Reflexivity in PHIR: let's have a reflexive talk!

Hospital Resilience to the COVID-19 Pandemic in Five Countries: A Multiple Case Study

Since the beginning of the pandemic, hospitals have been central to the COVID-19 response, often experiencing severe financial, material, and human constraints. In this special issue, we present some of the findings of the HoSPiCOVID research project. One of its main objectives was to compare hospital responses to the first and second waves of the COVID-19 pandemic in Brazil, Canada, France, Japan, and Mali. Studying and comparing how nine different hospitals coped with the pandemic in terms of preparedness and response allowed us to: 1) identify strengths and weaknesses of their responses, including challenges for hospital professionals; and 2) produce lessons learned, using a systematic approach to reflect and analyze their potential of resilience to the crisis. In the five countries, research teams conducted in-depth qualitative studies focused on nine large hospitals, using observation sessions, semistructured interviews with hospital professionals, and lessons learned workshops. The empirical work was supported by an original analytical framework on hospital resilience and a heuristic tool focused on configurations. The studies demonstrate that the hospitals were able to absorb and/or adapt to the crisis by deploying different coping mechanisms, which often required extensive involvement of hospital professionals. More extended study periods would be needed to assess the sustainability of these coping mechanisms and discern whether they have transformative potential. These international comparisons of hospital resilience, based on studies of contrasting contexts and epidemiological situations, allowed researchers to identify lessons learned to support hospital decision-makers in thinking more deeply about managing future health crises.

Effectiveness of Shared Decision-making Training Programs for Health Care Professionals Using Reflexivity Strategies: Secondary Analysis of a Systematic Review

BACKGROUND

Shared decision-making (SDM) leads to better health care processes through collaboration between health care professionals and patients. Training is recognized as a promising intervention to foster SDM by health care professionals. However, the most effective training type is still unclear. Reflexivity is an exercise that leads health care professionals to question their own values to better consider patient values and support patients while least influencing their decisions. Training that uses reflexivity strategies could motivate them to engage in SDM and be more open to diversity.

OBJECTIVE

In this secondary analysis of a 2018 Cochrane review of interventions for improving SDM by health care professionals, we aimed to identify SDM training programs that included reflexivity strategies and were assessed as effective. In addition, we aimed to explore whether further factors can be associated with or enhance their effectiveness.

METHODS

From the Cochrane review, we first extracted training programs targeting health care professionals. Second, we developed a grid to help identify training programs that used reflexivity strategies. Third, those identified were further categorized according to the type of strategy used. At each step, we identified the proportion of programs that were classified as effective by the Cochrane review (2018) so that we could compare their effectiveness. In addition, we wanted to see whether effectiveness was similar between programs using peer-to-peer group learning and those with an interprofessional orientation. Finally, the Cochrane review selected programs that were evaluated using patient-reported or observer-reported outcome measurements. We examined which of these measurements was most often used in effective training programs.

RESULTS

Of the 31 training programs extracted, 24 (77%) were interactive, among which 10 (42%) were considered effective. Of these 31 programs, 7 (23%) were unidirectional, among which 1 (14%) was considered effective. Of the 24 interactive programs, 7 (29%) included reflexivity strategies. Of the 7 training programs with reflexivity strategies, 5 (71%) used a peer-to-peer group learning strategy, among which 3 (60%) were effective; the other 2 (29%) used a self-appraisal individual learning strategy, neither of which was effective. Of the 31 training programs extracted, 5 (16%) programs had an interprofessional orientation, among which 3 (60%) were effective; the remaining 26 (84%) of the 31 programs were without interprofessional orientation, among which 8 (31%) were effective. Finally, 12 (39%) of 31 programs used observer-based measurements, among which more than half (7/12, 58%) were effective.

CONCLUSIONS

Our study is the first to evaluate the effectiveness of SDM training programs that include reflexivity strategies. Its conclusions open avenues for enriching future SDM training programs with reflexivity strategies. The grid developed to identify training programs that used reflexivity strategies, when further tested and validated, can guide future assessments of reflexivity components in SDM training.

