How are policy makers using evidence? Models of research utilisation and local NHS policy making

An integrated strategy of knowledge application for optimal e-health implementation: a multi-method study protocol

BACKGROUND

E-health is increasingly valued for supporting: 1) access to quality health care services for all citizens; 2) information flow and exchange; 3) integrated health care services and 4) interprofessional collaboration. Nevertheless, several questions remain on the factors allowing an optimal integration of e-health in health care policies, organisations and practices. An evidence-based integrated strategy would maximise the efficacy and efficiency of e-health implementation. However, decisions regarding e-health applications are usually not evidence-based, which can lead to a sub-optimal use of these technologies. This study aims at understanding factors influencing the application of scientific knowledge for an optimal implementation of e-health in the health care system.

METHODS

A three-year multi-method study is being conducted in the Province of Quebec (Canada). Decision-making at each decisional level (political, organisational and clinical) are analysed based on specific approaches. At the political level, critical incidents analysis is being used. This method will identify how decisions regarding the implementation of e-health could be influenced or not by scientific knowledge. Then, interviews with key-decision-makers will look at how knowledge was actually used to support their decisions, and what factors influenced its use. At the organisational level, e-health projects are being analysed as case studies in order to explore the use of scientific knowledge to support decision-making during the implementation of the technology. Interviews with promoters, managers and clinicians will be carried out in order to identify factors influencing the production and application of scientific knowledge. At the clinical level, questionnaires are being distributed to clinicians involved in e-health projects in order to analyse factors influencing knowledge application in their decision-making. Finally, a triangulation of the results will be done using mixed methodologies to allow a transversal analysis of the results at each of the decisional levels.

RESULTS

This study will identify factors influencing the use of scientific evidence and other types of knowledge by decision-makers involved in planning, financing, implementing and evaluating e-health projects.

CONCLUSION

These results will be highly relevant to inform decision-makers who wish to optimise the implementation of e-health in the Quebec health care system. This study is extremely relevant given the context of major transformations in the health care system where e-health becomes a must.

"It's sort of like being a detective": understanding how Australian men self-monitor their health prior to seeking help

BACKGROUND

It is commonly held that men delay help seeking because they are ignorant about and disinterested in their health. However, this discussion has not been informed by men's lay perspectives, which have remained almost entirely absent from scholarship relating to men's help seeking practices.

METHODS

In this qualitative paper, we draw on semi-structured interviews with 36 South Australian men to examine their understandings of help seeking and health service use.

RESULTS & DISCUSSION

We use participants' talk about self-monitoring to challenge the assumption that men are disinterested in their health, arguing instead that the men in our study monitored their health status and made conscious decisions about when and how to seek help. Using an inductive approach during the thematic analysis we were able to identify four key factors that influenced how men monitored their health and explain how these intersect with the way men sought help and used health services.

CONCLUSION

We show that the men in our study were actively engaged in the self-monitoring of their health. We suggest that these findings offer an alternative approach for understanding how we can promote men's interaction with health services.

A knowledge transfer strategy for public health decision makers

PURPOSE

The purpose of this study was to discover public health decision makers' preferences for content, format, and channels for receiving research knowledge, so as to begin development of a comprehensive national public health knowledge transfer strategy. A preliminary knowledge transfer strategy developed in part from the views expressed by public health decision makers in an earlier study (Dobbins et al. 2002b) was used as a foundation on which to base discussions. The research team believes strongly that consultation with potential users is crucial to ensure the conduct of relevant and timely research as well as the development of an effective knowledge transfer strategy.

METHODS

Nine focus groups of five to seven participants were held in seven Canadian cities. Participants included medical officers of health, public health managers and directors, health promotion mangers, and health policymakers at provincial and federal levels. A semi-structured, open-ended interview guide was used to facilitate the discussion. The focus groups were audiotaped, and results were analyzed independently by two members of the research team who then developed key themes through a consensus process.

RESULTS

Generally, participants spoke positively about the knowledge transfer strategy to which they were exposed. In addition, they supported the development of a registry of reviews evaluating the effectiveness of public health interventions rated by methodological quality of the evidence, with a summary statement of the reviews highlighting the results along with specific implications for practice. Participants also indicated they wanted to receive personalized updates of new reviews in their area of interest. Finally, the results highlighted a significant challenge related to knowledge management indicating opportunities for ongoing professional development and training.

