Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making

Strategies for knowledge exchange for action to address place-based determinants of health inequalities: an umbrella review

BACKGROUND

Place-based health inequalities persist despite decades of academics and other stakeholders generating ideas and evidence on how to reduce them. This may in part reflect a failure in effective knowledge exchange (KE). We aim to understand what KE strategies are effective in supporting actions on place-based determinants and the barriers and facilitators to this KE.

METHODS

An umbrella review was undertaken to identify relevant KE strategies. Systematic reviews were identified by searching academic databases (Medline, Embase, Scopus, Web of Science) and handsearching. Synthesis involved charting and thematic analysis.

RESULTS

Fourteen systematic reviews were included comprising 105 unique, relevant studies. Four approaches to KE were identified: improving access to knowledge, collaborative approaches, participatory models and KE as part of advocacy. While barriers and facilitators were reported, KE approaches were rarely evaluated for their effectiveness.

CONCLUSIONS

Based on these four approaches, our review produced a framework, which may support planning of future KE strategies. The findings also suggest the importance of attending to political context, including the ways in which this may impede a more upstream place-based focus in favour of behavioural interventions and the extent that researchers are willing to engage with politicized agendas.

Is bureaucracy being busted in research ethics and governance for health services research in the UK? Experiences and perspectives reported by stakeholders through an online survey

BACKGROUND

It has long been noted that the chain from identification of need (research gap) to impact in the real world is both long and tortuous. This study aimed to contribute evidence about research ethics and governance arrangements and processes in the UK with a focus on: what works well; problems; impacts on delivery; and potential improvements.

METHODS

Online questionnaire widely distributed 20th May 2021, with request to forward to other interested parties. The survey closed on 18th June 2021. Questionnaire included closed and open questions related to demographics, role, study objectives.

RESULTS

Responses were received from 252 respondents, 68% based in universities 25% in the NHS. Research methods used by respondents included interviews/focus groups (64%); surveys/questionnaires (63%); and experimental/quasi experimental (57%). Respondents reported that participants in the research they conducted most commonly included: patients (91%); NHS staff (64%) and public (50%). Aspects of research ethics and governance reported to work well were: online centralised systems; confidence in rigorous, respected systems; and helpful staff. Problems with workload, frustration and delays were reported, related to overly bureaucratic, unclear, repetitive, inflexible and inconsistent processes. Disproportionality of requirements for low-risk studies was raised across all areas, with systems reported to be risk averse, defensive and taking little account of the risks associated with delaying or deterring research. Some requirements were reported to have unintended effects on inclusion and diversity, particularly impacting Patient and Public Involvement (PPI) and engagement processes. Existing processes and requirements were reported to cause stress and demoralisation, particularly as many researchers are employed on fixed term contracts. High negative impacts on research delivery were reported, in terms of timescales for completing studies, discouraging research particularly for clinicians and students, quality of outputs and costs. Suggested improvements related to system level changes / overall approach and specific refinements to existing processes.

CONCLUSIONS

Consultation with those involved in Health Services Research in the UK revealed a picture of overwhelming and increasing bureaucracy, delays, costs and demoralisation related to gaining the approvals necessary to conduct research in the NHS. Suggestions for improvement across all three areas focused on reducing duplication and unnecessary paperwork/form filling and reaching a better balance between risks of harm through research and harms which occur because research to inform practice is delayed or deterred.

The use of future scenario thinking for child public health in a local authority

BACKGROUND

Socioeconomic, cultural, technological, environment and ecological changes are rapidly transforming how children and young people (CYP) grow up, yet their impacts on CYP are difficult to predict. The traditional ways that Public Health practitioners work may not capture such complex and dynamic change. To address this, Lambeth Council used future scenario thinking.

METHODS

A literature review looked at political, socioeconomic and other 'transitions' in the borough. Interviews, focus groups and workshops were held with CYP, parents, carers, local statutory and non-statutory stakeholders about the future for Lambeth CYP in the decade ahead. Themes were analysed to identify which had the potential for the biggest impact or the most uncertainty.

RESULTS

The main transitions were described, 100 stakeholders interviewed, and five 'drivers' of the future were identified: protracted austerity, technological explosion, demographic shift, 'democratic shake-up' and planetary health. From all these data, four future scenarios were developed: 'communities care for themselves', 'collaborating to care for all', 'nobody cares' and 'who cares?'

CONCLUSIONS

New insights were gained about promoting more responsibility for, and active participation of CYP. This led to Lambeth's CYP Plan and the 'Made in Lambeth' campaign aiming to enlist the community and business in creating a child-friendly borough.

