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1.  The impact of an intervention programme employing a hands-on technique to reduce the incidence of anal sphincter tears: interrupted time-series reanalysis 
BMJ Open  2013;3(10):e003355.
Objective
To re-evaluate previously published findings from an uncontrolled before–after evaluation of an intervention programme to reduce the incidence of anal sphincter tears. A key component of the programme was the use of a hands-on technique where the birth attendant presses the neonate's head during the final stage of delivery while simultaneously supporting the woman's perineum with the other hand.
Design
Interrupted time-series analysis using segmented regression modelling.
Setting
Obstetric departments of five Norwegian hospitals.
Participants
All women giving births vaginally in the study hospitals, 2002–2008.
Methods
The main data source was the Medical Birth Registry of Norway. We estimated the change in incidence of anal sphincter tears before and after implementation of the intervention in the five intervention hospitals, taking into account the trends in incidence before and after implementation.
Main outcome measures
Incidence of anal sphincter tears and episiotomies.
Results
There were 75 543 registered births at the five included hospitals. We found a 2% absolute reduction in incidence of anal sphincter tears associated with the hospital intervention programme, representing almost a halving in the number of women experiencing serious anal sphincter tears. This is a substantially smaller estimate than previously reported. However, it does represent a highly significant decrease in anal sphincter injuries. The programme was also associated with a significant increase in episiotomies.
Conclusions
The intervention programme was associated with a significant reduction in the incidence of obstetric anal sphincter tears. Still, the findings should be interpreted with caution as they seem to contradict the findings from randomised controlled studies of similar interventions.
doi:10.1136/bmjopen-2013-003355
PMCID: PMC3808759  PMID: 24154515
OBSTETRICS; STATISTICS & RESEARCH METHODS
2.  Comparison of Alternative Evidence Summary and Presentation Formats in Clinical Guideline Development: A Mixed-Method Study 
PLoS ONE  2013;8(1):e55067.
Background
Best formats for summarising and presenting evidence for use in clinical guideline development remain less well defined. We aimed to assess the effectiveness of different evidence summary formats to address this gap.
Methods
Healthcare professionals attending a one-week Kenyan, national guideline development workshop were randomly allocated to receive evidence packaged in three different formats: systematic reviews (SRs) alone, systematic reviews with summary-of-findings tables, and ‘graded-entry’ formats (a ‘front-end’ summary and a contextually framed narrative report plus the SR). The influence of format on the proportion of correct responses to key clinical questions, the primary outcome, was assessed using a written test. The secondary outcome was a composite endpoint, measured on a 5-point scale, of the clarity of presentation and ease of locating the quality of evidence for critical neonatal outcomes. Interviews conducted within two months following completion of trial data collection explored panel members’ views on the evidence summary formats and experiences with appraisal and use of research information.
Results
65 (93%) of 70 participants completed questions on the prespecified outcome measures. There were no differences between groups in the odds of correct responses to key clinical questions. ‘Graded-entry’ formats were associated with a higher mean composite score for clarity and accessibility of information about the quality of evidence for critical neonatal outcomes compared to systematic reviews alone (adjusted mean difference 0.52, 95% CI 0.06 to 0.99). There was no difference in the mean composite score between SR with SoF tables and SR alone. Findings from interviews with 16 panelists indicated that short narrative evidence reports were preferred for the improved clarity of information presentation and ease of use.
Conclusions
Our findings suggest that ‘graded-entry’ evidence summary formats may improve clarity and accessibility of research evidence in clinical guideline development.
Trial Registration
Controlled-Trials.com ISRCTN05154264
doi:10.1371/journal.pone.0055067
PMCID: PMC3555827  PMID: 23372813
3.  The “Child Health Evidence Week” and GRADE grid may aid transparency in the deliberative process of guideline development 
Journal of Clinical Epidemiology  2012;65(9-10):962-969.
Objective
To explore the evidence translation process during a 1-week national guideline development workshop (“Child Health Evidence Week”) in Kenya.
