Assessing the state of health research in the Eastern Mediterranean Region

Cancer Research in Vulnerable Populations: A Call for Collaboration and Sustainability From MENAT Countries

PURPOSE

Cancer is a major burden across Middle East, North Africa, Türkiye (MENAT). Many MENAT countries experience multiple conflicts that compound vulnerabilities, but little research investigates the linkages between vulnerability and cancer research. This study examines the current level and the potential for cancer research among vulnerable populations in the MENAT region, aiming to provide direction toward developing a research agenda on the region's vulnerable populations.

METHODS

Expert-driven meetings were arranged among the 10 authors. After obtaining institutional review board approval, a self-administered online survey questionnaire was circulated to more than 500 cancer practitioners working in 22 MENAT countries.

RESULTS

Two hundred sixteen cancer practitioners across the MENAT region responded. Fifty percent of the respondents identified clinical research in vulnerable patients with cancer as a significant issue; 21.8% reported previous research experience that included vulnerable populations, and 60% reported encountering vulnerable populations in their daily clinical practice. The main barriers to conducting research were lack of funding (60%), protected time (42%), and research training (35%). More than half of the respondents believed that wars/conflicts constituted an important source of vulnerability. The most vulnerable cancer populations were the elderly, palliative/terminally ill, those with concomitant mental health-related issues, those with other chronic illnesses, and socioeconomically deprived patients.

CONCLUSION

Results support that a major effort is needed to improve cancer research among vulnerable cancer populations in the MENAT region. We call for interdisciplinary research that accounts for the region's unique, compounding, and cumulative forms of vulnerability. This cancer research agenda on different vulnerable populations must balance sociobehavioral studies that explore sociopolitical barriers to quality care and clinical studies that gauge and refine treatment protocols. Building a research agenda through collaboration and solidarity with international partners is prime time.

Supporting Public Health Research Capacity, Quality, and Productivity in a Diverse Region

Public health research plays a critical role in strengthening health systems and improving their performance and impact. However, scholarly production in public health coming from the Eastern Mediterranean Region (EMR) remains well below the world average and lacks a tangible growth trend over time. During the seventh Eastern Mediterranean Public Health Network Regional Conference, a roundtable session brought together a panel of public health experts representing Global Health Development/Eastern Mediterranean Public Health Network affiliates, universities or academia, and research institutions from the region, where they shared insights on the current situation of public health research; challenges and barriers to research facing the different countries in the EMR and the region in general; and how research agendas, productivity, and quality can be supported through strengthening research capacity in the region. Although the region is diverse in terms of health system capacity and socioeconomic development, several common challenges were identified, including a lack of strategic prioritization to guide health research, insufficient funding, ineffective transfer of knowledge to policy and practice, limited availability of research facilities, and limited national and international research collaboration. Occupied countries and countries in a state of conflict, such as Palestine, face additional barriers, such as personal and social security, lack of control of borders and natural resources, travel and movement restrictions, and confidentiality challenges because of the continuing war conditions and occupation. However, there have been success stories in the EMR regarding research publications and their positive and effective impact on policy and decision-makers. To improve research resilience and public health care in the region, a collaborative approach involving institutions, policymakers, and relevant stakeholders is critical.

The Internal Reliability and Construct Validity of the Evidence-Based Practice Questionnaire (EBPQ): Evidence from Healthcare Professionals in the Eastern Mediterranean Region

BACKGROUND

Fostering a culture of clinical effectiveness among healthcare professionals (HCPs) is crucial to achieving optimal patient health outcomes. To our knowledge, there is a lack of robust evidence-based practice (EBP) tools to assess the competence of HCPs in EBP in the Eastern Mediterranean Region (EMR).

AIM

This study aims to comprehensively investigate the construct validity and internal reliability of the evidence-based practice questionnaire (EBPQ) among HCPs in the EMR.

METHODS

This multinational and multi-disciplinary cross-sectional study was conducted between 27 April and 11 May 2023. Convenience and snowball sampling methods were used to recruit a sample of HCPs (physicians, nurses, physiotherapists, dentists, and pharmacists) using an electronic survey questionnaire for data capture. To assess the reliability of the instrument, Cronbach's alpha, inter-item reliability, and split-half reliability analyses were conducted. Furthermore, the convergent and discriminant validity of the questionnaire was ensured by calculating the average variance extracted (AVE) and the correlation coefficient between the different constructs, respectively. Factor loadings and cross-loadings of different indicators within each construct were calculated by performing both exploratory and confirmatory factor analyses.

RESULTS

A total of 1536 HCPs from 18 countries in the EMR (response rate = 96.786%) with a median age of 28 years participated; 47% were female, and 55% had Arabic as their first language. English was the most common language for a bachelor's degree in science (54%). The construct validity of the EBPQ was investigated using exploratory factor analysis (EFA), which yielded four loaded factors. The confirmatory factor analysis (CFA) confirmed the four loaded factors. The CFA model showed that the root mean square error of approximation = 0.066, comparative fit index = 0.95, Tucker-Lewis's index = 0.94, standardized root mean square residual = 0.033, normal fit index = 0.94, goodness of fit = 0.91, and χ2 test statistic= 22,553, with p < 0.001. The AVE values of the four factors were close to 1 (knowledge = 0.6, practice = 0.6, attitude = 0.5, and sharing = 0.7), thus supporting the convergent validity of the EBPQ. The four domains had Cronbach's alpha coefficients and Omega ≥ 0.7 (knowledge = 0.9, practice = 0.9, attitude = 0.7, and sharing = 0.8), suggesting that the items within each domain had good internal consistency. These results support the discriminant validity of the EBPQ.

CONCLUSIONS

The EBPQ is a robust questionnaire that can be completed in less than 10 min by EMR HCPs and can be used as a gold-standard questionnaire to collect valid data on the attitudes, knowledge, and proficiency of HCPs in making clinical decisions based on evidence. Future studies are recommended to investigate the retest reliability.

