Showing papers in "Health Research Policy and Systems in 2017"

Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy?

Abstract: There is extensive health and public health literature on the 'evidence-policy gap', exploring the frustrating experiences of scientists trying to secure a response to the problems and solutions they raise and identifying the need for better evidence to reduce policymaker uncertainty. We offer a new perspective by using policy theory to propose research with greater impact, identifying the need to use persuasion to reduce ambiguity, and to adapt to multi-level policymaking systems.We identify insights from secondary data, namely systematic reviews, critical analysis and policy theories relevant to evidence-based policymaking. The studies are drawn primarily from countries such as the United States, United Kingdom, Canada, Australia and New Zealand. We combine empirical and normative elements to identify the ways in which scientists can, do and could influence policy.We identify two important dilemmas, for scientists and researchers, that arise from our initial advice. First, effective actors combine evidence with manipulative emotional appeals to influence the policy agenda - should scientists do the same, or would the reputational costs outweigh the policy benefits? Second, when adapting to multi-level policymaking, should scientists prioritise 'evidence-based' policymaking above other factors? The latter includes governance principles such the 'co-production' of policy between local public bodies, interest groups and service users. This process may be based primarily on values and involve actors with no commitment to a hierarchy of evidence.We conclude that successful engagement in 'evidence-based policymaking' requires pragmatism, combining scientific evidence with governance principles, and persuasion to translate complex evidence into simple stories. To maximise the use of scientific evidence in health and public health policy, researchers should recognise the tendency of policymakers to base judgements on their beliefs, and shortcuts based on their emotions and familiarity with information; learn 'where the action is', and be prepared to engage in long-term strategies to be able to influence policy; and, in both cases, decide how far you are willing to go to persuade policymakers to act and secure a hierarchy of evidence underpinning policy. These are value-driven and political, not just 'evidence-based', choices.

The concept of 'vulnerability' in research ethics: an in-depth analysis of policies and guidelines.

Abstract: The concept of vulnerability has held a central place in research ethics guidance since its introduction in the United States Belmont Report in 1979. It signals mindfulness for researchers and research ethics boards to the possibility that some participants may be at higher risk of harm or wrong. Despite its important intended purpose and widespread use, there is considerable disagreement in the scholarly literature about the meaning and delineation of vulnerability, stemming from a perceived lack of guidance within research ethics standards. The aim of this study was to assess the concept of vulnerability as it is employed in major national and international research ethics policies and guidelines. We conducted an in-depth analysis of 11 (five national and six international) research ethics policies and guidelines, exploring their discussions of the definition, application, normative justification and implications of vulnerability. Few policies and guidelines explicitly defined vulnerability, instead relying on implicit assumptions and the delineation of vulnerable groups and sources of vulnerability. On the whole, we found considerable richness in the content on vulnerability across policies, but note that this relies heavily on the structure imposed on the data through our analysis. Our results underscore a need for policymakers to revisit the guidance on vulnerability in research ethics, and we propose that a process of stakeholder engagement would well-support this effort.

Advancing gender equality through the Athena SWAN Charter for Women in Science: an exploratory study of women’s and men’s perceptions

Abstract: While in the United Kingdom, Ireland, and Australia, higher education and research institutions are widely engaged with the Athena SWAN Charter for Women in Science to advance gender equality, empirical research on this process and its impact is rare. This study combined two data sets (free- text comments from a survey and qualitative interviews) to explore the range of experiences and perceptions of participation in Athena SWAN in medical science departments of a research-intensive university in Oxford, United Kingdom. The study is based on the secondary analysis of data from two projects: 59 respondents to an anonymous online survey (42 women, 17 men) provided relevant free-text comments and, separately, 37 women participated in face-to-face narrative interviews. Free-text survey comments and narrative interviews were analysed thematically using constant comparison. Both women and men said that participation in Athena SWAN had brought about important structural and cultural changes, including increased support for women’s careers, greater appreciation of caring responsibilities, and efforts to challenge discrimination and bias. Many said that these positive changes would not have happened without linkage of Athena SWAN to government research funding, while others thought there were unintended consequences. Concerns about the programme design and implementation included a perception that Athena SWAN has limited ability to address longstanding and entrenched power and pay imbalances, persisting lack of work-life balance in academic medicine, questions about the sustainability of positive changes, belief that achieving the award could become an end in itself, resentment about perceived positive discrimination, and perceptions that further structural and cultural changes were needed in the university and wider society. The findings from this study suggest that Athena SWAN has a positive impact in advancing gender equality, but there may be limits to how much it can improve gender equality without wider institutional and societal changes. To address the fundamental causes of gender inequality would require cultural change and welfare state policies incentivising men to increase their participation in unpaid work in the family, which is beyond the scope of higher education and research policy.

