1 Volume 21 2022 e226252 Original Article Braz J Oral Sci. 2022;21:e226252http://dx.doi.org/10.20396/bjos.v21i00.8666252 1 Department of Dentistry, State University of Maringá, Maringá, PR, Brazil. 2 Global Research and Innovation Network – GRINN, Curitiba, PR, Brazil. 3 McGill University, Faculty of Dentistry, McGill Division of Oral, Health and Society, Montreal, Quebec, Canadá. Corresponding author: Mitsue Fujimaki Department of Dentistry, State University of Maringá. Av. Mandacaru 1.550, 87080000 – Maringá, PR, Brazil. Phone: (44) 991116464. E-mail: mfujimaki@uem.br Editor: Altair A. Del Bel Cury Received: July 2, 2021 Accepted: December 12, 2021 Oral healthcare management practices in Brazil: systematic review and metasummary Tânia Harumi Uchida1 , Uhana Seifert Guimarães Suga1 , Clarissa Garcia Rodrigues2 , Josely Emiko Umeda1 , Mark Tambe Keboa3 , Raquel Sano Suga Terada1 , Mitsue Fujimaki1,* Universal health coverage is a global target included in the United Nations Sustainable Development Goals agenda for 2030. Healthcare in Brazil has universal coverage through the Unified Health System (SUS), which guarantees health as basic right to the Brazilian population. Considering the principles of SUS, public oral healthcare management is a huge challenge. Aim: To identify good management practices for quality care adopted by local public oral healthcare managers and teams around Brazil. Methods: This study was registered with PROSPERO (CRD42017051639). Five databases (PubMed, Embase, Web of Science, Scopus and Lilacs) as well as the reference lists and citations of the included publications were searched according to PRISMA guidelines. Results: A total of 30,895 references were initially found, which were evaluated according to the defined eligibility criteria. Twenty qualitative studies, eight surveys and two mixed-model studies were selected. The practices (codes) were organized into three main groups (families), and the Frequency of the Effect Size (FES) of each code was calculated. Among the 20 codes identified, the most relevant ones were: Diagnosis and Health Planning (FES=80%) and Family Health Strategy (FES=66,7). The Intensity of the Effect Size of each study was also calculated to demonstrate the individual contribution of each study to the conclusions. Conclusion: The evidence emerging from this review showed that healthcare diagnosis, planning, and performance based on the family health strategy principles were the most relevant practices adopted by public oral healthcare managers in Brazil. The widespread adoption of these practices could lead to improved oral healthcare provision and management in Brazil. Keywords: Public health. Dentistry. Policy making. Health policy. Practice management. https://orcid.org/0000-0001-8170-1092 https://orcid.org/0000-0003-3150-0123 https://orcid.org/0000-0002-1821-5697 https://orcid.org/0000-0003-1106-4344 https://orcid.org/0000-0001-9754-7819 https://orcid.org/0000-0003-1344-9870 https://orcid.org/0000-0002-7824-3868 2 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Introduction Health is a valuable resource for sustainable human development. It contributes to national social equality, justice and peace, and increased quality of life. The impor- tance of health in global development is exemplified in the Sustainable Development Goals (SDGs) agenda for 2030 proposed by the United Nations1. Specifically, the third SDG seeks to “ensure a healthy life and promote well-being for all, at all ages”. The public health system in Brazil is aligned with this broad SDG, and has been described as a reference model for neighbouring countries2. For over 30 years, public healthcare has been enshrined in the Brazilian Constitution as an inalienable right of all members of the population. Brazil operates a Unified Health System (SUS - Sistema Único de Saúde, in Portuguese) that was created on the core principles of equity, integrality, and universality of healthcare provision. Under SUS, every person in the country is entitled to free healthcare, and are invited to take part in the formula- tion, evaluation and control of health policies3. Because oral health is inherent to a healthy life, the Brazilian National Oral Health Policy (BNOHP - Política Nacional de Saúde Bucal, in Portuguese), a program also known as “Smiling Brazil”, was created and incorporated into SUS. This policy has steadily been implemented by stakeholders at various levels, such as consumer protection agencies, public health professionals, and oral health professional4. Over the last decade, newer links have been forged between the BNOHP and non-dental actors within SUS such as health workers, managers, and the community. To fur- ther integrate oral healthcare within the universal system provided by SUS, prac- tice transformation, and the introduction of new concepts, contents, and forms of organization are required with the overarching intent of improving the oral health of the population5. However, managing SUS presents various levels of challenges. The complexity of a universal system in association with the fragmentation of health policies and programs, lack of management qualification and social control, and a hierarchical, regionalized network structure are some of the issues that encumber health actions and services6. Under such circumstances, unqualified management can become a critical leadership bottleneck, impairing the implementation of health policies7. Furthermore, the role of managers in the public sector is dependent on regulations that sometimes limit their autonomy. Indeed, difficulties experienced by managers in promoting healthcare integration at all levels of the public service have created barriers to full access to proper healthcare8. Hence, the combination of inadequate management qualification and the organizational complexities of a health sys- tem that is intended to be universal can compromise the very foundational princi- ples of SUS7. SUS management has become a major public health issue in Brazil3, and more effec- tive and efficient public management is required to facilitate the implementation of oral healthcare actions in line with the principles and guidelines of the national health- care system. Yet, insufficient attention has been given to the role of managers and the qualification they require as a way to achieve SUS objectives. 3 Uchida et al. Braz J Oral Sci. 2022;21:e226252 A possible approach to the problem is to highlight health management models employed in different parts of the country, which have the potential to face the chal- lenges and change the predominant traditional practices that are not in accordance with the BNOHP9. Therefore, the aim of this systematic review and metasummary was to identify good management practices for quality care adopted by local public oral healthcare managers and teams around Brazil. Materials and Methods Protocol and Registration This systematic review was conducted in accordance with the Preferred Reporting items for Systematic Review and Meta-Analyses (PRISMA) Statement10 and was registered with the International Register of Prospective Systematic Reviews (PROS- PERO) under the registration number CRD42017051639. Literature search The research question that guided this systematic review, according PICOS, was: “What practices have been adopted by local managers and teams within the public health service in Brazil aimed at improving oral healthcare management?”. To answer this question, a search was performed in the following electronic databases: PubMed, Embase, Web of Science, Scopus and Lilacs. A search was conducted until Septem- ber 2021. For the search in the databases, no terms related to the type of study were used, since the term “qualitative research” was introduced only in 1988 in the Embase database and in 2003 as a MeSH term in PubMed. Search strategy It was used the PICOS strategy, following terms that were used in the final search strategy: Patient (P) “policymaker”, “policy making”, “public health”, Intervention (I) “dentistry”. “MeSH terms” (PubMed), “entry terms” (EMBASE) and “Decs” (Lilacs) were also used to “construct” a highly sensitive search strategy. Some initial keywords were selected. Different strategies were tested in the databases, and key words were added or rejected according to the results obtained. Terms related to study type were not used because the term “qualitative research” was only introduced in EMBASE in 1988, and as a MeSH term in PubMed in 200311. Eligibility Criteria The inclusion criteria were as follows: qualitative studies, surveys, or mixed-model (qualitative-quantitative) articles that indicated the practices adopted by local pub- lic health managers to improve oral healthcare management in the Brazilian public sector. No limits were imposed on the date, language, or type of study. Moreover, no study was excluded a priori for reasons of quality. According to Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions12, this is a strategy that allows that potentially valuable themes remain included. 