Evidence for public health policy on inequalities: 1: the reality according to policymakers

Health inequalities in European cities: perceptions and beliefs among local policymakers

OBJECTIVE

To describe the knowledge and beliefs of public policymakers on social inequalities in health and policies to reduce them in cities from different parts of Europe during 2010 and 2011.

DESIGN

Phenomenological qualitative study.

SETTING

13 European cities.

PARTICIPANTS

19 elected politicians and officers with a directive status from 13 European cities.

MAIN OUTCOME

Policymaker's knowledge and beliefs.

RESULTS

Three emerging discourses were identified among the interviewees, depending on the city of the interviewee. Health inequalities were perceived by most policymakers as differences in life-expectancy between population with economic, social and geographical differences. Reducing health inequalities was a priority for the majority of cities which use surveys as sources of information to analyse these. Bureaucracy, funding and population beliefs were the main barriers.

CONCLUSIONS

The majority of the interviewed policymakers gave an account of interventions focusing on the immediate determinants and aimed at modifying lifestyles and behaviours in the more disadvantaged classes. More funding should be put towards academic research on effective universal policies, evaluation of their impact and training policymakers and officers on health inequalities in city governments.

A systematic review of barriers to and facilitators of the use of evidence by policymakers

Background

The gap between research and practice or policy is often described as a problem. To identify new barriers of and facilitators to the use of evidence by policymakers, and assess the state of research in this area, we updated a systematic review.

Methods

Systematic review. We searched online databases including Medline, Embase, SocSci Abstracts, CDS, DARE, Psychlit, Cochrane Library, NHSEED, HTA, PAIS, IBSS (Search dates: July 2000 - September 2012). Studies were included if they were primary research or systematic reviews about factors affecting the use of evidence in policy. Studies were coded to extract data on methods, topic, focus, results and population.

Results

145 new studies were identified, of which over half were published after 2010. Thirteen systematic reviews were included. Compared with the original review, a much wider range of policy topics was found. Although still primarily in the health field, studies were also drawn from criminal justice, traffic policy, drug policy, and partnership working. The most frequently reported barriers to evidence uptake were poor access to good quality relevant research, and lack of timely research output. The most frequently reported facilitators were collaboration between researchers and policymakers, and improved relationships and skills. There is an increasing amount of research into new models of knowledge transfer, and evaluations of interventions such as knowledge brokerage.

Conclusions

Timely access to good quality and relevant research evidence, collaborations with policymakers and relationship- and skills-building with policymakers are reported to be the most important factors in influencing the use of evidence. Although investigations into the use of evidence have spread beyond the health field and into more countries, the main barriers and facilitators remained the same as in the earlier review. Few studies provide clear definitions of policy, evidence or policymaker. Nor are empirical data about policy processes or implementation of policy widely available. It is therefore difficult to describe the role of evidence and other factors influencing policy. Future research and policy priorities should aim to illuminate these concepts and processes, target the factors identified in this review, and consider new methods of overcoming the barriers described.

A systematic review of barriers to and facilitators of the use of evidence by policymakers

BACKGROUND

The gap between research and practice or policy is often described as a problem. To identify new barriers of and facilitators to the use of evidence by policymakers, and assess the state of research in this area, we updated a systematic review.

METHODS

Systematic review. We searched online databases including Medline, Embase, SocSci Abstracts, CDS, DARE, Psychlit, Cochrane Library, NHSEED, HTA, PAIS, IBSS (Search dates: July 2000 - September 2012). Studies were included if they were primary research or systematic reviews about factors affecting the use of evidence in policy. Studies were coded to extract data on methods, topic, focus, results and population.

RESULTS

145 new studies were identified, of which over half were published after 2010. Thirteen systematic reviews were included. Compared with the original review, a much wider range of policy topics was found. Although still primarily in the health field, studies were also drawn from criminal justice, traffic policy, drug policy, and partnership working. The most frequently reported barriers to evidence uptake were poor access to good quality relevant research, and lack of timely research output. The most frequently reported facilitators were collaboration between researchers and policymakers, and improved relationships and skills. There is an increasing amount of research into new models of knowledge transfer, and evaluations of interventions such as knowledge brokerage.

CONCLUSIONS

Timely access to good quality and relevant research evidence, collaborations with policymakers and relationship- and skills-building with policymakers are reported to be the most important factors in influencing the use of evidence. Although investigations into the use of evidence have spread beyond the health field and into more countries, the main barriers and facilitators remained the same as in the earlier review. Few studies provide clear definitions of policy, evidence or policymaker. Nor are empirical data about policy processes or implementation of policy widely available. It is therefore difficult to describe the role of evidence and other factors influencing policy. Future research and policy priorities should aim to illuminate these concepts and processes, target the factors identified in this review, and consider new methods of overcoming the barriers described.

Evaluation of systems-oriented public health interventions: alternative research designs

The need to provide sound evidence of the costs and benefits of real-world public health interventions has driven advances in the development and analysis of designs other than the controlled trial in which individuals are randomized to an experimental condition. Attention to methodological quality is of critical importance to ensure that any evaluation can accurately answer three fundamental questions: (a) Has a change occurred, (b) did the change occur as a result of the intervention, and (c) is the degree of change significant? A range of alternatives to the individual randomized controlled trial (RCT) can be used for evaluating such interventions, including the cluster RCT, stepped wedge design, interrupted time series, multiple baseline, and controlled prepost designs. The key features and complexities associated with each of these designs are explored.

Perspectives on econometric modelling to inform policy: a UK qualitative case study of minimum unit pricing of alcohol

Background: Novel policy interventions may lack evaluation-based evidence. Considerations to introduce minimum unit pricing (MUP) of alcohol in the UK were informed by econometric modelling (the ‘Sheffield model’). We aim to investigate policy stakeholders’ views of the utility of modelling studies for public health policy. Methods: In-depth qualitative interviews with 36 individuals involved in MUP policy debates (purposively sampled to include civil servants, politicians, academics, advocates and industry-related actors) were conducted and thematically analysed. Results: Interviewees felt familiar with modelling studies and often displayed detailed understandings of the Sheffield model. Despite this, many were uneasy about the extent to which the Sheffield model could be relied on for informing policymaking and preferred traditional evaluations. A tension was identified between this preference for post hoc evaluations and a desire for evidence derived from local data, with modelling seen to offer high external validity. MUP critics expressed concern that the Sheffield model did not adequately capture the ‘real life’ world of the alcohol market, which was conceptualized as a complex and, to some extent, inherently unpredictable system. Communication of modelling results was considered intrinsically difficult but presenting an appropriate picture of the uncertainties inherent in modelling was viewed as desirable. There was general enthusiasm for increased use of econometric modelling to inform future policymaking but an appreciation that such evidence should only form one input into the process. Conclusion: Modelling studies are valued by policymakers as they provide contextually relevant evidence for novel policies, but tensions exist with views of traditional evaluation-based evidence.

