Protocol for a living evidence synthesis on variants of concern and COVID-19 vaccine effectiveness

BACKGROUND

It is evident that COVID-19 will remain a public health concern in the coming years, largely driven by variants of concern (VOC). It is critical to continuously monitor vaccine effectiveness as new variants emerge and new vaccines and/or boosters are developed. Systematic surveillance of the scientific evidence base is necessary to inform public health action and identify key uncertainties. Evidence syntheses may also be used to populate models to fill in research gaps and help to prepare for future public health crises. This protocol outlines the rationale and methods for a living evidence synthesis of the effectiveness of COVID-19 vaccines in reducing the morbidity and mortality associated with, and transmission of, VOC of SARS-CoV-2.

METHODS

Living evidence syntheses of vaccine effectiveness will be carried out over one year for (1) a range of potential outcomes in the index individual associated with VOC (pathogenesis); and (2) transmission of VOC. The literature search will be conducted up to May 2023. Observational and database-linkage primary studies will be included, as well as RCTs. Information sources include electronic databases (MEDLINE; Embase; Cochrane, L*OVE; the CNKI and Wangfang platforms), pre-print servers (medRxiv, BiorXiv), and online repositories of grey literature. Title and abstract and full-text screening will be performed by two reviewers using a liberal accelerated method. Data extraction and risk of bias assessment will be completed by one reviewer with verification of the assessment by a second reviewer. Results from included studies will be pooled via random effects meta-analysis when appropriate, or otherwise summarized narratively.

DISCUSSION

Evidence generated from our living evidence synthesis will be used to inform policy making, modelling, and prioritization of future research on the effectiveness of COVID-19 vaccines against VOC.

Impact of strategies to mitigate misinformation in diverse settings and populations: a protocol for a living evidence synthesis

INTRODUCTION

Misinformation refers to inadvertent misleading information that the public may be exposed and share without intent to cause harm, and can delay or prevent effective care, affect mental health, lead to misallocation of health resources and/or create or exacerbate public-health crises. There are many strategies to address misinformation, but there is a need to evaluate their effects. Our objective is to synthesise and routinely update evidence to assess the impact of strategies to mitigate health-related misinformation in diverse settings, and populations.

METHODS AND ANALYSIS

We will search seven databases in May 2023 with planned updates at 6 and 9 months, which will be supplemented with searches for grey literature and reference lists of included studies and contacting experts. Two reviewers will independently screen all search results for studies that evaluate one or more approaches to addressing health-related misinformation. One researcher will conduct data extraction and risk of bias assessments, which will be reviewed by a second reviewer for accuracy. We will include experimental, quasi-experimental and observational studies for any populations, settings and diseases without language or publication restrictions. We will conduct quantitative analysis if meta-analytical pooling is possible. If pooling is not possible, we will synthesise quantitative data according to outcomes and interventions addressed, and present a narrative summary of findings disaggregated by sex and/or gender, irrespective of whether differences were found.

ETHICS AND DISSEMINATION

There are no individuals or protected health information involved and no safety issues identified. Results will be published through the Global Commission on Evidence and COVID-END websites, in a peer-reviewed journal, as well as through plain-language materials.

PROSPERO REGISTRATION NUMBER

CRD42023421149.

Identifying priority questions regarding rapid systematic reviews' methods: protocol for an eDelphi study

INTRODUCTION

Rapid systematic reviews (RRs) have the potential to provide timely information to decision-makers, thus directly impacting healthcare. However, consensus regarding the most efficient approaches to performing RRs and the presence of several unaddressed methodological issues pose challenges. With such a large potential research agenda for RRs, it is unclear what should be prioritised.

OBJECTIVE

To elicit a consensus from RR experts and interested parties on what are the most important methodological questions (from the generation of the question to the writing of the report) for the field to address in order to guide the effective and efficient development of RRs.

METHODS AND ANALYSIS

An eDelphi study will be conducted. Researchers with experience in evidence synthesis and other interested parties (eg, knowledge users, patients, community members, policymaker, industry, journal editors and healthcare providers) will be invited to participate. The following steps will be taken: (1) a core group of experts in evidence synthesis will generate the first list of items based on the available literature; (2) using LimeSurvey, participants will be invited to rate and rank the importance of suggested RR methodological questions. Questions with open format responses will allow for modifications to the wording of items or the addition of new items; (3) three survey rounds will be performed asking participants to re-rate items, with items deemed of low importance being removed at each round; (4) a list of items will be generated with items believed to be of high importance by ≥75% of participants being included and (5) this list will be discussed at an online consensus meeting that will generate a summary document containing the final priority list. Data analysis will be performed using raw numbers, means and frequencies.

ETHICS AND DISSEMINATION

This study was approved by the Concordia University Human Research Ethics Committee (#30015229). Both traditional, for example, scientific conference presentations and publication in scientific journals, and non-traditional, for example, lay summaries and infographics, knowledge translation products will be created.

Training and capacity development in patient-oriented research: Ontario SPOR SUPPORT Unit (OSSU) initiatives

BACKGROUND

In Canada, the Canadian Institutes of Health Research launched the Strategy for Patient-Oriented Research (SPOR) in 2011. The strategy defines 'patient-oriented research' as a continuum of research that engages patients as partners, focuses on patient priorities, and leads to improved patient outcomes. The overarching term 'patient' is inclusive of individuals with personal experience of a health issue as well as informal caregivers including family and friends. The vision for the strategy is improved patient experiences and outcomes through the integration of patient-oriented research findings into practice, policy, and health system improvement. Building capacity in patient-oriented research among all relevant stakeholders, namely patients, practitioners, organizational leaders, policymakers, researchers, and research funders is a core element of the strategy.

