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Many international statements have urged researchers, policy-makers and health care providers to collaborate in efforts to bridge the gaps between research, policy and practice in low- and middle-income countries. We surveyed researchers in 10 countries about their involvement in such efforts.
We surveyed 308 researchers who conducted research on one of four clinical areas relevant to the Millennium Development Goals (prevention of malaria, care of women seeking contraception, care of children with diarrhea and care of patients with tuberculosis) in each of 10 low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania). We focused on their engagement in three promising bridging activities and examined system-level, organizational and individual correlates of these activities.
Less than half of the researchers surveyed reported that they engaged in one or more of the three promising bridging activities: 27% provided systematic reviews of the research literature to their target audiences, 40% provided access to a searchable database of research products on their topic, and 43% established or maintained long-term partnerships related to their topic with representatives of the target audience. Three factors emerged as statistically significant predictors of respondents’ engagement in these activities: the existence of structures and processes to link researchers and their target audiences predicted both the provision of access to a database (odds ratio [OR] 2.62, 95% CI 1.30–5.27) and the establishment or maintenance of partnerships (OR 2.65, 95% CI 1.25–5.64); stability in their contacts predicted the provision of systematic reviews (OR 2.88, 95% CI 1.35–6.13); and having managers and public (government) policy-makers among their target audiences predicted the provision of both systematic reviews (OR 4.57, 95% CI 1.78–11.72) and access to a database (OR 2.55, 95% CI 1.20–5.43).
Our findings suggest potential areas for improvement in light of the bridging strategies targeted at health care providers that have been found to be effective in some contexts and the factors that appear to increase the prospects for using research in policy-making.
The need to bridge the gaps between research, policy and practice appears to be a global phenomenon. Three recent, highly visible resolutions — the Mexico Action Statement on Health Research in 2004 (58 countries),1 the related World Health Assembly resolution in 2005 (193 countries)2 and the Bamako Call to Action on Research for Health in 2008 (53 countries) 3 — urged researchers, policy-makers and health care providers to collaborate in efforts to bridge these gaps. These efforts can range from bringing research-based evidence to the attention of those who could use it, to making research-based evidence available so that it can be readily retrieved when needed.
We are not aware of a survey having been conducted in a range of low- and middle-income countries about researchers’ bridging activities related to specific high-priority health topics. Researchers and research organizations have been surveyed about their bridging activities in single high-income countries such as Canada.4–6 Guideline-producing organizations and health technology assessment agencies have also been surveyed about their bridging activities;7 only in one case was the focus on bridging activities in low- and middle-income countries.8 Select research funding agencies have been studied in low- and middle-income countries.9 Yet the Millennium Development Goals and the goals of many countries call for topic-focused efforts to bridge the gaps between research, policy and practice.
We studied efforts to bridge the gaps between research, policy and practice in 10 low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania). In this article, we describe the findings from a survey of researchers in these countries who conducted research in one of four clinical areas relevant to the Millennium Development Goals: prevention of malaria (Ghana, Laos, Senegal and Tanzania), care of women seeking contraception (China, Kazakhstan, Laos and Mexico), care of children with diarrhea (Ghana, India, Pakistan and Senegal) and care of patients with tuberculosis (China, India, Iran and Mexico). In a related article, we describe the findings from a survey of health care providers in these countries who were practising in one of these clinical areas about their awareness of, access to and use of research-based evidence in these clinical areas and the influence of such evidence on their professional practice.10
The challenges associated with documenting such efforts include cross-country differences in the capacity to conduct surveys of researchers; the visibility of researchers depending on their alignment with priorities of government, development agencies, research funding agencies and industry (and hence their likelihood of being identified to participate in these surveys); and researchers’ familiarity with and attitudes toward the bridging activities asked about in these surveys.
We surveyed researchers in 10 low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania) who conducted research in one of the four clinical areas described earlier in the article. Within each area, a particular emphasis was placed on an intervention that was supported by strong evidence from international and local research: insecticide-treated materials to prevent malaria; intrauterine devices for family planning; oral rehydration therapy to prevent dehydration in children with diarrhea; and the DOTS strategy (directly observed treatment, short course) to control tuberculosis.