4 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Study selection, quality assessment, and data extraction followed a similar proce- dure. Two reviewers (THU and USGS) initially performed the task independently, and then met with a third reviewer (MF) for consultation and consensus. Study Selection All titles and abstracts of the articles retrieved were independently assessed by two reviewers (THU and USGS). These reviewers held weekly meetings for 18 weeks in the presence of a third reviewer (MF) with experience in public management, qualitative research and systematic reviews. Abstracts that did not provide suffi- cient information in relation to the eligibility criteria were maintained for full text evaluation. Afterwards, manual searches were performed in the references of the included articles, and citations were analyzed using Google Scholar. The authors of the included studies were contacted by e-mail for the identification of possible additional studies. Study Quality Assessment Qualitative studies were evaluated according to quality items adapted from the Crit- ical Appraisal Skills Program (CASP)13; Surveys were assessed based on quality items adapted from Bennett et al.14 (2010), while mixed-model studies were analyzed according to O’Cathain et al.15 (2008). Quality items were assessed and classificated as being present (yes) or absent (no). Studies which presented a prevalence of “yes” (>60% of the evaluated items) in the quality evaluation were considered as presenting low risk of bias. Studies with 40% - 60% of “yes” were considered moderate risk of bias. And studies with a prevalence of “no” (<40% of the items) were classified as presenting high risk of bias. Data extraction The following general data were collected from the studies: authors, year of publi- cation, and geographic region of the first author. Additionally, the following specific characteristics were also retrieved: study objective, type of study, place of research, intervention, number of participants in the sample, inclusion and exclusion crite- ria, participant characteristics, data collection methods, data analysis, main results, and conclusions. Data analysis Data analysis was conducted through a metasummary of the retrieved data. This is a quantitatively oriented aggregation approach for the synthesis of both qualitative studies and surveys. The methodology involves extracting, grouping and formatting the results to allow the calculation of the frequency of the effect size (FES) of each practice, and the intensity of the effect size (IES) of each study16. After extracting the results of the included studies, and grouping the relevant find- ings, major topics (concise but comprehensive representations) termed “Families” were created referring to the practices adopted by oral healthcare managers for https://translate.google.com/translate?hl=pt-BR&prev=_t&sl=pt-BR&tl=en&u=http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf https://translate.google.com/translate?hl=pt-BR&prev=_t&sl=pt-BR&tl=en&u=http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf https://translate.google.com/translate?hl=pt-BR&prev=_t&sl=pt-BR&tl=en&u=http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf https://translate.google.com/translate?hl=pt-BR&prev=_t&sl=pt-BR&tl=en&u=http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf 5 Uchida et al. Braz J Oral Sci. 2022;21:e226252 quality care. In each Family, individual practices, termed “codes”, were grouped based on similarity. For the coding step, the software ATLAS.ti 8.0 – Qualitative Data Analysis (Atlas.ti® Scientific Software Development, Berlin, Germany) was used. FES was calculated in order to evaluate the magnitude of the extracted results. It consisted on verifying the number of times a particular code emerged from all included articles. To do so, the number of studies that presented an individual code was divided by the total number of studies included, and the result was presented as a percentage. The IES of each study was calculated by checking the number of times codes emerged in each of the included articles. The calculation was performed to indicate which codes with FES > 25% contributed to answering the research question. In order to do this, the number codes contained in one study was divided by the total number of codes in all the studies. With this calculation, the articles were considered “stronger” or “weaker” based on their contribution to answering the research question. Thus, the number of codes with FES > 25% in one particular study was divided by the number of codes with FES > 25% across all studies11. This information assisted in interpreting the data in the metasummary, determining the individual contribution of studies to the conclusions of this systematic review17. Results Study selection Figure 1 show the flowchart of the study selection process. The initial search in the electronic databases yielded 30,895 references. After the removal of duplicates (3,485 references); title and abstract evaluations (27,385 references), 25 articles were considered potentially eligible. Full texts were retrieved and analyzed by applying the eligibility criteria. After the analysis of the references of these articles, quotes in Goo- gle Scholar, and studies indicated by the authors of the selected texts, 35 new articles were included for further eligibility evaluation. Of the 60 articles selected, 23 were excluded for the following reasons: 3 studies were non-scientific research; 19 articles did not present any practices to improve oral healthcare management; 2 articles were not on Dentistry; and in 6 studies, the subject interviewed could not be clearly identified. In the end of the evaluations, 30 articles were included in the systematic review and metasummary: 20 qualitative studies, 8 surveys and 2 mixed model studies. Study characteristics Table 1 presents information on the included studies (number of participants, setting, context of the study). The total number of participants was 1,010, among whom 498 were dentists and 512 were managers. The geographical distribution of the stud- ies was as follows: Amazonas (1 study); Bahia (5 studies); Ceará (2 studies); Minas Gerais (2 studies); Paraíba (2 studies); Paraná (4 studies); Pernambuco (1 study); Rio Grande do Norte (2 studies); Santa Catarina (6 studies); São Paulo (4 studies). Only 1 study was multicentric, involving the states of Paraná and São Paulo. 6 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Most of participants were enrolled in the Family Health Strategy (FHS - Estratégia Saúde da Família, in Portuguese), and most health managers held Municipal or State positions (Table 1). Id en ti fi ca ti on S cr ee ni ng El ig ib ili ty In cl ud ed Total of 30.895 records PubMed: 10.394 records Embase: 9.809 records Web of Science: 3.129 records Scopus: 7.117 records Lilacs: 446 records 3.485 Duplicates removed 24.410 records after duplicetes removed 25 Full-text articles for eligibility assessment 27.385 Articles excluded based on review of titles and/ or abstract 60 Full-text articles were assessed for eligibility 35 New records included for evaluation of eligibility after evaluation of citations, references and papers indicated by the authors of the complete texts 20 Qualitative studies included 8 Surveys included Exclusions: 03 studies were not scientific research; 19 records did not present practices for qualified management in dentistry; 02 records were not about dentistry; in 06 studies it was unclear who the research subject interviewed was. 2 Mixed studies included Figure 1. Flowchart of the study selection process. 