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Farran D, Salloum RG, El Jardali F, Abla R, Abu Rmeileh N, Al Sheyab N, Awaw-da S, Chalak A, Jawad M, Khader Y, Mostafa A, Nakkash R. From knowledge production to knowledge translation: Waterpipe tobacco control research in the Eastern Mediterranean Region. Tob Prev Cessat 2024; 10:TPC-10-03. [PMID: 38250221 PMCID: PMC10797642 DOI: 10.18332/tpc/175953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 01/23/2024]
Abstract
Waterpipe tobacco smoking (WTS) rates in the Eastern Mediterranean Region (EMR) are the highest worldwide, particularly among young people. Although fiscal policies to curb tobacco use have been recommended by the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), implementation has been suboptimal. The Eastern Mediterranean Consortium on the Economics of Waterpipe Tobacco Smoking (ECON-WTS) was formed in response to this need to produce knowledge on the economics of WTS in the EMR and apply a comprehensive Knowledge translation (KT) framework. The KT framework comprised priority setting, evidence synthesis, knowledge translation, and knowledge uptake. In this article, we discuss the approaches followed in applying the KT framework to WTS control, providing examples and noting challenges and lessons learned where possible.
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Affiliation(s)
- Dina Farran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Ramzi G. Salloum
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Fadi El Jardali
- Health Management and Policy Department, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Ruba Abla
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Niveen Abu Rmeileh
- Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Nihaya Al Sheyab
- Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Sameera Awaw-da
- Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
- Economics Department, Faculty of Business and Economics, Birzeit University, Birzeit, Palestine
| | - Ali Chalak
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Mohammed Jawad
- Public Health Policy Evaluation Unit, Imperial College London School of Public Health, London, UK
| | - Yousef Khader
- Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Aya Mostafa
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Lebanon
- Global and Community Health Department, George Mason University, Virginia, USA
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Bennett S, Jardali FE. Reimagining health systems: reflections from the 6th Global Symposium on Health Systems research. Health Policy Plan 2021; 36:i1-i3. [PMID: 34849894 PMCID: PMC8633629 DOI: 10.1093/heapol/czab102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St, Baltimore, MD 21205, USA
| | - Fadi El Jardali
- Faculty of Health Sciences, American University of Beirut, Riad El Solh, Beirut 1107, Lebanon
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Petkovic J, Riddle A, Akl EA, Khabsa J, Lytvyn L, Atwere P, Campbell P, Chalkidou K, Chang SM, Crowe S, Dans L, Jardali FE, Ghersi D, Graham ID, Grant S, Greer-Smith R, Guise JM, Hazlewood G, Jull J, Katikireddi SV, Langlois EV, Lyddiatt A, Maxwell L, Morley R, Mustafa RA, Nonino F, Pardo JP, Pollock A, Pottie K, Riva J, Schünemann H, Simeon R, Smith M, Stein AT, Synnot A, Tufte J, White H, Welch V, Concannon TW, Tugwell P. Protocol for the development of guidance for stakeholder engagement in health and healthcare guideline development and implementation. Syst Rev 2020; 9:21. [PMID: 32007104 PMCID: PMC6995157 DOI: 10.1186/s13643-020-1272-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/06/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Stakeholder engagement has become widely accepted as a necessary component of guideline development and implementation. While frameworks for developing guidelines express the need for those potentially affected by guideline recommendations to be involved in their development, there is a lack of consensus on how this should be done in practice. Further, there is a lack of guidance on how to equitably and meaningfully engage multiple stakeholders. We aim to develop guidance for the meaningful and equitable engagement of multiple stakeholders in guideline development and implementation. METHODS This will be a multi-stage project. The first stage is to conduct a series of four systematic reviews. These will (1) describe existing guidance and methods for stakeholder engagement in guideline development and implementation, (2) characterize barriers and facilitators to stakeholder engagement in guideline development and implementation, (3) explore the impact of stakeholder engagement on guideline development and implementation, and (4) identify issues related to conflicts of interest when engaging multiple stakeholders in guideline development and implementation. DISCUSSION We will collaborate with our multiple and diverse stakeholders to develop guidance for multi-stakeholder engagement in guideline development and implementation. We will use the results of the systematic reviews to develop a candidate list of draft guidance recommendations and will seek broad feedback on the draft guidance via an online survey of guideline developers and external stakeholders. An invited group of representatives from all stakeholder groups will discuss the results of the survey at a consensus meeting which will inform the development of the final guidance papers. Our overall goal is to improve the development of guidelines through meaningful and equitable multi-stakeholder engagement, and subsequently to improve health outcomes and reduce inequities in health.
