Evidence-based priority setting for health care and research: tools to support policy in maternal, neonatal, and child health in Africa

Using a priority setting exercise to identify priorities for guidelines on newborn and child health in South Africa, Malawi, and Nigeria

BACKGROUND

Sub-Saharan Africa is the region with the highest under-five mortality rate globally. Child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step in this process was to identify national priorities for newborn and child health guideline development, and this paper describes our approach.

METHODS

We followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. We established national Steering Groups (SG), comprising 10-13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with SGs where final priority topics were agreed.

RESULTS

Based on survey results, nine, 10 and 11 topics were identified in SA, Malawi, and Nigeria respectively, which informed consensus meetings. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In SA, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants.

CONCLUSIONS

Through dynamic and iterative stakeholder engagement, we identified three priority topics for guideline development on newborn and child health in SA, Malawi and Nigeria. Topics were specific to contexts, with no overlap, which highlights the importance of contextualised priority setting as well as of the relationships with key decisionmakers who help define the priorities.

Global health economics: The Equitable Impact Sensitive Tool (EQUIST) - development, validation, implementation and evaluation of impact (2011 to 2022)

Background

The Equitable Impact Sensitive Tool (EQUIST) was developed to address the limitations of the traditional cost-effectiveness analysis (CEA) in global health, which often overlooked equity considerations. Its primary aim was to create more effective and efficient health systems by explicitly incorporating equity as a key driver in health policy decisions. This was done in response to the recognition that, while CEA helped reduce mortality rates through interventions like childhood vaccinations, it was insufficient in addressing growing inequalities in health, especially in low-and-middle-income countries (LMICs).

Methods

The development of EQUIST involved a multi-stage process which began in 2011 with the recognition of the need for a more nuanced approach than CEA alone. This led to a proposal for creating a tool that balanced cost-effectiveness with equity. The conceptual framework, developed between March and May 2012, included assessments of intervention efficiency by equity strata, effectiveness, impact, and cost-effectiveness. Key to EQUIST's development was its integration with other data science platforms, notably the Lives Saved Tool and the Marginal Budgeting for Bottlenecks tool, allowing EQUIST to draw on comprehensive data sets and thus enabling a more detailed analysis of health interventions' impacts across different socio-economic strata.

Results

EQUIST was validated in 2012 through applications in five representative countries, demonstrating its ability to identify more equitable and cost-effective health interventions which targeted vulnerable populations, leading to more lives saved compared to traditional methods. It was then used to develop investment cases for the Global Financing Facility, resulting in significant funding being made available for maternal and child health programmes. Consequently, EQUIST directly influenced the development of national health policies and resource allocations in over 26 African countries.

Conclusions

EQUIST has proven to be a valuable tool in developing health policies that are both cost-effective and equitable. In the future, it will be further integrated with other tools and expanded in scope to address broader health issues, including adolescent health and human immunodeficiency virus/acquired immunodeficiency syndrome programme planning. Overall, EQUIST represents a paradigm shift in global health economics, emphasising the importance of equity alongside cost-effectiveness in health policy decisions. Its development and implementation have had a tangible impact on health outcomes, particularly in LMICs, where it has been instrumental in reducing maternal and child mortality while addressing health inequities.

What are the research priorities for strengthening public health emergency preparedness and response in Africa?

BACKGROUND

Research evidence is needed to strengthen capacities in emergency preparedness and response (EPR). However, the absence of a clear research agenda limits the optimal use of research evidence. This paper reports on the prioritization of research questions and topics that could contribute to evidence-informed strengthening of EPR capacities in the African region.

METHODS

The priority-setting consisted of desk review and stakeholder consultation workshop. Twenty-nine people participated in the workshop, including representatives from WHO regional office and EPR focal points in Africa, representatives of research institutions, and partners from Science for Africa Foundation, United Nations Children's Fund and Africa Center for Disease Control. Modified Delphi technique was used to systematically arrive at specific and cross-cutting research priorities in the three broad areas of the EPR, which are program Implementation, Clinical and Epidemiology. The research questions/topics were ranked on five-point Likert scale (1 = very low to 5 = very high) based on seven agreed-on criteria. Research priority score was calculated for each question as the mean of the criteria scores.

RESULTS

A total of 123 research questions comprising, 29 on Epidemiology, 22 on Clinical, 23 on program Implementation, and 49 on cross-cutting issues were ranked. The top ten research priorities were: knowledge and skills of healthcare workers in detecting and responding effectively to disease outbreaks; quality of data (accuracy, timeliness, completeness) for epidemic prone diseases; determinants of vaccine hesitancy; determinants of infection transmission among health care workers during PHE; effective measures for protecting health workers from highly infectious pathogens in PHE; strategies to improve the effectiveness of contact tracing for epidemic prone diseases; effectiveness of current case definitions as screening tools for epidemic and pandemic prone diseases; measures to strengthen national and sub-national laboratory capacity for timely disease confirmation within the Integrated Diseases Surveillance and Response framework; factors affecting prompt data sharing on epidemic-prone diseases; and effective strategies for appropriate community participation in EPR.

CONCLUSIONS

The collaborative multi-stakeholder workshop produced a starting list of priority research questions and topics for strengthening EPR capacities in Africa. Action needs to be taken to continuously update the research agenda and support member States to contextualize the research priorities and commission research for timely generation and uptake of evidence.

The effect of capacity building evidence-based medicine training on its implementation among healthcare professionals in Southwest Ethiopia: a controlled quasi-experimental outcome evaluation

BACKGROUND

Evidence-based medicine (EBM) bridges research and clinical practice to enhance medical knowledge and improve patient care. However, clinical decisions in many African countries don't base on the best available scientific evidence. Hence, this study aimed to determine the effect of training interventions on background knowledge and awareness of EBM sources, attitude, competence, and practice of EBM among healthcare professionals.

METHOD

We designed a controlled group quasi-experimental pre-post test study to evaluate the effect of capacity-building EBM training. A total of 192 healthcare professionals were recruited in the study (96 from the intervention and 96 from the control group). We used a difference-in-differences (DID) analysis to determine the effect of the training. Along the way, we used a fixed effect panel-data regression model to assess variables that could affect healthcare professionals' practice of EBM. The cut point to determine the significant effect of EBM training on healthcare professionals' background knowledge and awareness of EBM sources, attitude, and competence was at a P-value < 0.05.

RESULT

The DID estimator showed a significant net change of 8.0%, 17.1%, and 11.4% at P < 0.01 on attitude, competence, and practice of EBM, respectively, whereas no significant increment in the background knowledge and awareness of EBM sources. The fixed effect regression model showed that the attitude [OR = 2.288, 95% CI: (1.049, 4.989)], competence [OR = 4.174, 95% CI: 1.984, 8.780)], technical support [OR = 2.222, 95% CI: (1.043, 3.401)], and internet access [OR = 1.984, 95% CI: (1.073, 4.048)] were significantly affected EBM practice.

CONCLUSION

The capacity-building training improved attitude, competence, and EBM practice. Policymakers, government, and other concerned bodies recommended focusing on a well-designed training strategy to enhance the attitude, competence, and practice towards EBM among healthcare professionals. It was also recommended to enhance internet access and set mechanisms to provide technical support at health facilities.

Lack of systematicity in research prioritisation processes - a scoping review of evidence syntheses

BACKGROUND

A systematically and transparently prepared research priority-setting process within a specific scientific area is essential in order to develop a comprehensive and progressive evidence-based approach that will have a substantial societal impact on the site of interest. On the basis of two consensus workshops, the authors suggest the following methods for all such processes: use of experts, stakeholder involvement, literature review, and ranking.

OBJECTIVES

The identification, categorisation, and discussion of methods for preparing a research prioritisation process.

METHODS

Eligibility criteria: Evidence synthesis includes original studies presenting a research prioritisation process and which listed the methods used to create a research prioritisation process. Only evidence syntheses related to health research were included.

DATA SOURCES

We searched the following electronic databases, without limiting by date or language: MEDLINE Ovid, Embase Ovid, Epistemonikos, and CINAHL EBSCO.

CHARTING METHODS

The methods used were mapped and broken down into different elements, and the use of the elements was determined. To support the mapping, (A) all of the elements were collapsed into unique categories, and (B) four essential categories were selected as crucial to a successful research prioritisation process.

RESULTS

Twelve evidence syntheses were identified, including 416 original studies. The identification and categorisation of methods used resulted in 13 unique categories of methods used to prepare a research agenda.

CONCLUSION

None of the identified categories was used in all of the original studies. Surprisingly, all four of the essential categories were used in only one of the 416 original studies identified. There is seemingly no international consensus on which methods to use when preparing a research prioritisation process.

PROTOCOL REGISTRATION

The protocol was registered in Open Science Framework ( https://osf.io/dygz8/ ).

