' Knowledge and Practices Relating to Insecticide-Treated Nets and the Prevention of Malaria in Ghana, Laos, Senegal and Tanzania. Malaria Journal , 10 (363) , pp. 1-12. PDFAbstract

Background: Research evidence is not always being disseminated to healthcare providers who need it to inform their clinical practice. This can result in the provision of ineffective services and an inefficient use of resources, the implications of which might be felt particularly acutely in low- and middle-income countries. Malaria prevention is a particularly compelling domain to study evidence/practice gaps given the proven efficacy, cost-effectiveness and disappointing utilization of insecticide-treated nets (ITNs).

Methods: This study compares what is known about ITNs to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was developed, pilot tested, translated and administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). Ten questions tested participants' knowledge and clinical practice related to malaria prevention. Additional questions addressed their individual characteristics, working context and research-related activities. Ordinal logistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics.

Results: The survey achieved a 75% response rate (372/497) across Ghana (107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: 1) training in acquiring systematic reviews through the Cochrane Library (OR 2.48, 95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR 1.69, 95% CI 1.05-2.70). Statistically significant factors associated with better clinical practices within each country include: 1) reading scientific journals from their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchers to improve their clinical practice or quality of working life (OR 1.44, 95% CI 1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68, 95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI 1.08-2.14).

Conclusions: Improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilization and preventing malaria. This study points to several strategies that may help bridge the gap between what is known from research evidence and the knowledge and practices of healthcare providers. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.

Hoffman, S.J., 2011. Ending Medical Complicity in State-Sponsored Torture. The Lancet , 378 (9802) , pp. 1535-7. PDF
Hoffman, S.J. & Røttingen, J.-A., 2011. A Framework Convention on Obesity Control?. The Lancet , 378 (9809) , pp. 2068. PDF
Hoffman, S.J., Pogge, T. & Hollis, A., 2011. New Drug Development. Lancet , 377 (9769) , pp. 901-2. PDF
Hoffman, S.J. & Pogge, T., 2011. Revitalizing Pharmaceutical Innovation for Global Health. Health Affairs , 30 (2) , pp. 367. PDF
2010
Gilbert, J.H.V., et al., 2010. Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: World Health Organization. PDFAbstract

At a time when the world is facing a shortage of health workers, policymakers are looking for innovative strategies that can help them develop policy and programmes to bolster the global health workforce. The Framework for Action on Interprofessional Education and Collaborative Practice highlights the current status of interprofessional collaboration around the world, identifies the mechanisms that shape successful collaborative teamwork and outlines a series of action items that policy-makers can apply within their local health system. The goal of the Framework is to provide strategies and ideas that will help health policy-makers implement the elements of interprofessional education and collaborative practice that will be most beneficial in their own jurisdiction.

Guindon, E.G., et al., 2010. Bridging the Gaps Among Research, policy and Practice in Ten Low- and Middle-Income Countries: Development and Testing of a Questionnaire for Health-Care Providers. Health Research Policy and Systems , 8 (3) , pp. 1-9. PDFAbstract

Background: The reliability and validity of instruments used to survey health-care providers' views about and experiences with research evidence have seldom been examined.

Methods: Country teams from ten low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania) participated in the development, translation, pilot-testing and administration of a questionnaire designed to measure health-care providers' views and activities related to improving their clinical practice and their awareness of, access to and use of research evidence, as well as changes in their clinical practice that they attribute to particular sources of research evidence that they have used. We use internal consistency as a measure of the questionnaire's reliability and, whenever possible, we use explanatory factor analyses to assess the degree to which questions that pertain to a single domain actually address common themes. We assess the questionnaire's face validity and content validity and, to a lesser extent, we also explore its criterion validity.

Results: The questionnaire has high internal consistency, with Cronbach's alphas between 0.7 and 0.9 for 16 of 20 domains and sub-domains (identified by factor analyses). Cronbach's alphas are greater than 0.9 for two domains, suggesting some item redundancy. Pre- and post-field work assessments indicate the questionnaire has good face validity and content validity. Our limited assessment of criterion validity shows weak but statistically significant associations between the general influence of research evidence among providers and more specific measures of providers' change in approach to preventing or treating a clinical condition.

Conclusion: Our analysis points to a number of strengths of the questionnaire - high internal consistency (reliability) and good face and content validity - but also to areas where it can be shortened without losing important conceptual domains.

Cameron, D., et al., 2010. Bridging the Gaps Among Research, Policy and Practice in Ten Low- and Middle-Income Countries: Development and Testing of a Questionnaire for Researchers. Health Research Policy and Systems , 8 (4) , pp. 1-8. PDFAbstract

Background: A questionnaire could assist researchers, policymakers, and healthcare providers to describe and monitor changes in efforts to bridge the gaps among research, policy and practice. No questionnaire focused on researchers' engagement in bridging activities related to high-priority topics (or the potential correlates of their engagement) has been developed and tested in a range of low- and middle-income countries (LMICs).