Créer une communauté de pratique sur la recherche interventionnelle en santé mondiale

INTRODUCTION

In the French-speaking world, specifically in France, intervention research in global health has yet to be fully developed institutionally. The Institute of Research for Development (IRD) is one of the major public actors in global health research in France. Within this institute, researchers publish and communicate little on intervention research despite the fact that this is part of their daily work. This is why, for the past several years, the health and society department of the IRD has been working towards institutionalizing a network of IRD actors in population health intervention research (PHIR).

OBJECTIVE

The objective of this article is to analyze the needs of global health actors and elements that will allow for the construction of a community of practice in order to initiate an institutional anchoring of intervention research in global health through the mobilization of IRD actors.

METHOD

Qualitative research was carried out in 2017 including individual and group interviews. The results yielded several observations: 1) a definition of PHIR that differs according to the participants, 2) a need to strengthen formal and informal interactions to respond to the need for training and sharing experiences, to reinforce encounters and interpersonal bonds, to increase communication and visibility of implemented actions, 3) the participants’ desire to evolve together to overcome certain inherent challenges of global health such as interdisciplinarity, North-South partnerships, or communication with different populations.

CONCLUSION

Conducting population health intervention research requires a certain amount of reflection on the ways in which research is done and implies significant changes in the daily lives and work of researchers. It is essential to have institutional support to develop this, such as a community of practice. However, the absence of this community of practice three years later illustrates the operational challenges of implementing such an initiative.

Adapting a health equity tool to meet professional needs (Québec, Canada)

While numerous tools are available to better incorporate equity into population health actions, they are limited mainly by their lack of adaptation to professional practices and organizational realities. A study was conducted in Québec to identify and understand, from the perspective of future users, conditions that would facilitate use of a tool (Reflex-ISS) targeted at supporting collaborative action to improve consideration of social inequalities in health (SIH) within population health actions. Concept mapping and focus groups were implemented as complementary methods for investigating the conditions. Significant results that emerged were strong participant interest in the tool and the need for resources to better take SIH into account. The conditions for use that were identified referred to the tool itself (user-friendliness and literacy) and to resources for appropriating the tool, competency development, as well as the role and responsibilities of organizations and policies in promoting use of the tool in daily activities and more fundamentally in acting against SIH in general. Models for organizational innovation give an idea of the dimensions that need to be considered to strengthen the integration of equity into organizations and to support the changes in practice that result from using the tool. They provide a reminder that a health equity tool cannot be the cornerstone of an organizational strategy to fight against SIH; rather, it must be incorporated as part of a systemic strategy of professional and organizational development.

Participatory development and pilot testing of the Makasi intervention: a community-based outreach intervention to improve sub-Saharan and Caribbean immigrants' empowerment in sexual health

Background

Sub-Saharan and Caribbean immigrants are particularly affected by HIV in Europe, and recent evidence shows that a large portion of them acquired HIV after arrival. There is a need for efficient interventions that can reduce immigrants’ exposure to HIV. We describe the pilot phase of a community-based empowerment outreach intervention among sub-Saharan and Caribbean immigrants in the greater Paris area aimed at 1) constructing the intervention, 2) assessing its feasibility, and 3) assessing the feasibility of its evaluation based on a stepped-wedge approach.

Methods

1) To develop the intervention, a literature review was conducted on existing interventions and participatory approaches developed, including the constitution of peer groups. 2) To assess the intervention’s feasibility, a pilot was conducted between April 2018 and December 2018. A daily register was used to collect data on sociodemographic characteristics of all persons who visited the mobile team to assess eligibility and acceptability. 3) To assess the feasibility of performing a stepped-wedge trial to evaluate the intervention, we compared eligibility, enrolment and retention at 3 months in two arms (immediate vs deferred). Chi-squared tests were used to compare reach and retention between the two arms.

Results

Intervention development. The Makasi intervention was designed as an outreach intervention that starts with the persons’ capacities and helps them appropriate existing resources and information and obtain knowledge about sexual health, based upon motivational interviewing techniques.

Intervention Feasibility. Between April 2018 and December 2018, a total of 485 persons were identified as eligible. Participation in the intervention was proposed to 79% of eligible persons. When proposed, the persons enrolled in the intervention with a response rate of 69%. Some were lost to follow-up, and 188 persons were finally included.