7 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Table 1. Study characteristics and risk of bias (N = 30). Study Number of Participants Setting Context of the Study Dentists Managers Aguilera et al.18 (2013) 0 17 Paraná Municipal Health Office Aquilante and Aciole19 (2015) 38 11 São Paulo Regional Department of Health of São Paulo Araújo and Dimenstein20 (2006) 21 0 Rio Grande do Norte Dentists from the Family Health Strategy (FHS) Cavalcanti et al.21 (2012) 17 0 Paraíba Basic Health Unit (BHU) Chaves and da Silva22 (2007) 9 0 Bahia Dentists in the primary healthcare systems Correa et al.23 (2010) 6 2 Amazonas Dentists inserted in the FHS, Municipal Health Department and Oral Health Coordinator at FHS Fernandes et al.24 (2015) 11 0 Santa Catarina Dentists inserted in the FHS Lippert et al.25 (2020) 14 0 Paraná Dentists from the Basic Health Units (BHU) and Dental Specialties Centers Mello et al.26 (2014) 0 10 Santa Catarina SUS managers Moimaz et al.27 (2008) 0 3 São Paulo Regional Department of Health Nascimento et al.28 (2009) 58 0 São Paulo and Paraná Dentists worked in the ESF Padilha et al.29 (2005) 74* Paraíba Dentists worked in the FHS and as managers Pimentel et l.30 (2010) 3 12 Pernam-buco FHS Health District VI Rodrigues et al.31 (2011) 31* Bahia FHS Rossi and Chaves32 (2015) 8 5 Bahia Oral Health Management Team Sá et al.33 (2015) 23 1 Santa Catarina FHS Santos et al.34 (2007) 4 0 Bahia FHS Santos and Assis35 (2006) 11* Bahia FHS Silva Junior et al.36 (2020) 0 9 Ceará State Health Managers Vieira et al.37 (2013) 8 0 São Paulo Public Sector Baldani et al.38 (2005) 105 0 Paraná Oral health team (OHT) at the FHS Colussi and Calvo39 (2011) 0 207 Santa Catarina Municipal Health Managers Godoi et al.40 (2013) 0 1 Santa Catarina Municipal Health Managers Godoi et al.41 (2014) 0 12 Santa Catarina Municipal Health Managers Lessa and Vettore42 (2010) 0 3 Ceará Municipal Health Office Lourenço et al.43 (2009) 278** 166 Minas Gerais OHT at the FHS Mattos et al.5 (2014) 43 14 Minas Gerais OHT at the FHS Souza and Roncalli44 (2007) 25 19 Rio Grande do Norte OHT at the FHS Aquilante and Aciole45 (2015) 38 11 São Paulo Regional Department of Health of São Paulo Moretti et al.46 (2010) 67 9 Paraná OHT TOTAL 498 512 * Subjects excluded from the total sum, since it was not clear in the methodology how many were dentists and how many were managers. ** Subjects excluded from the total sum, because it was not clear in the methodology how many were dentist. 8 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Quality assessment The overall risk of bias of the selected studies is presented in Table 1. Of the 20 qual- itative articles, 20 (100%) presented high risk of bias (Table 2). Among the 8 surveys included in this systematic review, 2 (25%) had low risk of bias, 4 (50%) had moderate risk of bias and 2 (25%) high risk of bias (Table 2). The 2 mixed-model studies (100%) presented high risk of bias (Table 2). Frequency of the Effect Size (FES) Twenty practices (codes) were identified after analysis and coding of the 30 included articles. Similar codes were grouped into three families: “Oral Healthcare Structure”, “Oral Healthcare Provision”, and “Staff Management” (Table 3). Codes belonging to the family “Oral Healthcare Structure” with highest FES values, showed that the main practices adopted by managers to achieve qualified manage- ment were: Care Diagnosis and Planning (80%), Healthcare Networks (63,3%), Infra- structure and Materials, and Information Systems and Evaluation (30%). As for the family “Oral Healthcare Provision”, the following codes stood out: Family Health Strategy (66,7%), Expanded Clinical Service (56,7%), and Intersec- toriality (46,7%). Codes within the family “Staff Management” with the highest FES were: Interprofes- sional Teamwork (40%), Continuing Education (26,7%), Creativity, Initiative, Motivation and Innovation (10%), and University-Health Service Integration (6,7%). Intensity of the Effect Size (IES) The IES was calculated to verify the individual contribution of each study to the conclusions of this systematic review. All the qualitative studies, surveys and mixed-model studies contributed significantly to the practices for the qualification of oral healthcare management (Table 4). The study that presented the highest IES was Vieira et al. 2013 with 55%, followed by Aquilante and Aciole 2015 with 50%, Baldani et al. 2005 with 45%, and Lourenço et al. 2009 with 40%. Among the other 24 selected studies, 8 had scores between 5% and 15%, and 24 studies presented scores between 25% and 35%. Ten codes: Care Diagnosis and Planning, Family Health Strategy, Healthcare Net- works, Expanded Clinical Service, Intersectoriality, Interprofessional Teamwork, Ongoing Health Education, Infrastructure and Materials, Information Systems and Evaluation and Continuing Education presented FES > 25%, which resulted in IES > 25% in all included studies. 9 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Ta bl e 2. Q ua lit y as se ss m en t o f i nc lu de d st ud ie s. Q ua lit at iv e st ud ie s ac co rd in g C A S P (N =2 0) In cl ud ed a rt ic le s Q ua lit y va ri ab le s as se ss m en t* Risk of bias assessment Clarity of purpose Qualitative methodology appropriateness Justification for the qualitative methodology Participant recruitment strategy Data collection Relationship between researcher and participants Ethical issues Data analysis Clarity of results Study relevance A gu ile ra e t a l.1 8 ( 20 13 ) H ig h A qu ila nt e an d A ci ol e1 9 ( 20 15 ) H ig h A ra új o an d D im en st ei n2 0 ( 20 06 ) H ig h C av al ca nt i e t a l.2 1 ( 20 12 ) H ig h C ha ve s an d da S ilv a2 2 ( 20 07 ) H ig h C or re a et a l.2 3 ( 20 10 ) H ig h Fe rn an de s et a l.2 4 ( 20 15 ) H ig h Li pp er t e t a l. 25 (2 02 0) H ig h M el lo e t a l.2 6 ( 20 14 ) H ig h M oi m az e t a l.2 7 ( 20 08 ) H ig h N as ci m en to e t a l.2 8 ( 20 09 ) H ig h C on tin ue 10 Uchida et al. Braz J Oral Sci. 2022;21:e226252 C on tin ua tio n P ad ilh a et a l.2 9 ( 20 05 ) H ig h P im en te l e t a l.3 0 ( 20 10 ) H ig h R od rig ue s et a l.3 1 ( 20 11 ) H ig h R os si a nd C ha ve s3 2 ( 20 15 ) H ig h Sá e t a l.3 3 ( 20 15 ) H ig h Sa nt os e t a l.3 4 ( 20 07 ) H ig h Sa nt os a nd A ss is 35 (2 00 6) H ig h Si lv a et a l.3 6 ( 20 20 ) H ig h V ie ira e t a l.3 7 ( 20 13 ) H ig h S ur ve ys a cc or di ng B en ne tt (N =8 ) Q ua lit y va ria bl es a ss es sm en t* In cl ud ed a rt ic le Lo ur en ço e t a l.4 3 (2 00 9) B al da ni e t a l.3 8 (2 00 5) M at to s et a l.5 (2 01 4) G od oi e t a l.4 1 (2 01 4) S ou za a nd R on ca lli 44 (2 00 7) Le ss a an d V et to re 42 (2 01 0) C ol us si a nd C al vo 39 (2 01 1) G od oi e t a l.4 0 (2 01 3) Ju st ifi ca tio n of th e re se ar ch qu es tio n Ex pl ic it re se ar ch q ue st io n C la rit y of p ur po se C on tin ue 11 Uchida et al. Braz J Oral Sci. 2022;21:e226252 C on tin ua tio n D es cr ip tio n of m et ho ds u se d fo r d at a an al ys is M et ho d of a dm in is te rin g th e qu es tio nn ai re Lo ca tio n an d da te M et ho ds s uffi ci en tly de sc rib ed fo r r ep lic at io n Ev id en ce o f r el ia bi lit y Ev id en ce o f v al id ity U se o f e nc od in g Sa m pl e si ze c al cu la tio n R ep re se nt at iv en es s of th e sa m pl e Sa m pl e se le ct io n m et ho d D es cr ip tio n of th e sa m pl e po pu la tio n D es cr ip tio n of th e se ar ch to ol D es cr ip tio n of to ol de ve lo pm en t P re -t es t i ns tr um en t R el ia bi lit y an d va lid ity in st ru m en t C on tin ue 12 Uchida et al. Braz J Oral Sci. 2022;21:e226252 C on tin ua tio n C on se nt Et hi ca l a pp ro va l Ev id en ce o f e th ic al tr ea tm en t o f r es ea rc h pa rt ic ip an ts R is k of b ia s as se ss m en t Lo w Lo w M od er at e M od er at e M od er at e M od er at e H ig h H ig h M ix ed -m od el s tu di es a cc or di ng O ’C at ha in (N =2 ) In cl ud ed a rt ic le s Q ua lit y va ri ab le s as se ss m en t* R is k of b ia s as se ss m en t A ss es sm en t o f st ud y su cc es s A ss es sm en t o f st ud y de si gn A ss es sm en t of th e qu an ti ta ti ve co m po ne nt A ss es sm en t of th e qu al it at iv e co m po ne nt A ss es sm en t o f st ud y in te gr at io n A ss es sm en t o f st ud y in fe re nc es A qu ila nt e an d A ci ol e4 5 ( 20 15 ) H ig h M or et ti et a l.4 6 ( 20 10 ) H ig h * A da pt ed fr om C oc hr an e’ s C ol la bo ra tio n: Y es N o 13 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Ta bl e 3. F am ili es (O ra l H ea lth ca re S tr