Barriers to sustainable health research leadership in the Global South: Time for a Grand Bargain on localization of research leadership?

BACKGROUND

Strong Global South (GS) health research leadership, itself both dependent on and a requisite for strong health research systems, is essential to generate locally relevant research and ensure that evidence is translated into policy and practice. Strong GS health research systems and leadership are important for health development and in turn for strong health systems. However, many GS countries struggle to produce research and to improve performance on widely used research metrics measuring productivity and reflecting leadership. Drawing on literature from a rapid review, this viewpoint paper considers the barriers to GS health research leadership and proposes strategies to address these challenges.

FINDINGS

GS researchers and institutions face numerous barriers that undermine health research leadership potential. Barriers internal to the GS include researcher-level barriers such as insufficient mentorship, limited financial incentives and time constraints. Institutional barriers include limited availability of resources, restrictive and poorly developed research infrastructures, weak collaboration and obstructive policies and procedures. Structural barriers include political will, politicization of research and political instability. External barriers relate to the nature and extent of Global North (GN) activities and systems and include allocation and distribution of funding and resources, characteristics and focus of GN-GS research collaborations, and publication and information dissemination challenges.

CONCLUSIONS

Strengthening GS health research leadership requires acknowledgement of the many barriers, and adoption of mitigating measures by a range of actors at the institutional, national, regional and global levels. Particularly important are leadership capacity development integrating researcher, institutional and systems initiatives; new GN-GS partnership models emphasizing capacity exchange and shared leadership; supporting GS research communities to set, own and drive their research agendas; addressing biases against GS researchers; ensuring that GS institutions address their internal challenges; enhancing South-South collaborations; diversifying research funding flow to the GS; and learning from models that work. The time has come for a firm commitment to improving localization of research leadership, supported by adequate funding flow, to ensure strong and sustainable research systems and leadership in and from the GS. Just as the humanitarian donor and aid community adopted the Grand Bargain commitment to improve funding flow through local and national responders in times of crisis, we strongly urge the global health research community to adopt a Grand Bargain for research leadership.

What the policy and stewardship landscape of a national health research system looks like in a developing country like Iran: a qualitative study

BACKGROUND

The health research system (HRS) is an important national priority that requires a systematic and functional approach. Evaluating the HRS of Iran as a developing country and identifying its challenges reveals the stewardship-related role in how the whole system is operating well. This study aims to assess the HRS in terms of stewardship functions and highlight the enhancement points.

METHODS

This study was carried out between March 2020 and April 2021 using a systematic review and meta-synthesis of evidence to examine the Iranian HRS stewardship challenges and interview 32 stakeholders, using a critical case sampling and snowballing approach which included both semi-structured and in-depth interviews. The interviewees were selected based on criteria covering policy-makers, managers, research bodies and nongovernmental organizations (NGOs) in health research-related fields like higher education, research, technology, innovation and science. All data were analysed using content analysis to determine eight main groups of findings under three levels: macro, meso, and micro.

RESULTS

Analysis of the findings identified eight main themes. The most critical challenges were the lack of an integrated leadership model and a shared vision among different HRS stakeholders. Their scope and activities were often contradictory, and their role was not clarified in a predetermined big picture. The other challenges were legislation, priority-setting, monitoring and evaluation, networking, and using evidence as a decision support base.

CONCLUSIONS

Stewardship functions are not appropriately performed and are considered the root causes of many other HRS challenges in Iran. Formulating a clear shared vision and a work scope for HRS actors is critical, along with integrating all efforts towards a unified strategy that assists in addressing many challenges of HRS, including developing strategic plans and future-oriented and systematic research, and evaluating performance. Policy-makers and senior managers need to embrace and use evidence, and effective networking and communication mechanisms among stakeholders need to be enhanced. An effective HRS can be achieved by redesigning the processes, regulations and rules to promote transparency and accountability within a well-organized and systematic framework.

Published Research on COVID-19 in the Eastern Mediterranean Region: Bibliometric Analysis (Preprint)

Background

The challenges presented by the COVID-19 pandemic have led to unprecedented global research activity. The Eastern Mediterranean Region (EMR) continues to contribute to COVID-19 research driven by the unique challenges of the region, including the protracted conflicts, already stressed health systems, and serious health and social inequalities.

Objective

This study aims to provide an overview of the publication activities and trends in COVID-19 research in the EMR from the onset of the disease to early 2022 using bibliometric methods.

Methods

A literature search using Scopus was conducted from December 1, 2019, to January 31, 2022, using keywords relevant to COVID-19 and the World Health Organization (WHO) EMR country list. Data were exported and analyzed using Microsoft Excel and the Citation Overview function on Scopus. The quality of journals was determined using SCImago Journal Rank and CiteScore. VOSviewer software was used to visualize the relationships between authors, countries, and key terms used in the retrieved documents.

Results

A total of 6880 documents were retrieved, of which 1805 (26.24%) were from the Kingdom of Saudi Arabia (KSA) and 1782 (25.90%) from Iran, followed by Pakistan, Egypt, and Jordan. Most published documents were affiliated with EMR universities, primarily the Tehran University of Medical Sciences in Iran and King Saud University in KSA (396/6880, 5.76%, and 370/6880, 5.4%, respectively), while only 407 (5.92%) of 6880 documents were associated with universities outside the EMR. For most of the identified publications (5020/6880, 72.97%), no funding source was reported, while King Saud University contributed the largest share (282/1860, 15.16%) of funded publications. Retrieved documents were cited 53,516 times, with an average of 7.78 (SD 34.30). Iran was the EMR country with the most links to other countries (77 links and total link strength of 1279). The 5 authors with the most publications were from KSA, Qatar, and Jordan. There were 290 high-frequency keywords that occurred ≥10 times and were linked in 7 different clusters. The cluster with the most linked keywords was related to epidemiology and mortality. Recent topics included vaccines, vaccination, machine learning, and online learning.