Reducing social inequalities in health: the role of simulation modelling in chronic disease epidemiology to evaluate the impact of population health interventions

Reducing health inequalities has become a major public health priority internationally. However, how best to achieve this goal is not well understood. Population health intervention research has the potential to address some of this knowledge gap. This review argues that simulation studies can produce unique evidence to build the population health intervention research evidence base on reducing social inequalities in health. To this effect, the advantages of using simulation models over other population health intervention research methods are discussed. Key questions regarding the potential challenges of developing simulation models to investigate population health intervention research on reducing social inequalities in health and the types of population health intervention research questions that can be answered using this methodology are reviewed. We use the example of social inequalities in coronary heart disease to illustrate how simulation models can elucidate the effectiveness of a number of ‘what-if’ counterfactual population health interventions on reducing social inequalities in coronary heart disease. Simulation models are a flexible, cost-effective, evidence-based research method with the capacity to inform public health policy-makers regarding the implementation of population health interventions to reduce social inequalities in health.

Towards equitable commissioning for our multiethnic society: a mixed-methods qualitative investigation of evidence utilisation by strategic commissioners and public health managers

Background

The health-care commissioning cycle is an increasingly powerful determinant of the health services on offer and the care that patients receive. This study focuses on the mobilisation and use of evidence relating to ethnic diversity and inequality.

Objective

To describe the patterns and determinants of evidence use relating to ethnic diversity and inequality by managers within commissioning work and to identify promising routes for improvement.

Methods

In-depth semistructured interviews with 19 national key informants and documentation of good practice across England. Detailed case studies of three primary care trusts involving 70+ interviews with key strategic and operational actors, extensive observational work and detailed analysis of related documentation. A suite of commissioning resources based on findings across all elements were tested and refined through three national workshops of key stakeholders.

Results

Commissioners often lack clarity on how to access, appraise, weight or synthesise diverse sources of evidence and can limit the transformational shaping of services by a narrow conceptualisation of their role. Attention to evidence on ethnic diversity and inequality is frequently omitted at both national and local levels. Understanding of its importance is problematic and there are gaps in this evidence that create further barriers to its use within the commissioning cycle. Commissioning models provide no reward or sanction for inclusion or omission of evidence on ethnicity and commissioning teams or partners are not representative of minority ethnic populations. Neglect of this dimension within national drivers results in low demand for evidence. This organisational context can promote risk-averse attitudes that maintain the status quo. Pockets of good practice exist but they are largely dependent on individual expertise and commitment and are often not shared. Study findings suggested the need for action at three levels: creating an enabling environment; equipping health-care commissioners; and empowering wider stakeholders. Key enabling factors would be attention to ethnicity within policy drivers; senior-level commitment and resource; a diverse workforce; collaborative partnerships with relevant stakeholders; and the creation of local, regional and national infrastructure.

Limitations

It was harder to identify enablers of effective use of evidence in this area than barriers. Including a case study of an organisation that had achieved greater mainstreaming of the ethnic diversity agenda might have added to our understanding of enabling factors. The study was conducted during a period of fundamental restructuring of NHS commissioning structures. This caused some difficulties in gathering data and it is possible that widespread change and uncertainty may have produced more negative narratives from participants than would otherwise have been the case.

Conclusions

Knowledge mobilisation and utilisation within the commissioning cycle occurs in the context of dynamic interactions between individual agency, organisational context and the wider health-care setting, situated within the UK sociopolitical milieu. Our findings highlight isolated pockets of good practice amidst a general picture of limited organisational engagement, low priority and inadequate skills. Findings indicate the need for specific guidance alongside incentives and resources to support commissioning for a multiethnic population. A more comprehensive infrastructure and, most importantly, greater political will is needed to promote practice that focuses on reducing ethnic health inequalities at all stages of the commissioning cycle.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

GoWell: the challenges of evaluating regeneration as a population health intervention

OBJECTIVE

Urban regeneration can be considered a population health intervention (PHI). It is expected to impact on population health but the evidence is limited or weak, in part due to the difficulties of evaluating PHIs. We explore these challenges using GoWell as a case study.

METHOD

A 10-year evaluation of housing improvement and urban regeneration in 15 deprived areas in Glasgow, Scotland (2005-2015).

RESULTS

Challenges faced include: definition and changing nature of the intervention; identifying the recipients of the intervention; and constraints of study design affecting capacity to attribute effects. We have met these challenges by: adapting the evaluation to take account of changing intervention plans and delivery; making pragmatic choices about which populations to focus on for different parts of the study; and taking advantage of delayed delivery of some components to identify controls.

CONCLUSION

Commitment to a long-term evaluation by the Scottish Government and other partners has enabled us to develop a package of studies to investigate health and other outcomes, and the processes of a PHI. GoWell will contribute to the evidence base for interventions focused on tackling the wider determinants of health and help policymakers to be more explicit and realistic about what regeneration might achieve.

Knowledge translation strategies to improve the use of evidence in public health decision making in local government: intervention design and implementation plan

BACKGROUND

Knowledge translation strategies are an approach to increase the use of evidence within policy and practice decision-making contexts. In clinical and health service contexts, knowledge translation strategies have focused on individual behavior change, however the multi-system context of public health requires a multi-level, multi-strategy approach. This paper describes the design of and implementation plan for a knowledge translation intervention for public health decision making in local government.

METHODS

Four preliminary research studies contributed findings to the design of the intervention: a systematic review of knowledge translation intervention effectiveness research, a scoping study of knowledge translation perspectives and relevant theory literature, a survey of the local government public health workforce, and a study of the use of evidence-informed decision-making for public health in local government. A logic model was then developed to represent the putative pathways between intervention inputs, processes, and outcomes operating between individual-, organizational-, and system-level strategies. This formed the basis of the intervention plan.

RESULTS

The systematic and scoping reviews identified that effective and promising strategies to increase access to research evidence require an integrated intervention of skill development, access to a knowledge broker, resources and tools for evidence-informed decision making, and networking for information sharing. Interviews and survey analysis suggested that the intervention needs to operate at individual and organizational levels, comprising workforce development, access to evidence, and regular contact with a knowledge broker to increase access to intervention evidence; develop skills in appraisal and integration of evidence; strengthen networks; and explore organizational factors to build organizational cultures receptive to embedding evidence in practice. The logic model incorporated these inputs and strategies with a set of outcomes to measure the intervention's effectiveness based on the theoretical frameworks, evaluation studies, and decision-maker experiences.