uc tu re , O ra l H ea lth ca re P ro vi si on , a nd S ta ff M an ag em en t) a nd c od es w ith th ei r r es pe ct iv e fr eq ue nc y of th e ef fe ct s iz e (F ES ). S TR U C TU R A L M A N A G EM EN T C A R E M A N A G EM EN T M A N A G EM EN T O F TH E W O R K C od es / R ef er en ce s Ef fe ct s iz e fr eq ue nc y (% ) C od es / R ef er en ce s Ef fe ct s iz e fr eq ue nc y (% ) C od es / R ef er en ce s Ef fe ct s iz e fr eq ue nc y (% ) H ea lth ca re n et w or ks A gu ile ra e t a l.1 8 ( 20 13 ), A qu ila nt e an d A ci ol e4 5 ( 20 15 ), C av al ca nt i e t a l.2 1 ( 20 12 ), C ha ve s an d da S ilv a2 2 ( 20 07 ), C ol us si a nd C al vo 39 (2 01 1) , F er na nd es e t a l.2 4 ( 20 15 ), Li pp er t e t a l.2 5 ( 20 20 ), G od oi e t a l.4 0, 41 (2 01 3, 2 01 4) , L es sa a nd V et to re 42 (2 01 0) , Lo ur en ço e t a l.4 3 ( 20 09 ), M at to s et a l.5 (2 01 4) , M el lo e t a l.2 6 ( 20 14 ), P ad ilh a et a l.2 9 (2 00 5) , P im en te l e t a l.3 0 ( 20 10 ), R os si a nd C ha ve s3 2 ( 20 15 ), Si lv a et a l.3 6 ( 20 20 ), So uz a an d R on ca lli 44 (2 00 7) , V ie ira e t a l.3 7 ( 20 13 ) 63 ,3 U se r s at is fa ct io n C av al ca nt i e t a l.2 1 ( 20 12 ) 3, 3 A ut on om y of m an ag em en t V ie ira e t a l.3 7 ( 20 13 ) 3, 3 C ar e D ia gn os is a nd P la nn in g A gu ile ra e t a l.1 8 ( 20 13 ), A qu ila nt e an d A ci ol e1 9, 45 (2 01 5) , B al da ni e t a l.3 8 ( 20 05 ), C av al ca nt i e t a l.2 1 ( 20 12 ), C or re a et a l.2 3 ( 20 10 ), Fe rn an de s et a l.2 4 ( 20 15 ), G od oi e t a l.4 0, 41 (2 01 3, 2 01 4) , L es sa a nd V et to re 42 (2 01 0) , Lo ur en ço e t a l.4 3 ( 20 09 ), M at to s et a l.5 (2 01 4) , M el lo e t a l.2 6 ( 20 14 ), M oi m az e t a l.2 7 ( 20 08 ), M or et ti et a l.4 6 ( 20 10 ), N as ci m en to e t a l.2 8 (2 00 9) , P ad ilh a et a l.2 9 ( 20 05 ), R os si an d C ha ve s3 2 ( 20 15 ), Sá e t a l.3 3 ( 20 15 ), Sa nt os e t a l.3 4 ( 20 07 ), Sa nt os a nd A ss is 35 (2 00 6) , S ilv a Ju ni or e t a l.3 6 ( 20 20 ), So uz a an d R on ca lli 44 (2 00 7) , V ie ira e t a l.3 7 ( 20 13 ) 80 Ex pa nd ed C lin ic al S er vi ce A qu ila nt e an d A ci ol e1 9, 45 (2 01 5) , B al da ni e t a l. (2 00 5) 38 , C ha ve s an d da S ilv a2 2 ( 20 07 ), C ol us si an d C al vo 39 (2 01 1) , C or re a et a l. 23 (2 01 0) , Fe rn an de s et a l.2 4 ( 20 15 ), G od oi e t a l.4 1 ( 20 14 ), M at to s et a l.5 ,2 6 ( 20 14 ), M or et ti et a l.4 6 ( 20 10 ), N as ci m en to e t a l.2 8 ( 20 09 ), P im en te l e t a l.3 0 (2 01 0) , S an to s et a l.3 4 ( 20 07 ), Sa nt os a nd A ss is 35 (2 00 6) , S ou za a nd R on ca lli 44 (2 00 7) , V ie ira e t a l.3 7 (2 01 3) 56 ,7 In di vi du al p er fo rm an ce C ha ve s an d da S ilv a2 2 ( 20 07 ) 3, 3 B ud ge t a nd F un di ng Lo ur en ço e t a l.4 3 ( 20 09 ), M oi m az e t a l.2 7 (2 00 8) , R os si a nd C ha ve s3 2 ( 20 15 ), V ie ira e t a l.3 7 ( 20 13 ) 13 ,3 S oc ia l C on tr ol A qu ila nt e an d A ci ol e4 5 ( 20 15 ), B al da ni e t a l.3 8 (2 00 5) , C av al ca nt i e t a l.2 1 ( 20 12 ), C ol us si an d C al vo 39 (2 01 1) , M oi m az e t a l.2 7 ( 20 08 ), N as ci m en to e t a l.2 8 ( 20 09 ), Sa nt os e t a l.3 4 ( 20 07 ) 23 ,3 C re at iv ity , i ni tia tiv e, m ot iv at io n an d in no va tio n A qu ila nt e an d A ci ol e1 9 ( 20 15 ), C ha ve s an d da Si lv a2 2 ( 20 07 ), C or re a et a l.2 3 ( 20 10 ) 10 C on tin ue 14 Uchida et al. Braz J Oral Sci. 2022;21:e226252 C on tin ua tio n In fr as tr uc tu re a nd m at er ia ls A gu ile ra e t a l.1 8 ( 20 13 ), B al da ni e t a l.3 8 ( 20 05 ), C or re a et a l.2 3 ( 20 10 ), Lo ur en ço e t a l.4 3 ( 20 09 ), M el lo e t a l.2 6 (2 01 4) , S ou za a nd R on ca lli 44 (2 00 7) , R os si an d C ha ve s3 2 ( 20 15 ), Sa nt os e t a l.3 4 ( 20 07 ), V ie ira e t a l.3 7 ( 20 13 ) 30 O ng oi ng H ea lth E du ca tio n A qu ila nt e an d A ci ol e1 9, 45 (2 01 5) , B al da ni e t a l.3 8 ( 20 05 ), C av al ca nt i e t a l.2 1 ( 20 12 ), Fe rn an de s et a l.2 4 ( 20 15 ), G od oi e t a l.4 0, 41 (2 01 3, 20 14 ), Lo ur en ço e t a l.4 3 ( 20 09 ), M or et ti et a l.4 6 (2 01 0) , N as ci m en to e t a l.2 8 ( 20 09 ), Sa nt os a nd A ss is 35 (2 00 6) , S ou za a nd R on ca lli 44 (2 00 7) , V ie ira e t a l.3 7 ( 20 13 ) 43 ,3 C on tin ui ng E du ca tio n A gu ile ra e t a l.1 8 ( 20 13 ), A qu ila nt e an d A ci ol e4 5 ( 20 15 ), C ha ve s an d da S ilv a2 2 ( 20 07 ), Lo ur en ço e t a l.4 3 ( 20 09 ), N as ci m en to e t a l.2 8 (2 00 9) , R od rig ue s et a l.3 1 ( 20 11 ), Sa nt os a nd A ss is 35 (2 00 6) , V ie ira e t a l.3 7 ( 20 13 ) 26 ,7 In fo rm at io n sy st em s an d ev al ua tio n A qu ila nt e an d A ci ol e4 5 (2 01 5) , B al da ni e t a l.3 8 ( 20 05 ), C av al ca nt i e t a l.2 1 ( 20 12 ), C ol us si a nd C al vo 39 (2 01 1) , G od oi e t a l40 ,4 1 ( 20 13 , 2 01 4) , M oi m az e t a l.2 7 ( 20 08 ), P im en te l e t a l.3 0 (2 01 0) , S ou za a nd R on ca lli 44 (2 00 7) 30 Fa m ily H ea lth S tr at eg y A gu ile ra e t a l.1 8 ( 20 13 ), A qu ila nt e an d A ci ol e1 9, 45 (2 01 5) , A ra új o an d D im en st ei n2 0 ( 20 06 ), B al da ni e t a l.3 8 ( 20 05 ), C av al ca nt i e t a l.2 1 ( 20 12 ), C ha ve s an d da S ilv a2 2 (2 00 7) , F er na nd es e t a l.2 4 ( 20 15 ), G od oi e t a l40 ,4 1 ( 20 13 , 20 14 ), Le ss a an d Ve tt or e4 2 ( 20 10 ), Lo ur en ço e t a l.4 3 (2 00 9) , M at to s et a l.5 (2 01 4) , M or et ti et a l.4 6 ( 20 10 ), N as ci m en to e t a l.2 8 ( 20 09 ), P ad ilh a et a l.2 9 ( 20 05 ), P im en te l e t a l.3 0 ( 20 10 ), Sa nt os a nd A ss is 35 (2 00 6) , So uz a an d Ro nc al li4 4 ( 20 07 ), V ie ira e t a l.3 7 ( 20 13 ) 66 ,7 A ux ili ar y Te am (O ra l H ea lth T ec hn ic ia n an d O ra l H ea lth A ss is ta nt ) B al da ni e t a l.3 8 ( 20 05 ), C or re a et a l.2 3 ( 20 10 ), Fe rn an de s et a l.2 4 ( 20 15 ), 10 In te rs ec to ria lit y A qu ila nt e an d A ci ol e1 9, 45 (2 01 5) , B al da ni e t a l.3 8 (2 00 5) , C ha ve s an d da S ilv a2 2 ( 20 07 ), C ol us si a nd C al vo 39 (2 01 1) , G od oi e t a l.4 1 ( 20 14 ), M at to s et a l.5 (2 01 4) , M el lo e t a l.2 6 ( 20 14 ), M or et ti et a l.4 6 ( 20 10 ), P ad ilh a et a l.2 9 ( 20 05 ), P im en te l e t a l.3 0 ( 20 10 ), Sa nt os a nd A ss is 35 (2 00 6) , S ou za a nd R on ca lli 44 (2 00 7) , V ie ira e t a l.3 7 ( 20 13 ) 46 ,7 Q ua lifi ed M an ag er A qu ila nt e an d A ci ol e4 5 ( 20 15 ), Fe rn an de s et a l.2 4 (2 01 5) , R os si a nd C ha ve s3 2 ( 20 15 ) 10 U ni ve rs ity -H ea lth S er vi ce In te gr at io n G od oi e t a l.4 0, 41 (2 01 3, 2 01 4) , M el lo e t a l.2 6 ( 20 14 ) 6, 7 In te rp er so na l r el at io ns hi p V ie ira e t a l.3 7 ( 20 13 ) 3, 3 In te rp ro fe ss io na l t ea m w or k A qu ila nt e an d A ci ol e1 9, 45 (2 01 5) , B al da ni e t a l.3 8 (2 00 5) , C av al ca nt i e t a l.2 1 ( 20 12 ), C ha ve s an d da S ilv a2 2 ( 20 07 ), C ol us si a nd C al vo 39 (2 01 1) , Fe rn an de s et a l.2 4 ( 20 15 ), Lo ur en ço e t a l.4 3 ( 20 09 ), M el lo e t a l.2 6 ( 20 14 ), M or et ti et a l.4 6 ( 20 10 ), N as ci m en to e t a l.2 8 ( 20 09 ), P ad ilh a et a l.2 9 ( 20 05 ), P im en te l e t a l.3 0 ( 20 10 ) 40 15 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Discussion A total of 20 specific practices (codes) were identified in the metasummary of the retrieved data and allocated into three families: “Oral Healthcare Structure”, “Oral Healthcare Provision” and “Staff Management”. Adequate structure, including not only the physical structure itself, but also the knowledge about health system organization, is a basic requirement to address Table 4. Intensity of the effect size (IES) for all codes and codes with FES > 25%. Article IES % all codes (n = 20) IES % codes > 25% (n= 10) Aguilera et al.18 (2013) 15 30 Aquilante and Aciole19 (2015) 35 60 Aquilante and Aciole45 (2015) 50 90 Araújo and Dimenstein20 (2006) 10 20 Baldani et al.38 (2005) 45 80 Cavalcanti et al.21 (2012) 30 40 Chaves and da Silva22 (2007) 35 50 Colussi and Calvo39 (2011) 15 30 Correa et al.23 (2010) 25 30 Fernandes et al.24 (2015) 30 50 Godoi et al.40 (2013) 30 40 Godoi et al.41 (2014) 35 60 Lessa and Vettore42 (2010) 15 30 Lippert et al.25 (2020) 5 20 Lourenço et al.43 (2009) 40 70 Mattos et al.5 (2014) 25 50 Mello et al.26 (2014) 15 20 Moimaz et al.27 (2008) 15 10 Moretti et al46. (2010) 25 50 Nascimento et al.28 (2009) 35 60 Padilha et al.29 (2005) 35 70 Pimentel, Moura and Acioli30 (2010) 