Critical thinking and attitude of physicians toward evidence-based medicine in Egypt

A third of physicians in Egyptian university hospitals reported ‘feeling knowledge gap every day’ and this was associated with positive attitude towards evidence-based medicine and was also positively associated with the ability to answer questions related to critical reading of literature. (Beware the physician who thinks s/he knows it all.)

Below is the citation and abstract. Unfortunately the full text is restricted-access.

CITATION: J Egypt Public Health Assoc. 2015 Sep;90(3):115-120.

Critical thinking and attitude of physicians toward evidence-based medicine in Alexandria, Egypt.

Shehata GM1, Zaki A, Dowidar NL, El Sayed I.


BACKGROUND: Evidence-based practice is important for developing countries and is expected to thrive in a questioning culture. Experienced physicians differ in the making of clinical judgements, which are often not based on evidence. Although this topic is of paramount importance to the quality of care provided in the university hospitals in Alexandria, little research has been done about attitudes towards evidence-based medicine (EBM), and the extent of physicians’ skills to access and interpret evidence.

OBJECTIVE: This study aimed to investigate the relation between the attitude towards EBM and the indicators for questioning mind and critical appraisal skills among physicians in Alexandria, Egypt.

PARTICIPANTS AND METHODS: In a cross-sectional study, physicians (N=549) were randomly selected from different clinical departments in three of the university hospitals in Alexandria, Egypt using the stratified proportionate random sampling technique. A self-administrated questionnaire modified from the questionnaire used by McColl and colleagues was used.

RESULTS: A high percentage of physicians (83%) had positive attitude towards EBM. Feeling knowledge gap every day was reported by 34.2% of the physicians while 55.6% felt knowledge gap less frequently. The percentage of physicians who understood the meaning of different measures used to assess the importance of results and quality of evidence in meta-analysis studies ranged from 10.8 to 24.2%. Higher frequency of feeling knowledge gap in clinical practice and the ability to correctly answer different questions reflecting critical reading skills were all significantly associated with positive attitude towards EBM (P<0.05). A significant association (P<0.05) was also found between the frequency of feeling knowledge gap and the ability to answer questions related to critical reading of literature.

CONCLUSION AND RECOMMENDATIONS: This study has identified a significant relation between critical thinking skills and having a positive attitude towards EBM among physicians in the university hospitals in Alexandria. The study supported the hypothesis that strategies that encouraging critical thinking in medical education could improve the attitude of physicians towards EBM. Adopting teaching methods that encourage critical thinking in medical education as well as including the concepts and principals of critical appraisal of scientific research in the syllabus of both undergraduate and postgraduate medical students are recommended.

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IACAPAP Textbook of Child and Adolescent Mental Health

Thanks to Irina Ibraghimova and the LRC Network I have just learned about this new online IACAPAP Textbook of Child and Adolescent Mental Health. It looks very impressive; it is free to download and use offline; and it includes PowerPoint slides for teaching. Furthermore the publication is *open-access*. And it includes a quote from HIFA on its title page. Congratulations to the International Association for Child and Adolescent Psychiatry and Allied Professions for their generous contribution to child and adolescent mental health.

(By contrast, we have been trying unsuccessfully for several years to persuade the Royal College of Psychiatrists to make their publication Where There is No Psychiatrist freely available to all. This book is still needed as it is specifically for primary health workers in low-resource settings, yet ironically it is out of reach to most of those who would benefit from it, thereby failing to benefit the millions of people worldwide whose mental health depends on such health workers.)

You can freely access and download all chapters and PPTs of the new textbook here:

Comments on IACAPAP textbook:

“A work that rivals standard textbooks in scope; takes full advantage of its online format to include an array of color pictures, graphics, and video links; and gives voice to a medley of specialists, patients, and commentators from Amsterdam to Ankara, Beijing to Berlin…”

Journal of the American Academy of Child & Adolescent Psychiatry

“Each chapter is scholarly written, clinically oriented and of immense relevance to the practice of child and adolescent mental health… Some striking features set this work apart from traditional textbooks.”