Research utilisation and knowledge mobilisation in the commissioning and joint planning of public health interventions to reduce alcohol-related harms: a qualitative case design using a cocreation approach

Background

Considerable resources are spent on research to establish what works to improve the nation’s health. If the findings from this research are used, better health outcomes can follow, but we know that these findings are not always used. In public health, evidence of what works may not ‘fit’ everywhere, making it difficult to know what to do locally. Research suggests that evidence use is a social and dynamic process, not a simple application of research findings. It is unclear whether it is easier to get evidence used via a legal contracting process or within unified organisational arrangements with shared responsibilities.

Objective

To work in cocreation with research participants to investigate how research is utilised and knowledge mobilised in the commissioning and planning of public health services to reduce alcohol-related harms.

Design, setting and participants

Two in-depth, largely qualitative, cross-comparison case studies were undertaken to compare real-time research utilisation in commissioning across a purchaser–provider split (England) and in joint planning under unified organisational arrangements (Scotland) to reduce alcohol-related harms. Using an overarching realist approach and working in cocreation, case study partners (stakeholders in the process) picked the topic and helped to interpret the findings. In Scotland, the topic picked was licensing; in England, it was reducing maternal alcohol consumption.

Methods

Sixty-nine interviews, two focus groups, 14 observations of decision-making meetings, two local feedback workshops (n = 23 andn = 15) and one national workshop (n = 10) were undertaken. A questionnaire (n = 73) using a Behaviourally Anchored Rating Scale was issued to test the transferability of the 10 main findings. Given the small numbers, care must be taken in interpreting the findings.

Findings

Not all practitioners have the time, skills or interest to work in cocreation, but when there was collaboration, much was learned. Evidence included professional and tacit knowledge, and anecdotes, as well as findings from rigorous research designs. It was difficult to identify evidence in use and decisions were sometimes progressed in informal ways and in places we did not get to see. There are few formal evidence entry points. Evidence (prevalence and trends in public health issues) enters the process and is embedded in strategic documents to set priorities, but local data were collected in both sites to provide actionable messages (sometimes replicating the evidence base).

Conclusions

Two mid-range theories explain the findings. If evidence hassaliency(relates to ‘here and now’ as opposed to ‘there and then’) andimmediacy(short, presented verbally or visually and with emotional appeal) it is more likely to be used in both settings. A second mid-range theory explains how differing tensions pull and compete as feasible and acceptable local solutions are pursued across stakeholders. Answering what works depends on answering for whom and where simultaneously to find workable (if temporary) ‘blends’. Gaining this agreement across stakeholders appeared more difficult across the purchaser–provider split, because opportunities to interact were curtailed; however, more research is needed.

Funding

This study was funded by the Health Services and Delivery Research programme of the National Institute for Health Research.

Getting research to the policy table: a qualitative study with public health researchers on engaging with policy makers

INTRODUCTION

Little attention has been given to how researchers can best provide evidence to policy makers so that it informs policy making. The objectives of this study were to increase understanding about the current state of public health nutrition and obesity researcher practices, beliefs, barriers, and facilitators to communicating and engaging with policy makers, and to identify best practices and suggest improvements.

METHODS

Eighteen semistructured interviews were conducted from 2011 to 2013 with public health nutrition and obesity researchers who were highly involved in communicating research to policy makers. Interviews were transcribed verbatim, coded, and analyzed to identify common themes.

RESULTS

Study participants described wide variation in practices for communicating and engaging with policy makers and had mixed beliefs about whether and when researchers should engage. Besides a lack of formal policy communication training, barriers noted were promotion and tenure processes and a professional culture that does not value communicating and engaging with policy makers. Study participants cited facilitators to engaging with policy makers as ranging from the individual level (eg, desire to make a difference, relationships with collaborators) to the institutional level (eg, training/mentorship support, institutional recognition). Other facilitators identified were research- and funding-driven. Promising strategies suggested to improve policy engagement were more formal training, better use of intermediaries, and learning how to cultivate relationships with policy makers.

CONCLUSION

Study findings provide insights into the challenges that will need to be overcome and the strategies that might be tried to improve communication and engagement between public health researchers and policy makers.

New directions in evidence-based policy research: a critical analysis of the literature

Despite 40 years of research into evidence-based policy (EBP) and a continued drive from both policymakers and researchers to increase research uptake in policy, barriers to the use of evidence are persistently identified in the literature. However, it is not clear what explains this persistence - whether they represent real factors, or if they are artefacts of approaches used to study EBP. Based on an updated review, this paper analyses this literature to explain persistent barriers and facilitators. We critically describe the literature in terms of its theoretical underpinnings, definitions of 'evidence', methods, and underlying assumptions of research in the field, and aim to illuminate the EBP discourse by comparison with approaches from other fields. Much of the research in this area is theoretically naive, focusing primarily on the uptake of research evidence as opposed to evidence defined more broadly, and privileging academics' research priorities over those of policymakers. Little empirical data analysing the processes or impact of evidence use in policy is available to inform researchers or decision-makers. EBP research often assumes that policymakers do not use evidence and that more evidence - meaning research evidence - use would benefit policymakers and populations. We argue that these assumptions are unsupported, biasing much of EBP research. The agenda of 'getting evidence into policy' has side-lined the empirical description and analysis of how research and policy actually interact in vivo. Rather than asking how research evidence can be made more influential, academics should aim to understand what influences and constitutes policy, and produce more critically and theoretically informed studies of decision-making. We question the main assumptions made by EBP researchers, explore the implications of doing so, and propose new directions for EBP research, and health policy.

