further recommendations in research

The Ultimate Guide to Crafting Impactful Recommendations in Research

Are you ready to take your research to the next level? Crafting impactful recommendations is the key to unlocking the full potential of your study. By providing clear, actionable suggestions based on your findings, you can bridge the gap between research and real-world application.

In this ultimate guide, we'll show you how to write recommendations that make a difference in your research report or paper.

You'll learn how to craft specific, actionable recommendations that connect seamlessly with your research findings. Whether you're a student, writer, teacher, or journalist, this guide will help you master the art of writing recommendations in research. Let's get started and make your research count!

Understanding the Purpose of Recommendations

Recommendations in research serve as a vital bridge between your findings and their real-world applications. They provide specific, action-oriented suggestions to guide future studies and decision-making processes. Let's dive into the key purposes of crafting effective recommendations:

Guiding Future Research

Research recommendations play a crucial role in steering scholars and researchers towards promising avenues of exploration. By highlighting gaps in current knowledge and proposing new research questions, recommendations help advance the field and drive innovation.

Influencing Decision-Making

Well-crafted recommendations have the power to shape policies, programs, and strategies across various domains, such as:

• Policy-making
• Product development
• Marketing strategies
• Medical practice

By providing clear, evidence-based suggestions, recommendations facilitate informed decision-making and improve outcomes.

Connecting Research to Practice

Recommendations act as a conduit for transferring knowledge from researchers to practitioners, policymakers, and stakeholders. They bridge the gap between academic findings and their practical applications, ensuring that research insights are effectively translated into real-world solutions.

Enhancing Research Impact

By crafting impactful recommendations, you can amplify the reach and influence of your research, attracting attention from peers, funding agencies, and decision-makers.

Addressing Limitations

Recommendations provide an opportunity to acknowledge and address the limitations of your study. By suggesting concrete and actionable possibilities for future research, you demonstrate a thorough understanding of your work's scope and potential areas for improvement.

Identifying Areas for Future Research

Discovering research gaps is a crucial step in crafting impactful recommendations. It involves reviewing existing studies and identifying unanswered questions or problems that warrant further investigation. Here are some strategies to help you identify areas for future research:

Explore Research Limitations

Take a close look at the limitations section of relevant studies. These limitations often provide valuable insights into potential areas for future research. Consider how addressing these limitations could enhance our understanding of the topic at hand.

Critically Analyze Discussion and Future Research Sections

When reading articles, pay special attention to the discussion and future research sections. These sections often highlight gaps in the current knowledge base and propose avenues for further exploration. Take note of any recurring themes or unanswered questions that emerge across multiple studies.

Utilize Targeted Search Terms

To streamline your search for research gaps, use targeted search terms such as "literature gap" or "future research" in combination with your subject keywords. This approach can help you quickly identify articles that explicitly discuss areas for future investigation.

Seek Guidance from Experts

Don't hesitate to reach out to your research advisor or other experts in your field. Their wealth of knowledge and experience can provide valuable insights into potential research gaps and emerging trends.

By employing these strategies, you'll be well-equipped to identify research gaps and craft recommendations that push the boundaries of current knowledge. Remember, the goal is to refine your research questions and focus your efforts on areas where more understanding is needed.

Structuring Your Recommendations

When it comes to structuring your recommendations, it's essential to keep them concise, organized, and tailored to your audience. Here are some key tips to help you craft impactful recommendations:

Prioritize and Organize

• Limit your recommendations to the most relevant and targeted suggestions for your peers or colleagues in the field.
• Place your recommendations at the end of the report, as they are often top of mind for readers.
• Write your recommendations in order of priority, with the most important ones for decision-makers coming first.

Use a Clear and Actionable Format

• Write recommendations in a clear, concise manner using actionable words derived from the data analyzed in your research.
• Use bullet points instead of long paragraphs for clarity and readability.
• Ensure that your recommendations are specific, measurable, attainable, relevant, and timely (SMART).

Connect Recommendations to Research

By following this simple formula, you can ensure that your recommendations are directly connected to your research and supported by a clear rationale.

Tailor to Your Audience

• Consider the needs and interests of your target audience when crafting your recommendations.
• Explain how your recommendations can solve the issues explored in your research.
• Acknowledge any limitations or constraints of your study that may impact the implementation of your recommendations.

Avoid Common Pitfalls

• Don't undermine your own work by suggesting incomplete or unnecessary recommendations.
• Avoid using recommendations as a place for self-criticism or introducing new information not covered in your research.
• Ensure that your recommendations are achievable and comprehensive, offering practical solutions for the issues considered in your paper.

By structuring your recommendations effectively, you can enhance the reliability and validity of your research findings, provide valuable strategies and suggestions for future research, and deliver impactful solutions to real-world problems.

Crafting Actionable and Specific Recommendations

Crafting actionable and specific recommendations is the key to ensuring your research findings have a real-world impact. Here are some essential tips to keep in mind:

Embrace Flexibility and Feasibility

Your recommendations should be open to discussion and new information, rather than being set in stone. Consider the following:

• Be realistic and considerate of your team's capabilities when making recommendations.
• Prioritize recommendations based on impact and reach, but be prepared to adjust based on team effort levels.
• Focus on solutions that require the fewest changes first, adopting an MVP (Minimum Viable Product) approach.

Provide Detailed and Justified Recommendations

To avoid vagueness and misinterpretation, ensure your recommendations are:

• Detailed, including photos, videos, or screenshots whenever possible.
• Justified based on research findings, providing alternatives when findings don't align with expectations or business goals.

Use this formula when writing recommendations:

Observed problem/pain point/unmet need + consequence + potential solution

Adopt a Solution-Oriented Approach

Foster collaboration and participation.

• Promote staff education on current research and create strategies to encourage adoption of promising clinical protocols.
• Include representatives from the treatment community in the development of the research initiative and the review of proposals.
• Require active, early, and permanent participation of treatment staff in the development, implementation, and interpretation of the study.

Tailor Recommendations to the Opportunity

When writing recommendations for a specific opportunity or program:

• Highlight the strengths and qualifications of the researcher.
• Provide specific examples of their work and accomplishments.
• Explain how their research has contributed to the field.
• Emphasize the researcher's potential for future success and their unique contributions.

By following these guidelines, you'll craft actionable and specific recommendations that drive meaningful change and showcase the value of your research.

Connecting Recommendations with Research Findings

Connecting your recommendations with research findings is crucial for ensuring the credibility and impact of your suggestions. Here's how you can seamlessly link your recommendations to the evidence uncovered in your study:

Grounding Recommendations in Research

Your recommendations should be firmly rooted in the data and insights gathered during your research process. Avoid including measures or suggestions that were not discussed or supported by your study findings. This approach ensures that your recommendations are evidence-based and directly relevant to the research at hand.

Highlighting the Significance of Collaboration

Research collaborations offer a wealth of benefits that can enhance an agency's competitive position. Consider the following factors when discussing the importance of collaboration in your recommendations:

• Organizational Development: Participation in research collaborations depends on an agency's stage of development, compatibility with its mission and culture, and financial stability.
• Trust-Building: Long-term collaboration success often hinges on a history of increasing involvement and trust between partners.
• Infrastructure: A permanent infrastructure that facilitates long-term development is key to successful collaborative programs.

Emphasizing Commitment and Participation

Fostering quality improvement and organizational learning.

In your recommendations, highlight the importance of enhancing quality improvement strategies and fostering organizational learning. Show sensitivity to the needs and constraints of community-based programs, as this understanding is crucial for effective collaboration and implementation.

Addressing Limitations and Implications

If not already addressed in the discussion section, your recommendations should mention the limitations of the study and their implications. Examples of limitations include:

• Sample size or composition
• Participant attrition
• Study duration

By acknowledging these limitations, you demonstrate a comprehensive understanding of your research and its potential impact.

By connecting your recommendations with research findings, you provide a solid foundation for your suggestions, emphasize the significance of collaboration, and showcase the potential for future research and practical applications.

Crafting impactful recommendations is a vital skill for any researcher looking to bridge the gap between their findings and real-world applications. By understanding the purpose of recommendations, identifying areas for future research, structuring your suggestions effectively, and connecting them to your research findings, you can unlock the full potential of your study. Remember to prioritize actionable, specific, and evidence-based recommendations that foster collaboration and drive meaningful change.

As you embark on your research journey, embrace the power of well-crafted recommendations to amplify the impact of your work. By following the guidelines outlined in this ultimate guide, you'll be well-equipped to write recommendations that resonate with your audience, inspire further investigation, and contribute to the advancement of your field. So go forth, make your research count, and let your recommendations be the catalyst for positive change.

Q: What are the steps to formulating recommendations in research? A: To formulate recommendations in research, you should first gain a thorough understanding of the research question. Review the existing literature to inform your recommendations and consider the research methods that were used. Identify which data collection techniques were employed and propose suitable data analysis methods. It's also essential to consider any limitations and ethical considerations of your research. Justify your recommendations clearly and finally, provide a summary of your recommendations.

Q: Why are recommendations significant in research studies? A: Recommendations play a crucial role in research as they form a key part of the analysis phase. They provide specific suggestions for interventions or strategies that address the problems and limitations discovered during the study. Recommendations are a direct response to the main findings derived from data collection and analysis, and they can guide future actions or research.

Q: Can you outline the seven steps involved in writing a research paper? A: Certainly. The seven steps to writing an excellent research paper include:

• Allowing yourself sufficient time to complete the paper.
• Defining the scope of your essay and crafting a clear thesis statement.
• Conducting a thorough yet focused search for relevant research materials.
• Reading the research materials carefully and taking detailed notes.
• Writing your paper based on the information you've gathered and analyzed.
• Editing your paper to ensure clarity, coherence, and correctness.
• Submitting your paper following the guidelines provided.

Q: What tips can help make a research paper more effective? A: To enhance the effectiveness of a research paper, plan for the extensive process ahead and understand your audience. Decide on the structure your research writing will take and describe your methodology clearly. Write in a straightforward and clear manner, avoiding the use of clichés or overly complex language.

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Home » Research Recommendations – Examples and Writing Guide

Research Recommendations – Examples and Writing Guide

Table of Contents

Research Recommendations

Definition:

Research recommendations refer to suggestions or advice given to someone who is looking to conduct research on a specific topic or area. These recommendations may include suggestions for research methods, data collection techniques, sources of information, and other factors that can help to ensure that the research is conducted in a rigorous and effective manner. Research recommendations may be provided by experts in the field, such as professors, researchers, or consultants, and are intended to help guide the researcher towards the most appropriate and effective approach to their research project.

Parts of Research Recommendations

Research recommendations can vary depending on the specific project or area of research, but typically they will include some or all of the following parts:

• Research question or objective : This is the overarching goal or purpose of the research project.
• Research methods : This includes the specific techniques and strategies that will be used to collect and analyze data. The methods will depend on the research question and the type of data being collected.
• Data collection: This refers to the process of gathering information or data that will be used to answer the research question. This can involve a range of different methods, including surveys, interviews, observations, or experiments.
• Data analysis : This involves the process of examining and interpreting the data that has been collected. This can involve statistical analysis, qualitative analysis, or a combination of both.
• Results and conclusions: This section summarizes the findings of the research and presents any conclusions or recommendations based on those findings.
• Limitations and future research: This section discusses any limitations of the study and suggests areas for future research that could build on the findings of the current project.

How to Write Research Recommendations

Writing research recommendations involves providing specific suggestions or advice to a researcher on how to conduct their study. Here are some steps to consider when writing research recommendations:

• Understand the research question: Before writing research recommendations, it is important to have a clear understanding of the research question and the objectives of the study. This will help to ensure that the recommendations are relevant and appropriate.
• Consider the research methods: Consider the most appropriate research methods that could be used to collect and analyze data that will address the research question. Identify the strengths and weaknesses of the different methods and how they might apply to the specific research question.
• Provide specific recommendations: Provide specific and actionable recommendations that the researcher can implement in their study. This can include recommendations related to sample size, data collection techniques, research instruments, data analysis methods, or other relevant factors.
• Justify recommendations : Justify why each recommendation is being made and how it will help to address the research question or objective. It is important to provide a clear rationale for each recommendation to help the researcher understand why it is important.
• Consider limitations and ethical considerations : Consider any limitations or potential ethical considerations that may arise in conducting the research. Provide recommendations for addressing these issues or mitigating their impact.
• Summarize recommendations: Provide a summary of the recommendations at the end of the report or document, highlighting the most important points and emphasizing how the recommendations will contribute to the overall success of the research project.

Example of Research Recommendations

Example of Research Recommendations sample for students:

• Further investigate the effects of X on Y by conducting a larger-scale randomized controlled trial with a diverse population.
• Explore the relationship between A and B by conducting qualitative interviews with individuals who have experience with both.
• Investigate the long-term effects of intervention C by conducting a follow-up study with participants one year after completion.
• Examine the effectiveness of intervention D in a real-world setting by conducting a field study in a naturalistic environment.
• Compare and contrast the results of this study with those of previous research on the same topic to identify any discrepancies or inconsistencies in the findings.
• Expand upon the limitations of this study by addressing potential confounding variables and conducting further analyses to control for them.
• Investigate the relationship between E and F by conducting a meta-analysis of existing literature on the topic.
• Explore the potential moderating effects of variable G on the relationship between H and I by conducting subgroup analyses.
• Identify potential areas for future research based on the gaps in current literature and the findings of this study.
• Conduct a replication study to validate the results of this study and further establish the generalizability of the findings.

Applications of Research Recommendations

Research recommendations are important as they provide guidance on how to improve or solve a problem. The applications of research recommendations are numerous and can be used in various fields. Some of the applications of research recommendations include:

• Policy-making: Research recommendations can be used to develop policies that address specific issues. For example, recommendations from research on climate change can be used to develop policies that reduce carbon emissions and promote sustainability.
• Program development: Research recommendations can guide the development of programs that address specific issues. For example, recommendations from research on education can be used to develop programs that improve student achievement.
• Product development : Research recommendations can guide the development of products that meet specific needs. For example, recommendations from research on consumer behavior can be used to develop products that appeal to consumers.
• Marketing strategies: Research recommendations can be used to develop effective marketing strategies. For example, recommendations from research on target audiences can be used to develop marketing strategies that effectively reach specific demographic groups.
• Medical practice : Research recommendations can guide medical practitioners in providing the best possible care to patients. For example, recommendations from research on treatments for specific conditions can be used to improve patient outcomes.
• Scientific research: Research recommendations can guide future research in a specific field. For example, recommendations from research on a specific disease can be used to guide future research on treatments and cures for that disease.

Purpose of Research Recommendations

The purpose of research recommendations is to provide guidance on how to improve or solve a problem based on the findings of research. Research recommendations are typically made at the end of a research study and are based on the conclusions drawn from the research data. The purpose of research recommendations is to provide actionable advice to individuals or organizations that can help them make informed decisions, develop effective strategies, or implement changes that address the issues identified in the research.

The main purpose of research recommendations is to facilitate the transfer of knowledge from researchers to practitioners, policymakers, or other stakeholders who can benefit from the research findings. Recommendations can help bridge the gap between research and practice by providing specific actions that can be taken based on the research results. By providing clear and actionable recommendations, researchers can help ensure that their findings are put into practice, leading to improvements in various fields, such as healthcare, education, business, and public policy.

Characteristics of Research Recommendations

Research recommendations are a key component of research studies and are intended to provide practical guidance on how to apply research findings to real-world problems. The following are some of the key characteristics of research recommendations:

• Actionable : Research recommendations should be specific and actionable, providing clear guidance on what actions should be taken to address the problem identified in the research.
• Evidence-based: Research recommendations should be based on the findings of the research study, supported by the data collected and analyzed.
• Contextual: Research recommendations should be tailored to the specific context in which they will be implemented, taking into account the unique circumstances and constraints of the situation.
• Feasible : Research recommendations should be realistic and feasible, taking into account the available resources, time constraints, and other factors that may impact their implementation.
• Prioritized: Research recommendations should be prioritized based on their potential impact and feasibility, with the most important recommendations given the highest priority.
• Communicated effectively: Research recommendations should be communicated clearly and effectively, using language that is understandable to the target audience.
• Evaluated : Research recommendations should be evaluated to determine their effectiveness in addressing the problem identified in the research, and to identify opportunities for improvement.

Advantages of Research Recommendations

Research recommendations have several advantages, including:

• Providing practical guidance: Research recommendations provide practical guidance on how to apply research findings to real-world problems, helping to bridge the gap between research and practice.
• Improving decision-making: Research recommendations help decision-makers make informed decisions based on the findings of research, leading to better outcomes and improved performance.
• Enhancing accountability : Research recommendations can help enhance accountability by providing clear guidance on what actions should be taken, and by providing a basis for evaluating progress and outcomes.
• Informing policy development : Research recommendations can inform the development of policies that are evidence-based and tailored to the specific needs of a given situation.
• Enhancing knowledge transfer: Research recommendations help facilitate the transfer of knowledge from researchers to practitioners, policymakers, or other stakeholders who can benefit from the research findings.
• Encouraging further research : Research recommendations can help identify gaps in knowledge and areas for further research, encouraging continued exploration and discovery.
• Promoting innovation: Research recommendations can help identify innovative solutions to complex problems, leading to new ideas and approaches.

Limitations of Research Recommendations

While research recommendations have several advantages, there are also some limitations to consider. These limitations include:

• Context-specific: Research recommendations may be context-specific and may not be applicable in all situations. Recommendations developed in one context may not be suitable for another context, requiring adaptation or modification.
• I mplementation challenges: Implementation of research recommendations may face challenges, such as lack of resources, resistance to change, or lack of buy-in from stakeholders.
• Limited scope: Research recommendations may be limited in scope, focusing only on a specific issue or aspect of a problem, while other important factors may be overlooked.
• Uncertainty : Research recommendations may be uncertain, particularly when the research findings are inconclusive or when the recommendations are based on limited data.
• Bias : Research recommendations may be influenced by researcher bias or conflicts of interest, leading to recommendations that are not in the best interests of stakeholders.
• Timing : Research recommendations may be time-sensitive, requiring timely action to be effective. Delayed action may result in missed opportunities or reduced effectiveness.
• Lack of evaluation: Research recommendations may not be evaluated to determine their effectiveness or impact, making it difficult to assess whether they are successful or not.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Research Recommendations – Guiding policy-makers for evidence-based decision making

Research recommendations play a crucial role in guiding scholars and researchers toward fruitful avenues of exploration. In an era marked by rapid technological advancements and an ever-expanding knowledge base, refining the process of generating research recommendations becomes imperative.

But, what is a research recommendation?

Research recommendations are suggestions or advice provided to researchers to guide their study on a specific topic . They are typically given by experts in the field. Research recommendations are more action-oriented and provide specific guidance for decision-makers, unlike implications that are broader and focus on the broader significance and consequences of the research findings. However, both are crucial components of a research study.

Difference Between Research Recommendations and Implication

Although research recommendations and implications are distinct components of a research study, they are closely related. The differences between them are as follows:

Types of Research Recommendations

Recommendations in research can take various forms, which are as follows:

These recommendations aim to assist researchers in navigating the vast landscape of academic knowledge.

Let us dive deeper to know about its key components and the steps to write an impactful research recommendation.

Key Components of Research Recommendations

The key components of research recommendations include defining the research question or objective, specifying research methods, outlining data collection and analysis processes, presenting results and conclusions, addressing limitations, and suggesting areas for future research. Here are some characteristics of research recommendations:

Research recommendations offer various advantages and play a crucial role in ensuring that research findings contribute to positive outcomes in various fields. However, they also have few limitations which highlights the significance of a well-crafted research recommendation in offering the promised advantages.