Australasian Psychiatry

With best wishes,


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Lancet: Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health

This week’s print issue of The Lancet (14 November) carries the final report of The Rockefeller Foundation–Lancet Commission on Planetary Health. The authors define planetary health as: “The achievement of the highest attainable standard of health, wellbeing, and equity worldwide through judicious attention to the human systems—political, economic, and social—that shape the future of humanity and the Earth’s natural systems that define the safe environmental limits within which humanity can flourish. Put simply, planetary health is the health of human civilisation and the state of the natural systems on which it depends”.

Here are the key messages of the report:

1. The concept of planetary health is based on the understanding that human health and human civilisation depend on flourishing natural systems and the wise stewardship of those natural systems. However, natural systems are being degraded to an extent unprecedented in human history.

2. Environmental threats to human health and human civilisation will be characterised by surprise and uncertainty. Our societies face clear and potent dangers that require urgent and transformative actions to protect present and future generations.

3. The present systems of governance and organisation of human knowledge are inadequate to address the threats to planetary health. We call for improved governance to aid the integration of social, economic, and environmental policies and for the creation, synthesis, and application of interdisciplinary knowledge to strengthen planetary health.

4. Solutions lie within reach and should be based on the redefinition of prosperity to focus on the enhancement of quality of life and delivery of improved health for all, together with respect for the integrity of natural systems. This endeavour will necessitate that societies address the drivers of environmental change by promoting sustainable and equitable patterns of consumption, reducing population growth, and harnessing the power of technology for change.

Here is a selected extract of particular relevance to HIFA:

‘The final priority for research should be to prioritise translational research and implementation science to address the on-the-ground realities of what is feasible and relevant in the settings facing the greatest threats to planetary health. The dissemination, communication, and implementation of knowledge has to be central to research. Research can and does end up with recommendations that cannot to be translated into policy and action because the research did not fully capture the barriers to policy and behavioural change and how to address them. An unacceptable gap exists between the unprecedented amount of knowledge of diseases (including their control) and the implementation of that knowledge, especially in poor countries. Directed and innovative research is needed to analyse the causes of this situation and to point toward solutions at the global and local levels, both within and outside the health sector.’

CITATION: Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health

Dr Sarah Whitmee, PhD, Prof Andy Haines, FMedSci, Prof Chris Beyrer, MD, Frederick Boltz, PhD, Prof Anthony G Capon, PhD, Braulio Ferreira de Souza Dias, PhD, Alex Ezeh, PhD, Howard Frumkin, MD, Prof Peng Gong, PhD, Peter Head, BSc, Richard Horton, FMedSci, Prof Georgina M Mace, DPhil, Robert Marten, MPH, Samuel S Myers, MD, Sania Nishtar, PhD, Steven A Osofsky, DVM, Prof Subhrendu K Pattanayak, PhD, Montira J Pongsiri, PhD, Cristina Romanelli, MSc, Agnes Soucat, PhD, Jeanette Vega, MD, Derek Yach, MBChB

The Lancet Volume 386, No. 10007, p1973–2028, 14 November 2015

(free access after free registration)

Best wishes, Neil

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Free iPhone app to support Critical Appraisal Skills in English and Spanish

‘CASP The Critical Appraisal Skills Program is an efficient way to look at a paper and now you don’t need to use forms or papers to do this if you have an iphone because (CASPe) has created a CASP app for that.’