30 60 Rodrigues et al.31 (2011) 5 10 Rossi and Chaves32 (2015) 25 30 Sá et al.33 (2015) 5 10 Santos et al.34 (2007) 25 30 Santos and Assis35 (2006) 25 40 Silva et al.36 (2020) 10 10 Souza and Roncalli44 (2007) 25 50 Vieira et al.37 (2013) 55 80 16 Uchida et al. Braz J Oral Sci. 2022;21:e226252 the demands of universal health coverage. Apart from oral health clinical care, the involvement of the community, other health professionals, and other sectors of soci- ety are of great value to amplify habit changing and health promotion47. Additionally, healthcare staff motivation, interprofessional integration and continuing qualification are also important characteristics to improve working processes through individual contribution, and to strengthen interpersonal relationships. Although all the 20 spe- cific practices were not applied at the same time in the same place, it seems that their widespread implementation could place oral healthcare managers/teams onto a more progressive path to promote a healthier population in long-term practice. In all the included studies, samples were composed by dentists and/or oral health managers. The majority of the participants were oral health managers, who directly contributed to the implementation of oral healthcare practices within SUS. Dentists emerged as important protagonists, either working at Basic Health Units (BHUs), leading Oral Health Teams (OHTs), or occupying management positions. However, the evidence also shows that good management is not only dependant on qualified managers, but also on the efficient performance of OHT members. Among the 20 codes identified in the metasummary, three main practices emerged as being the most relevant: Care Diagnosis and Planning (FES = 82%), Family Health Strategy (FES = 71%), and Interprofessional teamwork (FES = 46%). In the family “Oral Healthcare Structure”, the code Care Diagnosis and Planning emerged from 23 of 28 studies included in the metasummary, clearly indicating that situational diagnosis based on the epidemiological status of care provision along action planning are essential for a quality service45. This finding is in agreement with the BNOHP guidelines, which indicate that epidemiology and information about the geographic area covered by the OHTs should be used to subsidize action planning30. Planning has been considered the instrument to consolidate the foundational princi- ples of SUS (universality, integrality and equity), and promote health improvements32. In several studies, the authors registered the need for managers to structure and organize oral healthcare provision based on action planning to increase access and ensure the continuity of treatment19,27,32,33,42-46. Moreover, proposed actions need to be permanently evaluated to ensure that improvements in the healthcare system and in the general health of the population are implemented step by step. The practices conducted by managers in municipalities with no water fluoridation and high preva- lence of dental caries is a good example. OHT members should be guided on the need to perform fluoridated mouthwashes or distribute sachets with fluoride to the local population23,30,41,45. Therefore, OHT professionals should be responsible for planning, organizing, developing and evaluating actions according to the requirements of their local community, seeking articulation with the most varied social actors involved in health promotion48. In the family “Oral Healthcare Provision”, the code Family Health Strategy emerged as the most important practice. Most of the studies analyzed proposed that OHTs should be more closely integrated into the FHS through group activities, regular home visits, and seeing the patient in a more holistic sense22,29,43,46,49. The FHS has been designed to renew the rationale of care, which must go beyond interventions directed to the cure of the individual34. The FHS philosophy involves the reorgani- 17 Uchida et al. Braz J Oral Sci. 2022;21:e226252 zation of care practices, by replacing the traditional model oriented to the treat- ment of diseases, to focusing on how families live and their immediate needs49. The FHS is responsible for monitoring a defined number of families, located in a defined geographical area, with focus on health promotion, prevention, recovery, and reha- bilitation of more frequent diseases50. The FHS endeavours to redirect the work flow through the interaction of multiprofessional teams, aiming at implementing the most resolutive and integral practices within the perspective of health surveillance. Hence, primary care organization based on FHS principles has been deemed as essential to the development of the service. Managers have reported on the impor- tance the FHS and community health agent programs, in addition to specific pro- grams for women’s and children’s health, control of systemic diseases such as diabetes and hypertension, and oral health programs24,30,42. In the family “Staff Management”, the code Interprofessional Teamwork highlights the importance of teamwork for the improvement of the FHS, emphasizing the integrality aspect of healthcare provision3. Thus, OHTs is the way to break away from more conventional models, by incorporating the expanded concept of health and sharing the burden of oral healthcare provision among different professional30. OHTs should not only assist in dealing with health issues, but also motivate the population to be engaged in selfcare. Moreover, OHTs are required for the collective construction of health actions. When difficulties arise, these can be the subject of discussion before they are eventually overcome. Thus, the presence of OHTs allows for the exchange of information and search of more adequate therapeutic plans for the user21,29,45. The evidence arising from this systematic review shows that the inte- gration of the OHT members within the FHS has been occurring through the devel- opment of activities designed to draw stakeholders together and integrate health actions in an interprofessional manner19,29,43. For instance, the inclusion of dentists in vaccination campaigns, ludic-educational activities, supervised brushing, and children’s diet evaluation30. The evidence emerging from the three families of codes indicate that care diagnosis, health planning, OHT/FHS integration, and interprofessional teamwork were the most relevant adopted practices. As a result, oral healthcare managers tend to perform well when: 1. They know the legislation, and SUS and BNOHP guidelines; 2. Their OHT members participate in ongoing health education; 3. They stimulate intersectionality within their local communities; and 4. They put into effect their leadership role. Thus, qualified oral healthcare managers provide support and guidance, foster cooperation while implementing government health policies, involve all healthcare stakeholders collectively, and are in close contact with the community. Reliable situational diag- nosis, establishment of coherent goals, and optimization of physical and financial resources are fundamental requirements for reorganizing and strengthening basic oral healthcare. Action planning, appropriate to the needs and priorities of the popu- lation in question through the FHS, can allow the provision of higher quality care and more comprehensive and resolute attention to SUS users. Concerning the relevance of individual studies to the outcome of this review, four studies stood out with the higest IES, two qualitative studies37,45 and two surveys38,43. Qualitative studies showed codes that surveys and mixed-model studies did not, rein- 18 Uchida et al. Braz J Oral Sci. 2022;21:e226252 forcing the importance of the qualitative methodology as a powerful tool for in-depth research in Dentistry. While all the 20 codes emerged from qualitative studies, 5 of them (User satisfaction, Management Autonomy, Individual Performance, Qualified Management and Interpersonal Relationship) appeared exclusively in qualitative studies. The advantage of qualitative studies resides in its design, which may permit a deeper insight into the perceptions, feelings and opinions that are sometimes dif- ficult to be captured by surveys11. Nonetheless, surveys can also make an important contribution when they are adequately designed. The quality of the included studies was evaluated by assessing the risk of bias, which considers the characteristics of individual