Conclusions

This is the first study to show trends in and project future developments of COVID-19 research activity in the EMR. Authors and institutions who led research on COVID-19 in the region were from Iran and KSA. There were multiple regional collaborative efforts; however, international collaboration was limited. Recently, interest has been shifting toward topics related to vaccination, machine learning, and online learning. Understanding the current state of research is instrumental to future research production, and our study will inform regional research initiatives on emerging concepts, as well as opportunities for collaboration and funding.

Pharmacy-related research for health in the Arab region: An analysis informed by WHO's global strategy on research for health

In 2012, WHO (the World Health Organisation) published a strategy on research for health based on the premise that policies and practices in support of health worldwide should be grounded in the best scientific knowledge derived from high-quality research. This strategy focuses attention on five interrelated goals: organisation, capacity, priorities, standards, and translation.¹ Whilst knowledge production and publication in many Arab countries have been on the rise, the overall global share of the Arab region in health research publication is smaller than its global share of population or wealth.² Inspired by the five WHO goals on research for health, this commentary shares factors and recommendations for consideration to enhance pharmacy-related research in the Arab region. These recommendations include establishing strategies for pharmacy-related research to address the context and local needs of the host country, creating intranational and intraregional collaborative research avenues, investing in research capacity, and fostering a culture of research in the workplace.

Mapping regional cooperation of state actors for health research systems in Africa: A social network analysis

Regional bodies can potentially play an important role in improving health research in Africa. This study analyses the network of African state-based regional organisations for health research and assesses their potential relationship with national health research performance metrics. After cataloguing organisations and their membership, we conducted a social network analysis to determine key network attributes of national governments' connections via regional organisations supporting functions of health research systems. This data was used to test the hypothesis that state actors with more connections to other actors via regional organisations would have higher levels of health research performance across indicators. With 21 unique regional organisations, the African continent is densely networked around health research systems issues. In general, the regional network for health research is inclusive. No single actor serves as a nexus. However, when statistics are grouped by African Union regions, influential poles emerge, with the most predominate spheres of influence in Eastern and Western Africa. Further, when connectivity data was analysed against national health research performance, there were no statistically significant relationships between increased connectivity and higher performance of key health research metrics. The inclusive and dense network dynamics of African regional organisations for health research strengthening present key opportunities for knowledge diffusion and cooperation to improve research capacity on the continent. Further reflection is needed on appropriate and meaningful ways to assess the role of regionalism and evaluate the influence of regional organisations in strengthening health research systems in Africa.

State of Research Quality and Knowledge Transfer and Translation and Capacity Strengthening Strategies for Sound Health Policy Decision-Making in Palestine

Objectives: Over the last 2 decades, the World Health Organization (WHO) has proposed a global strategy and initiatives to establish a Health Research System (HRS) focusing on Health Research Quality and Standardization (HRQS), Health Research Knowledge Transfer and Dissemination (HRKTD), and Health Research Translation and Utilization into Health Care Decisions and Policies (HRTUDP). Despite the increase in health research productivity over the past several decades, HRS Capacity (HRSC) in Palestine and in the Middle East and North Africa (MENA) region has rarely been objectively evaluated. This study aims at eliciting the perceptions of HRS performers in Palestine in order to understand the status of HRSC, identify gaps, and generate policies and solutions capable of strengthening HRSC in Palestine.

Methods: Key informants from three sectors, namely government, academia, and local and international organizations, were selected purposively based on different sampling methods: criterion, critical case, snowball, and homogeneous sampling. Fifty-two in-depth interviews with key informants and a total of fifty-two individuals, participating in six focus groups, were conducted by the principal investigator in Palestine. Data were analyzed by using MAXQDA 12.

Results: The overall pattern of the Palestinian HRSC is relatively weak. The key findings revealed that while HR productivity in Palestine is improving, HRQS is at an average level and quality guidelines are not followed due to paucity of understanding, policies, and resources. HRKTD is a central challenge with both a dearth of conceptualization of translational science and inadequate implementation. The factors related to inadequate HRKTD include lack of awareness on the part of the researchers, inadequate regulatory frameworks and mechanisms for both communication and collaboration between and among researchers and policy-makers and clinicians, and lack of availability of, and credibility in, systematized and reliable HR data. Despite the limited knowledge translation, in general, HRTUDP is not considered an essential decision-making methodology mainly due to the lack of interface between knowledge producers (researchers) and users (policymakers), understanding level, HR credibility and availability of applied research, and governance, resources, and political fluctuations. Recommendations to strengthen HRS in Palestine include: a consolidated research regulatory framework and an effective capacity strengthening strategy overseen by Palestinian authorities; the promotion of HRQS and concepts and practices of translational science; and, most importantly, the use of findings for evidence-based policies and practice.

Conclusion: Strengthening HRSC is both an imperative step and an opportunity to improve the Palestinian health system and ensure it is based on research evidence and knowledge. Building a successful HRS characterized by capacities of high-quality research and well-disseminated and translated knowledge is a prerequisite to effective health systems and services. This can be achieved by political commitment to support such strengthening, a consolidated leadership and governance structure, and a strong operational capacity strengthening strategy.

Health research capacity building of health workers in fragile and conflict-affected settings: a scoping review of challenges, strengths, and recommendations

BACKGROUND

Fragile and conflict-affected settings (FCAS) have a strong need to improve the capacity of local health workers to conduct health research in order to improve health policy and health outcomes. Health research capacity building (HRCB) programmes are ideal to equip health workers with the needed skills and knowledge to design and lead health-related research initiatives. The study aimed to review the characteristics of HRCB studies in FCASs in order to identify their strengths and weaknesses, and to recommend future directions for the field.

METHODS

We conducted a scoping review and searched four databases for peer-reviewed articles that reported an HRCB initiative targeting health workers in a FCAS and published after 2010. Commentaries and editorials, cross-sectional studies, presentations, and interventions that did not have a capacity building component were excluded. Data on bibliographies of the studies and HRCB interventions and their outcomes were extracted. A descriptive approach was used to report the data, and a thematic approach was used to analyse the qualitative data.