CONCLUSION

Documenting the design of and implementation plan for this knowledge translation intervention provides a transparent, theoretical, and practical approach to a complex intervention. It provides significant insights into how practitioners might engage with evidence in public health decision making. While this intervention model was designed for the local government context, it is likely to be applicable and generalizable across sectors and settings.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Register ACTRN12609000953235.

Developing a public health policy-research nexus: an evaluation of Nurse Practitioner models in aged care

A frustration often expressed by researchers and policy-makers in public health is an apparent mismatch between respective priorities and expectations for research. Academics bemoan an oversimplification of their work, a reticence for independent critique and the constant pressure to pursue evaluation funding. Meanwhile, policy-makers look for research reports written in plain language with clear application, which are attuned to current policy settings and produced quickly. In a context where there are calls in western nations for evidence based policy with stronger links to academic research, such a mismatch can present significant challenges to policy program evaluation. The purpose of this paper is to present one attempt to overcome these challenges. Specifically, the paper describes the development of a conceptual framework for a large-scale, multifaceted evaluation of an Australian Government health initiative to expand Nurse Practitioner models of practice in aged care service delivery. In doing so, the paper provides a brief review of key points for the facilitation of a strong research-policy nexus in public health evaluations, as well as describes how this particular evaluation embodies these key points. As such, the paper presents an evaluation approach which may be adopted and adapted by others undertaking public health policy program evaluations.

Prevention of common mental disorders: what can we learn from those who have gone before and where do we go next?

OBJECTIVE

Prevention strategies have made a major contribution to the considerable successes in reductions in cardiovascular disease and cancer mortality seen in recent decades. However, in the field of psychiatry, similar population-level initiatives in the prevention of common mental disorders, depression and anxiety, are noticeably lacking. This paper aims to provide a brief overview of the existing literature on the topic of the prevention of common mental disorders and a commentary regarding the way forward for prevention research and implementation.

METHODS

This commentary considers what we currently know, what we might learn from the successes and failures of those working in prevention of other high prevalence health conditions, and where we might go from here. Taking cognisance of previous preventive models, this commentary additionally explores new opportunities for preventive approaches to the common mental disorders.

RESULTS

The consensus from a large body of evidence supports the contention that interventions to prevent mental disorders across the lifespan can be both effective and cost-effective. However, funding for research in the area of prevention of common mental disorders is considerably lower than that for research in the areas of treatment, epidemiology and neurobiology. Thus, there is a clear imperative to direct funding towards prevention research to redress this imbalance. Future prevention interventions need to be methodologically rigorous, scalable to the population level and include economic evaluation. Evidence-based knowledge translation strategies should be developed to ensure that all stakeholders recognise preventing mental disorders as an imperative, with appropriate resources directed to this objective.

CONCLUSION

There has been a recent expansion of research into potentially modifiable risk factors for depression, and it is now timely to make a concerted effort to advance the field of prevention of common mental disorders.

Sustained impact of community-based physical activity interventions: key elements for success

Background

Compelling evidence supports the cost effectiveness and potential impact of physical activity on chronic disease prevention and health promotion. Quality of evidence is one piece, but certainly not the sole determinant of whether public health interventions, physical activity focused or otherwise, achieve their full potential for impact. Health promotion at both population and community levels must progress beyond health intervention models that isolate individuals from social, environmental, and political systems of influence.

We offer a critical evaluation of lessons learned from two successful research initiatives to provide insights as to how health promotion research contributes to sustained impact. We highlight factors key to success including the theoretical and methodological integration of: i) a social ecological approach; ii) participatory action research (PAR) methods; and iii) an interdisciplinary team.

Methods

To identify and illustrate the key elements of our success we layered an evaluation of steps taken atop a review of relevant literature.

Results

In the school-based case study (Action Schools! BC), the success of our approach included early and sustained engagement with a broad cross-section of stakeholders, establishing partnerships across sectors and at different levels of government, and team members across multiple disciplines. In the neighbourhood built environment case study, the three domains guided our approach through study design and team development, and the integration of older adults’ perspectives into greenway design plans. In each case study we describe how elements of the domains serve as a guide for our work.

Conclusion

To sustain and maximize the impact of community-based public health interventions we propose the integration of elements from three domains of research that acknowledge the interplay between social, environmental and poilitical systems of influence. We emphasize that a number of key factors determine whether evidence from public health interventions in school and built environment settings is applied in practice and policy sectors. These include relationship building at individual, community, and societal levels of the social ecological model, using participatory action research methods, and involving an engaged and committed interdisciplinary team.

Making evidence more wanted: a systematic review of facilitators to enhance the uptake of evidence from systematic reviews and meta-analyses

CONTEXT

The increased uptake of evidence from systematic reviews is advocated because of their potential to improve the quality of decision making for patient care. Systematic reviews can do this by decreasing inappropriate clinical variation and quickly expediting the application of current, effective advances to everyday practice. However, research suggests that evidence from systematic reviews has not been widely adopted by health professionals. Little is known about the facilitators to uptake of research evidence from systematic reviews and meta-analyses.

OBJECTIVE

To review the facilitators to the uptake by decision makers, of evidence from systematic, meta-analyses and the databases containing them.

SEARCH STRATEGY

We searched 19 databases covering the full range of publication years, utilised three search engines and also personally contacted investigators. Grey literature and knowledge translation research was particularly sought. Reference lists of primary studies and related reviews were also searched.

SELECTION CRITERIA

Studies were included if they reported on the views and perceptions of decision makers on the uptake of evidence from systematic reviews, meta-analyses and the databases associated with them. One investigator screened titles to identify candidate articles, and then two reviewers independently assessed the relevance of retrieved articles to exclude studies that did not meet the inclusion criteria. Quality of the included studies was also assessed.

DATA EXTRACTION

Using a pre-established taxonomy, two reviewers described the methods of included studies and extracted data that were summarised in tables and then analysed. Differences were resolved by consensus.

