Evidence-Based Practice: A Comprehensive Guide to Improving Patient Care

This comprehensive guide explores the principles and applications of evidence-based practice in healthcare. It delves into the process of searching for and appraising evidence, formulating answerable questions using the PICO format, and applying evidence to clinical decision-making. The guide also examines the challenges of manipulating evidence and the importance of ensuring its reliability and validity. Through real-world examples and case studies, it highlights the impact of evidence-based practice on patient outcomes and the role of healthcare professionals in promoting its effective implementation.

EVIDENCE BASED PRACTICE
Contents
INTRODUCTION...........................................................................................................................................2
SEARCH FOR EVIDENCE...............................................................................................................................3
PRACTICE GUIDELINES.................................................................................................................................6
NICE GUIDELINE.......................................................................................................................................6
WHO GUIDELINE......................................................................................................................................7
MANIPULATING THE EVIDENCE...................................................................................................................7
CONCLUSION.............................................................................................................................................11
REFERENCES..............................................................................................................................................12
APPENDIX 1...............................................................................................................................................16
APPENDIX 2...............................................................................................................................................18
APPENDIX 3...............................................................................................................................................22
1

INTRODUCTION
Evidence-based practice can be defined as the explicit, judicious and purposeful use of the available best
evidence for making decisions about the individual patient care. It also involves the integration of the
individual clinical skills and expertise with the available clinical evidence developed from systematic
search. The evidence-based practice has developed over time and integrates with the best research
methodologies, the clinical knowledge that is developed over time, patient’s individual circumstances and
values, and those situations and characteristics in which the clinician or the health professional works.
Hence, Evidence-based practice when delivered in the context of healthcare promotes the best practice
that is superior in quality and also provides improved patient outcome than care that is not patient-
oriented (Bleich, et al. 2013). The evidence-based practice also reduces the variations in the clinician’s
daily practice, promotes consistency of care and also contributes quality of care and patient safety agenda.
It also leads to improved satisfaction for the patient and assists in curbing the work stress for the nurses
while patient care guidelines are established. Evidence-based practice, therefore not only applies the best
available evidence to the area of practice but also utilizes the skills, training, and experience that have
been developed as a health care professional along with considering the patient’s opinions and choices.
The process that integrate this information is called as clinical reasoning that allows one to make
decisions about the patient care (Caraher, et al. 2013).
2

SEARCH FOR EVIDENCE
Working as a healthcare assistant in primary school involves monitoring student’s health and
ensuring the safety of children, promoting positive physical, mental &nutritional health and gives
a broader view of the unhealthy dietary habits of school children& its impact on their overall
well-being. There has been increased prevalence of obesity in primary schools as per the
statistics of National Child Measurement Programme (2005-06).This program statistics indicate
that 31.6% of children of 10-11 yr age group fell in overweight/obese category. 9.6% of children
in reception classes in 2016-17 are obese as compared to 9.3% the year before as per the NHS
Digital show. Unhealthy dietary habits have been associated with increased risk of obesity, DM,
CHD, abnormal sleep pattern, low self-esteem, and various other psychological problems in long
term. According to Haines et al (2007) childhood obesity has been associated with increased
incidence of Type-2 Diabetes among UK children. The purpose of this assignment is toassess the
outcomes of poor dietery habits among school children and frame interventions to prevent them.
Increasing childhood obesity is an alarming problem worldwide including UK and can be
termed as modern epidemic which needs attention and concern from government & healthcare
agencies, medical professional, school authorities, and public in general. Obesity not only affects
the individual but the society at large, in terms of increased level of morbidity & mortality rates,
health expenditures, loss of working days, increased load on health services. National Institute
for health & Care Excellence had issued “NICE guideline CG43 (2011)” for prioritizing this as
issue at all levels and for prevention and management of obesity and overweight. NHS England
and Public Health England (PHE) (2014) formed a working committee to address the issue of
obesity by working with local authorities.
Eldredge (2000) considered questions as driving force for evidence based practice & formatting
an answerable question is the biggest challenge in evidence based practice. PICO format helps to
frame a question that is directly relevant to the problem, is focused and well-articulated, &
facilitates search for precise answer.
3