CONCLUSIONS

These findings were used to create an online registry of reviews evaluating the effectiveness of public health and health promotion interventions. The registry is one component of a comprehensive national public health knowledge transfer strategy.

Knowledge translation for research utilization: design of a knowledge translation model at Tehran University of Medical Sciences

INTRODUCTION

The present study aimed to generate a model that would provide a conceptual framework for linking disparate components of knowledge translation. A theoretical model of such would enable the organization and evaluation of attempts to analyze current conditions and to design interventions on the transfer and utilization of research knowledge.

METHODS

This research, performed in 2006-2007 at the Tehran University of Medical Sciences (TUMS), utilized two distinct methodologies: a narrative review to identify existing knowledge transfer models and frameworks and focus group discussions to determine the views and opinions of researchers and decision makers regarding barriers to knowledge translation within the health system.

RESULTS

A knowledge translation cycle is described, with five domains: knowledge creation, knowledge transfer, research utilization, question transfer, and the context of organization.

DISCUSSION

The knowledge translation cycle offers a theoretical basis for identifying basic requirements and linking mechanisms in the translation of knowledge for research utilization.

The use and misuse of health research by parliamentary politicians during the development of a national smokefree law

BACKGROUND

We investigated the ways in which research evidence about the health effects from secondhand smoke (SHS) and smokefree policies was publicly used or regarded by New Zealand parliamentary politicians, during efforts to strengthen a smokefree law (ie, from 1997 to 2005).

METHODS

A documentary case study used published and unpublished material recording the use of research evidence by politicians. The material was collected for the period 1997-2005 from the parliamentary record, media and other databases. Additional searches were made to provide context for the politicians who used research.

RESULTS

Major themes identified included: (a) the employment of local estimates of SHS mortality, (b) linking specific health effects (eg, cancer) to SHS exposure, (c) a focus on the use of research relevant to bar workers, and (d) the use of research to downgrade the health effects, and attacks on the credibility of research showing health effects from SHS. Almost half of the 21 Members of Parliament (MPs), who spoke in parliament about SHS research during 2000-2005, denied or were sceptical about SHS harm. At least five MPs used tobacco industry funded or disseminated versions of research. There was some indirect evidence that the degree of exposure to the health sector, or the tobacco industry and its allies, may have been factors in the use by MPs of the research.

POLICY IMPLICATIONS

The willingness of some of this group of politicians to adopt tobacco industry arguments suggests possible options within health promotion. These include the better enforcement of consumer protection laws (preventing deceptive information by the tobacco industry and its allies), and the adoption of an increased focus on tobacco industry behaviour within tobacco control efforts. These moves may have beneficial effects for the use of research in public health policymaking. The strengthening by the health sector of its advocacy capacity and effectiveness may also be a crucial step in the better use of research by politicians in the policymaking process.

Addressing men's health policy concerns in Australia: what can be done?

There is a lack of consensus about what men's health constitutes in Australia. The absence of a widely accepted definition has been problematic for establishing state and national men's health policies. I consider that one impediment to the implementation of state and federal men's health policies has been a lack of willingness to approach men's health from a broad public health perspective. In particular, scant attention has been paid to exploring lay perspectives of how men define and understand health, and in turn, how these relate to significant policy problems such as men's health service use. I conclude by suggesting that a focus on men's lay perspectives of their health emerging from the United Kingdom and the Republic of Ireland provides a useful framework to guide men's health policy discussion in Australia.

Prioritising between direct observation of therapy and case-finding interventions for tuberculosis: use of population impact measures

BACKGROUND

Population impact measures (PIMs) have been developed as tools to help policy-makers with locally relevant decisions over health risks and benefits. This involves estimating and prioritizing potential benefits of interventions in specific populations. Using tuberculosis (TB) in India as an example, we examined the population impact of two interventions: direct observation of therapy and increasing case-finding.

METHODS

PIMs were calculated using published literature and national data for India, and applied to a notional population of 100,000 people. Data included the incidence or prevalence of smear-positive TB and the relative risk reduction from increasing case finding and the use of direct observation of therapy (applied to the baseline risks over the next year), and the incremental proportion of the population eligible for the proposed interventions.

RESULTS

In a population of 100,000 people in India, the directly observed component of the Directly Observed Treatment, Short-course (DOTS) programme may prevent 0.188 deaths from TB in the next year compared with 1.79 deaths by increasing TB case finding. The costs of direct observation are (in international dollars) 5960 I dollars and of case finding are 4839 I dollars or 31702 I dollars and 2703 I dollars per life saved respectively.