RESULTS

Out of 8822 articles, a total of 20 were included based on the eligibility criteria. Most of the initiatives centred around topics of health research methodology (70%), targeted an individual-level capacity building angle (95%), and were delivered in university or hospital settings (75%). Ten themes were identified and grouped into three categories. Significant challenges revolved around the lack of local research culture, shortages in logistic capability, interpersonal difficulties, and limited assessment and evaluation of HRCB programmes. Strengths of HRCB interventions included being locally driven, incorporating interactive pedagogies, and promoting multidisciplinary and holistic training. Common recommendations covered by the studies included opportunities to improve the content, logistics, and overarching structural components of HRCB initiatives.

CONCLUSION

Our findings have important implications on health research policy and related capacity building efforts. Importantly, FCASs should prioritize (1) funding HRCB efforts, (2) strengthening equitable international, regional, and national partnerships, (3) delivering locally led HRCB programmes, (4) ensuring long-term evaluations and implementing programmes at multiple levels of the healthcare system, and (5) adopting engaging and interactive approaches.

Capacity Building for Research in Critical Care: A Pilot Program in the Eastern Mediterranean Region

Research productivity in the Eastern Mediterranean Region is relatively low in all fields, including critical care. We describe a capacity-building research program that was piloted with 11 clinicians from the Eastern Mediterranean Region, who had minimal research experience. The program was conducted over 1 year, with a structure that specifically addressed factors that contribute to low research productivity. We describe the structure of the program, the faculty involved, the feasibility, and challenges faced, as well as the impact of the program on research output. At a small scale, the program was generally feasible and demonstrated promising results. Evaluating the feasibility of conducting such a program over a longer period of time and with a larger group of participants is necessary since research capacity-building programs require multiple years to demonstrate a significant impact on research output.

Ecology of War, Health Research and Knowledge Subjugation: Insights from the Middle East and North Africa Region

In an ecology of war, as experienced in the Middle East and North Africa region, health research faces several interrelated challenges: de-prioritization, paucity in the generation of reliable data, and its securitization. This directly contributes to local knowledge subjugation and research waste as local narratives are disqualified in favor of institutionalized and privileged global unitary knowledge. Huge efforts that require political will and commitment, coupled with multidisciplinary approaches and sustainable collaborations between researchers and humanitarian workers at the local, regional and global levels, are indispensable to give more space for the abandoned local knowledge in order to have contextualized and more impactful interventions where more lives are saved.

Capacity for health economics research and practice in Jordan, Lebanon, the occupied Palestinian territories and Turkey: needs assessment and options for development

Background

Capacity for health economics analysis and research is indispensable for evidence-informed allocations of scarce health resources; however, little is known about the experience and capacity strengthening preferences of academics and practitioners in the Eastern Mediterranean region. This study aimed to assess the needs for strengthening health economics capacity in Jordan, Lebanon, the occupied Palestinian territories and Turkey as part of the Research for Health in Conflict in the Middle East and North Africa (R4HC) project.

Methods

We combined a bibliometric analysis of health economics outputs based on a literature search conducted across seven databases with an online survey of academic researchers and non-academic practitioners. The records included in the bibliometric analysis were original studies and reviews with an explicit economic outcome related to health, disease or disability, had at least one author in Jordan, Lebanon, Palestine or Turkey, and were published between January 2014 and December 2018. Two types of analyses were conducted using VOSviewer software, namely keyword co-occurrence and co-publication networks across countries and organisations. The online survey asked academic researchers, analysts and decision-makers – identified through the bibliometric analysis and regional professional networks – about previous exposure to and priorities for capacity development in health economics.

Results

Of 15,185 records returned by the literature search, 566 were included in the bibliometric analysis. Organisations in Turkey contributed more than 80% of records and had the broadest and most diverse network of collaborators, nationally and internationally. Only 1% (n = 7) of studies were collaborations between researchers in two or more different jurisdictions. Cost analysis, cost-effectiveness analysis and health system economics were the main health economics topics across the included studies. Economic evaluations, measuring the economic burden of disease and health equity, were reported by survey respondents (n = 80) as the most important areas to develop in. Short courses, learn-by-doing and mentoring from an experienced professional were, in aggregate, the most preferred learning styles.

Conclusions

Existing pockets of health economic expertise in the region can constitute the base of future capacity development efforts. Building confidence toward applying specific methods and trust toward stimulating cross-jurisdiction collaborations appear essential components for sustainably developing health economics capacity.

Assessing the capacity for conflict and health research in Lebanon: a qualitative study

Background

Conflicts pose new challenges for health systems, requiring rapid and practical approaches to meet emerging needs on the ground. Lebanon has been highly influenced by surrounding conflicts in the Middle East and North Africa (MENA) region, especially the Syrian crisis. Strengthening research capacity to collect evidence on conflict in the MENA region and beyond is crucial to inform healthcare policy and practice. For targeted capacity strengthening interventions, the main objective of this paper is to present key findings of a needs assessment of conflict and health research in Lebanon. This will support recent efforts to scale up context-specific policies, interventions to strengthen the country’s health system, and research capacity.

Methods

The study is based on 30 semi-structured interviews with key informants such as specialist academics, humanitarian workers and public sector officials.

Results

Despite being ranked third in the number of publications on biomedical and health research per capita in MENA and in hosting reputable universities which are considered central academic hubs in the region, lack of nationwide research culture, insufficient funding and limited access to data were reported to be major challenges for health researchers in Lebanon. Even with the ongoing efforts, poor impact of research on policy continues to be a persistent gap. Large disparities in research capacities and taught skills were reported between different universities in Lebanon, with a disproportionate emphasis on quantitative over qualitative skills. Most medical students are not trained to conduct research or to practice in conflict settings. Concerns were also expressed regarding the ethics of research conducted, specifically by local non-governmental organizations.

