From research to evidence-informed decision making: a systematic approach

A scoping review of implementation science theories, models, and frameworks - an appraisal of purpose, characteristics, usability, applicability, and testability

BACKGROUND

A proliferation of theories, models, and frameworks (TMFs) have been developed in the implementation science field to facilitate the implementation process. The basic features of these TMFs have been identified by several reviews. However, systematic appraisals on the quality of these TMFs are inadequate. To fill this gap, this study aimed to assess the usability, applicability, and testability of the current TMFs in a structured way.

METHODS

A scoping review method was employed. Electronic databases were searched to locate English and Chinese articles published between January 2000 and April 2022. Search terms were specific to implementation science. Additionally, hand searches were administered to identify articles from related reviews. Purpose and characteristics such as the type of TMF, analytical level, and observation unit were extracted. Structured appraisal criteria were adapted from Birken et al.'s Theory Comparison and Selection Tool (T-CaST) to conduct an in-depth analysis of the TMFs' usability, applicability, and testability.

RESULTS

A total of 143 TMFs were included in this analysis. Among them, the most common purpose was to identify barriers and facilitators. Most TMFs applied the descriptive method to summarize the included constructs or the prescriptive method to propose courses of implementation actions. TMFs were mainly mid-range theories built on existing conceptual frameworks or demonstrated grand theories. The usability of the TMFs needs to be improved in terms of the provision of conceptually matched strategies to barriers and facilitators and instructions on the TMFs usage. Regarding the applicability, little attention was paid to the constructs of macro-level context, stages of scale-up and sustainability, and implementation outcomes like feasibility, cost, and penetration. Also, fewer TMFs could propose recommended research and measurement methods to apply the TMFs. Lastly, explicit hypotheses or propositions were lacking in most of the TMFs, and empirical evidence was lacking to support the claimed mechanisms between framework elements in testability.

CONCLUSIONS

Common limitations were found in the usability, application, and testability of the current TMFs. The findings of this review could provide insights for developers of TMFs for future theoretical advancements.

Comparative analysis of Australian climate change and COVID-19 vaccine audience segments shows climate skeptics can be vaccine enthusiasts

Denialism and the spreading of misinformation have occurred regarding both climate change and COVID-19, delaying uptake of urgent actions. Audience segmentation analysis identifies audience subgroups likely to have similar responses to messaging, and is a valuable tool for effective campaigns encouraging critical behaviors in both contexts. This study compared audience segmentations based on a representative sample of 1054 Australians. One segmentation was based on the 'Global Warming's Six Americas' online SASSY tool. The second segmentation applied the Theory of Planned Behavior and found five distinct COVID-19 vaccine segments. Both studies showed those most concerned and those most skeptical in the climate change segmentation tended to be in more enthusiastic COVID-19 vaccine segments, while those in the center on climate change were more skeptical on COVID-19 vaccines. Differences identified relating to age, gender, and political views may be explained by a combination of the specific nature and histories of these issues. These findings have implications for effective communication on science and health issues across diverse disciplines.

Identifying barriers and facilitators of translating research evidence into clinical practice: A systematic review of reviews

Translating research into clinical practice is a global priority because of its potential impact on health services delivery and outcomes. Despite the ever-increasing depth and breadth of health research, most areas across the globe seem to be slow to translate relevant research evidence into clinical practice. Thus, this review sought to synthesise existing literature to elucidate the barriers and facilitators to the translation of health research into clinical practice. A systematic review of reviews approach was utilised. Review studies were identified across PubMed, Scopus, Embase, CINAHL and Web of Science databases, from their inception to 15 March 2021. Searching was updated on 30 March 2022. All retrieved articles were screened by two authors; reviews meeting the inclusion criteria were retained. Based on the review type, two validated tools were employed to ascertain their quality: A Measurement Tool to Assess Systematic Reviews-2 and International Narrative Systematic assessment. The framework synthesis method was adopted to guide the analysis and narrative synthesis of data from selected articles. Ten reviews met the inclusion criteria. The study revealed that the translation of new evidence was limited predominantly by individual-level issues and less frequently by organisational factors. Inadequate knowledge and skills of individuals to conduct, organise, utilise and appraise research literature were the primary individual-level barriers. Limited access to research evidence and lack of equipment were the key organisational challenges. To circumvent these barriers, it is critical to establish collaborations and partnerships between policy makers and health professionals at all levels and stages of the research process. The study concluded that recognising barriers and facilitators could help set key priorities that aid in translating and integrating research evidence into practice. Effective stakeholder collaboration and co-operation should improve the translation of research findings into clinical practice.