studies that contributed to the outcome51. Overall, most studies presented low risk of bias. Important quality lim- itations were observed in the majority of the selected studies. For instance, many qualitative studies did not mention the type of relationship between researchers and participants; did not present an adequate sample description; did not disclose the criteria used to select research subjects or the way data were analyzed; some results lacked clarity; and the relevance of the study and ethical issues were also absent. Therefore, future qualitative studies in the area should make use of the Con- fidence in the Evidence from Reviews of Qualitative research (CERQual) and the Consolidated Criteria for Reporting Qualitative Research (COREQ). CERQual pro- vides a clear method for assessing confidence in the synthesis of qualitative find- ings52. COREQ is an instrument that defines verification criteria to help researchers to report important aspects related to research teams, methods, context, findings, analysis and interpretations53. Although most of the surveys (62%) included in this systematic review was identified as having low risk of bias, none of the selected studies presented any type of ques- tionnaire validation. The use of a validated instrument would have significantly con- tributed to increasing the quality of the evidence, since the validation process shows the reliability and veracity of the questionnaire applied to research subjects. The two mixed-model studies also showed a high risk of bias. None of the items evaluated by the instrument were found in the included studies, with weaknesses in both the quantitative and qualitative evaluation. In relation to the quantitative component, not enough information on the methodological outline could be found. On the other hand, in the qualitative component, there was no information on items related to sampling, methodology and the presence an experienced researcher. In relation to the metasummary, an important limiting factor concerns the absence of a quality assessment instrument to integrate qualitative studies, surveys and mixed-model studies. In conclusion, the evidence emerging from this systematic review and metasummary demonstrate that oral healthcare diagnosis, planning, and basic care based on the FHS principles were the most relevant practices adopted by public oral healthcare managers in Brazil to provide quality care. Although most studies included in this systematic review presented a high risk of bias, the emerg- ing evidence makes a significant contribution to the improvement of oral healthcare management within SUS in Brazil. Other countries with universal health systems, as well as those seeking to follow the United Nations SDGs, may also benefit from the present findings. 19 Uchida et al. Braz J Oral Sci. 2022;21:e226252 Acknowledgments The authors would like to thank the Coordination for the Improvement of Higher Edu- cation Personnel (CAPES) for the scholarships granted to the graduate student par- ticipating in the study and the National Council of Technological and Scientific Devel- opment (CNPq) for the research funding grant no. 401514/2013-7. Author Contribution Tânia Harumi Uchida: Data curation, investigation, methodology, project administra- tion, validation, original draft, writing, review and editing. Uhana Seifert Guimarães Suga: Data curation, Investigation, Methodology. 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Perception of dentists inserted in the Family Health Strategy on multiprofessional work. Rev Gepesvida. 2015;1(2):56-70. Portuguese. http://cqrmg.cochrane.org/supplemental-handbook-guidance http://cqrmg.cochrane.org/supplemental-handbook-guidance file:///C:\FOP-5 mar 2015\BJOS\Revisoes\2022\ 21 Uchida et al. Braz J Oral Sci. 2022;21:e226252 25. Lippert AO, Mendonça FF, Carvalho BG, Caldarelli PG. The dental specialties center as a point of attention in the oral health care network in a region of Paraná. Braz J Oral Sci. 2020;19:e209984. doi: 10.20396/bjos.v19i0.8659984. 26. Mello ALSF, de Andrade SR, Moysés SJ, Erdmann AL. Oral health care in the health network and the regionalization process. Cien Saude Colet. 2014;19(1):205-14. doi: 10.1590/1413-81232014191.1748. 27. Moimaz SAS, Garbin CAS, Garbin AJI, Ferreira NF, Gonçalves PE. Challenges and difficulties of financing oral health: a qualitative analysis. Rev Adm Publica. 2008;42(6):1121-35. Portuguese. doi: 10.1590/S0034-76122008000600005. 28. Nascimento AC, Moysés ST, Bisinelli JC, Moysés SJ. Oral health in the family health strategy: A change of practices or semantics diversionism. Rev Saude Publica. 2009 Jun;43(3):455-62. doi: 10.1590/s0034-89102009000300009. 29. Padilha WWN, Valença AMG, Cavalcanti AL, Almeida RVD, Taveira GS. Dental Planning in the Family Health Program of the State of Paraíba: a qualitative study. Rev Pesq Bras Odontoped Clin Integr. 2005;5(1):65-74. Portuguese. 30. Pimentel FC, Moura R, Acioli L. Análise da atenção à saúde bucal na Estratégia de Saúde da Família do Distrito Sanitário VI, Recife (PE). Ciência e Saúde Coletiva. 2010;15:2189–96. doi: https://doi.org/10.1590/S1413-81232010000400033 31. Rodrigues AAAO, Assis MMA, Nascimento MAA, Fonseca GS, Siqueira D. Oral Health in the Family Health Strategy in a municipality in the semi-arid region of Bahia. Rev Baiana Saude Publica. 2011;35(3):695-709. Portuguese. doi: 10.22278/2318-2660.2011.v35.n3.a326. 32. Rossi TRA, Chaves SCL. Secondary dental care implementation in two municipalities in the state of Bahia/Brazil. Saude Debate. 2015;39(spe):196-206. Portuguese. doi: 10.5935/0103-1104.2015S005186. 33. Sá CR, Kuhnen M, Santos IF, Arruda MP, Toassi RFC. Oral health planning in Primary health care: from theory to practice. Rev APS. 2015;18(1):92-101. Portuguese. 34. Santos AM, Assis MMA, Rodrigues AAAO, Nascimento MAA, Jorge M. Conflicting situations in the reception of oral health teams from the Family Health Program in Alagoinhas, Bahia, Brazil. Cad Saude Publica. 2007;23(1):75-85. Portuguese. doi: 10.1590/S0102-311X2007000100009. 35. Santos AM dos, Assis MMA. From fragmentation to integrality: constructing and reconstructing the practice of buccal health in the Alagoinhas (BA) Family Health Program. Cien Saude Colet. 2006;11(1):53-61. Portuguese. doi: 10.1590/S1413-81232006000100012. 36. Silva Junior CL, Almeida PF, Martins Filho MT, Lima LD. Implementation of Dental Specialty Centers in the context of health regionalization in the state of Ceará, Brazil. Physis. 2020;30(4):1-22. Portuguese. doi: 10.1590/S0103-73312020300404. 37. Vieira V, de Andrade FR, Castro CGJ, Bighetti TI, Narvai PC. Municipalization of health services according to oral health professionals in an upstate São Paulo municipality in Brazil. Saude Soc. 2013;22(3):795-803. Portuguese. doi: 10.1590/S0104-12902013000300013. 38. Baldani MH, Fadel CB, Possamai T, Queiroz MGS. [Inclusion of oral health services in the Family Health Program in the State of Paraná, Brazil]. Cad Saude Publica. 2005 Jul-Aug;21(4):1026-35. Portuguese. doi: 10.1590/s0102-311x2005000400005. 39. Colussi CF, Calvo MCM. An evaluation model for oral health in primary care. Cad Saude Publica. 2011 Sep;27(9):1731-45. Portuguese. doi: 10.1590/s0102-311x2011000900007. 40. Godoi H, de Mello ALSF, Caetano JC, Zanardi E. Oral Health Care Network: Limitations and Challenges in a Large Municipality of Santa Catarina, Brazil. Saude Transform Soc. 2013;4(4):69-77. Portuguese. 22 Uchida et al. Braz J Oral Sci. 2022;21:e226252 41. Godoi H, Mello ALSF de, Caetano JC. An oral health care network organized by large municipalities in Santa Catarina State, Brazil. Cad Saude Publica. 2014 Feb;30(2):318-32. Portuguese. doi: 10.1590/0102-311X00084513. 42. Lessa CFM, Vettore MV. Primary health care management in oral health in Fortaleza, Ceará, between 1999 and 2006 Saude Soc. 2010;19(3):547-56. Portuguese. doi: 10.1590/S0104-12902010000300007. 43. Lourenço EC, Silva ACB, Meneghin MC, Pereira AC. The insertion of oral health services in the Family Health Program at Minas Gerais State, Brazil. Cien Saude Colet. 2009 Oct;14 Suppl 1:1367-77. Portuguese. doi: 10.1590/s1413-81232009000800009. 44. Souza TMS de, Roncalli AG. Oral health in the Brazilian Family Health Program: a health care model evaluation. Cad Saude Publica. 2007 Nov;23(11):2727-39. Portuguese. doi: 10.1590/s0102-311x2007001100020. 