Evaluation Feasibility. The proportions of eligible (45 and 42%) individuals and of enrolled individuals (65 and 74%) were similar and not significantly different in the immediate and deferred arms, respectively.

Conclusions

A community-based outreach intervention aimed at improving sub-Saharan and Caribbean immigrants’ empowerment in sexual health is feasible. The pilot phase was key to identifying challenges, designing a relevant intervention and validating the stepped-wedge protocol for evaluation.

A health knowledge brokering intervention in a district of Burkina Faso: A qualitative retrospective implementation analysis

BACKGROUND

A knowledge brokering (KB) intervention was implemented in Burkina Faso. By creating partnerships with health system actors in one district, the broker was expected to assess their knowledge needs, survey the literature to provide the most recent research evidence, produce various knowledge translation tools, and support them in using research to improve their actions. The purpose of this study was to analyze the key factors that influenced the KB project and to make recommendations for future initiatives.

METHODS

The qualitative design involved a single case study in which the KB intervention implementation was evaluated retrospectively. Data came from interviews with the intervention team (n = 4) and with various actors involved in the intervention (n = 16). Data from formative evaluations conducted during the KB implementation and observation data from a two-month field mission were also used. Two conceptual frameworks were combined to guide the analysis: the Consolidated Framework for Implementation Research (Damschroder et al., 2009) and the Ecological Framework (Durlak & DuPre, 2008).

RESULTS

Various KB activities were conducted during the first two years of implementation at the local level. The project came to an early end following vain efforts to relocate the intervention at the central level in order to further influence the policy process. Certain shortcomings in the implementation team negatively influenced the implementation: inadequate leadership, no shared vision regarding the reorientation of the intervention, challenges related to the KB role, and lack of frank communications internally. Other impediments to the intervention's deployment included local actors' lack of decision-making authority, the unavailability of resources and of organizational incentives for involvement in the KB intervention, and contextual challenges in accessing the central level. However, the KB strategy presented several strengths: collaborative development, support provided to local partners by the broker, and training opportunities and support provided to the broker.

CONCLUSIONS

More attention must be paid to intervention planning, partners' engagement, human, financial and technical resources availability, continuous development of skills and of communications within the KB team, and periodic assessment of potential obstacles related to the complexity of the system within which the intervention has been implemented. Using implementation science frameworks when developing KB strategies in the West African context should be promoted.

Why public health matters today and tomorrow: the role of applied public health research

Public health is critical to a healthy, fair, and sustainable society. Realizing this vision requires imagining a public health community that can maintain its foundational core while adapting and responding to contemporary imperatives such as entrenched inequities and ecological degradation. In this commentary, we reflect on what tomorrow’s public health might look like, from the point of view of our collective experiences as researchers in Canada who are part of an Applied Public Health Chairs program designed to support “innovative population health research that improves health equity for citizens in Canada and around the world.” We view applied public health research as sitting at the intersection of core principles for population and public health: namely sustainability, equity, and effectiveness. We further identify three attributes of a robust applied public health research community that we argue are necessary to permit contribution to those principles: researcher autonomy, sustained intersectoral research capacity, and a critical perspective on the research-practice-policy interface. Our intention is to catalyze further discussion and debate about why and how public health matters today and tomorrow, and the role of applied public health research therein.

Barriers and recruitment strategies for precarious status migrants in Montreal, Canada

BACKGROUND

Precarious status migrants are a group of persons who are vulnerable, heterogeneous, and often suspicious of research teams. They are underrepresented in population-based research projects, and strategies to recruit them are described exclusively in terms of a single cultural group. We analyzed the recruitment strategies implemented during a research project aimed at understanding precarious status migrants' health status and healthcare access in Montreal, Canada. The research sample consisted of 854 persons recruited from a variety of ethnocultural communities between June 2016 and September 2017. This article analyzes the strategies implemented by the research team to respond to the challenges of that recruitment, and assess the effectiveness of those strategies. Based on the results, we share the lessons learned with a view to increasing precarious status migrants' representation in research.