‘CASP now has a great easy to use mobile app that is free for iphone. With this app you can appraise eight kinds of studies. The app will store your results and it is easy to use even while sitting in a conference or a classroom. The CASP app was built for the iphone but mine works on the ipad too. The CASP app comes in English and Spanish. It takes minutes to do an appraisal and yet CASP leaves the work to you. The CASP developers offer expert tools for the job in a simple easy to use format. The app prompts you to create a title for your journal article review, add the PubMed ID or link and select the appropriate CASP worksheet (eight different study design options are included). CASP contains an outstanding A-Z Evidence Based Practice glossary and a section called Calculators that you can use to work out a number needed to treat (NNT) and pretest probabilities. If you need more guidance you can always get this from the CASP website and if you are Spanish see the critical appraisal program in Spain (CASPe) The Spanish group were the app creators lead by Dr Juan Cabello’.

Best wishes, Neil

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Imagining Global Health with Justice: In Defense of the Right to Health

Below is the citation and abstract of a new paper by HIFA member Eric Friedman and Lawrence Gostin.

Full text is freely available here:

CITATION: Imagining Global Health with Justice: In Defense of the Right to Health

Eric A. Friedman, Lawrence O. Gostin

Health Care Analysis, December 2015, Volume 23, Issue 4, pp 308-329

Published online: October, 2015


The singular message in Global Health Law is that we must strive to achieve global health with justice—improved population health, with a fairer distribution of benefits of good health. Global health entails ensuring the conditions of good health—public health, universal health coverage, and the social determinants of health—while justice requires closing today’s vast domestic and global health inequities. These conditions for good health should be incorporated into public policy, supplemented by specific actions to overcome barriers to equity.

A new global health treaty grounded in the right to health and aimed at health equity — a Framework Convention on Global Health (FCGH) — stands out for its possibilities in helping to achieve global health with justice.

This far-reaching legal instrument would establish minimum standards for universal health coverage and public health measures, with an accompanying national and international financing framework, require a constant focus on health equity, promote Health in All Policies and global governance for health, and advance the principles of good governance, including accountability.

While achieving an FCGH is certainly ambitious, it is a struggle worth the efforts of us all. The treaty’s basis in the right to health, which has been agreed to by all governments, has powerful potential to form the foundation of global governance for health. From interpretations of UN treaty bodies to judgments of national courts, the right to health is now sufficiently articulated to serve this role, with the individual’s right to health best understood as a function of a social, political, and economic environment aimed at equity. However great the political challenge of securing state agreement to the FCGH, it is possible.

States have joined other treaties with significant resource requirements and limitations on their sovereignty without significant reciprocal benefits from other states, while important state interests would benefit from the FCGH. And from integrating the FCGH into the existing human rights system to creative forms of compliance and enforcement and strengthened domestic legal and political accountability mechanisms, the treaty stands to improve right to health compliance. The potential for the FCGH to bring the right to health nearer universal reality calls for us to embark on the journey towards securing this global treaty.

Best wishes, Neil

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Wellcome Trust: Perceptions of the UK general public about antibiotics and antibiotic resistance

The Wellcome Trust has polled people in the UK about their beliefs and knowledge of antibiotics and antibiotic resistance. ‘The aim was to get a deep understanding of how people think and feel about

antibiotics, their current understanding of the resistance issue and the language they use around this area – how they talk about it and what words they use.’

Some of the key findings are shown below. The full text is available here:

Most people think they know when they need antibiotics – they don’t need the doctor to tell them

The deciding factor is nearly always how ill they feel – it’s about severity rather than type of illness

And this means there is a strong sense of ‘validation’ connected to antibiotics – getting them is ‘proof’ you’re ill

And ‘resistance’ is either not on the radar or misunderstood – everyone assumes it’s the person that becomes resistant

And there’s a belief that ‘they’/ scientists will sort it out before it becomes a real problem

All of which means it’s really hard to make it feel relevant to the individual

When people really understand resistance and ‘get it’ it makes a difference – but it’s really difficult to grasp

The bottom line is clarity and directness. As in: “Bacteria are getting stronger. Antibiotics won’t work anymore. You could die.” The Atlantic

The authors of the above study say we should stop talking about ‘antibiotic resistance’ and instead talk about ‘antibiotic-resistant infections’.