Methods: Country teams from ten LMICs (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal, and Tanzania) participated in the development and testing of a questionnaire. To assess reliability we calculated the internal consistency of items within each of the ten conceptual domains related to bridging activities (specifically Cronbach's alpha). To assess face and content validity we convened several teleconferences and a workshop. To assess construct validity we calculated the correlation between scales and counts (i.e., criterion measures) for the three countries that employed both and we calculated the correlation between different but theoretically related (i.e., convergent) measures for all countries.

Results: Internal consistency (Cronbach's alpha) for sets of related items was very high, ranging from 0.89 (0.86-0.91) to 0.96 (0.95-0.97), suggesting some item redundancy. Both face and content validity were determined to be high. Assessments of construct validity using criterion-related measures showed statistically significant associations for related measures (with gammas ranging from 0.36 to 0.73). Assessments using convergent measures also showed significant associations (with gammas ranging from 0.30 to 0.50).

Conclusions: While no direct comparison can be made to a comparable questionnaire, our findings do suggest a number of strengths of the questionnaire but also the need to reduce item redundancy and to test its capacity to monitor changes over time.

Lavis, J.N., et al., 2010. Bridging the Gaps Between Research, Policy and Practice in Low- and Middle-Income Countries: a Survey of Researchers. Canadian Medical Association Journal , 182 (9) , pp. E350 - E361. PDFAbstract

Background: Many international statements have urged researchers, policy-makers and health care providers to collaborate in efforts to bridge the gaps between research, policy and practice in low- and middle-income countries. We surveyed researchers in 10 countries about their involvement in such efforts.

Methods: We surveyed 308 researchers who conducted research on one of four clinical areas relevant to the Millennium Development Goals (prevention of malaria, care of women seeking contraception, care of children with diarrhea and care of patients with tuberculosis) in each of 10 low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania). We focused on their engagement in three promising bridging activities and examined system-level, organizational and individual correlates of these activities.

Results: Less than half of the researchers surveyed reported that they engaged in one or more of the three promising bridging activities: 27% provided systematic reviews of the research literature to their target audiences, 40% provided access to a searchable database of research products on their topic, and 43% established or maintained long-term partnerships related to their topic with representatives of the target audience. Three factors emerged as statistically significant predictors of respondents’ engagement in these activities: the existence of structures and processes to link researchers and their target audiences predicted both the provision of access to a database (odds ratio [OR] 2.62, 95% CI 1.30–5.27) and the establishment or maintenance of partnerships (OR 2.65, 95% CI 1.25–5.64); stability in their contacts predicted the provision of systematic reviews (OR 2.88, 95% CI 1.35–6.13); and having managers and public (government) policy-makers among their target audiences predicted the provision of both systematic reviews (OR 4.57, 95% CI 1.78–11.72) and access to a database (OR 2.55, 95% CI 1.20–5.43).

Interpretation: Our findings suggest potential areas for improvement in light of the bridging strategies targeted at health care providers that have been found to be effective in some contexts and the factors that appear to increase the prospects for using research in policy-making.

Sossin, L. & Hoffman, S.J., 2010. Evaluating the Impact of Remedial Authority: Adjudicative Tribunals in the Health Sector. In K. Roach & R. J. Sharpe, ed. Taking Remedies Seriously. Montreal. Montreal: Canadian Institute for Administration of Justice, pp. 521-548. Publisher's VersionAbstract
Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.
Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.

Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.

Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.

Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.Evaluating the success of adjudicative tribunals is an important but elusive undertaking. Adjudicative tribunals are created by governments and given statutory authority by legislatures for a host of reasons. These reasons may and often do include legal aspects, policy aspects and partisan aspects. While such tribunals are increasingly being asked by governments to be accountable, too often this devolves into publishing statistics on their caseload, dispositions, budgets and staffing. We are interested in a different and more basic question - are these tribunals successful? How do we know, for example, whether the remedies ordered by a tribunal actually do advance the purposes for which it was created? Can the success of an adjudicative tribunal be subject to meaningful empirical validation? While issues of evaluation and accountability cut across national and jurisdictional boundaries, the authors argue that this type of question can only be addressed empirically, by actually looking to the practice of a particular board or boards, in the context of a particular statute or statutes, and in particular jurisdictions at particular times. Such accounts can and should form the basis for comparative study. Only through comparative study can the value and limitations of particular methodologies become apparent. This study takes as its case study the role of adjudicative tribunals in the health system. The authors draw primarily from Canadian tribunal experience, though examples from other jurisdictions are used to demonstrate the potential of empirical evaluation. The authors discuss the relative dearth of empirical study in administrative law and argue that it ought to be the focus of the discussion on accountability in administrative justice.

PDF
Hoffman, S.J. ed., 2010. Student Voices: Advocating for Global Health through Evidence, Insight and Action, Hamilton, Ontario, Canada. PDF
Hoffman, S.J., 2010. Strengthening Global Health Diplomacy in Canada's Foreign Policy Architecture: Literature Review and Key Informant Interviews. Canadian Foreign Policy Journal , 16 (3) , pp. 17 - 41. PDFAbstract

Global health is a growing concern because it its potential to affect the peace, security and prosperity of individuals worldwide. Global health diplomacy can mitigate this concern by integrating leadership across health and foreign policy spheres. Given the limited resources available for global health initiatives, it is important to show that investment in this area can bring tangible results for participants. In the case study of health diplomacy in Canada, several comparative advantages are identified including a strong international reputation, technical expertise and membership in a variety of multilateral organizations. However, there is still room for Canada to improve elements of its health diplomacy, such as by prioritizing health in foreign policy, promoting collaboration across government departments, engaging with key partners and stakeholders.