MAIN BODY

The objective of this paper is to describe capacity building initiatives in patient-oriented research led by the Ontario SPOR SUPPORT Unit in Ontario, Canada over the period 2014-2020.

CONCLUSION

The Ontario SPOR SUPPORT Unit Working Group in Training and Capacity Development has led numerous capacity building initiatives: developed a Capacity Building Compendium (accessed greater than 45,000 times); hosted Masterclasses that have trained hundreds of stakeholders (patients, practitioners, organizational leaders, policymakers, researchers, and trainees) in the conduct and use of patient-oriented research; funded the development of online curricula on patient-oriented research that have reached thousands of stakeholders; developed a patient engagement resource center that has been accessed by tens of thousands of stakeholders; identified core competencies for research teams and research environments to ensure authentic and meaningful patient partnerships in health research; and shared these resources and learnings with stakeholders across Canada, North America, and internationally.

A framework for considering the utility of models when facing tough decisions in public health: a guideline for policy-makers

The COVID-19 pandemic has brought the combined disciplines of public health, infectious disease and policy modelling squarely into the spotlight. Never before have decisions regarding public health measures and their impacts been such a topic of international deliberation, from the level of individuals and communities through to global leaders. Nor have models-developed at rapid pace and often in the absence of complete information-ever been so central to the decision-making process. However, after nearly 3 years of experience with modelling, policy-makers need to be more confident about which models will be most helpful to support them when taking public health decisions, and modellers need to better understand the factors that will lead to successful model adoption and utilization. We present a three-stage framework for achieving these ends.

Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis

BACKGROUND

Context is recognized as important to successful knowledge translation (KT) in health settings. What is meant by context, however, is poorly understood. The purpose of the current study was to elicit tacit knowledge about what is perceived to constitute context by conducting interviews with a variety of health system stakeholders internationally so as to compile a comprehensive list of contextual attributes and their features relevant to KT in healthcare.

METHODS

A descriptive qualitative study design was used. Semi-structured interviews were conducted with health system stakeholders (change agents/KT specialists and KT researchers) in four countries: Australia, Canada, the United Kingdom, and the United States. Interview transcripts were analyzed using inductive thematic content analysis in four steps: (1) selection of utterances describing context, (2) coding of features of context, (3) categorizing of features into attributes of context, (4) comparison of attributes and features by: country, KT experience, and role.

RESULTS

A total of 39 interviews were conducted. We identified 66 unique features of context, categorized into 16 attributes. One attribute, Facility Characteristics, was not represented in previously published KT frameworks. We found instances of all 16 attributes in the interviews irrespective of country, level of experience with KT, and primary role (change agent/KT specialist vs. KT researcher), revealing robustness and transferability of the attributes identified. We also identified 30 new context features (across 13 of the 16 attributes).

CONCLUSION

The findings from this study represent an important advancement in the KT field; we provide much needed conceptual clarity in context, which is essential to the development of common assessment tools to measure context to determine which context attributes and features are more or less important in different contexts for improving KT success.

Domains and processes for institutionalizing evidence-informed health policy-making: a critical interpretive synthesis

Background

While calls for institutionalization of evidence-informed policy-making (EIP) have become stronger in recent years, there is a paucity of methods that governments and organizational knowledge brokers can use to sustain and integrate EIP as part of mainstream health policy-making. The objective of this paper was to conduct a knowledge synthesis of the published and grey literatures to develop a theoretical framework with the key features of EIP institutionalization.

Methods

We applied a critical interpretive synthesis (CIS) that allowed for a systematic, yet iterative and dynamic analysis of heterogeneous bodies of literature to develop an explanatory framework for EIP institutionalization. We used a “compass” question to create a detailed search strategy and conducted electronic searches to identify papers based on their potential relevance to EIP institutionalization. Papers were screened and extracted independently and in duplicate. A constant comparative method was applied to develop a framework on EIP institutionalization. The CIS was triangulated with the findings of stakeholder dialogues that involved civil servants, policy-makers and researchers.

Results

We identified 3001 references, of which 88 papers met our eligibility criteria. This CIS resulted in a definition of EIP institutionalization as the “process and outcome of (re-)creating, maintaining and reinforcing norms, regulations, and standard practices that, based on collective meaning and values, actions as well as endowment of resources, allow evidence to become—over time—a legitimate and taken-for-granted part of health policy-making”. The resulting theoretical framework comprised six key domains of EIP institutionalization that capture both structure and agency: (1) governance; (2) standards and routinized processes; (3) partnership, collective action and support; (4) leadership and commitment; (5) resources; and (6) culture. Furthermore, EIP institutionalization is being achieved through five overlapping stages: (i) precipitating events; (ii) de-institutionalization; (iii) semi-institutionalization (comprising theorization and diffusion); (iv) (re)-institutionalization; and (v) renewed de-institutionalization processes.

Conclusions

This CIS advances the theoretical and conceptual discussions on EIP institutionalization, and provides new insights into an evidence-informed framework for initiating, strengthening and/or assessing efforts to institutionalize EIP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00820-7.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Policy options for strengthening evidence-informed health policy-making in Iran: overall SASHA project findings

Background

The institutionalization of evidence-informed health policy-making (EIHP) is complex and complicated. It is complex because it has many players and is complicated because its institutionalization will require many changes that will be challenging to make. Like many other issues, strengthening EIHP needs a road map, which should consider challenges and address them through effective, harmonized and contextualized strategies. This study aims to develop a road map for enhancing EIHP in Iran based on steps of planning.