‘There is a need for a communications campaign for the public which makes the issue feel real and relevant, so that the tide of opinion is behind taking action.’

It seems highly likely that these misperceptions apply not only in the UK but in all countries.

Best wishes, Neil

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WHO/USAID/UNICEF – Improving nutrition outcomes with better WASH: Practical solutions for policy and programmes

Improving nutrition outcomes with better water, sanitation, and hygiene: Practical solutions for policy and programmes, 2015. WHO/USAID/UNICEF.

The report is on the WHO website

This document provides an overview of the evidence of nutrition gains that can be achieved with improved WASH, a description of key WASH practices, and practical knowledge and guidance on how to integrate WASH into nutrition programmes, including important monitoring and evaluation (M&E) aspects. The document concludes by providing a suite of case-studies and lessons learnt in ntegrating WASH with nutrition efforts.

This publication is intended primarily for nutrition programme managers and implementers working in developing countries who are seeking information about key WASH interventions that support nutritional outcomes, how to integrate such interventions into nutrition programmes, and related M&E considerations.

An important secondary audience is WASH programme managers and implementers who will find models and platforms at the household, health care facility and community levels for supporting integration efforts and establishing partnerships across sectors.

Finally, this publication can be useful for governments, donors, foundations and nongovernmental

organizations (NGOs) that are seeking to maximize health gains through greater integration and joint monitoring of nutrition and WASH efforts.

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How to stop antibiotic resistance? Here’s a WHO prescription

“We are speeding up the process dramatically by using antibiotics too much and often in the wrong contexts” says Marc Sprenger, Director of the WHO’s secretariat for antimicrobial resistance. His commentary is published today by WHO:

The prescription for action from WHO starts as follows:

‘Doctors, nurses, veterinarians and other health workers: Don’t prescribe or dispense antibiotics unless they are truly necessary and you have made all efforts to test and confirm which antibiotic your human patient or the animal you are treating should have. Today, it is estimated that in half of all cases, antibiotics are prescribed for conditions caused by viruses, where they do no good. You can also do more to prevent infections in the first place by ensuring your hands, instruments and environment are clean, and employing vaccines where appropriate.’

‘People using healthcare: Take antibiotics only when prescribed by a certified health professional, but also don’t be timid about asking if you feel you really need them. If you take an antibiotic, always complete the full prescription, even if you feel better, because stopping treatment early promotes the growth of drug-resistant bacteria.’

Yes, but I would emphasise that access to reliable information on medicines, in a form that is readily understandable, is a fundamental prerequisite for the above (both for health professionals and the general public). Given the enormity of the global threat of antimicrobial resistance, it is hard to understand why Information on Medicines For All is not seen as a priority. I was saddened and surprised to learn recently that the International Network for the Rational Use of Drugs have virtually ceased operations due to lack of funding. Who is now leading on this issue?

For more information on Information on Medicines for All, and the HIFA Working Group on Information for Prescribers and Users of Medicines, see:

Best wishes, Neil

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‘Who attracts whom to rural general practice? Variation in temperament and character profiles of GP registrars across different vocational training pathways’

To help attract and retain the ‘right’ graduates to the rural workforce and mitigate the ongoing rural doctor workforce shortage, this study compares demographic, temperament and character trait profiles of general practice Registrars across three Australian training pathways. The combination of trait levels that tend to differentiate Registrars on a rural path correlate strongly with high levels of resilience, which may be of greater benefit for the rural context.

Economists’ declaration on universal health coverage

‘Economists from 44 countries call on global policy makers to prioritise a pro-poor pathway to universal health coverage (UHC) as an essential pillar of development.’

