The primacy of politics: the rise and fall of evidence-based public health policy?

Systems Thinking and Complexity Science Methods and the Policy Process in Non-communicable Disease Prevention: A Systematic Scoping Review

BACKGROUND

Given the complex determinants of non-communicable diseases (NCDs), and the dynamic policy landscape, researchers and policymakers are exploring the use of systems thinking and complexity science (STCS) in developing effective policies. The aim of this review is to systematically identify and analyse existing applications of STCS-informed methods in NCD prevention policy.

METHODS

Systematic scoping review: We searched academic databases (Medline, Scopus, Web of Science, EMBASE) for all publications indexed by 13 October 2020, screening titles, abstracts and full texts and extracting data according to published guidelines. We summarised key data from each study, mapping applications of methods informed by STCS to policy process domains. We conducted a thematic analysis to identify advantages, limitations, barriers and facilitators to using STCS.

RESULTS

4681 papers were screened and 112 papers were included in this review. The most common policy areas were tobacco control, obesity prevention and physical activity promotion. Methods applied included system dynamics modelling, agent-based modelling and concept mapping. Advantages included supporting evidence-informed decision-making; modelling complex systems and addressing multi-sectoral problems. Limitations included the abstraction of reality by STCS methods, despite aims of encompassing greater complexity. Challenges included resource-intensiveness; lack of stakeholder trust in models; and results that were too complex to be comprehensible to stakeholders. Ensuring stakeholder ownership and presenting findings in a user-friendly way facilitated STCS use.

CONCLUSION

This review maps the proliferating applications of STCS methods in NCD prevention policy. STCS methods have the potential to generate tailored and dynamic evidence, adding robustness to evidence-informed policymaking, but must be accessible to policy stakeholders and have strong stakeholder ownership to build consensus and change stakeholder perspectives. Evaluations of whether, and under what circumstances, STCS methods lead to more effective policies compared to conventional methods are lacking, and would enable more targeted and constructive use of these methods.

Systems thinking and complexity science methods and the policy process in non-communicable disease prevention: a systematic scoping review protocol

INTRODUCTION

Given the complex causal origins of many non-communicable diseases (NCDs), and the complex landscapes in which policies designed to tackle them are made and unfold, the need for systems thinking and complexity science (STCS) in developing effective policy solutions has been emphasised. While numerous methods informed by STCS have been applied to the policy process in NCD prevention, these applications have not been systematically catalogued. The aim of this scoping review is to identify existing applications of methods informed by STCS to the policy process for NCD prevention, documenting which domains of the policy process they have been applied to.

METHODS AND ANALYSIS

A systematic scoping review methodology will be used.

IDENTIFICATION

We will search Medline, SCOPUS, Embase and Web of Science using search terms combining STCS, NCD prevention and the policy process. All records published in English will be eligible for inclusion, regardless of study design.

SELECTION

We will screen titles and abstracts and extract data according to published guidelines for scoping reviews. In order to determine the quality of the included studies, we will use the approach developed by Dixon-Woods et al, excluding studies identified as fatally flawed, and determining the credibility and contribution of included studies.

SYNTHESIS

We will identify relevant studies, summarising key data from each study and mapping applications of methods informed by STCS to different parts of the policy process. Review findings will provide a useful reference for policy-makers, outlining which domains of the policy process different methods have been applied to.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as the study does not involve primary data collection. The findings of this study will be disseminated through a peer-reviewed publication, presentations and summaries for key stakeholders.

Linking political exposures to child and maternal health outcomes: a realist review

BACKGROUND

Conceptual and theoretical links between politics and public health are longstanding. Internationally comparative systematic review evidence has shown links between four key political exposures - the welfare state, political tradition, democracy and globalisation - on population health outcomes. However, the pathways through which these influences may operate have not been systematically appraised. Therefore, focusing on child and maternal health outcomes, we present a realist re-analysis of the dataset from a recent systematic review.

METHODS

The database from a recent systematic review on the political determinants of health was used as the data source for this realist review. Included studies from the systematic review were re-evaluated and those relating to child and/or maternal health outcomes were included in the realist synthesis. Initial programme theories were generated through realist engagement with the prior systematic review. These programme theories were adjudicated and refined through detailed engagement with the evidence base using a realist re-synthesis involving two independent reviewers. The revised theories that best corresponded to the evidence base formed the final programme theories.