The importance of research recommendations ranges in various fields, influencing policy-making, program development, product development, marketing strategies, medical practice, and scientific research. Their purpose is to transfer knowledge from researchers to practitioners, policymakers, or stakeholders, facilitating informed decision-making and improving outcomes in different domains.

How to Write Research Recommendations?

Research recommendations can be generated through various means, including algorithmic approaches, expert opinions, or collaborative filtering techniques. Here is a step-wise guide to build your understanding on the development of research recommendations.

1. Understand the Research Question:

Understand the research question and objectives before writing recommendations. Also, ensure that your recommendations are relevant and directly address the goals of the study.

2. Review Existing Literature:

Familiarize yourself with relevant existing literature to help you identify gaps , and offer informed recommendations that contribute to the existing body of research.

3. Consider Research Methods:

Evaluate the appropriateness of different research methods in addressing the research question. Also, consider the nature of the data, the study design, and the specific objectives.

4. Identify Data Collection Techniques:

Gather dataset from diverse authentic sources. Include information such as keywords, abstracts, authors, publication dates, and citation metrics to provide a rich foundation for analysis.

5. Propose Data Analysis Methods:

Suggest appropriate data analysis methods based on the type of data collected. Consider whether statistical analysis, qualitative analysis, or a mixed-methods approach is most suitable.

6. Consider Limitations and Ethical Considerations:

Acknowledge any limitations and potential ethical considerations of the study. Furthermore, address these limitations or mitigate ethical concerns to ensure responsible research.

7. Justify Recommendations:

Explain how your recommendation contributes to addressing the research question or objective. Provide a strong rationale to help researchers understand the importance of following your suggestions.

8. Summarize Recommendations:

Provide a concise summary at the end of the report to emphasize how following these recommendations will contribute to the overall success of the research project.

By following these steps, you can create research recommendations that are actionable and contribute meaningfully to the success of the research project.

Download now to unlock some tips to improve your journey of writing research recommendations.

Example of a Research Recommendation

Here is an example of a research recommendation based on a hypothetical research to improve your understanding.

Research Recommendation: Enhancing Student Learning through Integrated Learning Platforms

Background:

The research study investigated the impact of an integrated learning platform on student learning outcomes in high school mathematics classes. The findings revealed a statistically significant improvement in student performance and engagement when compared to traditional teaching methods.

Recommendation:

In light of the research findings, it is recommended that educational institutions consider adopting and integrating the identified learning platform into their mathematics curriculum. The following specific recommendations are provided:

• Implementation of the Integrated Learning Platform:

Schools are encouraged to adopt the integrated learning platform in mathematics classrooms, ensuring proper training for teachers on its effective utilization.

• Professional Development for Educators:

Develop and implement professional programs to train educators in the effective use of the integrated learning platform to address any challenges teachers may face during the transition.

• Monitoring and Evaluation:

Establish a monitoring and evaluation system to track the impact of the integrated learning platform on student performance over time.

• Resource Allocation:

Allocate sufficient resources, both financial and technical, to support the widespread implementation of the integrated learning platform.

By implementing these recommendations, educational institutions can harness the potential of the integrated learning platform and enhance student learning experiences and academic achievements in mathematics.

This example covers the components of a research recommendation, providing specific actions based on the research findings, identifying the target audience, and outlining practical steps for implementation.

Using AI in Research Recommendation Writing

Enhancing research recommendations is an ongoing endeavor that requires the integration of cutting-edge technologies, collaborative efforts, and ethical considerations. By embracing data-driven approaches and leveraging advanced technologies, the research community can create more effective and personalized recommendation systems. However, it is accompanied by several limitations. Therefore, it is essential to approach the use of AI in research with a critical mindset, and complement its capabilities with human expertise and judgment.

Here are some limitations of integrating AI in writing research recommendation and some ways on how to counter them.

1. Data Bias

AI systems rely heavily on data for training. If the training data is biased or incomplete, the AI model may produce biased results or recommendations.

How to tackle: Audit regularly the model’s performance to identify any discrepancies and adjust the training data and algorithms accordingly.

2. Lack of Understanding of Context:

AI models may struggle to understand the nuanced context of a particular research problem. They may misinterpret information, leading to inaccurate recommendations.

How to tackle: Use AI to characterize research articles and topics. Employ them to extract features like keywords, authorship patterns and content-based details.

3. Ethical Considerations:

AI models might stereotype certain concepts or generate recommendations that could have negative consequences for certain individuals or groups.

How to tackle: Incorporate user feedback mechanisms to reduce redundancies. Establish an ethics review process for AI models in research recommendation writing.

4. Lack of Creativity and Intuition:

AI may struggle with tasks that require a deep understanding of the underlying principles or the ability to think outside the box.

How to tackle: Hybrid approaches can be employed by integrating AI in data analysis and identifying patterns for accelerating the data interpretation process.

5. Interpretability:

Many AI models, especially complex deep learning models, lack transparency on how the model arrived at a particular recommendation.

How to tackle: Implement models like decision trees or linear models. Provide clear explanation of the model architecture, training process, and decision-making criteria.

6. Dynamic Nature of Research:

Research fields are dynamic, and new information is constantly emerging. AI models may struggle to keep up with the rapidly changing landscape and may not be able to adapt to new developments.

How to tackle: Establish a feedback loop for continuous improvement. Regularly update the recommendation system based on user feedback and emerging research trends.

The integration of AI in research recommendation writing holds great promise for advancing knowledge and streamlining the research process. However, navigating these concerns is pivotal in ensuring the responsible deployment of these technologies. Researchers need to understand the use of responsible use of AI in research and must be aware of the ethical considerations.

Exploring research recommendations plays a critical role in shaping the trajectory of scientific inquiry. It serves as a compass, guiding researchers toward more robust methodologies, collaborative endeavors, and innovative approaches. Embracing these suggestions not only enhances the quality of individual studies but also contributes to the collective advancement of human understanding.

Frequently Asked Questions

The purpose of recommendations in research is to provide practical and actionable suggestions based on the study's findings, guiding future actions, policies, or interventions in a specific field or context. Recommendations bridges the gap between research outcomes and their real-world application.

To make a research recommendation, analyze your findings, identify key insights, and propose specific, evidence-based actions. Include the relevance of the recommendations to the study's objectives and provide practical steps for implementation.

Begin a recommendation by succinctly summarizing the key findings of the research. Clearly state the purpose of the recommendation and its intended impact. Use a direct and actionable language to convey the suggested course of action.

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• Peer review
• Polly Brown ( pbrown{at}bmjgroup.com ) , publishing manager 1 ,
• Klara Brunnhuber , clinical editor 1 ,
• Kalipso Chalkidou , associate director, research and development 2 ,
• Iain Chalmers , director 3 ,
• Mike Clarke , director 4 ,
• Mark Fenton , editor 3 ,
• Carol Forbes , reviews manager 5 ,
• Julie Glanville , associate director/information service manager 5 ,
• Nicholas J Hicks , consultant in public health medicine 6 ,
• Janet Moody , identification and prioritisation manager 6 ,
• Sara Twaddle , director 7 ,
• Hazim Timimi , systems developer 8 ,
• Pamela Young , senior programme manager 6
• 1 BMJ Publishing Group, London WC1H 9JR,
• 2 National Institute for Health and Clinical Excellence, London WC1V 6NA,
• 3 Database of Uncertainties about the Effects of Treatments, James Lind Alliance Secretariat, James Lind Initiative, Oxford OX2 7LG,
• 4 UK Cochrane Centre, Oxford OX2 7LG,
• 5 Centre for Reviews and Dissemination, University of York, York YO10 5DD,
• 6 National Coordinating Centre for Health Technology Assessment, University of Southampton, Southampton SO16 7PX,
• 7 Scottish Intercollegiate Guidelines Network, Edinburgh EH2 1EN,
• 8 Update Software, Oxford OX2 7LG
• Correspondence to: PBrown
• Accepted 22 September 2006

“More research is needed” is a conclusion that fits most systematic reviews. But authors need to be more specific about what exactly is required

Long awaited reports of new research, systematic reviews, and clinical guidelines are too often a disappointing anticlimax for those wishing to use them to direct future research. After many months or years of effort and intellectual energy put into these projects, authors miss the opportunity to identify unanswered questions and outstanding gaps in the evidence. Most reports contain only a less than helpful, general research recommendation. This means that the potential value of these recommendations is lost.

Current recommendations

In 2005, representatives of organisations commissioning and summarising research, including the BMJ Publishing Group, the Centre for Reviews and Dissemination, the National Coordinating Centre for Health Technology Assessment, the National Institute for Health and Clinical Excellence, the Scottish Intercollegiate Guidelines Network, and the UK Cochrane Centre, met as members of the development group for the Database of Uncertainties about the Effects of Treatments (see bmj.com for details on all participating organisations). Our aim was to discuss the state of research recommendations within our organisations and to develop guidelines for improving the presentation of proposals for further research. All organisations had found weaknesses in the way researchers and authors of systematic reviews and clinical guidelines stated the need for further research. As part of the project, a member of the Centre for Reviews and Dissemination under-took a rapid literature search to identify information on research recommendation models, which found some individual methods but no group initiatives to attempt to standardise recommendations.

Suggested format for research recommendations on the effects of treatments

Core elements.

E Evidence (What is the current state of the evidence?)

P Population (What is the population of interest?)

I Intervention (What are the interventions of interest?)

C Comparison (What are the comparisons of interest?)

O Outcome (What are the outcomes of interest?)

T Time stamp (Date of recommendation)

Optional elements

d Disease burden or relevance

t Time aspect of core elements of EPICOT

s Appropriate study type according to local need

In January 2006, the National Coordinating Centre for Health Technology Assessment presented the findings of an initial comparative analysis of how different organisations currently structure their research recommendations. The National Institute for Health and Clinical Excellence and the National Coordinating Centre for Health Technology Assessment request authors to present recommendations in a four component format for formulating well built clinical questions around treatments: population, intervention, comparison, and outcomes (PICO). 1 In addition, the research recommendation is dated and authors are asked to provide the current state of the evidence to support the proposal.

Clinical Evidence , although not directly standardising its sections for research recommendations, presents gaps in the evidence using a slightly extended version of the PICO format: evidence, population, intervention, comparison, outcomes, and time (EPICOT). Clinical Evidence has used this inherent structure to feed research recommendations on interventions categorised as “unknown effectiveness” back to the National Coordinating Centre for Health Technology Assessment and for inclusion in the Database of Uncertainties about the Effects of Treatments ( http://www.duets.nhs.uk/ ).

We decided to propose the EPICOT format as the basis for its statement on formulating research recommendations and tested this proposal through discussion and example. We agreed that this set of components provided enough context for formulating research recommendations without limiting researchers. In order for the proposed framework to be flexible and more widely applicable, the group discussed using several optional components when they seemed relevant or were proposed by one or more of the group members. The final outcome of discussions resulted in the proposed EPICOT+ format (box).

A recent BMJ article highlighted how lack of research hinders the applicability of existing guidelines to patients in primary care who have had a stroke or transient ischaemic attack. 2 Most research in the area had been conducted in younger patients with a recent episode and in a hospital setting. The authors concluded that “further evidence should be collected on the efficacy and adverse effects of intensive blood pressure lowering in representative populations before we implement this guidance [from national and international guidelines] in primary care.” Table 1 outlines how their recommendations could be formulated using the EPICOT+ format. The decision on whether additional research is indeed clinically and ethically warranted will still lie with the organisation considering commissioning the research.

Research recommendation based on gap in the evidence identified by a cross sectional study of clinical guidelines for management of patients who have had a stroke

• View inline

Table 2 shows the use of EPICOT+ for an unanswered question on the effectiveness of compliance therapy in people with schizophrenia, identified by the Database of Uncertainties about the Effects of Treatments.

Research recommendation based on a gap in the evidence on treatment of schizophrenia identified by the Database of Uncertainties about the Effects of Treatments

Discussions around optional elements

Although the group agreed that the PICO elements should be core requirements for a research recommendation, intense discussion centred on the inclusion of factors defining a more detailed context, such as current state of evidence (E), appropriate study type (s), disease burden and relevance (d), and timeliness (t).

Initially, group members interpreted E differently. Some viewed it as the supporting evidence for a research recommendation and others as the suggested study type for a research recommendation. After discussion, we agreed that E should be used to refer to the amount and quality of research supporting the recommendation. However, the issue remained contentious as some of us thought that if a systematic review was available, its reference would sufficiently identify the strength of the existing evidence. Others thought that adding evidence to the set of core elements was important as it provided a summary of the supporting evidence, particularly as the recommendation was likely to be abstracted and used separately from the review or research that led to its formulation. In contrast, the suggested study type (s) was left as an optional element.

A research recommendation will rarely have an absolute value in itself. Its relative priority will be influenced by the burden of ill health (d), which is itself dependent on factors such as local prevalence, disease severity, relevant risk factors, and the priorities of the organisation considering commissioning the research.

Similarly, the issue of time (t) could be seen to be relevant to each of the core elements in varying ways—for example, duration of treatment, length of follow-up. The group therefore agreed that time had a subsidiary role within each core item; however, T as the date of the recommendation served to define its shelf life and therefore retained individual importance.

Applicability and usability

The proposed statement on research recommendations applies to uncertainties of the effects of any form of health intervention or treatment and is intended for research in humans rather than basic scientific research. Further investigation is required to assess the applicability of the format for questions around diagnosis, signs and symptoms, prognosis, investigations, and patient preference.

When the proposed format is applied to a specific research recommendation, the emphasis placed on the relevant part(s) of the EPICOT+ format may vary by author, audience, and intended purpose. For example, a recommendation for research into treatments for transient ischaemic attack may or may not define valid outcome measures to assess quality of life or gather data on adverse effects. Among many other factors, its implementation will also depend on the strength of current findings—that is, strong evidence may support a tightly focused recommendation whereas a lack of evidence would result in a more general recommendation.

The controversy within the group, especially around the optional components, reflects the different perspectives of the participating organisations—whether they were involved in commissioning, undertaking, or summarising research. Further issues will arise during the implementation of the proposed format, and we welcome feedback and discussion.

Summary points

No common guidelines exist for the formulation of recommendations for research on the effects of treatments

Major organisations involved in commissioning or summarising research compared their approaches and agreed on core questions

The essential items can be summarised as EPICOT+ (evidence, population, intervention, comparison, outcome, and time)

Further details, such as disease burden and appropriate study type, should be considered as required

We thank Patricia Atkinson and Jeremy Wyatt.

Contributors and sources All authors contributed to manuscript preparation and approved the final draft. NJH is the guarantor.

Competing interests None declared.

• Richardson WS ,
• Wilson MC ,
• Nishikawa J ,
• Hayward RSA
• McManus RJ ,
• Leonardi-Bee J ,
• PROGRESS Collaborative Group
• Warburton E
• Rothwell P ,
• McIntosh AM ,
• Lawrie SM ,
• Stanfield AC
• O'Donnell C ,
• Donohoe G ,
• Sharkey L ,
• Jablensky A ,
• Sartorius N ,
• Ernberg G ,

Conclusions and Recommendations for Future Research

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Janssenswillen, G. (2021). Conclusions and Recommendations for Future Research. In: Unearthing the Real Process Behind the Event Data. Lecture Notes in Business Information Processing, vol 412. Springer, Cham. https://doi.org/10.1007/978-3-030-70733-0_10

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• GETTING STARTED
• Introduction
• FUNDAMENTALS
• Acknowledgements
• Research questions & hypotheses
• Concepts, constructs & variables
• Research limitations
• Getting started
• Sampling Strategy
• Research Quality
• Research Ethics
• Data Analysis

FUTURE RESEARCH

Types of future research suggestion.

The Future Research section of your dissertation is often combined with the Research Limitations section of your final, Conclusions chapter. This is because your future research suggestions generally arise out of the research limitations you have identified in your own dissertation. In this article, we discuss six types of future research suggestion. These include: (1) building on a particular finding in your research; (2) addressing a flaw in your research; examining (or testing) a theory (framework or model) either (3) for the first time or (4) in a new context, location and/or culture; (5) re-evaluating and (6) expanding a theory (framework or model). The goal of the article is to help you think about the potential types of future research suggestion that you may want to include in your dissertation.

Before we discuss each of these types of future research suggestion, we should explain why we use the word examining and then put or testing in brackets. This is simply because the word examining may be considered more appropriate when students use a qualitative research design; whereas the word testing fits better with dissertations drawing on a quantitative research design. We also put the words framework or model in brackets after the word theory . We do this because a theory , framework and model are not the same things. In the sections that follow, we discuss six types of future research suggestion.

Addressing research limitations in your dissertation

Building on a particular finding or aspect of your research, examining a conceptual framework (or testing a theoretical model) for the first time, examining a conceptual framework (or testing a theoretical model) in a new context, location and/or culture.

• Expanding a conceptual framework (or testing a theoretical model)

Re-evaluating a conceptual framework (or theoretical model)

In the Research Limitations section of your Conclusions chapter, you will have inevitably detailed the potential flaws (i.e., research limitations) of your dissertation. These may include:

An inability to answer your research questions

Theoretical and conceptual problems

Limitations of your research strategy

Problems of research quality

Identifying what these research limitations were and proposing future research suggestions that address them is arguably the easiest and quickest ways to complete the Future Research section of your Conclusions chapter.

Often, the findings from your dissertation research will highlight a number of new avenues that could be explored in future studies. These can be grouped into two categories:

Your dissertation will inevitably lead to findings that you did not anticipate from the start. These are useful when making future research suggestions because they can lead to entirely new avenues to explore in future studies. If this was the case, it is worth (a) briefly describing what these unanticipated findings were and (b) suggesting a research strategy that could be used to explore such findings in future.

Sometimes, dissertations manage to address all aspects of the research questions that were set. However, this is seldom the case. Typically, there will be aspects of your research questions that could not be answered. This is not necessarily a flaw in your research strategy, but may simply reflect that fact that the findings did not provide all the answers you hoped for. If this was the case, it is worth (a) briefly describing what aspects of your research questions were not answered and (b) suggesting a research strategy that could be used to explore such aspects in future.

You may want to recommend that future research examines the conceptual framework (or tests the theoretical model) that you developed. This is based on the assumption that the primary goal of your dissertation was to set out a conceptual framework (or build a theoretical model). It is also based on the assumption that whilst such a conceptual framework (or theoretical model) was presented, your dissertation did not attempt to examine (or test) it in the field . The focus of your dissertations was most likely a review of the literature rather than something that involved you conducting primary research.

Whilst it is quite rare for dissertations at the undergraduate and master's level to be primarily theoretical in nature like this, it is not unknown. If this was the case, you should think about how the conceptual framework (or theoretical model) that you have presented could be best examined (or tested) in the field . In understanding the how , you should think about two factors in particular:

What is the context, location and/or culture that would best lend itself to my conceptual framework (or theoretical model) if it were to be examined (or tested) in the field?

What research strategy is most appropriate to examine my conceptual framework (or test my theoretical model)?

If the future research suggestion that you want to make is based on examining your conceptual framework (or testing your theoretical model) in the field , you need to suggest the best scenario for doing so.

More often than not, you will not only have set out a conceptual framework (or theoretical model), as described in the previous section, but you will also have examined (or tested) it in the field . When you do this, focus is typically placed on a specific context, location and/or culture.

If this is the case, the obvious future research suggestion that you could propose would be to examine your conceptual framework (or test the theoretical model) in a new context, location and/or culture. For example, perhaps you focused on consumers (rather than businesses), or Canada (rather than the United Kingdom), or a more individualistic culture like the United States (rather than a more collectivist culture like China).

