What prevents health policy being 'evidence-based'? New ways to think about evidence, policy and interventions in health

The use of evidence to guide decision-making during the COVID-19 pandemic: divergent perspectives from a qualitative case study in British Columbia, Canada

BACKGROUND

The challenges of evidence-informed decision-making in a public health emergency have never been so notable as during the COVID-19 pandemic. Questions about the decision-making process, including what forms of evidence were used, and how evidence informed-or did not inform-policy have been debated.

METHODS

We examined decision-makers' observations on evidence-use in early COVID-19 policy-making in British Columbia (BC), Canada through a qualitative case study. From July 2021- January 2022, we conducted 18 semi-structured key informant interviews with BC elected officials, provincial and regional-level health officials, and civil society actors involved in the public health response. The questions focused on: (1) the use of evidence in policy-making; (2) the interface between researchers and policy-makers; and (3) key challenges perceived by respondents as barriers to applying evidence to COVID-19 policy decisions. Data were analyzed thematically, using a constant comparative method. Framework analysis was also employed to generate analytic insights across stakeholder perspectives.

RESULTS

Overall, while many actors' impressions were that BC's early COVID-19 policy response was evidence-informed, an overarching theme was a lack of clarity and uncertainty as to what evidence was used and how it flowed into decision-making processes. Perspectives diverged on the relationship between 'government' and public health expertise, and whether or not public health actors had an independent voice in articulating evidence to inform pandemic governance. Respondents perceived a lack of coordination and continuity across data sources, and a lack of explicit guidelines on evidence-use in the decision-making process, which resulted in a sense of fragmentation. The tension between the processes involved in research and the need for rapid decision-making was perceived as a barrier to using evidence to inform policy.

CONCLUSIONS

Areas to be considered in planning for future emergencies include: information flow between policy-makers and researchers, coordination of data collection and use, and transparency as to how decisions are made-all of which reflect a need to improve communication. Based on our findings, clear mechanisms and processes for channeling varied forms of evidence into decision-making need to be identified, and doing so will strengthen preparedness for future public health crises.

Deliberative process of health technology reassessment by health technology assessment agency in Korea

In 2019, the National Evidence-based Healthcare Collaborating Agency (NECA) in Korea established a health technology reassessment (HTR) system to manage the life cycle of health technologies and develop operational measures promoting the efficient use of healthcare resources. The purpose of this study is to introduce the detailed implementation process and practical functional methods of the HTR implemented by NECA.The HTR is a structured multidisciplinary method for analyzing health technologies currently used in the healthcare system based on the latest information on parameters, such as clinical safety, effectiveness, and cost-effectiveness of optimizing the use of healthcare resources as well as social and ethical issues. All decision-making stages of the HTR are carefully reviewed and transparently managed. The HTR committee makes significant decisions, and the subcommittee decides the details related to the assessment process.Since the pilot began in 2018, 262 cases have been reassessed, of which, 126 cases (48.1 percent) were health services not covered by the National Health Insurance (NHI). Over the past 5 years, approximately 130 recommendations for the in-use technologies were determined by the HTR committee. In the near future, it will be necessary to officially develop and establish a Korean HTR system and a legal foundation to optimize the NHI system.

A regulatory gap analysis of midwifery to deliver essential reproductive, maternal, newborn, child and adolescent health services in Lao People's Democratic Republic

Background

In Lao Peoples Democratic Republic, midwives are the main providers of primary reproductive, maternal, newborn, child and adolescent (RMNCAH) services. We analyzed to what extent practice regulations allow midwives to provide nationally defined essential RMNCAH services.

Methods

Stakeholder consultations and document reviews were conducted to identify the essential RMNCAH interventions and care tasks midwives are expected to provide without physicians. These were defined in: 1) the Essential Health Service Package (EHSP) and 2) 18 national standards and guidelines. We then mapped whether midwifery regulations, which provide the legal framework for clinical service provision, supported delivery of these standards to identify regulatory gaps. Data were used to update regulations.

