Institutional capacity for health systems research in East and Central African Schools of Public Health: strengthening human and financial resources

Factors Associated with Research knowledge and Attitude among Clinical Midwives Working at Public Health Facilities of Northwest Ethiopia, 2021: A Cross-Sectional Study

INTRODUCTION

Evidence-based care is pivotal in health, and needs experience and scientific evidence. Clinical midwives are busy with patient care and not involved in research, so their research knowledge and attitudes are not scientifically assessed. Our study aimed to address this gap so as to help set interventions to provide evidence-based midwifery care.

METHODS

An institution-based cross-sectional study was conducted from September to October 2021 among clinical midwives working at public health facilities in Ethiopia. A structured and pretested self-administered questionnaire was used to collect data, which were transferred to Epi Info software. Descriptive statistics explained the variables. To identify factors, bivariate and multivariate (for knowledge) and ordinal logistic regression and correlations (for attitudes) were computed using Stata 14. P≤0.05 was taken as significant. ORs and Spearman correlation coefficients are also reported.

RESULTS

Of 335 originally selected, 314 participated, for a response rate of 93.7%. In sum, 154 (49%, 95% CI 43.5%-54.6%) had good knowledge on research. Having taken a research-methods course (AOR 6.93, 95% CI 3.37-14.24), having research skills (AOR 2.25, 95% CI 1.30, 3.91), and having participated in research (AOR 3.08, 95% CI 1.37-6.90) showed significant associations with good knowledge on research. Of all, 252 (80.3%, 95% CI 84.8%-92.1%) had positive attitudes toward research. Age and having a positive attitude in the independent variables were significant predictors of a positive attitude toward research. There was a significantly positive correlation (ρ=0.183, P=0.001) between knowledge and attitudes toward research.

CONCLUSION

Although a majority had a positive attitude, a significant proportion had poor knowledge of research. Provision of capacity-building activities (training and opportunities) and allocated time for research are important for the provision of evidence-based midwifery care.

The association between the density of vaccination workers and immunization coverage in Zhejiang province, East China

Background: We aimed to evaluate whether the density of vaccination workers was associated with the immunization coverage in Zhejiang province.Methods: The immunization coverage of measles-containing vaccine (MCV), the third dose of diphtheria, tetanus, and pertussis combined vaccine (DTP3), and the third dose of poliomyelitis vaccine (PV3) was selected as the dependent variables. Immunization coverage data of children aged 13-23 months were taken from the Zhejiang immunization information system (ZJIIS). The aggregate density of vaccination workers was an independent variable in one set of regressions, while the full-time and part-time vaccination workers were adopted separately in other sets.Results: The density of total vaccination workers was positively and significantly associated with the immunization coverage (MCV: AOR = 3.36; DTP3: AOR = 2.68; PV3: AOR = 2.37). However, when the effects of full-time vaccination workers and part-time vaccination workers were assessed separately, we only found that the density of full-time vaccination workers was positively and significantly associated with the immunization coverage (MCV: AOR = 5.59; DTP3: AOR = 4.13; PV3: AOR = 3.28). The proportion of migrant children < 7 years and Land area were found as negative and significant factors for immunization coverage.Conclusions: A higher density of vaccination workers could improve the availability of vaccination services and immunization coverage. We recommended that government or other non-government organization should, apart from vaccine-related assistance, focus their efforts on human resources for vaccination.

Review of published evidence on knowledge translation capacity, practice and support among researchers and research institutions in low- and middle-income countries

BACKGROUND

Knowledge translation (KT) is a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to yield beneficial outcomes for society. Effective KT requires researchers to play an active role in promoting evidence uptake. This paper presents a systematised review of evidence on low- and middle-income country (LMIC) researchers' KT capacity, practice and interventions for enhancing their KT practice (support) with the aim of identifying gaps and informing future research and interventions.

METHODS

An electronic search for peer-reviewed publications focusing on LMIC researchers' KT capacity, practice and support across all academic fields, authored in English and from the earliest records available to February 2019, was conducted using PubMed and Scopus. Selected studies were appraised using the Mixed Methods Appraisal Tool, data pertaining to publication characteristics and study design extracted, and an a priori thematic analysis of reported research findings completed.