Methods

This study consisted of three phases: (1) identifying barriers to EIHP, (2) recognizing interventions and (3) measuring the use of evidence in Iran's health policy-making. A set of activities was established for conducting these, including foresight, systematic review and policy dialogue, to identify the current and potential barriers for the first phase. For the second phase, an evidence synthesis was performed through a scoping review, by searching the websites of benchmark institutions which had good examples of EIHP practices in order to extract and identify interventions, and through eight policy dialogues and two broad opinion polls to contextualize the list of interventions. Simultaneously, two qualitative-quantitative studies were conducted to design and use a tool for assessing EIHP in the third phase.

Results

We identified 97 barriers to EIHP and categorized them into three groups, including 35 barriers on the “generation of evidence” (push side), 41 on the “use of evidence” (pull side) and 21 on the “interaction between these two” (exchange side). The list of 41 interventions identified through evidence synthesis and eight policy dialogues was reduced to 32 interventions after two expert opinion polling rounds. These interventions were classified into four main strategies for strengthening (1) the education and training system (6 interventions), (2) the incentives programmes (7 interventions), (3) the structure of policy support organizations (4 interventions) and (4) the enabling processes to support EIHP (15 interventions).

Conclusion

The policy options developed in the study provide a comprehensive framework to chart a path for strengthening the country’s EIHP considering both global practices and the context of Iran. It is recommended that operational plans be prepared for road map interventions, and the necessary resources provided for their implementation. The implementation of the road map will require attention to the principles of good governance, with a focus on transparency and accountability.

The impacts of accountable care organizations on patient experience, health outcomes and costs: a rapid review

Objectives

Accountable care organizations were implemented as a system-level approach to address quality differences and curb increasing healthcare costs in the United States of America, and have garnered the interest of policy makers in other countries to support better management of patients. The objectives of this paper are to: (1) identify the impacts of accountable care organizations on improving the quadruple aim goals of improving patient experience of care, enhancing population health outcomes, reducing the per capita cost of health care and ensuring positive provider experiences and (2) determine how and why such impacts have been achieved through accountable care organizations.

Methods

We used a rapid review approach, searching Health Systems Evidence (for systematic reviews) and PubMed (for reviews and studies). Results were reviewed for inclusion independently by two researchers. Data were extracted by one reviewer and checked for consistency by another.

Results

We identified one recent systematic review and 59 primary studies that addressed the first objective ( n = 54), the second objective ( n = 4) or both objectives ( n = 1). The reviewed studies suggest that accountable care organizations reduce costs without reducing quality. Key findings related to objective 1 include: (1) there are positive trends across the quadruple–aim outcomes for accountable care organizations as compared to Medicare fee-for-service or group physician fee-for-service models; (2) accountable care organizations produced modest cost savings, which are largely attributable to savings in outpatient expenses among the most medically complex patients and reductions in the delivery of low-value services; (3) accountable care organization models met the majority of quality measures and perform better than their fee-for-service counterparts and (4) there is relatively little evidence about the impact of accountable care organizations on provider experience. Qualitative studies related to objective 2 highlighted mechanisms that were important for enabling accountable care organizations, including supplemental staff to enhance coordination and accountable care organization-wide electronic health records.

Conclusions

General trends and increased adoption of models similar to accountable care organizations outside of the USA suggest that these models outperform traditional fee-for-service models across the quadruple aim goals, although with mixed evidence about health outcomes.

Policy options to increase motivation for improving evidence-informed health policy-making in Iran

BACKGROUND

Current incentive programmes are not sufficient to motivate researchers and policy-makers to use research evidence in policy-making. We conducted a mixed-methods design to identify context-based policy options for strengthening motivations among health researchers and policy-makers to support evidence-informed health policy-making (EIHP) in Iran.

METHODS

This study was conducted in 2019 in two phases. In the first phase, we conducted a scoping review to extract interventions implemented or proposed to strengthen motivations to support EIHP. Additionally, we employed a comparative case study design for reviewing the performance evaluation (PE) processes in Iran and other selected countries to determine the current individual and organizational incentives to encourage EIHP. In the second phase, we developed two policy briefs and then convened two policy dialogues, with 12 and 8 key informants, respectively, where the briefs were discussed. Data were analysed using manifest content analysis in order to propose contextualized policy options.

RESULTS

The policy options identified to motivate health researchers and policy-makers to support EIHP in Iran were: revising the criteria of academic PE; designing appropriate incentive programmes for nonacademic researchers; developing an indicator for the evaluation of research impact on policy-making or health outcomes; revising the current policies of scientific journals; revising existing funding mechanisms; presenting the knowledge translation plan when submitting a research proposal, as a mandatory condition; encouraging and supporting mechanisms for increasing interactions between policy-makers and researchers; and revising some administrative processes (e.g. managers and staff PEs; selection, appointment, and changing managers and reward mechanisms).

CONCLUSIONS

The current individual or organizational incentives are mainly focused on publications, rather than encouraging researchers and policy-makers to support EIHP. Relying more on incentives that consider the other impacts of research (e.g. impacts on health system and policy, or health outcomes) is recommended. These incentives may encourage individuals and organizations to be more involved in conducting research evidence, resulting in promoting EIHP.

TRIAL REGISTRATION

NA.