Population health needs assessment and healthcare services use in a 3 years follow-up on administrative and clinical data: results from the Brisighella Heart Study

INTRODUCTION

A large number of epidemiological trials clearly show the impact of the main cardiovascular disease risk factors in term of hospitalization and related cost, but relatively less frequently if this reflect the health needs of a given population.

AIM

To develop a model for the health needs-assessment that will be applied to verify if and how the prevalence of some classical risk factors for cardiovascular disease predicts mortality and hospitalisation episodes at 3 years, and if it could express the health need of that population. The long-life clinical record of 1,704 subjects, recruited during the 2004 Brisighella Heart Study survey, has been monitored. We defined the health profile of these subjects at 2004 (based on clinical history, smoking and dietary habits, physical activity, drug use, anthropometric data, blood pressure, and hematological data) and then sampled data relative to their hospitalisations, mortality, and general medical assistance.

RESULTS

Our results shows that age over 65 years (OR 4.08; 95 % CI 2.74-6.08), hypertension (OR 3.44; 95 % CI 2.36-5.01) and hypercholesterolemia (OR 1.33; 95 % CI 0.92-1.94) increase the probability to get hospitalised. Furthermore, the burden of care was defined and computed for our sample. Vascular and respiratory diseases [Burden of health care (Bc) = 24.5 and 36.5, respectively] are the most costly DRGs which means that the biggest part of our resources directed to cardiovascular patients were provided for these diagnoses.

CONCLUSION

The application of the proposed model could help policy makers and researchers in directing resources and workforce in the treatment of cardiovascular diseases.

Use of evidence to support healthy public policy: a policy effectiveness-feasibility loop

Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a "policy effectiveness-feasibility loop" (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach.

Barriers to partnership working in public health: a qualitative study

BACKGROUND

Public health provision in England is undergoing dramatic changes. Currently established partnerships are thus likely to be significantly disrupted by the radical reforms outlined in the Public Health White Paper. We therefore explored the process of partnership working in public health, in order to better understand the potential opportunities and threats associated with the proposed changes.

METHODOLOGY/PRINCIPAL FINDINGS

70 participants took part in an in-depth qualitative study involving 40 semi-structured interviews and three focus group discussions. Participants were senior and middle grade public health decision makers working in Primary Care Trusts, Local Authorities, Department of Health, academia, General Practice and Hospital Trusts and the third sector in England. Despite mature arrangements for partnership working in many areas, and much support for joint working in principle, many important barriers exist. These include cultural issues such as a lack of shared values and language, the inherent complexity of intersectoral collaboration for public health, and macro issues including political and resource constraints. There is particular uncertainty and anxiety about the future of joint working relating to the availability and distribution of scarce and diminishing financial resources. There is also the concern that existing effective collaborative networks may be completely disrupted as the proposed changes unfold. The extent to which the proposed reforms might mitigate or potentiate these issues remains unclear. However the threats currently remain more salient than opportunities.

CONCLUSIONS

The current re-organisation of public health offers real opportunity to address some of the barriers to partnership working identified in this study. However, significant threats exist. These include the breakup of established networks, and the risk of cost cutting on effective public health interventions.

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

Background

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

Methods

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

Findings

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

Conclusions

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

Development of modelling method selection tool for health services management: from problem structuring methods to modelling and simulation methods

BACKGROUND

There is an increasing recognition that modelling and simulation can assist in the process of designing health care policies, strategies and operations. However, the current use is limited and answers to questions such as what methods to use and when remain somewhat underdeveloped.

AIM

The aim of this study is to provide a mechanism for decision makers in health services planning and management to compare a broad range of modelling and simulation methods so that they can better select and use them or better commission relevant modelling and simulation work.

METHODS

This paper proposes a modelling and simulation method comparison and selection tool developed from a comprehensive literature review, the research team's extensive expertise and inputs from potential users. Twenty-eight different methods were identified, characterised by their relevance to different application areas, project life cycle stages, types of output and levels of insight, and four input resources required (time, money, knowledge and data).

RESULTS

The characterisation is presented in matrix forms to allow quick comparison and selection. This paper also highlights significant knowledge gaps in the existing literature when assessing the applicability of particular approaches to health services management, where modelling and simulation skills are scarce let alone money and time.