Tracking implementation strategies: a description of a practical approach and early findings

Abstract: Published descriptions of implementation strategies often lack precision and consistency, limiting replicability and slowing accumulation of knowledge. Recent publication guidelines for implementation strategies call for improved description of the activities, dose, rationale and expected outcome(s) of strategies. However, capturing implementation strategies with this level of detail can be challenging, as responsibility for implementation is often diffuse and strategies may be flexibly applied as barriers and challenges emerge. We describe and demonstrate the development and application of a practical approach to identifying implementation strategies used in research and practice that could be used to guide their description and specification. An approach to tracking implementation strategies using activity logs completed by project personnel was developed to facilitate identification of discrete strategies. This approach was piloted in the context of a multi-component project to improve children’s access to behavioural health services in a county-based child welfare agency. Key project personnel completed monthly activity logs that gathered data on strategies used over 17 months. Logs collected information about implementation activities, intent, duration and individuals involved. Using a consensus approach, two sets of coders categorised each activity based upon Powell et al.’s (Med Care Res Rev 69:123–57, 2012) taxonomy of implementation strategies. Participants reported on 473 activities, which represent 45 unique strategies. Initial implementation was characterised by planning strategies followed by educational strategies. After project launch, quality management strategies predominated, suggesting a progression of implementation over time. Together, these strategies accounted for 1594 person-hours, many of which were reported by the leadership team that was responsible for project design, implementation and oversight. This approach allows for identifying discrete implementation strategies used over time, estimating dose, describing temporal ordering of implementation strategies, and pinpointing the major implementation actors. This detail could facilitate clear reporting of a full range of implementation strategies, including those that may be less observable. This approach could lead to a more nuanced understanding of what it takes to implement different innovations, the types of strategies that are most useful during specific phases of implementation, and how implementation strategies need to be adaptively applied throughout the course of a given initiative.

Travelling models and the challenge of pragmatic contexts and practical norms: the case of maternal health

Abstract: As in other areas of international development, we are witnessing the proliferation of ‘traveling models’ developed by international experts and introduced in an almost identical format across numerous countries to improve some aspect of maternal health systems in low- and middle-income countries. These policies and protocols are based on ‘miracle mechanisms’ that have been taken out of their original context but are believed to be intrinsically effective in light of their operational devices. In reality, standardised interventions are, in Africa and elsewhere, confronted with pragmatic implementation contexts that are always varied and specific, and which lead to drifts, distortions, dismemberments and bypasses. The partogram, focused antenatal care, the prevention of mother-to-child transmission of HIV or performance-based payment all illustrate these implementation gaps, often caused by the routine behaviour of health personnel who follow practical norms (and a professional culture) that are often distinct from official norms – as is the case with midwives. Experiences in maternal and child health in Africa suggest that an alternative approach would be to start with the daily reality of social and practical norms instead of relying on models, and to promote innovations that emerge from within local health systems.

Development and validation of SEER (Seeking, Engaging with and Evaluating Research): a measure of policymakers' capacity to engage with and use research.

Abstract: Capacity building strategies are widely used to increase the use of research in policy development. However, a lack of well-validated measures for policy contexts has hampered efforts to identify priorities for capacity building and to evaluate the impact of strategies. We aimed to address this gap by developing SEER (Seeking, Engaging with and Evaluating Research), a self-report measure of individual policymakers’ capacity to engage with and use research. We used the SPIRIT Action Framework to identify pertinent domains and guide development of items for measuring each domain. Scales covered (1) individual capacity to use research (confidence in using research, value placed on research, individual perceptions of the value their organisation places on research, supporting tools and systems), (2) actions taken to engage with research and researchers, and (3) use of research to inform policy (extent and type of research use). A sample of policymakers engaged in health policy development provided data to examine scale reliability (internal consistency, test-retest) and validity (relation to measures of similar concepts, relation to a measure of intention to use research, internal structure of the individual capacity scales). Response rates were 55% (150/272 people, 12 agencies) for the validity and internal consistency analyses, and 54% (57/105 people, 9 agencies) for test-retest reliability. The individual capacity scales demonstrated adequate internal consistency reliability (alpha coefficients > 0.7, all four scales) and test-retest reliability (intra-class correlation coefficients > 0.7 for three scales and 0.59 for fourth scale). Scores on individual capacity scales converged as predicted with measures of similar concepts (moderate correlations of > 0.4), and confirmatory factor analysis provided evidence that the scales measured related but distinct concepts. Items in each of these four scales related as predicted to concepts in the measurement model derived from the SPIRIT Action Framework. Evidence about the reliability and validity of the research engagement actions and research use scales was equivocal. Initial testing of SEER suggests that the four individual capacity scales may be used in policy settings to examine current capacity and identify areas for capacity building. The relation between capacity, research engagement actions and research use requires further investigation.

Knowledge sharing in global health research – the impact, uptake and cost of open access to scholarly literature

Abstract: In 1982, the Annals of Virology published a paper showing how Liberia has a highly endemic potential of Ebola warning health authorities of the risk for potential outbreaks; this journal is only available by subscription. Limiting the accessibility of such knowledge may have reduced information propagation toward public health actors who were indeed surprised by and unprepared for the 2014 epidemic. Open access (OA) publication can allow for increased access to global health research (GHR). Our study aims to assess the use, cost and impact of OA diffusion in the context of GHR. A total of 3366 research articles indexed under the Medical Heading Subject Heading “Global Health” published between 2010 and 2014 were retrieved using PubMed to (1) quantify the uptake of various types of OA, (2) estimate the article processing charges (APCs) of OA, and (3) analyse the relationship between different types of OA, their scholarly impact and gross national income per capita of citing countries. Most GHR publications are not available directly on the journal’s website (69%). Further, 60.8% of researchers do not self-archive their work even when it is free and in keeping with journal policy. The total amount paid for APCs was estimated at US$1.7 million for 627 papers, with authors paying on average US$2732 per publication; 94% of APCs were paid to journals owned by the ten most prominent publication houses from high-income countries. Researchers from low- and middle-income countries are generally citing less expensive types of OA, while researchers in high-income countries are citing the most expensive OA. Although OA may help in building global research capacity in GHR, the majority of publications remain subscription only. It is logical and cost-efficient for institutions and researchers to promote OA by self-archiving publications of restricted access, as it not only allows research to be cited by a broader audience, it also augments citation rates. Although OA does not ensure full knowledge transfer from research to practice, limiting public access can negatively impact implementation and outcomes of health policy and reduce public understanding of health issues.