IMAGINE Network's Mind And Gut Interactions Cohort (MAGIC) Study: a protocol for a prospective observational multicentre cohort study in inflammatory bowel disease and irritable bowel syndrome

INTRODUCTION

Gut microbiome and diet may be important in irritable bowel syndrome (IBS), inflammatory bowel disease (IBD) and comorbid psychiatric conditions, but the mechanisms are unclear. We will create a large cohort of patients with IBS, IBD and healthy controls, and follow them over time, collecting dietary and mental health information and biological samples, to assess their gastrointestinal (GI) and psychological symptoms in association with their diet, gut microbiome and metabolome.

METHODS AND ANALYSIS

This 5-year observational prospective cohort study is recruiting 8000 participants from 15 Canadian centres. Persons with IBS who are 13 years of age and older or IBD ≥5 years will be recruited. Healthy controls will be recruited from the general public and from friends or relatives of those with IBD or IBS who do not have GI symptoms. Participants answer surveys and provide blood, urine and stool samples annually. Surveys assess disease activity, quality of life, physical pain, lifestyle factors, psychological status and diet. The main outcomes evaluated will be the association between the diet, inflammatory, genetic, microbiome and metabolomic profiles in those with IBD and IBS compared with healthy controls using multivariate logistic regression. We will also compare these profiles in those with active versus quiescent disease and those with and without psychological comorbidity.

ETHICS AND DISSEMINATION

Approval has been obtained from the institutional review boards of all centres taking part in the study. We will develop evidence-based knowledge translation initiatives for patients, clinicians and policymakers to disseminate results to relevant stakeholders.Trial registration number: NCT03131414.

How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field

Background

Research funders in Canada and abroad have made substantial investments in supporting collaborative research approaches to generating and translating knowledge as it is believed to increase knowledge use. Canadian health research funders have advocated for the use of integrated knowledge translation (IKT) in health research, however, there is limited research around how IKT compares to other collaborative research approaches. Our objective was to better understand how IKT compares with engaged scholarship, Mode 2 research, co-production and participatory research by identifying the differences and similarities among them in order to provide conceptual clarity and reduce researcher and knowledge user confusion about these common approaches.

Methods

We employed a qualitative descriptive method using interview data to better understand experts’ perspectives and experiences on collaborative research approaches. Participants’ responses were analysed through thematic analysis to elicit core themes. The analysis was centred around the concept of IKT, as it is the most recent approach; IKT was then compared and contrasted with engaged scholarship, Mode 2 research, co-production and participatory research. As this was an iterative process, data triangulation and member-checking were conducted with participants to ensure accuracy of the emergent themes and analysis process.

Results

Differences were noted in the orientation (i.e. original purpose), historical roots (i.e. disciplinary origin) and partnership/engagement (i.e. role of partners etc.). Similarities among the approaches included (1) true partnerships rather than simple engagement, (2) focus on essential components and processes rather than labels, (3) collaborative research orientations rather than research methods, (4) core values and principles, and (5) extensive time and financial investment. Core values and principles among the approaches included co-creation, reciprocity, trust, fostering relationships, respect, co-learning, active participation, and shared decision-making in the generation and application of knowledge. All approaches require extensive time and financial investment to develop and maintain true partnerships.

Conclusions

This qualitative study is the first to systematically synthesise experts’ perspectives and experiences in a comparison of collaborative research approaches. This work contributes to developing a shared understanding of collaborative research approaches to facilitate conceptual clarity in use, reporting, indexing and communication among researchers, trainees, knowledge users and stakeholders to advance IKT and implementation science.

Feasibility and implementation of a healthy lifestyles program in a community setting in Ontario, Canada: protocol for a pragmatic mixed methods pilot study

INTRODUCTION

Rates of chronic conditions, such as diabetes, cardiovascular disease and obesity are increasing in Canada and internationally. There are effective lifestyle interventions that are known to improve chronic conditions. However, there is often a gap in 'how to' make lifestyle changes. Mental health and other determinants of health play a role in the development and progression of chronic conditions. Changing habits takes time and requires the use of multiple techniques, including mental health and behavioural change strategies, based on a person's needs. A new, multidisciplinary, person-centred and evidence-based and practice-based programme has been created to address these needs. This proposal aims to evaluate the feasibility and implementation of this programme and to determine changes in participant-directed and clinical outcomes through a pilot study.

METHODS AND ANALYSIS

A pragmatic mixed methods design will be used to study multiple dimensions of the year-long healthy lifestyles programme. The pilot study includes a randomised controlled trial, with 30 participants randomised to either the programme or to a comparator arm, and qualitative components to determine the feasibility of the programme, including recruitment and retention, data missing rates and resources needed to run this programme. Changes in participant-directed and clinical outcomes will be measured. Descriptive statistics, t-tests and repeated measures analysis of variance (ANOVA) for within group comparisons and generalised estimating equations for between group analyses will be used. Qualitative interviews of programme staff and healthcare providers and family focus groups will be used to further enhance the findings and improve the programme.

ETHICS AND DISSEMINATION

Approval from the Hamilton Integrated Research Ethics Board (HiREB) has been obtained. Informed consent will be obtained prior to enrolling any participant into the study. Participant IDs will be used during data collection and entry. Peer-reviewed publications and presentations will target researchers, health professionals and stakeholders.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03258138.HiREB project number: 3793.

Attributes of context relevant to healthcare professionals' use of research evidence in clinical practice: a multi-study analysis

BACKGROUND

To increase the likelihood of successful implementation of evidence-based practices, researchers, knowledge users, and healthcare professionals must consider aspects of context that promote and hinder implementation in their setting. The purpose of the current study was to identify contextual attributes and their features relevant to implementation by healthcare professionals and compare and contrast these attributes and features across different clinical settings and healthcare professional roles.