45. Aquilante AG, Aciole GG. Building a “Smiling Brazil”? [a “Smiling Brazil”? Implementation of the Brazilian National Oral Health Policy in a health region in the State of São Paulo. Cad Saude Publica. 2015 Jan;31(1):82-96. Portuguese. doi: 10.1590/0102-311x00193313. 46. Moretti AC, Teixeira FF, Suss FMB, Lawden JAC, Lima LSM, Bueno RE, et al. Intersectoriality in health promotion actions carried out by the oral health team of Curitiba, Paraná State. Cien Saude Colet. 2010 Jun;15 Suppl 1:1827-34. Portuguese. doi: 10.1590/s1413-81232010000700095. 47. Peduzzi M, Agreli HF. Teamwork and collaborative practice in Primary Health Care. Interface. 2018;22(Supl.2):1525-34. doi: 10.1590/1807-57622017.0827. 48. Melo LMLL, Moimaz SAS, Garbin CAS, Garbin AJI, Saliba NA. Oral health assessment from the perspective of the municipal manager. RGO. 2016;64(4):402-10. doi: 10.1590/1981-863720160003000063096. 49. Assis MMA, Alves JS SA. Human resources policies and the (re)signification of workers’ practices in the Unified Health System (SUS): notes for the debate. Rev Baiana Saude Publica. 2008;32(Suppl 1):7-15. Portuguese. doi: 10.22278/2318-2660.2008.v32.n0.a1453. [referência não citada no texto] 50. Moraes Dos Santos ML, Zafalon EJ, Bomfim RA, Kodjaoglanian VL, Mendonça de Moraes SH, do Nascimento DDG, et al. Impact of distance education on primary health care indicators in central Brazil: An ecological study with time trend analysis. PLoS One. 2019 Mar 26;14(3):e0214485. doi: 10.1371/journal.pone.0214485. 51. Neves RG, Flores TR, Duro SMS, Nunes BP, Tomasi E. Time trend of Family Health Strategy coverage in Brazil, its Regions and Federative Units, 2006-2016. Epidemiol Serv Saude 2018;27(3):e2017170. doi: 10.5123/s1679-49742018000300008. 52. Galvão TF, Pereira MG. Rating the quality of evidence of systematic reviews. Epidemiol Serv Saude. 2015;24(1):173-5. Portuguese. doi: 10.5123/S1679-49742015000100019. 53. Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvins CJ, Gülmezoglu M, et al. Using qualitative evidence in decision making for Health and Social Interventions: an approach to assess confidence in findings from Qualitative Evidence Syntheses (GRADE-CERQual). PLoS Med 12(10): e1001895. doi: 10.1371/journal.pmed.1001895. 54. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007 Dec;19(6):349-57. doi: 10.1093/intqhc/mzm042. http://dx.doi.org/10.1590/1981-863720160003000063096 23 Uchida et al. Braz J Oral Sci. 2022;21:e226252 S up po rt in g in fo rm at io n A pp en di x 1. S ea rc h st ra te gy u se d in P ub m ed . G ro up K ey w or ds S ea rc h st ra te gy (M es h an d en tr y te rm s) P = P at ie nt de nt is t, de nt is ts / ge ne ra l d en ta l pr ac tit io ne r / ge ne ra l d en ta l pr ac tit io ne rs po lic ym ak er , po lic ym ak er s / po lic y m ak er , po lic y m ak er s (“ D en tis t” [A ll Fi el ds ] O R “ D en tis ts ”[A ll Fi el ds ] O R “ G en er al D en ta l P ra ct iti on er ”[A ll Fi el ds ] O R “ G en er al D en ta l P ra ct iti on er s” [A ll Fi el ds ] O R “p ol ic ym ak er s” [A ll Fi el ds ] O R “p ol ic ym ak er ”[A ll Fi el ds ] O R “p ol ic y m ak er s” [A ll Fi el ds ] O R “p ol ic y m ak er ”[A ll Fi el ds ] O R “ he al th ca re m an ag er ”[A ll Fi el ds ] O R “ he al th ca re m an ag er s” [A ll Fi el ds ] O R “ he al th p er so nn el ”[A ll Fi el ds ] O R “a dm in is tr at iv e pe rs on ne l”[ A ll Fi el ds ] O R “p er so nn el , a dm in is tr at iv e” [A ll Fi el ds ] O R “a dm in is tr at or s” [A ll Fi el ds ] O R “a dm in is tr at or ”[A ll Fi el ds ] O R “ he al th fa ci lit y ad m in is tr at or s” [A ll Fi el ds ] O R “ he al th fa ci lit y ad m in is tr at or s” [A ll Fi el ds ] O R (“ he al th fa ci lit y ad m in is tr at or s” [M eS H T er m s] O R (“ he al th ”[A ll Fi el ds ] A N D “f ac ili ty ”[A ll Fi el ds ] A N D “a dm in is tr at or s” [A ll Fi el ds ]) O R “ he al th fa ci lit y ad m in is tr at or s” [A ll Fi el ds ] O R (“ ad m in is tr at or ”[A ll Fi el ds ] A N D “h ea lth ”[A ll Fi el ds ] A N D “ fa ci lit y” [A ll Fi el ds ])) O R (“ he al th fa ci lit y ad m in is tr at or s” [M eS H T er m s] O R (“ he al th ”[A ll Fi el ds ] A N D “ fa ci lit y” [A ll Fi el ds ] A N D “a dm in is tr at or s” [A ll Fi el ds ]) O R “ he al th fa ci lit y ad m in is tr at or s” [A ll Fi el ds ] O R (“ ad m in is tr at or s” [A ll Fi el ds ] A N D “ he al th ”[A ll Fi el ds ] A N D “ fa ci lit y” [A ll Fi el ds ])) O R (“ he al th fa ci lit y ad m in is tr at or s” [M eS H T er m s] O R (“ he al th ”[A ll Fi el ds ] A N D “ fa ci lit y” [A ll Fi el ds ] A N D “a dm in is tr at or s” [A ll Fi el ds ]) O R “ he al th fa ci lit y ad m in is tr at or s” [A ll Fi el ds ] O R (“ fa ci lit y” [A ll Fi el ds ] A N D “a dm in is tr at or ”[A ll Fi el ds ] A N D “ he al th ”[A ll Fi el ds ])) O R (“ he al th fa ci lit y ad m in is tr at or s” [M eS H T er m s] O R (“ he al th ”[A ll Fi el ds ] A N D “ fa ci lit y” [A ll Fi el ds ] A N D “a dm in is tr at or s” [A ll Fi el ds ]) O R “ he al th fa ci lit y ad m in is tr at or s” [A ll Fi el ds ] O R (“ fa ci lit y” [A ll Fi el ds ] A N D “a dm in is tr at or s” [A ll Fi el ds ] A N D “h ea lth ”[A ll Fi el ds ])) O R “ he al th fa ci lit y ad m in is tr at or s” [A ll Fi el ds ] O R “d ec is io n m ak er s” [A ll Fi el ds ] O R “d ec is io n m ak er ”[A ll Fi el ds ] O R “m an ag er ”[A ll Fi el ds ] O R “m an ag er s” [A ll Fi el ds ] O R “d ec is io n- m ak er s” [A ll Fi el ds ] O R “d ec is io n- m ak er ”[A ll Fi el ds ] O R “ le ad d en tis ts ”[A ll Fi el ds ] O R (( “le ad ”[M eS H T er m s] O R “ le ad ”[A ll Fi el ds ]) A N D (“ de nt is ts ”[M eS H T er m s] O R “d en tis ts ”[A ll Fi el ds ] O R “d en tis t” [A ll Fi el ds ])) O R “ le ad er s” [A ll Fi el ds ] O R “ le ad er ”[A ll Fi el ds ] O R “d en ta l l ea de rs ”[A ll Fi el ds ] O R “d en ta l l ea de r” [A ll Fi el ds ] O R “d en ta l p ub lic h ea lth co ns ul ta nt s” [A ll Fi el ds ] O R “a ct or s” [A ll Fi el ds ]) (“ po lic y m ak in g” [A ll Fi el ds ] O R “ he al th p ol ic ym ak in g” [A ll Fi el ds ] O R “d en ta l p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R (( “o rg an iz at io n an d ad m in is tr at io n” [M eS H T er m s] O R (“ or ga ni za tio n” [A ll Fi el ds ] A N D “a dm in is tr at io n” [A ll Fi el ds ]) O R “o rg an iz at io n an d ad m in is tr at io n” [A ll Fi el ds ] O R “m an ag em en t” [A ll Fi el ds ] O R “d is ea se m an ag em en t” [M eS H T er m s] O R (“ di se as e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ]) O R “d is ea se m an ag em en t” [A ll Fi el ds ]) A N D (“ D en t P ra ct ”[J ou rn al ] O R (“ de nt al ”[A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ]) O R “d en ta l p ra ct ic e” [A ll Fi el ds ] O R “ D en t P ra ct (E w el l)” [J ou rn al ] O R (“ de nt al ”[A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ]) O R “d en ta l p ra ct ic e” [A ll Fi el ds ] O R “A us t D en t P ra ct ”[J ou rn al ] O R (“ de nt al ”[A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ]) O R “d en ta l p ra ct ic e” [A ll Fi el ds ])) O R (“ pr ac tic e m an ag em en t” [M eS H Te rm s] O R (“ pr ac tic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ]) O R “p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R (“ m an ag em en t” [A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ])) O R (“ pr ac tic e m an ag em en t” [M eS H T er m s] O R (“ pr ac tic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ]) O R “p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R (“ m an ag em en ts ”[A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ])) O R “p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R “p ra ct ic e m an ag em en t s er vi ce s” [A ll Fi el ds ] O R (“ pr ac tic e m an ag em en t” [M eS H T er m s] O R (“ pr ac tic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ]) O R “p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R (“ m an ag em en t” [A ll Fi el ds ] A N D “s er vi ce ”[A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ])) O R “p ra ct ic e m an ag em en t s er vi ce ”[A ll Fi el ds ] O R C on tin ue 24 Uchida et al. Braz J Oral Sci. 2022;21:e226252 C on tin ua tio n P = P at ie nt de nt is t, de nt is ts / ge ne ra l d en ta l pr ac tit io ne r / ge ne ra l d en ta l pr ac tit io ne rs po lic ym ak er , po lic ym ak er s / po lic y m ak er , po lic y m ak er s (“ pr ac tic e m an ag em en t” [M eS H T er m s] O R (“ pr ac tic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ]) O