RESULTS

The search resulted in 334 screened articles, of which 66 met the inclusion criteria. Most (n = 43) of the articles presented original research findings, 22 were commentaries and 1 was a structured review; 47 articles reported on researchers' KT practice, 12 assessed the KT capacity of researchers or academic/research institutions and 9 reported on KT support for researchers. More than half (59%) of the articles focused on sub-Saharan Africa and the majority (91%) on health research. Most of the primary studies used the case study design (41%). The findings suggest that LMIC researchers rarely conduct KT and face a range of barriers at individual and institutional levels that limit their KT practice, including inadequate KT knowledge and skills, particularly for communicating research and interacting with research end-users, insufficient funding, and inadequate institutional guidelines, structures and incentives promoting KT practice. Furthermore, the evidence-base on effective interventions for enhancing LMIC researchers' KT practice is insufficient and largely of weak quality.

CONCLUSIONS

More high-quality research on researchers' KT capacity, practice and effective KT capacity strengthening interventions is needed. Study designs that extend beyond case studies and descriptive studies are recommended, including better designed evaluation studies, e.g. use of realist approaches, pragmatic trials, impact evaluations, implementation research and participatory action research.

Adapting operational research training to the Rwandan context: the Intermediate Operational Research Training programme

Background: Promoting national health research agendas in low- and middle-income countries (LMICs) requires adequate numbers of individuals with skills to initiate and conduct research. Recently, non-governmental organizations (NGOs) have joined research capacity building efforts to increase research leadership by LMIC nationals. Partners In Health, an international NGO operating in Rwanda, implemented its first Intermediate Operational Research Training (IORT) course to cultivate Rwandan research talent and generate evidence to improve health care delivery.

Objective: This paper describes the implementation of IORT to share experiences with other organizations interested in developing similar training programmes.

Methods: The Intermediate Operational Research Training utilized a deliverable-driven training model, using learning-by-doing pedagogy with intensive hands-on mentorship to build research skills from protocol development to scientific publication. The course had short (two-day) but frequent training sessions (seven sessions over eight months). Trainees were clinical and programme staff working at the district level who were paired to jointly lead a research project.

Results: Of 10 trainees admitted to the course from a pool of 24 applicants, nine trainees completed the course with five research projects published in peer-reviewed journals. Strengths of the course included supportive national and institutional research capacity guidelines, building from a successful training model, and trainee commitment. Challenges included delays in ethical review, high mentorship workload of up to 250 hours of practicum mentorship, lack of access to literature in subscription journals and high costs of open access publication.

Conclusions: The IORT course was an effective way to support the district-based government and NGO staff in gaining research skills, as well as answering research questions relevant to health service delivery at district hospitals. Other NGOs should build on successful programmes while adapting course elements to address context-specific challenges. Mentorship for LMIC trainees is critical for effectiveness of research capacity building initiatives.

The impact of water crises and climate changes on the transmission of protozoan parasites in Africa

Waterborne protozoa (WBP) are important cause of several outbreaks all over the world. The report system of WBP in Africa is weak. More than one third of African countries (21/54) reported WBP with absent reports in the remaining countries (33/54). The top reported WBP were Cryptosporidium, Giardia, FLA and Entamoeba contaminating different African water resources. Other protozoa were less documented even though it is abundant and robust. More than one protozoa were detected in contaminated African water including drinking sources, a prediction index to popular epidemics and real presence of undocumented WBP outbreaks. Risk factors in Africa were observed to be abundant and multi-factorial 'socioeconomic, governmental, pathogen in water and climate change. Climate change is an important factor impacting Africa. Increasing droughts in Africa with other extreme weather events will lead to water crises. Incidence and transmission of WBP will change, with new manifested strains/species. Recognizing future consequences of water crises in Africa are important. Governments and population unity will be needed to protect against expected raise and spread of WBP diseases and water shortages.