METHODS

We conducted a secondary analysis of 145 semi-structured interviews comprising 11 studies (10 from Canada and one from Australia) investigating healthcare professionals' perceived barriers and enablers to their use of research evidence in clinical practice. The data was collected using semi-structured interview guides informed by the Theoretical Domains Framework across different healthcare professional roles, settings, and practices. We analyzed these data inductively, using constant comparative analysis, to identify attributes of context and their features reported in the interviews. We compared these data by (1) setting (primary care, hospital-medical/surgical, hospital-emergency room, hospital-critical care) and (2) professional role (physicians and residents, nurses and organ donor coordinators).

RESULTS

We identified 62 unique features of context, which we categorized under 14 broader attributes of context. The 14 attributes were resource access, work structure, patient characteristics, professional role, culture, facility characteristics, system features, healthcare professional characteristics, financial, collaboration, leadership, evaluation, regulatory or legislative standards, and societal influences. We found instances of the majority (n = 12, 86%) of attributes of context across multiple (n = 6 or more) clinical behaviors. We also found little variation in the 14 attributes of context by setting (primary care and hospitals) and professional role (physicians and residents, and nurses and organ donor coordinators).

CONCLUSIONS

There was considerable consistency in the 14 attributes identified irrespective of the clinical behavior, setting, or professional role, supporting broad utility of the attributes of context identified in this study. There was more variation in the finer-grained features of these attributes with the most substantial variation being by setting.

A roadmap for strengthening evidence-informed health policy-making in Iran: protocol for a research programme

BACKGROUND

Many initiatives have been taken in the Islamic Republic of Iran to promote evidence-informed health policy-making (EIHP). However, these initiatives are not systematic. Since the implementation of EIHP is not consistent and the interventions in this regard are complex, a comprehensive plan could be a useful tool for employing initiatives to achieve and promote EIHP. Hence, this study aims to develop a roadmap for strengthening EIHP over a 3-year period in Iran.

METHODS

Nine projects will be conducted to define the roadmap for strengthening EIHP. These projects include two reviews and a stakeholder analysis to identify the factors that facilitate or hinder achieving EIHP. The next study will be a qualitative study to prioritise the challenges and outline the main causes. The following steps will be a review of reviews to extract global experiences on interventions used for strengthening EIHP and two qualitative studies to examine the adoption of these interventions and develop an operational plan for strengthening EIHP in Iran. The research will be completed through conducting two qualitative-quantitative studies to design a tool for measuring EIHP and assessing EIHP in Iran at baseline.

DISCUSSION

This national EIHP roadmap will surely be able to identify the gaps and bumps that might exist in the implementation plan for establishing EIHP and eliminate them as needed in the future. This roadmap can be a step in moving towards transparency and accountability in the health system and as thus towards good governance and improvement of the health system's performance. Although the plan can be a good model for developing countries and may promote the use of evidence in health policy-making, we should assume that there are some critical contextual factors that could potentially hinder the complete and successful implementation of EIHP. Thus, to enhance EIHP in these countries with a policy-making context that does not fully support the use of evidence, it is crucial to think about not only those interventions that directly address the EIHP barriers, but also some long-term strategies to make required changes in the context, both beyond and within the health system.

Supporting the use of research evidence in the Canadian health sector

Interventions to support evidence-informed decision making have increased in recent years, but they are often fragmented across different clinical, management and policy environments. Many of these efforts also place varying emphasis on supporting the use of research evidence, with some choosing to focus more on expert knowledge and/or media coverage and others focusing on supporting the use of actionable messages arising from high-quality, relevant and optimally packaged research evidence. In this paper, we profile five Canadian contributions--EvidenceUpdates, Rx for Change, Health-Evidence.ca, Health Systems Evidence and the McMaster Health Forum--that allow providers, managers and policy makers to efficiently find and use research evidence when they need it. These contributions are critical for supporting both local and global efforts to provide optimal and cost-effective care, improving the quality of care and strengthening health systems.

Second Global Symposium on Health Systems Research: a conference impact evaluation

Evaluation researchers have confirmed the importance of conference evaluation, but there remains little research on the topic, perhaps in part because evaluation methodology related to conference impact is underdeveloped. We conducted a study evaluating a 4-day long health conference, the Second Global Symposium on Health Systems Research (HSR), which took place in Beijing in November 2012. Using a conference evaluation framework and a mixed-methods approach that involved in-conference surveys, in-conference interviews and 7-month post-conference interviews, we evaluated the impact of the Symposium on attendees' work and the field of health systems research. The three major impacts on participants' work were new knowledge, new skills and new networks, and many participants were able to provide examples of how obtaining new knowledge, skills or collaborations had changed the way they conduct their work. Participants noted that the Symposium influenced the field of HSR only in so far as it influenced the capacity of stakeholders, but did not lead to any high level agenda or policy changes, perhaps due to the insufficient length of time (7 months) between the Symposium and post-conference follow-up. This study provides an illustration of a framework useful for conference organizers in the evaluation of future conferences, and of a unique methodology for evaluation researchers.

Capturing lessons learned from evidence-to-policy initiatives through structured reflection

Background

Knowledge translation platforms (KTPs), which are partnerships between policymakers, stakeholders, and researchers, are being established in low- and middle-income countries (LMICs) to enhance evidence-informed health policymaking (EIHP). This study aims to gain a better understanding of the i) activities conducted by KTPs, ii) the way in which KTP leaders, policymakers, and stakeholders perceive these activities and their outputs, iii) facilitators that support KTP work and challenges, and the lessons learned for overcoming such challenges, and iv) factors that can help to ensure the sustainability of KTPs.