Allied health research positions: a qualitative evaluation of their impact

Abstract: Research positions embedded within healthcare settings have been identified as an enabler to allied health professional (AHP) research capacity; however, there is currently limited research formally evaluating their impact. In 2008, a Health Practitioner industrial agreement funded a research capacity building initiative within Queensland Health, Australia, which included 15 new allied health research positions. The present project used a qualitative and realist approach to explore the impact of these research positions, as well as the mechanisms which facilitated or hindered their success within their respective organisations. Forty-four AHP employees from six governmental health services in Queensland, Australia, participated in the study. Individual interviews were undertaken, with individuals in research positions (n = 8) and their reporting line managers (n = 8). Four stakeholder focus groups were also conducted with clinicians, team leaders and professional heads who had engaged with the research positions. Nine key outcomes of the research positions were identified across individual, team/service and organisational/community levels. These outcomes included clinician skill development, increased research activity, clinical and service changes, increased research outputs and collaborations, enhanced research and workplace culture, improved profile of allied health, development of research infrastructure, and professional development of individuals in the research positions. Different mechanisms that influenced these outcomes were identified. These mechanisms were grouped by those related to the (1) research position itself, (2) organisational factors and (3) implementation factors. The present findings highlight the potential value of the research positions for individuals, teams and clinical services across different governmental healthcare services, and demonstrate the impact of the roles on building the internal and external profile of allied health. Results build upon the emerging evidence base for allied health research positions and have important implications for a number of stakeholders (i.e. individuals in the research positions, AHPs and their managers, university partners and state-wide executives). Key recommendations are provided for all stakeholders to enhance the ongoing impact of these roles and the potential advocacy for additional positions and resources to support them.

How do we define the policy impact of public health research? A systematic review.

Abstract: In order to understand and measure the policy impact of research we need a definition of research impact that is suited to the task. This article systematically reviewed both peer-reviewed and grey literature for definitions of research impact to develop a definition of research impact that can be used to investigate how public health research influences policy. Keyword searches of the electronic databases Web of Science, ProQuest, PubMed, EMBASE, CINAHL, Informit, PsycINFO, The Cochrane Database of Systematic Reviews and Google Scholar were conducted between August 2015 and April 2016. Keywords included ‘definition’ and ‘policy’ and ‘research impact’ or ‘research evidence’. The search terms ‘health’, public health’ or ‘mental health’ and ‘knowledge transfer’ or ‘research translation’ were used to focus the search on relevant health discipline approaches. Studies included in the review described processes, theories or frameworks associated with public health, health services or mental health policy. We identified 108 definitions in 83 publications. The key findings were that literature on research impact is growing, but only 23% of peer-reviewed publications on the topic explicitly defined the term and that the majority (76%) of definitions were derived from research organisations and funding institutions. We identified four main types of definition, namely (1) definitions that conceptualise research impacts in terms of positive changes or effects that evidence can bring about when transferred into policies (example Research Excellence Framework definition), (2) definitions that interpret research impacts as measurable outcomes (Research Councils UK), and (3) bibliometric and (4) use-based definitions. We identified four constructs underpinning these definitions that related to concepts of contribution, change, avenues and levels of impact. The dominance of bureaucratic definitions, the tendency to discuss but not define the concept of research impact, and the heterogeneity of definitions confirm the need for conceptual clarity in this area. We propose a working definition of research impact that can be used in a range of health policy contexts.

Integrating consumer engagement in health and medical research - an Australian framework

Abstract: Quality practice of consumer engagement is still in its infancy in many sectors of medical research. The South Australian Health and Medical Research Institute (SAHMRI) identified, early in its development, the opportunity to integrate evidence-driven consumer and community engagement into its operations. SAHMRI partnered with Health Consumers Alliance and consumers in evidence generation. A Partnership Steering Committee of researchers and consumers was formed for the project. An iterative mixed-method qualitative process was used to generate a framework for consumer engagement. This process included a literature review followed by semi-structured interviews with experts in consumer engagement and lead medical researchers, group discussions and a consensus workshop with the Partnership Steering Committee, facilitated by Health Consumer Alliance. The literature revealed a dearth of evidence about effective consumer engagement methodologies. Four organisational dimensions are reported to contribute to success, namely governance, infrastructure, capacity and advocacy. Key themes identified through the stakeholder interviews included sustained leadership, tangible benefits, engagement strategies should be varied, resourcing, a moral dimension, and challenges. The consensus workshop produced a framework and tangible strategies. Comprehensive examples of consumer participation in health and medical research are limited. There are few documented studies of what techniques are effective. This evidence-driven framework, developed in collaboration with consumers, is being integrated in a health and medical research institute with diverse programs of research. This framework is offered as a contribution to the evidence base around meaningful consumer engagement and as a template for other research institutions to utilise.