When you propose a new context, location and/or culture as your future research suggestion, make sure you justify the choice that you make. For example, there may be little value in future studies looking at different cultures if culture is not an important component underlying your conceptual framework (or theoretical model). If you are not sure whether a new context, location or culture is more appropriate, or what new context, location or culture you should select, a review the literature will often help clarify where you focus should be.

Expanding a conceptual framework (or theoretical model)

Assuming that you have set out a conceptual framework (or theoretical model) and examined (or tested) it in the field , another series of future research suggestions comes out of expanding that conceptual framework (or theoretical model).

We talk about a series of future research suggestions because there are so many ways that you can expand on your conceptual framework (or theoretical model). For example, you can do this by:

Examining constructs (or variables) that were included in your conceptual framework (or theoretical model) but were not focused.

Looking at a particular relationship aspect of your conceptual framework (or theoretical model) further.

Adding new constructs (or variables) to the conceptual framework (or theoretical model) you set out (if justified by the literature).

It would be possible to include one or a number of these as future research suggestions. Again, make sure that any suggestions you make have are justified , either by your findings or the literature.

With the dissertation process at the undergraduate and master's level lasting between 3 and 9 months, a lot a can happen in between. For example, a specific event (e.g., 9/11, the economic crisis) or some new theory or evidence that undermines (or questions) the literature (theory) and assumptions underpinning your conceptual framework (or theoretical model). Clearly, there is little you can do about this. However, if this happens, reflecting on it and re-evaluating your conceptual framework (or theoretical model), as well as your findings, is an obvious source of future research suggestions.

Implications or Recommendations in Research: What's the Difference?

• Peer Review

High-quality research articles that get many citations contain both implications and recommendations. Implications are the impact your research makes, whereas recommendations are specific actions that can then be taken based on your findings, such as for more research or for policymaking.

Updated on August 23, 2022

That seems clear enough, but the two are commonly confused.

This confusion is especially true if you come from a so-called high-context culture in which information is often implied based on the situation, as in many Asian cultures. High-context cultures are different from low-context cultures where information is more direct and explicit (as in North America and many European cultures).

Let's set these two straight in a low-context way; i.e., we'll be specific and direct! This is the best way to be in English academic writing because you're writing for the world.

Implications and recommendations in a research article

The standard format of STEM research articles is what's called IMRaD:

• Introduction
• Discussion/conclusions

Some journals call for a separate conclusions section, while others have the conclusions as the last part of the discussion. You'll write these four (or five) sections in the same sequence, though, no matter the journal.

The discussion section is typically where you restate your results and how well they confirmed your hypotheses. Give readers the answer to the questions for which they're looking to you for an answer.

At this point, many researchers assume their paper is finished. After all, aren't the results the most important part? As you might have guessed, no, you're not quite done yet.

The discussion/conclusions section is where to say what happened and what should now happen

The discussion/conclusions section of every good scientific article should contain the implications and recommendations.

The implications, first of all, are the impact your results have on your specific field. A high-impact, highly cited article will also broaden the scope here and provide implications to other fields. This is what makes research cross-disciplinary.

Recommendations, however, are suggestions to improve your field based on your results.

These two aspects help the reader understand your broader content: How and why your work is important to the world. They also tell the reader what can be changed in the future based on your results.

These aspects are what editors are looking for when selecting papers for peer review.

Implications and recommendations are, thus, written at the end of the discussion section, and before the concluding paragraph. They help to “wrap up” your paper. Once your reader understands what you found, the next logical step is what those results mean and what should come next.

Then they can take the baton, in the form of your work, and run with it. That gets you cited and extends your impact!

The order of implications and recommendations also matters. Both are written after you've summarized your main findings in the discussion section. Then, those results are interpreted based on ongoing work in the field. After this, the implications are stated, followed by the recommendations.

Writing an academic research paper is a bit like running a race. Finish strong, with your most important conclusion (recommendation) at the end. Leave readers with an understanding of your work's importance. Avoid generic, obvious phrases like "more research is needed to fully address this issue." Be specific.

The main differences between implications and recommendations (table)

Now let's dig a bit deeper into actually how to write these parts.

What are implications?

Research implications tell us how and why your results are important for the field at large. They help answer the question of “what does it mean?” Implications tell us how your work contributes to your field and what it adds to it. They're used when you want to tell your peers why your research is important for ongoing theory, practice, policymaking, and for future research.

Crucially, your implications must be evidence-based. This means they must be derived from the results in the paper.

Implications are written after you've summarized your main findings in the discussion section. They come before the recommendations and before the concluding paragraph. There is no specific section dedicated to implications. They must be integrated into your discussion so that the reader understands why the results are meaningful and what they add to the field.

A good strategy is to separate your implications into types. Implications can be social, political, technological, related to policies, or others, depending on your topic. The most frequently used types are theoretical and practical. Theoretical implications relate to how your findings connect to other theories or ideas in your field, while practical implications are related to what we can do with the results.

Key features of implications

• State the impact your research makes
• Helps us understand why your results are important
• Must be evidence-based
• Written in the discussion, before recommendations
• Can be theoretical, practical, or other (social, political, etc.)

Examples of implications

Let's take a look at some examples of research results below with their implications.

The result : one study found that learning items over time improves memory more than cramming material in a bunch of information at once .

The implications : This result suggests memory is better when studying is spread out over time, which could be due to memory consolidation processes.

The result : an intervention study found that mindfulness helps improve mental health if you have anxiety.

The implications : This result has implications for the role of executive functions on anxiety.

The result : a study found that musical learning helps language learning in children .

The implications : these findings suggest that language and music may work together to aid development.

What are recommendations?

As noted above, explaining how your results contribute to the real world is an important part of a successful article.

Likewise, stating how your findings can be used to improve something in future research is equally important. This brings us to the recommendations.

Research recommendations are suggestions and solutions you give for certain situations based on your results. Once the reader understands what your results mean with the implications, the next question they need to know is "what's next?"

Recommendations are calls to action on ways certain things in the field can be improved in the future based on your results. Recommendations are used when you want to convey that something different should be done based on what your analyses revealed.

Similar to implications, recommendations are also evidence-based. This means that your recommendations to the field must be drawn directly from your results.

The goal of the recommendations is to make clear, specific, and realistic suggestions to future researchers before they conduct a similar experiment. No matter what area your research is in, there will always be further research to do. Try to think about what would be helpful for other researchers to know before starting their work.

Recommendations are also written in the discussion section. They come after the implications and before the concluding paragraphs. Similar to the implications, there is usually no specific section dedicated to the recommendations. However, depending on how many solutions you want to suggest to the field, they may be written as a subsection.

Key features of recommendations

• Statements about what can be done differently in the field based on your findings
• Must be realistic and specific
• Written in the discussion, after implications and before conclusions
• Related to both your field and, preferably, a wider context to the research

Examples of recommendations

Here are some research results and their recommendations.

A meta-analysis found that actively recalling material from your memory is better than simply re-reading it .

• The recommendation: Based on these findings, teachers and other educators should encourage students to practice active recall strategies.

A medical intervention found that daily exercise helps prevent cardiovascular disease .

• The recommendation: Based on these results, physicians are recommended to encourage patients to exercise and walk regularly. Also recommended is to encourage more walking through public health offices in communities.

A study found that many research articles do not contain the sample sizes needed to statistically confirm their findings .

The recommendation: To improve the current state of the field, researchers should consider doing power analysis based on their experiment's design.

What else is important about implications and recommendations?

When writing recommendations and implications, be careful not to overstate the impact of your results. It can be tempting for researchers to inflate the importance of their findings and make grandiose statements about what their work means.

Remember that implications and recommendations must be coming directly from your results. Therefore, they must be straightforward, realistic, and plausible.

Another good thing to remember is to make sure the implications and recommendations are stated clearly and separately. Do not attach them to the endings of other paragraphs just to add them in. Use similar example phrases as those listed in the table when starting your sentences to clearly indicate when it's an implication and when it's a recommendation.

When your peers, or brand-new readers, read your paper, they shouldn't have to hunt through your discussion to find the implications and recommendations. They should be clear, visible, and understandable on their own.

That'll get you cited more, and you'll make a greater contribution to your area of science while extending the life and impact of your work.

The AJE Team

See our "Privacy Policy"

Suggestions for Future Research

Your dissertation needs to include suggestions for future research. Depending on requirements of your university, suggestions for future research can be either integrated into Research Limitations section or it can be a separate section.

You will need to propose 4-5 suggestions for future studies and these can include the following:

1. Building upon findings of your research . These may relate to findings of your study that you did not anticipate. Moreover, you may suggest future research to address unanswered aspects of your research problem.

2. Addressing limitations of your research . Your research will not be free from limitations and these may relate to formulation of research aim and objectives, application of data collection method, sample size, scope of discussions and analysis etc. You can propose future research suggestions that address the limitations of your study.

3. Constructing the same research in a new context, location and/or culture . It is most likely that you have addressed your research problem within the settings of specific context, location and/or culture. Accordingly, you can propose future studies that can address the same research problem in a different settings, context, location and/or culture.

4. Re-assessing and expanding theory, framework or model you have addressed in your research . Future studies can address the effects of specific event, emergence of a new theory or evidence and/or other recent phenomenon on your research problem.

My e-book,  The Ultimate Guide to Writing a Dissertation in Business Studies: a step by step assistance  offers practical assistance to complete a dissertation with minimum or no stress. The e-book covers all stages of writing a dissertation starting from the selection to the research area to submitting the completed version of the work within the deadline. John Dudovskiy

Improving the Nation's Water Security: Opportunities for Research (2007)

Chapter: 6 recommendations for future research directions, 6 recommendations for future research directions.

Progress has been made in the Environmental Protection Agency’s (EPA’s) water security research program (see Chapter 4 ), but many important research questions and technical support needs remain. In Chapter 3 , a framework is suggested for evaluating water security research initiatives that gives priority to research that improves response and recovery and/or develops risk reduction or consequence mitigation measures. The research should also produce tools with a reasonable likelihood of implementation and, where feasible, dual-use benefits. Based on this framework and the review of water security efforts already under way, two important water security research gaps are identified and discussed briefly in this chapter. In addition, short- and long-term water security research recommendations are made. The research recommendations are organized in this chapter according to the three long-term program objectives proposed in Chapter 5 emphasizing pre-incident, incident, and post-incident applications: (1) develop products to support more resilient design and operation of facilities and systems, (2) improve the ability of operators and responders to detect and assess incidents, and (3) improve response and recovery. Both drinking water and wastewater research priorities are addressed together within these three objectives to maximize research synergies that may exist.

KEY RESEARCH GAPS

The Water Security Research and Technical Support Action Plan (EPA, 2004a) set out a comprehensive guide for the EPA’s near-term research initiatives. Although the Action Plan was intended to provide a short-term (three- to four- year) research agenda, the previous National Research Council review (NRC, 2004) noted that several of the Action Plan projects represented long-term research questions not easily ad-

dressed in the original time frame. Therefore, the Action Plan provides a reasonable starting point for building the EPA’s future research program. Nevertheless, the short-term planning horizon of the Action Plan prevented consideration of two key subjects that are critical to a long-term water security research program: behavioral science and innovative system design. The committee recommends the EPA work in collaboration with other organizations to build research initiatives in these two areas.

Behavioral Science

The threat of bioterrorism presents new and different types of risks that are dynamic and pose difficult trade-offs, bringing about intellectual challenges and an emotional valence possibly more important than the risks themselves. Developing an effective communication strategy that meets the needs of the broad range of stakeholders (e.g., response organizations, water organizations and utilities, public health agencies, the public, the media) while addressing security concerns is clearly a high-priority research area. The EPA’s work on risk communication is focused primarily on the development of guidance, protocols, and training, and little emphasis has been devoted to interdisciplinary behavioral science research to better prepare stakeholders for water security incidents or to build confidence in their ability to respond. Behavioral science research could help address, for example, what the public’s beliefs, opinions, and knowledge about water security risks are; how risk perception and other psychological factors affect responses to water-related events; and how to communicate these risks with the public (Gray and Ropeik, 2002; Means, 2002; Roberson and Morely, 2005b). A better understanding of what short-term disruptions customers are prepared to tolerate may also guide response and recovery planning and the development of recovery technologies.

Previous experience with natural disasters and environmental risks provides a basis for investigating and predicting human behavior in risky situations (Fischoff, 2005). Existing models of human behavior during other kinds of crises, however, may not be adequate to forecast human behavior during bioterrorism or water security incidents (DiGiovanni et al., 2003).

Risk communicators consider empirical findings from psychology, cognitive science, communications, and other behavioral and social sciences to varying extents (Bostrom and Lofstedt, 2003). Although decision makers frequently predict panic and irrational behavior in times of

crisis, behavioral science researchers have found that people respond reasonably to such challenges (e.g., Fishoff, 2005). Given the urgency of terror risk communication, risk communicators are obliged to incorporate existing behavioral science research as it relates to water security risks.

The EPA should take advantage of existing behavioral science research that may be applicable to water security issues, but this requires knowledge and experience in behavioral science research. Where gaps exist, the EPA will need to engage in interdisciplinary, rigorous empirical research to obtain the necessary knowledge.

Innovative Designs for Secure and Resilient Water and Wastewater Systems

Innovative designs for water and wastewater infrastructure were not addressed in the EPA Action Plan, but the topic deserves a place in a long-term water security research program. The EPA’s research mission has traditionally included the development and testing of new concepts, technologies, and management structures for water and wastewater utilities to achieve practical objectives in public health, sustainability and cost-effectiveness. The addition of homeland security to its mission provides a unique opportunity to take a holistic view of current design and management of water and wastewater infrastructures. Innovation is needed to address the problem of aging infrastructures while making new water systems more resilient to natural hazards and malicious incidents. The EPA should, therefore, take a leadership role in providing guidance for the planning, design, and implementation of new, more sustainable and resilient water and wastewater facilities for the 21st century.

Disagreggation of large water and wastewater systems should be an overarching theme of innovation. Large and complex systems have developed in the United States following the pattern of urban and suburban sprawl. While there are clear economies of scale for large utilities in construction and system management, there are distinct disadvantages as well. The complexity of large systems makes security measures difficult to implement and complicates the response to an attack. For example, locating the source of incursion within the distribution system and isolating contaminated sections are more difficult in large and complex water systems. Long water residence times are also more likely to occur in large drinking water systems, and, as a result, disinfectant residual may be lacking in the extremities of the system because of the chemical and biological reactions that occur during transport. From a security perspec-

tive, inadequate disinfectant residual means less protection against intentional contamination by a microbial agent.

A breadth of possibilities exists for improving security through innovative infrastructure design. Satellite water treatment plants could boost water quality. Strategic placement of treatment devices (e.g., ultraviolet lamp arrays) within the distribution system could counter a bioterrorism attack. Wastewater treatment systems could be interconnected to provide more flexibility in case of attack, and diversion devices could be installed to isolate contaminants. Box 6-1 describes some of these concepts in greater detail, and specific research recommendations are suggested in the following section.

RESEARCH RECOMMENDATIONS: DEVELOP PRODUCTS TO SUPPORT MORE RESILIENT DESIGN AND OPERATION OF FACILITIES AND SYSTEMS

Specific research topics are suggested here in two areas to support development of more resilient water and wastewater systems: (1) innovative designs for water and wastewater and (2) improved methods for risk assessment, including processes for threat and consequence assessments.

Innovative Designs for Water and Wastewater Systems

Innovative changes to water infrastructure will require long-term investment in research. Existing systems have been in place for more than a century in older cities. Thus, bold new directions will understandably require intensive research at the outset to produce a defensible economic argument for change. On the other hand, the EPA has the opportunity to develop innovative approaches that can be implemented almost immediately in relatively new, as well as planned, urban and suburban areas. The first step in research would be to enumerate the opportunities for innovation, recognizing the constraints brought about by the size, age, and complexity of existing water and wastewater infrastructures. A broad-gauge, economic analysis should follow that would quantify the costs and multiple benefits of these innovative designs (e.g., increased security, improved drinking water quality, enhanced sustainability of water resources). In addition, there is an implicit need for EPA research-

ers to coordinate with the agency’s regulatory branch to validate the feasibility of the innovative concepts that are proposed.

Each of the infrastructure concepts illustrated in Box 6-1 require far more research to become feasible. The recommendations below outline specific research topics that, if addressed, could improve the safety and sustainability of water resources in the 21st century.

Disaggregation of Water and Wastewater Systems

The “distributed optimal technology network” (DOT-Net) concept (Norton and Weber, 2005; Weber, 2002; 2004) hinges upon the feasibility of distributed treatment via point-of-use (POU)/point-of-entry (POE) devices installed at the scale of individual buildings or perhaps small neighborhoods. The corollary premise is that installation of expensive advanced treatment technology at the centralized water treatment facility is unnecessary when only a fraction of the service area outside a “critical radius” requires additional protection. Only a broad economic analysis of this concept has been published thus far for a hypothetical urban center, but the assumptions need to be verified for actual systems, particularly because of the unique characteristics of individual cities. In addition, far more research is needed on the utility management required to ensure the reliability of POU/POE devices in widespread implementation.

Dual water systems have also been proposed to address aging infrastructure (see Box 6-1 ; Okun, 1997; 2005). As with the DOT-Net concept, long-term research is needed to determine the costs and benefits of constructing an entirely new paradigm for distribution system design. Research issues would include assessing the acceptability of reclaimed water for progressively more intense levels of nonpotable use (e.g., irrigation, toilet flushing, laundering), the acceptability and management demands of decentralized wastewater treatment facilities, and the net benefits to water security.

In-Pipe Interventions to Reduce Exposure

In-pipe engineering interventions (see Box 6-1 ) are deserving of research in a long-term water security research strategy. For example, research is needed to optimize the location of disinfection booster stations or to examine the effectiveness and feasibility of in situ ultraviolet (UV)

irradiation systems as a decontamination strategy. EPA research could also examine various pipe materials (e.g., stainless steel) and evaluate their benefits for security and sustainability relative to their costs.

Infrastructure Designs to Enable Isolation and Interconnection

Most large drinking water systems have the ability to isolate portions of their distribution systems during necessary system repairs, but security concerns provide a new impetus for rapid and effective isolation mechanisms. Research on innovative mechanisms to isolate or divert contaminated water in drinking water and wastewater systems would be useful. The EPA should identify these design options, research their costs and benefits (including dual-use benefits) and their feasibility both for existing systems and new infrastructure, and make this information available to system managers.

Improved Risk Assessments Procedures

A sound risk assessment process allows utilities to make better resource management decisions for enhancing their recovery capacity or security strategies to mitigate the consequences of an attack. The risk assessment process includes assessments of threat, consequences, and vulnerability. To date, most of the efforts to guide utilities in their own risk assessments have focused on vulnerabilities.

Threat Assessment

Water and wastewater utilities today are making resource management decisions related to security without adequate information about the nature and likelihood of threats to their systems. As discussed in Chapter 4 , the EPA has focused their efforts on identifying contaminant threats without conducting similarly detailed analyses of possible physical and cyber threats. Both the nature and likelihood of these threats are needed for efficient allocation of resources at the utility level and within the EPA’s research program. Improved threat assessment would require the EPA and/or a consortium of water experts to work closely with the intelligence community and local law enforcement agencies. Other national and federal laboratory expertise within the Department of Energy,

Department of Defense, and private-public community might be needed as well. Threat assessments for water and wastewater should be periodically reviewed to identify threat scenarios that should be added to the list and to remove those that are no longer a concern. The development of a threat assessment process for local water and wastewater utilities with current techniques used in other infrastructures would also be helpful, provided the threat information could be communicated to those who need it (ASME, 2004; Sandia National Laboratories, 2001).