R “p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R (“ se rv ic e” [A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ])) O R (“ pr ac tic e m an ag em en t, de nt al ”[M eS H T er m s] O R (“ pr ac tic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ] A N D “d en ta l”[ A ll Fi el ds ]) O R “d en ta l p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R (“ de nt al ”[A ll Fi el ds ] A N D “p ra ct ic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ] A N D “s er vi ce s” [A ll Fi el ds ])) O R (“ pr ac tic e m an ag em en t, de nt al ”[M eS H Te rm s] O R (“ pr ac tic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ] A N D “d en ta l”[ A ll Fi el ds ]) O R “d en ta l p ra ct ic e m an ag em en t” [A ll Fi el ds ] O R (“ pr ac tic e” [A ll Fi el ds ] A N D “m an ag em en t” [A ll Fi el ds ] A N D “s er vi ce s” [A ll Fi el ds ] A N D “d en ta l”[ A ll Fi el ds ])) O R “m an ag ed c ar e” [A ll Fi el ds ] O R “p ub lic h ea lth m an ag em en t” [A ll Fi el ds ] O R “ he al th m an ag em en t” [A ll Fi el ds ] O R “ he al th p ol ic ym ak in g” [A ll Fi el ds ] O R “d ec is io n m ak in g” [A ll Fi el ds ] O R “ he al th c ar e m an ag em en t” [A ll Fi el ds ] O R “p ub lic p ol ic ie s” [A ll Fi el ds ] O R “p ub lic p ol ic y” [A ll Fi el ds ] O R “ he al th p ol ic ie s” [A ll Fi el ds ] O R “ he al th p ol ic y” [A ll Fi el ds ] O R “p ol ic ie s, h ea lth ”[A ll Fi el ds ] O R “p ol ic y, h ea lth ”[A ll Fi el ds ] O R “n at io na l h ea lth p ol ic y” [A ll Fi el ds ] O R (“ he al th po lic y” [M eS H T er m s] O R (“ he al th ”[A ll Fi el ds ] A N D “p ol ic y” [A ll Fi el ds ]) O R “ he al th p ol ic y” [A ll Fi el ds ] O R (“ he al th ”[A ll Fi el ds ] A N D “p ol ic ie s” [A ll Fi el ds ] A N D “n at io na l”[ A ll Fi el ds ])) O R (“ he al th p ol ic y” [M eS H T er m s] O R (“ he al th ”[A ll Fi el ds ] A N D “p ol ic y” [A ll Fi el ds ]) O R “ he al th p ol ic y” [A ll Fi el ds ] O R (“ he al th ”[A ll Fi el ds ] A N D “p ol ic y” [A ll Fi el ds ] A N D “n at io na l”[ A ll Fi el ds ])) O R “n at io na l h ea lth p ol ic ie s” [A ll Fi el ds ] O R (“ he al th po lic y” [M eS H T er m s] O R (“ he al th ”[A ll Fi el ds ] A N D “p ol ic y” [A ll Fi el ds ]) O R “ he al th p ol ic y” [A ll Fi el ds ] O R (“ po lic ie s” [A ll Fi el ds ] A N D “n at io na l”[ A ll Fi el ds ] A N D “ he al th ”[A ll Fi el ds ])) O R (p ol cy [A ll Fi el ds ] A N D (“ fe de ra l g ov er nm en t” [M eS H T er m s] O R (“ fe de ra l”[ A ll Fi el ds ] A N D “g ov er nm en t” [A ll Fi el ds ]) O R “ fe de ra l g ov er nm en t” [A ll Fi el ds ] O R “n at io na l”[ A ll Fi el ds ]) A N D (“ he al th ”[M eS H T er m s] O R “ he al th ”[A ll Fi el ds ])) O R “g ov er na nc e” [A ll Fi el ds ] O R “c lin ic al g ov er na nc e” [A ll Fi el ds ] O R “m an ag em en t” [A ll Fi el ds ] O R “d ec is io n- m ak in g” [A ll Fi el ds ] O R “m an ag in g re so ur ce s” [A ll Fi el ds ] O R “ le ad er sh ip ”[A ll Fi el ds ]) I = In te rv en tio n de nt is tr y / or al he al th / d en ta l ca re / d en ta l he al th s er vi ce (“ de nt is tr y” [A ll Fi el ds ] O R “o ra l h ea lth ”[A ll Fi el ds ] O R “ he al th , o ra l”[ A ll Fi el ds ] O R “d en ta l c ar e” [A ll Fi el ds ] O R “c ar e, d en ta l”[ A ll Fi el ds ] O R “d en ta l he al th s er vi ce s” [A ll Fi el ds ] O R (“ de nt al h ea lth s er vi ce s” [M eS H T er m s] O R (“ de nt al ”[A ll Fi el ds ] A N D “ he al th ”[A ll Fi el ds ] A N D “s er vi ce s” [A ll Fi el ds ]) O R “d en ta l h ea lth s er vi ce s” [A ll Fi el ds ] O R (“ se rv ic es ”[A ll Fi el ds ] A N D “d en ta l”[ A ll Fi el ds ] A N D “ he al th ”[A ll Fi el ds ])) O R (“ de nt al he al th s er vi ce s” [M eS H T er m s] O R (“ de nt al ”[A ll Fi el ds ] A N D “ he al th ”[A ll Fi el ds ] A N D “s er vi ce s” [A ll Fi el ds ]) O R “d en ta l h ea lth s er vi ce s” [A ll Fi el ds ] O R (“ he al th ”[A ll Fi el ds ] A N D “s er vi ce s” [A ll Fi el ds ] A N D “d en ta l”[ A ll Fi el ds ])) O R “d en ta l h ea lth s er vi ce ”[A ll Fi el ds ] O R (“ de nt al h ea lth se rv ic es ”[M eS H T er m s] O R (“ de nt al ”[A ll Fi el ds ] A N D “ he al th ”[A ll Fi el ds ] A N D “s er vi ce s” [A ll Fi el ds ]) O R “d en ta l h ea lth s er vi ce s” [A ll Fi el ds ] O R (“ he al th ”[A ll Fi el ds ] A N D “s er vi ce ”[A ll Fi el ds ] A N D “d en ta l”[ A ll Fi el ds ])) O R (“ de nt al h ea lth s er vi ce s” [M eS H T er m s] O R (“ de nt al ”[A ll Fi el ds ] A N D “h ea lth ”[A ll Fi el ds ] A N D “s er vi ce s” [A ll Fi el ds ]) O R “d en ta l h ea lth s er vi ce s” [A ll Fi el ds ] O R (“ se rv ic e” [A ll Fi el ds ] A N D “d en ta l”[ A ll Fi el ds ] A N D “h ea lth ”[A ll Fi el ds ])) O R “p ub lic d en ta l s er vi ce ”[A ll Fi el ds ]) 25 Uchida et al. Braz J Oral Sci. 2022;21:e226252 P R IS M A 2 00 9 C he ck lis t S ec ti on /t op ic # C he ck lis t i te m R ep or te d on pa ge # TI TL E Ti tle 1 Id en tif y th e re po rt a s a sy st em at ic re vi ew , m et a- an al ys is , o r b ot h. Ti tle A B S TR A C T St ru ct ur ed s um m ar y 2 P ro vi de a s tr uc tu re d su m m ar y in cl ud in g, a s ap pl ic ab le : b ac kg ro un d; o bj ec tiv es ; d at a so ur ce s; s tu dy e lig ib ili ty c rit er ia , p ar tic ip an ts , a nd in te rv en tio ns ; s tu dy a pp ra is al a nd s yn th es is m et ho ds ; r es ul ts ; l im ita tio ns ; c on cl us io ns a nd im pl ic at io ns o f k ey fi nd in gs ; s ys te m at ic re vi ew re gi st ra tio n nu m be r. A bs tr ac t IN TR O D U C TI O N R at io na le 3 D es cr ib e th e ra tio na le fo r t he re vi ew in th e co nt ex t o f w ha t i s al re ad y kn ow n. In tr od uc tio n O bj ec tiv es 4 P ro vi de a n ex pl ic it st at em en t o f q ue st io ns b ei ng a dd re ss ed w ith re fe re nc e to p ar tic ip an ts , i nt er ve nt io ns , c om pa ris on s, o ut co m es , a nd st ud y de si gn (P IC O S) . In tr od uc tio n M ET H O D S P ro to co l a nd re gi st ra tio n 5 In di ca te if a re vi ew p ro to co l e xi st s, if a nd w he re it c an b e ac ce ss ed (e .g ., W eb a dd re ss ), an d, if a va ila bl e, p ro vi de re gi st ra tio n in fo rm at io n in cl ud in g re gi st ra tio n nu m be r. M et ho ds El ig ib ili ty c rit er ia 6 Sp ec ify s tu dy c ha ra ct er is tic s (e .g ., P IC O S, le ng th o f f ol lo w -u p) a nd re po rt c ha ra ct er is tic s (e .g ., ye ar s co ns id er ed , l an gu ag e, p ub lic at io n st at us ) u se d as c rit er ia fo r e lig ib ili ty , g iv in g ra tio na le . M et ho ds In fo rm at io n so ur ce s 7 D es cr ib e al l i nf or m at io n so ur ce s (e .g ., da ta ba se s w ith d at es o f c ov er ag e, c on ta ct w ith s tu dy a ut ho rs to id en tif y ad di tio na l s tu di es ) i n th e se ar ch a nd d at e la st s ea rc he d. M et ho ds Se ar ch 8 P re se nt fu ll el ec tr on ic s ea rc h st ra te gy fo r a t l ea st o ne d at ab as e, in cl ud in g an y lim its u se d, s uc h th at it c ou ld b e re pe at ed . A pp en di x St ud y se le ct io n 9 St at e th e pr oc es s fo r s el ec tin g st ud ie s (i. e. , s cr ee ni ng , e lig ib ili ty , i nc lu de d in s ys te m at ic re vi ew , a nd , i f a pp lic ab le , i nc lu de d in th e m et a- an al ys is ). M et ho ds D at a co lle ct io n pr oc es s 10 D es cr ib e m et ho d of d at a ex tr ac tio n fr om re po rt s (e .g ., pi lo te d fo rm s, in de pe nd en tly , i n du pl ic at e) a nd a ny p ro ce ss es fo r o bt ai ni ng a nd co nfi rm in g da ta fr om in ve st ig at or s. M et ho ds D at a ite m s 11 Li st a nd d efi ne a ll va ria bl es fo r w hi ch d at a w er e so ug ht (e .g ., P IC O S, fu nd in g so ur ce s) a nd a ny a ss um pt io ns a nd s im pl ifi ca tio ns m ad e. M et ho ds R is k of b ia s in in di vi du al s tu di es 12 D es cr ib e m et ho ds u se d fo r a ss es si ng ri sk o f b ia s of in di vi du al s tu di es (i nc lu di ng s pe ci fic at io n of w he th er th is w as d on e at th e st ud y or ou tc om e le ve l), a nd h ow th is in fo rm at io n is to b e us ed in a ny d at a sy nt he si s. M et ho ds Su m m ar y m ea su re s 13 St at e th e pr in ci pa l s um m ar y m ea su re s (e .g ., ris k ra tio , d iff er en ce in m ea ns ). M et ho ds Sy nt he si s of re su lts 14 D es cr ib e th e m et ho ds o f h an dl in g da ta a nd c om bi ni ng re su lts o f s tu di es , i f d on e, in cl ud in g m ea su re s of c on si st en cy (e .g ., I2 ) fo r e ac h m et a- an al ys is . M et ho ds