METHOD

A mixed sequential design was used to combine qualitative data gathered from members of the research team at a reflexive workshop (n = 16) and in individual interviews (n = 15) with qualitative and quantitative data collected using the conceptual mapping method (n = 10).

RESULTS

The research team encountered challenges in implementing the strategies, related to the identification of the target population, the establishment of community partnerships, and suspicion on the part of the individuals approached. The combination of a venue-based sampling method, a communications strategy, and the snowball sampling method was key to the recruitment. Linking people with resources that could help them was useful in obtaining their effective and non-instrumental participation in the study. Creating a diverse and multicultural team helped build trust with participants. However, the strategy of matching the ethnocultural identity of the interviewer with that of the respondent was not systematically effective.

CONCLUSION

The interviewers' experience and their understanding of the issue are important factors to take into consideration in future research. More over, the development of a community resource guide tailored to the needs of participants should be major components of any research project targeting migrants. Finally, strategies should be implemented as the result of a continuous reflexive process among all members of the research team.

Une formation complémentaire et appliquée : un besoin pour la relève en recherche interventionnelle en santé des populations

Population Health Intervention Research (PHIR) is an emerging and distinct field that combines scientific research and public health practice. However, traditional academic training in research, which is founded on specific disciplinary orientations, does not sufficiently inform and prepare new PHIR researchers. In this commentary, we advance the idea that PHIR requires a broader range of competencies and knowledge that must be developed through a complementary and applied training program. Drawing on our experience as 4P Strategic Training Program fellows, we identified key elements of the program that have helped prepare us in our careers as future and new PHIR researchers. We believe that complementary and applied training programs such as the 4P Program are a promising strategy in training and supporting the next generation of PHIR researchers in their efforts to improve population health.

Une politique concernant les données issues d’un programme de recherches interventionnelles en santé mondiale

La recherche interventionnelle en santé mondiale est souvent effectuée au moyen de partenariats scientifiques internationaux. Mais la réalisation de telles recherches, notamment dans les pays à faible revenu où les enjeux de pouvoir, d’argent et de relations interculturelles sont exacerbés, soulève de nombreux défis éthiques, notamment concernant la conduite responsable lors des recherches collaboratives. L’un d’eux est la conservation, l’accès, l’utilisation et la publication des données. Malgré l’existence de multiples politiques et documents phares sur l’éthique et la conduite responsable de la recherche, les chercheurs en recherche interventionnelle sont encore peu outillés pour faire face à ce défi. Dans le contexte d’un programme de recherches interventionnelles réalisées au Burkina Faso, les auteurs souhaitent partager leur expérience dans le développement d’une politique interne concernant leurs données. Après avoir évoqué le contexte global et particulier, l’article présente le processus de formulation et d’adoption de cette politique par les chercheurs d’une équipe interdisciplinaire et internationale (Allemagne, Burkina Faso, Canada, France). Les valeurs qui enchâssent cette politique interne sont la transparence, la prévention, le consensus autour du processus de production, le respect des principes internationaux, l’accès libre aux connaissances produites et la préoccupation pour leur diffusion et utilisation. La politique se présente en plusieurs parties : objet, types et statuts des chercheurs impliqués, conservation des données, accès et utilisation des données, production scientifique et paternité. Les principaux défis rencontrés par les chercheurs pour formuler cette politique sont analysés dans un souci de partage pour susciter un débat rarement abordé. La confiance, la transparence et le respect mutuel doivent être au coeur de tout partenariat scientifique en recherche interventionnelle.

What we have learnt (so far) about deliberative dialogue for evidence-based policymaking in West Africa

Policy decisions do not always take into account research results, and there is still little research being conducted on interventions that promote their use, particularly in Africa. To promote the use of research evidence in Africa, deliberative dialogue workshops are increasingly recommended as a means to establish evidence-informed dialogue among multiple stakeholders engaged in policy decision-making. In this paper, we reflect on our experiences of conducting national workshops in six African countries, and we propose operational recommendations for those wishing to organise deliberative dialogue. Our reflective and cross-sectional analysis of six national deliberative dialogue workshops in which we participated shows there are many specific challenges that should be taken into account when organising such encounters. In conclusion, we offer operational recommendations, drawn from our experience, to guide the preparation and conduct of deliberative workshops.