Consequence Assessment

A consequence assessment should accompany the threat assessment within the risk assessment process. Consequence assessments would provide decision makers with information on the potential for fatalities, public health impacts, economic impacts, property damage, systems disruption, effects on other infrastructures, and loss of public confidence. Procedures for determining the expected consequences from an attack or natural disaster are not currently being systematically developed. As a result, water system managers do not have sufficient data to make decisions about the benefits of risk reduction relative to the costs. The development and application of a consequence assessment procedure would provide decision makers with information needed to decide whether to mitigate the consequences, upgrade with countermeasures, take steps to improve response and recovery capacity, and/or decide to accept the level of risk and take no further action. A fault tree analysis that includes, for example, options for redundant systems or contingency water supplies could provide vital information on whether to invest in security upgrades or less costly consequence mitigation strategies . Many of these approaches have already been developed for other infrastructures (e.g., Risk Assessment Methodology [RAM]-T for the high-voltage power transmission industry or RAM-D for dams, locks, and levees; see Sandia National Laboratories, 2001; 2002). A thorough review of other RAM methodologies could provide guidance for consequence assessment strategies that could be incorporated into the Risk Assessment Methodology for Water Utilities (RAM-W).

The EPA has worked to develop the AT Planner tool to assist utilities in assessing the consequences from physical attacks (see Chapter 4 ). While AT Planner has been validated against actual blast test data for nonwater systems, there remains significant uncertainty in the applicability of the modeling for water security because it has not been validated

against the structures specific to those systems. Therefore, the ongoing evaluation of AT Planner by the EPA and select water utility operators should include an assessment of the applicability of AT Planner for each of the critical and high-consequence components of a water system. The EPA and water utilities should then consider whether any additional validation testing is needed to determine specific failure modes of relevant water system components (e.g., actual storage tanks, pumps, water conduits, chlorine tanks) and possible countermeasures.

Summary of Research Priorities for Secure and Resilient Systems

Short-term priorities.

Develop an improved understanding of physical, cyber, and contaminant threats to water and wastewater systems, especially focusing on physical and cyber threats.

Communicate information on threats and consequences to water system managers through training and information exchange.

Develop an improved threat assessment procedure for water and wastewater utilities that will assist local utilities with their security and response planning.

Develop a process to assist local utilities in determining the consequences from physical, cyber, and contaminant attacks.

Update the risk assessment methodology for water systems to incorporate the latest approaches used in other industries, including developing credible threat descriptions and identifying cascading consequences.

Long-Term Priorities

Develop innovative design strategies for drinking water and wastewater systems that mitigate security risks and identify their costs and benefits in the context of public health, sustainability, cost-effectiveness, and homeland security. These designs might include:

In-pipe intervention strategies for drinking water systems,

Disaggregation of water and wastewater treatment facilities to achieve dual-use benefits, and

Designs that allow for interconnections and isolation.

Evaluate the need to validate AT Planner against structures specific to water systems.

Periodically review the EPA’s prioritized list of threats, contaminants, and threat scenarios to identify items that should be added to the list and remove items that are no longer a concern.

Continue development of technology transfer/training programs so that utilities understand the value of the EPA’s products for both homeland security incidents and natural disasters and know how to utilize the tools to their full extent.

Implementation of Priorities

Some of the research recommendations to support more resilient design and operation of drinking water and wastewater systems lie outside of the EPA’s traditional areas of expertise. To support the Action Plan efforts so far, the EPA has relied heavily on expert contractors to conduct this type of work. The EPA should continue to seek the relevant expertise of other federal agencies and national laboratories in these future efforts. However, the EPA will need to consider how best to balance intramural and extramural research funding to carry out this research, while maintaining appropriate oversight and input into the research activities (see also Chapter 5 ). Increasing staff expertise in some key areas, such as physical security, will be necessary to build a strong and well-rounded water security research program to support more resilient system design and operation.

RESEARCH RECOMMENDATIONS: IMPROVE THE ABILITY OF OPERATORS AND RESPONDERS TO DETECT AND ASSESS INCIDENTS

Suggestions are provided in this section for future research that should improve the ability of operators and responders to detect and assess water security incidents. Specific research suggestions in the areas of analytical methodologies and monitoring and distribution system modeling are discussed below.

Analytical Methodologies and Monitoring

Expanding existing analytical methods.

For some analytes of relevance to water security concerns, the available or approved detection methods are poor (e.g., some nonregulated analytes). More work needs to be done to expand existing methods to a broader range of analytes. For example, method 300.1 (EPA, 2000) covers only the common anions but could be extended to others, including toxic substances. The extension of existing methods to new analytes would allow a broader range of laboratories to expand their capabilities into the water security area.

Screening methods using conventional gas chromatography (GC) or high-performance liquid chromatography (HPLC) should also be investigated. Modern high-resolution chromatography combined with high-sensitivity detection (e.g., electron capture, fluorescence) is a powerful, yet accessible tool. Protocols should be developed to make the best use of these widely available capabilities. Software will have to be developed to facilitate the documentation of normal, background signals (fingerprint-type chromatograms). This background information can then be used to detect anomalies. Final protocols would have to be tested thoroughly against priority chemical contaminants. Chromatographic finger-prints have been used to monitor water supplies for nonintentional contamination, so this line of research would provide a dual benefit (D. Metz, Ohio River, personal communication, 2006; P. Schulhof, Seine River, personal communication, 2006).

Progress is being made with the protocol to concentrate samples and identify biological contaminants by polymerase chain reaction (PCR) analysis. Continued research, however, needs to be directed towards reducing the time and effort required to collect, process, and identify samples by automating portions of the protocol such as the concentration step. Such automated collection and sample processing systems would be especially valuable in response to security threats, when water samples could be channeled to existing or new detection technologies capable of onsite processing. The EPA should continue to expand the number of biothreat agents tested with the concentration/PCR protocol to include microbes other than spores, prioritizing test organisms that are both a threat to public health and resistant to chlorine (Morales-Morales, et al., 2003; Straub and Chandler, 2003). Continued testing of the concentration/PCR protocol should include various mixed suspensions of a target

microbe and background microbes to determine specificity of detection and various dilutions of the target microbe to determine sensitivity of detection. The protocol should also be tested on chloraminated water samples.

Developing New Monitoring Technologies

Chemical Detection. New chemical monitoring technologies for security-relevant analytes should be investigated. Examples include quartz crystal microbalance (QCM) sensors, microfluidic devices (lab-on-a-chip), ion-sensitive field-effect transistors (ISFETs), and larger-scale optrodes. Extramural agency and corporate partnerships developed by the EPA and longer-term research projects will help the evaluation and consideration of a broader range of detection platforms.

Biological Detection. Biological monitoring devices are essential to assess the type and extent of contamination in a suspected water security event. A broader range of innovative and developing detection technologies for biological agents, including methods that are field deployable and reagent-free, should be considered and evaluated. Innovative, field-deployable detection technologies (e.g., genetic fingerprinting, immunodetection, other technologies in development by universities, the Department of Defense, and industry) could reduce the time and effort for detection and enable earlier response efforts (Iqbal et al., 2000; Ivnitski et al., 2003; Lim et al., 2005; Monk and Walt, 2004; Yu and Bruno, 1996; Zhu et al., 2004). These new technologies might also increase the accuracy of detecting deliberate contamination events and reduce false alarms. Methods that can detect multiple biological agents and those with dual-use benefits should be emphasized over those methods limited to very specific agents (Peruski and Peruski, 2003; Rogers and Mulchandani, 1998). For example, DNA fingerprinting might be more useful than immunodetection systems dependent on a highly specific antibody for operation. The accuracy of these detection methods will depend on availability of quality reagents such as antibodies and primers; therefore, researchers will need to work closely with the Centers for Disease Control and Prevention (CDC) and other agencies that have access to such reagents.

Monitoring Devices for Wastewater Collection Systems . Contamination incidents have the potential to disrupt wastewater biological treat-

ment systems; thus, a long-term research program should also include research on monitoring technologies relevant to wastewater security concerns. Although a number of devices are available that can be used to monitor physical, chemical, and biological parameters, none of the currently available devices are robust or reliable enough when used in untreated wastewater to meet security requirements. The EPA should, therefore, encourage development of robust or reliable monitoring devices for wastewater infrastructure.

Syndromic Surveillance Tools. Syndromic surveillance tools may have the potential for detecting disease outbreaks and for investigating the possible role of water in such outbreaks (Berger et al., 2006). The EPA is already working to test two syndromic disease surveillance tools (RODS, ESSENCE) against prior water contamination outbreak data. There are substantive research needs that should be undertaken, however. Clearly, the improvement of existing syndromic surveillance tools is a long-term research objective. For syndromic surveillance to become worthwhile, it should achieve a favorable cost-benefit ratio considering the costs of false positives, and syndromic surveillance should also be adequately integrated into response plans. The implementation of syndromic surveillance systems on a large scale would require a more detailed linkage between disparate databases used in the public health sector and the water supply sector. Research to develop tools to allow local systems to readily fuse information from these disparate sources would be desirable. Such linkages would improve detection and response to waterborne disease outbreaks and more rapidly exclude water as a possible vehicle of disease. This would have important applications for both intentional and nonintentional water contamination events.

Real-Time Monitoring Systems

The development of a fully functional, easy-to-maintain, real-time monitoring system (RTMS) that could someday be used to prevent harm from deliberate attacks on the water system (“detect to prevent”), even with substantial research investments, is many years away. Therefore, the primary emphasis of future research on RTMSs, at least in the near term, should be on developing these technologies to assess the spread of contaminants, not to prevent exposure.

The committee also questions the likelihood of implementation of real-time monitoring devices for specific chemical or biological parame-

ters that are not useful in the day-to-day operation of a system (see Chapters 2 and 4 ). However, there are a few scenarios where implementation of continuous monitors for biological contaminants might be valuable, such as their use in certain water systems under heightened threat conditions (e.g., utilities for which specific intelligence information indicates they may be targeted). As discussed in Chapter 4 , deployment under these circumstances has a greater likelihood for success because the probability of an event is estimated to be much higher and the length of monitoring time is shortened. The use of highly sensitive and specific detection devices under such targeted circumstances would significantly lower the probability of false alarms and reduce the problem of poor positive predictive value (see Chapter 2 ) while also minimizing implementation and maintenance costs. Thus, improving monitoring systems for specific chemical or biological agents in drinking water is a valid long-term research goal. The EPA may find that longer-term research on more speculative sensor development could benefit from a further broadening of the circle of collaborators. Such speculative research may be more appropriately funded through the National Science Foundation or the Homeland Security Advanced Research Projects Agency, thus freeing up EPA resources for other purposes. To encourage such research, the EPA may wish to build its connections with the private sector on this technology.

Research on detection methods for RTMSs should proceed with careful consideration of the likelihood of implementation of the monitoring devices. In its near-term research plans, the EPA should adopt a first-stage approach to RTMSs, emphasizing generic sensors to detect intrusion or a system anomaly. The intrusion detection would then trigger more resource-intensive follow-up monitoring and analysis. Such an approach has significant dual-use benefits for routine contamination events that could outweigh the costs of implementing and operating these systems. Additional effort to develop cheaper, more accurate, and more easily deployable and maintainable sensors for routine water quality parameters would be useful both for anomaly detection and routine operation. Additional research is also needed, even in first-stage RTMSs, to understand normal water quality variations and distinguish variations that might be caused by a deliberate contamination attack. For example, continuous monitoring of chlorine residual at multiple points in the distribution system often reveals wide variations at different temporal scales due to changes in water demand that affect water residence time (e.g., operation of storage tanks). Although some work to understand inherent water quality variability in distribution systems is being conducted through the

Water Sentinel program, a significant amount of work is needed to translate the findings of this research into criteria for RTMSs to develop systems that have a reasonable likelihood of implementation.

An important component of RTMS research should include data fusion, whereby multiple anomalies must occur before an alarm signal is sent (see also Chapter 4 ). The private sector seems to be taking the lead on many types of multiparameter approaches to RTMSs and the processing of data, especially as described by contaminant or event signatures. It is important that the algorithms are open to peer review and can be accessed by all for development of new and refined approaches.

RTMS sensor research should consider a broader range of technologies, including full-spectrum UV and visible absorption, fluorescence excitation emission matrices, and ionization sensors (Alupoaei et al., 2004; Fenselau and Demirev, 2001; Lay, 2001). Many of these techniques are used as nonspecific chromatography detectors, and as such, they are highly sensitive. Most prototype RTMSs are composed of existing sensors that are designed to measure a specific contaminant, and some technologies have been excluded because they have not led to sensors with a high degree of selectivity. However, RTMSs need not be contaminant-specific; they only need to detect anomalies. Detection of an anomaly can then be followed by more specific contaminant analyses.

The problem of false positive signals from real-time contaminant-specific warning systems has been discussed in Chapter 2 . In essence, the problem is one of unfavorable arithmetic when the probability of a true positive is very small, as it would be for an intentional contamination attack on any particular water system of the tens of thousands of such systems. Therefore, most contaminant-specific alarm signals will be false positives. The EPA should consider the consequences of various rates of false positive signals for both large and small utilities and collect information on how alarms are currently handled by utilities. Workshops and structured surveys on this issue would provide valuable information on current practices, the extent to which positive signals are confirmed, the costs of false alarms, and the views of utility operators on their tolerance for various levels and types of false alarms. This research would provide useful guidance for the developers of water quality monitoring devices, for utilities that are considering implementing devices that are commercially available, and for local and state regulatory agencies who will need assistance interpreting alarm signals in light of the public health consequences.

Technology Testing

The EPA has developed a rigorous technology testing program to provide security product guidance to end users focusing on monitoring and decontamination technology. However, as noted in Chapter 4 , the number of relevant security technologies and agents of interest exceed the capacity and budget of the Technology Testing and Evaluation Program (TTEP). Therefore, developing a test-prioritization plan for TTEP seems especially important and is strongly recommended. Although the process of identifying technologies of interest has begun through the use of stakeholder meetings and advisory boards, activities to date have been weighted toward doing the easiest things first, and only some of these tests provided dual-use benefits. Balancing the homeland security benefits and the benefits to routine water system operations in TTEP will likely require additional strategic planning. One strategy has been to test equipment that is commercially available regardless of whether it addresses a high-risk agent. Instead, the EPA should look beyond the easy-to-identify commercially available equipment and make a greater effort to identify technologies in development that have the potential to address those agents identified as posing the greatest risk to water, considering the likelihood of the threat (including the ease of acquiring particular chemical or biological agents), the potential consequences, and the likelihood of implementing the technology. For a few of the highest-priority threats, the EPA may wish to consider providing technical support and/or funding to encourage more rapid development of a particularly promising technology that has a high likelihood of implementation and significant dual-use benefits, similar to the EPA Superfund Innovative Technology Evaluation (SITE) Emerging Technology Program.

Develop Laboratory Capability and Capacity

Adequate laboratory capacity is critical for responding to a terrorist incident affecting water supplies, and although this is not a research issue, the EPA has much to contribute from an applied perspective. The need for mobile analysis units capable of supplementing local laboratories and rapidly responding to geographical areas impacted by terrorist events should be considered. Such mobile laboratories could also address analytical needs that arise during natural catastrophes, such as Hurricane Katrina. Many states have begun to develop mobile laboratory

capabilities as part of their water security activities, and the EPA could glean information on their experiences to date.

The EPA is working with utilities and state and federal agencies to build a national laboratory response network for water sample analysis (i.e., the Water Laboratory Alliance). Some university laboratories may have capabilities that could merit inclusion in the nationwide network. Other laboratories may be stimulated to conduct additional research on improved analytical methods for toxic and biothreat agents if they were better informed of the current state of knowledge and had access to reference standards (access to some reference standards is currently limited due to security concerns). To be successful, a dual-use philosophy should be adopted whenever possible in the development of laboratory capacity (e.g., employing methods/instruments that can also be used for standard analytes).

Distribution System Modeling Tools

Distribution system models provide valuable tools for locating the source of contamination or assessing the spread if the source is known, estimating exposure, identifying locations for sampling, and developing decontamination strategies (see also Chapter 4 ). Distribution system models also have important dual-use applications to routine water quality concerns, and the EPA should continue to emphasize the dual-use value of its modeling tools. Specific recommendations are provided below to advance the capabilities and implementation of the Threat Ensemble Vulnerability Assessment (TEVA) and EPANET models.

Experimental Verification of Species Interaction Subcomponent Models

The final goal of producing a more flexible EPANET model through Multi-Species EPANET (MS-EPANET) is commendable. However, the new subcomponents are based upon developing better fundamental knowledge of reactions within the distribution system involving chemistry (e.g., disinfection kinetics, chemical partitioning), biology (e.g., development of biofilms, release and attachment of microbes), and materials science (e.g., corrosion of pipe materials and its relationship to disinfection efficacy). The large number of system constants in both MS-EPANET and TEVA necessitate significant investment in sensitivity

analysis research to quantify the accuracy of model predictions. The development and testing of all new features of MS-EPANET should be a long-term research goal. Until the validity of these subcomponents is verified and system constants can be assigned with more certainty, the water industry will be reluctant to use the full capability of MS-EPANET. Limitations in the accuracy of model predictions will need to be addressed in guidance to decision makers. A significant commitment will be needed in resources for experimental verification.

Alternate Approaches to Uncertainty Modeling

The Action Plan acknowledges correctly that the distribution system model simulations should incorporate an analysis of uncertainty because the point of attack is unknown. This has led to the use of the well-known Monte Carlo analysis to randomize the location of the attack and run repeated distribution system model simulations (1,000 or more) to generate a probability distribution to relate point of attack to human exposure impact. The focus on short-term results, however, has produced weaknesses in the current EPA approach to uncertainty research.

A broader discussion about how to incorporate uncertainty into the TEVA model should be invited. Approaches such as fuzzy logic (McKone and Deshpande, 2005) and Bayesian Maximum Entropy modeling (Serre and Christakos, 1999) are showing promise but have been applied mainly to homogenous space rather than to network domains. The EPA should encourage alternative ideas for handling uncertainty. If the expertise is not available within the agency, there needs to be a mechanism to expand extramural support for research, particularly within the university community.

Technology Transfer and Training in Use of the TEVA and EPANET Models

Advances in the TEVA model add significant complexity to the EPANET model, which may limit its widespread implementation. The EPA should work to communicate the capabilities of EPANET, MS-EPANET, and TEVA to utilities, emphasizing their value for routine water quality concerns, advanced homeland security planning, and contamination assessment and response activities. Until TEVA and MS-EPANET are further developed and widely available, the EPA should

consider an interim strategy to better inform water utilities on the value and use of existing distribution system models, such as EPANET. Progressive water utilities are already using EPANET to examine possible locations of attack and to track the concentration of contaminants within the distribution system.

Training in the use of MS-EPANET and the proposed TEVA model is also needed. Water utility managers need to be convinced that the costs for adapting a new model for their respective distribution systems are worthwhile, because many utilities have already invested heavily in development, verification, and calibration of existing models. The complexity of the TEVA model may increase these costs further, because many more implementation steps follow those for EPANET to adapt the TEVA “template” to the specifics of each water utility.

Summary of Research Priorities for Better Equipping Operators to Detect and Assess Incidents

Automate the concentration step of the concentration/PCR protocol.