Study Design and Setting
Nonparticipant observational study of the discussions of a multidisciplinary guideline development panel in Kenya. Discussions were aided by GRADE (Grading of Recommendations Assessment, Development, and Evaluation) grid.
Results
Three key thematic categories emerged: 1) “referral to other evidence to support or refute the proposed recommendations;” 2) “assessment of the presented research evidence;” and 3) “assessment of the local applicability of evidence.” The types of evidence cited included research evidence and anecdotal evidence based on clinician experiences. Assessment of the research evidence revealed important challenges in the translation of evidence into recommendations, including absence of evidence, low quality or inconclusive evidence, inadequate reporting of key features of the management under consideration, and differences in panelists’ interpretation of the research literature. A broad range of factors with potential to affect local applicability of evidence were discussed.
Conclusion
The process of the “Child Health Evidence Week” combined with the GRADE grid may aid transparency in the deliberative process of guideline development, and provide a mechanism for comprehensive assessment, documentation, and reporting of multiple factors that influence the quality and applicability of guideline recommendations.
doi:10.1016/j.jclinepi.2012.03.004
PMCID: PMC3413881  PMID: 22742914
Clinical practice guidelines; Evidence; Knowledge translation; Transparency; GRADE; Pediatrics
4.  Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis 
Background
Diabetes self-management education (DSME) can be delivered in many forms. Group based DSME is widespread due to being a cheaper method and the added advantages of having patient meet and discuss with each other. assess effects of group-based DSME compared to routine treatment on clinical, lifestyle and psychosocial outcomes in type-2 diabetes patients.
Methods
A systematic review with meta-analysis. Computerised bibliographic database were searched up to January 2008 for randomised controlled trials evaluating group-based DSME for adult type-2 diabetics versus routine treatment where the intervention had at least one session and =/>6 months follow-up. At least two reviewers independently extracted data and assessed study quality.
Results
In total 21 studies (26 publications, 2833 participants) were included. Of all the participants 4 out of 10 were male, baseline age was 60 years, BMI 31.6, HbA1c 8.23%, diabetes duration 8 years and 82% used medication. For the main clinical outcomes, HbA1c was significantly reduced at 6 months (0.44% points; P = 0.0006, 13 studies, 1883 participants), 12 months (0.46% points; P = 0.001, 11 studies, 1503 participants) and 2 years (0.87% points; P < 0.00001, 3 studies, 397 participants) and fasting blood glucose levels were also significantly reduced at 12 months (1.26 mmol/l; P < 0.00001, 5 studies, 690 participants) but not at 6 months. For the main lifestyle outcomes, diabetes knowledge was improved significantly at 6 months (SMD 0.83; P = 0.00001, 6 studies, 768 participants), 12 months (SMD 0.85; P < 0.00001, 5 studies, 955 participants) and 2 years (SMD 1.59; P = 0.03, 2 studies, 355 participants) and self-management skills also improved significantly at 6 months (SMD 0.55; P = 0.01, 4 studies, 534 participants). For the main psychosocial outcomes, there were significant improvement for empowerment/self-efficacy (SMD 0.28, P = 0.01, 2 studies, 326 participants) after 6 months. For quality of life no conclusion could be drawn due to high heterogeneity. For the secondary outcomes there were significant improvements in patient satisfaction and body weight at 12 months for the intervention group. There were no differences between the groups in mortality rate, body mass index, blood pressure and lipid profile.
Conclusions
Group-based DSME in people with type 2 diabetes results in improvements in clinical, lifestyle and psychosocial outcomes.
doi:10.1186/1472-6963-12-213
PMCID: PMC3418213  PMID: 22824531
Patient education as topic; Self-care; Type 2 diabetes mellitus; Systematic review
5.  Comparative effectiveness of antihypertensive medication for primary prevention of cardiovascular disease: systematic review and multiple treatments meta-analysis 
BMC Medicine  2012;10:33.
Background
We conducted a systematic review of evidence from randomized controlled trials to answer the following research question: What are the relative effects of different classes of antihypertensive drugs in reducing the incidence of cardiovascular disease outcomes for healthy people at risk of cardiovascular disease?