Embedding Research on Implementation of Primary Health Care Systems Strengthening: A Commentary on Collaborative Experiences in Ethiopia, Ghana, and Mozambique

Achieving universal health care coverage requires the adoption of primary health care policies and delivery strategies that are evidence based. Although this has been confronted by manifold challenges, particularly in the health systems of sub-Saharan Africa, there are promising approaches for accomplishing this objective. Salient among these is embedding implementation research (i.e., the study of methods to promote the systematic uptake of evidence-based interventions (EBIs) into routine practice) into policy making and implementation processes. Since 2007, the African Health Initiative of the Doris Duke Charitable Foundation supported partnerships that strengthened primary health systems and policy implementation in 7 countries in sub-Saharan Africa using the embedded implementation research as a core strategy. This programmatic review and analysis aims to identify the core features and processes that characterized how the partnerships operationalized the embedded implementation research approach and understand the factors that helped and constrained partnerships' effective use of this approach. For this, we drew upon findings from a desk review that consisted of 30 examples of embedded implementation research conducted by 3 African Health Initiative partnerships between 2016 and 2021 in Ethiopia, Ghana, and Mozambique. In addition, we conducted and analyzed 13 in-depth interviews with embedded implementation research stakeholders of the 3 projects. Core features and processes of embedded implementation research were: (1) the leadership role of policy decision makers and implementation leaders; (2) positioning research with program implementation at multiple levels of health systems; (3) multidisciplinary and multisectoral partnerships; (4) focus on research capacity building; and (5) real-time feedback loops and knowledge translation. Factors influencing the effectiveness of the embedded implementation research experiences involved: (1) the implementation climate and leadership; (2) opportunities and capacities to circulate and absorb new information; and (3) stakeholders' baseline knowledge and embedded scientists' identification within their organizations.

Mapping and determinants of consumption of egg and/or flesh foods and zero vegetables or fruits among young children in SSA

Zero vegetable or fruit and egg and/or flesh foods are the latest indicators for assessing infant and young child feeding practices. Understanding national and subnational heterogeneity and regional clustering in children with SSA is becoming increasingly essential for geographic targeting and policy prioritization. Geographical case identification, determinants, and impacts were all investigated. SSA children's consumption of vegetable or fruit, egg and/or flesh food, and both were low. In SSA, some portions of the Southern, South direction of the Western and Central regions have a lower weight of all bad conditions than others, although children continue to suffer in considerable numbers in all disadvantage circumstances. Children under the age of 1 year, from rural areas, uneducated families, and low income were all disadvantaged by both feeding techniques. To improve child nutrition status, multisectoral collaboration is essential. This framework allows for the tracking, planning, and implementation of nutritional treatments.

Prioritising child health and maternity evidence-based interventions or service models: a stakeholder-driven process

Aim

A UK programme, led by the National Institute for Health Research (NIHR) (https://www.nihr.ac.uk) and coordinated by Applied Research Collaborations (ARC), (https://www.nihr.ac.uk/explore-nihr/support/collaborating-in-applied-health-research.htm) aimed to identify and select evidence-based, implementation-ready service innovations for evaluation. The programme focused on seven areas of health provision. We report on a prioritisation process designed to identify and assess innovations in one of these areas: child and maternal health (CH&M).

Methods

We developed a three-stage, online, stakeholder driven process to 1) identify, 2) assess and prioritise and 3) select evidence-based interventions or service models, using crowdsourcing to identify projects and the APEASE criteria to assess and select projects. A brief evidence review was conducted for all initial suggestions to identify those with the largest evidence-base to take forward for ranking by stakeholders. Stakeholder workshops considered and ranked these suggestions using the APEASE criteria. We then conducted in-depth evidence reviews for the highest ranked suggestions. The Project Management Group and Advisory Board used these reviews and the APEASE criteria to select the final projects.

Results

We received 32 initial suggestions from a range of clinicians, practitioners and researchers. Fourteen of the most evidence-based suggestions were considered and ranked at four themed stakeholder workshops. Nine suggestions were ranked for further in-depth evidence review and a final four projects were selected for implementation evaluation using the APEASE criteria. These were: 1. Maternal Mental Health Services Multidisciplinary Teams 2. Early years tooth brushing programme 3. Trauma-focused CBT for young people in care and 4. Independent Domestic Violence Advisors in maternity settings. Feedback from participants suggested that having public representatives participating in all stakeholder meetings, rather than being consulted separately, focused discussions clearly on patient benefit rather than research aims.

Conclusions

The stakeholder-driven process achieved its aim of identifying, prioritising and assessing and selecting, evidence-based projects for wider implementation and evaluation. The concurrent process could be adapted by other researchers or policy makers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08110-2.

Research priority setting in obesity: a systematic review

AIM

Obesity research priority setting, if conducted to a high standard, can help promote policy-relevant and efficient research. Therefore, there is a need to identify existing research priority setting studies conducted in the topic area of obesity and to determine the extent to which they followed good practice principles for research priority setting.

METHOD

Studies examining research priority setting in obesity were identified through searching the MEDLINE, PBSC, CINAHL, PsycINFO databases and the grey literature. The nine common themes of good practice in research priority setting were used as a methodological framework to evaluate the processes of the included studies. These were context, use of a comprehensive approach, inclusiveness, information gathering, planning for implementation, criteria, methods for deciding on priorities, evaluation and transparency.

RESULTS

Thirteen articles reporting research prioritisation exercises conducted in different areas of obesity research were included. All studies reported engaging with various stakeholders such as policy makers, researchers and healthcare professionals. Public involvement was included in six studies. Methods of research prioritisation commonly included both Delphi and nominal group techniques and surveys. None of the 13 studies fulfilled all nine of the good practice criteria for research priority setting, with the most common limitations including not using a comprehensive approach and lack of inclusivity and evaluating on their processes.

CONCLUSION

There is a need for research priority setting studies in obesity to involve the public and to evaluate their exercises to ensure they are of high quality.

Intravenous Amoxicillin Plus Intravenous Gentamicin for Children with Severe Pneumonia in Bangladesh: An Open-Label, Randomized, Non-Inferiority Controlled Trial

The World Health Organization (WHO) recommends intravenous (IV) ampicillin and gentamicin as first-line therapy to treat severe pneumonia in children under five years of age. Ampicillin needs to be administered at a six-hourly interval, which requires frequent nursing intervention and bed occupancy for 5-7 days, limiting its utility in resource-poor settings. We compared the efficacy of IV amoxicillin over IV ampicillin, which is a potential alternative drug in treating severe pneumonia in children between 2-59 months. We conducted an unblinded, randomized, controlled, non-inferiority trial in the Dhaka hospital of icddr,b from 1 January 2018 to 31 October 2019. Children from 2-59 months of age presenting with WHO defined severe pneumonia with respiratory danger signs were randomly assigned 1:1 to either 50 mg/kg ampicillin or 40 mg/kg amoxicillin per day with 7.5 mg/kg gentamicin. The primary outcome was treatment failure as per the standard definition of persistence of danger sign(s) of severe pneumonia beyond 48 h or deterioration within 24 h of therapy initiation. The secondary outcomes were: (i) time required for resolution of danger signs since enrolment, (ii) length of hospital stay, (iii) death during hospitalization, and (iv) rate of nosocomial infections. Among 308 enrolled participants, baseline characteristics were similar among the two groups. Sixty-two (20%) children ended up with treatment failure, 21 (14%) in amoxicillin, and 41 (27%) in ampicillin arm, which is statistically significant (relative risk [RR] 0.51, 95% CI 0.32-0.82; p = 0.004). We reported 14 deaths for serious adverse events, 4 (3%) and 10 (6%) among amoxicillin and ampicillin arm, respectively. IV amoxicillin and IV gentamicin combination is not inferior to combined IV ampicillin and IV gentamicin in treating severe pneumonia in under-five children in Bangladesh. Considering the less frequent dosing and more compliance, IV amoxicillin is a better choice for treating children with severe pneumonia in resource-limited settings.

Involving stakeholders in research priority setting: a scoping review

BACKGROUND

This scoping review provides a thorough analysis of how stakeholders have so far been involved in research priority setting. The review describes, synthesizes, and evaluates research priority setting projects not only for the field of health-as previous reviews have done-but does so on a much broader scale for any research area.

METHODS

A comprehensive electronic literature search was conducted in the databases PubMed, Scopus, and Web of Science. Reflecting the importance of grey literature, Google Scholar and relevant websites were also screened for eligible publications. A computational approach was then used for the study selection. The final screening for inclusion was done manually.

RESULTS

The scoping review encompasses 731 research priority setting projects published until the end of 2020. Overall, the projects were conducted within the realm of 50 subject areas ranging from agriculture and environment over health to social work and technology. Key learnings include that nearly all priority setting projects aimed to identify research priorities for the field of health (93%), particularly for nursing and care, cancer, pediatrics, and mental, behavioral and neurodevelopmental disorders. Only 6% of the projects were not health-related and 1% identified research priorities at the interface between health and a non-health area. Over time, 30 different stakeholder groups took part in research priority setting. The stakeholders most frequently asked to identify research priorities were doctors, patients, academics/researchers, nurses, allied healthcare professionals, family members, friends, and carers. Nearly two thirds of all projects have been conducted in Europe and North America. Overall, only 9% of the projects emphasized the importance of stakeholders in their goals and rationales and actively involved them. In around a quarter of the projects, stakeholders deliberated on their research priorities throughout the entire process.