CONCLUSIONS

A modelling and simulation method comparison and selection tool is developed to assist with the selection of methods appropriate to supporting specific decision making processes. In particular it addresses the issue of which method is most appropriate to which specific health services management problem, what the user might expect to be obtained from the method, and what is required to use the method. In summary, we believe the tool adds value to the scarce existing literature on methods comparison and selection.

Ministers of Health: short-term tenure for long-term goals?

CONTEXT AND OBJECTIVE

Healthcare investments should consider short and long-term demands. The objectives here were to compare the average tenures of ministers of health in Brazil and in another 22 countries and to evaluate the relationship between ministers' tenures and a number of indicators.

DESIGN AND SETTING

Descriptive study conducted at Centro Paulista de Economia da Saúde (CPES).

METHODS

Twenty-two countries with the highest Human Development Indices (HDIs) and Brazil were included. The number of ministers over the past 20 years was investigated through each country's Ministry of Health website. Pearson's correlation coefficient was used to compare the number of ministers in each country with that country's indicators. The Mann-Whitney test was used to compare ministers' tenures in Brazil and other countries.

RESULTS

The mean tenure (standard deviation, SD) of Brazilian ministers of health was 15 (12) months, a period that is statistically significantly shorter than the mean tenure of 33 (18) months in the other 22 countries (P < 0.05). There was a moderate and statistically significant positive correlation between the number of ministers and mortality rates for several conditions. The number of ministers also presented moderate and statistically significant negative correlations with per capita total healthcare expenditure (r = -0.567) and with per capita government healthcare expenditure (r = -0.530).

CONCLUSION

On average, ministers of health have extremely short tenures. There is an urgent need to think and plan healthcare systems from a long-term perspective.

Barriers to evidence-based decision making in public health: a national survey of chronic disease practitioners

OBJECTIVE

Existing knowledge of evidence-based chronic disease prevention is not systematically disseminated or applied. This study investigated state and territorial chronic disease practitioners' self-reported barriers to evidence-based decision making (EBDM).

METHODS

In a nationwide survey, participants indicated the extent to which they agreed with statements reflecting four personal and five organizational barriers to EBDM. Responses were measured on a Likert scale from 0 to 10, with higher scores indicating a larger barrier to EBDM. We analyzed mean levels of barriers and calculated adjusted odds ratios for barriers that were considered modifiable through interventions.

RESULTS

Overall, survey participants (n=447) reported higher scores for organizational barriers than for personal barriers. The largest reported barriers to EBDM were lack of incentives/rewards, inadequate funding, a perception of state legislators not supporting evidence-based interventions and policies, and feeling the need to be an expert on many issues. In adjusted models, women were more likely to report a lack of skills in developing evidence-based programs and in communicating with policy makers. Participants with a bachelor's degree as their highest degree were more likely than those with public health master's degrees to report lacking skills in developing evidence-based programs. Men, specialists, and individuals with doctoral degrees were all more likely to feel the need to be an expert on many issues to effectively make evidence-based decisions.

CONCLUSIONS

Approaches must be developed to address organizational barriers to EBDM. Focused skills development is needed to address personal barriers, particularly for chronic disease practitioners without graduate-level training.

Defining features of the practice of global health research: an examination of 14 global health research teams

Objectives

This paper strives to develop a pragmatic view of the scope of practice and core characteristics of global health research (GHR) by examining the activities of 14 Canadian-funded global health teams that were in the process of implementing research programs.

Methods

Information was collected by a reflective exploration of team proposals and progress reports, a content analysis of the outputs from an all-team meeting and review of the literature.

Results

Teams adopted equity-centered, problem-focused, systems-based approaches intended to find upstream determinants that could make people more resilient to social and ecological factors impacting their health. Long-term visions and time frames were needed to develop and solidify fully functional interdisciplinary, multinational, multicultural partnerships. The implementation of research into practice was a motivating factor for all teams, but to do this, they recognized the need for evidence-based advice on how to best do this. Traditional measures of biomedical research excellence were necessary but not sufficient to encompass views of excellence of team-based interdisciplinary research, which includes features like originality, coherence and cumulative contributions to fields of study, acceptance by peers and success in translating research into gains in health status. An innovative and nuanced approached to GHR ethics was needed to deal with some unique ethical issues because the needs for GHR were not adequately addressed by institutional biomedical research ethics boards. Core competencies for GHR researchers were a blend of those needed for health promotion, population health, international development, sustainable development, and systems science.

Discussion

Developing acceptable and meaningful ways to evaluate the short-term contributions for GHR and forecast its long-term impacts is a strategic priority needed to defend decisions being made in GHR development. Planning and investing to support the underlying GHR elements and competencies that allow for adaptive, innovative, and supportive research partnerships to achieve ‘health for all’ are more likely to have long-term impacts than building research strategies around specific diseases of interest.