RESULTS

Of articles initially identified, we selected unique published studies describing at least one facilitator to the uptake of evidence from systematic reviews. The 15 unique studies reported 10 surveys, three qualitative investigations and two mixed studies that addressed potential facilitators. Five studies were from Canada, four from the UK, three from Australia, one from Iran and one from South-east Asia (Indonesia, Malaysia, Thailand and the Philippines), with one study covering both Canada and UK. In total, the 15 studies covered eight countries from four continents. Of 2495 participants in the 15 studies, at least 1343 (53.8%) were physicians. Perceived facilitators to the use of evidence from systematic reviews varied. The 15 studies yielded 54 potential facilitators to systematic review uptake. The five most commonly reported perceived facilitators to uptake of evidence from systematic reviews were the following: the perception that systematic reviews have multiple uses for improving knowledge, research, clinical protocols and evidence-based medicine skills (6/15); a content that included benefits, harms and costs and is current, transparent and timely (6/15); a format with a 1:3:25 staged access and executive summary (5/15); training in use (4/15); and peer-group support (4/15).

CONCLUSION

The results expand our understanding of how multiple factors act as facilitators to optimal clinical practice. This systematic review reveals that interventions to foster uptake of evidence from systematic reviews, meta-analyses and The Cochrane Library can build on a broad range of facilitators.

Inequalities in the use of dental services among adults in inner South East London

Improving access to National Health Service (NHS) dentistry is a public health issue that has been a focus for successive governments and policy makers in the UK. To inform this process, commissioners of services need to understand trends in service use and demands of the local population. This study explored inequalities in dental services use among adults in a socially deprived, ethnically diverse metropolitan area of London; satisfaction with services; and public views for improvement of services. Data from 695 adults were analysed for this study (56% of the eligible sample). Inequalities in dental services use and satisfaction with care according to sociodemographic factors were assessed in unadjusted and fully adjusted models. The proportion of participants who reported attending the dentist in the last 24 months was 69%, with inequalities according to social grade, ethnicity, sex and age but not according to borough of residence. The most common areas identified by respondents for service improvement were availability of dentists, affordability of care, and accommodation of services. Among those who visited the dentist in the last 24 months, 90% were satisfied with the quality of care provided. However, there were inequalities in satisfaction with care according to borough and reason for the last dental visit.

Who runs public health? A mixed-methods study combining qualitative and network analyses

BACKGROUND

Persistent health inequalities encourage researchers to identify new ways of understanding the policy process. Informal relationships are implicated in finding evidence and making decisions for public health policy (PHP), but few studies use specialized methods to identify key actors in the policy process.

METHODS

We combined network and qualitative data to identify the most influential individuals in PHP in a UK conurbation and describe their strategies to influence policy. Network data were collected by asking for nominations of powerful and influential people in PHP (n = 152, response rate 80%), and 23 semi-structured interviews were analysed using a framework approach.

RESULTS

The most influential PHP makers in this conurbation were mid-level managers in the National Health Service and local government, characterized by managerial skills: controlling policy processes through gate keeping key organizations, providing policy content and managing selected experts and executives to lead on policies. Public health professionals and academics are indirectly connected to policy via managers.

CONCLUSIONS

The most powerful individuals in public health are managers, not usually considered targets for research. As we show, they are highly influential through all stages of the policy process. This study shows the importance of understanding the daily activities of influential policy individuals.

Developing engagement, linkage and exchange between health services managers and researchers: Experience from the UK

Objectives

The UK National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Management Fellowship programme enabled health services managers and university researchers to collaborate on research projects with the aim of improving research, managers’ research knowledge and skills, and the use of research in management. Our aim was to evaluate whether the programme encouraged greater engagement, linkage and exchange between researchers and managers.

Methods

A case-study approach with each case-study centred on 11 health care managers appointed as Fellows, chief investigators ( n = 13) and Fellows’ line managers ( n = 12). Data were collected through semi-structured face-to-face and telephone interviews. Interviews were analysed thematically to explore the impact of the programme, reported issues and to identify any lessons learned.

Results

Researchers benefited from the flow of (insider) knowledge and contacts from the workplace via the Fellow to the project. Engagement, linkage and exchange as a result of the Fellowship were less developed for the workplace. Reasons for this related to the fit of the research project with workplace interests, Fellows’ contact with the health care organization, feedback structures and training. The potential for co-production of knowledge was under-developed. A transactional notion of exchange was found in operation in workplaces.

Conclusions

The programme’s aim to enhance engagement, linkage and exchange was largely achieved, although exchange tended to be narrowly conceived. Knowing how models of exchange work in practice can ensure effort is put to best use.

Disparities in Health, Poverty, Incarceration, and Social Justice among Racial Groups in the United States: A Critical Review of Evidence of Close Links with Neoliberalism

Problems of poverty, poor health, and incarceration are unevenly distributed among racial and ethnic minorities in the United States. We argue that this is due, in part, to the ascendance of United States-style neoliberalism, a prevailing political and economic doctrine that shapes social policy, including public health and anti-poverty intervention strategies. Public health research most often associates inequalities in health outcomes, poverty, and incarceration with individual and cultural risk factors. Contextual links to structural inequality and the neoliberal doctrine animating state-sanctioned interventions are given less attention. The interrelationships among these are not clear in the extant literature. Less is known about public health and incarceration. Thus, the authors describe the linkages between neoliberalism, public health, and criminal justice outcomes. We suggest that neoliberalism exacerbates racial disparities in health, poverty, and incarceration in the United States. We conclude by calling for a new direction in public health research that advances a pro-poor public health agenda to improve the general well-being of disadvantaged groups.

Prospects for progress on health inequalities in England in the post-primary care trust era: professional views on challenges, risks and opportunities

BACKGROUND

Addressing health inequalities remains a prominent policy objective of the current UK government, but current NHS reforms involve a significant shift in roles and responsibilities. Clinicians are now placed at the heart of healthcare commissioning through which significant inequalities in access, uptake and impact of healthcare services must be addressed. Questions arise as to whether these new arrangements will help or hinder progress on health inequalities. This paper explores the perspectives of experienced healthcare professionals working within the commissioning arena; many of whom are likely to remain key actors in this unfolding scenario.

METHODS

Semi-structured interviews were conducted with 42 professionals involved with health and social care commissioning at national and local levels. These included representatives from the Department of Health, Primary Care Trusts, Strategic Health Authorities, Local Authorities, and third sector organisations.

RESULTS

In general, respondents lamented the lack of progress on health inequalities during the PCT commissioning era, where strong policy had not resulted in measurable improvements. However, there was concern that GP-led commissioning will fare little better, particularly in a time of reduced spending. Specific concerns centred on: reduced commitment to a health inequalities agenda; inadequate skills and loss of expertise; and weakened partnership working and engagement. There were more mixed opinions as to whether GP commissioners would be better able than their predecessors to challenge large provider trusts and shift spend towards prevention and early intervention, and whether GPs' clinical experience would support commissioning action on inequalities. Though largely pessimistic, respondents highlighted some opportunities, including the potential for greater accountability of healthcare commissioners to the public and more influential needs assessments via emergent Health & Wellbeing Boards.