Can reflexivity be learned? An experience with tobacco control practitioners in Canada

Summary

To explore an example of a reflexive intervention with health professionals working in tobacco control (TC). This study reports the perceived intervention effects regarding: (i) participants' understanding of reflexivity and personal learning and (ii) conditions needed in order to integrate reflexivity into professional and organizational practices. This is a qualitative study using an interpretative evaluation framework to assess the perceived effects of a reflexive intervention in Montréal, Québec. Semi-structured qualitative interviews (n = 8) gathered data. Data analysis began deductively, guided by the broad categories found in research questions. Sub-categories to populate these broad categories captured the inhibitors and facilitators through an inductive thematic analysis. Our study reveals that, following the intervention, most participants had a generally good understanding of reflexivity and described concrete learning in association with the intervention. Main facilitators and inhibitors to conducting a reflexive workshop pertained to the organizational context as well as to the professional and individual characteristics of the participants. Some participants implemented sustainable changes as a result of the intervention, such as creating a tool, reviewing work plans and developing new mechanisms to integrate the voice of their clientele in the planning process. The need and interest for dialogue among health professionals about how TC intervention activities may inadvertently contribute to social inequalities in smoking is apparent. While there appears to be potential for reflexive practice, the integration of reflexivity into practice is reliant upon the organizational context (financial and time constraints, culture, support, and climate) and the reflexivity concept itself (intangibility, complexity and fuzziness).

A Knowledge Brokering Program in Burkina Faso (West Africa): Reflections from Our Experience

Abstract-In Burkina Faso, inadequate interaction among researchers, decision makers, and practitioners, together with low use of research results, impedes the development of health policies and interventions to improve equity. A knowledge translation strategy was implemented as part of a research program. The broker and his team promoted links between actors (health agents, nongovernmental organizations, public administration, policy makers, researchers), provided them with research results related to their needs, and supported them in applying this knowledge in their practices. The strategy was first implemented in Kaya District, Burkina Faso. To increase impact on population health, the strategy included widening the sphere of action through collaboration with the Ministry of Health. The broker was affiliated with a public health consulting firm in the capital, Ouagadougou, and supported by Canadian experts and a senior Burkinabè broker. Evaluation shows that research use increased at the local level among health mutuals, regional nongovernmental organizations, and health professionals in Kaya, but the objective of reaching Ministry of Health decision makers was not achieved. Results highlight the need for better training in knowledge transfer for both local and international researchers and proper identification of the gateways to reach high level decision makers. This ambitious strategy encountered several obstacles: difficult access to decision makers, poor team communication, and broker's nonconducive working environment. Future brokering strategies should analyze the political situation in depth to determine when and how to approach national and regional decision makers; invest time and effort in developing different actors' (including researchers') knowledge transfer skills; and ensure sufficient and good quality communications and resources within the team.

Building the field of population health intervention research: The development and use of an initial set of competencies

Population health intervention research (PHIR) is a relatively new research field that studies interventions that can improve health and health equity at a population level. Competencies are one way to give legitimacy and definition to a field. An initial set of PHIR competencies was developed with leadership from a multi-sector group in Canada. This paper describes the development process for these competencies and their possible uses.

Methods to develop the competencies included key informant interviews; a targeted review of scientific and gray literature; a 2-round, online adapted Delphi study with a 24-member panel; and a focus group with 9 international PHIR experts.

The resulting competencies consist of 25 items grouped into 6 categories. They include principles of good science applicable though not exclusive to PHIR, and more suitable for PHIR teams rather than individuals.

This initial set of competencies, released in 2013, may be used to develop graduate student curriculum, recruit trainees and faculty to academic institutions, plan non-degree professional development, and develop job descriptions for PHIR-related research and professional positions. The competencies provide some initial guideposts for the field and will need to be adapted as the PHIR field matures and to meet unique needs of different jurisdictions.

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Population health intervention research (PHIR) is a relatively new research field.

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PHIR competencies provide definition and initial guideposts for the PHIR field.

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PHIR competencies include principles of good science and unique features of PHIR.

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PHIR competencies can guide academic and professional training and job descriptions.