Methods
We searched MEDLINE, EMBASE, AMED (up to February 2011) and CENTRAL (up to May 2009), and reference lists in recent systematic reviews. Titles and abstracts were assessed for relevance and those potentially fulfilling our inclusion criteria were then assessed in full text. Two reviewers made independent assessments at each step. We selected the following main outcomes: total mortality, myocardial infarction and stroke. We also report on angina, heart failure and incidence of diabetes. We conducted a multiple treatments meta-analysis using random-effects models. We assessed the quality of the evidence using the GRADE-instrument.
Results
We included 25 trials. Overall, the results were mixed, with few significant dif-ferences, and with no drug-class standing out as superior across multiple outcomes. The only significant finding for total mortality based on moderate to high quality evidence was that beta-blockers (atenolol) were inferior to angiotensin receptor blockers (ARB) (relative risk (RR) 1.14; 95% credibility interval (CrI) 1.02 to 1.28). Angiotensin converting enzyme (ACE)-inhibitors came out inferior to calcium-channel blockers (CCB) regarding stroke-risk (RR 1.19; 1.03 to 1.38), but superior regarding risk of heart failure (RR 0.82; 0.69 to 0.94), both based on moderate quality evidence. Diuretics reduced the risk of myocardial infarction compared to beta-blockers (RR 0.82; 0.68 to 0.98), and lowered the risk of heart failure compared to CCB (RR 0.73; 0.62 to 0.84), beta-blockers (RR 0.73; 0.54 to 0.96), and alpha-blockers (RR 0.51; 0.40 to 0.64). The risk of diabetes increased with diuretics compared to ACE-inhibitors (RR 1.43; 1.12 to 1.83) and CCB (RR 1.27; 1.05 to 1.57).
Conclusion
Based on the available evidence, there seems to be little or no difference between commonly used blood pressure lowering medications for primary prevention of cardiovascular disease. Beta-blockers (atenolol) and alpha-blockers may not be first-choice drugs as they were the only drug-classes that were not significantly superior to any other, for any outcomes.
Review registration: CRD database ("PROSPERO") CRD42011001066
doi:10.1186/1741-7015-10-33
PMCID: PMC3354999  PMID: 22480336
6.  Choice of generic antihypertensive drugs for the primary prevention of cardiovascular disease - A cost-effectiveness analysis 
Background
Hypertension is one of the leading causes of cardiovascular disease (CVD). A range of antihypertensive drugs exists, and their prices vary widely mainly due to patent rights. The objective of this study was to explore the cost-effectiveness of different generic antihypertensive drugs as first, second and third choice for primary prevention of cardiovascular disease.
Methods
We used the Norwegian Cardiovascular Disease model (NorCaD) to simulate the cardiovascular life of patients from hypertension without symptoms until they were all dead or 100 years old. The risk of CVD events and costs were based on recent Norwegian sources.
Results
In single-drug treatment, all antihypertensives are cost-effective compared to no drug treatment. In the base-case analysis, the first, second and third choice of antihypertensive were calcium channel blocker, thiazide and angiotensin-converting enzyme inhibitor. However the sensitivity and scenario analyses indicated considerable uncertainty in that angiotensin receptor blockers as well as, angiotensin-converting enzyme inhibitors, beta blockers and thiazides could be the most cost-effective antihypertensive drugs.
Conclusions
Generic antihypertensives are cost-effective in a wide range of risk groups. There is considerable uncertainty, however, regarding which drug is the most cost-effective.
doi:10.1186/1471-2261-12-26
PMCID: PMC3353849  PMID: 22475076
7.  Meningitis Dipstick Rapid Test: Evaluating Diagnostic Performance during an Urban Neisseria meningitidis Serogroup A Outbreak, Burkina Faso, 2007 
PLoS ONE  2010;5(6):e11086.