CONCLUSIONS

There is doubt about the ability of GP commissioners to take clearer action on health inequalities than PCTs have historically achieved. Key actors expect the contribution from commissioning to address health inequalities to become even more piecemeal in the new arrangements, as it will be dependent upon the interest and agency of particular individuals within the new commissioning groups to engage and influence a wider range of stakeholders.

Epidemiologia e políticas públicas

Este ensaio trata das relações entre a epidemiologia e as políticas públicas, destacando inicialmente a posição da disciplina no campo da saúde coletiva, analisando os impactos de políticas públicas sobre o perfil epidemiológico e as contribuições da epidemiologia para a formulação, implementação e avaliação de políticas públicas de saúde. No primeiro tópico são discutidos os vínculos da disciplina com o campo da saúde coletiva, o modelo de determinantes sociais e de ação política formulados pela Comissão de Determinantes Sociais em Saúde da OMS, e diferentes enfoques de políticas de saúde. O segundo tópico analisa a redução da desnutrição infantil no Brasil como um exemplo de políticas públicas com impacto no perfil epidemiológico. No terceiro tópico são apresentados três temas estratégicos para a ação das políticas públicas em saúde: redução das desigualdades sociais em saúde, promoção da saúde e regulação sobre bens e serviços com impacto na saúde. O quarto tópico discute as possibilidades e dificuldades de incorporação dos conhecimentos epidemiológicos na formulação, implementação e avaliação de políticas públicas e, finalmente, são apresentados exemplos concretos dessa relação entre epidemiologia e políticas públicas.

Successfully integrating aged care services: a review of the evidence and tools emerging from a long-term care program

Background

Providing efficient and effective aged care services is one of the greatest public policy concerns currently facing governments. Increasing the integration of care services has the potential to provide many benefits including increased access, promoting greater efficiency, and improving care outcomes. There is little research, however, investigating how integrated aged care can be successfully achieved. The PRISMA (Program of Research to Integrate Services for the Maintenance of Autonomy) project, from Quebec, Canada, is one of the most systematic and sustained bodies of research investigating the translation and outcomes of an integrated care policy into practice. The PRISMA research program has run since 1988, yet there has been no independent systematic review of this work to draw out the lessons learnt.

Methods

Narrative review of all literature emanating from the PRISMA project between 1988 and 2012. Researchers accessed an online list of all published papers from the program website. The reference lists of papers were hand searched to identify additional literature. Finally, Medline, Pubmed, EMBASE and Google Scholar indexing databases were searched using key terms and author names. Results were extracted into specially designed spread sheets for analysis.

Results

Forty-five journal articles and two books authored or co-authored by the PRISMA team were identified. Research was primarily concerned with: the design, development and validation of screening and assessment tools; and results generated from their application. Both quasi-experimental and cross sectional analytic designs were used extensively. Contextually appropriate expert opinion was obtained using variations on the Delphi Method. Literature analysis revealed the structures, processes and outcomes which underpinned the implementation. PRISMA provides evidence that integrating care for older persons is beneficial to individuals through reducing incidence of functional decline and handicap levels, and improving feelings of empowerment and satisfaction with care provided. The research also demonstrated benefits to the health system, including a more appropriate use of emergency rooms, and decreased consultations with medical specialists.

Discussion

Reviewing the body of research reveals the importance of both designing programs with an eye to local context, and building in flexibility allowing the program to be adapted to changing circumstances. Creating partnerships between policy designers, project implementers, and academic teams is an important element in achieving these goals. Partnerships are also valuable for achieving effective monitoring and evaluation, and support to ‘evidence-based’ policy-making processes. Despite a shared electronic health record being a key component of the service model, there was an under-investigation of the impact this technology on facilitating and enabling integration and the outcomes achieved.

Conclusions

PRISMA provides evidence of the benefits that can arise from integrating care for older persons, particularly in terms of increased feelings of personal empowerment, and improved client satisfaction with the care provided. Taken alongside other integrated care experiments, PRISMA provides further evidentiary support to policy-makers pursuing integrated care programs. The scale and scope of the research body highlights the long-term and complex nature of program evaluations, but underscores the benefits of evaluation, review and subsequent adaptation of programs. The role of information technology in supporting integration of services is likely to substantially expand in the future and the potential this technology offers should be investigated and harnessed.

The role and status of evidence and innovation in the healthy towns programme in England: a qualitative stakeholder interview study

BACKGROUND

In 2008, the Healthy Community Challenge Fund commissioned nine 'healthy towns' in England to implement and evaluate community-based environmental interventions to prevent obesity. This paper examines the role of evidence in informing intervention development, innovation and the potential for programmes to contribute to the evidence base on the effectiveness of interventions that tackle population obesity.

METHOD

Twenty qualitative interviews with local programme stakeholders and national policy actors were conducted. Interview transcripts were coded and thematically analysed. Initial analyses were guided by research questions regarding the nature and role of evidence in the development and implementation of the healthy towns programme and the capacity for evidence generation to inform future intervention design, policy and practice.

FINDINGS

Stakeholders relied on local anecdotal and observational evidence to guide programme development. While the programme was considered an opportunity to trial new and innovative approaches, the requirement to predict likely health impacts and adopt evidence-based practice was viewed contradictory to this aim. Stakeholders believed there were missed opportunities to add to the existing empirical evidence base due to a lack of clarity and planning, particularly around timing, in local and national evaluations.

CONCLUSIONS

A strong emphasis on relying on existing evidence-based practice and producing positive impacts and outcomes may have impeded the opportunity to implement truly innovative programmes because of fear of failure. Building more time for development, implementation and evaluation into future initiatives would maximise the use and generation of robust and relevant evidence for public health policy and practice.

Systematic reviews need to consider applicability to disadvantaged populations: inter-rater agreement for a health equity plausibility algorithm

Background

Systematic reviews have been challenged to consider effects on disadvantaged groups. A priori specification of subgroup analyses is recommended to increase the credibility of these analyses. This study aimed to develop and assess inter-rater agreement for an algorithm for systematic review authors to predict whether differences in effect measures are likely for disadvantaged populations relative to advantaged populations (only relative effect measures were addressed).