CONCLUSION

By mapping out the complex landscape of stakeholder involvement in research priority setting, this review guides future efforts to involve stakeholders effectively, inclusively, and transparently, which in turn may increase the overall value of research for society. As a practical addition to this review, the first worldwide research priority setting database was created: https://ois.lbg.ac.at/en/project-database . The database contains all the projects analyzed for this review and is constantly updated with the latest published research priority setting projects.

Improving Food Systems: A Participatory Consultation Exercise to Determine Priority Research and Action Areas in Viet Nam

With increased burden of malnutrition on global health, there is a need to set clear and transparent priorities for action in food systems at a global and local level. While priority settings methods are available for several adjacent domains, such as nutrition and health policies, setting priorities for food system research has not been documented and streamlined. The challenges involve food systems' multisector, multi-stakeholder and multi-outcome nature. Where data exists, it is not easy to aggregate data from across food system dimensions and stakeholders to make an informed analysis of the overall picture of the food system, as well as current and potential food system trade-offs to inform research and policy. Once research priorities are set, they risk staying on paper and never make their ways to concrete outputs and outcomes. In this paper, we documented and assessed the inclusive process of setting research priorities for a local food system, taking Vietnamese food systems as a case study. From this exercise, we examined how priority setting for food systems research could learn from and improve upon earlier priority setting research practices in other domains. We discussed the lessons for research and policies in local food systems, such as the need for a concrete follow-up plan accompanying the priority setting process.

Putting the local back into planning-experiences and perceptions of state and district health functionaries of seven aspirational districts in India on an innovative planning capacity building approach

District functionaries have ostensibly a major responsibility to develop evidence based plans. However, this responsibility is not commensurate with skills and expertise among functionaries in many Indian states. Vriddhi project-technical partner of the government, developed a planning tool for maternal and neonatal health programmes, called RMNCH + A Action Agenda using Strategic Approach (RAASTA), which was introduced in a workshop format in two states and attended by program officers. Qualitative feedback was obtained from selected participants to understand their experience of the workshop and of the planning tool. It emerged that previous planning process had little application of local evidence based solutions. Participants appreciated the alternative approach as RAASTA equipped them to use local evidence. Several action plans derived at the workshop were included in the state plan. At the same time, apprehension was expressed by participants about translating their learnings to practical application as planning was not a central priority in their scheme of duties and tasks. Enhanced support from states in refreshing district planners' skills would be an important step. One state government has scaled up the RAASTA tool while an electronic version is being developed for future use as it demonstrates great potential to equip and aid district officials in developing evidence based plans.

Child health and the implementation of Community and District-management Empowerment for Scale-up (CODES) in Uganda: a randomised controlled trial

Introduction

Uganda’s district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services.

Methods

A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger.

Results

Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers’ ability to implement solutions identified through CODES.

Conclusion

Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model’s suitability for health systems strengthening in Uganda and other decentralised contexts.

Trial registration number

ISRCTN15705788.

Using evidence, expert opinion and epidemiological model to understand pathways to survival and mortality: The Pathways to Survival (PATHS) Tool

Background

The reasons why episodes of illness can lead to fatal outcomes in affected persons in low resource settings are numerous and complex. A tool that allows policy makers to better understand those complexities could be useful to improve success of programmes that are implemented globally to reduce mortality.

Methods

We developed a “Pathways to Survival” (PATHS) tool: an epidemiological model using decision trees, available evidence and expert opinion. PATHS visualises the “architecture” of mortality in the population by following the entire population cohort over a certain period of time. It explains how initially healthy persons progress through health systems to lethal outcomes at the end of the specified time period. We developed an illustrative example based on the 136 million newborns and an estimated 907 000 deaths from newborn sepsis in the year 2008. This allowed us to develop an epidemiological model that described pathways to deaths from neonatal sepsis globally in 2010.

Results

The model described the “status quo’ situation in 2010 with 907 000 deaths to allow an assessment of the potential impact and feasibility of different interventions and programmes at various level of health systems in reducing this cause of mortality. A useful model should incorporate both a ‘horizontal’ and a ‘vertical’ component. The ‘horizontal’ would track the progress of all neonates globally through time, ie, their first 28 days of life, and separate them into different ‘pathways’ every time a change in their risk of dying from neonatal infection occurs because of their specific contextual circumstances. The ‘vertical’ would track their position within the health systems of their countries and separate them into different categories based on the ability of health system to intervene and reduce their risk of dying. Based on those requirements, PATHS tool was developed which is based on decision trees where different “branches” of the trees are associated with varying case-fatality rates.

Conclusions

The application of the PATHS tool on the example of newborn sepsis revealed that novel diagnostic tests could save many lives, so we should continue to invest in them to improve their validity, deliverability and affordability. However, PATHS showed that investments in better diagnostics have limited impact unless they are coupled with improvements of the context. Programs for parental education improve compliance and care seeking. Promoting legislation change to empower community health workers (CHWs) to actively engage in prevention, diagnosis and care also makes a difference, as well as programs for training CHWs to use diagnostic tests and administer treatments correctly. Care-seeking behaviour can also be improved through programs of conditional cash transfers. Finally, PATHS demonstrated that improving access to primary and secondary health care for everyone is the most powerful contextual change.

Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings

Background

An estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are women and children. Prioritizing a global research agenda to inform guidance, service delivery, access to and quality of services is essential to improve the survival and health of women, children and adolescents in humanitarian settings.

Method

A mixed-methods design was adapted from the Child Health and Nutrition Research Initiative (CHNRI) methodology to solicit priority research questions across the sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) domains in humanitarian settings. The first step (CHNRI) involved data collection and scoring of perceived priority questions, using a web-based survey over two rounds (first, to generate the questions and secondly, to score them). Over 1000 stakeholders from across the globe were approached; 177 took part in the first survey and 69 took part in the second. These research questions were prioritized by generating a research prioritization score (RPP) across four dimensions: answerability, program feasibility, public health relevance and equity. A Delphi process of 29 experts followed, where the 50 scored and prioritized CHRNI research questions were shortlisted. The top five questions from the CHNRI scored list for each SRMNCAH domain were voted on, rendering a final list per domain.

Results

A total of 280 questions were generated. Generated questions covered sexual and reproductive health (SRH) (n = 90, 32.1%), maternal health (n = 75, 26.8%), newborn health (n = 42, 15.0%), child health (n = 43, 15.4%), and non-SRH aspects of adolescent health (n = 31, 11.1%). A shortlist of the top ten prioritized questions for each domain were generated on the basis of the computed RPPs. During the Delphi process, the prioritized questions, based on the CHNRI process, were further refined. Five questions from the shortlist of each of the SRMNCAH domain were formulated, resulting in 25 priority questions across SRMNCAH. For example, one of the prioritized SRH shortlisted and prioritized research question included: “What are effective strategies to implement good quality comprehensive contraceptive services (long-acting, short-acting and EC) for women and girls in humanitarian settings?”

Conclusion

Data needs, effective intervention strategies and approaches, as well as greater efficiency and quality during delivery of care in humanitarian settings were prioritized. The findings from this research provide guidance for researchers, program implementers, as well as donor agencies on SRMNCAH research priorities in humanitarian settings. A global research agenda could save the lives of those who are at greatest risk and vulnerability as well as increase opportunities for translation and innovation for SRMNCAH in humanitarian settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00353-w.

Priority Setting in the Polish Health Care System According to Patients' Perspective

Identification of health priorities is concerned with equitable distribution of resources and is an important part of strategic planning in the health care system. The aim of this article is to describe health priorities in the Polish health care system from the patients’ perspective. The study included 533 patients hospitalized in the Lodz region. The average age of the respondents was 48.5 years and one third (36.6%) had university education. Most of the respondents (64.9%) negatively assessed the functioning of the health care system in Poland. Most of them claimed the following aspects require improvements: financing health services (85.8%), determining priorities in health care (80.3%), the role of health insurance (80.3%), and medical education (70.8%). Over 70% of the respondents agreed the role of politicians in designing and implementing health system reforms should be limited. The fact that the respondents so negatively assessed the Polish health care system implies there is a need for full discussion on redefining health priorities.

Political prioritization and the competing definitions of adolescent pregnancy in Kenya: An application of the Public Arenas Model

BACKGROUND

Approximately one in every five adolescent girls in Kenya has either had a live birth or is pregnant with her first child. There is an urgent need to understand the language and symbols used to represent adolescent pregnancy, if the current trend in adolescent pregnancy is to be reversed. Agreement on the definition of a societal problem is an important precursor to a social issue's political prioritization and priority setting.

METHODS

We apply the Public Arenas Model to appraise the environments, definitions, competition dynamics, principles of selection and current actors involved in problem-solving and prioritizing adolescent pregnancy as a policy issue. Using a focused ethnographic approach, we undertook semi-structured interviews with 14 members of adolescent sexual reproductive health networks at the national level and conducted thematic analysis of the interviews.