Challenges to evidence-informed decision-making in the context of pandemics: qualitative study of COVID-19 policy advisor perspectives

INTRODUCTION

The exceptional production of research evidence during the COVID-19 pandemic required deployment of scientists to act in advisory roles to aid policy-makers in making evidence-informed decisions. The unprecedented breadth, scale and duration of the pandemic provides an opportunity to understand how science advisors experience and mitigate challenges associated with insufficient, evolving and/or conflicting evidence to inform public health decision-making.

OBJECTIVES

To explore critically the challenges for advising evidence-informed decision-making (EIDM) in pandemic contexts, particularly around non-pharmaceutical control measures, from the perspective of experts advising policy-makers during COVID-19 globally.

METHODS

We conducted in-depth qualitative interviews with 27 scientific experts and advisors who are/were engaged in COVID-19 EIDM representing four WHO regions and 11 countries (Australia, Canada, Colombia, Denmark, Ghana, Hong Kong, Nigeria, Sweden, Uganda, UK, USA) from December 2020 to May 2021. Participants informed decision-making at various and multiple levels of governance, including local/city (n=3), state/provincial (n=8), federal or national (n=20), regional or international (n=3) and university-level advising (n=3). Following each interview, we conducted member checks with participants and thematically analysed interview data using NVivo for Mac software.

RESULTS

Findings from this study indicate multiple overarching challenges to pandemic EIDM specific to interpretation and translation of evidence, including the speed and influx of new, evolving, and conflicting evidence; concerns about scientific integrity and misinterpretation of evidence; the limited capacity to assess and produce evidence, and adapting evidence from other contexts; multiple forms of evidence and perspectives needed for EIDM; the need to make decisions quickly and under conditions of uncertainty; and a lack of transparency in how decisions are made and applied.

CONCLUSIONS

Findings suggest the urgent need for global EIDM guidance that countries can adapt for in-country decisions as well as coordinated global response to future pandemics.

Integrative Psychotherapy With Physicians In the Trenches: Convergence of Cognitive, Existential, and Psychodynamic Processes

In this article, I present insights gleaned from over a decade of working in therapy with physicians in the trenches who practice at general hospitals located in an area afflicted by the community and political violence, and recently, by the COVID-19 pandemic. Psychotherapy with these physicians requires an integrative psychotherapeutic approach that heeds their changing needs. Espousing cognitive-existential psychodynamics (CEP), a theory-based psychotherapeutic perspective developed for complex cases, I show how cognitive, existential, and psychodynamic processes strongly converge during the treatment of physicians in the trenches. Such convergence is manifested in issues of mental representations (of death, medicine, and the hospital) and choice/meaning.

Implementing 'universal' access to antiretroviral treatment in South Africa: a scoping review on research priorities

‘Universal’ access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control; yet, findings from numerous ‘test and treat’ trials and implementation studies in sub-Saharan Africa suggest that bringing ‘universal' access to ART to scale is more complex than anticipated. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. To do so, we adapted Arksey and O’Malley’s six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 2000 and 2017. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker–client relationship, clinic/community context, health systems infrastructure and/or policy context. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. The peer-reviewed literature focused on the individual and health systems infrastructure; opinion pieces focused on changing roles of individuals, communities and health services implementers. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa’s HIV programme expands. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control.