Methods

A health equity plausibility algorithm was developed using clinimetric methods with three items based on literature review, key informant interviews and methodology studies. The three items dealt with the plausibility of differences in relative effects across sex or socioeconomic status (SES) due to: 1) patient characteristics; 2) intervention delivery (i.e., implementation); and 3) comparators. Thirty-five respondents (consisting of clinicians, methodologists and research users) assessed the likelihood of differences across sex and SES for ten systematic reviews with these questions. We assessed inter-rater reliability using Fleiss multi-rater kappa.

Results

The proportion agreement was 66% for patient characteristics (95% confidence interval: 61%-71%), 67% for intervention delivery (95% confidence interval: 62% to 72%) and 55% for the comparator (95% confidence interval: 50% to 60%). Inter-rater kappa, assessed with Fleiss kappa, ranged from 0 to 0.199, representing very low agreement beyond chance.

Conclusions

Users of systematic reviews rated that important differences in relative effects across sex and socioeconomic status were plausible for a range of individual and population-level interventions. However, there was very low inter-rater agreement for these assessments. There is an unmet need for discussion of plausibility of differential effects in systematic reviews. Increased consideration of external validity and applicability to different populations and settings is warranted in systematic reviews to meet this need.

Are we producing the right kind of actionable evidence for the social determinants of health?

Globally, health and social inequities are growing and are created, actively maintained, and aggravated by existing policies and practices. The call for evidence-based policy making to address this injustice seems a promising strategy to facilitate a reversal of existing strategies and the design of new effective programming. Acting on evidence to address inequities requires congruence between identifying the major drivers of disparities and the study of their causes and solutions. Yet, current research on inequities tends to focus on documenting disparities among individuals or subpopulations with little focus on identifying the macro-social causes of adverse population health. Moreover, the research base falls far short of a focus on the solutions to the complex multilevel drivers of disparities. This paper focuses upon recommendations to refocus and improve the public health research evidence generated to inform and create strong evidence-based recommendations for improving population health.

HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention

BACKGROUND

Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention.

METHODS

We undertook a realist review to answer the research question: 'How are HIV prevention interventions in high-income countries adapted to suit immigrants' needs?' A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms.

RESULTS

Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of 'consonance' mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms - 'understanding', 'specificity' and 'embeddedness' - which indicated that using the language of immigrants, usually the 'mother tongue', targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of 'authenticity' and 'framing' mechanisms and only partial evidence to support role of 'endorsement' mechanisms.

CONCLUSIONS

This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.

REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol

BACKGROUND

The implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international settings with negative consequences particularly for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology--Participatory Learning and Action--to investigate and support implementation of such guidelines and training initiatives in routine practice.

METHODS

This is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders-migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory's four constructs--coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings.

DISCUSSION

This research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.

A game of Chinese whispers in Malaysia: contextual analysis of child road safety education

In 2006, the Malaysian government began implementing road safety education (RSE) programs in primary schools, involving numerous stakeholders. We interviewed 19 stakeholders. Thematic analysis led to the identification of four themes: road traffic injuries (RTIs) among children in Malaysia, the role of RSE, factors affecting successful implementation, and intersectoral involvement. The latter was identified as a significant strength of the overall approach to implementation, and is one of the first examples in Malaysia and in the region of such an approach. Lack of official documentation surrounding ownership, funding responsibilities, and roles among the various sectors led to resistance from some groups. Although we know from scientific studies what works in terms of reducing RTIs, the more important question is how such interventions can be successfully and sustainably implemented, particularly in low- and middle-income countries (LMIC). The results of this study permit stronger understanding of issues surrounding the implementation of RTI interventions in LMIC.

Collaboration between health services managers and researchers: making a difference?

OBJECTIVE

Our aim was to evaluate whether the involvement of health care managers in research projects improves the quality and relevance of research, and whether collaboration builds capacity in the managerial community.

METHODS

The NIHR Service Delivery and Organization Management Fellowship programme supports the direct involvement of health care managers in research projects. Data were collected from face-to-face interviews with management fellows and chief investigators of research projects at 10 case study sites. Data were analysed thematically using an adapted Kirkpatrick framework for programme evaluation.

RESULTS

Management fellows improved the relevance and quality of research through enhancing its validity, efficiency and credibility. This was achieved by: using their contextual understanding to enable and support access and recruitment participants, data collection tools, processes and analysis; supporting dissemination activities; and undertaking additional work which was complementary to the main project. Capacity was developed through formal courses and exposure to new knowledge, ideas and practices. Factors found to enable or impede improvements in research included management fellows' knowledge and experience of the NHS, their background and personal characteristics, mutual respect, timing and flexibility. Consequences were not always predictable. Costs for management fellows included foregone opportunities, specifically for promoted posts. Researchers reported time-costs associated with administering the fellowship.

CONCLUSIONS

Collaborations between managers and researchers can improve research relevance and quality and research capacity development. Factors critical to success relate to the fit between the project and the management fellow and how clearly the purpose is understood.

Evidence in oral health promotion-implications for oral health planning

I have explored the debates on evidence-based oral health promotion and examined the practicality of promoting oral health care within a whole system (social, cultural, and environmental) approach. The use of evidence-based decision-making in health services and planning is a viable mechanism to identify optimal health benefits; however, barriers to the effective adoption of evidence-based health practice, including barriers that apply to oral health promotion, have been identified. Evidence-based oral health promotion highlights the importance of examining health promotion activities within a defined social context-a departure from the focus on improving study designs and research methods. Thus, the basis for evidence in health activities is grounded in social and organizational systems. This could contribute to sustainable health efforts.

Judgment, resources, and complexity: a qualitative study of the experiences of systematic reviewers of health promotion

Systematic reviews play an increasingly important role in decision making in health promotion and public health. However, little has been published on how systematic reviewers acquire necessary knowledge and skills, and on the challenges they face in producing reviews. Semistructured interviews were conducted with a purposive sample of 17 systematic reviewers of health promotion. They described practice, training, and mentoring as being key ways that they learned reviewing skills, often in combination. Practice-based learning was considered to be particularly beneficial. Training was generally easy to access, though questions were raised about the feasibility of training stakeholders such as health professionals to become reviewers. It was suggested that an understanding of research methods is beneficial for novice reviewers. While funding opportunities for doing reviews are available, long-term investment is needed to support an infrastructure for the production of high-quality systematic reviews of important health promotion priorities.