Thus the research question “Does school meals increase the risk of obesity in Primary school
girls aged 5-12 years old in England?” has been formulated using PICO and further research
done by reviewing the available literature. PICO has been attached as Appendix 1.
Once a researchable question is framed, it was followed by literature search using various search
engine like Google, Google Scholar, and various database for original published articles like
PubMed, Mesh, Medline, CINAHL, and electronic resources of evidence based database like the
Cochrane database of systematic review, OVID Medline, TRIP Database plus, E- Medicine etc.
The database search gave large number of studies, but emphasis was given to meta-analysis,
systematic reviews, randomized controlled trials and landmark studies. These search engines
used key words which in this case were Primary schools, girls,5-12 years old, England. The three
Boolean operatorsAND, OR and NOT for combining key words were used to further refine the
search. Use of inclusion criteria like gender, age, year of publication, language resulted in more
specific articles.
HIERARCHY OF EVIDENCE (National Health and Medical Research Council, 2009)
4
SystematicReviews&Meta-analysisCriticallyappraisedtopics(evidencesyntheses&guidelines)Criticallyappraisedindividualarticles(articlesynopses)RandomizedControllegTrialCohortStudiesCaseControlStudiescaseseries/casereportsBackgroundinformation,expertopinionFiltered
informartion
Unfiltered
informartion

In most hierarchy of evidences, systematic reviews & meta-analysis occupy the top of pyramid
while background information and expert opinion occupy the base of pyramid. Study designs at
the top of pyramids, with more extensive methodology reduce study bias and increase accuracy
of study results.
The best study design can be also be decided on the basis of type of question
Meta-analysisinvolves compilation of aggregate data from primary studies. Despite being
difficult to perform, they offer advantages such as precise and accurate estimation of true effect.
Since they involve mathematical pooling of results there is increase in sample size, thereby
increasing the statistical power of study. However these accuracy of meta-analysis do depend on
the accuracy of primary studies that are used for pooling.
Systematic review methodically and exhaustively identifies studies focusing on specific topic,
gauge their methodology, enumerate the results, identifies cause of difference among different
studies and give limitations to present knowledge and understanding of things (Kapoor, 2016).
The quality of review can easily be assessed on the basis of compilation of data, and potential for
bias. A standard systemic review is the best research evidence for any focused clinical question
as it is a systematic compilation of data with complete transparency at each step, with fixed
inclusion criteria and extensive research.
Randomized control trial are gold standards for determining relationship between a factor and
event &inherently have the factors like randomization, blinding, control (Petrisor,
2007).Randomization helps in reduction of bias which may otherwise effect the study results by
5

over or underestimation of true treatment outcomes. Randomization controls both known and
unknown prognostic variables, thereby ensuring equal distribution of these variables in both
groups.
Cohort study occupies a higher position in hierarchy pyramid as it is a prospective study and
involves two groups that can be matched in an attempt to reduce bias atleast for known
prognostic variables and follow up can be closely monitored and made as complete as possible.
They can measure multiple outcomes, adjust for confounding variables and calculate attributed
risk (Petrisor, 2007). However they are costly, time consuming and do not measure rare
outcomes.
Case control studies usually start with a group that has an outcome of interest, match them with
controls that do not have the outcome, and try to identify the factor responsible for the outcome.
They have benefits of being quick, less expensive, used to formulate hypothesis, good for rare
outcomes, give odds ratio, & examine association of exposure to disease; &weaknesses like high
tendency for bias, can study only one outcome, doesn’t give incidence, prevalence, relative risk
Case series are used to depict some unusual or rare condition, are less expensive, simple and
useful in generating hypothesis, but lack control, are of short duration and have chances of bias
in case of incomplete data collection or follow up.
6