Findings

Midwives were expected to provide 39 RMNCAH interventions without physicians, representing 1100 care tasks. Midwifery practice regulations allowed eight of 39 interventions (20.5%) and 705 of 1100 care tasks (64.1%) at baseline. Of the 31 interventions not allowed for provision by midwives, 83.9% (26) required prescribing and giving medicines, 51.6% (16) ordering and conducting diagnostics, 38.7% (12) making a clinical diagnosis, and 22.6% (7) use of non-pharmacological interventions. The Ministry of Health convened a multi-stakeholder group to revise the midwifery practice regulations, which increased the legally supported interventions and care tasks to 37 (94.9%) and 1081 (98.3%), respectively.

Interpretation

This novel methodology enabled systematic identification and quantification of regulatory gaps in midwifery practice and data-driven revisions. Consequently, regulatory support for delivery of primary RMNCAH interventions vastly improved. The approach can be applied to other clinical cadres, service areas and countries.

Funding

Korea Foundation for International Health Care (KOFIH) supported research operation.

Evaluation of the use of modelling in resource allocation decisions for HIV and TB

INTRODUCTION

Globally, resources for health spending, including HIV and tuberculosis (TB), are constrained, and a substantial gap exists between spending and estimated needs. Optima is an allocative efficiency modelling tool that has been used since 2010 in over 50 settings to generate evidence for country-level HIV and TB resource allocation decisions. This evaluation assessed the utilisation of modelling to inform financing priorities from the perspective of country stakeholders and their international partners.

METHODS

In October to December 2021, the World Bank and Burnet Institute led 16 semi-structured small-group virtual interviews with 54 representatives from national governments and international health and funding organisations. Interviews probed participants' roles and satisfaction with Optima analyses and how model findings have had been used and impacted resource allocation. Interviewed stakeholders represented nine countries and 11 different disease programme-country contexts with prior Optima modelling analyses. Interview notes were thematically analysed to assess factors influencing the utilisation of modelling evidence in health policy and outcomes.

RESULTS

Common influences on utilisation of Optima findings encompassed the perceived validity of findings, health system financing mechanisms, the extent of stakeholder participation in the modelling process-including engagement of funding organisations, sociopolitical context and timeliness of the analysis. Using workshops can facilitate effective stakeholder engagement and collaboration. Model findings were often used conceptually to localise global evidence and facilitate discussion. Secondary outputs included informing strategic and financial planning, funding advocacy, grant proposals and influencing investment shifts.

CONCLUSION

Allocative efficiency modelling has supported evidence-informed decision-making in numerous contexts and enhanced the conceptual and practical understanding of allocative efficiency. Most immediately, greater involvement of country stakeholders in modelling studies and timing studies to key strategic and financial planning decisions may increase the impact on decision-making. Better consideration for integrated disease modelling, equity goals and financing constraints may improve relevance and utilisation of modelling findings.

The multiple makings of a supervised consumption service in a hospital setting

BACKGROUND

Whereas supervised consumption services (SCSs) are common in many community settings, they are seldomly found in acute care hospitals. As hospitals present unique circumstances that can shape the impacts of an SCS, careful consideration of local implementation contexts and practices is required. We explored the pre-implementation stage of an SCS, to examine how an SCS is made and made differently in relation to the material-discursive context of the hospital.

METHODS

We conducted 11 focus groups with 83 staff and clinicians at an inner-city hospital in Toronto, Canada. Data analysis followed principles of grounded theory and was informed by an 'evidence making interventions' framework.

RESULTS

While most participants indicated they would support the establishment of an SCS at the hospital, multiple enactments of an SCS emerged. An SCS was enacted: as a means to reduce drug-related risks for all people who use drugs, as an opportunity to intervene on patients' drug use, as a means to centralize drug use, and as a transformative intervention for the hospital. In our findings, harm reduction, abstinence, security, and risk mitigation goals existed closely together, yielding overlaying realities.

CONCLUSION

Our findings revealed various enactments of an SCS, some of which are likely to negatively affect people who use drugs and service access. As more hospitals consider the implementation of an SCS, understanding how an SCS is made in practice will be key to building a service that focuses on the needs of people who use drugs.