CONCLUSION

Increasing case-finding for TB will save nearly 10 times more lives than will the use of the directly observed component of DOTS in India, at a smaller cost per life saved. The demonstration of the population impact, using simple and explicit numbers, may be of value to policy-makers as they prioritize interventions for their populations.

The role and theoretical evolution of knowledge translation and exchange in public health

BACKGROUND

There is an increased emphasis in public health research on effective models and strategies to support knowledge translation (KT), the exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users. In other words, KT can be seen as an acceleration of the knowledge cycle-an acceleration of the natural transformation of knowledge into use (Canadian Institutes of Health Services Research. Knowledge Translation Strategy, 2004). The most recent conceptualizations consider the complexities of public health decision-making. The role of practitioners and communities is increasingly considered.

METHODS

We identify, describe and discuss the theoretical underpinnings of KT and recommend a way forward to build the evidence for more effective practice.

RESULTS

Theoretical perspectives increasingly influence research on KT in public health. A range of innovative work is being conducted to explore methods for KT using practical tools, often with the support of government.

CONCLUSIONS

KT describes a crucial and to date under-developed element of the research process. There is an important gap in theoretically informed empirical studies of effectiveness of proposed approaches in public health, health promotion and preventive medicine, and thus much of the debate remains abstract. There is clearly an urgent policy need to establish the effectiveness of KT models in a range of contexts. This must include both the consideration of development and the utilization of knowledge.

Managing partnerships and impact on decision-making: the example of health technology assessment in genetics

For an emerging field such as Public Health Genetics, the partnerships that will be developed with stakeholders are of strategic importance, since they may affect long-term impact on policy-making. A concrete example in the field of health technology assessment in genetics was chosen to illustrate how the context in which scientific advisory bodies operate and the nature of partnerships developed over time influence the impact on decision-making at different levels, from the micro (professional) level through the meso (institutional) level to the macro (policy) level. As pointed out in the knowledge transfer literature, impact is not only reflected by instrumental use of knowledge, but also by problem-framing and strategic use of knowledge. Solid partnerships at the micro level, with researchers and health care professionals, are essential to build credibility and trust, and they lay the groundwork for contextualized and relevant advice and potential impact at the policy level. Even though maintaining the necessary critical distance with respect to all stakeholders is easier for institutions that are at arm's length from government, achieving the right balance between an institution's independence and service relationship is a real challenge.

Understanding the limited impact of economic evaluation in health care resource allocation: a conceptual framework

Concern has increasingly been expressed at the low level of impact that economic evaluations have on the priority setting decisions they are designed to inform. The concern to maximise the impact of economic evaluation in health care is reminiscent of research utilisation debates rehearsed in the various policy studies disciplines. This paper draws on selected themes and frameworks from this literature in order to explore issues and map out an agenda relating to the uptake and use of cost effectiveness analysis in health policy decisions. The authors consider the implications for health economics, and other policy-related research and evaluation, of adopting either a rational or interactive model of research utilisation. Economic evaluations can be normative or descriptive decision tools. The choice of approach will reflect the assumed model of research utilisation and has implications for overcoming barriers to impact on policy. There is an underlying conceptual link between the rational model of research utilisation, the normative approach to economic evaluation and a focus on barriers to the accessibility of published analyses. In contrast, acknowledgement of an interactive and incremental policy process predisposes the analyst to a more descriptive approach and suggests the importance of broader systems, process and ethical barriers to the use of economic evaluation. We address the crucial issue of the importance of establishing objectives and discuss how this issue effects how those seeking to influence policy should proceed. Finally, we discuss indirect or 'enlightenment' models of research utilisation and the implications of these for the community of health economists.

From rhetoric to reality: barriers faced by Health For All initiatives

The last two decades have witnessed an upsurge in the development and implementation of 'Health For All-type' initiatives in many parts of the world. However, despite the popularity of the approach, barriers and constraints to the fulfillment of their remit still persist, making it difficult for them to achieve the potential originally envisaged. Drawing upon considerable empirical work while evaluating the European Healthy City projects and English Health Action Zones, this paper explores the differences between barriers and constraints and then focuses on barriers as they manifest themselves in England. It distinguishes between cultural barriers, stemming from different philosophical, organisational, and professional/experiential cultures, and political barriers, stemming from both party political and realpolitik concerns. It discusses how these barriers often operate together, compounding their individual impacts, with detrimental effects for Health For All initiatives. Consequently, while the prevailing rhetoric appears to promote an alternative, and more appropriate, vision of how health can be maintained and enhanced, these barriers effectively function to sustain the hegemony of the status quo which was, and is, based on a different and outdated vision. We argue that acknowledging the continuous persistence of these barriers is an essential first step towards turning the prevailing health-related rhetoric into reality.