RESULTS

Out of the 176 included studies from the systematic review, a total of 67 included child and/or maternal health outcomes and were included in the realist re-analysis. Sixty-three of these studies were ecological and data were collected between 1950 and 2014. Six initial programme theories were generated. Following theory adjudication, three theories in revised form were supported and formed the final programme theories. These related to a more generous welfare state leading to better child and maternal health especially in developed countries through progressive social welfare policies, left-of-centre political tradition leading to lower child mortality and low birth weight especially in developed countries through greater focus on welfare measures, and increased globalisation leading to greater child and infant mortality and youth smoking rates in LMECs through greater influence of multinational corporations and neoliberal trade organisations.

CONCLUSION

We present a realist re-analysis of a large systematically identified body of evidence on how four key political exposures - the welfare state, democracy, political tradition and globalisation - relate to child and maternal health outcomes. Three final programme theories were supported.

Evidence-based information needs of public health workers: a systematized review

Objective

This study assessed public health workers’ evidence-based information needs, based on a review of the literature using a systematic search strategy. This study is based on a thesis project conducted as part of the author’s master’s in public health coursework and is considered a systematized review.

Methods

Four databases were searched for English-language articles published between 2005 and 2015: PubMed, Web of Science, Library Literature & Information Science Index, and Library, Information Science & Technology Abstracts (LISTA). Studies were excluded if there was no primary data collection, the population in the study was not identified as public health workers, “information” was not defined according to specific criteria, or evidence-based information and public health workers were not the major focus. Studies included in the final analysis underwent data extraction, critical appraisal using CASP and STROBE checklists, and thematic analysis.

Results

Thirty-three research studies were identified in the search, including twenty-one using quantitative methods and twelve using qualitative methods. Critical appraisal revealed many potential biases, particularly in the validity of research. Thematic analysis revealed five common themes: (1) definition of information needs, (2) current information-seeking behavior and use, (3) definition of evidence-based information, (4) barriers to information needs, and (5) public health–specific issues.

Conclusions

Recommendations are given for how librarians can increase the use of evidence-based information in public health research, practice, and policy making. Further research using rigorous methodologies and transparent reporting practices in a wider variety of settings is needed to further evaluate public health workers’ information needs.

Benefits and barriers to the public health pharmacy: a qualitative exploration of providers’ and commissioners’ perceptions of the Healthy Living Pharmacy framework

Aims:

The aims of this study were to explore the barriers to the implementation and progression of the Healthy Living Pharmacy (HLP) framework, from both provider and commissioner perspectives, and to ascertain whether the successes and barriers of the framework perceived by pharmacies are shared with commissioners.

Methods:

A structured qualitative interview study, using purposive sampling, was undertaken with 11 community pharmacists and 11 Healthy Living Champions (providers) from HLPs in the north of England. Four commissioners of such services were also interviewed. Interviews were analysed using a thematic approach.

Results:

There were many aspects of the HLP framework that the service ‘providers’ were positive about, namely, workforce development, engagement (particularly with the smoking cessation service) and as a motivation for pharmacy teams. However, there were areas of concern about low awareness among pharmacy users, the time involved in delivery, as well as financial considerations. These were exemplified by the health checks element. Commissioners also expressed concerns about health checks as well as a lack of cohesion between commissioners and service providers and a poor understanding of the broader framework.

Conclusion:

The HLP framework was perceived as valuable by providers although there were areas of concern. A key barrier to the framework – perceived by both providers and commissioners – was the implementation of health checks. This should be considered in future commissioning.

Are health and well-being strategies in England fit for purpose? A thematic content analysis

BACKGROUND

Since 1 April 2013, local authority (LA) health and well-being boards (HWBs) in England are required to publish a health and well-being strategy (HWS). HWSs should identify how population health needs are to be addressed. The extent to which this has been achieved is not known. We analysed HWSs to assess how LAs have interpreted statutory guidance, how evidence has been used within HWSs and the relationship of HWSs to Joint Strategic Needs Assessments (JSNAs).

METHODS

Qualitative thematic content analysis of a random sample of one-third of upper tier LA HWSs in 2013-14.

RESULTS

Fifty out of 152 LAs were sampled and 47 HWSs analysed. Strategies varied in timescale, length and structure. The term 'evidence' was used most commonly referring to local need, rather than evidence of effectiveness. All, except two, referred to JSNAs.

CONCLUSIONS

HWSs are dominated by evidence of need and could be strengthened by greater use of evidence of effectiveness for public health interventions. Public health agencies and academics can support the development of effective HWSs by improving the accessibility of evidence and conducting research when evidence is absent. To strengthen HWSs' impact, the statutory guidance should clarify the distinction between evidence of need and evidence of effectiveness.