PRACTICE GUIDELINES
NICE GUIDELINE
As per the NICE guidelines, the BMI and the waist size is an important indicator for obesity and the
guideline also suggests having an absolute record of height, weight and BMI (Body Metabolic Index) at
all times is helpful to analyze the progress made in terms of reducing the obesity. The guideline also
suggests monitoring of physical activity, nutrition, and diet patterns for controlling the obesity in girls
within the age group of 5-13 years (Christian, et al. 2013). The Agree II score sheet of NICE guidelines
has been attached as Appendix 2.
WHO GUIDELINE
WHO developed a guideline in regards to the millions of girls who are found obese or overweight. This
was done with an aim to identify the weak links which are acting as the seeding factor for their obesity
and augments the risk of cardiovascular diseases, diabetes or premature death. Along with this, these
children also suffer from major physical and psychological consequences during their childhood
(Damsgaard, et al. 2014).
WHO guidelines recommend all the schools to initiate detailed records which can secure the body height-
for-weight ratio so as to gauge the development of the girls. The guidelines recommended by WHO
especially promotes the intake of high protein diet in schools and less consumption of sugary or fatty
foods items. There should also be a regular record of the amount of food the girl consumes so as to
appraise the expected outcome (de Leeuw, et al. 2014). The Agree II score sheet of WHO guidelines has
been attached as Appendix 3.
Although both the guidelines are elaborate in terms of their aims yet the comparative analysis suggests
that the guideline developed by WHO is more suitable for controlling the obesity in girls between the age
group of 5-13 years. This is because the WHO guideline is specifically descriptive on obese conditions
observed often in girls.
MANIPULATING THE EVIDENCE
Evidence-based medicine has been announced since the 1990s as ‘new paradigm’ for better patient care,
however, there is lack of distinct clinical evidence that Evidence-based medicine has certainly achieved
7

its aim. Since the time Evidence-based medicine has been introduced, there is a lack of clarity and high-
quality evidence which proves significantly improved patient outcomes. There are several pieces of
evidence that are being manipulated in a way that promotes the certain group, drugs, procedure, etc. and
these flaws are maximum is found in the industry-funded researchers (Fairclough, et al. 2013). Further,
most of the healthcare researchers are industry-based, this is a matter of serious concern. Clinical
decisions that are made on such evidence are likely to be manipulative and misleading with the affected
patient outcome and expensive or harmful treatments. This calls out for more investment in the
independent research and an urgent need to set up the clinical priorities (Ghavamzadeh, et al. 2013).
As an example, researchers from the International Centre for Allied Health Evidence (iCAHE) mutually
decided to examine and verify the existing issue of conflicting evidence in healthcare practice. Their topic
of research was the best evidence that contributes towards the manual therapy, manipulation, and
mobilization for headaches (Hillier-Brown, et al. 2014). Problems such as the cervicogenic headaches,
migraine, and tension-type headache are the common complaints that can impact the employment, family
as well s social life of an individual. The most common forms of treatment that are advised in such cases
include massage, reflexology, trigger therapy, spinal manipulation, exercise therapy, therapeutic heat, soft
tissue techniques and spinal mobilization regularly used by the health professionals for managing health
disorders (Kelishadi and Azizi-Soleiman, 2014).
Upon a rapid review that was conducted on the last three published best evidence resources, two
systematic reviews have been found and one guideline that was evidence-based was chosen. The
systematic review was based on seven randomized controlled trials (RCTs) where the findings indicate
that physiotherapy, massage therapy, relaxation and spinal manipulation are equally effective as the
prophylactic medications that are advised for the treatment of a migraine (Larson and Story, 2013).
However, after the research, there was a statement mentioned by the researchers which concluded that
‘the evaluated RCTs had several shortcomings’. Therefore any conclusion will be based upon well-
conducted RCTs that needs to be conducted in the future. Hence this statement keeps the readers in a
dilemma about the effectiveness of the manual therapy unless further research with a sound basis is
forwarded (Lobstein, et al. 2015).
As per the evidence-based guideline developed by Bryans and colleagues for the spinal manipulation as a
treatment option for a headache in adults, 21 articles were included which comprised of randomized
controlled trials and systematic reviews. According to the guideline ‘chiropractic care that includes spinal
manipulation has the capability to relieve a cervicogenic headache and migraine concerns’ ( Malik, et al.
2013). Although their guideline recognizes the methodological concerns associated with evidence,
8