Collaborative action for person-centred coordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care

Abstract: Fragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable ‘blue print’ mean that services are ‘experimenting’ with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings. Two centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations. Extensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the exchange of services and interactions. If collaborative action can foster P3C it will require sustained commitment from both research and practice. This approach is a radical departure from how policy, research and practice traditionally work, but one that we argue is now necessary to deal with the most complex health and social problems.

Global toxocariasis research trends from 1932 to 2015: a bibliometric analysis

Abstract: Toxocariasis is a highly prevalent parasitic disease in the tropical regions of the world, with its impact on public health being typically underestimated. To better recognise the trends and characteristics of toxocariasis research, this study is a bibliometric analysis of the global toxocariasis research. Searches were completed on April 5, 2016, using the Scopus database. A search without any language restriction was performed to extract publications dealing with toxocariasis. Terms related to toxocariasis were used to perform a title keyword search. A total of 2765 publications comprising 11 document types and published between 1932 and 2015 were included in the analysis. Articles were the most popular document form, accounting for 83.62% of all publications, followed by letters (3.80%) and reviews (3.4%). The annual number of research publications increased from 30 in 1980 to 111 in 2015, indicating that the number of publications on toxocariasis has increased slowly over the past 35 years. The United States of America and Japan are the predominant countries of origin, with 303 articles and 207 articles, respectively, followed by Brazil and the United Kingdom, with 180 (6.5%) each. The h-index for all the publications was 60. The highest h-index were for publications from the United Kingdom (h-index value = 43) and the United States (h-index value = 39); these two countries were also involved with the highest number of international collaborations, with 27 and 28 countries, respectively. Developed countries, including the United States, Japan, the United Kingdom, France, Germany and Italy, are the world’s leaders in toxocariasis research, contributing to more than 34% of the total published literature. In addition, developing countries, such as Brazil, Poland, Argentina and India, showed a noticeable increase in published papers on toxocariasis research in recent years. A push for more collaboration is needed to achieve a superior research strategy related to toxocariasis at the global level from the viewpoint of epidemiological data, clinical aspects, medical ecology, molecular aspects and treatment practices associated with toxocariasis.

The impact on healthcare, policy and practice from 36 multi-project research programmes: findings from two reviews.

Abstract: We sought to analyse the impacts found, and the methods used, in a series of assessments of programmes and portfolios of health research consisting of multiple projects. We analysed a sample of 36 impact studies of multi-project research programmes, selected from a wider sample of impact studies included in two narrative systematic reviews published in 2007 and 2016. We included impact studies in which the individual projects in a programme had been assessed for wider impact, especially on policy or practice, and where findings had been described in such a way that allowed them to be collated and compared. Included programmes were highly diverse in terms of location (11 different countries plus two multi-country ones), number of component projects (8 to 178), nature of the programme, research field, mode of funding, time between completion and impact assessment, methods used to assess impact, and level of impact identified. Thirty-one studies reported on policy impact, 17 on clinician behaviour or informing clinical practice, three on a combined category such as policy and clinician impact, and 12 on wider elements of impact (health gain, patient benefit, improved care or other benefits to the healthcare system). In those multi-programme projects that assessed the respective categories, the percentage of projects that reported some impact was policy 35% (range 5–100%), practice 32% (10–69%), combined category 64% (60–67%), and health gain/health services 27% (6–48%). Variations in levels of impact achieved partly reflected differences in the types of programme, levels of collaboration with users, and methods and timing of impact assessment. Most commonly, principal investigators were surveyed; some studies involved desk research and some interviews with investigators and/or stakeholders. Most studies used a conceptual framework such as the Payback Framework. One study attempted to assess the monetary value of a research programme’s health gain. The widespread impact reported for some multi-project programmes, including needs-led and collaborative ones, could potentially be used to promote further research funding. Moves towards greater standardisation of assessment methods could address existing inconsistencies and better inform strategic decisions about research investment; however, unresolved issues about such moves remain.

Institutional capacity to generate and use evidence in LMICs: current state and opportunities for HPSR.

Abstract: Evidence-informed decision-making for health is far from the norm, particularly in many low- and middle-income countries (LMICs). Health policy and systems research (HPSR) has an important role in providing the context-sensitive and -relevant evidence that is needed. However, there remain significant challenges both on the supply side, in terms of capacity for generation of policy-relevant knowledge such as HPSR, and on the demand side in terms of the demand for and use of evidence for policy decisions. This paper brings together elements from both sides to analyse institutional capacity for the generation of HPSR and the use of evidence (including HPSR) more broadly in LMICs. The paper uses literature review methods and two survey instruments (directed at research institutions and Ministries of Health, respectively) to explore the types of institutional support required to enhance the generation and use of evidence. Findings from the survey of research institutions identified the absence of core funding, the lack of definitional clarity and academic incentive structures for HPSR as significant constraints. On the other hand, the survey of Ministries of Health identified a lack of locally relevant evidence, poor presentation of research findings and low institutional prioritisation of evidence use as significant constraints to evidence uptake. In contrast, improved communication between researchers and decision-makers and increased availability of relevant evidence were identified as facilitators of evidence uptake. The findings make a case for institutional arrangements in research that provide support for career development, collaboration and cross-learning for researchers, as well as the setting up of institutional arrangements and processes to incentivise the use of evidence among Ministries of Health and other decision-making institutions. The paper ends with a series of recommendations to build institutional capacity in HPSR through engaging multiple stakeholders in identifying and maintaining incentive structures, improving research (including HPSR) training, and developing stronger tools for synthesising non-traditional forms of local, policy-relevant evidence such as grey literature. Addressing challenges on both the supply and demand side can build institutional capacity in the research and policy worlds and support the enhanced uptake of high quality evidence in policy decisions.