Below are extracts from the declaration in this week’s issue of The Lancet (21 November):

‘UHC means ensuring that everyone can obtain essential health services at high quality without suffering financial hardship. Resource constraints require individual countries to determine their own definition of “essential”…’

‘The success of the next development chapter hinges on the ability to actually deliver proven health solutions to the poorest and most marginalised populations…’

‘Every country has the opportunity to achieve UHC…’

‘We, the undersigned, therefore urge that:

– Heads of government increase domestic funds for convergence and provide vocal political leadership to implement policy reforms toward pro-poor UHC

– Donor countries meet their pledges for international development assistance and commit to investing in the global functions of DAH, particularly research and development for diseases of poverty

– Development financing discussions explicitly address equity, including who pays domestically and who benefits

– National policy makers embrace UHC, as defined above, as an integrated approach for measuring progress toward health targets in the post-2015 global development framework.’

Best wishes, Neil

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Health education relating to medical terminology in LMICs

You may be interested in a training methodology which uses participatory activities to ‘translate’ medical terminology for LMIC health programmes and low literacy contexts.  For example, to explain immune function, viral load, HIV mutation and why treatment adherence is vital, patients or community members wearing “White Blood Cell”, “HIV”, “Infection”, and “ARV” masks are involved in role playing the interactions between these different characters. includes a short video with clips of this and related activities being used in health education programmes throughout Africa.  

Invitation to participate/send delegates to the 9th Nigerian Conference on Telemedicine and eHealth (NICTe2015)

6th November 2015

Dear Sir / Madam,


The Society for Telemedicine and eHealth in Nigeria, SfTeHIN exists to facilitate the international dissemination of knowledge and experience in Telemedicine and eHealth, and to provide access to recognized experts in the field worldwide. This responsibility she has carried out successfully in last ten years through numerous activities including annual conferences, and workshops as well as collaboration with relevant stakeholders in Nigeria.

In keeping with our tradition, this year’s annual conference, the 9th Nigerian Conference on Telemedicine and eHealth (NICTe2015) is scheduled to take place from 3rd – 4th December 2015 at the Banquet Hall of the National Center for Women Development, Tafawa Balewa Street, Central Business District in Abuja Nigeria. With the theme “The Business of eHealth”, the two-day event scientific conference cum exhibition will also mark in a special way, the 10th anniversary of SFTeHIN. NICTe2015 will be the leading eHealth event in Africa to share knowledge and experiences from across the country on actual solutions, technologies, products and services. It will also be a formidable platform for networking and engagement.

Towards this end, we are pleased to invite you to participate in the conference as a delegate by sponsoring yourself to the conference, and a stakeholder by sponsoring at least 3 persons from your organization to attend the event.

Your participation will once again reinforce your institution’s commitment to actualizing the vision for improvement in our health sector. Conference fee, Speaking/Sponsorship /Exhibition opportunities and other details are available at We therefore eagerly expect your favourable response to our invitation.

Yours faithfully,

Dr Olajide Adebola

President, Society for Telemedicine and eHealth

Democratic engagement is a core health issue

Are we powerless to effect change? It’s a notion that’s been popular for many election cycles. But just try telling a local community group that’s just rallied for a new service or program, that they are powerless. The truth is, there are some very achievable changes we can make to the Canadian democratic system, to get everyone a lot more engaged…..more

Collaboration processes and perceived effectiveness of integrated care projects in primary care: a longitudinal mixed-methods study



Collaborative partnerships are considered an essential strategy for integrating local disjointed health and social services. Currently, little evidence is available on how integrated care arrangements between professionals and organisations are achieved through the evolution of collaboration processes over time. The first aim was to develop a typology of integrated care projects (ICPs) based on the final degree of integration as perceived by multiple stakeholders. The second aim was to study how types of integration differ in changes of collaboration processes over time and final perceived effectiveness.


A longitudinal mixed-methods study design based on two data sources (surveys and interviews) was used to identify the perceived degree of integration and patterns in collaboration among 42 ICPs in primary care in The Netherlands. We used cluster analysis to identify distinct subgroups of ICPs based on the final perceived degree of integration from a professional, organisational and system perspective. With the use of ANOVAs, the subgroups were contrasted based on: 1) changes in collaboration processes over time (shared ambition, interests and mutual gains, relationship dynamics, organisational dynamics and process management) and 2) final perceived effectiveness (i.e. rated success) at the professional, organisational and system levels.