Services for adults with an autism spectrum disorder

The need for useful evidence about services is increasing as larger numbers of children identified with an autism spectrum disorder (ASD) age toward adulthood. The objective of this review was to characterize the topical and methodological aspects of research on services for supporting success in work, education, and social participation among adults with an ASD and to propose recommendations for moving this area of research forward. We reviewed the literature published in English from 2000 to 2010 and found that the evidence base about services for adults with an ASD is underdeveloped and can be considered a field of inquiry that is relatively unformed. Extant research does not reflect the demographic or impairment heterogeneity of the population, the range of services that adults with autism require to function with purposeful lives in the community, and the need for coordination across service systems and sectors. Future studies must examine issues related to cost and efficiency, given the broader sociopolitical and economic context of service provision. Further, future research needs to consider how demographic and impairment heterogeneity have implications for building an evidence base that will have greater external validity.

'The Anglo-Saxon disease': a pilot study of the barriers to and facilitators of the use of randomised controlled trials of social programmes in an international context

Background

There appears to be considerable variation between different national jurisdictions and between different sectors of public policy in the use of evidence and particularly the use of randomised controlled trials (RCTs) to evaluate non-healthcare sector programmes.

Methods

As part of a wider study attempting to identify RCTs of public policy sector programmes and the reasons for variation between countries and sectors in their use, we carried out a pilot study which interviewed 10 policy makers and researchers in six countries to elicit views on barriers to and facilitators of the use of RCTs for social programmes.

Results

While in common with earlier studies, those interviewed expressed a need for unambiguous findings, timely results and significant effect sizes, users could, in fact, be ambivalent about robust methods and robust answers about what works, does not work or makes no difference, particularly where investment or a policy announcement was planned. Different national and policy sector cultures varied in their use of and support for RCTs.

Conclusions

In order to maximise the use of robust evaluations of public programmes across the world it would be useful to examine, systematically, cross-national and cross-sectoral variations in the use of different methods including RCTs and barriers to and facilitators of their use. Sound research methods, whatever their scientific value, are no guarantee that findings will be useful or used. ‘Stories’ have been shown to influence policy; those advocating the use of RCTs may need to provide convincing narratives to avoid repetition about their value.

Does consideration and assessment of effects on health equity affect the conclusions of systematic reviews? A methodology study

Introduction

Tackling health inequities both within and between countries remains high on the agenda of international organizations including the World Health Organization and local, regional and national governments. Systematic reviews can be a useful tool to assess effects on equity in health status because they include studies conducted in a variety of settings and populations. This study aims to describe the extent to which the impacts of health interventions on equity in health status are considered in systematic reviews, describe methods used, and assess the implications of their equity related findings for policy, practice and research.

Methods

We conducted a methodology study of equity assessment in systematic reviews. Two independent reviewers extracted information on the reporting and analysis of impacts of health interventions on equity in health status in a group of 300 systematic reviews collected from all systematic reviews indexed in one month of MEDLINE, using a pre-tested data collection form. Any differences in data extraction were resolved by discussion.

Results

Of the 300 systematic reviews, 224 assessed the effectiveness of interventions on health outcomes. Of these 224 reviews, 29 systematic reviews assessed effects on equity in health status using subgroup analysis or targeted analyses of vulnerable populations. Of these, seven conducted subgroup analyses related to health equity which were reported in insufficient detail to judge their credibility. Of these 29 reviews, 18 described implications for policy and practice based on assessment of effects on health equity.

Conclusion

The quality and completeness of reporting should be enhanced as a priority, because without this policymakers and practitioners will continue lack the evidence base they need to inform decision-making about health inequity. Furthermore, there is a need to develop methods to systematically consider impacts on equity in health status that is currently lacking in systematic reviews.

Evidence in the development of health policy

For over a century and a half, reformers, researchers and politicians have complained that social and public health policy is not based on evidence. Linear models of knowledge transfer gaps are consistently shown to be poor predictors of research uptake. Public health research, in particular, involves more elements than the linear biomedical model of translation into healthcare products or interventions. Policy makers certainly need to be more sophisticated in understanding and commissioning different types of research and acting on it. However, researchers also need to be much more sophisticated and less naive in understanding how research does and does not influence policy, and how to go about helping policy makers to interpret the jigsaw of evidence, and its relevance and usability.

Galvanizers, guides, champions, and shields: the many ways that policymakers use public health researchers

CONTEXT

Public health researchers make a limited but important contribution to policy development. Some engage with policy directly through committees, advisory boards, advocacy coalitions, ministerial briefings, intervention design consultation, and research partnerships with government, as well as by championing research-informed policy in the media. Nevertheless, the research utilization literature has paid little attention to these diverse roles and the ways that policymakers use them. This article describes how policymakers use researchers in policymaking and examines how these activities relate to models of research utilization. It also explores the extent to which policymakers' accounts of using researchers concur with the experiences of "policy-engaged" public health researchers.

METHODS

We conducted semi-structured interviews with thirty-two Australian civil servants, parliamentary ministers, and ministerial advisers identified as "research-engaged" by public health researchers. We used structured and inductive coding to generate categories that we then compared with some of the major research utilization models.

FINDINGS

Policymakers were sophisticated and multifaceted users of researchers for purposes that we describe as Galvanizing Ideas, Clarification and Advice, Persuasion, and Defense. These categories overlapped but did not wholly fit with research utilization models. Despite the negative connotation, "being used" was reported as reciprocal and uncompromising, although researchers and policymakers were likely to categorize these uses differently. Policymakers countered views expressed by some researchers. That is, they sought robust dialogue and creative thinking rather than compliance, and they valued expert opinion when research was insufficient for decision making. The technical/political character of policy development shaped the ways in which researchers were used.

CONCLUSIONS

Elucidating the diverse roles that public health researchers play in policymaking, and the multiple ways that policymakers use these roles, provides researchers and policymakers with a framework for negotiating and reflecting on activities that may advance the public health goals shared by both.

PRISMA-Equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity

Vivian Welch and colleagues present consensus-based guidelines for reporting equity-focused systematic reviews, the PRISMA-Equity extension.

The e-Health Implementation Toolkit: qualitative evaluation across four European countries

BACKGROUND

Implementation researchers have attempted to overcome the research-practice gap in e-health by developing tools that summarize and synthesize research evidence of factors that impede or facilitate implementation of innovation in healthcare settings. The e-Health Implementation Toolkit (e-HIT) is an example of such a tool that was designed within the context of the United Kingdom National Health Service to promote implementation of e-health services. Its utility in international settings is unknown.

METHODS

We conducted a qualitative evaluation of the e-HIT in use across four countries--Finland, Norway, Scotland, and Sweden. Data were generated using a combination of interview approaches (n = 22) to document e-HIT users' experiences of the tool to guide decision making about the selection of e-health pilot services and to monitor their progress over time.