Institutional capacity to generate and use evidence in LMICs: current state and opportunities for HPSR

BACKGROUND

Evidence-informed decision-making for health is far from the norm, particularly in many low- and middle-income countries (LMICs). Health policy and systems research (HPSR) has an important role in providing the context-sensitive and -relevant evidence that is needed. However, there remain significant challenges both on the supply side, in terms of capacity for generation of policy-relevant knowledge such as HPSR, and on the demand side in terms of the demand for and use of evidence for policy decisions. This paper brings together elements from both sides to analyse institutional capacity for the generation of HPSR and the use of evidence (including HPSR) more broadly in LMICs.

METHODS

The paper uses literature review methods and two survey instruments (directed at research institutions and Ministries of Health, respectively) to explore the types of institutional support required to enhance the generation and use of evidence.

RESULTS

Findings from the survey of research institutions identified the absence of core funding, the lack of definitional clarity and academic incentive structures for HPSR as significant constraints. On the other hand, the survey of Ministries of Health identified a lack of locally relevant evidence, poor presentation of research findings and low institutional prioritisation of evidence use as significant constraints to evidence uptake. In contrast, improved communication between researchers and decision-makers and increased availability of relevant evidence were identified as facilitators of evidence uptake.

CONCLUSION

The findings make a case for institutional arrangements in research that provide support for career development, collaboration and cross-learning for researchers, as well as the setting up of institutional arrangements and processes to incentivise the use of evidence among Ministries of Health and other decision-making institutions. The paper ends with a series of recommendations to build institutional capacity in HPSR through engaging multiple stakeholders in identifying and maintaining incentive structures, improving research (including HPSR) training, and developing stronger tools for synthesising non-traditional forms of local, policy-relevant evidence such as grey literature. Addressing challenges on both the supply and demand side can build institutional capacity in the research and policy worlds and support the enhanced uptake of high quality evidence in policy decisions.

'Knowledge for better health' revisited - the increasing significance of health research systems: a review by departing Editors-in-Chief

How can nations organise research investments to obtain the best bundle of knowledge and the maximum level of improved health, spread as equitably as possible? This question was the central focus of a major initiative from WHO led by Prof Tikki Pang, which resulted in a range of developments, including the publication of a conceptual framework for national health research systems - Knowledge for better health - in 2003, and in the founding of the journal Health Research Policy and Systems (HARPS). As Editors-in-Chief of the journal since 2006, we mark our retirement by tracking both the progress of the journal and the development of national health research systems. HARPS has maintained its focus on a range of central themes that are key components of a national health research system in any country. These include building capacity to conduct and use health research, identifying appropriate priorities, securing funds and allocating them accountably, producing scientifically valid research outputs, promoting the use of research in polices and practice in order to improve health, and monitoring and evaluating the health research system. Some of the themes covered in HARPS are now receiving increased attention and, for example, with the assessment of research impact and development of knowledge translation platforms, the journal has covered their progress throughout that expansion of interest. In addition, there is increasing recognition of new imperatives, including the importance of promoting gender equality in health research if benefits are to be maximised. In this Editorial, we outline some of the diverse and developing perspectives considered within each theme, as well as considering how they are held together by the growing desire to build effective health research systems in all countries.From 2003 until mid-June 2017, HARPS published 590 articles on the above and related themes, with authors being located in 76 countries. We present quantitative data tracing the journal's growth and the increasing external recognition of its role. We thank the many colleagues who have kindly contributed to the journal's success, and finish on an exciting note by welcoming the new Editors-in-Chief who will take HARPS forward.

A system approach to improving maternal and child health care delivery in Kenya: innovations at the community and primary care facilities (a protocol)

Background

Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under 5 health indicators, more rapid progress is needed to meet the targets including the Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain the targets of the SDG 3 by 2030. We describe the structure and methods of a study to assess the impact of an innovative system approach on maternal, neonatal and under-five children outcomes.

This will be implemented in two clusters in the Counties of Busia and Bungoma in Kenya. There will be 4 control clusters in Kakamega, UasinGishu, Trans Nzoia and Elgeyo Marakwet Counties in Kenya. The study population will be pregnant women, newborns and under-five children identified over the study period. The objective of the study is to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies six WHO pillars of the health system and community owned initiatives including Community Based Organisations and Income Generating Activities.