The ICPs were classified into three subgroups with: ‘United Integration Perspectives (UIP)’, ‘Disunited Integration Perspectives (DIP)’ and ‘Professional-oriented Integration Perspectives (PIP)’. ICPs within the UIP subgroup made the strongest increase in trust-based (mutual gains and relationship dynamics) as well as control-based (organisational dynamics and process management) collaboration processes and had the highest overall effectiveness rates. On the other hand, ICPs with the DIP subgroup decreased on collaboration processes and had the lowest overall effectiveness rates. ICPs within the PIP subgroup increased in control-based collaboration processes (organisational dynamics and process management) and had the highest effectiveness rates at the professional level.


The differences across the three subgroups in terms of the development of collaboration processes and the final perceived effectiveness provide evidence that united stakeholders’ perspectives are achieved through a constructive collaboration process over time. Disunited perspectives at the professional, organisation and system levels can be aligned by both trust-based and control-based collaboration processes.


Implementing the WHO Safe Childbirth Checklist in Pakistan

‘The main causes of maternal and newborn mortality are well-known and many can be prevented by relatively simple and inexpensive interventions… many of the resulting maternal and newborn deaths are at least partly due to simple oversights and a lack of consistency early on in the treatment process… community midwives and staff in primary care facilities sometimes are too slow to make referrals or fail to recognise problems and carry out basic diagnostic tests…

‘The WHO Safe Childbirth Checklist… aims to help health care workers to improve the quality of care around childbirth and minimise complications and deaths. For Dr Haroon, the benefits are clear. “Most of the time I lack the information that I need” she explains. “Implementing the Checklist will help to identify problems early on and make sure that the right decision is taken at the right time.”…

‘In 2008 the World Health Organization (WHO) started to develop a checklist-based tool to address these difficulties. The resulting Safe Childbirth Checklist ( translates a range of known best practices into a simple format that health workers can use in their daily work. The Checklist is still in development, however, the pilot edition contains 29-items that address the main causes of morbidity and mortality around the time of childbirth. Each item on the list prompts the health worker to consider a critical action that, if missed, could lead to complications or death.’

Full text here

Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA:  

The Great Fall of China and the rise of Africa

CHINA’s one-child policy, instituted in 1978, slowed population growth to 0.47% last year, with the country’s total population now standing at 1.376-billion. The demographics have had a limited effect on the economy, which has slowed from a growth rate of about 10% per annum a few years ago to 7% today. The latter is a rate that most nations would die for, but for the Chinese it has been a bit of a disappointment. One reason the economy is doing relatively well is that people of 65 and over represent 9.4% of the population, much lower than America’s 14.5%. But this is about to change. Look at projections of China’s demographics to 2030 and an extraordinary thing happens…..more

Lancet: ICD-10: there’s a code for that

The International Classification of Diseases (ICD) is the system for describing and coding mortality and morbidity incidents, implemented by most WHO member states. As of Oct 1, 2015, the USA formally transitioned to the updated codes, although they have already been in use in 117 other WHO member states (such as China and Canada) since release in 1992. The directive by the US Federal Government for ICD-10 compliance has been a major and controversial administrative and financial undertaking for health-care professionals, hospitals and health centres, and insurance companies…..more

Lancet: HIV: the question is not when to treat, but how to treat

Last week, WHO expedited release of their Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV, ahead of the updated comprehensive guidelines scheduled for publication later this year. The early-release guideline recommends immediate initiation of antiretroviral therapy (ART) for all individuals living with HIV, irrespective of age and CD4 cell count. Previously, ART has been recommended only for individuals with CD4 cell counts less than 500 cells per μL (in addition to pregnant women, discordant partners, and those with other conditions such as active tuberculosis)…..more