Recommendations

To conduct contextualized trainings on research skills with a stronger focus on qualitative approaches, medical practice, and ethical research in conflict. To better involve policymakers in designing research agendas by organizing multiple stakeholder meetings.

Conclusion

The study indicates that health research in Lebanon is characterized by considerable strengths in terms of human capital and research capacities of certain universities. However, the Lebanese research infrastructure needs further development in terms of ensuring sustainable funding, providing access to data, teaching qualitative research skills, conducting ethical and multidisciplinary research, and promoting cross-sectoral knowledge transfer.

Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence

BACKGROUND

Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict.

OBJECTIVE

The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale.

METHODS

We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme.

RESULTS

Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%).

CONCLUSIONS

This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.

A novel conceptual model and heuristic tool to strengthen understanding and capacities for health inequalities research

Background

Despite increasing evidence on health inequalities over the past decades, further efforts to strengthen capacities to produce research on this topic are still urgently needed to inform effective interventions aiming to address these inequalities. To strengthen these research capacities, an initial comprehensive understanding of the health inequalities research production process is vital. However, most existing research and models are focused on understanding the relationship between health inequalities research and policy, with less focus on the health inequalities research production process itself. Existing conceptual frameworks provide valuable, yet limited, advancements on this topic; for example, they lack the capacity to comprehensively explain the health (and more specifically the health inequalities) research production process at the local level, including the potential pathways, components and determinants as well as the dynamics that might be involved. This therefore reduces their ability to be empirically tested and to provide practical guidance on how to strengthen the health inequalities research process and research capacities in different settings. Several scholars have also highlighted the need for further understanding and guidance in this area to inform effective action.

Methods

Through a critical review, we developed a novel conceptual model that integrates the social determinants of health and political economy perspectives to provide a comprehensive understanding of how health inequalities research and the related research capacities are likely to be produced (or inhibited) at local level.

Results

Our model represents a global hypothesis on the fundamental processes involved, and can serve as a heuristic tool to guide local level assessments of the determinants, dynamics and relations that might be relevant to better understand the health inequalities research production process and the related research capacities.

Conclusions

This type of knowledge can assist researchers and decision-makers to identify any information gaps or barriers to be addressed, and establish new entry points to effectively strengthen these research capacities. This can lead to the production of a stronger evidence base, both locally and globally, which can be used to inform strategic efforts aimed at achieving health equity.

A narrative review of health research capacity strengthening in low and middle-income countries: lessons for conflict-affected areas

Conducting health research in conflict-affected areas and other complex environments is difficult, yet vital. However, the capacity to undertake such research is often limited and with little translation into practice, particularly in poorer countries. There is therefore a need to strengthen health research capacity in conflict-affected countries and regions.In this narrative review, we draw together evidence from low and middle-income countries to highlight challenges to research capacity strengthening in conflict, as well as examples of good practice. We find that authorship trends in health research indicate global imbalances in research capacity, with implications for the type and priorities of research produced, equity within epistemic communities and the development of sustainable research capacity in low and middle-income countries. Yet, there is little evidence on what constitutes effective health research capacity strengthening in conflict-affected areas. There is more evidence on health research capacity strengthening in general, from which several key enablers emerge: adequate and sustained financing; effective stewardship and equitable research partnerships; mentorship of researchers of all levels; and effective linkages of research to policy and practice.Strengthening health research capacity in conflict-affected areas needs to occur at multiple levels to ensure sustainability and equity. Capacity strengthening interventions need to take into consideration the dynamics of conflict, power dynamics within research collaborations, the potential impact of technology, and the wider political environment in which they take place.

Evaluating the Published Critical Care Research from the World Health Organization Eastern Mediterranean Region

Objectives

Evaluation of published research in a region provides insight into relevant aspects of clinical care and research priorities. This study aimed to provide a comprehensive assessment of the type of critical care research published in the World Health Organization Eastern Mediterranean region (EMR) over a 10-year period.

Results

During the study period (2007–2016), the search strategy revealed 4303 publications, of which 1537 were included in the analysis; studies were excluded for the following reasons: not critical care, conducted in non-EMR countries, editorials, case reports, in-vitro or animal studies, as well as those conducted in multiple countries and those that evaluated foreign military personal. Countries varied in the number of publications produced, ranging from none in Somalia to 620 in Iran. The majority of the studies were observational (78%), evaluated adults (73%), and the most common areas of research were infectious (29%) and respiratory (10%) diseases. Median sample size was 120 and the mean (SD) impact factor of the journals in which the articles were published was 1.02 (0.7).

Evolution of Iran's health research system over the past 50 years: a narrative review

BACKGROUND

A substantial growth has been reported in Iran's health research output over the last recent decades, throughout the times of economic, social, and political instability. This study reviewed the existing literature to provide a better understanding of the evolution of Iran's health research system over this period.

METHODS

A narrative review of studies addressing health research system (HRS) in Iran was performed. The search strategy and categorization of the retrieved data was informed by the HRS framework of the World Health Organization (WHO). This framework proposes four functions for HRS: (i) stewardship; (ii) financing; (iii) creating and sustaining resources; and (iv) producing and using research. Searches in MEDLINE through PubMed (using MeSH terms) complemented with semantic searches through PubMed and Google Scholar were conducted.

RESULTS

After removing the duplicates, 805 articles were retrieved, of which 601 were irrelevant, and 204 were reviewed.

CONCLUSIONS

Iran has made substantial progress in different components of its HRS over the last few decades, such as starting a discourse surrounding health research ethics, priority-setting, and placing monitoring mechanisms while increasing the capacity for conducting and publishing research. However, there is still room for improvements, or even a need for fundamental changes, in several components, such as regarding increasing the research budget and improving the funding allocation mechanisms; improving the education curriculum; and promoting the use of evidence. The findings emphasized that improvement of HRS functions requires addressing context-specific problems. This review provides essential lessons to share with other low- and middle-income countries and international organizations, eg, the WHO.