A systematic approach to context-mapping to prepare for health interventions: development and validation of the SETTING-tool in four countries

Effectiveness of health interventions can be substantially impaired by implementation failure. Context-driven implementation strategies are critical for successful implementation. However, there is no practical, evidence-based guidance on how to map the context in order to design context-driven strategies. Therefore, this practice paper describes the development and validation of a systematic context-mapping tool. The tool was cocreated with local end-users through a multistage approach. As proof of concept, the tool was used to map beliefs and behaviour related to chronic respiratory disease within the FRESH AIR project in Uganda, Kyrgyzstan, Vietnam and Greece. Feasibility and acceptability were evaluated using the modified Conceptual Framework for Implementation Fidelity. Effectiveness was assessed by the degree to which context-driven adjustments were made to implementation strategies of FRESH AIR health interventions. The resulting Setting-Exploration-Treasure-Trail-to-Inform-implementatioN-strateGies (SETTING-tool) consisted of six steps: (1) Coset study priorities with local stakeholders, (2) Combine a qualitative rapid assessment with a quantitative survey (a mixed-method design), (3) Use context-sensitive materials, (4) Collect data involving community researchers, (5) Analyse pragmatically and/or in-depth to ensure timely communication of findings and (6) Continuously disseminate findings to relevant stakeholders. Use of the tool proved highly feasible, acceptable and effective in each setting. To conclude, the SETTING-tool is validated to systematically map local contexts for (lung) health interventions in diverse low-resource settings. It can support policy-makers, non-governmental organisations and health workers in the design of context-driven implementation strategies. This can reduce the risk of implementation failure and the waste of resource potential. Ultimately, this could improve health outcomes.

Implementation research approaches to promoting universal health coverage in Africa: a scoping review

BACKGROUND

Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of initiatives promoting the uptake of implementation research in Africa, its role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). Hence, this scoping review aimed to identify and characterise the use of implementation research initiatives for assessing UHC-related interventions or programmes in Africa.

METHODS

The review protocol was developed based on the methodological framework proposed by Arksey and O'Malley, as enhanced by the Joanna Briggs Institute. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). MEDLINE, Scopus and the Cochrane Library were searched. The search also included a hand search of relevant grey literature and reference lists. Literature sources involving the application of implementation research in the context of UHC in Africa were eligible for inclusion.

RESULTS

The database search yielded 2153 records. We identified 12 additional records from hand search of reference lists. After the removal of duplicates, we had 2051 unique records, of which 26 studies were included in the review. Implementation research was used within ten distinct UHC-related contexts, including HIV; maternal and child health; voluntary male medical circumcision; healthcare financing; immunisation; healthcare data quality; malaria diagnosis; primary healthcare quality improvement; surgery and typhoid fever control. The consolidated framework for implementation research (CFIR) was the most frequently used framework. Qualitative and mixed-methods study designs were the commonest methods used. Implementation research was mostly used to guide post-implementation evaluation of health programmes and the contextualisation of findings to improve future implementation outcomes. The most commonly reported contextual facilitators were political support, funding, sustained collaboration and effective programme leadership. Reported barriers included inadequate human and other resources; lack of incentives; perception of implementation as additional work burden; and socio-cultural barriers.

CONCLUSIONS

This review demonstrates that implementation research can be used to achieve UHC-related outcomes in Africa. It has identified important facilitators and barriers to the use of implementation research for promoting UHC in the region.

Protocol for a scoping review of implementation research approaches to universal health coverage in Africa

INTRODUCTION

Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of institutions and initiatives promoting the uptake of implementation research in Africa, their role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). This review aims to extensively identify and characterise the nature, facilitators and barriers to the use of implementation research for assessing or evaluating UHC-related interventions or programmes in Africa.

METHODS AND ANALYSIS

This scoping review will be developed based on the methodological framework proposed by Arksey and O'Malley and enhanced by the Joanna Briggs Institute. It will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A comprehensive search of the following electronic databases will be conducted: Medline (via PubMed), Scopus and the Cochrane Library. Relevant grey literature and reference lists will also be searched. All publications describing the application of implementation research in the context of UHC will be considered for inclusion. Findings will be narratively synthesised and analysed using a predefined conceptual framework. Where applicable, quantitative evidence will be aggregated using summary statistics. There will be consultation of stakeholders, including UHC-oriented health professionals, programme managers, implementation researchers and policy-makers; to provide methodological, conceptual and practical insights.