Methods

This paper triangulated qualitative data from: i) 17 semi-structured interviews with 47 key informants including KTP leaders, policymakers, and stakeholders from 10 KTPs; ii) document reviews, and iii) observation of deliberations at the International Forum on EIHP in LMICs held in Addis Ababa in August 2012. Purposive sampling was used and data were analyzed using thematic analysis.

Results

Deliberative dialogues informed by evidence briefs were identified as the most commendable tools by interviewees for enhancing EIHP. KTPs reported that they have contributed to increased awareness of the importance of EIHP and strengthened relationships among policymakers, stakeholders, and researchers. Support from policymakers and international funders facilitated KTP activities, while the lack of skilled human resources to conduct EIHP activities impeded KTPs. Ensuring the sustainability of EIHP initiatives after the end of funding was a major challenge for KTPs. KTPs reported that institutionalization within the government has helped to retain human resources and secure funding, whereas KTPs hosted by universities highlighted the advantage of autonomy from political interests.

Conclusions

The establishment of KTPs is a promising development in supporting EIHP. Real-time lesson drawing from the experiences of KTPs can support improvements in the functioning of KTPs in the short term, while making the case for sustaining their work in the long term. Lessons learned can help to promote similar EIHP initiatives in other countries.

Labor force participation and health-related quality of life in HIV-positive men who have sex with men: the Multicenter AIDS Cohort Study

Too many people with HIV have left the job market permanently and those with reduced work capacity have been unable to keep their jobs. There is a need to examine the health effects of labor force participation in people with HIV. This study presents longitudinal data from 1,415 HIV-positive men who have sex with men taking part in the Multicenter AIDS Cohort Study. Generalized Estimating Equations show that employment is associated with better physical and mental health quality of life and suggests that there may be an adaptation process to the experience of unemployment. Post hoc analyses also suggest that people who are more physically vulnerable may undergo steeper health declines due to job loss than those who are generally healthier. However, this may also be the result of a selection effect whereby poor physical health contributes to unemployment. Policies that promote labor force participation may not only increase employment rates but also improve the health of people living with HIV.

Influence of employment and job security on physical and mental health in adults living with HIV: cross-sectional analysis

BACKGROUND

In the general population, job insecurity may be as harmful to health as unemployment. Some evidence suggests that employment is associated with better health outcomes among people with HIV, but it is not known whether job security offers additional quality-of-life benefits beyond the benefits of employment alone.

METHODS

We used baseline data for 1660 men and 270 women who participated in the Ontario HIV Treatment Network Cohort Study, an ongoing observational cohort study that collects clinical and socio-behavioural data from people with HIV in the province of Ontario, Canada. We performed multivariable regression analyses to determine the contribution of employment and job security to health-related quality of life after controlling for potential confounders.

RESULTS

Employed men with secure jobs reported significantly higher mental health-related quality of life than those who were non-employed (β = 5.27, 95% confidence interval [CI] 4.07 to 6.48), but insecure employment was not associated with higher mental health scores relative to non-employment (β = 0.18, 95% CI -1.53 to 1.90). Thus, job security was associated with a 5.09-point increase on a 100-point mental health quality-of-life score (95% CI 3.32 to 6.86). Among women, being employed was significantly associated with both physical and mental health quality of life, but job security was not associated with additional health benefits.

INTERPRETATION

Participation in employment was associated with better quality of life for both men and women with HIV. Among men, job security was associated with better mental health, which suggests that employment may offer a mental health benefit only if the job is perceived to be secure. Employment policies that promote job security may offer not only income stability but also mental health benefits, although this additional benefit was observed only for men.

Association of returning to work with better health in working-aged adults: a systematic review

OBJECTIVES

We systematically reviewed the literature on the impact of returning to work on health among working-aged adults.

METHODS

We searched 6 electronic databases in 2005. We selected longitudinal studies that documented a transition from unemployment to employment and included a comparison group. Two reviewers independently appraised the retrieved literature for potential relevance and methodological quality.

RESULTS

Eighteen studies met our inclusion criteria, including 1 randomized controlled trial. Fifteen studies revealed a beneficial effect of returning to work on health, either demonstrating a significant improvement in health after reemployment or a significant decline in health attributed to continued unemployment. We also found evidence for health selection, suggesting that poor health interferes with people's ability to go back to work. Some evidence suggested that earlier reemployment may be associated with better health.

CONCLUSIONS

Beneficial health effects of returning to work have been documented in a variety of populations, times, and settings. Return-to-work programs may improve not only financial situations but also health.

Climate for evidence-informed health systems: a profile of systematic review production in 41 low- and middle-income countries, 1996-2008

OBJECTIVE

To describe systematic review production in 41 countries in Africa, the Americas, Asia and the eastern Mediterranean to understand one dimension of the climate for evidence-informed health systems and to provide a baseline for an evaluation of knowledge translation initiatives.

METHODS

Our focus was systematic reviews published between 1996 and 2008 that had a corresponding author based in, or that appeared to target, one of the countries in these regions. We searched both Medline and Embase using validated search strategies, identified citations with a country name in the corresponding author's institutional affiliation or as a textword (i.e., an explicit mention in the title or abstract) or keyword, and coded articles describing a systematic review. We followed the same citation identification procedure for Health Systems Evidence, a database containing systematic reviews about health systems.