We purposively sampled countries to achieve breadth in levels of economic and health care systems development, political systems and geographic locations. In addition, all country teams had to have demonstrated (through collaborations with the World Health Organization [WHO]) a strong interest in bridging the gaps between research, policy and practice and in further developing the capacity to evaluate such efforts. The selected countries differ in their health status indicators, rates of coverage for the interventions under study, and access to the Internet or computers with a CD-ROM (Appendix 1, available at www.cmaj.ca/cgi/content/full/cmaj.081164/DC1).
We identified researchers using three sources: lists of authors identified through a search of MEDLINE and ISI Web of Science for each combination of country and topic; lists of researchers identified by WHO staff; and lists of researchers identified by country teams. We defined researchers as those who spent at least 10% of their time doing research, including the production, synthesis and sharing of research. Our definition could include clinician scientists, university professors, research managers in nongovernmental organizations and civil servants with program-evaluation responsibilities.
We did not calculate the sample sizes needed because we sought to survey, whenever possible, all researchers involved in conducting research on each topic in each country. In only four countries — Ghana, Iran, Pakistan and Senegal — was a sample selected because the number of eligible researchers was significantly more than 25.
We developed a self-administered questionnaire comprised of two main sets of questions: one set addressed researchers’ activities in bridging the gaps between research, policy and practice; the other addressed potential system-level, organizational and individual correlates of researchers’ engagement in these bridging activities. For the first set of questions, we drew on the WHO’s “World Report on Knowledge for Better Health”11 and four existing questionnaires4,5,12,13 to identify conceptual domains to be covered by the questionnaire. We retained the wording and order of the questions whenever possible.
We grouped the domains into three broad categories: (a) “producer-push” efforts (what is “pushed,” or communicated, to target audiences outside the research community; to whom; by whom; how; and with what effect); (b) efforts to facilitate “user pull” (i.e., what strategies are used to provide access to research and to develop target audiences’ capacity to use research); and (c) exchange efforts (i.e., how target audiences are involved in research and bridging activities). The development and testing of our questionnaire are described elsewhere.14 WHO’s translation service translated the questionnaire for China, Kazakhstan, Mexico and Senegal; country teams translated the questionnaire for Iran and Laos.
We mailed the questionnaire or used a drop-off and pick-up approach in all countries except China (for one of its two topics [family planning] and Iran (for its one topic [tuberculosis treatment]), where for each topic we administered the questionnaire at a meeting where all eligible researchers were expected to be present. We used several approaches to increase the response rate: personalized letters, follow-up of contacts and provision of a set of WHO publications as an incentive.15 Survey work was completed in all 10 countries between April 2004 and April 2005.
We checked, coded and managed all data centrally in order to permit the analysis of pooled data from all 10 countries. We calculated proportions for most surveyed researchers’ characteristics, bridging activities and potential correlates of engagement in these bridging activities. We combined the top two categories whenever an ordinal scale was used (e.g., frequently or always undertaking an activity, agreeing or strongly agreeing with a statement).
For the dependent variables in the logistic regression models, we selected three bridging activities, one from each broad category of the organizing framework, that offer particular promise. For one of the three bridging activities, we selected “providing systematic reviews” as a promising producer-push effort because reviews can reduce bias and the play of chance in estimating effects and can save time for those those who can draw on them rather than have them identify, select, appraise and synthesize the research literature on their own.16 We selected “providing access to a searchable database of research products about the topic” as a promising bridging activity to facilitate user pull because timeliness was one of only two factors identified with some consistency in a systematic review of factors that increase the prospects for use of research in policy-making.17 For the third bridging activity, we selected “establishing or maintaining long-term partnerships related to the topic with target audience representatives” as an exchange effort because interaction was the second of the two factors that emerged in the systematic review.17
Based on a combination of the research literature and our own knowledge of the field and the contexts in which researchers function, we selected 20 potential system-level, organizational and individual correlates to examine in each logistic regression model. For missing values, we used multiple imputation, whereby each missing value was replaced by the mean of 10 different estimates. We adjusted standard errors according to Rubin’s rules.18 We excluded observations when the dependent variable was missing. We estimated all models using Stata/SE 9.2 for Macintosh with robust variances.19
We present results by topic rather than by country so that sample sizes would be larger and because the Millennium Development Goals, and most national health goals, focus on topic-specific bridging activities.
We received 368 completed questionnaires from the 544 researchers who were contacted, for an overall response rate of 67.6%. Sixty of the 368 respondents were deemed ineligible either because they did not undertake bridging activities or because their objective in undertaking such activities was exclusively related to commercial interests. Response rates at the level of single countries ranged from 30% to 100%. For the majority of variables, data were missing for less than 5% of respondents. For only two variables, data were missing for more than 10% of respondents.