ETHICS AND DISSEMINATION

The data used in this review will be sourced from publicly available literature; hence, this study will not require ethical approval. Findings and recommendations will be disseminated to reach a diverse audience, including UHC advocates, implementation researchers and key health system stakeholders within the African region. Additionally, findings will be disseminated through an open-access publication in a relevant peer-reviewed journal.

Effectiveness of Technology-Enabled Knowledge Translation Strategies in Improving the Use of Research in Public Health: Systematic Review

Background

Knowledge translation (KT) aims to facilitate the use of research evidence in decision making. Changes in technology have provided considerable opportunities for KT strategies to improve access and use of evidence in decision making by public health policy makers and practitioners. Despite this opportunity, there have been no reviews that have assessed the effects of digital technology-enabled KT (TEKT) in the field of public health.

Objective

This study aims to examine the effectiveness of digital TEKT strategies in (1) improving the capacity for evidence-based decision making by public health policy makers and practitioners, (2) changing public health policy or practice, and (3) changes in individual or population health outcomes.

Methods

A search strategy was developed to identify randomized trials assessing the effectiveness of digital TEKT strategies in public health. Any primary research study with a randomized trial design was eligible. Searches for eligible studies were undertaken in multiple electronic bibliographic databases (Medical Literature Analysis and Retrieval System Online [MEDLINE], Excerpta Medica dataBASE [EMBASE], PsycINFO, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and Scopus) and the reference lists of included studies. A hand search of 2 journals (Implementation Science and Journal of Medical Internet Research) and a gray literature search were also conducted. Pairs of independent review authors screened studies, assessed the risk of bias, and extracted data from relevant studies.

Results

Of the 6819 citations screened, 8 eligible randomized trials were included in the review. The studies examined the impact of digital TEKT strategies on health professionals, including nurses, child care health consultants, physiotherapists, primary health care workers, and public health practitioners. Overall, 5 of the interventions were web-training programs. The remaining 3 interventions included simulation games, access to digital resource materials and the use of tailored messaging, and a web-based registry. The findings suggest that digital TEKT interventions may be effective in improving the knowledge of public health professionals, relative to control, and may be as effective as a face-to-face KT approach. The effectiveness of digital TEKT strategies relative to a control or other digital KT interventions on measures of health professional self-efficacy to use evidence to enhance practice behavior or behavioral intention outcomes was mixed. The evidence regarding the effects on changes to health policy or practice following exposure to digital TEKT was mixed. No trials assessed the effects on individual or population-level health outcomes.

Conclusions

This review is the first to synthesize the effectiveness of digital TEKT interventions in a public health setting. Despite its potential, relatively few trials have been undertaken to investigate the impacts of digital TEKT interventions. The findings suggest that although a digital TEKT intervention may improve knowledge, the effects of such interventions on other outcomes are equivocal.

What steps can researchers take to increase research uptake by policymakers? A case study in China

Empirical analysis of the connections between research and health policymaking is scarce in middle-income countries. In this study, we focused on a national multidrug-resistant tuberculosis (TB) healthcare provider training programme in China as a case study to examine the role that research plays in influencing health policy. We specifically focused on the factors that influence research uptake within the complex Chinese policymaking process. Qualitative data were collected from 34 participants working at multilateral organizations, funding agencies, academia, government agencies and hospitals through 14 in-depth interviews and 2 focus group discussions with 10 participants each. Themes were derived inductively from data and grouped based on the 'Research and Policy in Developing countries' framework developed by the Overseas Development Institute. We further classified how actors derive their power to influence policy decisions following the six sources of power identified by Sriram et al. We found that research uptake by policymakers in China is influenced by perceived importance of the health issues addressed in the research, relevance of the research to policymakers' information needs and government's priorities, the research quality and the composition of the research team. Our analysis identified that international donors are influential in the TB policy process through their financial power. Furthermore, the dual roles of two government agencies as both evidence providers and actors who have the power to influence policy decisions through their technical expertise make them natural intermediaries in the TB policy process. We concluded that resolving the conflict of interests between researchers and policymakers, as suggested in the 'two-communities theory', is not enough to improve evidence use by policymakers. Strategies such as framing research to accommodate the fast-changing policy environment and making alliances with key policy actors can be effective to improve the communication of research findings into the policy process, particularly in countries undergoing rapid economic and political development.