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Affiliation(s)
- Jennifer Petkovic
- Bruyère Research Institute, Bruyère Continuing Care and University of Ottawa, 85 Primrose Ave East, Ottawa, Ontario, Canada.
| | - Alison Riddle
- Bruyère Research Institute, Bruyère Continuing Care and University of Ottawa, 85 Primrose Ave East, Ottawa, Ontario, Canada
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Joanne Khabsa
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | | | - Pearl Atwere
- Bruyère Research Institute, 85 Primrose Ave East, Ottawa, Ontario, Canada
| | - Pauline Campbell
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Kalipso Chalkidou
- Faculty of Medicine, School of Public Health Imperial College, London, UK
| | | | | | - Leonila Dans
- Department of Clinical Epidemiology, University of the Philippines-Manila, Taft Ave, 1000, Manila, Philippines
| | | | - Davina Ghersi
- National Health and Medical Research Council, Canberra, Australia
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sean Grant
- Department of Social & Behavioral Sciences, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, RG 6046, Indianapolis, IN, 46202, USA
| | | | - Jeanne-Marie Guise
- Departments of Obstetrics and Gynecology, Medical Informatics & Clinical Epidemiology, Emergency Medicine Oregon Health & Science, University School of Medicine and the OHSU-PSU School of Public Health, Portland, USA
| | | | - Janet Jull
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - S Vittal Katikireddi
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK
| | - Etienne V Langlois
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
| | - Anne Lyddiatt
- Cochrane Musculoskeletal Group, London, Ontario, Canada
| | | | - Richard Morley
- The Cochrane Collaboration, Cochrane Consumer Network, London, UK
| | - Reem A Mustafa
- Department of Internal Medicine/Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas, USA
| | - Francesco Nonino
- Unit of Epidemiology and Statistics, IRCCS - Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Jordi Pardo Pardo
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Alex Pollock
- Nursing Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Kevin Pottie
- Departments of Family Medicine and Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Primary Care Research Group and Equity Methods Group, Bruyère Research Institute, Ottawa, Canada
| | - John Riva
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Holger Schünemann
- Department of Health Research Methods, Evidence, and Impact, Cochrane Canada and McMaster GRADE Centre, Hamilton, Canada
| | - Rosiane Simeon
- Bruyère Research Institute, Bruyère Continuing Care and University of Ottawa, 85 Primrose Ave East, Ottawa, Ontario, Canada
| | - Maureen Smith
- Cochrane Consumer Executive, Ottawa, Ontario, Canada
| | - Airton T Stein
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA, Rua Sarmento Leite 245, Porto Alegre, RS, 90050-170, Brazil
| | - Anneliese Synnot
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Howard White
- Alfred Deakin University, Geelong, Australia.,Journal of Development Studies and Journal of Development Effectiveness, Geelong, Victoria, Australia
| | - Vivian Welch
- Bruyère Research Institute, Bruyère Continuing Care and University of Ottawa, 85 Primrose Ave East, Ottawa, Ontario, Canada.,The Campbell Collaboration, Oslo, Norway
| | - Thomas W Concannon
- The RAND Corporation, Boston, MA, USA.,Tufts Clinical & Translational Science Institute, Tufts University School of Medicine, Boston, MA, USA
| | - Peter Tugwell
- University of Ottawa, Department of Medicine, Faculty of Medicine, Ottawa, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Canada.,University of Ottawa, School of Epidemiology and Public Health, Faculty of Medicine, Ottawa, Canada
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Koon AD, Windmeyer L, Bigdeli M, Charles J, El Jardali F, Uneke J, Bennett S. A scoping review of the uses and institutionalisation of knowledge for health policy in low- and middle-income countries. Health Res Policy Syst 2020; 18:7. [PMID: 31959208 PMCID: PMC6971874 DOI: 10.1186/s12961-019-0522-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 12/20/2019] [Indexed: 12/21/2022] Open
Abstract
There is growing interest in how different forms of knowledge can strengthen policy-making in low- and middle-income country (LMIC) health systems. Additionally, health policy and systems researchers are increasingly aware of the need to design effective institutions for supporting knowledge utilisation in LMICs. To address these interwoven agendas, this scoping review uses the Arskey and O’Malley framework to review the literature on knowledge utilisation in LMIC health systems, using eight public health and social science databases. Articles that described the process for how knowledge was used in policy-making, specified the type of knowledge used, identified actors involved (individual, organisation or professional), and were set in specific LMICs were included. A total of 53 articles, from 1999 to 2016 and representing 56 countries, were identified. The majority of articles in this review presented knowledge utilisation as utilisation of research findings, and to a lesser extent routine health system data, survey data and technical advice. Most of the articles centered on domestic public sector employees and their interactions with civil society representatives, international stakeholders or academics in utilising epistemic knowledge for policy-making in LMICs. Furthermore, nearly all of the articles identified normative dimensions of institutionalisation. While there is some evidence of how different uses and institutionalisation of knowledge can strengthen health systems, the evidence on how these processes can ultimately improve health outcomes remains unclear. Further research on the ways in which knowledge can be effectively utilised and institutionalised is needed to advance the collective understanding of health systems strengthening and enhance evidence-informed policy formulation.