Methods/Design

A five year quasi-experimental design will be used to compare the outcomes of the implementation of the EHC using the Find Link Treat and retain (FLTR) strategy in one cluster, community owned initiatives in one cluster and four control clusters at baseline and at the end of the study. A Baseline survey will be conducted in year one and an endline in the fifth year in which maternal, neonatal and underfive childhood outcomes will be compared.

Discussion

The expected findings from the study include showing trends in improvement in the intervention clusters for morbidity, mortality, health service utilization and access indicators. Use of the health systems approach in health care provision is expected to provide a holistic improvement in the quality of care in the study populations in the intervention clusters that will lead to improved health indicators including morbidity and mortality. It is expected that the findings will inform health policy of the national and county governments in Kenya and worldwide.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND

Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges.

MAIN TEXT

The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs).

CONCLUSION

SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Four centuries on from Bacon: progress in building health research systems to improve health systems?

In 1627, Francis Bacon’s New Atlantis described a utopian society in which an embryonic research system contributed to meeting the needs of the society. In this editorial, we use some of the aspirations described in New Atlantis to provide a context within which to consider recent progress in building health research systems to improve health systems and population health. In particular, we reflect on efforts to build research capacity, link research to policy, identify the wider impacts made by the science, and generally build fully functioning research systems to address the needs identified.

In 2014, Health Research Policy and Systems has continued to publish one-off papers and article collections covering a range of these issues in both high income countries and low- and middle-income countries. Analysis of these contributions, in the context of some earlier ones, is brought together to identify achievements, challenges and possible ways forward. We show how 2014 is likely to be a pivotal year in the development of ways to assess the impact of health research on policies, practice, health systems, population health, and economic benefits.

We demonstrate how the increasing focus on health research systems will contribute to realising the hopes expressed in the World Health Report, 2013, namely that all nations would take a systematic approach to evaluating the outputs and applications resulting from their research investment.

Institutional capacity for health systems research in East and Central African schools of public health: knowledge translation and effective communication

BACKGROUND

Local health systems research (HSR) provides policymakers and practitioners with contextual, evidence-based solutions to health problems. However, producers and users of HSR rarely understand the complexities of the context within which each operates, leading to the "know-do" gap. Universities are well placed to conduct knowledge translation (KT) integrating research production with uptake. The HEALTH Alliance Africa Hub, a consortium of seven schools of public health (SPHs) in East and Central Africa, was formed to build capacity in HSR. This paper presents information on the capacity of the various SPHs to conduct KT activities.

METHODS

In 2011, each member of the Africa Hub undertook an institutional HSR capacity assessment using a context-adapted and modified self-assessment tool. KT capacity was measured by several indicators including the presence of a KT strategy, an organizational structure to support KT activities, KT skills, and institutional links with stakeholders and media. Respondents rated their opinions on the various indicators using a 5-point Likert scale. Averages across all respondents for each school were calculated. Thereafter, each school held a results validation workshop.

RESULTS

A total of 123 respondents from all seven SPHs participated. Only one school had a clear KT strategy; more commonly, research was disseminated at scientific conferences and workshops. While most respondents perceived their SPH as having strong institutional ties with organizations interested in HSR as well as strong institutional leadership, the organizational structures required to support KT activities were absent. Furthermore, individual researchers indicated that they had little time or skills to conduct KT. Additionally, institutional and individual links with policymakers and media were reported as weak.

CONCLUSIONS

Few SPHs in Africa have a clear KT strategy. Strengthening the weak KT capacity of the SPHs requires working with institutional leadership to develop KT strategies designed to guide organizational structure and development of networks with both the media and policymakers to improve research uptake.

Institutional capacity for health systems research in East and Central African schools of public health: experiences with a capacity assessment tool

BACKGROUND

Despite significant investments in health systems research (HSR) capacity development, there is a dearth of information regarding how to assess HSR capacity. An alliance of schools of public health (SPHs) in East and Central Africa developed a tool for the self-assessment of HSR capacity with the aim of producing institutional capacity development plans.