Continue to test the concentration/PCR protocol:

Expand the number of biothreat agents tested to four or five organisms that include microbes other than spores, focusing on microbes that are both a threat to public health and resistant to chlorine.

Test the concentration/PCR protocol with chloraminated water samples.

Test the concentration/PCR protocol to determine sensitivity and specificity of detection.

Field-test RTMSs to determine false positive/false negative rates and maintenance requirements and develop basic criteria for the technology that might lead to a reasonable likelihood of implementation.

Continue research to develop a first-stage RTMS based on routine water quality sensors with dual-use applications.

Analyze the consequences of false positive signals from realtime monitoring systems, emphasizing current practices, the extent to which positive signals are confirmed, the costs of false alarms, and the tolerance of utility operators for false alarms.

Test standard chromatographic methods for their ability to screen for a broad range of toxic agents in routine laboratory testing.

Develop a test-prioritization strategy for TTEP to optimize the resources devoted to this effort.

Invite external peer review of the TEVA model before investing in field testing.

Long-term Priorities

Continue to develop portable, field-deployable systems that can be used to collect and process samples at event locations.

Formulate protocols and develop software for using GC- and HPLC-based fingerprinting to detect suspicious anomalies.

Stimulate research and ultimately development of new sensors for water security analytes based on innovative technologies, such as QCM, ISFETS, and microfluidics.

Evaluate and develop new field-deployable detection technologies for biological agents, including genetic fingerprinting, immunodetection, and reagentless technologies, that have the necessary sensitivity, specificity, and multiplex capabilities.

Develop improved, cheaper, and accurate RTMSs for routine water quality measurements.

Examine the use of nonspecific detection technologies for RTMSs.

Develop data fusion approaches for RTMSs that can minimize false positives.

Develop and test new monitoring technologies suitable for wastewater security applications.

Improve syndromic surveillance tools and develop a health surveillance network with appropriate linkages to water quality monitoring.

Continue to develop and refine the efficiency of a system-wide laboratory response network, including the development of mobile analysis units.

Continue fundamental research to understand the chemical and biological reactions that affect the fate and transport of contaminants in distribution systems to verify the constants used in MS-EPANET and TEVA.

Include alternative approaches to uncertainty design (e.g., fuzzy logic, Bayesian Maximum Entropy) in the TEVA model that are based more strongly upon stochastic than deterministic principles given that many of the input parameters to the current TEVA model are highly uncertain.

Develop projects for training water utilities in the value and use of EPANET, MS-EPANET, and TEVA.

Some of these research priorities may be more appropriately accomplished by universities, companies, or other agencies that have the necessary expertise, resources, and funding to successfully complete these tasks. The development of multiplex detection protocols and portable, field-deployable platforms are examples of tasks that might be better managed by some group other than the EPA. Work to determine the sensitivity and specificity of designated protocols for different biothreat agents could be conducted by university laboratories or private industry, with collaborative input from the EPA, considering their understanding of the needs of the water sector. Utilization of research resources outside the EPA would expand the variety of emerging, innovative analytical technologies that might be used to support the EPA’s efforts in enhancing the nation’s water security.

RESEARCH RECOMMENDATIONS: IMPROVED RESPONSE AND RECOVERY

Recommendations are provided in this section for future research that should improve response and recovery after a water security incident. Research suggestions related to tools and data for emergency planning and response, contingencies, risk communication and behavioral sciences, decontamination, and lessons learned from natural disasters are presented below.

Tools and Data for Emergency Planning and Response

Continued development of emergency response databases.

The EPA released preliminary versions of the Water Contamination Information Tool (WCIT) and the Consequence Assessment Tool (CAT) to provide data on contaminant properties, toxicity, and exposure threats (see Chapter 4 ), but the databases are still in their infancy, and numerous data gaps exist. The EPA will need to prioritize its continued efforts to further develop these response databases. Therefore, the EPA should develop strategic plans for WCIT and CAT, outlining the long-term goals for the databases and addressing questions such as:

What stakeholders will be served by the databases?

What categories of information do these stakeholders need?

How many contaminants should be included?

What linkages to other databases should be established?

The EPA will need to determine criteria for prioritizing what contaminants are added to the database and how to maintain and update the information. If WCIT and CAT are not continually revised to incorporate the latest scientific knowledge, the databases will become outdated. Expanding or even maintaining a database requires considerable resources, both intellectual and financial. If a commitment is not made initially for the necessary resources to update and maintain a database, spending the resources to create it becomes debatable. The EPA is currently facing similar issues maintaining its Integrated Risk Information System (IRIS) database.

The EPA should also clearly define the data quality objectives for WCIT/CAT and incorporate peer review of the data, as necessary, to meet these objectives. For example, the EPA may decide that some information about a contaminant is better than none, even if that information has limitations. This is a legitimate approach; however, the EPA should provide a mechanism that helps to ensure that individuals using the databases understand the data quality and their limitations. One mechanism for accomplishing this would be to add quality notations for each datum. Regardless of the approach taken, the EPA needs to describe the extent to which the data have been reviewed.

Evaluation and Improvement of Tools and Databases

With the forthcoming completion of at least the first stages of many tools and databases (e.g., WCIT, CAT), the EPA should consider the evaluation/improvement cycle. This will require the development of procedures to evaluate the utility and usability of these tools by potential constituencies. In addition, the EPA should take advantage of the tests afforded in response to “real-life” incidents. For example, some of the tools and databases were used (albeit in an early stage of their development) in the response to Hurricane Katrina. A formal assessment of knowledge gained from this experience could assist in the improvement and development of the tools.

Filling Data Gaps

The state of knowledge of the health risks from water contaminants that could be used in a malicious event is quite limited, as shown by the limited number of chemicals and even fewer biologicals in the WCIT/CAT databases and the many blank data fields in these databases. Important experimental and computational research is under way at the EPA to address some of these data gaps (see Chapter 4 , Section 3.6), but many gaps remain. There are two applications of toxicity/infectivity information that would be useful to the EPA for response and recovery efforts. The first is development of guidance for dissolved concentrations that would pose an immediate acute risk to exposed individuals, analogous to the inhalation immediate danger to life and health values of the National Institute for Occupational Safety and Health. The EPA is currently working on this problem by developing a database on acute and

chronic health effects associated with priority contaminants, although much work remains to be done. The second is guidance for determining the appropriate “acceptable” level remaining after cleanup/decontamination. This second aspect has not yet been strongly emphasized in the EPA research program. It is recommended that the EPA convene a working group to develop research and prioritization strategies for filling these data gaps and for ascertaining current gaps in knowledge with respect to rapid estimation of toxicity/infectivity in the absence of specific experimental information. Decisions for setting priorities for the data gathering efforts should be made with full consideration of dual-use benefits.

Contingencies for Water System Emergencies

Further study of water supply alternatives should be a high priority, considering their pivotal role in response and recovery and their dual-use applications for natural disasters or system failures. However, the subject of water supply contingencies seems to have been given a low priority in the EPA’s research program to date. Completion of the work in progress should be the first priority. The committee debated the value of investing significant resources in developing technologies that could supply drinking water for large communities over long-term disruptions because of the rarity of the need for such technologies. Nevertheless, the EPA should draw upon the research and development efforts of the Department of Defense in this area and work to test the application of these technologies to water security scenarios.

The EPA should consider including new research on contingencies for failures of the human subsystem in water system security. Such research could examine current practices for identifying back-up operators in the case of widespread incapacitation in both short-term and long-term scenarios. This research could also identify best practices, which could be incorporated into EPA guidance to water utilities for their emergency response planning.

Preliminary research suggests that geographic information systems (GIS) could be of significant value to utilities for identifying contingencies in the event of system failures. Therefore, further efforts may be needed to inform utilities about the value of GIS for emergency response and provide guidance for integrating GIS into their emergency planning procedures. National geodata standards may be needed to promote consistency and facilitate data exchange among users.

Behavioral Sciences and Risk Communication

The National Homeland Security Research Center (NHSRC) has made substantial progress in the development of risk communication guidance and training (see Chapter 4 ), but very little emphasis has been devoted to research on understanding how the public may respond to risk communication messages and how to improve communication of risks to the public. Terrorism presents risks that are new, evolving, and difficult to characterize; thus, water security poses communication challenges that should be addressed using scientifically rigorous research in the fields of risk communication and behavioral sciences. The EPA should continually reassess the role risk communication has in its overall risk management framework and fully integrate risk communication efforts into the overall risk management program. Behavioral science and associated risk communication research should be a high priority in the EPA’s future water security research plans. The following recommendations are targeted toward water-security events, but the proposed research has dual benefits for improving non-security-related communications with the public.

Analysis of Factors that Build Trust and Improve Communication

Research and experience prove that one of the most important keys to communication success is an organization’s ability to establish, maintain, and increase trust and credibility with key stakeholders, including employees, regulatory agencies, citizen groups, the public, and the media. To improve overall communication strategies in a water-related emergency, research is needed that analyzes factors that build trust and reduce fear (e.g., What types of concerns do people have related to public health emergencies, water security issues, or bioterrorism? How do utilities build trust and credibility with the public around water security incidents?). In addition, research is needed to analyze methods to counter and reduce the possibility of misinformation or false information being distributed to the public and key stakeholders.

Understanding Institutional Behavior

Building response and recovery capacity requires agencies that might be involved in a water security event to develop stronger working relationships. Although water utilities, public health agencies, law enforcement, emergency responders, and the media do not have a long history of collaborating and working together, several state drinking water programs have taken the lead in carrying out tabletop exercises as well as on-the-ground exercises to address this issue. These state programs have also undertaken measures to facilitate an understanding of the roles and responsibilities of the various potential players, including federal, state, and local law enforcement; state and local health agencies; state and local emergency response agencies; and water utilities. The EPA could glean useful information from these ongoing state and local activities. Nevertheless, additional research is needed to better understand the culture of the agencies that will be responding to events, how these agencies will interact in a water-related crisis, and what level of effort is needed to maintain collaboration in planning and preparedness. This research could identify barriers to more effective collaboration, and these findings could be used to create training scenarios that could improve coordination and resolve potential conflicts in advance. This research is a short-term priority given the importance of coordinated interaction during a crisis. The research could be performed relatively quickly because there is a wealth of experiences, particularly at the state level, related to agency interactions in water-related crises.

Investigate Applicability of Research in Behavioral Science

While some of the recommended research on risk communication and behavioral science may need to be managed by the EPA to address specific water security-related issues, the EPA should also take advantage of other behavioral science research currently being conducted through university-based partnerships, including those established by the Homeland Security Centers of Excellence program. For example, the University of Maryland’s National Consortium for the Study of Terrorism and Responses to Terror (START) is conducting original research on issues that are poorly understood, including risk perception and communication, household and community preparedness for terrorist attacks, likely behavioral responses by the public, social and psychological vulnerability to terrorism, and strategies for mitigating negative psychologi-

cal effects and enhancing resilience in the face of the terror threat. The START center is also synthesizing existing research findings in order to provide timely guidance for decision makers and the public, paying special attention to how diverse audiences react to and are affected by threats and preparedness efforts.

In addition, the CDC has developed a national network of 50 Centers for Public Health Preparedness (CPHP) to train the public health workforce to respond to threats to our nation's health, including bioterrorism. These centers work to strengthen terrorism preparedness and emergency public health response at the state and local level and to develop a network of academic-based programs contributing to national terrorism preparedness and emergency response capacity. Information from the CPHP may be relevant and useful to the water sector.

Pretesting Risk Communication Messages

Although the message mapping workshops are a good start to assist stakeholders in preparing messages that will be relevant in a water security incident, the messages have not been tested and evaluated. Therefore, the EPA should engage the research community in pretesting messages being developed by the Center for Risk Communication so that case studies and scenarios can be analyzed for effectiveness in reaching key audiences, and problems can be corrected in advance. Sophisticated evaluation techniques and standard research procedures are used by the CDC to pretest public messages. This evaluation research should be based on standard criteria established in the risk communication literature (e.g., Mailback and Parrott, 1995; National Cancer Institute, 2002; Witte et al., 2001).

Analysis of the Risks and Benefits of Releasing Security Information

The decision of when to release or withhold water security information is critical to the development of a risk communication strategy. Therefore, the EPA should analyze the risks and benefits of releasing water security information, considering input from its broad range of constituents, and develop transparent agency guidance on when to release information versus when to withhold it due to security concerns.

The committee considers this a priority because of the difficulty and importance of the information sharing problem.

Water-Related Risk Communication Training

As the lead U.S. agency in water system security, the EPA should assume the responsibility for developing a national training program on water-related risk communication planning and implementation for water managers. This should be done in collaboration with the water and wastewater organizations, state government agencies, public health officials, health care officials, and others engaged in communication of risks during water-related emergencies.

Decontamination

Decontamination research is critical to improving response and recovery, and the products are applicable to address unintentional contamination events from natural disasters (e.g., hurricanes, floods, earthquakes) and routine malfunctions (e.g., pipe breaks, negative pressures due to power losses). The EPA has numerous ongoing projects in this area that should be completed, but additional research topics are also suggested below.

Addressing Data Gaps

EPA decontamination research products released thus far have shown that fundamental physical, chemical, and/or biological characteristics of many threat agents of concern are not yet known. Therefore, additional laboratory research is needed related to the behavior of contaminants in water supply and wastewater systems and methods for decontaminating water infrastructure. For example, one research priority would be to develop inactivation rate data for all microbes of concern with both free and combined chlorine strategies, because both approaches are used in the water industry. Rate and equilibrium data for adsorption/desorption of contaminants on pipe walls is also needed, although the EPA could also take advantage of existing databases on structure-activity relationships to predict these behaviors. Long-term re-

search, perhaps in partnership with other Office of Research and Development units, could enhance our understanding of the fate, transport, and transformation of toxics in water and wastewater environments.

Decontamination Strategies

The EPA should build on its ongoing work in the area of decontamination and address gaps in the current knowledge base. For example, research is needed to examine readily available household inactivation methods for biological agents (including spore-formers), such as microwaving. The EPA should also work to further the development of innovative decontamination technologies that address important water security concerns. Research and development on new POU/POE technologies, such as superheated water devices, could help overcome operational disadvantages of the products currently on the market.

Prioritizing Future Surrogate Research

Surrogates are relevant to numerous water security research applications, including research on contaminant fate and transport, human exposure risks, and decontamination. Research is ongoing to identify surrogates or simulants for biological agents, to determine which surrogates are appropriate, and to determine the ability of typical drinking water disinfection practices (chlorination and chloramination) to inactivate those agents (see Chapter 4 , Section 3.2). Much of the research has focused on Bacillus anthracis and other bacterial agents, but the EPA should determine if surrogates for research on biotoxins and viruses are needed and whether additional surrogates are needed for other bacterial agents. A viral simulant or surrogate would be helpful to examine virus survival in fresh water, drinking water, and sewage, as well as virus susceptibility to water disinfectants. Research in this area has relevance to viral bioterrorism agents and also has strong dual-use research applications because viral surrogates could facilitate risk assessment studies on natural viruses (e.g., SARS, avian influenza).

Surrogate research is a laborious experimental process (see Box 4-1 ) that must be conducted in one of the few laboratories already authorized to keep and work with select agents. Considerable research is required to compare the select agent with candidate surrogates under the experimental conditions of interest. As discussed in Chapter 4 , surrogates need not

mimic in all respects the agents they stand in for. For some important security or decontamination uses, it may only be necessary that they provide an appropriate bound on the characteristic of interest in the target agent (e.g., persistence, disinfectant sensitivity). Therefore, the EPA should carefully consider and prioritize the agents and the research applications for which surrogates are needed. The prioritization process for surrogates should consider the following:

Which types of research could be greatly facilitated through the availability of surrogates?

Which types of research with surrogates might have “dual-use” applications (i.e., could the properties of certain surrogates also be usefully extrapolated to other common organisms)?

Which types of research should be done only with select agents?

How closely should the surrogate properties of interest match that of the target organism?

What are the costs and benefits to the research program associated with surrogate development versus use of the pathogenic agents?

The EPA should engage a limited number of individuals (e.g., federal partners, academics) who are involved in similar research in this prioritization process.

Lessons Learned from Natural Disasters

Midway through the committee’s work, NRC (2005; see Appendix A ) suggested the EPA take advantage of experience gained in the aftermath of Katrina so as to improve future response and recovery efforts for water security. While a hurricane caused this catastrophe, it is conceivable that a similar result might have occurred if the levees had been destroyed by terrorist explosives. Thus, New Orleans offered a living laboratory to study many aspects of the impacts of a disaster on water and wastewater systems of all sizes. Failure modes, infrastructure interdependencies, decontamination and service restoration strategies, the availability of alternative supplies, communication strategies, and the ability to service special institutions (e.g., hospitals) and special needs individuals could all have been examined in the immediate aftermath of the hurricane. To the best of the committee’s knowledge, however, the EPA has not attempted to compile a knowledge base from this experience. As

time passes, it will become increasingly difficult to reconstruct what transpired. Other natural or manmade disasters, such as the earthquakes in California in 1989 and 1994 or the “Great Flood of 1993” in the Mid-west, or natural contamination events, such as the Milwaukee C ryptosporidium outbreak, may also offer opportunities to mine important data about the failure or recovery of water and wastewater systems, but detailed information on these earlier occurrences may be lacking. In the future, the NHSRC should be poised to seize opportunities for learning about response and recovery after major natural or man-made disasters affecting water or wastewater systems.

Summary of Research Priorities for Improving Response and Recovery

Determine strategic plans for managing and maintaining the WCIT/CAT databases, considering the likely uses and long-term goals for the databases.

Develop and implement a strategy for evaluating the utility and usability of the response tools and databases, including stakeholder feedback and lessons learned during their use under “real-life” incidents.

Convene a working group to develop research strategies for filling the data gaps in WCIT/CAT and other planned emergency response databases.

Contingencies for Water Emergencies

Complete the work in progress on contingencies and infrastructure interdependencies under Section 3.5 of the Action Plan.

Test and evaluate the most promising innovative water supply technologies that enable or enhance the short- or long-term delivery of drinking water in the event of systemic failure of water systems. Analyze the positive features and those areas needing improvement prior to full-scale deployment.

Conduct research on potential contingencies for failures of the “human subsystem.”

Analyze factors that build trust, reduce fear, and prevent panic to improve overall communication strategies in a water-related emergency.

Investigate the behavioral science research being conducted by the Homeland Security University Centers of Excellence and other federal agencies for applicability to the water sector.

Pretest messages being developed by the Center for Risk Communication and analyze case studies and scenarios for effectiveness.

Analyze the risks and benefits of releasing security information to inform the EPA’s risk communication strategies and its practices on information sharing.

Fully integrate risk communication efforts into the overall risk management program and provide adequate resources that ensure these efforts remain a high priority in the EPA’s future water security research program.

Conduct research to better understand how agencies will interact in a water-related crisis situation and determine what strategies will be most effective in encouraging and maintaining collaboration in planning and preparedness.

Complete the many decontamination projects in progress under Section 3.4 of the Action Plan.

Develop predictive models or laboratory data for inactivation of bioterrorism agents in both free chlorine and chloramines that can be used in MS-EPANET and the TEVA model.

Explore development and testing of new POU/POE devices that may overcome the disadvantages of existing devices.

Examine readily available household inactivation methods for biological agents (including spore-forming agents), such as microwaving.

Determine the costs and benefits of further research to identify additional surrogates, considering which agents under which conditions or applications should be prioritized for surrogate development research.