FINDINGS

We found that existing definitions center around adolescent pregnancy as a "disease" that needs prevention and treatment, socially deviant behaviour that requires individual agency, and a national social concern that drains public resources and therefore needs to be regulated. These competing definitions contribute to the rarity of the topic achieving traction within the political agenda and contribute to conflicting solutions, such as lowering the legal age of consenting to sex, while limiting access to contraceptive information and services to minors.

CONCLUSION

This paper provides a timely theoretical approach to draw attention to the different competing definitions and subsequent divergent interpretations of the problem of adolescent pregnancy in Kenya. Adolescent reproductive health stakeholders need to be familiar with the existing definitions and deliberately reframe this important social problem for better political prioritization and resource allocation. We recommend a definition of adolescent pregnancy that cuts across different arenas, and leverages already existing dominant and concurrent social and economic issues that are already on the agenda table.

Determinants of technology use for a mobile health intervention across public health facilities in rural India: Protocol for implementation research

This paper presents a research protocol for implementation research (IR) to investigate contextual factors influencing the implementation of ASMAN mobile health intervention and their association with maternal, newborn, and child health outcomes. The IR will cover roughly 16-20 public health facilities across the states of Rajasthan and Madhya Pradesh in India. These facilities will be a sub-sample of 49 facilities covered separately under the outcome evaluation. The study employs a longitudinal mixed-methods multiple case study design with sequential data collection using constructs under the Consolidated Framework for Implementation Research (CFIR) across two phases. The first phase will be exploratory and use qualitative inquiry to contextualize the CFIR constructs. The second phase will employ a mixed-methods explanatory design with both validated and contextualized CFIR constructs and standard quantitative measures collected through outcome evaluation. Findings from this study will provide insights into factors that facilitate or impede the implementation of mobile health interventions and their association with MNCH outcomes in public health facilities in India.

Research Priorities in the Field of Patient Safety in Iran: Results of a Delphi Study

There is inadequate evidence to direct and support patient safety practice. Therefore, identifying research priorities in this field is relevant for many stakeholders. This study, which was built on the World Health Organization work, aimed to identify and prioritize research topics for patient safety in Iran. A 3-round Modified Delphi process was used. We purposefully recruited a panel of 45 policy makers, planners, health care managers and staff, and academic members with experience or expertise in patient safety research. A review of the literature was used to develop the first questionnaire, including 24 research topics. Respondents were asked to rate their agreement with each research topic and propose new topics. Based on the results of round 1, the second questionnaire was developed and the respondents were requested to rate 45 research topics and also put similar research topics in the same groups. Given the responses of round 2, the third questionnaire including a list of 45 research priorities categorized in 4 groups was developed. Respondents were asked to reflect their opinions. Content analysis was used to analyze round 1 data and descriptive statistics for round 2 and round 3 data. Forty-five identified research topics in round 1 prioritized and grouped in subsequent rounds. Among 4 research groups, the extent and epidemiology threatening patient safety group received the highest priority; and among research topics, adverse drug events and its epidemiology were the top-ranked research priorities. In addition to the priorities identified in previous work, more research priorities that reflect important and needed issue related to patient safety, especially in Iran, were recognized. This priority research list, which most stakeholders agree with it, can serve as a blueprint for patient safety research.

Non-communicable diseases research output in the Eastern Mediterranean region: an overview of systematic reviews

BACKGROUND

Rates of non-communicable diseases (NCDs) are rapidly rising in the Eastern Mediterranean Region (EMR). Systematic reviews satisfy the demand from practitioners and policy makers for prompt comprehensive evidence. The aim of this study is to review trends in NCD systematic reviews research output and quality by time and place, describe design and focus, and examine gaps in knowledge produced.

METHODS

Using the Montori et al. systematic reviews filter, MeSH and keywords were applied to search Medline Ovid, Cochrane Central and Epistemonikos for publications from 1996 until 2015 in the 22 countries of the EMR. The 'Measurement Tool to Assess Systematic Reviews', AMSTAR, was used to assess the methodological quality of the papers.

RESULTS

Our search yielded 2439 papers for abstract and title screening, and 89 papers for full text screening. A total of 39 (43.8%) studies included meta-analysis. Most of the papers were judged as being of low AMSTAR quality (83.2%), and only one paper was judged as being of high AMSTAR quality. Whilst annual number of papers increased over the years, the growth was mainly attributed to an increase in low-quality publications approaching in 2015 over four times the number of medium-quality publications. Reviews were significantly more likely to be characterized by higher AMSTAR scores (±SD) when meta-analysis was performed compared to when meta-analysis was not performed (3.4 ± 1.5 vs 2.6 ± 2.0; p-value = 0.034); and when critical appraisal of the included studies was conducted (4.3 ± 2.3 vs 2.5 ± 1.5; p-value = 0.004). Most of the reviews focused on cancer and diabetes as an outcome (25.8% and 24.7%, respectively), and on smoking, dietary habits and physical activity as exposures (15.7%, 12.4%, 9.0%, respectively). There was a blatant deficit in reviews examining associations between behaviors and physiologic factors, notably metabolic conditions.

CONCLUSIONS

Systematic reviews research in the EMR region are overwhelmingly of low quality, with gaps in the literature for studies on cardiovascular disease and on associations between behavioral factors and intermediary physiologic parameters. This study raises awareness of the need for high-quality evidence guided by locally driven research agenda responsive to emerging needs in countries of the EMR.

The relationship between government research funding and the cancer burden in South Korea: implications for prioritising health research

Background

In this study, we aimed to assess health research funding allocation in South Korea by analysing the relationship between government funding and disease burden in South Korea, specifically focusing on cancers.

Methods

The relationship between research funding and the cancer burden, measured in disability-adjusted life-years (DALYs), was analysed using a linear regression method over a 10-year interval. Funding information on 25 types of cancer was obtained from the National Science and Technology Information Service portal in South Korea. Measures of cancer burden were obtained from Global Burden of Disease studies. The funding predictions were derived from regression analysis and compared with actual funding allocations. In addition, we evaluated how the funding distribution reflected long-term changes in the burden and the burden specific to South Korea compared with global values.

Results

Korean funding in four periods, 2005–2007, 2008–2010, 2011–2013 and 2015–2017, were associated with the cancer burden in 2003, 2006, 2009 and 2013, respectively. For DALYs, the correlation coefficients were 0.79 and 0.82 in 2003 and 2013, respectively, which were higher than the values from other countries. However, the changes in DALYs (1990–2006) were not associated with the funding changes (from 2005 to 2007 to 2015–2017). In addition, the value differences between Korean and global DALYs were not associated with Korean government research funding.

Conclusions

Although research funding was associated with the cancer burden in South Korea during the last decade, the distribution of research funds did not appropriately reflect the changes in burden nor the differences between the South Korean and global burden levels. The policy-makers involved in health research budgeting should consider not only the absolute burden values for singular years but also the long-term changes in burden and the country-specific burden when they prioritise public research projects.

Challenges to generating political prioritization for adolescent sexual and reproductive health in Kenya: A qualitative study

BACKGROUND

Despite the high burden of adverse adolescent sexual and reproductive health (SRH) outcomes, it has remained a low political priority in Kenya. We examined factors that have shaped the lack of current political prioritization of adolescent SRH service provision.

METHODS

We used the Shiffman and Smith policy framework consisting of four categories-actor power, ideas, political contexts, and issue characteristics-to analyse factors that have shaped political prioritization of adolescent SRH. We undertook semi-structured interviews with 14 members of adolescent SRH networks between February and April 2019 at the national level and conducted thematic analysis of the interviews.

FINDINGS

Several factors hinder the attainment of political priority for adolescent SRH in Kenya. On actor power, the adolescent SRH community was diverse and united in adoption of international norms and policies, but lacked policy entrepreneurs to provide strong leadership, and policy windows were often missed. Regarding ideas, community members lacked consensus on a cohesive public positioning of the problem. On issue characteristics, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. Pertaining to political contexts, sectoral funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination and overall inefficiency. However, the SRH community has several strengths that augur well for future political support. These include the diverse multi-sectoral background of its members, commitment to improving adolescent SRH, and the potential to link with other health priorities such as maternal health and HIV/AIDS.

CONCLUSION

In order to increase political attention to adolescent SRH in Kenya, there is an urgent need for policy actors to: 1) create a more cohesive community of advocates across sectors, 2) develop a clearer public positioning of adolescent SRH, 3) agree on a set of precise approaches that will resonate with the political system, and 4) identify and nurture policy entrepreneurs to facilitate the coupling of adolescent SRH with potential solutions when windows of opportunity arise.

