Just to clarify the database ‘Rx for change’ website that I mentioned on my blog entry on Day 1 of the workshop: the website address is http://www.cadth.ca/en/resources/rx-for-change . (There are some websites with more or less the same name, but they are different sites.) This specific ‘Rx for change’ database is “a searchable database containing current research evidence about intervention strategies used to alter behaviours of health technology prescribing, practice, and use. The intent of this database is to help inform the choice and use of practical, evidence-based interventions”. This database includes Cochrane reviews about consumer- and provider-targeted implementation strategies, as well as non-Cochrane systematic reviews on this topic.
This morning some working groups had meetings with the workshop presenters, and the rest of us worked further on our PhD proposals or policy briefs. Prof Lavis then closed the workshop with a summary presentation. There is a one-pager that summarises the workshop effectively and concisely. It can be found on http://www.mcmasterhealthforum.org/healthsystemsevidence-en. You have to register before you can get to this document, but registration is free and quick (and this database is a very good source to search for systematic reviews, so you anyway have to register!). After logging in, look under “Tools” and click on “Finding and Using Research Evidence”. This PDF document takes you through the process of:
(1) Clarifying a problem (that needs addressing in a policy, but it can also help to
clarify problems for other purposes than policies),
(2) Framing and evaluating different options to address the defined problem,
(3) Considerations of implementation.
This document also contains the main sources where one should search for evidence (primarily systematic reviews of clinical effects, public health programmes, implementation strategies and economic evaluations; but also policy briefs/evidence summaries).
We’re off to lunch now where after we’re going on a real African outing to see Cameroon’s gorillas! Tonight I am catching the plane back to South Africa. I would like to thank the organisers and presenters for all their hard work and friendliness – the workshop was most definitely a capacity building event in the field of knowledge translation and specifically related to policy –making. It was a privilege to could have learnt from Prof Lavis – an international expert in the field of knowledge translation all the way from Canada – as well as from Dr Ongolo-Zogo and Prof Sewankambo who have lots of experience in writing policy briefs in Africa. And then last, but certainly not least, I would like to thank all of you who learned with me by following my blog!
The day kicked off with half an hour to work on our one-page policy briefs. We had the opportunity of sending our draft policy brief to the presenters to get valuable feedback.
Next on the agenda for the day was Anthony Obuku (workshop participant from Uganda) who presented his PhD proposal by taking the approach that we’ve learned in this workshop so far. He stated the context and the problem, stated four different options which can address the problem, and took us through the outcomes he plans to measure and comparisons between countries he wants to make for one of the options. This option is the establishing of a Knowledge and Transfer Exchange Platform for postgraduate student research so that such research can be taken up by decision-makers. Then he took us through potential benefits, risks, cost, adaptations and implementation considerations for this option. Anthony’s presentation led to a discussion regarding whether recommendations should be part of research (and in particular postgraduate student projects) or not. My view is that researchers and postgraduate students can suggest future research to build on the existing research on a specific healthcare problem, but recommendations should be left to decision-makers as different recommendations may be needed for different settings and health systems.
The presentation for the day was given by Prof Lavis, which involved identifying knowledge gaps and communicating this gap to funders in such a way to secure financial support for the project. Reading systematic reviews on a particular question is a good start to identify knowledge gaps, but it may be that there aren’t any systematic reviews to address your question. The first step will then be to conduct such a systematic review. Another good place to look for knowledge gaps is to read policy (evidence) briefs – especially gaps about adaptations in health systems, implementation strategies and cost-effectiveness may be found here. To practice, we were given a list of good presentation tips and asked to prepare a 2 to 3 minute presentation about a key knowledge gap for which you would like to obtain funding. The ‘take-home’ messages I got were:
- Clear problem statement
- Provide compelling research evidence (i.e. pitch your project in the context of the existing evidence base)
- Have strong arguments in favour of your solution for the knowledge gap/problem
- Be prepared to address arguments against your proposal (i.e. be able to defend the weaknesses)
- Use a compelling anecdote if you can to capture attention
- Use image(s) to strengthen your concept
At the end of the day each participant or working group presented their solution for a knowledge gap to a ‘panel of funders’ (a.k.a. our three workshop presenters) who decided where to put their money… Everyone, whether in English or French, fought for their fair share!
To summarise the workshop so far, we have covered the following:
- Introduction of knowledge translation
- Where to search for research evidence
- The approach: research to policy
– What is the problem?
– What options are best suited to address the problem?
– How can change be brought about? (Implementation)
- Other key skills needed to take research to policy-making:
– Writing evidence briefs
– Convening policy dialogues
– Identifying and communicating knowledge gaps
Tomorrow morning we are going to receive feedback on our one-page policy briefs, wrap up and close the workshop. The afternoon we have free to explore Cameroon’s markets.
This morning we resumed where we left off yesterday: working group feedback. Among the presenters were PhD students who shared their proposals. They were privileged to get valuable input. Engaging in embedded knowledge translation (see blog post earlier today) increase your chance of having your (PhD) research been taken up in policy and practice. Again there was a lot of discussion which took us to our well-earned tea break.
Prof Lavis then presented a lecture about implementation considerations. Following the same approach than the past two days, we were introduced to a set of questions to work through within our respective Units/Centres:
- What are the potential barriers to the successful implementation of the policy or programme?
- What strategies should be considered in order to facilitate the necessary behavioural changes:
- Among patients/consumers?