The quality of free antenatal and delivery services in Northern Sierra Leone

Abstract: The number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone. A cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities. The quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care. The health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.

Knowledge mobilisation for policy development: implementing systems approaches through participatory dynamic simulation modelling.

Abstract: Evidence-based decision-making is an important foundation for health policy and service planning decisions, yet there remain challenges in ensuring that the many forms of available evidence are considered when decisions are being made. Mobilising knowledge for policy and practice is an emergent process, and one that is highly relational, often messy and profoundly context dependent. Systems approaches, such as dynamic simulation modelling can be used to examine both complex health issues and the context in which they are embedded, and to develop decision support tools. This paper reports on the novel use of participatory simulation modelling as a knowledge mobilisation tool in Australian real-world policy settings. We describe how this approach combined systems science methodology and some of the core elements of knowledge mobilisation best practice. We describe the strategies adopted in three case studies to address both technical and socio-political issues, and compile the experiential lessons derived. Finally, we consider the implications of these knowledge mobilisation case studies and provide evidence for the feasibility of this approach in policy development settings. Participatory dynamic simulation modelling builds on contemporary knowledge mobilisation approaches for health stakeholders to collaborate and explore policy and health service scenarios for priority public health topics. The participatory methods place the decision-maker at the centre of the process and embed deliberative methods and co-production of knowledge. The simulation models function as health policy and programme dynamic decision support tools that integrate diverse forms of evidence, including research evidence, expert knowledge and localised contextual information. Further research is underway to determine the impact of these methods on health service decision-making.

Situating mobile health: a qualitative study of mHealth expectations in the rural health district of Nouna, Burkina Faso

Abstract: The implementation of mobile health (mHealth) projects in low- and middle-income countries raises high and well-documented expectations among development agencies, policymakers and researchers. By contrast, the expectations of direct and indirect mHealth users are not often examined. In preparation for a proposed intervention in the Nouna Health District, in rural Burkina Faso, this study investigates the expected benefits, challenges and limitations associated with mHealth, approaching these expectations as a form of situated knowledge, inseparable from local conditions, practices and experiences. The study was conducted within the Nouna Health District. We used a qualitative approach, and conducted individual semi-structured interviews and group interviews (n = 10). Participants included healthcare workers (n = 19), godmothers (n = 24), pregnant women (n = 19), women with children aged 12–24 months (n = 33), and women of childbearing age (n = 92). Thematic and content qualitative analyses were conducted. Participants expect mHealth to help retrieve patients lost to follow-up, improve maternal care monitoring, and build stronger relationships between pregnant women and primary health centres. Expected benefits are not reducible to a technological realisation (sending messages), but rather point towards a wider network of support. mHealth implementation is expected to present considerable challenges, including technological barriers, organisational challenges, gender issues, confidentiality concerns and unplanned aftereffects. mHealth is also expected to come with intrinsic limitations, to be found as obstacles to maternal care access with which pregnant women are confronted and on which mHealth is not expected to have any significant impact. mHealth expectations appear as situated knowledges, inseparable from local health-related experiences, practices and constraints. This problematises universalistic approaches to mHealth knowledge, while nevertheless hinting at concrete, expected benefits. Findings from this study will help guide the design and implementation of mHealth initiatives, thus optimising their chances for success.

Exploring the dynamics of food-related policymaking processes and evidence use in Fiji using systems thinking.

Abstract: Obesity and non-communicable diseases are significant public health issues globally and particularly in the Pacific. Poor diet is a major contributor to this issue and policy change is a powerful lever to improve food security and diet quality. This study aims to apply systems thinking to identify the causes and consequences of poor evidence use in food-related policymaking in selected government ministries in Fiji and to illicit strategies to strengthen the use of evidence in policymaking. The Ministry of Health and Medical Services and the Ministry of Agriculture in Fiji were invited through their respective Permanent Secretaries to participate in the study. Three 180-minute group model building (GMB) workshops were conducted separately in each ministry over three consecutive days with selected policymakers who were instrumental in developing food-related policies designed to prevent non-communicable diseases. The GMB workshops mapped the process of food-related policymaking and the contribution of scientific and local evidence to the process, and identified actions to enhance the use of evidence in policymaking. An average of 10 policymakers participated from each ministry. The causal loop diagrams produced by each ministry illustrated the causes and consequences of insufficient evidence use in developing food policies or precursors of the specific actions. These included (1) consultation, (2) engagement with stakeholders, (3) access and use of evidence, and (4) delays in policy processes. Participants agreed to potential leverage points on the themes above, addressing pertinent policymaker challenges in precursor control, including political influence, understanding of trade policies, competing government priorities and level of awareness on the problem. Specific actions for strengthening evidence use included training in policy development and research skills, and strengthening of coordination between ministries. The GMB workshops improved participants’ understanding of how different parts of the policy system interact. The causal loop diagrams and subsequent action plans enabled the identification of systems-level interventions in both ministries to improve evidence-informed policy development. A guide for integrating multi-sectoral consultation and stakeholder engagement in developing cross-cutting policies is currently being developed.