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Affiliation(s)
- Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD, 21205, United States of America. .,International Development Division, Abt Associates Inc, Rockville, MD, United States of America.
| | - Lauren Windmeyer
- Upstream USA, Oakland, CA, United States of America.,John F Kennedy School of Government, Harvard University, Cambridge, MA, United States of America
| | | | - Jodi Charles
- Office of Health Systems, United States Agency for International Development, Washington, D.C, United States of America
| | | | | | - Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD, 21205, United States of America
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Williamson A, Tait H, El Jardali F, Wolfenden L, Thackway S, Stewart J, O'Leary L, Dixon J. How are evidence generation partnerships between researchers and policy-makers enacted in practice? A qualitative interview study. Health Res Policy Syst 2019; 17:41. [PMID: 30987644 PMCID: PMC6466802 DOI: 10.1186/s12961-019-0441-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 03/19/2019] [Indexed: 12/20/2022] Open
Abstract
Background Evidence generation partnerships between researchers and policy-makers are a potential method for producing more relevant research with greater potential to impact on policy and practice. Little is known about how such partnerships are enacted in practice, however, or how to increase their effectiveness. We aimed to determine why researchers and policy-makers choose to work together, how they work together, which partnership models are most common, and what the key (1) relationship-based and (2) practical components of successful research partnerships are. Methods Semi-structured qualitative interviews were conducted with 18 key informants largely based in New South Wales, Australia, who were (1) researchers experienced in working in partnership with policy in health or health-related areas or (2) policy and programme developers and health system decision-makers experienced in working in partnership with researchers. Data was analysed thematically by two researchers. Results Researcher-initiated and policy agency-initiated evidence generation partnerships were common. While policy-initiated partnerships were thought to be the most likely to result in impact, researcher-initiated projects were considered important in advancing the science and were favoured by researchers due to greater perceived opportunities to achieve key academic career metrics. Participants acknowledged that levels of collaboration varied widely in research/policy partnerships from minimal to co-production. Co-production was considered a worthy goal by all, conferring a range of benefits, but one that was difficult to achieve in practice. Some participants asserted that the increased time and resources required for effective co-production meant it was best suited to evaluation and implementation projects where the tacit, experiential knowledge of policy-makers provided critical nuance to underpin study design, implementation and analysis. Partnerships that were mutually considered to have produced the desired outcomes were seen to be underpinned by a range of both relationship-based (such as shared aims and goals and trust) and practical factors (such as sound governance and processes). Conclusions Our findings highlight the important role of policy-makers in New South Wales in ensuring the relevance of research. There is still much to understand about how to initiate and sustain successful research/policy partnerships, particularly at the highly collaborative end. Electronic supplementary material The online version of this article (10.1186/s12961-019-0441-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Williamson
- The Sax Institute, PO Box K617, Haymarket, NSW, 1240, Australia. .,University of Sydney, Sydney, Australia. .,University of New South Wales, Sydney, Australia.