- Among healthcare workers?
- Within organisations?
- Within the health system as a whole?
- What evidence is available about the effectiveness of the strategies?
- Which stakeholders are likely to actively support the change and which stakeholders are likely to oppose the change?
We were given time before and during the session after lunch to work on addressing these questions.
The afternoon session presented by Prof Lavis was titled “Writing evidence briefs for policy and convening policy dialogues”. In an earlier blog post there is a short summary of what gets addressed in a policy brief and at the end of this post we will come back to that. A fellow workshop participant, Dr Rhona Mijumbi, explained to me what ‘dialogue’ refers to in the context of policymaking:
- After the policy brief was written and distributed to various decision-makers, they get together (physically or virtually) to discuss the policy brief. These discussions then get recorded and written down, forming the ‘dialogue’.
From the presentation I learned that the following are some of the potential features that come out in such a dialogue:
- Whether it is a priority issue
- Discussion of the problem
- Discussion of the different options that were taken up in the evidence brief as possibilities to address the problem
- Discussion of implementation of the options
- Discussion around who could do what
Prof Lavis shared interim results from a study he and colleagues is doing to assess the visual depiction of policy briefs and dialogues. What stood out for me is that in the 9 policy briefs from African countries assessed so far, only 47% used a systematic approach (i.e. they stated what methods they used in order to come up with the brief) and only 27% considered the quality of the evidence that were included in the brief. I find it interesting that one of the features that varied most between the 9 evidence briefs is whether the brief included recommendations. Sixty percent of the sampled briefs did not include recommendations. The main argument for not including recommendations is that recommendations have the risk of being contaminated with authors’ personal views and interests. I can imagine that the other group will feel that recommendations done by experts but which are based on research evidence ease the task of the final decision-makers. But I take the stand with the ‘no recommendations’ group.
Interim results for dialogue evaluations (N = 7) showed inter alia that only in 31% decision-makers discussed who should do what. I would say that on the prospect of uptake and implementation it is important that specific people take responsibility for specific actions and are held accountable for that.
Before moving on to preparing a draft one-page summary of our policy briefs, Dr Ongolo-Zogo, Prof Sewankambo and Prof Lavis provided us with good writing tips. I already shared with you the class exercise that Dr Ongolo-Zogo gave us to do (see blog post titled “2 minutes with your country’s President”). Prof Sewankambo emphasised the importance of stating what you have to say clearly, but as short as possible. Busy policymakers do not want to read 40-page documents! Prof Lavis shared with us the following:
- Use sign postings to sketch your reader the bigger picture and to point out what issue in this bigger picture are you discussing now. In practice this relates to using bullet points and numbering to list the steps, options, etc.
- Write in the active voice, i.e. the subject of the sentence should come before the verb: “We used purposive sampling to…” instead of “Purposive sampling were used to…”. Most medical journals nowadays demands writing in the active voice.
- Paragraphs should start with strong sentences, meaning that by only reading the first sentence the reader should get the core of what this paragraph will be about. It is known that some professors and academics admit to reading only the first sentence of long documents such as reports and student theses (as they have quite a lot of reading to get through during each day). If the document is written well, the reader will be able to get the clear picture by only reading the opening sentence of each paragraph.
Prof Lavis concluded with ‘do what you have to do to engage your reader’s attention, and to keep them following’. The above tips will help you with this.
The presentation and third workshop day ended with Prof Lavis providing us with a set of issues that we must work through in our working groups. The end-product should be a one-page summary of your policy brief. The issues are:
- Sketch the context (including referring to the health system and political system)
- State the problem
- Provide three options that can address the problem
- Provide the available evidence for the different options (for exercise purposes only for one option) regarding the benefits, risks, costs or cost-effectiveness, adaptions required, and views and experiences
- Provide the available evidence about one possible implementation strategy, including pointing out the benefits, risks, etc.
We were reminded to employ the good writing tips when preparing this summary policy brief. Happy writing!
Dr Pierre Ongolo-Zogo led a session on ‘Principles of good writing’. He started with giving us a quick class exercise: “Imagine you step into a lift and find your country’s President inside. You have two minutes going from the fifth to the ground floor (it is a slow lift!) to motivate why a specific health problem should be addressed in your country. What will you say to him/her?”
Below I share mine with you. I dare all my fellow workshop participants to comment on this blog post and share their ‘dream’ conversation!
“President Zuma, there is no current regulation of nutritional supplements in South Africa. The draft regulation does not explicitly state nutritional supplements and its health claims, including sport supplements. The nutritional supplement industry is a multi-million rand industry, even though effectiveness of the health claims is not established for many products. We need regulation of nutritional supplements to protect consumers from spending hard-earned money on products with health claims that are not evidence-based. This regulation should include using findings from systematic reviews to assess effectiveness of health claims. My Centre for Evidence-based Health Care would like to help develop this regulation and help drive implementation.”
The article by Lavis et al (2009) that was published in Health Research Policy and Systems 2009, 7(Suppl 1):S9 is very useful for researchers writing policy briefs, healthcare providers and policy-makers who have to decide whether the findings from a systematic review can be generalised to their specific setting. Also, this article is very important for authors of systematic reviews so that they can be aware of what issues they must address in their systematic reviews to make it more user-friendly for assessment by decision-makers. The full text of the article can be found at http://www.health-policy-systems.com/content/7/S1/S9.