Use the remaining data from the experience of Hurricane Katrina to analyze the optimal response and recovery techniques (e.g., water supply alternatives, contingency planning, and infrastructure interdependencies) that would also apply to water security events.

Integrate experience with decontamination of the distribution system in New Orleans after Hurricane Katrina to improve EPA guidance for water security decontamination.

Evaluate risk communication strategies related to Hurricane Katrina or other past disaster events to determine if communication strategies related to drinking water safety reached the most vulnerable populations.

Develop a post-event strategy for learning from future natural disasters affecting water systems. This strategy should support on-site assessments of impacts and interdependencies and evaluations of successes and failures during response and recovery.

Continue to develop and maintain the WCIT/CAT databases according to the objectives set forth in the strategic database management plan. Incorporate a mechanism to provide on-going peer review of the data to meet its data quality objectives.

Continue experimental and computational research to fill critical data gaps in WCIT/CAT, including research on the health effects of both acute and chronic exposure to priority contaminants.

Develop new, innovative technologies for supplying drinking water to affected customers over both short- and long-term water system failures.

Risk Communication and Behavioral Sciences

Develop a program of interdisciplinary empirical research in behavioral sciences to better understand how to prepare stakeholders for water security incidents. The EPA should support original research that will help address critical knowledge gaps. For example:

What are the public’s beliefs, opinions, and knowledge about water security risks?

How do risk perception and other psychological factors affect responses to water-related events?

How can these risks be communicated more effectively to the public?

Develop a national training program on water-related risk communication planning and implementation for water managers.

Continue laboratory research to fill the data gaps related to behavior of contaminants in water supply and wastewater systems and methods for decontaminating water infrastructure.

Continue surrogate research based on the research prioritization determined in collaboration with an interagency working group. The EPA should also explore ways that this surrogate research could assist in responding to everyday agents or to other routes of exposure (e.g., inhalation, inactivating agents on surfaces).

The EPA has historically been a lead federal agency in understanding the fate and transport of contaminants in the environment and has a clear understanding of the practical concerns of the water sector. Thus, the EPA remains the appropriate lead agency to develop the tools for emergency response and to prioritize the research needed to fill the remaining gaps, with input from key stakeholders. The EPA is also well suited to develop a national training program on water-related risk communication and to evaluate lessons learned from Hurricane Katrina and other past disaster events. However, innovative technology development research, such as the development of novel technologies for supplying water during system failures, should be conducted by other agencies,

university researchers, or firms with the greatest expertise. The EPA, instead, should focus its efforts on harvesting information on existing technologies, synthesizing this information for end users, and providing guidance to developers on unique technology needs for water security. Behavioral science research and evaluation research is more appropriately conducted by universities or other federal agencies (e.g., CDC) that have the necessary expertise to complete these tasks. However, the EPA still needs in-house behavioral science experts able to supervise and use this work to best advantage.

CONCLUSIONS AND RECOMMENDATIONS

In this chapter, recommendations are provided for future research directions in the area of water security. Two key water security research gaps—behavioral science and innovative future system design—that were not considered in the short-term planning horizon of the Action Plan are identified. In accordance with the committee’s charge (see Chapter 1 ), short- and long-term water security research priorities are presented in three areas: (1) developing products to support more resilient design and operation of facilities and systems, (2) improving the ability of operators and responders to detect and assess incidents, and (3) improving response and recovery.

The EPA should develop a program of interdisciplinary empiri cal research in behavioral science to better understand how to pre pare stakeholders for water security incidents. The risks of terrorism are dynamic and uncertain and involve complex behavioral phenomena. The EPA should take advantage of existing behavioral science research that could be applied to water security issues to improve response and recovery efforts. At the same time, when gaps exist, the EPA should support rigorous empirical research that will help address, for example, what the public’s beliefs, opinions, and knowledge about water security risks are; how risk perception and other psychological factors affect responses to water-related events; and how to communicate these risks effectively to the public.

The EPA should take a leadership role in providing guidance for the planning, design, and implementation of new, more sustainable and resilient water and wastewater facilities for the 21st century. Given the investments necessary to upgrade and sustain the country’s water and wastewater systems, research on innovative approaches to make the infrastructure more sustainable and resilient both to routine and

malicious incidents would provide substantial dual-use benefits. The EPA should help develop and test new concepts, technologies, and management structures for water and wastewater utilities to meet objectives of public health, sustainability, cost-effectiveness, and homeland security. Specific research topics related to drinking water and wastewater, such as decentralized systems and in-pipe interventions to reduce exposure from contaminants, are suggested.

Recommended research topics in the area of supporting more resilient design and operation of drinking water and wastewater systems include improved processes for threat and consequence assessments and innovative designs for water and wastewater. A thorough and balanced threat assessment encompassing physical, cyber, and contaminant threats is lacking. To date, the EPA has focused its threat assessments on contaminant threats, but physical and cyber threats deserve more attention and analysis because this information could influence the EPA’s future research priorities and utilities’ preparedness and response planning.

Research suggestions that improve the ability of operators and responders to detect and assess incidents build upon the EPA’s current research in the areas of analytical methodologies and monitoring and distribution system modeling. In the short term, the EPA should continue research to develop and refine a first-stage RTMS based on routine water quality parameters with dual-use applications. Long-term research recommendations include the development of innovative detection technologies and cheaper, more accurate RTMSs. To support the simulation models in development, a substantial amount of fundamental research is needed to improve understanding of the fate and transport of contaminants in distribution systems. Based on the number of emerging technologies and agents of interest, the EPA should develop a prioritization strategy for technology testing to optimize the resources devoted to this effort.

Recommendations for future research priorities to improve response and recovery emphasize the sustainability of tools for emergency planning and response (e.g., WCIT/CAT) and improving research on water security contingencies, behavioral sciences, and risk communication. The EPA should also evaluate the relative importance of future laboratory work on surrogate development and address data gaps in the knowledge of decontamination processes and behavior. So far, the EPA has not taken advantage of the many opportunities from Hurricane Katrina to harvest lessons learned related to response and recovery, and the window of opportunity is rapidly closing.

Some of the research recommendations provided in this chapter lie outside of the EPA’s traditional areas of expertise. The EPA will need to consider how best to balance intramural and extramural research funding to carry out this research, while maintaining appropriate oversight and input into the research activities. Increasing staff expertise in some key areas, such as physical security and behavioral sciences, will be necessary to build a strong and well-rounded water security research program.

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• Open access
• Published: 20 May 2024

Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

• Andrea Lavinio 1 , 2 ,
• Jonathan P. Coles 1 , 2 ,
• Chiara Robba 3 ,
• Marcel Aries 4 , 5 ,
• Pierre Bouzat 6 ,
• Dara Chean 7 ,
• Shirin Frisvold 8 , 9 ,
• Laura Galarza 10 ,
• Raimund Helbok 11 , 12 ,
• Jeroen Hermanides 13 ,
• Mathieu van der Jagt 14 ,
• David K. Menon 1 , 2 ,
• Geert Meyfroidt 15 ,
• Jean-Francois Payen 6 ,
• Daniele Poole 16 ,
• Frank Rasulo 17 ,
• Jonathan Rhodes 18 ,
• Emily Sidlow 19 ,
• Luzius A. Steiner 20 ,
• Fabio Silvio Taccone 21 , 22 &
• Riikka Takala 23 , 24  

Critical Care volume  28 , Article number:  170 ( 2024 ) Cite this article

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Aims and scope

The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and require admission to the intensive care unit for intracranial pressure (ICP) management.

A group of 18 international neuro-intensive care experts in the acute management of TBI participated in a modified Delphi process. An online anonymised survey based on a systematic literature review was completed ahead of the meeting, before the group convened to explore the level of consensus on TTC following TBI. Outputs from the meeting were combined into a further anonymous online survey round to finalise recommendations. Thresholds of ≥ 16 out of 18 panel members in agreement (≥ 88%) for strong consensus and ≥ 14 out of 18 (≥ 78%) for moderate consensus were prospectively set for all statements.

Strong consensus was reached on TTC being essential for high-quality TBI care. It was recommended that temperature should be monitored continuously, and that fever should be promptly identified and managed in patients perceived to be at risk of secondary brain injury. Controlled normothermia (36.0–37.5 °C) was strongly recommended as a therapeutic option to be considered in tier 1 and 2 of the Seattle International Severe Traumatic Brain Injury Consensus Conference ICP management protocol. Temperature control targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.

Conclusions

Based on a modified Delphi expert consensus process, this report aims to inform on best practices for TTC delivery for patients following TBI, and to highlight areas of need for further research to improve clinical guidelines in this setting.

Introduction

Traumatic brain injury (TBI) is a complex and heterogeneous disease, and a major cause of death and disability globally [ 1 , 2 , 3 ]. Amongst other common neurological diseases, TBI is estimated to have the highest prevalence and incidence, impacting up to 60 million people worldwide annually and representing a substantial public health burden [ 4 ].

TBI is defined as an alteration in brain function or other evidence of brain pathology caused by an external force [ 5 ], and requires immediate and sustained management strategies to optimise clinical outcome. The injury processes that follow from a TBI are divided into two stages: primary and secondary [ 6 ], where primary injury refers to the damage caused by the original physical impact, which can trigger a pathophysiological cascade resulting in secondary injury with deleterious effects on neurological outcome and survival [ 7 , 8 ]. In order to prevent or mitigate secondary injury, immediate treatment following severe TBI focuses on the prevention of further brain damage. As the brain remains susceptible to secondary injury from processes that extend beyond the zone of primary injury such as ischaemia, oedema, herniation, seizures and altered metabolism [ 9 ], immediate treatment following severe TBI focuses on prevention or mitigation of such injury. This is achieved through the control of intracranial pressure (ICP), and prompt treatment of systemic insults such as hypoxia, hypercapnia, and systemic hypotension [ 10 ].

In the neuro-intensive care unit (NICU), fever is a prevalent occurrence with heterogenous underlying causes, and it may contribute to secondary injury. Across patients with TBI, subarachnoid haemorrhage and stroke [ 11 , 12 , 13 ], hyperthermia has been found to increase the risk of complications and is believed to be associated with unfavourable clinical outcome including death [ 9 , 11 , 14 , 15 ].

Targeted temperature control (TTC) is a complex intervention that aims to control body or brain temperature to prevent further brain injury and improve neurological outcome [ 9 ]. The term TTC may refer to different degrees of temperature control, from fever prevention, maintenance of normothermia to the induction of hypothermia, at different levels [ 9 , 16 ]. In TBI, TTC can be used to modulate a range of important physiological parameters such as cerebral metabolism and ICP. However, its role in improving long-term outcome, as well as the appropriate indications, targets and duration of TTC in severe or moderate TBI are currently unknown.

This work aims to utilise a Delphi approach to develop best-practice consensus recommendations from international experts for the real-world application of TTC in severe TBI with ICP guided treatments.

Review of the literature and evidence quality assessment

Statements and questions were informed by a systematic review of the literature, which identified observational studies, meta-analyses and randomised controlled trials (RCTs) relevant to the topics under discussion. This review search focused on evidence released since 2013. Following this first review, the methodology group of ESICM conducted an independent systematic review of the literature, considering only published RCTs regarding TTC in TBI patients with ICP monitoring. This review confirmed the paucity of RCTs and the substantial clinical heterogeneity between them, which precluded meta-analytical combination. The outputs from the reviews were shared with the expert panel members ahead of the Delphi process. A detailed reporting of the literature reviews is provided as Additional files 1 and 4 .

Participants

The 18 expert attendees for the Delphi process were chosen from members of three professional societies: the Neuro Anaesthesia and Critical Care Society (NACCS), the European Society of Intensive Care Medicine (ESICM), and the European Society of Anaesthesiology and Intensive Care (ESAIC). Selection was based on a documented history of publications in the fields of traumatic brain injury and/or targeted temperature management, as well as their established professional profiles and expertise as leading intensive care practitioners in teaching university hospitals. We endeavoured to ensure balanced representation, covering the geographic areas of the EU, Switzerland, and the UK.

Delphi rounds

A modified Delphi consensus method was employed, involving a combination of an online survey (Round 1), a face-to-face meeting (Round 2), an additional online survey containing the refined questions from the previous steps, (Round 3) and post-meeting reviews of the consensus results. The questions asked at Round 1 can be found in the Additional file 2 , and the results following Round 3 are shown in Table  1 . Round 1 was conducted via the SmartSurvey® online platform, and Round 2 was held as a hybrid meeting in London, UK, on Tuesday 10th October 2023. AL acted as Chair, with an independent facilitator (ES) moderating the meeting. After the results from the final survey of Round 3 were received, the recommendations and final manuscript were developed, with documents shared by e-mail and feedback collected independently from each participant by the facilitator. The predefined agreed cut-off for strong consensus was to have ≥ 16 out of 18 (≥ 88%) of panel members in agreement, and for moderate consensus was to have ≥ 14 out of 18 (≥ 78%) of panel members in agreement. The Delphi methodology and process was adopted from the manuscript published by Lavinio et al. [ 17 ]. In a Delphi process, conflicting opinions are addressed through a structured framework that promotes consensus-building among experts. Initially, participants are asked to provide their views anonymously, which are then summarised and shared with the group. This approach facilitates open and unbiased input, as the anonymity helps mitigate the influence of dominant personalities or hierarchical pressures. When conflicting opinions emerge, they are documented and presented back to the participants, along with any common ground that has been identified. In subsequent rounds, individuals are encouraged to reconsider their positions in light of the collective feedback, which often leads to a convergence of opinions. If discrepancies persist, these are explored through further iterative rounds, with an emphasis on clarifying rationale and seeking areas of agreement. The Delphi method's iterative nature, combined with the feedback mechanism, effectively manages conflicting opinions by fostering a gradual move towards consensus, or at least a clearer understanding of the points of divergence. The process for the Delphi panel and subsequent manuscript development is visualised in Fig.  1 . A detailed overview of the iterative Delphi process is provided in the Additional files 2 and 3 .

Summary of the Delphi process. ESAIC European Society of Anaesthesiology and Intensive Care, ESICM European Society of Intensive Care Medicine, NACCS Neuro Anaesthesia and Critical Care Society

Definitions

To guide discussions during the Delphi process, clinical terms were defined with the values as shown below.

Declarations and conflicts of interest

The face-to face meeting in London was supported by Becton, Dickinson and Company (“BD”) through the provision of travel costs, meeting space and refreshments. Representatives from BD were allowed to silently observe the conference, without any interaction with the panellists or the process. No donors or other outside parties influenced any portion of these recommendations. There was no industry input into recommendation development, and no panel member received honoraria for their involvement. Panellists completed conflict of interest forms relevant to TBI management. There were no conflicts mandating recusal of any participant. No funding was provided by the societies involved.

The results of the final consensus are presented in Table  1 . We highlight and expand upon statements in which consensus was reached in the discussion section. Some consideration is added to statements in which consensus was not reached, proposing them as potential areas for valuable future research.

To date, there is a lack of definitive evidence regarding the use of TTC with an automated feedback-controlled device for managing temperature in severe TBI. This underlines the importance of consensus discussion in identifying areas of uncertainty where evidence is lacking, and in encouraging harmonised care delivery across different settings.

Pathophysiology

Temperature measurement and control is an essential aspect of high-quality care in patients with severe TBI

In patients with impending cerebral herniation, temperature control is essential

As an introduction to the discussions, the group debated the recommendation for temperature measurement and control following severe TBI and, after extensive discussion, concluded that core temperature measurement and control is essential for the provision of high-quality care, especially in patients perceived to be at high risk of secondary brain injury. Noting the phrasing of ‘temperature control’ in the recent guidelines for temperature control following cardiac arrest [ 18 ], the group agreed that as an entry point into high-quality care following TBI, the notion of temperature measurement and control is key, opening the door to the full practice of targeted temperature management. This nuanced phrasing was intended to set the scene for the group’s work, with the specifics of the TTC process such as temperature ranges and duration of control being addressed throughout the remainder of the discussions.

Highlighting the wealth of physiological data available on the management of temperature in stroke and cardiac arrest, the group noted that the guidelines for temperature management in TBI are less specific. Fundamentally, the group agreed that high-quality TBI care does include monitoring temperature and implementing some form of temperature control, recognising its potential role in optimising outcome. The group highlighted the importance of treatment titration based on an individualised risk–benefit assessment and stratification. In particular, it was noted that in patients with exhausted intracranial compensatory reserve and at risk of cerebral herniation or ischaemia—there exists an extreme susceptibility to secondary brain injury precipitated by suboptimal temperature control.

Cerebral herniation is a life-threatening event that requires early diagnosis and prompt management in order to prevent irreversible pathological cascades that can lead to death [ 19 ]. Increases in brain temperature have been linked to a linear rise in ICP, with the relationships between temperature, ICP and cerebral perfusion pressure (CPP) becoming more apparent with rapid temperature changes. The impact of temperature on ICP supports the recommendation from the group that temperature control is an essential aspect of care in patients at risk of herniation [ 20 ]. The group agreed that while control of ICP and prevention of herniation were important reasons for TTC in TBI, benefits of TTC in the acute phase of TBI also extended to patients without intracranial hypertension.

During the discussions the group highlighted that different pathologies often dictate different patient management. For example, patients in whom fluctuations in ICP are well-tolerated (e.g., patients with high intracranial compliance) will be managed differently to patients with obliterated basal cisterns, obliterated cortical sulci, and midline shift (e.g., intracranial mass effect). In patients with exhausted intracranial volume-buffering reserve, strict control of physiological parameters such as CO 2 and temperature, is strongly recommended.

Continuous temperature monitoring is preferable over intermittent temperature measurements in patients with severe TBI.

Monitoring core temperature (e.g., bladder, oesophageal, brain) is strongly recommended over measuring or monitoring superficial temperature (e.g., skin, tympanic) in severe TBI.

When brain temperature monitoring is in place, it is advisable to assess an additional source of core temperature monitoring (i.e. oesophageal, bladder).

The group widely agreed, in line with supporting literature, that continuous temperature monitoring is preferable over intermittent temperature measurements with severe TBI. Intermittent monitoring and recording of temperature can result in large fluctuations in temperature being missed, as highlighted by supporting literature investigating the use of TTC following cardiac arrest, TBI and stroke [ 17 , 21 , 22 ].

Discussions amongst the group drew attention to the fact that inaccurately measured temperatures can negatively impact patient care and outcome. Several temperature monitoring sites are available for TTC, and the group widely agreed that core temperature measurements, i.e., bladder and oesophageal sites, are strongly preferred over superficial measurements such as those taken at skin and tympanic sites. Following acknowledgement of their limitations [ 23 ], bladder and oesophageal were singled out as favoured core temperature measurements. The group acknowledged the widespread use of oesophageal probes due to their relative ease of insertion and the challenges of finding MRI compatible bladder probes. Confirmation of preference between the two was acknowledged as being beyond the scope of the group due to these nuances. Rectal temperature monitoring was widely regarded as impractical for reasons such as the lag time and a high rate of dislocation [ 16 , 23 ]. Peripheral sites were unanimously deemed to be insufficiently accurate to guide temperature treatment [ 16 ].

Some panel members argued that monitoring target organ (i.e. brain) temperature could add a layer of clinical safety, improve pathophysiological understanding and allow selective and individualised titration of treatment (i.e. selective brain cooling). It was, however, agreed by the group that more research is needed into optimum methods for measuring brain temperature and its interpretation from both a clinical and resource-availability perspective. In particular, it was highlighted that temperature thresholds for harm are less well defined for brain temperature than core temperature. When brain temperature monitoring is available and in place, the group advised that core temperature should also be assessed with bladder or oesophageal probes since this is part of routine practice and has been studied to a greater extent than brain temperature. The group noted the importance of having a dual source of temperature monitoring when using automated TTC devices to reduce the risk of probe malfunction and subsequent over or undercooling [ 24 ].