Priority setting for new systematic reviews: processes and lessons learned in three regions in Africa

Priority setting to identify topical and context relevant questions for systematic reviews involves an explicit, iterative and inclusive process. In resource-constrained settings of low-income and middle-income countries, priority setting for health related research activities ensures efficient use of resources. In this paper, we critically reflect on the approaches and specific processes adopted across three regions of Africa, present some of the outcomes and share the lessons learnt while carrying out these activities. Priority setting for new systematic reviews was conducted between 2016 and 2018 across three regions in Africa. Different approaches were used: Multimodal approach (Central Africa), Modified Delphi approach (West Africa) and Multilevel stakeholder discussion (Southern-Eastern Africa). Several questions that can feed into systematic reviews have emerged from these activities. We have learnt that collaborative subregional efforts using an integrative approach can effectively lead to the identification of region specific priorities. Systematic review workshops including discussion about the role and value of reviews to inform policy and research agendas were a useful part of the engagements. This may also enable relevant stakeholders to contribute towards the priority setting process in meaningful ways. However, certain shared challenges were identified, including that emerging priorities may be overlooked due to differences in burden of disease data and differences in language can hinder effective participation by stakeholders. We found that face-to-face contact is crucial for success and follow-up engagement with stakeholders is critical in driving acceptance of the findings and planning future progress.

How can we improve priority-setting for investments in health research? A case study of tuberculosis

Background

Although enhanced priority-setting for investments in health research for development is essential to tackling inequalities in global health, there is a lack of consensus on an optimal priority-setting process. In light of the current surge in tuberculosis (TB) research investment, we use TB as a case study.

Methods

We investigated two critical aspects of a research prioritisation process, namely the criteria that should be used to rank alternative research options and which stakeholders should be involved in priority-setting. We conducted semi-structured interviews with 24 key informants purposively selected from four distinct groups – academia, funding bodies, international policy or technical agencies, and national disease control programmes. Interview transcripts were analysed verbatim using a framework approach. We also performed a systematic analysis of seven diverse TB research prioritisation processes.

Results

There was consensus that well-defined and transparent criteria for assessing research options need to be agreed at the outset of any prioritisation process. It was recommended that criteria should select for research that is likely to have the greatest public health impact in affected countries rather than research that mainly fills scientific knowledge gaps. Some interviewees expressed strong views about the need – and reluctance – to make politically challenging decisions that place some research areas at a lower priority for funding. The importance of taking input from stakeholders from countries with high disease burden was emphasised; such stakeholders were notably absent from the majority of prioritisation processes we analysed.

Conclusions

This study indicated two critical areas for improvement of research prioritisation processes such that inequalities in health are better addressed – the need to deprioritise some research areas to generate a specific and meaningful list for investment, and greater involvement of experts working in high disease-burden countries.

Identifying priorities for HIV-associated tuberculosis research through the WHO guidelines process

PURPOSE OF REVIEW

Guidelines developed by the WHO aim to provide recommendations to support best practice in health delivery, with a focus on low-income and middle-income countries. As part of the guideline development process, critical knowledge gaps are identified and one of the core functions of WHO guidelines is to set forth priorities for future research. A review of research priorities identified through the WHO guideline development has recently been promoted as one approach to building an overarching priority research agenda in a given area. This paper outlines priorities for HIV-associated TB research identified in WHO HIV and TB guidelines published since 2015.

RECENT FINDINGS

Nine guidelines were reviewed and 29 priority research questions were identified. Research priorities were identified for prevention of HIV-associated TB (11 questions), screening of latent and active TB in people living with HIV (six questions), treatment of drug sensitive (four questions), and drug-resistant (two questions) TB, and treatment of HIV in people coinfected with TB (three questions).

SUMMARY

Multiple approaches to defining priority research questions for health research exist. Research priorities that arise from the WHO guideline development process are limited to those areas for which guidelines are developed. One strength of this approach is that it takes as a starting point a desire to make actionable recommendations for policy makers. WHO is working to further refine the formulation of research questions within the guideline development process.

What matters most to patients about primary healthcare: mixed-methods patient priority setting exercises within the PREFeR (PRioritiEs For Research) project

OBJECTIVES

To identify patient-generated priority topics for future primary care research in British Columbia (BC), Canada within a diverse patient population.

DESIGN

Mixed-methods priority setting exercises framed by the dialogue model, using the nominal group technique (rank-ordered scoring) and province-wide online surveys capturing importance ratings of the top 10 primary healthcare topics from patients and primary care providers.

SETTING

BC, Canada.

PARTICIPANTS

Topic identification was completed by 10 patient partners (7 female, 3 male) from the BC Primary Health Care Research Network Patient Advisory; online surveys were completed by 464 patients and 173 primary care providers.

RESULTS

The 10 members recruited to the patient advisory provided over 80 experiences of what stood out for them in BC primary care, which were grouped thematically into 18 topics, 10 of which were retained in province-wide surveys. Top-rated survey topics for both patients (n=464) and providers (n=173) included being unable to find a regular family doctor/other primary healthcare provider, support for living with chronic conditions, mental health resources and information sharing, including electronic medical records. However, all 10 topics were rated important, on average, by both groups.

CONCLUSIONS

The current project activities demonstrate the feasibility of including patients in priority setting exercises for primary healthcare in general, rather than focusing on a condition-specific population or disease area. There was considerable overlap between patient-generated topics and topics previously identified by other stakeholders, but patients identified two additional topics (mental health resources, improve and strengthen patient-provider communication). More similarities than differences in topic importance between patients and providers emerged in the online surveys. The project activities that follow (rapid literature reviews, multistakeholder dialogue) will highlight under-researched topics and inform the development of specific research questions.

Decision-making in district health planning in Uganda: does use of district-specific evidence matter?

BACKGROUND

In a decentralised health system, district health managers are tasked with planning for health service delivery, which should be evidence based. However, planning in low-income countries such as Uganda has been described as ad hoc. A systematic approach to the planning process using district-specific evidence was introduced to district health managers in Uganda. However, little is known about how the use of district-specific evidence informs the planning process. In this study, we investigate how the use of this evidence affects decision-making in the planning process and how stakeholders in the planning process perceived the use of evidence.

METHODS

A convergent parallel mixed-methods study design was used, where quantitative data was collected from district health annual work plans for the financial years 2012/2013, 2013/2014, 2014/2015 and 2015/2016 as well as from bottleneck analysis reports for 2012, 2013, 2014 and 2015. Qualitative data was collected through semi-structured interviews with key informants from the two study districts.

RESULTS

District managers reported that they were able to produce more robust district annual work plans when they used the systematic approach of using district-specific evidence. Approximately half of the prioritised activities in the annual work plans were evidence based. Procurement and logistics, training, and support supervision activities were the most prioritised activities. Between 4% and 5.5% of the total planned expenditure was for child survival, of which 47% to 94% was from donor and other partner contributions.

CONCLUSION

District-specific evidence and a structured process for its use to prioritise activities and make decisions in the planning process at the district level helped systematise the planning process. However, the reported limited decision and fiscal space, inadequate funding and high dependency on donor funding did not always allow for the use of district-specific evidence in the planning process.

A systematic review of frameworks for the interrelationships of mental health evidence and policy in low- and middle-income countries

BACKGROUND

The interrelationships between research evidence and policy-making are complex. Different theoretical frameworks exist to explain general evidence-policy interactions. One largely unexplored element of these interrelationships is how evidence interrelates with, and influences, policy/political agenda-setting. This review aims to identify the elements and processes of theories, frameworks and models on interrelationships of research evidence and health policy-making, with a focus on actionability and agenda-setting in the context of mental health in low- and middle-income countries (LMICs).

METHODS

A systematic review of theories was conducted based on the BeHeMOTh search method, using a tested and refined search strategy. Nine electronic databases and other relevant sources were searched for peer-reviewed and grey literature. Two reviewers screened the abstracts, reviewed full-text articles, extracted data and performed quality assessments. Analysis was based on a thematic analysis. The included papers had to present an actionable theoretical framework/model on evidence and policy interrelationships, such as knowledge translation or evidence-based policy, specifically target the agenda-setting process, focus on mental health, be from LMICs and published in English.

RESULTS

From 236 publications included in the full text analysis, no studies fully complied with our inclusion criteria. Widening the focus by leaving out 'agenda-setting', we included ten studies, four of which had unique conceptual frameworks focusing on mental health and LMICs but not agenda-setting. The four analysed frameworks confirmed research gaps from LMICs and mental health, and a lack of focus on agenda-setting. Frameworks and models from other health and policy areas provide interesting conceptual approaches and lessons with regards to agenda-setting.

CONCLUSION

Our systematic review identified frameworks on evidence and policy interrelations that differ in their elements and processes. No framework fulfilled all inclusion criteria. Four actionable frameworks are applicable to mental health and LMICs, but none specifically target agenda-setting. We have identified agenda-setting as a research theory gap in the context of mental health knowledge translation in LMICs. Frameworks from other health/policy areas could offer lessons on agenda-setting and new approaches for creating policy impact for mental health and to tackle the translational gap in LMICs.

Priority-setting in public health research funding organisations: an exploratory qualitative study among five high-profile funders

Background

Priority-driven funding streams for population and public health are an important part of the health research landscape and contribute to orienting future scholarship in the field. While research priorities are often made public through targeted calls for research, less is known about how research funding organisations arrive at said priorities. Our objective was to explore how public health research funding organisations develop priorities for strategic extramural research funding programmes.

Methods

Content analysis of published academic and grey literature and key informant interviews for five public and private funders of public health research in the United Kingdom, Australia, the United States and France were performed.