Costs associated with management of non-communicable diseases in the Arab Region: a scoping review

BACKGROUND

Global mortality rates resulting from non-communicable diseases (NCDs) are reaching alarming levels, especially in low- and middle-income countries, imposing a considerable burden on individuals and health systems as a whole. This scoping review aims at synthesizing the existing literature evaluating the cost associated with the management and treatment of major NCDs across all Arab countries; at evaluating the quality of these studies; and at identifying the gap in existing literature.

METHODS

A systematic search was conducted using Medline electronic database to retrieve articles evaluating costs associated with management of NCDs in Arab countries, published in English between January 2000 and April 2016. 55 studies met the eligibility criteria and were independently screened by two reviewers who extracted/calculated the following information: country, theme (management of NCD, treatment/medication, or procedure), study design, setting, population/sample size, publication year, year for cost data cost conversion (US$), costing approach, costing perspective, type of costs, source of information and quality evaluation using the Newcastle-Ottawa Scale (NOS).

RESULTS

The reviewed articles covered 16 countries in the Arab region. Most of the studies were observational with a retrospective or prospective design, with a relatively low to very low quality score. Our synthesis revealed that NCDs' management costs in the Arab region are high; however, there is a large variation in the methods used to quantify the costs of NCDs in these countries, making it difficult to conduct any type of comparisons.

CONCLUSIONS

The findings revealed that data on the direct costs of NCDs remains limited by the paucity of this type of evidence and the generally low quality of studies published in this area. There is a need for future studies, of improved and harmonized methodology, as such evidence is key for decision-makers and directs health care planning.

Health Care Workers in the setting of the "Arab Spring": a scoping review for the Lancet-AUB Commission on Syria

Background

"Health Care Workers in Conflict Areas" emerged as one of the priority themes for a Lancet Commission addressing health in conflict. The objective of our study was to conduct a scoping review on health workers in the setting of the Syrian conflict, addressing four topics of interest: violence against health care workers, education, practicing in conflict setting, and migration.

Methods

Considering the likelihood of scarcity of data, we broadened the scope of the scoping review to include indirect evidence on health care workers from other countries affected by the "Arab Spring". We electronically searched six electronic databases. We conducted descriptive analysis of the general characteristics of the included papers. We also used the results of this scoping review to build an evidence gap map.

Results

Out of the 11 165 identified citations, 136 met our eligibility criteria. The majority of the articles tackled the issue of violence against health care workers (63%) followed by practicing in conflict setting (19%), migration (17%) and education (10%). Countries in focus of most articles were: Syria (35%), Iraq (33%), and Bahrain (29%). News, editorials, commentaries and opinion pieces made up 81% of all included papers, while primary studies made up only 9%. All the primary studies identified in this review were conducted on Iraq. Most of the articles about violence against health care workers were on Bahrain, followed by Syria and Iraq. The first and corresponding authors were most frequently affiliated with institutions from non-Arab countries (79% and 79% respectively).

Conclusions

Research evidence on health care workers in the setting of the "Arab Spring" is scarce. This review and the gap map can inform the research agendas of funders and researchers working in the field of health care workers in conflict setting. More well-designed primary studies are needed to inform the decisions of policymakers and other interested parties.

Assessment of research systems in universal health coverage-related organizations

Background: Universal health coverage (UHC) is the desired goal of achieving universal access to health services without having to endure pain and financial difficulties. Multiple factors can help steer countries toward UHC. One of the most important factors is the production of valid quality evidence that can be achieved through research. The present study aimed at outlining the status of research systems in UHC–related organizations and identifying the barriers faced by research.

Methods: The key individuals and organizations that could provide rich, relevant, and diverse data in response to the research question were purposively selected for the interviews. Thematic analysis was used to analyze the interviews. Categories and subcategories were deductively extracted from the text based on research system performance as follows: resource provision, production and utilization of knowledge, existing resources, and stewardship. Then, the themes were inductively extracted from the interviews.

Results: Many barriers existed for performing research in UHC–related organizations. The stewardship barrier seemed to play a key role such that structural changes in organizations affected the production & utilization of evidence. Limited financial and human resources were evident in most of the organizations. Research questions were not comprehensively identified. The conducted studies either were not designed to answer the relevant questions and/or were not appropriately reported to policy makers. As a result, their implementation in decision- making did not reach the ideal status.

Conclusion: Research utilization aimed at achieving UHC will come to realize only when and if research is conducted to produce evidence required for decision–making and implementation. Therefore, in addition to the interventions recommended by the World Health Organization, we should design and implement interventions tailored to the local barriers and needs of UHC–related organizations.

The Palestinian health research system: who orchestrates the system, how and based on what? A qualitative assessment

BACKGROUND

In 2011, the WHO Eastern Mediterranean Region committee launched a strategy for scaling up research in the region to address the countries' health needs through formulating and analysing the National Health Research System (HRS). Stewardship comprises three functions, namely governance, policy and priorities, and is a central pillar of this system to ensure a well-organised and functioning HRS. This study aims to examine the perceptions of the HRS performers to understand these functions and to generate insights for system strengthening.

METHODS

The study was carried out in Palestine, targetting three sectors in the health field, including relevant governmental health institutions, schools of public health, and major local and international health agencies. The data were collected through 52 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) with policy-makers, academics, directors, and experts. Participants and institutions were selected purposively based on a set of criteria and peer review.

RESULTS

A total of 104 experts participated in the IDIs (52 participants) and FGDs (52 participants in 6 FGDs), highlighting that stewardship functions remain problematic and insufficiently performed, mainly due to a missing health research structural and regulatory framework and dispersed health research work. Despite the limited good practices, the majority of the participants described the Ethical Review and Clearance as weak due to the lack of an agreed-upon national committee and procedural quality and ethics guidelines for non-compliance. A policy or strategy dedicated to health research is lacking. The exercises of research priority-setting appear to be evolving despite the lack of consensus and the low levels of knowledge and experience in research prioritisation. Common gaps, such as weak political will and capacity support, the absence of a national unified regulating body, and the indirect effects of political conditions on strengthening the HRS as well as other sectors, also emerged.