After TBI, brain temperature has often been shown to be higher than systemic temperature and can vary independently, with literature noting a difference of as much as 2 °C depending on the individual characteristics of brain pathology and/or probe location, making a consistent and accurate link between the two challenging and possibly inaccurate [ 25 , 26 ]. The group highlighted that targeting brain temperature may allow precise titration of treatment dose, including titration of selective brain cooling with brain temperature management technologies, theoretically reducing side effects associated with systemic hypothermia, whilst delivering neuroprotection and brain temperature management. However, it was concluded that further research is needed in this regard and that not enough evidence exists to support practical recommendations.

ICP management

Temperature control is a key component of ICP management in severe TBI.

Controlled normothermia (i.e., target core temperature 36.0–37.5 °C) should be included as an addition to the Tier 1 and Tier 2 treatments defined within the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) 2019 guidelines.

Therapeutic hypothermia (i.e., target core temperature ≤ 36.0 °C) should be considered in cases where tier 1 and 2 treatments (as per SIBICC guidance) have failed to control ICP.

If hypothermia is considered to control ICP, target temperature should be managed as close to normothermia as possible.

ICP monitoring remains a critical component in the management of severe TBI [ 27 , 28 ]. The group unanimously agreed that temperature control is a key aspect of managing ICP, highlighting that an increase in temperature can lead to an increase in cerebral metabolism and augmented cerebral blood flow, and a simultaneous increase in cerebral blood volume. In cases of exhausted compensatory mechanisms, these factors can precipitate intracranial hypertension [ 20 ], which in turn can have a deleterious effect on overall outcome.

Because there is often no single pathophysiological pathway of ICP elevation, its management is complex. The most recent versions of the Brain Trauma Foundation TBI guidelines do not contain treatment protocols, in part due to a lack of solid evidence around the relative efficacy of available interventions [ 27 ]. To address this, the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) developed a consensus-based practical algorithm for tiered management of severe TBI guided by ICP measurements [ 28 ].

One of the most impactful outcomes from this consensus meeting was the acknowledgement of the essential role of temperature control for ICP management in severe TBI, and the recommendation that controlled normothermia (i.e., target core temperature 36.0–37.5 °C) should be considered in addition to Tier 1 and Tier 2 treatments. The group was keen to harmonise this output with SIBICC by suggesting a more aggressive and specific management with the addition of controlled normothermia in Tiers 1 and 2, adding a layer of clinical safety beyond merely the avoidance of fever over 38.0 °C in Tier 0, as shown in Fig.  2 . In cases when hypothermia is considered (i.e., SIBICC Tier 3), the group recommended that target temperature be managed as close to normothermia as possible, based on an individualised risk–benefit assessment [ 29 ].

Intracranial pressure management algorithm for severe TBI edited from SIBICC 2019 [ 28 ]. * Including TTC in tiers 1 and 2 is the suggested addition from the TTC-TBI group to the original SIBICC tiers (green bars). *When possible, the lowest tier should be used. It is not necessary to use all modalities in a previous tier before moving to the next tier. Consider repeat CT and surgical options for space occupying lesions. CPP cerebral perfusion pressure, CT computed tomography, EEG electroencephalography, Hb haemoglobin, kPa kilopascal, mmHg milimetre of mercury, PaCO 2 arterial partial pressure of carbon dioxide, SpO 2 arterial oxygen saturation

No consensus was reached on whether hypothermia was a viable temporising strategy in patients with impending cerebral herniation, in patients awaiting haematoma evacuation or decompression, or before consideration of barbiturate coma. Whilst the group acknowledged that therapeutic hypothermia can be effective in reducing ICP, there was no consensus on whether this could be induced rapidly enough in these circumstances, and it was felt that insufficient evidence was available to provide pragmatic recommendations on its indication in these extreme clinical circumstances.

Whilst the majority of experts indicated 35.0 °C as the lowest target temperature to be considered in these circumstances, no consensus was reached. The discussion highlighted that insufficient evidence exists to support practical recommendations and highlighted the importance of an individualised risk–benefit assessment. It was also noted that centres might have a varying degree of familiarity with different therapeutic options, including ease of access to neurosurgical options (i.e. ventricular drainage, decompression) and this may have an impact on clinician preference for hypothermia as a temporising therapeutic modality.

The group also discussed the indication of barbiturates in the context of ICP control following severe TBI, not reaching consensus on whether therapeutic hypothermia should be attempted before considering barbiturates. The group noted that both barbiturate-induced burst-suppression and therapeutic hypothermia have distinctive side effects and concluded that no recommendations for standard clinical practice could be made beyond what was already stated in SIBICC guidance.

Neurogenic fever (core temperature > 37.5 °C) driven by neurological dysregulation in the absence of sepsis or a clinically significant systemic inflammatory process is relatively common in TBI, and it should be promptly detected and treated (i.e., with controlled normothermia targeting 36.0 °C to 37.5 °C), irrespective of ICP level.

Controlled normothermia should be considered when pyrexia is secondary to sepsis or inflammatory processes, and when the patient is perceived to be at risk of secondary brain injury, especially in the acute phase of TBI.

Uncontrolled fever (neurogenic or secondary to inflammation or infection) can precipitate secondary brain injury in patients with severe TBI.

It was widely agreed that neurogenic fever, defined here as core temperature > 37.5 °C driven by neurological dysregulation in the absence of sepsis or a clinically significant inflammatory process is common in intensive care and it has been found to be associated with an increased risk of complications and unfavourable outcome [ 9 , 14 , 15 ]. In the setting of neurogenic fever developing in comatose patients with acute traumatic encephalopathies, controlled normothermia targeting 36.0–37.5 °C was recommended in tier 1 and 2 of the ICP management algorithm.

Correctly differentiating central fever against fever of infectious origin is both challenging and clinically important due to the impact of failing to identify a treatable condition, the negative consequences of antibiotic overuse, and the detrimental effect of hyperthermia on brain-injured patients [ 17 , 30 , 31 ]. However, the group noted that physiological processes such as brain metabolic rate of oxygen, CO 2 control, brain tissue oxygenation (P bt O 2 ) and ICP are directly related to temperature, and that the deleterious effects and likelihood of secondary injury may occur irrespective of whether temperature is raised due to infection or impaired thermoregulation. This therefore highlights the need for acute management of temperature regardless of the source of the pyrexia, although added focus must be placed on the management of nuanced patient characteristics such as those with severe TBI with impending herniation and/or obliterated basal cisterns, as opposed those with low ICP and preserved intracranial compliance.

In line with current research [ 9 , 11 , 32 ], it was agreed that the development of fever is common in TBI cases, and that it can precipitate secondary brain injury and adversely affect patient outcome. It is therefore of utmost importance to prevent or promptly treat fever when detected. The group agreed that while some degree of controlled pyrexia may be allowed during the subacute phase of disease, ‘uncontrolled’ fever requires urgent management in the acute phase as long as the patient is still perceived to be at significant risk of secondary brain injury.

Fever control is recommended in patients with severe TBI who have seizures or are perceived to be at high risk of seizures.

In patients with severe TBI who are sedated and ventilated, controlled normothermia, irrespective of ICP, should be initiated reactively when fever is detected.

When neurogenic fever is detected in TBI cases, controlled normothermia should be continued for as long as the brain remains at risk of secondary brain damage.

The group strongly recommended that fever control and controlled normothermia are of particular relevance in patients perceived to be at high risk of seizures and, more in general, secondary brain injury. The assessment of whether an individual patient should be considered ‘at risk of seizures’ or ‘at risk of secondary brain injury’ remains the responsibility of the managing physician. The group defined risk factors for seizures as a history of seizures, the presence of temporal contusions or depressed skull fractures. Features associated with a higher ‘risk of secondary brain injury’ included labile ICP, obliterated basal cisterns, midline shift or subfalcine herniation, and other signs of exhausted intracranial volume buffering reserve. While no consensus was reached on a specific temperature range to target during controlled normothermia, the group agreed that the reactive initiation of temperature control was important in sedated and ventilated TBI patients, with agreement on a pragmatic setting of a target core temperature range of 36.0–37.5 °C to accommodate expected fluctuations of ± 0.5 °C while avoiding spikes over 38.0 °C [ 28 ].

Hypothermic TTC induction

It is recommended that the rapid induction of hypothermia in traumatic brain injury cases should be achieved with automated feedback-controlled temperature management devices.

In line with current research [ 17 ], the group widely agreed on the reactive use of an automated feedback-controlled device for the application of optimal TTC. The TTC process can be divided into three phases: induction, maintenance, and rewarming [ 9 , 16 ]. As explained in existing literature, varying availability of devices and financial aspects may dictate choice, and while non-automated methods of temperature control are cheaper and easier to apply, the level of control offered is poor and their use should be limited to the induction phase, as adjuncts to automated devices. [ 17 , 33 ] Whilst antipyretics such as acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs (NSAIDs) are widely acknowledged in intensive care unit (ICU) settings for their role in fever management, it is recognised that in the context of severe TBI, the efficacy of antipyretics in controlling fever and minimising temperature variability is limited. The application of therapeutic hypothermia requires constant monitoring of core body temperature in order to achieve an accurate target temperature during induction to prevent overcooling, to assess variations during the maintenance phase, and to ensure a steady, controlled rewarming phase [ 16 ].

There was no agreed recommendation from the group as to whether ICUs should stock readily available ice-cold NaCl solutions of different concentrations for the management of ICP crises, citing a lack of clear evidence to draw upon. The group did however highlight the fact that the rapid infusion of ice-cold saline is an inexpensive and readily available option for lowering core body temperature [ 9 ], with the rapidity of response to ice-cold infusions being regarded as a valuable aspect of TTC induction.

TTC maintenance

An automated feedback-controlled TTC device that enables precise temperature control is desirable for the initiation of TTC and maintenance at target temperature in patients with severe TBI.

The maximum temperature variation that a patient should experience during normothermia is less than or equal to +/− 0.5 °C per hour and ≤ 1 °C per 24-hperiod

When hypothermia is indicated, treatment should be continued for as long as the brain is considered to be at risk of secondary brain injury.

Automated feedback-controlled devices for TTC are powerful tools, encouraging the delivery of quality care and aiming to improve neurological outcome [ 13 , 17 ], minimising the chances of temperature variability. Temperature variability is the deviation of patient temperature outside of the goal, typically reported as mean deviation or percent of time outside of target [ 9 ]. The group noted that there is a level of pragmatism to be adopted in TTC maintenance, discussing that while more time spent in fever can negatively impact neurological outcome, fluctuations in temperature may also affect outcome [ 17 ], and consensus was reached on the importance of maintaining temperature at as consistent a level as possible with the group settling on a fluctuation range of less than or equal to ± 0.5 °C per hour and ≤ 1 °C per 24-h period. In instances where an automated feedback-controlled device is not available, the group noted the importance of increased staff awareness of patient status to ensure fluctuations outside of this range are appropriately managed. The group highlighted that a dedicated protocol for sedation, analgesia and shivering management might be helpful to ensure consistent application of optimal TTC.

The group agreed that when indicated, hypothermia should be continued for as long as the individual practitioner considers the brain to be at risk of secondary injury. These considerations were supported with a suggestion that it should be maintained for as short a time as possible.

Rewarming following hypothermic TTC

Obtaining an interval scan and/or an alternative assessment of intracranial compliance, in addition to the absolute number of ICP, is recommended before rewarming.

Rebound hyperthermia should be prevented whenever possible or promptly treated in cases when the brain is perceived to be at risk of secondary brain injury.

In cases in which the patient is being rewarmed from therapeutic hypothermia (core temperature lower than 36.0 °C), the group agreed that once ICP has been maintained within controlled limits and de-escalation of treatment intensity is considered, it is sensible to ensure the patient has sufficient intracranial volume buffering reserve through the use of an interval scan and/or an alternative measure of intracranial compliance, before commencing the rewarming process. The group also noted the high prevalence and potential risks associated with rebound hyperthermia when TTC is discontinued following therapeutic hypothermia, highlighting the importance of continued vigilance and careful temperature control in the rewarming phase.

Whilst no consensus was reached on recommended rewarming rates, the group agreed that controlled rewarming with an automated feedback-controlled device may reduce the risk of rapid temperature variations and rebound pyrexia that can precipitate secondary brain injury and compromise care [ 16 , 33 ]. The group highlighted how controlled rewarming may improve the ability of clinicians to more effectively control important inter-dependent clinical variables such as PaCO 2 , ventilation settings and depth of sedation.

TTC for shivering

It is important to assess, document and manage shivering in severe TBI patients.

Whenever ICP is labile and shivering is detected, neuromuscular blockers should be considered after ensuring appropriate depth of sedation.

In self-ventilating patients in the subacute phase of severe TBI, an individualised risk–benefit assessment should be undertaken regarding the strict indications of controlled normothermia.

Permissive hyperthermia should be considered in cases where risk of secondary brain injury resulting from pyrexia is thought to be low, and when shivering cannot be controlled with first line treatments such as NSAIDs, opiates, magnesium or counter warming.

In line with current literature, it was widely agreed that shivering should be managed in patients following severe TBI. Shivering can reduce brain tissue oxygenation leading to cerebral metabolic stress, which may therefore negate the neuroprotective benefits of TTC [ 9 , 34 , 35 , 36 ].

Titration of sedation and the use of neuromuscular blocking agents provides intensivists with readily available and effective options for shivering control in critically ill patients [ 37 ]. To ensure appropriate and effective use however, treating staff must be aware of the nuances of selecting the correct agent, monitoring the depth of neuromuscular blockade, and ensuring adequate skeletal muscle recovery once therapy with neuromuscular blockers has ceased. In cases of shivering when ICP is labile, the group agreed in line with current literature that ensuring depth of sedation before administering neuromuscular blockers is of utmost importance [ 37 , 38 ]. When using pharmacologic agents for shivering management, treating staff must consider potential pharmacokinetic and pharmacodynamic variation and monitor for efficacy (i.e. shivering control) and safety (i.e. adverse events and drug-drug interactions) [ 9 ].

The group agreed that in patients who are perceived to be at relatively lower risk of secondary brain injury (i.e. self-ventilating patients in the sub-acute phase of severe TBI), permissive hyperthermia may be considered over TTC, especially if the latter therapeutic option would require sedation or other invasive interventions. The group agreed that an individualised risk–benefit assessment should ultimately be undertaken before commencing controlled normothermia in such patients.

‘Time within target range’, ‘burden of fever’ and similar metrics can be considered as indicators of quality of temperature management.

‘Time within target range’ and ‘burden of fever’ were considered by the group to be appropriate metrics of quality temperature management. It was widely acknowledged that these metrics should be weighed by patient length of stay and/or duration of monitoring for appropriate statistical interpretation. The group was also careful to note that the administrative burden on physicians is already high and acknowledged the fact that some centres may not have access to electronic patient data management systems, so it was agreed that it was unrealistic for this group to issue prescriptive recommendations on auditing practices. In light of the high heterogeneity across centres [ 9 ], here the group were keen to clarify that wherever possible, documenting metrics such as ‘time within target range’ and ‘burden of fever’ may improve their ability to deliver data-driven service improvement and temperature control.

This consensus review was undertaken to evaluate current evidence on the application of TTC in the management of severe TBI in a critical care setting, and to develop a set of practical recommendations to address identified gaps in current published evidence.

As highlighted by the SIBICC 2020 group, the gap between published evidence and management protocols is bridged by expert opinion [ 39 ]. The optimal method for the provision of high-quality TTC remains unknown, and barriers to its consistent implementation include the lack of evidence-based treatment protocols, knowledge deficiencies, limited access to equipment, lack of financial resources and staff workload. This document aims to address key practice gaps and optimise patient care through multimodal assessment following TBI.

Strengths and limitations

The Delphi process has a number of strengths. Participants are able to reconsider their views in light of the evolving discussions, allowing for an element of reflection that isn’t regularly seen in other studies involving a single time point such as interviews or focus groups [ 40 ]. The element of anonymity offered to the panellists in the survey rounds avoids group conformity and promotes honesty, and the controlled and iterative discussions offer a flexible approach to gathering expert viewpoints on the set research questions. The Delphi method is an iterative process allowing the anonymous inclusion of a number of individuals across diverse locations and areas of expertise and avoiding dominance by any one individual. It uses a systematic progression of repeated rounds of voting and is an effective process for determining expert group consensus where there is little or no definitive evidence and where opinion is important [ 41 , 42 ]. The modified Delphi approach used here combined the early flow of structured information and submission of anonymous responses with the (hybrid) face-to-face discussion and further voting to gain consensus (or establish lack thereof) and expert insight into usual practice regarding non-pharmacological TTC with an automated feedback-controlled device. As cited in existing literature however [ 13 , 17 ], the Delphi process has limitations. The process is vulnerable to drop-outs and technical issues, with the online voting process during our meeting seeing some participants unable to cast their votes on a number of questions, leading to the need for a final anonymous survey round. The group opinions during the meeting may have been impacted by social bias, and the voices across the in-person and online participants may not have been equally heard, highlighting a potential need to ensure consistency in attendance in the same format in future panel meetings.

Our recommendations for the use of automated feedback-controlled TTC devices are based on expert consensus and theoretical benefits, such as precise temperature control and reduced temperature variability, which are thought to potentially improve outcomes in severe TBI management. We acknowledge the current evidence gap and strongly emphasise the need for rigorous research to evaluate the effectiveness of these devices, especially in diverse healthcare settings, including lower-income countries where resource limitations are critical. Future updates to these best-practice recommendations will incorporate emerging evidence to ensure relevance and applicability across different healthcare contexts, aiming for the highest standards of care within the constraints of available resources. While automated feedback-controlled TTC devices represent a significant advancement in the management of temperature in severe TBI patients, offering potential benefits in terms of precision and consistency, it is imperative to recognise the value and applicability of a wide range of temperature management approaches. These include both manual methods and simpler devices, which remain vital in many clinical settings around the world. Our guidelines advocate for the adaptation and implementation of TTC principles based on the specific resources, capabilities, and needs of each clinical setting.

This report has been developed by an expert panel comprised of specialists in neuro-critical care experienced in the management of severe TBI, therefore the recommendations focus on patients managed in a critical care environment. An individualised risk–benefit assessment should be undertaken for each domain to accommodate the high levels of heterogeneity seen across TBI patients, local practice settings, staff training and equipment availability [ 9 ].

TTC is a therapy that has a role in ICP management and may reduce secondary injury and improve long-term neurological outcome for victims of TBI [ 9 ]. Appropriate methods for the implementation of TTC across widely heterogenous clinical settings and patient populations are relatively understudied, and due to a lack of consistent and high-quality evidence, remain largely unknown. Areas of consensus emerging from the Delphi process included TTC being recognised as an essential aspect of high-quality TBI care. Controlled normothermia (36.0–37.5 °C) was strongly recommended as a therapeutic option to be considered in Tier 1 and 2 of the SIBICC ICP management protocol. Temperature management targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.

Availability of data and materials

All data generated or analysed during this study are included in this article and its supplementary information files.