Results

We found important distinctions in how funding organisations processed potential research priorities through four non-sequential phases, namely idea generation, idea analysis, idea socialisation and idea selection. Funders generally involved the public health research community and public health decision-makers in idea generation and socialisation, but other groups of stakeholders (e.g. the public, advocacy organisations) were not as frequently included.

Conclusions

Priority-setting for strategic funding programmes in public health research involves consultation mainly with researchers in the early phase of the process. There is an opportunity for greater breadth of participation and more transparency in priority-setting mechanisms for strategic funding programmes in population and public health research.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0335-8) contains supplementary material, which is available to authorized users.

A comparison between health research output and burden of disease in Arab countries: evidence from Palestine

BACKGROUND

Research conducted on conditions responsible for the greatest disease burden should be given the highest priority, particularly in resource-limited settings. The present study aimed to assess the research output in relation to disease burden in Palestine and to identify the conditions which are under- or over-investigated, if any.

METHODS

We searched PubMed and Scopus for reports of original research relevant to human health or healthcare authored by researchers affiliated with Palestinian institutions and published between January 2000 and December 2015. We categorised the condition studied in included articles using the Global Burden of Disease (GBD) taxonomy. Data regarding burden of disease (percentage of deaths and disability-adjusted life years (DALYs)) was obtained from the Palestine profile in the GBD study. We examined the degree of discordance between the observed number of published articles for each disease/condition with the expected number based on the proportion of disease burden of that disease/condition.

RESULTS

Our search identified 2469 potentially relevant records, from which 1650 were excluded following the screening of titles and abstracts. Of the remaining 819 full-text articles, we included 511 in our review. Communicable (infectious) diseases (n = 103; 20%) was the condition with the highest number of published studies. However, cancer (n = 15; 3%) and chronic respiratory diseases (n = 15; 3%) were the conditions with the lowest number of published studies. Research output was poorly associated with disease burden, irrespective of whether it was measured in terms of DALYs (rho = -0.116, P = 0.7) or death (rho = 0.217, P = 0.5). Cardiovascular disease, cancer, and maternal and neonatal deaths accounted for more than two-thirds of the total deaths in Palestine (67%), but were infrequently addressed (23%) in published articles.

CONCLUSIONS

There is evidence of research waste measured by a mismatch between the health burden of certain diseases/conditions and the number of published research reports on those diseases/conditions in Palestine. A national research priority-setting agenda should be developed to meet the local community's need for quality evidence to implement independent and informed health policies.

Research priority-setting: reproductive health in the occupied Palestinian territory

BACKGROUND

Occupied Palestinian territory (oPt) is an authority with limited resources. Therefore, research conducted in such a setting should be prioritized and coordinated to follow a national research agenda. This study aims to produce a research agenda for reproductive health in the oPt that can be utilized by reproductive health stakeholders and contribute to the development of policy-based evidence to guide health practice.

METHODS

In the current study, we followed research prioritization methods developed by the World Health Organization-Child Health and Nutrition Research Initiative. Research questions were obtained from reproductive health experts in the oPt. The questions were then grouped into thematic areas which were prioritized by the reproductive health experts. Scores were calculated and sorted to define the top priority research areas.

RESULTS

A total of 232 research questions were prioritized by 30 reproductive health experts. Health system issues were the most addressed in the top 50 research questions. They included questions on the quality of services and health professionals' knowledge and continuous professional training. Adolescents' sexual and reproductive health and gender-based violence were rarely mentioned in the top 50 questions. The number of questions related to safe motherhood was around 50% followed by questions related to health system. Questions related to elderly women and menopause as well as reproductive system cancers were also within the top 50 ranked questions.

CONCLUSIONS

Priority research areas in reproductive health were identified for the oPt, which should be utilized by researchers with a focus on the high priority areas. Policy makers and funders should coordinate their efforts to ensure the production of research with value to the Palestinian context, in the most efficient way possible.

Study design and the estimation of the size of key populations at risk of HIV: lessons from Viet Nam

BACKGROUND

Estimation of the size of populations at risk of HIV is a key activity in the surveillance of the HIV epidemic. The existing framework for considering future research needs may provide decision-makers with a basis for a fair process of deciding on the methods of the estimation of the size of key populations at risk of HIV. This study explores the extent to which stakeholders involved with population size estimation agree with this framework, and thus, the study updates the framework.

METHODS

We conducted 16 in-depth interviews with key informants from city and provincial governments, NGOs, research institutes, and the community of people at risk of HIV. Transcripts were analyzed and reviewed for significant statements pertaining to criteria. Variations and agreement around criteria were analyzed, and emerging criteria were validated against the existing framework.

RESULTS

Eleven themes emerged which are relevant to the estimation of the size of populations at risk of HIV in Viet Nam. Findings on missing criteria, inclusive participation, community perspectives and conflicting weight and direction of criteria provide insights for an improved framework for the prioritization of population size estimation methods.

CONCLUSIONS

The findings suggest that the exclusion of community members from decision-making on population size estimation methods in Viet Nam may affect the validity, use, and efficiency of the evidence generated. However, a wider group of decision-makers, including community members among others, may introduce diverse definitions, weight and direction of criteria. Although findings here may not apply to every country with a transitioning economy or to every emerging epidemic, the principles of fair decision-making, value of community participation in decision-making and the expected challenges faced, merit consideration in every situation.

What is kangaroo mother care? Systematic review of the literature

BACKGROUND

Kangaroo mother care (KMC), often defined as skin-to-skin contact between a mother and her newborn, frequent or exclusive breastfeeding, and early discharge from the hospital has been effective in reducing the risk of mortality among preterm and low birth weight infants. Research studies and program implementation of KMC have used various definitions.

OBJECTIVES

To describe the current definitions of KMC in various settings, analyze the presence or absence of KMC components in each definition, and present a core definition of KMC based on common components that are present in KMC literature.

METHODS

We conducted a systematic review and searched PubMed, Embase, Scopus, Web of Science, and the World Health Organization Regional Databases for studies with key words "kangaroo mother care", "kangaroo care" or "skin to skin care" from 1 January 1960 to 24 April 2014. Two independent reviewers screened articles and abstracted data.

FINDINGS

We screened 1035 articles and reports; 299 contained data on KMC and neonatal outcomes or qualitative information on KMC implementation. Eighty-eight of the studies (29%) did not define KMC. Two hundred and eleven studies (71%) included skin-to-skin contact (SSC) in their KMC definition, 49 (16%) included exclusive or nearly exclusive breastfeeding, 22 (7%) included early discharge criteria, and 36 (12%) included follow-up after discharge. One hundred and sixty-seven studies (56%) described the duration of SSC.

CONCLUSIONS

There exists significant heterogeneity in the definition of KMC. A large number of studies did not report definitions of KMC. Skin-to-skin contact is the core component of KMC, whereas components such as breastfeeding, early discharge, and follow-up care are context specific. To implement KMC effectively development of a global standardized definition of KMC is needed.

Using the missed opportunity tool as an application of the Lives Saved Tool (LiST) for intervention prioritization

Background

The Missed Opportunity tool was developed as an application in the Lives Saved Tool (LiST) to allow users to quickly compare the relative impact of interventions. Global Financing Facility (GFF) investment cases have been identified as a potential application of the Missed Opportunity analyses in Democratic Republic of the Congo (DRC), Ethiopia, Kenya, and Tanzania, to use ‘lives saved’ as a normative factor to set priorities.

Methods

The Missed Opportunity analysis draws on data and methods in LiST to project maternal, stillbirth, and child deaths averted based on changes in interventions’ coverage. Coverage of each individual intervention in LiST was automated to be scaled up from current coverage to 90% in the next year, to simulate a scenario where almost every mother and child receive proven interventions that they need. The main outcome of the Missed Opportunity analysis is deaths averted due to each intervention.

Results

When reducing unmet need for contraception is included in the analysis, it ranks as the top missed opportunity across the four countries. When it is not included in the analysis, top interventions with the most total deaths averted are hospital-based interventions such as labor and delivery management in the CEmOC and BEmOC level, and full treatment and supportive care for premature babies, and for sepsis/pneumonia.

Conclusions

The Missed Opportunity tool can be used to provide a quick, first look at missed opportunities in a country or geographic region, and help identify interventions for prioritization. While it is a useful advocate for evidence-based priority setting, decision makers need to consider other factors that influence decision making, and also discuss how to implement, deliver, and sustain programs to achieve high coverage.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4736-3) contains supplementary material, which is available to authorized users.