Guindon, E.G., et al., 2010. Bridging the Gaps Between Research, Policy and Practice in Low- and Middle-Income Countries: a Survey of Health Care Providers. Canadian Medical Association Journal , 182 (9) , pp. E362-72. PDFAbstract

Background: Gaps continue to exist between research-based evidence and clinical practice. We surveyed health care providers in 10 low- and middle-income countries about their use of research-based evidence and examined factors that may facilitate or impede such use.

Methods: We surveyed 1499 health care providers practising in one of four areas relevant to the Millennium Development Goals (prevention of malaria, care of women seeking contraception, care of children with diarrhea and care of patients with tuberculosis) in each of China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania.

Results: The proportion of respondents who reported that research was likely to change their clinical practice if performed and published in their own country (84.6% and 86.0% respectively) was higher than the proportion who reported the same about research and publications from their region (66.4% and 63.1%) or from high-income countries (55.8% and 55.5%). Respondents who were most likely to report that the use of research-based evidence led to changes in their practice included those who reported using clinical practice guidelines in paper format (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.03-2.28), using scientific journals from their own country in paper format (OR 1.70, 95% CI 1.26-2.28), viewing the quality of research performed in their country as above average or excellent (OR 1.93, 95% CI 1.16-3.22); trusting systematic reviews of randomized controlled trials (OR 1.59, 95% CI 1.08-2.35); and having easy access to the Internet (OR 1.90, 95% CI 1.19-3.02).

Interpretation: Locally conducted or published research has played an important role in changing the professional practice of health care providers surveyed in low- and middle-income countries. Increased investments in local research, or at least in locally adapted publications of research-based evidence from other settings, are therefore needed. Although access to the Internet was viewed as a significant factor in whether research-based evidence led to concrete changes in practice, few respondents reported having easy access to the Internet. Therefore, efforts to improve Internet access in clinical settings need to be accelerated.

Hoffman, S.J., 2010. The Evolution, Etiology and Eventualities of the Global Health Security Regime. Health Policy Plan , 25 (6) , pp. 510-22. PDFAbstract

Background: Attention to global health security governance is more important now than ever before. Scientists predict that a possible influenza pandemic could affect 1.5 billion people, cause up to 150 million deaths and leave US$3 trillion in economic damages. A public health emergency in one country is now only hours away from affecting many others.

Methods: Using regime analysis from political science, the principles, norms, rules and decision-making procedures by which states govern health security are examined in the historical context of their punctuated evolution. This methodology illuminates the catalytic agents of change, distributional consequences and possible future orders that can help to better inform progress in this area.

Findings: Four periods of global health security governance are identified. The first is characterized by unilateral quarantine regulations (1377-1851), the second by multiple sanitary conferences (1851-92), the third by several international sanitary conventions and international health organizations (1892-1946) and the fourth by the hegemonic leadership of the World Health Organization (1946-????). This final regime, like others before it, is challenged by globalization (e.g. limitations of the new International Health Regulations), changing diplomacy (e.g. proliferation of global health security organizations), new tools (e.g. global health law, human rights and health diplomacy) and shock-activated vulnerabilities (e.g. bioterrorism and avian/swine influenza). This understanding, in turn, allows us to appreciate the impact of this evolving regime on class, race and gender, as well as to consider four possible future configurations of power, including greater authority for the World Health Organization, a concert of powers, developing countries and civil society organizations.

Conclusions: This regime analysis allows us to understand the evolution, etiology and eventualities of the global health security regime, which is essential for national and international health policymakers, practitioners and academics to know where and how to act effectively in preparation for tomorrow's challenges.

2009
Hoffman, S.J., Lavis, J.N. & Bennett, S., 2009. The Use of Research Evidence in Two International Organizations' Recommendations about Health Systems. Healthcare Policy , 5 (1) , pp. 66-86. PDFAbstract

Background: Little is known about the extent to which research evidence informs the development of recommendations by international organizations.

Methods: We identified specific World Health Organization (WHO) and World Bank recommendations on five topics (contracting, healthcare financing, health human resources, tuberculosis control and tobacco control), catalogued the related systematic reviews and assessed the recommendations to determine their consistency with the systematic reviews that were available at the time of their formulation.

Findings: Only two of the eight publications examined were found to cite systematic reviews, and only five of 14 WHO and two of seven World Bank recommendations were consistent with both the direction and nature of effect claims from systematic reviews. Ten of 14 WHO and five of seven World Bank recommendations were consistent with the direction of effect claims only.

Conclusion: WHO and the World Bank - working with donor agencies and national governments - can improve their use of (or at least, their reporting about their use of) research evidence. Decision-makers and clinicians should critically evaluate the quality and local applicability of recommendations from any source, including international organizations, prior to their implementation.

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