Towards fair and effective North-South collaboration: realising a programme for demand-driven and locally led research.

Abstract: At the turn of the 90s, studies showed that health research contributed little to health and development in low- and middle-income countries because it was oriented towards international priorities and dominated by researchers from the North. A new approach to North–South collaboration was required that would support demand-driven and locally led research in the South. The aim of this study was to analyse the development and functioning of a programme for demand-driven and locally led research in Ghana that was supported by a North–South collaboration. For this mixed-method case study, we combined document analysis, key informant interviews and observation of programme events. The development of the research programme started with constructing a sponsorship constellation in the Netherlands. After highlighting the problems with traditional research collaboration, an advisory council formulated a vision for a more equal and effective approach to North–South collaboration. Together with Ghanaian partners, this vision was turned into a proposal for a Ghanaian-led programme for demand-driven and locally led research, which was funded by the Netherlands government. Research priority setting showed that the Ghanaian research needs were very different from the priorities of foreign funders and researchers. After a slow start, the number of locally submitted proposals increased from 13 in 2001 to 94 in 2005, revealing the existence of a substantial, but partly latent reservoir of research capacity. In total, 79 studies were funded. An impact evaluation showed that the results of the majority of the studies were used to contribute to action. Despite its success, the research programme came to an end in 2008 after the sponsorship constellation in the Netherlands fell apart. Our study shows that realising a programme for demand-driven and locally led research in the South provides an effective approach to North–South collaboration in which results are used and local capacities and institutions are strengthened.

Responding to non-communicable diseases in Zambia: a policy analysis.

Abstract: Non-communicable diseases (NCDs) are an emerging global health concern. Reports have shown that, in Zambia, NCDs are also an emerging problem and the government has begun initiating a policy response. The present study explores the policy response to NCDs by the Ministry of Health in Zambia using the policy triangle framework of Walt and Gilson. A qualitative approach was used for the study. Data collected through key informant interviews with stakeholders who were involved in the NCD health policy development process as well as review of key planning and policy documents were analysed using thematic analysis. The government’s policy response was as a result of international strategies from WHO, evidence of increasing disease burden from NCDs and pressure from interest groups. The government developed the NCD strategic plan based on the WHO Global Action Plan for NCDs 2013–2030. Development of the NCD strategic plan was driven by the government through the Ministry of Health, who set the agenda and adopted the final document. Stakeholders participated in the fine tuning of the draft document from the Ministry of Health. The policy development process was lengthy and this affected consistency in composition of the stakeholders and policy development momentum. Lack of representative research evidence for some prioritised NCDs and use of generic targets and indicators resulted in the NCD strategic plan being inadequate for the Zambian context. The interventions in the strategic plan also underutilised the potential of preventing NCDs through health education. Recent government pronouncements were also seen to be conflicting the risk factor reduction strategies outlined in the NCD strategic plan. The content of the NCD strategic plan inadequately covered all the major NCDs in Zambia. Although contextual factors like international strategies and commitments are crucial catalysts to policy development, there is need for domestication of international guidelines and frameworks to match the disease burden, resources and capacities in the local context if policy measures are to be comprehensive, relevant and measurable. Such domestication should be guided by representative local research evidence.

Expanding the knowledge translation metaphor.

Abstract: Knowledge translation (KT) is a buzzword in modern medical science. However, there has been little theoretical reflection on translation as a process of meaning production in KT. In this paper, we argue that KT will benefit from the incorporation of a more theoretical notion of translation as an entangled material, textual and cultural process. We discuss and challenge fundamental assumptions in KT, drawing on theories of translation from the human sciences. We show that the current construal of KT as separate from and secondary to the original scientific message is close to the now deeply compromised literary view of translation as the simple act of copying the original. Inspired by recent theories of translation, we claim that KT can be more adequately understood in terms of a ‘double supplement’ – on the one hand, KT offers new approaches to the communication of scientific knowledge to different groups in the healthcare system with the aim of supplementing a lack of knowledge among clinicians (and patients). On the other, it demonstrates that a textual and cultural supplement, namely a concern with target audiences (clinicians and patients), is inevitable in the creation of an ‘autonomous’ science. Hence, the division between science and its translation is unproductive and impossible to maintain. We discuss some possible implications of our suggested shift in concept by drawing on pharmaceutical interventions for the prevention of HIV as a case. We argue that such interventions are based on a supplementary and paradoxical relation to the target audiences, both presupposing and denying their existence. More sophisticated theories of translation can lay the foundation for an expanded model of KT that incorporates a more adequate and reflective description of the interdependency of scientific, cultural, textual and material practices.

What do we think we are doing? How might a clinical information network be promoting implementation of recommended paediatric care practices in Kenyan hospitals?