| | - Hannah Tait
- The Sax Institute, PO Box K617, Haymarket, NSW, 1240, Australia
| | | | - Luke Wolfenden
- University of Newcastle, Callaghan, Australia.,Hunter New England Population Health, New Lambton, Australia
| | | | - Jessica Stewart
- Department of Family and Community Services (FACS) Insights, Analysis and Research (FACSIAR), Ashfield, Australia
| | - Lyndal O'Leary
- Western NSW & Far West Local Health Districts, Dubbo, Australia
| | - Julie Dixon
- South Eastern Sydney Local Health District (SESLHD), Carringbah, Australia
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Younan L, Clinton M, Fares S, Jardali FE, Samaha H. The relationship between work-related musculoskeletal disorders, chronic occupational fatigue, and work organization: A multi-hospital cross-sectional study. J Adv Nurs 2019; 75:1667-1677. [DOI: 10.1111/jan.13952] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/31/2018] [Accepted: 12/07/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Lina Younan
- Hariri School of Nursing; American University of Beirut; Beirut Lebanon
| | - Michael Clinton
- Hariri School of Nursing; American University of Beirut; Beirut Lebanon
| | - Souha Fares
- Hariri School of Nursing; American University of Beirut; Beirut Lebanon
| | - Fadi El Jardali
- Department of Health Management & Policy; American University of Beirut; Beirut Lebanon
| | - Helen Samaha
- Academic and Administrative Nursing Affairs; Order of Nurses in Lebanon; Beirut Lebanon
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Sheikh K, Bennett SC, El Jardali F, Gotsadze G. Privilege and inclusivity in shaping Global Health agendas. Health Policy Plan 2018; 32:303-304. [PMID: 27935804 DOI: 10.1093/heapol/czw146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kabir Sheikh
- Public Health Foundation of India, Plot 47, Sector 44, Institutional Area Gurgaon 122002, Haryana, India
| | - Sara C Bennett
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Fadi El Jardali
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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El Jardali F, Mandil A, Jamal D, BouKarroum L, El Feky S, Nour M, Al Abbar M. Engagement of health research institutions in knowledge translation in the Eastern Mediterranean Region. East Mediterr Health J 2018; 24:672-679. [DOI: 10.26719/2018.24.7.672] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 08/08/2018] [Indexed: 11/09/2022]
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Mandil A, El Jardali F, El Feky S, Nour M, Al Abbar M, Bou Karroum L. Health research institutional mapping: an Eastern Mediterranean Regional perspective. East Mediterr Health J 2018. [DOI: 10.26719/2018.24.2.189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Yehia F, El Jardali F. Applying knowledge translation tools to inform policy: the case of mental health in Lebanon. Health Res Policy Syst 2015; 13:29. [PMID: 26047619 PMCID: PMC4461900 DOI: 10.1186/s12961-015-0018-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 05/26/2015] [Indexed: 12/27/2022] Open
Abstract
Background Many reform efforts in health systems fall short because the use of research evidence to inform policy remains scarce. In Lebanon, one in four adults suffers from a mental illness, yet access to mental healthcare services in primary healthcare (PHC) settings is limited. Using an “integrated” knowledge framework to link research to action, this study examines the process of influencing the mental health agenda in Lebanon through the application of Knowledge Translation (KT) tools and the use of a KT Platform (KTP) as an intermediary between researchers and policymakers. Methods This study employed the following KT tools: 1) development of a policy brief to address the lack of access to mental health services in PHC centres, 2) semi-structured interviews with 10 policymakers and key informants, 3) convening of a national policy dialogue, 4) evaluation of the policy brief and dialogue, and 5) a post-dialogue survey. Results Findings from the key informant interviews and a comprehensive synthesis of evidence were used to develop a policy brief which defined the problem and presented three elements of a policy approach to address it. This policy brief was circulated to 24 participants prior to the dialogue to inform the discussion. The policy dialogue validated the evidence synthesized in the brief, whereby integrating mental health into PHC services was the element most supported by evidence as well as participants. The post-dialogue survey showed that, in the following 6 months, several implementation steps were taken by stakeholders, including establishing national taskforce, training PHC staff, and updating the national essential drug list to include psychiatric medications. Relationships among policymakers, researchers, and stakeholders were strengthened as they conducted their own workshops and meetings after the dialogue to further discuss implementation, and their awareness about and demand for KT tools increased. Conclusions This case study showed that the use of KT tools in Lebanon to help generate evidence-informed programs is promising. This experience provided insights into the most helpful features of the tools. The role of the KTP in engaging stakeholders, particularly policymakers, prior to the dialogue and linking them with researchers was vital in securing their support for the KT process and uptake of the research evidence. Electronic supplementary material The online version of this article (doi:10.1186/s12961-015-0018-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Farah Yehia
- Department of Psychiatry, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, 1107 2020, Beirut, Lebanon. .,Knowledge to Policy (K2P) Center, American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020, Beirut, Lebanon.
| | - Fadi El Jardali
- Department of Health Management and Policy, Faculty of Health Sciences American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020, Beirut, Lebanon. .,Knowledge to Policy (K2P) Center, American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020, Beirut, Lebanon. .,Center for Systematic Reviews of Health Policy and Systems Research (SPARK), American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020, Beirut, Lebanon. .,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
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