Mapping the range of policies relevant to care of small and nutritionally at-risk infants under 6 months and their mothers in Ethiopia: a scoping review protocol

INTRODUCTION

Evidence gaps limit management of small and/or nutritionally at-risk infants under 6 months and their mothers, who are at higher risk of death, illness, malnutrition and poor growth and development. These infants may be low birth weight, wasted, stunted and/or underweight. An integrated care model to guide their management (MAMI Care Pathway) is being tested in a randomised controlled trial in Ethiopia. Evaluating the extent to which an innovation is consistent with national policies and priorities will aid evidence uptake and plan for scale.

METHODS AND ANALYSIS

This review will evaluate the extent to which the MAMI Care Pathway is consistent with national policies that relate to the care of at-risk infants under 6 months and their mothers in Ethiopia. The objectives are to describe the range and characteristics, concepts, strategic interventions, coherence and alignment of existing policies and identify opportunities and gaps. It will be conducted in accordance with the JBI methodology for scoping reviews (PRISMA-ScR). Eligible documents include infant and maternal health, nutrition, child development, food and social welfare-related policies publicly available in English and Amharic. The protocol was registered on the Open Science Framework Registry on 20 June 2022 (https://osf.io/m4jt6).Grey literature will be identified through government and agency websites, national and subnational contacts and Google Scholar, and published policies through electronic database searches (MEDLINE, EMBASE and Global and Health Information). The searches will take place between October 2023 and March 2024. A standardised data extraction tool will be used. Descriptive analysis of data will be undertaken. Data will be mapped visually and tabulated. Results will be described in narrative form. National stakeholder discussions will inform conclusions and recommendations.

ETHICS AND DISSEMINATION

Ethical approval is not required as data consist solely of publicly available material. Findings will be used to evidence national and international policy and practice.

Grading Evidence to Support Legislative and Budget Proposals-Veterans Health Administration's Key to Implementing the Evidence Act

OBJECTIVES

The Foundations for Evidence-Based Policymaking Act of 2018 requires cabinet-level agencies to use evidence to justify and support budget and policy making. As investigators from the Quality Enhancement Research Initiative (QUERI) program, we were tasked with assisting Veterans Health Administration (VHA) leadership with the implementation of the Evidence-Based Policymaking Act of 2018. Through meetings with stakeholders, we identified a gap in the review process for legislative and budget proposals; no systematic process existed to evaluate the supporting evidence base for proposals.

METHODS

Here, we describe the development, refinement, and use of a checklist to assess the strength of evidence included in VHA legislative and budget proposals for changes to care delivery; clinical, research, and administrative operations; and staffing and workforce issues.

RESULTS

The evidence assessment checklist is now part of the regular review process for VHA legislative and budget proposals. It is also being adapted for use elsewhere within the Department of Veterans Affairs. The checklist has provided a framework for briefings and training on best practices for using evidence to guide policy and budget decisions.

CONCLUSION

Including evidence reviews in the legislative and budget proposal prioritization process may be an effective institutional arrangement to promote the use of evidence to inform high-level health policy decisions and to build a "culture of evidence" within the government.

Prevalence of self-reported lifetime medical diagnosis of depression in Brazil: analysis of data from the 2019 Brazilian National Health Survey

OBJECTIVES

To assess the prevalence of and factors associated with the lifetime medical diagnosis of depression in Brazil.

DESIGN

Population-based, cross-sectional study.

SETTING

Analysis of data from the 2019 Brazilian National Health Survey.

PARTICIPANTS

90 846 individuals aged ≥15 years were included.

OUTCOME MEASURE

The self-reported medical diagnosis of depression at some point in one's life was the main outcome. Prevalence ratios (PRs) with 95% CIs were calculated by Poisson regression with robust variance. The independent variables included the geographical area of residence, sociodemographic characteristics, current smoking status, alcohol abuse, daily screen time, and the presence of physical disorders and mental health comorbidities.

