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Background Health research teams increasingly partner with stakeholders to produce research that is relevant, accessible, and widely used. Previous work has covered stakeholder group identification. Objective We aimed to develop factors for health research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership, with the aim of forming equitable and informed teams. Design Consensus development. Participants We involved 16 stakeholders from the international Multi-Stakeholder Engagement (MuSE) Consortium, including patients and the public, providers, payers of health services/purchasers, policy makers, programme managers, peer review editors, and principal investigators. Approach We engaged stakeholders in factor development and as co-authors of this manuscript. Using a modified Delphi approach, we gathered stakeholder views concerning a preliminary list of 18 factors. Over two feedback rounds, using qualitative and quantitative analysis, we concentrated these into ten factors. Key Results We present seven highly desirable factors: ‘expertise or experience’, ‘ability and willingness to represent the stakeholder group’, ‘inclusivity (equity, diversity and intersectionality)’, ‘communication skills’, ‘commitment and time capacity’, ‘financial and non-financial relationships and activities, and conflict of interest’, ‘training support and funding needs’. Additionally, three factors are desirable: ‘influence’, ‘research relevant values’, ‘previous stakeholder engagement’. Conclusions We present factors for research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership. Policy makers and guideline developers may benefit from considering the factors in stakeholder identification and invitation. Research funders may consider stipulating consideration of the factors in funding applications. We outline how these factors can be implemented and exemplify how their use has the potential to improve the quality and relevancy of health research.

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

Background Breast cancer is a common disease in Tunisia and is associated with high mortality rates. The “Instance Nationale de l’Evaluation et de l’Accréditation en Santé” (INEAS) and the Tunisian Society of Oncology decided to develop practice guidelines on the subject. While the development of de novo guidelines on breast cancer screening is a demanding process, guideline adaptation appears more appropriate and context sensitive. The objective of this paper is to describe the adaptation process of the European Guidelines on Breast Cancer Screening and Diagnosis to the Tunisian setting in terms of the methodological process, contextual differences between the source and adoloped guideline, and changes in the recommendations. Methods We used the ‘Grading of Recommendations Assessment, Development and Evaluation’ (GRADE)-ADOLOPMENT methodology to prioritize the topic, select the source guideline, and prioritize the questions and the outcomes. Once the source guideline was selected—the European Breast Cancer Guidelines—the European Commission´s Joint Research Centre shared with the project team in Tunisia all relevant documents and files. In parallel, the project team searched for local studies on the disease prevalence, associated outcomes’ baseline risks, patients’ values and preferences, cost, cost-effectiveness, acceptability, and feasibility. Then, the adoloping panel reviewed the GRADE evidence tables and the Evidence to Decision tables and discussed whether their own judgments were consistent with those from the source guideline or not. They based their judgments on the evidence on health effects, the contextual evidence, and their own experiences. Results The most relevant contextual differences between the source and adoloped guidelines were related to the perspective, scope, prioritized questions, rating of outcome importance, baseline risks, and indirectness of the evidence. The ADOLOPMENT process resulted in keeping 5 out of 6 recommendations unmodified. One recommendation addressing “screening versus no screening with ultrasound in women with high breast density on mammography screening” was modified from ‘conditional against’ to ‘conditional for either’ due to more favorable ratings by the adoloping panel in terms of equity and feasibility. Conclusion This process illustrates both the feasibility of GRADE-ADOLOPMENT approach and the importance of consideration of contextual evidence. It also highlights the value of collaboration with the organization that developed the source guideline.

The activity of the Reproductive Medicine poses a dilemma in this pandemic Covid-19. In fact, this is a theoretically non-emergency activity except for fertility preservation with oncological reasons. The majority of fertility societies in the world such as the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) recommended stopping the inclusion of new patients and continuing only the In Vitro Fertilization (IVF) cycles that have already been initiated by promoting Freeze-all as much as possible. Initilaly, the "Société Tunisienne de Gynécologie Obstétrique" (STGO) issued national recommendations that echo the international recommendations. These recommendations were followed by the majority of IVF center in Tunisia. However, a number of new data are prompting us to update these recommendations.

INTRODUCTION:Tunisia recently implemented a Health Technology Assessment (HTA) agency (INASanté) to inform decisions around health technologies and to improve clinical practice by means of the elaboration of Clinical Practice Guidelines (CPG). However many decisions on new and emerging technologies, their implementation and coverage in the health care system are still taken at the hospital level without any structured process that informs the decisions. The aim of this project was to improve the methods and flow-chart of decision-making processes on innovation uptake in the Tunisia Healthcare System.METHODS:By means of the toolkit of EuroScan for the implementation of an early awareness and alert system (EAAS), and its checklist, it was discussed specifically within INASanté the characteristics of the Tunisia Healthcare System and its specificities regarding decisions on drugs and medical devices. The analysis included the process of innovation uptake at the hospital level and its specific flow-chart. In depth interviews and a devoted workshop were performed with personal in INASanté: two physicians (one involved in CPG elaboration and the second in accreditation), three pharmacists (HTA), one nutritionist (HTA), two librarians and other stakeholders, including the Directorate of Hospitals.RESULTS:The uptake of innovations in Tunisia does not follow a structured process. In fact, there is no central purchase of medical devices in Tunisia and most medical devices are purchased by hospitals within a tender process in accordance with the Tunisian public procurement law. The main pitfalls are: lack of awareness around innovations that could impact the system, non-structured process of information sharing among the different decision-makers that promotes inequity in access to technologies and services, and lack of explicit criteria that determine decisions around health technologies.CONCLUSIONS:Tunisia requires a structured and informed process on decisions around innovation uptake in the healthcare system. The principles that should govern this system are: anticipation of the impact of new health technologies, establishing priorities and criteria for decision making in all places of decision. The decisions should be recorded and publicly shared to avoid inequities in the access to technologies.

INTRODUCTION:Health Technology Assessment (HTA) reports adaptation process is an important tool for emerging HTA agencies. INASanté (National Instance for Accreditation in Healthcare) has chosen to rely on this approach, to develop its first health intervention assessment report: comparative study of computed tomographic colonography versus standard colonoscopy for colorectal cancer screening.METHODS:Following consultations with healthcare professionals, the PICO question related to the colorectal cancer screening issue in Tunisia was determined. A literature search strategy covering 10 years (2006-2016) was carried out. Several databases including HTA on the net were explored. Then two independent reviewers conducted literature screening and realized a PRISMA flow diagram. Full text selected reports were submitted to three critical appraisal tools: PRISMA checklist, INAHTA checklist and Critical Appraisal Tools (FLC 2.0). The EUnetHTA adaptation toolkit was used to determine reports adaptability by assessing relevance, reliability and transferability. A structured study of the Tunisian context based on a qualitative data analysis was elaborated. The data synthesis and reporting were finalized with the contribution of a working group. Then an external peer review was conducted before the report dissemination.RESULTS:Eighty reports were screened to finally retain four eligible. After a critical appraisal performed by two independent reviewers, two reports from the Canadian Agency for Drug and Technolgies in Healthcare and AETSA were selected to be assessed using the EUnetHTA adaptation toolkit. Regarding transferability criteria, the second report was retained. The context study has consisted in a qualitative analysis of seventeen individual interviews with healthcare professionals involved in colorectal cancer screening issues and an up to date Tunisian literature review. The final adapted report was a combination between relevant extracted data from AETSA report and synthesis of the Tunisian context analysis.CONCLUSIONS:This HTA report represents a tool for policy makers to establish the appropriate colorectal cancer screening program for the Tunisian context. HTA reports adaptation process is the best way to give evidence on emerging technologies without wasting time and resources.