however, their recommendations differ majorly when compared to the other systematic reviews. Further,
the systematic reviews utilized sound methodological processes and included only one primary and
secondary evidence resource yet the recommendations that came to were conflicting ( Muthuri, et al.
2014). This leads to a confused state for the readers while following the relevant evidence-based research.
These examples highlight the important concern of manipulated evidence which often results in
conflicting results or may confront the engaged or involved stakeholders associated with the research
evidence.
Another example describes the two modes of treatment for curing psychosis: through typical
antipsychotics and atypical antipsychotics (Pulgarón, 2013). The atypical antipsychotics were reviewed to
be better and the evidence state that atypicals are improved version of medications. This supported their
high cost and surge in their demand. However, after the actual studies, it has been found that atypical
drugs are not better, cost-effective or relevant as compared to the typical drugs (Rawlins, et al. 2013).
It is also found that the pharmaceutical companies also manipulate the data for their personal choices,
financial benefits or influence. As per the study conducted by de Leeuw, et al. in 2015, there was an
opportunity for them to research on the marketing department of the pharmaceutical companies in the
medical world. It was studied that between 1993 to 1998, SmithKline Beecham provided high funds to
the academic institutions for researching on paroxetine. The results were published in 2001 by Keller et
al. that paroxetine as a drug is well tolerated and is safe. There was, however, a serious misinterpretation
of the information that was shared with the others on the basis of drug safety and its effectiveness ( Ruel,
et al. 2013). The article contained all the manipulated information about paroxetine that was
misinterpreted. This occurred due to misinterpretation of one of the primary outcomes so that it appears
positive and all the secondary outcomes were deleted and were replaced with the favourable ones. Also,
SKB articles have revealed that minimum eight individuals in the paroxetine group have reported suicidal
tendency or self-harmful behaviour. This is further to notice that the article did not report such suicidal
tendency and instead described it as an emotional liability.
There are certain major implications of evidence manipulation on the final outcome of the evidence-based
research. These implications include:
Minimal patient participation in the research which results in lack of patient’s choices or opinions. This
also results in lack of significant experiences that the researcher develops over time for generating the
error-free conclusion and synopsis. The studies are usually conducted in an era where political or
organizational based decisions overpower the patient’s interest and the researcher are aware of their
9

research topic, their findings and conclusion and do not require much feedback for the same ( Sobol‐
Goldberg, et al. 2013).
Due to this, power imbalance suppresses the patient’s voice. This results in promotion of only those
evidence that is beneficial for meeting one specific objective. As a result, at times the clinicians often
follow the recommendations without giving a self-test trial which can majorly impact the health status of
their patients. This also causes dissatisfaction amongst the users who are being covered by the treatment
plan.
10

CONCLUSION
The evidence-based practice integrates the experiences of the medical practitioner, patient’s choices with
the best and the most suitable available evidence for health care set up and decision making. This
approach necessarily involves five major steps which are: identifying the questions, accessing the suitable
information, appraising that information for reliability and validity, applying that information for patient
care and evaluating its impact for the expected outcome. For the health outcomes to be high in quality
perspective, the evidence should be sound, genuine and cost-effective (Williams, et al. 2013).
The evidence-based practice tries to cover the pitfalls that are left in the patient care and aims to achieve a
healthier position by blending clinical expertise with suitable evidence. It further takes into account
patient’s values and suggestions for promoting better experience. It also offers the clinicians or the nurses
to expand their job roles and completely transform the obsolete pattern of care. The evidence-based
research takes into account the collection, evaluation, and implementation of evidence for improving the
patient care and clinical outcome. There is a significant reliability of these findings on expertise and
experience of the clinician for benefitting the patients (Williams, et al. 2014). Thus, the evidence-based
model is not a static one rather it is the model that incorporates continually updated research.
The above assignment is based on the evidence-based research for analyzing if the meals in schools are
the cause of childhood obesity in school girls of the age between 5-13 years of age. This assignment also
discusses the importance of having a healthy diet in schools for girls so as to avoid obesity and have the
correct body height: weight ratio. This has further been illustrated by the inclusion of the national/local
guidelines that strategize the plans for enabling healthy diet in schools for the girls within this age group
(Wright, et al. 2013).
11