RESULTS

The self-reported lifetime prevalence of medical diagnosis of depression was 9.9% (95% CI 9.5% to 10.2%). The probability of having received a medical diagnosis of depression was higher among urban residents (PR 1.23; 95% CI 1.12 to 1.35); females (2.75; 2.52 to 2.99); those aged 20-29 years (1.17; 0.91 to 1.51), 30-39 years (1.73; 1.36 to 2.19), 40-49 years (2.30; 1.81 to 2.91), 50-59 years (2.32; 1.84 to 2.93) and 60-69 years (2.27; 1.78 to 2.90) compared with those under 20 years; white-skinned people (0.69 (0.61 to 0.78) for black-skinned people and 0.74 (0.69 to 0.80) for indigenous, yellow and brown-skinned people compared with white-skinned people); those with fewer years of education (1.33(1.12 to 1.58) among those with 9-11 years, 1.14 (0.96 to 1.34) among those with 1-8 years and 1.29 (1.11 to 1.50) among those with 0 years compared with those with ≥12 years of education); those who were separated/divorced (1.43; 1.29 to 1.59), widowed (1.06; 0.95 to 1.19) and single (1.01; 0.93 to 1.10) compared with married people; smokers (1.26; 1.14 to 1.38); heavy screen users (1.31; 1.16 to 1.48) compared with those whose usage was <6 hours/day; those with a medical diagnosis of a physical disorder (1.80; 1.67 to 1.97); and individuals with a medical diagnosis of a mental health comorbidity (5.05; 4.68 to 5.46).

CONCLUSION

This nationwide population-based study of self-reported lifetime medical diagnosis of depression in Brazil showed that the prevalence was almost 10%. Considering the current Brazilian population, this prevalence corresponds to more than 2 million people who have been diagnosed with depression at some point in their lives.

The hammer and the nail: The triple lock of methods, realities and institutional contexts in Australian research on nightlife violence

There is considerable public and policy debate in Australia about measures to reduce violence associated with alcohol and young people in the night-time economy. Though overrepresented in violence, the role of men and masculinities is rarely explicitly addressed in policy responses to such violence, which rest on a narrow range of mainly quantitative research and recommendations favouring blanket alcohol restrictions. Drawing on John Law and colleagues' account of the 'double social life of methods' (2011), we analyse interviews conducted with Australian quantitative researchers about the role of gender in such violence. According to Law et al., methods inhabit and reproduce particular ecologies and reflect the concerns of those who advocate them. From this 'triple lock' of methods, realities, and institutional advocacies and contexts emerges particular modes of knowing. Participants described a research ecology in which the authority of quantitative research methods emerged in relation to an imperative to respond in a 'timely' and 'pragmatic' fashion to public policy debates, and prevailing governmental and policy priorities and public framings of violence. Though participants frequently acknowledged the role of men in violence, these arrangements sustain taken-for-granted assumptions about the properties and effects of alcohol while displacing men and masculinities from policy attention. The political consequences of these arrangements demand the development of innovative policy responses and new modes of knowing that make visible the gendering of violence.

Uncomfortable science: How mathematical models, and consensus, come to be in public policy

We explore messy translations of evidence in policy as a site of 'uncomfortable science'. Drawing on the work of John Law, we follow evidence as a 'fluid object' of its situation, also enacted in relation to a hinterland of practices. Working with the qualitative interview accounts of mathematical modellers and other scientists engaged in the UK COVID-19 response, we trace how models perform as evidence. Our point of departure is a moment of controversy in the public announcement of second national lockdown in the UK, and specifically, the projected daily deaths from COVID-19 presented in support of this policy decision. We reflect on this event to trace the messy translations of "scientific consensus" in the face of uncertainty. Efforts among scientists to realise evidence-based expectation and to manage the troubled translations of models in policy, including via "scientific consensus", can extend the dis-ease of uncomfortable science rather than clean it up or close it down. We argue that the project of evidence-based policy is not so much in need of technical management or repair, but that we need to be thinking altogether differently.