Research priority setting for integrated early child development and violence prevention (ECD+) in low and middle income countries: An expert opinion exercise

Child development in low and middle income countries (LMIC) is compromised by multiple risk factors. Reducing children's exposure to harmful events is essential for early childhood development (ECD). In particular, preventing violence against children - a highly prevalent risk factor that negatively affects optimal child development - should be an intervention priority. We used the Child Health and Nutrition Initiative (CHNRI) method for the setting of research priorities in integrated Early Childhood Development and violence prevention programs (ECD+). An expert group was identified and invited to systematically list and score research questions. A total of 186 stakeholders were asked to contribute five research questions each, and contributions were received from 81 respondents. These were subsequently evaluated using a set of five criteria: answerability; effectiveness; feasibility and/or affordability; applicability and impact; and equity. Of the 400 questions generated, a composite group of 50 were scored by 55 respondents. The highest scoring research questions related to the training of Community Health Workers (CHW's) to deliver ECD+ interventions effectively and whether ECD+ interventions could be integrated within existing delivery platforms such as HIV, nutrition or mental health platforms. The priority research questions can direct new research initiatives, mainly in focusing on the effectiveness of an ECD+ approach, as well as on service delivery questions. To the best of our knowledge, this is the first systematic exercise of its kind in the field of ECD+. The findings from this research priority setting exercise can help guide donors and other development actors towards funding priorities for important future research related to ECD and violence prevention.

Stakeholders' views on maternity care shortcomings in rural Ghana: An ethnographic study among women, providers, public, and quasiprivate policy sector actors

Access to skilled provider and emergency obstetric care is not universal across all districts in Ghana. The lived experiences of 3 stakeholder groups on maternity care shortcomings in 3 rural Ghanaian districts are examined in this study. We applied an ethnographic study approach where field data were collected between March to May 2015 in 3 rural districts of northern Ghana. Data were collected among women with recent births experiences (n = 90), health care providers (n = 16), and policy actors (n = 6). Transcripts were read through to identify similar and divergent stakeholders' views. Significant expressions and experiences of stakeholders on maternity care shortcomings were extracted and evaluated to define key themes. Four themes emerged: social/community factors, payments for health care, facility level factors, and policy level factors. The results show that traditional women's roles divest time for maternity care. Poor transport arrangements, insufficient health workforce, health funding gaps, insurance reimbursements delays, and catastrophic health expenditures on travel and drugs are attested as major barriers across all stakeholder groups in all districts studied. The discussion of the study findings suggests it is important to ascertain the scale of informal payments and their impacts on health access. Investments in health workforce and reliable ambulatory service systems could help address poor referral difficulties in rural areas of the country. Social support for community initiatives that pool funds could provide extra resources and relieve cost access-related challenges for using maternity care in rural settings in Ghana.

Empowering districts to target priorities for improving child health service in Uganda using change management and rapid assessment methods

BACKGROUND

Local health system managers in low- and middle-income countries have the responsibility to set health priorities and allocate resources accordingly. Although tools exist to aid this process, they are not widely applied for various reasons including non-availability, poor knowledge of the tools, and poor adaptability into the local context. In Uganda, delivery of basic services is devolved to the District Local Governments through the District Health Teams (DHTs). The Community and District Empowerment for Scale-up (CODES) project aims to provide a set of management tools that aid contextualised priority setting, fund allocation, and problem-solving in a systematic way to improve effective coverage and quality of child survival interventions.

DESIGN

Although the various tools have previously been used at the national level, the project aims to combine them in an integral way for implementation at the district level. These tools include Lot Quality Assurance Sampling (LQAS) surveys to generate local evidence, Bottleneck analysis and Causal analysis as analytical tools, Continuous Quality Improvement, and Community Dialogues based on Citizen Report Cards and U reports. The tools enable identification of gaps, prioritisation of possible solutions, and allocation of resources accordingly. This paper presents some of the tools used by the project in five districts in Uganda during the proof-of-concept phase of the project.

RESULTS

All five districts were trained and participated in LQAS surveys and readily adopted the tools for priority setting and resource allocation. All districts developed health operational work plans, which were based on the evidence and each of the districts implemented more than three of the priority activities which were included in their work plans.

CONCLUSIONS

In the five districts, the CODES project demonstrated that DHTs can adopt and integrate these tools in the planning process by systematically identifying gaps and setting priority interventions for child survival.

Setting priorities in health research using the model proposed by the World Health Organization: development of a quantitative methodology using tuberculosis in South Africa as a worked example

Background

Setting priorities is important in health research given the limited resources available for research. Various guidelines exist to assist in the priority setting process; however, priority setting still faces significant challenges such as the clear ranking of identified priorities. The World Health Organization (WHO) proposed a Disability Adjusted Life Year (DALY)-based model to rank priorities by research area (basic, health systems and biomedical) by dividing the DALYs into ‘unavertable with existing interventions’, ‘avertable with improved efficiency’ and ‘avertable with existing but non-cost-effective interventions’, respectively. However, the model has conceptual flaws and no clear methodology for its construction. Therefore, the aim of this paper was to amend the model to address these flaws, and develop a clear methodology by using tuberculosis in South Africa as a worked example.

Methods

An amended model was constructed to represent total DALYs as the product of DALYs per person and absolute burden of disease. These figures were calculated for all countries from WHO datasets. The lowest figures achieved by any country were assumed to represent ‘unavertable with existing interventions’ if extrapolated to South Africa. The ratio of ‘cost per patient treated’ (adjusted for purchasing power and outcome weighted) between South Africa and the best country was used to calculate the ‘avertable with improved efficiency section’. Finally, ‘avertable with existing but non-cost-effective interventions’ was calculated using Disease Control Priorities Project efficacy data, and the ratio between the best intervention and South Africa’s current intervention, irrespective of cost.

Results

The amended model shows that South Africa has a tuberculosis burden of 1,009,837.3 DALYs; 0.009% of DALYs are unavertable with existing interventions and 96.3% of DALYs could be averted with improvements in efficiency. Of the remaining DALYs, a further 56.9% could be averted with existing but non-cost-effective interventions.

Conclusions

The amended model was successfully constructed using limited data sources. The generalizability of the data used is the main limitation of the model. More complex formulas are required to deal with such potential confounding variables; however, the results act as starting point for development of a more robust model.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0081-8) contains supplementary material, which is available to authorized users.

National health research systems in the WHO African Region: current status and the way forward

BACKGROUND

A number of resolutions of the World Health Assembly and the WHO Regional Committee for Africa call upon African countries and their development partners to make the required investments in national health research systems (NHRS) to generate knowledge and promote its use in tackling priority public health challenges. Implementation of these resolutions is critical for Africa to progress with the rest of the world in achieving the post-2015 health sustainable development goal. This study assesses the current status of some NHRS components in the 47 countries of the WHO African Region, identifies the factors that enable and constrain NHRS, and proposes the way forward.

METHODS

To track progress in NHRS components and for comparison, a questionnaire that was used in NHRS surveys in 2003 and 2009 was administered in all 47 countries in the African Region. The national health research focal persons were responsible for completing the questionnaire, which had been hand-delivered to them by the WHO country office staff in charge of research, who also briefed them on the survey, went through the questionnaire for clarity, and sought their informed consent.

RESULTS

All the 47 countries responded to the questionnaire, but some did not answer all questions. Of the countries responding to various questions 49 % (23/47) had a national health research policy; 47 % (22/47) had a health strategic plan; 40 % (19/47) had legislation governing research; 53 % (25/47) had a national health research priority agenda; 51 % (24/47) reported having a functional NHRS and a national health research management forum; 91 % (43/47) had an ethical review committee; 49 % (23/47) had hospitals with ethical review committees to review clinical research proposals; 51 % (24/47) had a scientific review committee; 62 % (29/47) had health institutions with scientific review committees; 83 % (39/47) had a national health research focal point; 51 % (24/47) had a health research programme; 55 % (26/47) had a national health or medical research institute or council; 93 % (41/44) had at least one university faculty of health sciences that conducted health research; and 33 % (15/46) had a knowledge translation platform. Forty-seven percent of countries reported having a budget line for research for health in the ministry of health budget. Between 2003 and 2014, the countries with a functional NHRS increased from 30 % to 51 %.

CONCLUSION

Compared with 2003 and 2009 surveys, our survey found many countries to have made progress in strengthening some of the functions of their NHRS. However, there remains an urgent need for countries without NHRS to establish them and for others to improve the functionality and efficiency of every NHRS component. This is necessary for the national governments to effectively execute their leadership and governance of NHRS and to create an enabling environment within which research for health can flourish.

Approaches, tools and methods used for setting priorities in health research in the 21(st) century

BACKGROUND

Health research is difficult to prioritize, because the number of possible competing ideas for research is large, the outcome of research is inherently uncertain, and the impact of research is difficult to predict and measure. A systematic and transparent process to assist policy makers and research funding agencies in making investment decisions is a permanent need.

METHODS

To obtain a better understanding of the landscape of approaches, tools and methods used to prioritize health research, I conducted a methodical review using the PubMed database for the period 2001-2014.

RESULTS

A total of 165 relevant studies were identified, in which health research prioritization was conducted. They most frequently used the CHNRI method (26%), followed by the Delphi method (24%), James Lind Alliance method (8%), the Combined Approach Matrix (CAM) method (2%) and the Essential National Health Research method (<1%). About 3% of studies reported no clear process and provided very little information on how priorities were set. A further 19% used a combination of expert panel interview and focus group discussion ("consultation process") but provided few details, while a further 2% used approaches that were clearly described, but not established as a replicable method. Online surveys that were not accompanied by face-to-face meetings were used in 8% of studies, while 9% used a combination of literature review and questionnaire to scrutinise the research options for prioritization among the participating experts.