Overall, 35% of the surveyed researchers conducted clinical research and 30% conducted research on population or public health. There was a link between the area of focus and the area of research specialization (e.g., research related to intrauterine devices tended to be conducted by those engaged in clinical research) (Table 1). Overall, 69% of the respondents targeted health care providers among others in their bridging activities, and 42% targeted public (government) policy-makers among others. Most (84%) of the respondents reported that they worked with or for an organization that undertook bridging activities with them or on their behalf, although they still spent on average a day or more of their own work time involved in bridging activities (median 20%, mean 25%).
Only a few bridging activities were undertaken by more than half of the surveyed researchers: developed messages for target audiences that specified possible action (57%); obtained or reviewed information that described the needs or goals of specific target audiences (55%); and interacted with target audiences both through and outside the research process (51%–59%) (Table 2). Likewise, few bridging activities were undertaken by less than a quarter of the respondents: mailed or emailed research products without an explicit request (15%); and developed capacity of target audiences to acquire research on the topic (23%).
Between a quarter and half of the respondents said that they engaged in what we identified as three particularly promising bridging activities: provided systematic reviews of the research literature to their target audiences (27%); provided access to a searchable database of articles, reports, syntheses or systematic reviews on the topic (40%); and established or maintained long-term partnerships related to the topic with representatives of their target audiences (43%). For 13 of 20 bridging activities, there was a difference of 20% or more in the spread of proportions across topics (i.e., at least one in five researchers differed in whether they engaged in a bridging activity). Researchers in diarrheal disease accounted for the highest proportion for 7 of these 13 activities; researchers in malaria prevention accounted for the lowest proportion for 9 activities. Researchers in tuberculosis treatment were mixed, accounting for the highest proportions for 5 of these 13 activities and the lowest proportions for 4 activities.
Only six facilitators of engagement in bridging activities were reported by more than half of the respondents (Table 3). Three potential correlates were reported by more than two-thirds: have access to a personal computer with a functional Internet connection at all times to conduct and download searches (72%); their research coincides with the needs and expectations of their target audiences (85%); and researchers and target audiences are jointly responsible for bridging activities related to the topic (71%). No potential correlates were reported by less than one quarter of the surveyed researchers. For five potential correlates, there was a difference of at least 20% in the spread of proportions across topics. Researchers in family planning accounted for the highest proportions for four of these five correlates; researchers in diarrheal disease accounted for the lowest proportions for four of them.
From a pool of 20 potential correlates examined, three factors emerged as statistically significant predictors of respondents’ engagement in three promising bridging activities (Table 4). Stability in researchers’ personal and organizational contacts among their target audiences predicted the provision of systematic reviews (OR 2.88, 95% CI 1.35–6.13), as did having managers and public policy-makers among their target audiences (OR 4.57, 95% CI 1.78–11.72). The existence of structures and processes to link researchers and their target audiences predicted the provision of access to a searchable database of research products on the topic (OR 2.62, 95% CI 1.30–5.27), as did having managers and public policy-makers among their target audiences (OR 2.55, 95% CI 1.20–5.43). The existence of structures and processes to link researchers and their target audiences was a significant predictor of researchers establishing or maintaining long-term partnerships related to the topic with representatives of their target audiences (OR 2.65, 95% CI 1.25–5.64).
Engagement in a variety of promising bridging activities was reported by less than half of the surveyed researchers. In particular, targeted dissemination of research products and the development of the capacity of target audiences to find and use research were rarely undertaken. The variability in engagement in bridging activities across topics cannot be readily explained by level of economic development: the groups with the highest proportions (researchers in diarrheal disease) and the lowest proportions (researchers in malaria prevention) of engagement in particular bridging activities were all based in low-income countries. A number of facilitators of engagement in bridging activities were reported by more than half of the respondents, including increasing the support for bridging activities over time within their organization and country. Only a small number of factors, such as having managers and public policy-makers among their target audiences and the existence of structures and processes to link researchers and their target audiences, emerged as statistically significant predictors of engagement in three promising bridging activities.