Abbreviations

Cerebral perfusion pressure

Computed tomography

Electroencephalography

European Society of Anaesthesiology and Intensive Care

European Society of Intensive Care Medicine

Haemoglobin

• Intracranial pressure

Intensive care unit

Neuro Anaesthesia and Critical Care Society

Sodium chloride

Neuro-intensive care unit

Nonsteroidal anti-inflammatory drugs

Arterial partial pressure of carbon dioxide

Brain tissue oxygenation

Randomised controlled trial

Seattle International Severe Traumatic Brain Injury Consensus Conference

Arterial oxygen saturation

• Traumatic brain injury
• Targeted temperature control

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Acknowledgements

The group would like to acknowledge the support of Page & Page, London UK in facilitating the Delphi meeting.

The Delphi Panel meeting in October 2023 was facilitated (through the provision of travel costs, meeting space and refreshments) by Becton, Dickinson and Company. The development of these consensus recommendations was conducted with strict measures to ensure independence from its sponsor. The research team independently conducted all data analyses and drafted the manuscript. The role of BD was limited to providing logistical support for the Delphi panel meeting held in London, including travel costs, meeting space, and refreshments, without any influence over the study's content or conclusions. The Delphi voting process was conducted anonymously, ensuring that panel members could freely express their professional opinions without bias or influence from the sponsoring body or among panel members. The manuscript's drafting, review, and revision processes were carried out independently of BD. The sponsor had no editorial control, ensuring that the recommendations are based on the authors’ independent, professional expertise in targeted temperature management following traumatic brain injury. This article contains the personal and professional opinions of the individual authors and does not necessarily reflect the views and opinions of Becton, Dickinson and Company (“BD”) or any Business Unit or affiliate of BD. If drugs and/or medical devices are cited in the article, please consult package insert and instructions for use of them to know indications, contraindications, and any other more detailed safety information.

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Andrea Lavinio, Jonathan P. Coles & David K. Menon

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IRCCS Policlinico San Martino, Genoa, Italy

Chiara Robba

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Marcel Aries

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Jeroen Hermanides

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Mathieu van der Jagt

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Geert Meyfroidt

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All authors took part in the Delphi process. All authors read, revised and approved the manuscript.

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AL received consultancy and speaker fees from Beckton, Dickinson and Company (“BD”) for Chairing the Delphi panel and for contributing to the writing of the article. RH received speaker fees from BD and Zoll.

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Supplementary Information

Additional file 1.

. Evaluation of five randomized controlled trials by the ESICM Methodology Group evaluates evulating cooling strategies against traditional interventions. The evaluation highlights methodological heterogeneities and evidential challenges.

Additional file 2

. Delphi questionnaire: Round 1.

Additional file 3

. Delphi questionnaire. Round 3.

Additional file 4

. Systematic review of the literature on targeted temperature control in traumatic brain injury, covering clinical studies from 2013 to 2023.

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Lavinio, A., Coles, J.P., Robba, C. et al. Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations. Crit Care 28 , 170 (2024). https://doi.org/10.1186/s13054-024-04951-x

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Adams J, Bateman B, Becker F, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study and discrete choice experiment. Southampton (UK): NIHR Journals Library; 2015 Nov. (Health Technology Assessment, No. 19.94.)

Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study and discrete choice experiment.

Chapter 7 recommendations for future research.

Recommendations for future research have been considered in the discussion sections of Chapters 3 – 5 and are summarised here for ease of reference. We have attempted to place these in priority order.

• Further evidence is required on the effectiveness and cost-effectiveness of parental financial incentive and quasi-mandatory interventions for encouraging the uptake of preschool vaccinations. As such, interventions are likely to be implemented on a large scale; evaluation strategies such as natural experiments and step-wedge designs may be most useful in generating such evidence. 82
• Further evidence is required on the most effective and cost-effective configuration of any parental financial incentive and quasi-mandatory interventions for encouraging the uptake of preschool vaccinations. Intervention development work, taking account of existing behaviour-change theory, may be useful to maximise the potential effectiveness of incentive interventions. This should involve further consideration of the effective component, or components, of financial incentive interventions.
• Further consideration of reasons for non-vaccination should be incorporated into new interventions for promoting the uptake of preschool vaccinations. Parental financial incentive and quasi-mandatory interventions for encouraging uptake of preschool vaccinations may not adequately address the reasons for non-vaccination in high-income countries that tend to achieve overall high coverage of preschool vaccinations.
• Further consideration of how a quasi-mandatory intervention for encouraging the uptake of preschool vaccinations could be designed and implemented is required. Particular issues requiring further consideration include data sharing of vaccination status between health-care providers and schools, responsibilities of different sectors and staff, and how provision would be made for legitimate opt-out.
• If high-quality evidence of effectiveness of parental financial incentive and quasi-mandatory interventions for encouraging uptake of preschool vaccinations is generated, further evidence is required on how to effectively communicate this information to all stakeholders. As acceptability is linked to perceived effectiveness, further evidence on the impact of well-communicated effectiveness evidence on perceived acceptability is also required.
• The factors that may increase acceptance of mandatory schemes warrant further research, and additional DCEs could be conducted to explore parental preferences on how a mandate for vaccination might be imposed.
• Further consideration may be required of how existing systems and resources for encouraging the uptake of preschool vaccinations can be optimised. In particular, further evidence may be required on how to provide accessible information and education, and how to deliver accessible vaccination services. However, although these issues were raised in the present work, we did not conduct a systematic review on these topics and, as such, cannot make definitive recommendations for future research.
• Research engaging parents in an iterative codesign process to design optimally acceptable and usable information that conveys robust and balanced data on the consequences of disease and the benefits and risks of vaccinations is required.

Included under terms of UK Non-commercial Government License .

• Cite this Page Adams J, Bateman B, Becker F, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study and discrete choice experiment. Southampton (UK): NIHR Journals Library; 2015 Nov. (Health Technology Assessment, No. 19.94.) Chapter 7, Recommendations for future research.
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Scholars advocate for private sector expansion to boost youth employment.

In light of recent findings from a comprehensive study on the effects of digitalization on youth employment, scholars, including Dr. Matovu Fred, the Principal Investigator, are calling for a significant expansion of the private sector to address the rising unemployment rates among educated youth. The research, which delves into how the youth in Uganda are adapting to technological advancements, highlights several key areas that require urgent policy intervention.

The study reveals that Ugandan youth are increasingly adapting to technological changes through self-education, peer-to-peer learning, and continuous formal education. Despite their proactive approach, only a few organizations are offering necessary training for technological adaptation, leaving many youths to navigate these changes on their own.

Importantly, the youth have shown a strong willingness to invest in acquiring digital skills to remain competitive in the job market. Many see the digital trend not as a threat but as an opportunity to secure more decent jobs, including remote work opportunities and the ability to undertake multiple jobs simultaneously.

Policy Recommendations

Based on these findings, the researchers have put forward several policy recommendations:

• Expansion of the Private Sector : There is a pressing need to expand the private sector to absorb the growing number of educated youth entering the job market. This expansion is critical to providing more employment opportunities and leveraging the skills of the young workforce.
• Improving Internet Connectivity : To support uninterrupted use of digital systems in workplaces, it is essential to improve the reliability of internet connectivity. This improvement will ensure that digitalization efforts are not hampered by technical issues, enabling smoother and more efficient work processes.
• Reducing Data Costs : Lowering subscription fees and the cost of data is crucial to expanding bandwidth availability, which is necessary for activities such as big data analytics. Affordable internet access will empower more youths to engage in digital learning and work.
• Enhancing Cybersecurity : The research underscores the need for central coordination of cybersecurity safeguards. Implementing early warning systems for hackers and related threats will protect company systems and bolster the digital economy’s integrity.
• Reliable Data Protection Systems : Ensuring that data protection systems are trustworthy is vital. Building trust in enterprise data among third-party users and government agencies, such as the Uganda Registration Services Bureau (URSB), Uganda Revenue Authority (URA), and Kampala Capital City Authority (KCCA), will encourage more businesses to digitize their operations.

Government and Private Sector Collaboration

The study’s authors emphasize that collaboration between the government and private sector is essential to implementing these recommendations effectively. By working together, they can create an environment that not only supports the digital adaptation of the youth but also drives economic growth and job creation.

In response to these findings, government officials and private sector leaders are urged to prioritize these policy recommendations. Expanding the private sector and improving digital infrastructure will play a critical role in harnessing the potential of Uganda’s youth, fostering innovation, and securing a brighter economic future for the nation.

As the digital landscape continues to evolve, these strategic measures will ensure that Uganda’s youth are not left behind but are instead at the forefront of the country’s economic transformation.

The research was funded by the government of Uganda through Makerere University Research and Innovation Fund .

The research team

PI: Fred Matovu:  Principal Investigator (PI), Makerere University

Susan Kavuma: Co-PI, Makerere University

Hassan Mbaziira:  Ministry of Gender, Labour and Social Development

Richard Sebaggala: Uganda Christian University, Mukono

Activists Urge Government to Integrate Gender Mainstreaming in Public Policy Making

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Activists have called on the government to incorporate gender considerations in public policy making to achieve economic transformation and social sustainability. This appeal was made during a policy dialogue at Makerere University on May 21, organized by the College of Business and Management Sciences in collaboration with American University.

Ms. Safia Nalule Jjuuko, Chairperson of the Equal Opportunities Commission, emphasized the importance of gender mainstreaming in social and public policy enactment. She highlighted that for Ugandans to fully benefit from government initiatives, gender considerations must be central to policy planning.

“Gender extends beyond male and female. It encompasses various societal groups, including the disabled and the poor. Government institutions must consider these groups to effectively plan for all Ugandans through policies that serve the best interests of all citizens,” Nalule stated. She added that thorough knowledge of the population is crucial for effective planning.

Dr. Joseph Muvawala, Prime Minister of Busoga Kingdom and Executive Director of the National Planning Authority, reiterated the need for gender to be a fundamental element in all policy endeavors. “Institutions should establish units dedicated to gender mainstreaming to address societal challenges,” he said. Muvawala pointed out that addressing gender disparities is essential for social, political, and economic development. “When examining employment, a gender perspective reveals much about societal progress,” he noted. He warned that neglecting gender considerations in policy making risks losing the diverse experiences and realities of individuals.

Dr. Anna Ninsiima from the School of Women and Gender Studies at Makerere University identified institutional failures to provide quality services as a major barrier to gender equality. She stressed the need to strengthen health, education, and human resource institutions, highlighting that gender dynamics must not be overlooked. “For instance, girls are dropping out of school due to a lack of sanitary towels,” Dr. Ninsiima said. She also called for the implementation of policies, noting that many remain unexecuted.

Ms. Agnes Kisembo, the Programme Specialist at UN Women, said the United Nations Sustainable Development Goals (SDGs) place a strong emphasis on gender equality and the importance of gender mainstreaming in policy making. Specifically, SDG 5: Gender Equality, is dedicated to achieving gender equality and empowering all women and girls. She urged government to prioritize gender-responsive policies and programs to ensure the full realization of women’s rights and participation in decision-making processes. Ms. Kisembo emphasized the need for collaboration between government, civil society, and other stakeholders to address gender disparities effectively.

Dr. David Mpiima, from the School of Gender and Women Studies, Makerere University, emphasized that it is crucial to recognize that gender mainstreaming goes beyond just addressing disparities but also involves promoting equality, equity, and inclusivity in all aspects of society. By understanding the dynamics of power and influence, stakeholders can work towards creating a more equitable and just society for all individuals, regardless of gender.

Gender-Based Violence (GBV) was a significant topic of discussion at the dialogue. SSP Irene Adibaa, representing the Uganda Police Force, noted that domestic violence is predominantly reported by women, who often bear the primary caregiving responsibilities for children. She acknowledged that men also report cases of domestic violence, albeit less frequently, due to societal norms.

 “Some women are the source of conflict in their homes, which is why we see a high number of domestic violence cases linked to financial issues,” Adibaa said. She urged men to participate actively in combating gender-based violence and mentioned the recruitment of men into the Child and Family Protection Unit to encourage more open communication among men.

The 2023 Police Crime Report revealed 14,681 domestic violence cases reported nationwide. Of these, 1,520 cases went to court, with 10,792 involving adult female victims, 3,243 adult male victims, 505 male juveniles, and 644 female juveniles. Additionally, 242 murders due to domestic violence were reported, with 122 cases going to court, 16 not pursued, and 104 still under investigation. North Kyoga recorded the highest number of domestic violence cases, followed by Aswa and Rwizi regions, each with 28 cases.

Citing a 2019 UNFPA report, Ms Elisabeth Kemigisha from FIDA said Uganda loses USD77 billion to gender based violence. She stressed the importance of investing in gender equality initiatives to not only reduce economic losses but also to create a more prosperous and sustainable future for Uganda. Ms. Kemigisha also highlighted the need for comprehensive policies and programs that address the root causes of gender-based violence in order to effectively combat this issue.

Sharing experiences from South Africa, Dr. Jamela B. Hoveni, from the Institute for   Economic Justice, South Africa said South Africa’s Policy on Gender-Based Violence, through the National Strategic Plan on Gender-Based Violence and Femicide (NSPGBVF) and other legislative measures, focuses on a multi-faceted approach to prevent and respond to GBV. It emphasizes strong leadership, coordination, prevention through education, justice system improvements, comprehensive support for survivors, economic empowerment, and robust data management. These policies aim to create a society where all individuals can live free from violence and discrimination, ensuring that survivors receive the support and justice they deserve.

Prof. Eria Hisali, Principal of the College of Business and Management Sciences, acknowledged steps taken by Parliament to ensure inclusive policy making. He emphasized the need for continuous efforts to integrate gender considerations into all aspects of public policy to address the complex challenges faced by society.

CoBAMS Faculty to Support Uganda’s First Digital Census 2024

In a significant leap toward harnessing technology for national planning and development, Uganda is set to conduct a landmark digital census starting with 9 th May 2024 as the Census reference night and the enumeration period scheduled for 10 th -19 th May 2024.  As specified in the Plan for National Statistical Development (PNSD), the 2024 National Population and Housing Census (NPHC) is carried out by Uganda Bureau of Statistics (UBOS) led by the Census Commissioner (CC) who is the Executive Director (ED) Dr. Chris Mukiza.  The digital census will be carried out using Computer Assisted Personal interview (CAPI) tablets and use of Global Positioning System (GPS). The census information can be used in leveraging government programs including Parish development model, youth livelihood program and also in the development of NDP IV, as we aim at becoming a middle income economy as stipulated in Vision 2040.

Distinguished staff members from Makerere University , School of Statistics and Planning (SSP), College of Business and Management Sciences (COBAMS) have played a pivotal role in supporting the census preparation phase and enumeration phases to ensure a successful digital census.  This engagement aims to ensure the collection of accurate, timely, comprehensive data to guide the country’s policies, planning and vision.

The selected team comprises Dr. Odur Bernard, Dr. Nansubuga Elizabeth, Dr. Nankinga Olivia, Dr. Patricia Ndugga and Dr. Margaret Banga. The selected staff members bring a wealth of knowledge and experience, making them ideal contributors to the national census’s success. These were been deployed to different areas as District or City Census Commissioner’s Representative. Their role involves providing oversight, supervision and ensuring the smooth running of the census exercise in these districts in collaboration with UBOS.

Pivotal to this exercise, the faculty also trained district and sub-county officers of which information the officers would later use in training the enumerators and the parish/ward supervisors on the entire census process and data collection.

Makerere University through the school of statistics and planning has also been represented at the Census Technical Advisory Committee (CTAC) by Assoc. Prof. James Wokadala. The CTAC is composed of members of the Inter-Agency Committee of the Plan for National Statistics Development (PNSD) and other co-opted members from Academia, Media and Research institutions. Further, the involvement of Makerere University ‘s staff brings a level of expertise and dedication that will undoubtedly contribute to the census’s success. With their support, Uganda is poised to set a new standard in data collection and analysis, paving the way for a more informed and progressive nation.

Bridging Academia and National Development

The Uganda Bureau of Statistics (UBOS) has a standing partnership with Makerere University , as represented by Dr. Allen Kabagenyi a staff member of SSP who was appointed by Cabinet as member of the UBOS Board of Directors as representative of all academic institutions in Uganda teaching statistics.  The partnership between Makerere University and UBOS underscores the importance of collaboration between academia and government in achieving national development goals.

To support the 2024 Census, Makerere University adjusted the Semester and Examinations excluding 8 th – 10 th May 2024 to enable staff and students participate in the national exercise resuming on 11 th May 2024. The university is applauded for revising the semester for this important 2024 digital census represents a significant step toward modernizing Uganda’s data collection practices, allowing for more efficient analysis, timely dissemination for better-informed decision-making.

Dr. Kabagenyi, mentioned that the overall aim of the National Population and Housing Census (NPHC) 2024 was to provide benchmark information on the spatial population distribution, age and sex structure, as well as other key socio-economic and demographic characteristics.  She further said the Department of Population Studies, part of the School of Statistics and Planning, has over the years trained scholars in different methodologies of Collecting population Data and the national population Census being one of them.  The Census provides information on the country’s population size, distribution, demographic and the socio economic characteristics of a county’s population.

Further by “leveraging on digital technologies, we can collect more accurate, detailed and timely data, which is crucial for national planning. Our team is excited to contribute to this historic event and support Uganda’s journey toward a more data-driven future.” She further applauds Makerere University Council and Management for adjusting Semester II 2023/2024 for a critical government national program.  

Sharing some insight into the census process, Dr. Kabagenyi said if one is not at home, another person who is knowledgeable enough to respond to the census questionnaire can be interviewed. 

 “It Matters to be counted”

Dr. Joweria Teera Hands Over Office to Dr. Faisal Buyinza

The Department of Economic Theory and Analysis at Makerere University witnessed a significant transition as Dr. Joweria Teera handed over the reins to Dr. Faisal Buyinza. This ceremonial handover, held in the university’s Faculty of Economics, marked a new chapter in the department’s journey while celebrating the achievements and contributions of Dr. Teera during her tenure.

A Legacy of Excellence and Innovation

Dr. Teera, who has served as the head of the department for the past eight years, is recognized for her transformative leadership and dedication to academic excellence. Under her guidance, the department has seen substantial growth in research output, student engagement, and partnerships with external organizations. She spearheaded initiatives that modernized the curriculum, integrating innovative teaching methods and focusing on real-world economic challenges.

In her parting remarks, Dr. Teera expressed gratitude to her colleagues and students for their support throughout her tenure. “It has been an honor to lead this department, and I am proud of what we have accomplished together,” she said. “I am confident that Dr. Buyinza will continue to drive our mission forward, bringing fresh perspectives and energy to the role.”

A Vision for the Future

Dr. Buyinza, who has an extensive background in economic analysis and research, is no stranger to the department. He has served as a senior lecturer and has been instrumental in guiding graduate students through complex research projects. His appointment as head of the department brings new enthusiasm and a vision for continued growth.

In his acceptance speech, Dr. Buyinza outlined his plans for the department, focusing on strengthening interdisciplinary research and enhancing collaborations with industry stakeholders. “I am excited to build on the strong foundation laid by Dr. Teera,” he stated. “Together, we will work towards creating a more dynamic and impactful department, one that contributes meaningfully to the field of economics and to Uganda’s development.”

Celebrating Collaboration and Teamwork

The handover ceremony was attended by faculty members, and representatives from the university administration. Dean of the School of Economics, Prof. Ibrahim Mike Okumu, praised Dr. Teera for her leadership and welcomed Dr. Buyinza to his new role. “Dr. Teera’s leadership has been invaluable, and we are grateful for her contributions,” he said. “We also look forward to working with Dr. Buyinza as he takes on this important position.”

As Dr. Buyinza steps into his new role, the Department of Economic Theory and Analysis at Makerere University is poised for a vibrant future, with a strong focus on fostering economic understanding and contributing to the broader academic and economic landscape.

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