The journey of policies during the COVID-19 pandemic in Indonesia: a need of evidence-informed policy

[No abstract available]

Diversity via datafication? Digital patient records and citizenship for sexuality and gender diverse people

In 2018, the Australian Government adopted an ‘opt-out’ strategy to increase participation in My Health Record (MHR), the national digital patient record system. Opt out was rationalised through discourse on the universal right to health. Media controversy ensued due to privacy fears, security and commercial exploitation of patient information. LGBT community organisations warned that people with complex health needs should consider their privacy and legal situation when deciding whether or not to opt out of MHR. With reference to the health needs of sexuality and gender diverse people, we examine MHR’s rights universalism, possessive individualism, and state-based rationalisation of health governance. MHR hails all but no-one in particular, erasing diversity and straightwashing data medicine. It is a technological solution to state-based imperatives for health governance, an emphasis that does not serve minority communities or address health needs that attract stigma and prejudice. We counterpose these effects with citizenship framings seated in critical approaches to data assemblages and sexuality and gender diversity. We suggest ways in which data medicine, of which MHR is but one example, can be made more relevant and effective for individuals and communities whose healthcare is poorly served by mainstream health systems.

New directions for participatory modelling in health: Redistributing expertise in relation to localised matters of concern

Participatory modelling seeks to foster stakeholder engagement to better attune models to their decision-making and policy contexts. Such approaches are increasingly advocated for use in the field of health. We review the instrumental and epistemological claims made in support of participatory modelling approaches. These accentuate participatory models as offering a better evidence-base for health policy decisions. By drawing attention to recent modelling experiments in a sector outside of health, that of water management, we outline a different way of thinking about participation and modelling. Here, the participatory model is configured in relation to matters of 'knowledge controversy', with modelling constituted as an 'evidence-making intervention' in relation to the making of science and expertise. Rather than presenting participatory models as an improved technical solution to addressing given policy problems within an evidence-based intervention approach, models are alternatively potentiated as sites for the redistribution of expertise among actor networks as they seek to engage politically in a matter of concern. This leads us to consider possible new directions for participatory modelling in the field of health.

Advancing Use of Nutrition Knowledge to Improve Practice by Policy and Program Communities in India During a Political Transition

Models are needed for how to advance use of knowledge by programs and policy officials to make evidence-based decisions about nutrition. How to advance use of nutrition knowledge in India from 2011 to 2015 during a political transition was investigated through studying a knowledge initiative led by the International Food Policy Research Institute. Semistructured interviews were conducted with 37 diverse participants, and 1091 news articles, 318 Twitter and 175 Facebook posts, 12 YouTube events, 65 knowledge products, and 130 engaging events were assessed. Open-axial coding, content and themes analysis, triangulation, and process tracing were used. The knowledge initiative analyzed the landscape, made knowledge available, mobilized it, and engendered its use. After political transition, knowledge was readied for the reassembled nutrition technical community, including timely responses to governmental information needs. Making nutrition knowledge available, mobilizing it, and engendering its use can be advanced through knowledge initiatives in large, complex countries during political transitions.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.

Towards an ontological politics of drug policy: Intervening through policy, evidence and method

Increasing attention has been paid to matters of ontology, and its accompanying politics, in the drug policy field. In this commentary, we consider what an 'ontological politics' might mean for how we think about what drug policy is and what it might become, as well as for how we think about (and do) research in drug policy. Thinking ontopolitically questions the tacitly accepted status of 'drug problems', calls into question the realist presumptions which underpin much drug policy analysis, and provokes thinking about what counts as 'evidence' and the 'evidence-based policy' paradigm itself. We call attention to the inventive possibilities of method when grappling with the challenges thrown forth by the ontological turn, with a renewed focus on practice and relations. An ontological politics disrupts consensual claims and draws critical attention to objects that might otherwise appear 'finished' or 'ready-made', not least the things we call 'drugs' and 'drug policy'. Working with 'drug policy multiples' invites new thinking and dialogue to provoke an ethico-political mode of intervention in the field of drug policy and drugs research.