Developing an evidence base for policies and interventions to address health inequalities: the analysis of "public health regimes"

Systematic reviews have become an important methodology in the United Kingdom by which research informs health policy, and their use now extends beyond evidence-based medicine to evidence-based public health and, particularly, health inequalities policies. This article reviews the limitations of systematic reviews as stand-alone tools for this purpose and suggests a complementary approach to make better use of the evidence. That is, systematic reviews and other sources of evidence should be incorporated into a wider analytical framework, the public health regime (defined here as the specific legislative, social, political, and economic structures that have an impact on both public health and the appropriateness and effectiveness of public health interventions adopted). At the national level this approach would facilitate analysis at all levels of the policy framework, countering the current focus on individual interventions. It could also differentiate at the international level between those policies and interventions that are effective in different contexts and are therefore potentially generalizable and those that depend on particular conditions for success.

Informing policy making and management in healthcare: the place for synthesis

Research synthesis has an important role supporting the transfer of knowledge between researchers and healthcare decision-makers. But if our goal is to make knowledge more useable and context specific, then extending the scope of systematic reviews or producing syntheses with policy makers and managers may be insufficient. Dialogues, partnerships and reinterpretations of evidence in context will help us achieve this goal.

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.

Pathways to "evidence-informed" policy and practice: a framework for action

Bowen and Zwi propose a new framework that can help researchers and policy makers to navigate the use of evidence.

Toward better sleep for workers: impressions of some needs

We know there are persons exposed demanding work schedules and sleep loss in almost every occupation or industry, but we still need better population-based information on how many sleepy or inattentive workers there are, where they are, and to what extent they are a risk to themselves or others. The absence of such information, however, does not prevent us from continuing to conduct worksite interventions and demonstrations that will produce good, evidence-based guidelines to help workers and workplace administrators make informed choices about sleep and provide optimal conditions for sleep. In addition, systematic study and publication of how managers and policy-makers accept our research to make worksite changes, and what factors beside our research influence their decisions, would contribute techniques to the greater public health community aiming to translate research results into good practice.

Improving research transfer in the addictions field: a perspective from Canada

This paper discusses how to enhance the research-to-practice exchange in the addictions field, while maintaining a balance with the demands and complexities of program delivery and policy development. It outlines the evolution of the concept of evidence-based practice, discusses the practical limitations and ways to improve transferring research to practice, and provides examples of research transfer activities in Canada. Practical limitations to research transfer include individual, organizational, and community factors. A strategic approach to research transfer includes addressing these limitations by combining dissemination activities with interventions such as individual instruction and incentives; building relationships among researchers, practitioners, and populations served; and obtaining commitments at a systemic level from funding bodies and research organizations to support research transfer. The potential is noted for the concept of workforce development to facilitate research transfer at organizational levels. The conclusion shown in this paper is that the tools and concept of evidence-based practice can lead the way to strengthening addictions programs and policies, and the development of a conceptual model for addiction research transfer in Canada would be a useful next step.

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

OBJECTIVE

To explore with UK and international policy advisors how research evidence influences public health policy making, and how its relevance and utility could be improved, with specific reference to the evidence on the production and reduction of health inequalities.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative residential workshop involving senior policy advisors with a substantive role in policy development across a range of sectors (mainly public health, but also including education, social welfare, and health services). In four in depth sessions, facilitated by the authors, focused questions were presented to participants. Their responses were then analysed thematically to identify key themes, relating to the availability and utility of existing evidence on health inequalities.

MAIN RESULTS

The lack of an equity dimension in much aetiological and evaluative research was highlighted by participants. Much public health research was also felt to have weak underlying theoretical underpinnings. As well as evaluations of the effectiveness and cost-effectiveness of policy and other interventions, they identified a need for predictive research, and for methodological research to further develop methods for assessing the impact on health of clusters of interventions.

CONCLUSIONS

This study reinforces the view that there is a lack of information on the effectiveness and cost-effectiveness of policies, and it uncovered additional gaps in the health inequalities evidence base. A companion paper discusses researchers' views of how the production of more relevant public health evidence can be stimulated.