RESULTS

e-HIT users evaluated the tool positively in terms of its scope to organize and enhance their critical thinking about their implementation work and, importantly, to facilitate discussion between those involved in that work. It was easy to use in either its paper- or web-based format, and its visual elements were positively received. There were some minor criticisms of the e-HIT with some suggestions for content changes and comments about its design as a generic tool (rather than specific to sites and e-health services). However, overall, e-HIT users considered it to be a highly workable tool that they found useful, which they would use again, and which they would recommend to other e-health implementers.

CONCLUSION

The use of the e-HIT is feasible and acceptable in a range of international contexts by a range of professionals for a range of different e-health systems.

The use of research evidence in public health decision making processes: systematic review

Background

The use of research evidence to underpin public health policy is strongly promoted. However, its implementation has not been straightforward. The objectives of this systematic review were to synthesise empirical evidence on the use of research evidence by public health decision makers in settings with universal health care systems.

Methods

To locate eligible studies, 13 bibliographic databases were screened, organisational websites were scanned, key informants were contacted and bibliographies of included studies were scrutinised. Two reviewers independently assessed studies for inclusion, extracted data and assessed methodological quality. Data were synthesised as a narrative review.

Findings

18 studies were included: 15 qualitative studies, and three surveys. Their methodological quality was mixed. They were set in a range of country and decision making settings. Study participants included 1063 public health decision makers, 72 researchers, and 174 with overlapping roles. Decision making processes varied widely between settings, and were viewed differently by key players. A range of research evidence was accessed. However, there was no reliable evidence on the extent of its use. Its impact was often indirect, competing with other influences. Barriers to the use of research evidence included: decision makers' perceptions of research evidence; the gulf between researchers and decision makers; the culture of decision making; competing influences on decision making; and practical constraints. Suggested (but largely untested) ways of overcoming these barriers included: research targeted at the needs of decision makers; research clearly highlighting key messages; and capacity building. There was little evidence on the role of research evidence in decision making to reduce inequalities.

Conclusions

To more effectively implement research informed public health policy, action is required by decision makers and researchers to address the barriers identified in this systematic review. There is an urgent need for evidence to support the use of research evidence to inform public health decision making to reduce inequalities.

Assessing the evaluability of complex public health interventions: five questions for researchers, funders, and policymakers

CONTEXT

Evidence to support government programs to improve public health often is weak. Recognition of this "knowledge gap" has led to calls for more and better evaluation, but decisions about priorities for evaluation also need to be addressed in regard to financial restraint.

METHODS

Using England's Healthy Community Challenge Fund as a case study, this article presents a set of questions to stimulate and structure debate among researchers, funders, and policymakers and help make decisions about evaluation within and between complex public health interventions as they evolve from initial concept to dissemination of full-scale intervention packages.

FINDINGS

This approach can be used to identify the types of knowledge that might be generated from any evaluation, given the strength of evidence available in response to each of five questions, and to support a more systematic consideration of resource allocation decisions, depending on the types of knowledge required.

CONCLUSIONS

The principles of this approach may be generalizable, and should be tested and refined for other complex public health and wider social interventions.

Maximizing the impact of systematic reviews in health care decision making: a systematic scoping review of knowledge-translation resources

CONTEXT

Barriers to the use of systematic reviews by policymakers may be overcome by resources that adapt and present the findings in formats more directly tailored to their needs. We performed a systematic scoping review to identify such knowledge-translation resources and evaluations of them.

METHODS

Resources were eligible for inclusion in this study if they were based exclusively or primarily on systematic reviews and were aimed at health care policymakers at the national or local level. Resources were identified by screening the websites of health technology assessment agencies and systematic review producers, supplemented by an email survey. Electronic databases and proceedings of the Cochrane Colloquium and HTA International were searched as well for published and unpublished evaluations of knowledge-translation resources. Resources were classified as summaries, overviews, or policy briefs using a previously published classification.

FINDINGS

Twenty knowledge-translation resources were identified, of which eleven were classified as summaries, six as overviews, and three as policy briefs. Resources added value to systematic reviews by, for example, evaluating their methodological quality or assessing the reliability of their conclusions or their generalizability to particular settings. The literature search found four published evaluation studies of knowledge-translation resources, and the screening of abstracts and contact with authors found three more unpublished studies. The majority of studies reported on the perceived usefulness of the service, although there were some examples of review-based resources being used to assist actual decision making.

CONCLUSIONS

Systematic review producers provide a variety of resources to help policymakers, of which focused summaries are the most common. More evaluations of these resources are required to ensure users' needs are being met, to demonstrate their impact, and to justify their funding.

An exploratory cluster randomised controlled trial of knowledge translation strategies to support evidence-informed decision-making in local governments (The KT4LG study)

BACKGROUND

Childhood overweight and obesity is the most prevalent and, arguably, politically complex child health problem internationally. Governments, communities and industry have important roles to play, and are increasingly expected to deliver an evidence-informed system-wide prevention program. However, efforts are impeded by a lack of organisational access to and use of research evidence. This study aims to identify feasible, acceptable and ideally, effective knowledge translation (KT) strategies to increase evidence-informed decision-making in local governments, within the context of childhood obesity prevention as a national policy priority.

METHODS/DESIGN

This paper describes the methods for KT4LG, a cluster randomised controlled trial which is exploratory in nature, given the limited evidence base and methodological advances. KT4LG aims to examine a program of KT strategies to increase the use of research evidence in informing public health decisions in local governments. KT4LG will also assess the feasibility and acceptability of the intervention. The intervention program comprises a facilitated program of evidence awareness, access to tailored research evidence, critical appraisal skills development, networking and evidence summaries and will be compared to provision of evidence summaries alone in the control program. 28 local governments were randomised to intervention or control, using computer generated numbers, stratified by budget tertile (high, medium or low). Questionnaires will be used to measure impact, costs, and outcomes, and key informant interviews will be used to examine processes, feasibility, and experiences. Policy tracer studies will be included to examine impact of intervention on policies within relevant government policy documents.

DISCUSSION

Knowledge translation intervention studies with a focus on public health and prevention are very few in number. Thus, this study will provide essential data on the experience of program implementation and evaluation of a system-integrated intervention program employed within the local government public health context. Standardised programs of system, organisational and individual KT strategies have not been described or rigorously evaluated. As such, the findings will make a significant contribution to understanding whether a facilitated program of KT strategies hold promise for facilitating evidence-informed public health decision making within complex multisectoral government organisations.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000953235.