Abstract: The creation of a clinical network was proposed as a means to promote implementation of a set of recommended clinical practices targeting inpatient paediatric care in Kenya. The rationale for selecting a network as a strategy has been previously described. Here, we aim to describe network activities actually conducted over its first 2.5 years, deconstruct its implementation into specific components and provide our ‘insider’ interpretation of how the network is functioning as an intervention. We articulate key activities that together have constituted network processes over 2.5 years and then utilise a recently published typology of implementation components to give greater granularity to this description from the perspective of those delivering the intervention. Using the Behaviour Change Wheel we then suggest how the network may operate to achieve change and offer examples of change before making an effort to synthesise our understanding in the form of a realist context–mechanism–outcome configuration. We suggest our network is likely to comprise 22 from a total of 73 identifiable intervention components, of which 12 and 10 we consider major and minor components, respectively. At the policy level, we employed clinical guidelines, marketing and communication strategies with intervention characteristics operating through incentivisation, persuasion, education, enablement, modelling and environmental restructuring. These might influence behaviours by enhancing psychological capability, creating social opportunity and increasing motivation largely through a reflective pathway. We previously proposed a clinical network as a solution to challenges implementing recommended practices in Kenyan hospitals based on our understanding of theory and context. Here, we report how we have enacted what was proposed and use a recent typology to deconstruct the intervention into its elements and articulate how we think the network may produce change. We offer a more generalised statement of our theory of change in a context–mechanism–outcome configuration. We hope this will complement a planned independent evaluation of ‘how things work’, will help others interpret results of change reported more formally in the future and encourage others to consider further examination of networks as means to scale up improvement practices in health in lower income countries.

The translation of sports injury prevention and safety promotion knowledge: insights from key intermediary organisations

Abstract: A recognised research-to-practice gap exists in the health research field of sports injury prevention and safety promotion. There is a need for improved insight into increasing the relevancy, accessibility and legitimacy of injury prevention and safety promotion research knowledge for sport settings. The role of key organisations as intermediaries in the process of health knowledge translation for sports settings remains under-explored, and this paper aims to determine, and describe, the processes of knowledge translation undertaken by a set of key organisations in developing and distributing injury prevention and safety promotion resources. The National Guidance for Australian Football Partnerships and Safety (NoGAPS) project provided the context for this study. Representatives from five key NoGAPS organisations participated in individual face-to-face interviews about organisational processes of knowledge translation. A qualitative descriptive methodology was used to analyse participants’ descriptions of knowledge translation activities undertaken at their respective organisations. Several themes emerged around health knowledge translation processes and considerations, including (1) identifying a need for knowledge translation, (2) developing and disseminating resources, and (3) barriers and enablers to knowledge translation. This study provides insight into the processes that key organisations employ when developing and disseminating injury prevention and safety promotion resources within sport settings. The relevancy, accessibility and legitimacy of health research knowledge is foregrounded, with a view to increasing the influence of research on the development of health-related resources suitable for community sport settings.

Understanding the state of health policy and systems research in West Africa and capacity strengthening needs: scoping of peer-reviewed publications trends and patterns 1990-2015.

Abstract: The need for locally-driven, locally-generated evidence to guide health policy and systems decision-making and implementation in West Africa remains urgent. Thus, health policy and systems research (HPSR) is a field with great potential for addressing many of the sub-region’s intransigent health challenges. This paper presents an analysis of trends and patterns of peer-reviewed HPSR publications across the Economic Community of West African States (ECOWAS), to help understand trends and patterns of HPSR publication and the degree of involvement of West African researchers in HPSR evidence generation in the sub-region. Our goal was to use the findings to inform the development of a sub-regional strategy to strengthen HPSR and its use to inform development and improvement of health outcomes. A scoping review was conducted over a 25-year period from January 1990 to September 2015. Literature searches were conducted in English and French using Google Scholar, PubMed Central and Cairn.info. A total of 258 articles were retrieved. Of these, 246 were statistically analysed, with 54% having West African lead authors. Two thirds of the papers originated from three out of the 15 countries of the ECOWAS, specifically Nigeria (28.86%), Burkina Faso (21.54%) and Ghana (17.07%). Most authors were based in academic institutions and participation of authors from ministries of health, hospitals and non-governmental organisations was limited. English was the predominant language for publication even for papers originating from Francophone West African countries. There has been a progressive increase in publications over the studied period. Despite progressive improvements over time, West Africa remains a weak sub-region in terms of peer-reviewed HPSR publications. Within the overall weakness, there is country-to-country variation. The fact that only a handful of countries accounted for nearly 70% of the total volume of publications in West Africa attests to the great disparities in individual, institutional and contextual capacities for HPSR evidence generation. Bridging the gap between lead institutions (universities and research centres) and the practice community (ministries, hospitals, non-governmental organisations) is indispensable for ensuring the practical use of HPSR evidence. There remains a major need for investments in HPSR capacity building in West Africa.

Health systems research in fragile and conflict affected states: a qualitative study of associated challenges

Abstract: High quality health systems research (HSR) in fragile and conflict-affected states (FCAS) is essential to guiding the policies and programmes that will improve access to health services and, ultimately, health outcomes. Yet, conducting HSR in FCAS is challenging. An understanding of these challenges is essential to tackling them and to supporting research conducted in these complex environments. Led by the Thematic Working Group on Health Systems in FCAS, the primary aim of this study was to develop a research agenda on HSR in FCAS. The secondary aim was to identify the challenges associated with conducting HSR in these contexts. This paper presents these challenges. Guided by a purposely-selected steering group, this qualitative study collected respondents’ perspectives through an online survey (n = 61) and a group discussion at the Third Global Symposium on HSR in September 2014 (n = 11). Respondents with knowledge and/or experience of HSR in FCAS were intentionally recruited. Of those ever involved in HSR in FCAS (45/61, 75%), almost all (98%) experienced challenges in conducting their research. Challenges fall under three broad thematic areas: (1) lack of appropriate support; (2) complex local research environment, including access constraints, weak local research capacity, collaboration challenges and lack of trust in the research process; and (3) limited research application, including rapidly outdated findings and lack of engagement with the research process and results. This study shows that those familiar with HSR in FCAS face many challenges in gaining support for and in conducting and applying high-quality research. There is a need for more sustainable support, including commitment to and long-term funding of HSR in FCAS; investment in capacity building within FCAS to meet the challenges related to implementation of research in these complex environments; relationship and trust building among stakeholders involved in HSR, particularly between local and international researchers and between researchers and participants; and innovative and flexible approaches to research design and implementation in these insecure and rapidly changing contexts.