RESULTS

Systematic review production increased between three-fold (for Africa in Medline) and 110-fold (for Asia in Embase) between the first period (1996-2002) and second period (2003-2008). In the second period, China was more often the home of corresponding authors and the target of reviews than any other country. No systematic reviews were produced by a corresponding author based in nine countries, or appeared to target five countries. Only 48 reviews identified through Medline and Embase addressed health systems, and 35 health systems reviews identified through Health Systems Evidence addressed these countries.

CONCLUSION

In many countries, those seeking to support evidence-informed health systems cannot turn to experienced local systematic reviewers to help them to find and use systematic reviews or to conduct reviews on high priority topics when none exists. These findings suggest the need for local capacity-building initiatives.

Impact of Clinician Judgement on Formulary Committees’ Recommendations in Canada

Objectives

In formulary committee deliberations, evidence for the efficacy of medications is often based on changes in the scale scores of patient-reported outcome measures. Our aim was to examine whether clinician judgement about the efficacy of medications for Alzheimer's disease, when added to scale score evidence, affects formulary committee members’ recommendations about providing these medications under public insurance.

Methods

The study was conducted using mixed methods. In a survey of formulary committee members in Canada, 32 participants were presented with scenarios that outlined different levels of efficacy for a medication. For each scenario, participants were asked to specify their likelihood of recommending that the medication be provided under public insurance. Of the 32 participants, 23 agreed to take part in an interview to explain the survey results. Content analysis was used to elicit recurrent themes across the interviews.

Results

When a medication was disease modifying, use of clinician judgement increased the mean likelihood of recommending that the medication be provided under public insurance. Despite this, some participants felt formulary committees should not use clinician judgement because of risks of subjectivity and bias. However, other participants believed the addition of clinician judgement would enhance the clinical relevance of evidence that might otherwise be based entirely on changes in scale score.

Conclusions

Clinician judgement about the efficacy of medications can influence formulary committee recommendations. This suggests the need for a new approach to govern the consideration of expert evidence during formulary committee deliberations.

Policy development in malaria vector management in Mozambique, South Africa and Zimbabwe

INTRODUCTION

Indoor residual spraying (IRS) and insecticide-treated nets (ITNs), two principal malaria control strategies, are similar in cost and efficacy. We aimed to describe recent policy development regarding their use in Mozambique, South Africa and Zimbabwe.

METHODS

Using a qualitative case study methodology, we undertook semi-structured interviews of key informants from May 2004 to March 2005, carried out document reviews and developed timelines of key events. We used an analytical framework that distinguished three broad categories: interests, ideas and events.

RESULTS

A disparate mix of interests and ideas slowed the uptake of ITNs in Mozambique and Zimbabwe and prevented uptake in South Africa. Most respondents strongly favoured one strategy over the other. In all three countries, national policy makers favoured IRS, and only in Mozambique did national researchers support ITNs. Outside interests in favour of IRS included manufacturers who supplied the insecticides and groups opposing environmental regulation. International research networks, multilateral organizations, bilateral donors and international NGOs supported ITNs. Research evidence, local conditions, logistic feasibility, past experience, reaction to outside ideas, community acceptability, the role of government and NGOs, and harm from insecticides used in spraying influenced the choice of strategy. The end of apartheid permitted a strongly pro-IRS South Africa to influence the region, and in Mozambique and Zimbabwe, floods provided conditions conducive to ITN distribution.

CONCLUSIONS

Both IRS and ITNs have a place in integrated malaria vector management, but pro-IRS interests and ideas slowed or prevented the uptake of ITNs. Policy makers needed more than evidence from trials to change from the time-honoured IRS strategy that they perceived was working. Those intending to promote new policies such as ITNs should examine the interests and ideas motivating key stakeholders and their own institutions, and identify where shifts in thinking or coalitions among the like-minded may be possible.

The BLISS cluster randomised controlled trial of the effect of 'active dissemination of information' on standards of care for premature babies in England (BEADI) study protocol [ISRCTN89683698]

Background

Gaps between research knowledge and practice have been consistently reported. Traditional ways of communicating information have limited impact on practice changes. Strategies to disseminate information need to be more interactive and based on techniques reported in systematic reviews of implementation of changes. There is a need for clarification as to which dissemination strategies work best to translate evidence into practice in neonatal units across England. The objective of this trial is to assess whether an innovative active strategy for the dissemination of neonatal research findings, recommendations, and national neonatal guidelines is more likely to lead to changes in policy and practice than the traditional (more passive) forms of dissemination in England.

Methods/design

Cluster randomised controlled trial of all neonatal units in England (randomised by hospital, n = 182 and stratified by neonatal regional networks and neonatal units level of care) to assess the relative effectiveness of active dissemination strategies on changes in local policies and practices. Participants will be mainly consultant lead clinicians in each unit. The intervention will be multifaceted using: audit and feedback; educational meetings for local staff (evidence-based lectures on selected topics, interactive workshop to examine current practice and draw up plans for change); and quality improvement and organisational changes methods. Policies and practice outcomes for the babies involved will be collected before and after the intervention. Outcomes will assess all premature babies born in England during a three month period for timing of surfactant administration at birth, temperature control at birth, and resuscitation team (qualification and numbers) present at birth.

Trial registration

Current controlled trials ISRCTN89683698

Conceptions and uses of public health ideas by New Zealand government policymakers: report on a five-agency survey

OBJECTIVES

This article describes New Zealand government policymakers' awareness of, attitudes toward and self-reported use of ideas about the determinants of health. Some comparison with an earlier Canadian study is provided.

METHODS

Employees with policymaking and advisory responsibilities in government departments of health, social development, housing, education and finance were surveyed.