Reflections and proposals for the establishment of Family and Community Medicine Master's Programs in Brazil

While Primary Health Care (PHC) and Family and Community Medicine (FCM) have expanded their space and relevance in health care and undergraduate medical courses, Brazil has no stricto sensu FCM postgraduate programs. In this paper, we analyze some aspects of the Brazilian public health field and the national stricto sensu postgraduate system that can help to explain this scenario. As a contribution to the debate on this topic, we also gathered information from international postgraduate and research experiences in FCM and devised a curriculum proposal for future national FCM master's courses. In the end, we discussed some key strategies for the emergence of stricto sensu postgraduate courses in this discipline in Brazil, highlighting the potential of these programs for evaluation and qualification of primary care services, especially the Family Health Strategy, and the training of PHC specialists required for the consolidation of the Unified Health System (SUS) as an accessible, comprehensive and equitable health system for the Brazilian population.

An educational intervention to update health workers about HIV and infant feeding

Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.

From public health and demographic research to decision making: An intervention study in Giza Governorate-Egypt

The purpose of the current study was to develop an empirical model that shows how various contextual data are analyzed, interpreted and presented as evidence-based information for decision making and action taking. A Pre-test-Posttest intervention study was conducted at the National Population Council (NPC)-Giza governorate (GG) where all data were collected from all governmental organizations on an annual basis at the district level (19 districts), which include 28 indicators. Composite indices and indicators (n = 9) had been ranked and presented as a matrix that assigned districts into three situations: Best (green zone), prospective (yellow zone) and critical (red zone).

INTERVENTION

Presentation of the "Districts' Enactment Matrix" (DEM) for the year 2014 in GG -Regional Council for Population (RCP) quarterly meetings, headed by the governor and attended by representatives of all ministries. The feedback and recommendation for action taking by participants were reported by the researchers. Evaluation of the intervention was done by comparing DEM 2014 and DEM 2016.

RESULTS

At the governorate level, short-term strategies were used to improve the situation. All the districts in red zone 2014 and two districts in the yellow zone had demonstrated positive changes in their 28 indicators.

CONCLUSION

The DEM model is a simple tool that facilitates communication between researchers and decision-makers that could be applied in different public health and population programs.

Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems

BACKGROUND

The need for research-based knowledge to inform health policy formulation and implementation is a chronic global concern impacting health systems functioning and impeding the provision of quality healthcare for all. This paper provides a systematic overview of the literature on knowledge translation (KT) strategies employed by health system researchers and policy-makers in African countries.

METHODS

Evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of KT strategies, outcomes, facilitators and barriers. Four reference databases were searched using defined criteria. Studies were screened and a searchable database containing 62 eligible studies was compiled using Microsoft Access. Frequency and thematic analysis were used to report study characteristics and to establish the final evidence map. Focus was placed on KT in policy formulation processes in order to better manage the diversity of available literature.

RESULTS

The KT literature in African countries is widely distributed, problematically diverse and growing. Significant disparities exist between reports on KT in different countries, and there are many settings without published evidence of local KT characteristics. Commonly reported KT strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct KT activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited KT outcomes reflect persisting difficulties in outcome identification and reporting.

CONCLUSION

This study has identified substantial geographical gaps in knowledge and evidenced the need to boost local research capacities on KT practices in low- and middle-income countries. Evidence mapping is also shown to be a useful approach that can assist local decision-making to enhance KT in policy and practice.