Operations research in global health: a scoping review with a focus on the themes of health equity and impact.

Abstract: Operations research (OR) is a discipline that uses advanced analytical methods (e.g. simulation, optimisation, decision analysis) to better understand complex systems and aid in decision-making. Herein, we present a scoping review of the use of OR to analyse issues in global health, with an emphasis on health equity and research impact. A systematic search of five databases was designed to identify relevant published literature. A global overview of 1099 studies highlights the geographic distribution of OR and common OR methods used. From this collection of literature, a narrative description of the use of OR across four main application areas of global health – health systems and operations, clinical medicine, public health and health innovation – is also presented. The theme of health equity is then explored in detail through a subset of 44 studies. Health equity is a critical element of global health that cuts across all four application areas, and is an issue particularly amenable to analysis through OR. Finally, we present seven select cases of OR analyses that have been implemented or have influenced decision-making in global health policy or practice. Based on these cases, we identify three key drivers for success in bridging the gap between OR and global health policy, namely international collaboration with stakeholders, use of contextually appropriate data, and varied communication outlets for research findings. Such cases, however, represent a very small proportion of the literature found. Poor availability of representative and quality data, and a lack of collaboration between those who develop OR models and stakeholders in the contexts where OR analyses are intended to serve, were found to be common challenges for effective OR modelling in global health.

Using Theories of Change to Inform Implementation of Health Systems Research and Innovation: Experiences of Future Health Systems Consortium Partners in Bangladesh, India and Uganda

Abstract: The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening. This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams’ experiences along four potential uses of ToCs, namely planning, communication, learning and accountability. The three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams’ experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams’ initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes. The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.

A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda

Abstract: Many approaches to improving health managers’ capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers’ capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers’ capacity in Eastern Uganda. This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers’ capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus. The findings indicate that the participatory action research approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness. Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers’ capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers’ capacity.

Donor funding health policy and systems research in low- and middle-income countries: how much, from where and to whom

Abstract: The need for sufficient and reliable funding to support health policy and systems research (HPSR) in low- and middle-income countries (LMICs) has been widely recognised. Currently, most resources to support such activities come from traditional development assistance for health (DAH) donors; however, few studies have examined the levels, trends, sources and national recipients of such support – a gap this research seeks to address. Using OECD’s Creditor Reporting System database, we classified donor funding commitments using a keyword analysis of the project-level descriptions of donor supported projects to estimate total funding available for HPSR-related activities annually from bilateral and multilateral donors, as well as the Bill and Melinda Gates Foundation, to LMICs over the period 2000–2014. Total commitments to HPSR-related activities have greatly increased since 2000, peaked in 2010, and have held steady since 2011. Over the entire study period (2000–2014), donors committed a total of $4 billion in funding for HPSR-related activities or an average of $266 million a year. Over the last 5 years (2010–2014), donors committed an average of $434 million a year to HPSR-related activities. Funding for HPSR is heavily concentrated, with more than 93% coming from just 10 donors and only represents approximately 2% of all donor funding for health and population projects. Countries in the sub-Saharan African region are the major recipients of HPSR funding. Funding for HPSR-related activities has generally increased over the study period; however, donor support to such activities represents only a small proportion of total DAH and has not grown in recent years. Donors should consider increasing the proportion of funds they allocate to support HPSR activities in order to further build the evidence base on how to build stronger health systems.

A mixed-methods study of system-level sustainability of evidence-based practices in 12 large-scale implementation initiatives.

Abstract: In recent decades, evidence-based practices (EBPs) have been broadly promoted in community behavioural health systems in the United States of America, yet reported EBP penetration rates remain low. Determining how to systematically sustain EBPs in complex, multi-level service systems has important implications for public health. This study examined factors impacting the sustainability of parent-child interaction therapy (PCIT) in large-scale initiatives in order to identify potential predictors of sustainment. A mixed-methods approach to data collection was used. Qualitative interviews and quantitative surveys examining sustainability processes and outcomes were completed by participants from 12 large-scale initiatives. Sustainment strategies fell into nine categories, including infrastructure, training, marketing, integration and building partnerships. Strategies involving integration of PCIT into existing practices and quality monitoring predicted sustainment, while financing also emerged as a key factor. The reported factors and strategies impacting sustainability varied across initiatives; however, integration into existing practices, monitoring quality and financing appear central to high levels of sustainability of PCIT in community-based systems. More detailed examination of the progression of specific activities related to these strategies may aide in identifying priorities to include in strategic planning of future large-scale initiatives. ClinicalTrials.gov ID NCT02543359 ; Protocol number PRO12060529.