CONCLUSIONS

The stewardship functions of the Palestinian HRS remain weak along with substantial political, structural, and resources and capacity gaps. The study emphasises the imperative need to initiate strategic efforts led by the MOH and the Palestinian National Institute of Public Health alongside with other players to strengthen a national HRS through improving the stewardship functions. To achieve this, attention and support of decision-makers, involvement, mobilisation and strategic dialogue are indispensable, in order to embark on building a well-regulated and coordinated structure, operational research policy, and prioritisation of essential research.

Assessing policy-makers', academics' and experts' satisfaction with the performance of the Palestinian health research system: a qualitative study

Background

There is a growing demand within international health agencies to ensure health research systems (HRSs) are strengthened and well-functioning to support healthcare systems (HCSs). Understanding HRS performance through system actors is an indispensable move in analysing this system. This study aims to examine policy-makers’, academics’ and experts’ satisfaction with overall HRS performance, while also investigating their perceptions about political will and attention towards health research. Ultimately, we want to identify gaps related to performance and generate insights on how to move forward for HRS performance strengthening.

Methods

This study was carried out in Palestine, targeting three sectors, namely government institutions, public health universities, and major local and international health non-governmental organisations (NGOs). Semi-structured, in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with participants. The institutions from the three sectors were selected based on stated criteria and peer reviews. Data were translated from Arabic into English, transcribed, content checked by the principal investigator, imported to a software programme (MAXQDA 12), and then coded. Thematic content analysis was used.

Results

A total of 104 experts participated in 52 IDIs and 52 experts participated in 6 FGDs. Findings revealed three principal domains. First, the HRS in Palestine is remarkably underperforming, and the majority of experts were unsatisfied. Participants perceived the system as ineffective and inefficient, poorly managed and lacking systematic assessment. Second, the factors behind system underperformance were (1) an unstructured system and the lack of a research culture as well as of a governing body or policies; (2) health research was seen as individualistic, non-development driven and unutilised in policy decisions; and (3) considerably deficient coordination and essential resources. The third finding showed inadequate political support and engagement, which then also related to system underperformance.

Conclusions

The Palestinian HRS is perceived as underperforming by health experts at different levels, where research is not on the leadership agendas. Potential actions should be taken to actively engage the state health decision-makers and inform them of the importance, uses and impacts of performance assessment. Findings urge policy-makers and legislators to build an inclusive and national body of governance with agreed strategies including fundamentally hybrid and aligned performance assessment mechanisms, such as a research observatory platform. In addition, it is recommended to establish a strategic plan to expand professionals’ research awareness and abilities, as well as empower the institution’s research monitoring and evaluation capacities.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0341-x) contains supplementary material, which is available to authorized users.

Understanding the concept and importance of the health research system in Palestine: a qualitative study

Background

The importance of a health research system (HRS), namely an instrument for developing and enabling health systems, is increasing, particularly in developing countries. Assessing the perceptions of system performers is a necessary part of system analysis, which seeks to recognize a system’s strengths and limitations aiming towards improvement. This study assesses the perceptions of policy-makers, academicians and experts regarding the HRS concept and its importance to generate insights for system strengthening. In Palestine, HRS is just emerging, helping to address the many public health-related challenges faced by the country.

Methods

The study was implemented from January until July 2016, targeting three sectors, namely relevant government institutions, schools of public health, and major local and international health agencies. Data was collected through 52 in-depth interviews and six focus group discussions (FGDs) with policy-makers, academics, directors and experts. Participants and institutions were selected based on stated criteria and peer review. Data were translated, transcribed, checked and then imported to a software program (MAXQDA 12) for thematic and content analysis.

Results

A total of 104 experts participated, wherein 52 were interviewed and 52 participated in the six FGDs. The HRS concept, as defined by WHO, was conceptualized differently among participants with unclear delineations between various components. Inconsistencies appeared when participants attempted to conceptualize HRS in broader contexts, though HRS goals and functions were sufficiently delineated. The majority of participants agreed that HRS correlates with notions of ‘improvement’ and recognized HRS ‘as a significant gain’. Neglect of HRS was perceived as a big loss.

Conclusions

The study revealed that the level of understanding of HRS among health experts in Palestine is inadequate and not sufficiently conceptualized for its application. Findings also underlined the need to establish a central governance coordination body that promotes HRS understanding, awareness and culture as an enabler for HRS strengthening.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0315-z) contains supplementary material, which is available to authorized users.

The Practice of Research Ethics in Lebanon and Qatar: Perspectives of Researchers on Informed Consent

Informed consent requirements for conducting research with human participants are set by institutional review boards (IRBs) following established guidelines. Despite this, researchers continue to face challenges in seeking and obtaining informed consent. This study discusses researchers' views of such problems in Lebanon and Qatar, which vary in research regulation. We conducted in-depth interviews with 52 academic researchers from various fields of research in both countries and analyzed them using thematic analysis. Important disjunctions emerged between IRB requirements and actual practice. Variations in obtaining informed consent were affected by the research context, type of research, and the prevalent cultural norms and values. Regulatory systems and guidelines for informed consent do not necessarily ensure ethical research conduct. Implications for improvement are presented.

Landscape of Research on Older Adults' Health in the Arab Region: Is It Demography-Driven or Development-Dependent?

Objectives

To describe the quantity, methods, themes, and collaboration profiles of research on older adults' health in the Arab world, and map research productivity against demographic, economic, and development indicators.

Methods

A scoping review of research on older adults' health drawing from 7 databases and covering the period 1994-2013.

Results

Aging research output has increased 6-fold over the study period, with middle-income countries showing the sharpest rise. The majority of the reviewed publications are descriptive in nature, oriented toward examining the extent of disease or factors associated with various morbidity and mortality outcomes (88.5%). Despite the increasing regional instability, there is a dearth of studies on "seniors in emergencies." Collaboration with international coauthors (16.0%) has been more frequent than with regional coauthors (4.2%). Correlation analysis suggests that research production has been more strongly influenced by literacy rates than by population aging indicators, Gross Domestic Product, or government investment in research and development.