CONCLUSION

The number of priority setting exercises in health research published in PubMed-indexed journals is increasing, especially since 2010. These exercises are being conducted at a variety of levels, ranging from the global level to the level of an individual hospital. With the development of new tools and methods which have a well-defined structure - such as the CHNRI method, James Lind Alliance Method and Combined Approach Matrix - it is likely that the Delphi method and non-replicable consultation processes will gradually be replaced by these emerging tools, which offer more transparency and replicability. It is too early to say whether any single method can address the needs of most exercises conducted at different levels, or if better results may perhaps be achieved through combination of components of several methods.

Ethical considerations of physician career involvement in global health work: a framework

Examining the ethics of long-term, career involvement by physicians in global health work is vital, given growing professional interest and potential health implications for communities abroad. However, current literature remains heavily focused on ethical considerations of short-term global health training experiences. A literature review informed our development of an ethics framework centered on two perspectives: the practitioner perspective, further subdivided into extrinsic and intrinsic factors, and community perspectives, specifically that of the host community and the physician's home community. Some physician factors included cultural/linguistic differences, power imbalances, and sustainable skills/competencies. Receiving community factors included resource limitations, standard of care disparities, and community autonomy. Home community factors focused on the opportunity cost of an unavailable physician who was trained and supported by the local community. Descriptive review permitted comparison with existing short-term literature, noting similarities and differences. Our framework provides a basis for further research and critical analysis of ethical implications of career-long physician global health work.

Setting global research priorities for developmental disabilities, including intellectual disabilities and autism

OBJECTIVES

The prevalence of intellectual disabilities (ID) has been estimated at 10.4/1000 worldwide with higher rates among children and adolescents in lower income countries. The objective of this paper is to address research priorities for development disabilities, notably ID and autism, at the global level and to propose the more rational use of scarce funds in addressing this under-investigated area.

METHODS

An expert group was identified and invited to systematically list and score research questions. They applied the priority setting methodology of the Child Health and Nutrition Research Initiative (CHNRI) to generate research questions and to evaluate them using a set of five criteria: answerability, feasibility, applicability and impact, support within the context and equity.

FINDINGS

The results of this process clearly indicated that the important priorities for future research related to the need for effective and efficient approaches to early intervention, empowerment of families supporting a person with developmental disability and to address preventable causes of poor health in people with ID and autism.

CONCLUSIONS

For the public health and other systems to become more effective in delivering appropriate support to persons with developmental disabilities, greater (and more targeted) investment in research is required to produce evidence of what works consistent with international human rights standards.

A decade of nutrition research in Africa: assessment of the evidence base and academic collaboration

OBJECTIVE

Malnutrition in Africa has not improved compared with other regions in the world. Investment in the build-up of a strong African research workforce is essential to provide contextual solutions to the nutritional problems of Africa. To orientate this process, we reviewed nutrition research carried out in Africa and published during the last decade.

DESIGN

We assessed nutrition research from Africa published between 2000 and 2010 from MEDLINE and EMBASE and analysed the study design and type of intervention for studies indexed with major MeSH terms for vitamin A deficiency, protein-energy malnutrition, obesity, breast-feeding, nutritional status and food security. Affiliations of first authors were visualised as a network and power of affiliations was assessed using centrality metrics.

SETTING

Africa.

SUBJECTS

Africans, all age groups.

RESULTS

Most research on the topics was conducted in Southern (36%) and Western Africa (34%). The intervention studies (9%; n 95) mainly tested technological and curative approaches to the nutritional problems. Only for papers on protein-energy malnutrition and obesity did lead authorship from Africa exceed that from non-African affiliations. The 10% most powerfully connected affiliations were situated mainly outside Africa for publications on vitamin A deficiency, breast-feeding, nutritional status and food security.

CONCLUSIONS

The development of the evidence base for nutrition research in Africa is focused on treatment and the potential for cross-African networks to publish nutrition research from Africa remains grossly underutilised. Efforts to build capacity for effective nutrition action in Africa will require forging a true academic partnership between African and non-African research institutions.

How are health research priorities set in low and middle income countries? A systematic review of published reports

BACKGROUND

Priority setting is increasingly recognised as essential for directing finite resources to support research that maximizes public health benefits and drives health equity. Priority setting processes have been undertaken in a number of low- and middle-income country (LMIC) settings, using a variety of methods. We undertook a critical review of reports of these processes.

METHODS AND FINDINGS

We searched electronic databases and online for peer reviewed and non-peer reviewed literature. We found 91 initiatives that met inclusion criteria. The majority took place at the global level (46%). For regional or national initiatives, most focused on Sub Saharan Africa (49%), followed by East Asia and Pacific (20%) and Latin America and the Caribbean (18%). A quarter of initiatives aimed to cover all areas of health research, with a further 20% covering communicable diseases. The most frequently used process was a conference or workshop to determine priorities (24%), followed by the Child Health and Nutrition Initiative (CHNRI) method (18%). The majority were initiated by an international organization or collaboration (46%). Researchers and government were the most frequently represented stakeholders. There was limited evidence of any implementation or follow-up strategies. Challenges in priority setting included engagement with stakeholders, data availability, and capacity constraints.

CONCLUSIONS

Health research priority setting (HRPS) has been undertaken in a variety of LMIC settings. While not consistently used, the application of established methods provides a means of identifying health research priorities in a repeatable and transparent manner. In the absence of published information on implementation or evaluation, it is not possible to assess what the impact and effectiveness of health research priority setting may have been.

African stakeholders' views of research options to improve nutritional status in sub-Saharan Africa

BACKGROUND

Setting research priorities for improving nutrition in Africa is currently ad hoc and there is a need to shift the status quo in the light of slow progress in reducing malnutrition. This study explored African stakeholders' views on research priorities in the context of environmental and socio-demographic changes that will impact on nutritional status in Africa in the coming years.

METHODS

Using Multi-Criteria Mapping, quantitative and qualitative data were gathered from 91 stakeholders representing 6 stakeholder groups (health professionals, food Industry, government, civil society, academics and research funders) in Benin, Mozambique, South Africa, Tanzania, Togo and Uganda. Stakeholders appraised six research options (ecological nutrition, nutritional epidemiology, community nutrition interventions, behavioural nutrition, clinical nutrition and molecular nutrition) for how well they could address malnutrition in Africa.

RESULTS

Impact (28.3%), research efficacy (23.6%) and social acceptability (22.4%) were the criteria chosen the most to evaluate the performance of research options. Research on the effectiveness of community interventions was seen as a priority by stakeholders because they were perceived as likely to have an impact relatively quickly, were inexpensive and cost-effective, involved communities and provided direct evidence of what works. Behavioural nutrition research was also highly appraised. Many stakeholders, particularly academics and government were optimistic about the value of ecological nutrition research (the impact of environmental change on nutritional status). Research funders did not share this enthusiasm. Molecular nutrition was least preferred, considered expensive, slow to have an impact and requiring infrastructure. South Africa ranked clinical and molecular nutrition the highest of all countries.

CONCLUSION

Research funders should redirect research funds in Africa towards the priorities identified by giving precedence to develop the evidence for effective community nutrition interventions. Expanding research funding in behavioural and ecological nutrition was also valued and require multi-disciplinary collaborations between nutritionists, social scientists, agricultural and climate change scientists.

Setting research priorities to reduce malaria burden in a post graduate training programme: lessons learnt from the Nigeria field epidemiology and laboratory training programme scientific workshop

Although several research groups within institutions in Nigeria have been involved in extensive malaria research, the link between the research community and policy formulation has not been optimal. The workshop aimed to assist post graduate students to identify knowledge gaps and to develop relevant Malaria-related research proposals in line with identified research priorities. A training needs assessment questionnaire was completed by 22 students two week prior to the workshop. Also, a one page concept letter was received from 40 residents. Thirty students were selected based the following six criteria: - answerability and ethics; efficacy and impact; deliverability, affordability; scalability, sustainability; health systems, partnership and community involvement; and equity in achieved disease burden reduction. The workshop was over a three day period. The participants at the workshop were 30 Nigeria Field Epidemiology and Laboratory Training Programme (NFELTP) residents from cohorts 4 and 5. Ten technical papers were presented by the experts from the academia, National Malaria Elimination (NMEP) Programme, NFELTP Faculty and Implementing partners including CDC/PMI. Draft proposals were developed and presented by the residents. The "strongest need" for training was on malaria prevention, followed by malaria diagnosis. Forty seven new research questions were generated, while the 19 developed by the NMEP were shared. Evaluation revealed that all (100%) students either "agreed" that the workshop objectives were met. Full proposals were developed by some of the residents. A debriefing meeting was held with the NMEP coordinator to discuss funding of the projects. Future collaborative partnership has developed as the residents have supported NMEP to develop a research protocol for a national evaluation. Research prioritization workshops are required in most training programmes to ensure that students embark on studies that address the research needs of their country and foster collaborative linkages.