RESULTS

More than half of the respondents (58%) were familiar with ideas about health determinants. Eighty percent felt that health determinants should be considered in all government policy, but that more practical information on effective policy interventions is needed. Commitment to the idea that the economy should take precedence over reducing health inequalities was low.

CONCLUSIONS

There is a demand for literature on health determinants that is sector specific and which provides practical and proven information about effective interventions that influence health.

Towards systematic reviews that inform health care management and policy-making

OBJECTIVES

To identify ways to improve the usefulness of systematic reviews for health care managers and policy-makers that could then be evaluated prospectively.

METHODS

We systematically reviewed studies of decision-making by health care managers and policy-makers, conducted interviews with a purposive sample of them in Canada and the United Kingdom (n = 29), and reviewed the websites of research funders, producers/purveyors of research, and journals that include them among their target audiences (n = 45).

RESULTS

Our systematic review identified that factors such as interactions between researchers and health care policy-makers and timing/timeliness appear to increase the prospects for research use among policy-makers. Our interviews with health care managers and policy-makers suggest that they would benefit from having information that is relevant for decisions highlighted for them (e.g. contextual factors that affect a review's local applicability and information about the benefits, harms/risks and costs of interventions) and having reviews presented in a way that allows for rapid scanning for relevance and then graded entry (such as one page of take-home messages, a three-page executive summary and a 25-page report). Managers and policy-makers have mixed views about the helpfulness of recommendations. Our analysis of websites found that contextual factors were rarely highlighted, recommendations were often provided and graded entry formats were rarely used.

CONCLUSIONS

Researchers could help to ensure that the future flow of systematic reviews will better inform health care management and policy-making by involving health care managers and policy-makers in their production and better highlighting information that is relevant for decisions. Research funders could help to ensure that the global stock of systematic reviews will better inform health care management and policy-making by supporting and evaluating local adaptation processes such as developing and making available online more user-friendly 'front ends' for potentially relevant systematic reviews.

Partnership experiences: involving decision-makers in the research process

OBJECTIVES

To describe researchers' experiences with involving health system managers and public policy-makers (i.e. decision-makers) in the research process, and decision-makers' experiences with the research process, including their assessments of the benefits and costs of the involvement, and their recommendations for facilitating it.

METHODS

We conducted semi-structured interviews with principal investigators and research staff for the seven research programmes funded by the Canadian Health Services Research Foundation in the 1999 and 2000 competition years, and with the decision-makers they involved in the research programmes.

RESULTS

We identify three models of decision-maker involvement--formal supporter, responsive audience, and integral partner--each of which yielded important contributions to the research process. Four factors--the stage of the research process, time commitment required, alignment between decision-maker expertise and programme needs, and an existing relationship between the researcher and decision-maker--influenced the role played by decision-makers.

CONCLUSIONS

While on balance a beneficial experience, the further promotion of decision-maker involvement in the research process should involve helping researchers and decision-makers identify strategic opportunities for decision-maker involvement and support the costs associated with the involvement. Consideration should also be given to undertaking and evaluating interactions between researchers and decision-makers outside of the research process.

Measuring the impact of health research

Measuring the decision-making impact of applied health research should constitute a core function for many research funders and research organizations. Different target audiences warrant different measures of impact. The target audiences for applied health research include the general public, patients (and their families), clinicians, managers (in hospitals, regional health authorities and health plans), research and development officers (in biotechnology firms) and public policy-makers (i.e. elected officials, political staff and civil servants). Making meaningful assessments within peer groups that fund or produce similar types of research knowledge for similar types of target audiences makes more sense than a one-size-fits-all approach to impact assessment. User-pull and interactive measures of impact (i.e. measures of cultural shifts that would facilitate the on-going use of research knowledge to inform decision-making) can supplement more traditional producer-push measures that assess researchers' active efforts to inform decision-making and the outcome of these efforts. Cultural shifts may include the creation of a research-attuned culture among decision-makers and a decision-relevant culture among researchers. Moving beyond whether research was used to examine how it was used is also important. Research knowledge may be used in instrumental, conceptual or symbolic ways. These actions, coupled with on-going refinements to the proposed assessment tool as research evidence evolves, would take us a long way towards assessment and accountability in the health sector.

Primary care in Canada: so much innovation, so little change

The development of Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change in primary care through their cumulative effects on the health care system and the process of health policy development. The pursuit of radical systemwide change in the face of unfavorable circumstances (created in large part by those legacies) has resulted in missed opportunities for cumulative incremental change. While major changes in primary care policy seem unlikely in the near future, significant incremental change is possible, but it will require a reorientation of the policy development process.

The costs of HIV prevention strategies in developing countries

Since many evaluations of HIV (human immunodeficiency virus) prevention programmes do not include data on costs, a preliminary analysis of the costs and outputs of a sample of HIV prevention projects was attempted. Case studies, representing six broad HIV prevention strategies in developing countries with differing levels of per capita gross domestic product, were sought on the basis of availability of data and potential generalizability. The six prevention strategies studied were mass media campaigns, peer education programmes, sexually transmitted disease treatment, condom social marketing, safe blood provision, and needle exchange/bleach provision programmes. Financial cost data were abstracted from published studies or were obtained directly from project coordinators. Although estimates of cost-effectiveness were not made, calculations of the relative cost per common process measure of output were compared. Condom distribution costs ranged from US$ 0.02 to 0.70 per condom distributed, and costs of strategies involving personal educational input ranged from US$ 0.15 to 12.59 per contact.