Discussion

This study lays the basis for a "roadmap" for research on older adults' health in the Arab region. It calls for cooperation among various stakeholders to produce a targeted and well-informed research agenda that is more responsive to emerging and context-specific needs of older adults in the region.

Does published research on non-communicable disease (NCD) in Arab countries reflect NCD disease burden?

Objectives

To review trends in non-communicable (NCD) research output in the Arab region, in terms of quantity and quality, study design, setting and focus. We also examined differences by time and place, and assessed gaps between research output and NCD burden.

Methods

A scoping review of a total of 3,776 NCD-related reports published between 2000 and 2013 was conducted for seven Arab countries. Countries were selected to represent diverse socio-economic development levels in the region: Regression analyses were used to assess trends in publications over time and by country. Research gaps were assessed by examining the degree of match between proportionate literature coverage of the four main NCDs (CVD, cancer, DM, and COPD) and cause-specific proportional mortality rates (PMR).

Results

The annual number of NCD publications rose nearly 5-fold during the study period, with higher income countries having the higher publication rates (per million populations) and the most rapid increases. The increase in the publication rate was particularly prominent for descriptive observational studies, while interventional studies and systematic reviews remained infrequent (slope coefficients = 13.484 and 0.883, respectively). Gap analysis showed a mismatch between cause-specific PMR burden and NCD research output, with a relative surplus of reports on cancer (pooled estimate +38.3%) and a relative deficit of reports on CVDs (pooled estimate -30.3%).

Conclusion

The widening disparity between higher and lower-income countries and the discordance between research output and disease burden call for the need for ongoing collaboration among Arab academic institutions, funding agencies and researchers to guide country-specific and regional research agendas, support and conduct.

A survey of knowledge-to-action pathways of aging policies and programs in the Arab region: the role of institutional arrangements

BACKGROUND

While population aging challenges Arab governments to ensure well-being in old age, knowledge translation is gaining support worldwide in evidence-based policymaking and service provision. This study examines the status of existing knowledge translation efforts of aging-related research in Arab countries and evaluates the additional role that institutional arrangements (such as ministry departments, national committees, etc.) play in the relationship between knowledge creation and social and health policies and programs.

METHODS

Data were triangulated from two regional surveys and a supplementary desk review of academic, civil society, ministry, and UN documents. Using a set of indicators, standardized summative indices (out of 100) were generated for five constructs, namely knowledge creation, institutional arrangements, knowledge translation, and health and social policies and programs. Correlations were assessed using Spearman's rank correlation (r s), and bootstrap multiple linear regression models were used.

RESULTS

Arab countries scored highest on the institutional arrangements index (median = 69.5), followed by the knowledge creation index (median = 45.9), and lowest on the knowledge translation index (median = 30.2). Both institutional arrangements and knowledge creation significantly correlated with social and health policies and programs. However, when adjusted for knowledge translation, only institutional arrangements retained a significant association with both outcomes (r s = 0.63, p value =0.009 and r s = 0.69, p value =0.01, respectively). Adjusting for institutional arrangements and knowledge creation, the association of knowledge translation with social and health policies and programs was attenuated and non-significant (r s = 0.08, p value =0.671 and r s = 0.12, p value =0.634, respectively).

CONCLUSIONS

There are two key messages from this study. Firstly, institutional arrangements play a central role in aging social and health policy and program development in the Arab region. Secondly, knowledge translation paradigms in Arab countries may be deficient in factors pertinent for promoting evidence-based decision-making and policy-relevant research. These findings call for the need of strengthening institutional arrangements on aging and for promoting knowledge production that meets policy-relevant priorities.

Research's Practice and Barriers of Knowledge Translation in Iran

BACKGROUND

Knowledge Translation is a process that includes synthesis, dissemination, exchange and application of knowledge to improve the health, services and products In this study we have attempted to examine the knowledge translation practice and its perceived barriers on the universalities and research institutes (research sector) in Iran.

METHODS

Both qualitative and quantitative approaches were used. In the quantitative section, a questionnaire had prepared for this study was completed by 88 authors country wide from randomly selected papers. In the qualitative section 13 in-depth interviews and 6 focus group discussions were held with managers and policy makers, clinical and health service providers, and researchers.

RESULTS

Twenty four percent of the authors had no interaction whatsoever with the target audience. Lack of expectation toward creating change in the target audience, researchers' incentives, low level of trust among researchers and decision makers, absence of a predefined mechanism for delivery of research results and inappropriate research priorities were among the most important barriers identified in the qualitative section.

CONCLUSION

Translation of research findings into some concrete outputs which can affect health of people is not in mandate of researchers and subsequently they are not prepared for this as well. Based on the barriers identified, it seems that the following interventions are necessary: cooperation among policy makers at macro and meso (organizational) level and the research sector; establishing networks for researchers and decision makers in choosing the research topic, priority setting, and building trust among researchers and policy makers.

Diabetes in the Middle-East and North Africa: an update

In recent decades, the prevalence of diabetes has risen dramatically in many countries of the International Diabetes Federation's (IDF) Middle-East and North Africa (MENA) Region. This increase has been driven by a range of factors that include rapid economic development and urbanisation; changes in lifestyle that have led to reduced levels of physical activity, increased intake of refined carbohydrates, and a rise in obesity. These changes have resulted in the countries of MENA Region now having among the highest rates of diabetes prevalence in the world. The current prevalence of diabetes in adults in the Region is estimated to be around 9.2%. Of the 34 million people affected by diabetes, nearly 17 million were undiagnosed and therefore at considerable risk of diabetes complications and poor health outcomes. Enhanced research on the epidemiology of diabetes in the MENA Region needs to be combined with more effective primary prevention of diabetes; and early detection and improved management of patients with established diabetes, including an increased focus on self-management and management in primary care and community settings.