METHODS

Between June and November 2011, seven SPHs across the Democratic Republic of Congo, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda implemented this co-created tool. The objectives of the institutional assessments were to assess existing capacities for HSR and to develop capacity development plans to address prioritized gaps. A mixed-method approach was employed consisting of document analysis, self-assessment questionnaires, in-depth interviews, and institutional dialogues aimed at capturing individual perceptions of institutional leadership, collective HSR skills, knowledge translation, and faculty incentives to engage in HSR. Implementation strategies for the capacity assessment varied across the SPHs. This paper reports findings from semi-structured interviews with focal persons from each SPH, to reflect on the process used at each SPH to execute the institutional assessments as well as the perceived strengths and weaknesses of the assessment process.

RESULTS

The assessment tool was robust enough to be utilized in its entirety across all seven SPHs resulting in a thorough HSR capacity assessment and a capacity development plan for each SPH. Successful implementation of the capacity assessment exercises depended on four factors: (i) support from senior leadership and collaborators, (ii) a common understanding of HSR, (iii) adequate human and financial resources for the exercise, and (iv) availability of data. Methods of extracting information from the results of the assessments, however, were tailored to the unique objectives of each SPH.

CONCLUSIONS

This institutional HSR capacity assessment tool and the process for its utilization may be valuable for any SPH. The self-assessments, as well as interviews with external stakeholders, provided diverse sources of input and galvanized interest around HSR at multiple levels.

Institutional capacity for health systems research in East and Central Africa schools of public health: enhancing capacity to design and implement teaching programs

BACKGROUND

The role of health systems research (HSR) in informing and guiding national programs and policies has been increasingly recognized. Yet, many universities in sub-Saharan African countries have relatively limited capacity to teach HSR. Seven schools of public health (SPHs) in East and Central Africa undertook an HSR institutional capacity assessment, which included a review of current HSR teaching programs. This study determines the extent to which SPHs are engaged in teaching HSR-relevant courses and assessing their capacities to effectively design and implement HSR curricula whose graduates are equipped to address HSR needs while helping to strengthen public health policy.

METHODS

This study used a cross-sectional study design employing both quantitative and qualitative approaches. An organizational profile tool was administered to senior staff across the seven SPHs to assess existing teaching programs. A self-assessment tool included nine questions relevant to teaching capacity for HSR curricula. The analysis triangulates the data, with reflections on the responses from within and across the seven SPHs. Proportions and average of values from the Likert scale are compared to determine strengths and weaknesses, while themes relevant to the objectives are identified and clustered to elicit in-depth interpretation.

RESULTS

None of the SPHs offer an HSR-specific degree program; however, all seven offer courses in the Master of Public Health (MPH) degree that are relevant to HSR. The general MPH curricula partially embrace principles of competency-based education. Different strengths in curricula design and staff interest in HSR at each SPH were exhibited but a number of common constraints were identified, including out-of-date curricula, face-to-face delivery approaches, inadequate staff competencies, and limited access to materials. Opportunities to align health system priorities to teaching programs include existing networks.

CONCLUSIONS

Each SPH has key strengths that can be leveraged to design and implement HSR teaching curricula. We propose networking for standardizing HSR curricula competencies, institutionalizing sharing of teaching resources, creating an HSR eLearning platform to expand access, regularly reviewing HSR teaching content to infuse competency-based approaches, and strengthening staff capacity to deliver such curricula.

Learning lessons from operational research in infectious diseases: can the same model be used for noncommunicable diseases in developing countries?

About three-quarters of global deaths from noncommunicable diseases (NCDs) occur in developing countries. Nearly a third of these deaths occur before the age of 60 years. These deaths are projected to increase, fueled by such factors as urbanization, nutrition transition, lifestyle changes, and aging. Despite this burden, there is a paucity of research on NCDs, due to the higher priority given to infectious disease research. Less than 10% of research on cardiovascular diseases comes from developing countries. This paper assesses what lessons from operational research on infectious diseases could be applied to NCDs. The lessons are drawn from the priority setting for research, integration of research into programs and routine service delivery, the use of routine data, rapid-assessment survey methods, modeling, chemoprophylaxis, and the translational process of findings into policy and practice. With the lines between infectious diseases and NCDs becoming blurred, it is justifiable to integrate the programs for the two disease groups wherever possible, eg, screening for diabetes in tuberculosis. Applying these lessons will require increased political will, research capacity, ownership, use of local expertise, and research funding.