Although the relatively low levels of engagement in many promising bridging activities may be disheartening to some, the survey was conducted shortly after the first wave of calls to support such activities. We did find that the surveyed researchers perceived the climate for such activities to have improved over time. With a cross-sectional survey, we cannot confirm whether engagement levels are rising. What has changed is the publication of many systematic reviews and overviews of reviews that can assist researchers in selecting activities relevant to their topic and local context.17,20–24 These researchers can also now become connected to a range of partnerships involving policy-makers (e.g., the WHO-sponsored Evidence-Informed Policy Networks) that both constitute and create the types of structures and processes that can support bridging efforts.25
Our study had four limitations worth noting. First, the potential for social desirability bias (researchers may have reported higher levels of engagement in bridging activities than might actually be the case) exists. Second, the questionnaire included questions that applied to all target audiences (even though some activities, such as disseminating clinical practice guidelines, may have been relevant only to a target audience such as health care providers) and required researchers to provide a single response even if some responses may have varied by target audience. Third, linguistic or cultural differences may have affected respondents’ interpretation of select questions. Fourth, the missing or imprecise responses to an open-ended question about institutional affiliations precluded us from adjusting for clustering (at the organizational level) in the regression models; however, this would have affected the standard errors but not the point estimates.
Our findings indicate that researchers in low- and middle-income countries report frequent engagement in only some types of promising bridging activities. Future initatives could focus on supporting those bridging strategies targeted at health care providers that have been found to be effective in some contexts. They could also focus on addressing those factors that appear to increase the prospects for using research in policy-making. In light of 53 ministerial delegations calling for renewed efforts to bridge gaps between research, policy and practice,3 our survey provides a baseline against which these future initiatives can be measured.
The authors thank the technical experts who provided support to one or more phases of the study and the participants in the project workshop held in Geneva to discuss the data-collection process, interim findings, and potential implications for dissemination and next steps. The authors also thank Andrew Kennedy and Carol D’Souza for providing scientific input in one or more phases of the study, and Prince Dhillon for assisting with the final set of analyses and the preparation of tables.
Funding: The Alliance for Health Policy and Systems Research funded part of all phases of the project. McMaster University and the World Health Organization provided substantial in-kind donations of staff time and other resources. The Global Development Network funded an early phase of the project. John Lavis receives salary support as the Canada Research Chair in Knowledge Transfer and Exchange. Emmanuel Guindon is supported by a Canada Graduate Scholarship from the Social Sciences and Humanities Research Council of Canada. The views expressed in this paper are those of the authors and do not represent the views of the funding organizations.
Previously published at www.cmaj.ca
Competing interests: None declared.
Contributors: John Lavis contributed substantially to the study concept and design and to the acquisition, analysis and interpretation of data; he drafted and revised the article critically for important intellectual content. Emmanuel Guindon, David Cameron, Boungnong Boupha, Masoumeh Dejman, Eric Osei and Ritu Sadana contributed substantially to the study concept and design, the acquisition of data, or the analysis and interpretation of data and revised the article critically for important intellectual content. All of the authors gave final approval of the version to be published.
Members of the Research to Policy and Practice Study Team: Writing group: John N. Lavis, G. Emmanuel Guindon and David Cameron (Canada); Boungnong Boupha (Lao People’s Democratic Republic); Masoumeh Dejman (Iran); Eric J.A. Osei (Ghana); and Ritu Sadana (World Health Organization). Other members: Steven J. Hoffman (Canada); Guang Shi and Tinglin Qiu (China); Kudjoe Dovlo (Ghana); Prema Ramachandran and C. Ashok K. Yesudian (India); Hossein Malek-Afzali, Katayoun Falahat, Monir Baradaran, Elham Habibi, Hoshmand Kohanzad, Mahshid Nasehi and Salek Salek (Iran); Aikan A. Akanov, Botagoz S. Turdaliyeva, Nurgul K. Hamzina, Kazbek A. Tulebayev, Tatiana I. Clazhneva and Zhamilya Battakova (Kazakhstan); Sengchanh Kounnavong and Latsamy Siengsounthone (Lao People’s Democratic Republic); Francisco Becerra-Posada, Leticia Alfaro Ramos and Israel Mejia (Mexico); Tasleem Akhtar and M. Mubashir A. Khan (Pakistan); Mintou Fall Sidibe, Awa Sidibe and Djiby Ndiaye (Senegal); Godwin D. Ndossi and Julius Massaga (Tanzania); and Tikki Pang (World Health Organization)
This article has been peer reviewed.