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of a cooking intervention in English primary schools. Appetite, 62, 50-59.
Christian, M. S., Evans, C. E., Hancock, N., Nykjaer, C., & Cade, J. E. (2013). Family meals can
help children reach their 5 A Day: a cross-sectional survey of children's dietary intake from
London primary schools. J Epidemiol Community Health, 67(4), 332-338.
Damsgaard, C. T., Dalskov, S. M., Laursen, R. P., Ritz, C., Hjorth, M. F., Lauritzen, L., ... &
Andersen, R. (2014). Provision of healthy school meals does not affect the metabolic syndrome
score in 8–11-year-old children, but reduces cardiometabolic risk markers despite increasing
waist circumference. British Journal of Nutrition, 112(11), 1826-1836.
de Leeuw, E., Clavier, C. and Breton, E., (2014). Health policy–why research it and how: health
political science. Health Research Policy and Systems, 12(1), p.55.
Fairclough, S. J., Hackett, A. F., Davies, I. G., Gobbi, R., Mackintosh, K. A., Warburton, G. L., ... &
Boddy, L. M. (2013). Promoting healthy weight in primary school children through physical
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intervention study. BMC public health, 13(1), 626.
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G. A. Rees , C. J. Richards , J. Gregory Food and nutrient intakes of primary school children: a
comparison of school meals and packed lunches
Ghavamzadeh, S., Khalkhali, H. R., & Alizadeh, M. (2013). TV viewing, independent of physical
activity and obesogenic foods, increases overweight and obesity in adolescents. Journal of
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Haines, L., Wan, K. C., Lynn, R., Barrett, T. G., & Shield, J. P. (2007). Rising incidence of type 2
diabetes in children in the UK. Diabetes care, 30(5), 1097-1101.
Hillier-Brown, F. C., Bambra, C. L., Cairns, J. M., Kasim, A., Moore, H. J., & Summerbell, C. D.
(2014). A systematic review of the effectiveness of individual, community and societal level
interventions at reducing socioeconomic inequalities in obesity amongst children. BMC Public
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Kapoor, M.C., 2016. Types of studies and research design. Indian journal of anaesthesia, 60(9),
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Larson, N., & Story, M. (2013). A review of snacking patterns among children and adolescents:
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Muthuri, S. K., Francis, C. E., Wachira, L. J. M., LeBlanc, A. G., Sampson, M., Onywera, V. O., &
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Williams, J., Scarborough, P., Matthews, A., Cowburn, G., Foster, C., Roberts, N., & Rayner, M.
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15

APPENDIX 1
PICO
PROBLEM
Do school meals increase the risk of obesity in Primary school girls aged 5-12 years old in
England?”
INTERVENTION:
Effective obesity intervention requites both family based and school based multicomponent
programs like promotion of physical activity, counselling and training of parents, behaviour
modification knowledge about nutrition & balanced diet, along with community based and
environmental interventions (American Dietetic Association, 2006).
Some of the strategies that can be implemented are:
 Educational programs promoting importance of healthy diet and avoiding junk food,
sweetened drinks
 Media campaigns focusing on importance of healthy food (fruits, vegetables), food pricing
strategies (i.e. taxation to reduce consumption of unhealthy food), modifying individuals
local food environment & school food environment (Afshin et al, 2015).
 Implement programs that promote physical activity among school children and reduce
sedentary behaviour
 Motivational interviewing and counselling session to be held, to promote healthy eating
habits, importance of physical activity, balanced diet.
COMPARISON:
G. A. Rees et al (2008) observed that student consuming packed lunch consumed double the
amount of sugar and 50% more sodium & saturated fat in meal as compared to those having
lunch in school.
OUTCOME:
16

Introduction of healthy meal in primary school will have a positive impact on overall
development of children, leading to academic success, inclusion of healthy life style, resolution
of diseases. All round involvement of family & child in school based programmes extends
positive behaviour learned in school to family. Successful school obesity intervention
programme can be linked to improved mental health & cognitive development, and prevention
from chronic diseases (Wang et al, 2008).
17

APPENDIX 2
AGREE II SCORE SHEET (NICE GUIDELINE)
Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
Scope and
purpose
1. The overall objective(s)
of the guideline is (are)
specifically described.
Yes
2. The health question(s)
covered by the
guideline is (are)
specifically described.
Yes
3. The population
(patients, public, etc.) to
whom the guideline is
meant to apply is
specifically described.
Yes
Stakeholder
involvement
4. The guideline
development group
includes individuals
from all the relevant
professional groups.
Yes
5. The views and
preferences of the target
population (patients,
public, etc.) have been
sought.
Yes
6. The target users of the
guideline are clearly
Yes
18

Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
defined.
Rigor of
development
7. Systematic methods
were used to search for
evidence.
Yes
8. The criteria for
selecting the evidence
are clearly described.
Yes
9. The strengths and
limitations of the body
of evidence are clearly
described.
Yes
10. The methods for
formulating the
recommendations are
clearly described.
Yes
11. The health benefits,
side effects and risks
have been considered in
formulating the
recommendations.
Yes
12. There is an explicit link
between the
recommendations and
the supporting
evidence.
Yes
13. The guideline has been
externally reviewed by
Yes
19

Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
experts prior to its
publication.
14. A procedure for
updating the guideline
is provided.
Yes
Clarity of
presentation
15. The recommendations
are specific and
unambiguous.
Yes
16. The different options
for management of the
condition or health
issue are clearly
presented.
Yes
17. Key recommendations
are easily identifiable.
Yes
Applicability 18. The guideline describes
facilitators and barriers
to its application.
Yes
19. The guideline provides
advice and/or tools on
how the
recommendations can
be put into practice.
Yes
20. The potential resource
implications of
applying the
recommendations have
Yes
20

Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
been considered.
21. The guideline presents
monitoring and/ or
auditing criteria.
Yes
Editorial
independence
22. The views of the
funding body have not
influenced the content
of the guideline.
Yes
23. Competing interests of
guideline development
group members have
been recorded and
addressed.
Yes
Overall
Guideline
Assessment
1. Rate the overall quality
of this guideline.
1
Lowest
possible
quality
2 3 4 5 6
7 Highest
possible
quality
Overall
Guideline
Assessment
2. I would recommend this
guideline for use.
Yes Yes, with modifications No
Yes
21

APPENDIX 3
AGREE II SCORE SHEET (WHO GUIDELINE)
Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
Scope and
purpose
24. The overall objective(s) of
the guideline is (are)
specifically described.
Yes
25. The health question(s)
covered by the guideline is
(are) specifically described.
Yes
26. The population (patients,
public, etc.) to whom the
guideline is meant to apply is
specifically described.
Yes
Stakeholder
involvement
27. The guideline development
group includes individuals
from all the relevant
professional groups.
Yes
28. The views and preferences of
the target population
(patients, public, etc.) have
been sought.
Yes
29. The target users of the
guideline are clearly defined.
Yes
Rigor of 30. Systematic methods were Yes
22

Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
development used to search for evidence.
31. The criteria for selecting the
evidence are clearly
described.
Yes
32. The strengths and limitations
of the body of evidence are
clearly described.
Yes
33. The methods for formulating
the recommendations are
clearly described.
Yes
34. The health benefits, side
effects and risks have been
considered in formulating the
recommendations.
Yes
35. There is an explicit link
between the
recommendations and the
supporting evidence.
Yes
36. The guideline has been
externally reviewed by
experts prior to its
publication.
Yes
37. A procedure for updating the
guideline is provided.
Yes
Clarity of
presentation
38. The recommendations are
specific and unambiguous.
23

Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
39. The different options for
management of the condition
or health issue are clearly
presented.
Yes
40. Key recommendations are
easily identifiable.
Yes
Applicability 41. The guideline describes
facilitators and barriers to its
application.
Yes
42. The guideline provides
advice and/or tools on how
the recommendations can be
put into practice.
Yes
43. The potential resource
implications of applying the
recommendations have been
considered.
Yes
44. The guideline presents
monitoring and/ or auditing
criteria.
Yes
Editorial
independence
45. The views of the funding
body have not influenced the
content of the guideline.
Yes
46. Competing interests of
guideline development group
members have been recorded
and addressed.
Yes
24

Domain Item
AGREE II Rating
1 Strongly
Disagree 2 3 4 5 6 7 Strongly
Agree
Overall
Guideline
Assessment
3. Rate the overall quality of
this guideline.
1
Lowest
possible
quality
2 3 4 5 6
7 Highest
possible
quality
Yes
Overall
Guideline
Assessment
4. I would recommend this
guideline for use.
Yes Yes, with
modifications
No
Yes
25