Meningococcal meningitis outbreaks occur every year during the dry season in the “meningitis belt” of sub-Saharan Africa. Identification of the causative strain is crucial before launching mass vaccination campaigns, to assure use of the correct vaccine. Rapid agglutination (latex) tests are most commonly available in district-level laboratories at the beginning of the epidemic season; limitations include a short shelf-life and the need for refrigeration and good technical skills. Recently, a new dipstick rapid diagnostic test (RDT) was developed to identify and differentiate disease caused by meningococcal serogroups A, W135, C and Y. We evaluated the diagnostic performance of this dipstick RDT during an urban outbreak of meningitis caused by N. meningitidis serogroup A in Ouagadougou, Burkina Faso; first against an in-country reference standard of culture and/or multiplex PCR; and second against culture and/or a highly sensitive nested PCR technique performed in Oslo, Norway. We included 267 patients with suspected acute bacterial meningitis. Using the in-country reference standard, 50 samples (19%) were positive. Dipstick RDT sensitivity (N = 265) was 70% (95%CI 55–82) and specificity 97% (95%CI 93–99). Using culture and/or nested PCR, 126/259 (49%) samples were positive; dipstick RDT sensitivity (N = 257) was 32% (95%CI 24–41), and specificity was 99% (95%CI 95–100). We found dipstick RDT sensitivity lower than values reported from (i) assessments under ideal laboratory conditions (>90%), and (ii) a prior field evaluation in Niger [89% (95%CI 80–95)]. Specificity, however, was similar to (i), and higher than (ii) [62% (95%CI 48–75)]. At this stage in development, therefore, other tests (e.g., latex) might be preferred for use in peripheral health centres. We highlight the value of field evaluations for new diagnostic tests, and note relatively low sensitivity of a reference standard using multiplex vs. nested PCR. Although the former is the current standard for bacterial meningitis surveillance in the meningitis belt, nested PCR performed in a certified laboratory should be used as an absolute reference when evaluating new diagnostic tests.
doi:10.1371/journal.pone.0011086
PMCID: PMC2884039  PMID: 20552035
8.  Clinical Reasoning in the Real World Is Mediated by Bounded Rationality: Implications for Diagnostic Clinical Practice Guidelines 
PLoS ONE  2010;5(4):e10265.
Background
Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment.
Method
This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil.
Results
Four main themes were identified: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision.
Discussion
Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration.
doi:10.1371/journal.pone.0010265
PMCID: PMC2857648  PMID: 20421920
9.  The Effect of How Outcomes Are Framed on Decisions about Whether to Take Antihypertensive Medication: A Randomized Trial 
PLoS ONE  2010;5(3):e9469.
Background
We conducted an Internet-based randomized trial comparing three valence framing presentations of the benefits of antihypertensive medication in preventing cardiovascular disease (CVD) for people with newly diagnosed hypertension to determine which framing presentation resulted in choices most consistent with participants' values.
Methods and Findings
In this second in a series of televised trials in cooperation with the Norwegian Broadcasting Company, adult volunteers rated the relative importance of the consequences of taking antihypertensive medication using visual analogue scales (VAS). Participants viewed information (or no information) to which they were randomized and decided whether or not to take medication. We compared positive framing over 10 years (the number escaping CVD per 1000); negative framing over 10 years (the number that will have CVD) and negative framing per year over 10 years of the effects of antihypertensive medication on the 10-year risk for CVD for a 40 year-old man with newly diagnosed hypertension without other risk factors. Finally, all participants were shown all presentations and detailed patient information about hypertension and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS-scores for the undesirable consequences of antihypertensive medication from the VAS-score for the benefit of CVD risk reduction. We used logistic regression to determine the association between participants' RIS and their choice. 1,528 participants completed the study. The statistically significant differences between the groups in the likelihood of choosing to take antihypertensive medication in relation to different values (RIS) increased as the RIS increased. Positively framed information lead to decisions most consistent with those made by everyone for the second, more fully informed decision. There was a statistically significant decrease in deciding to take antihypertensives on the second decision, both within groups and overall.
Conclusions
For decisions about taking antihypertensive medication for people with a relatively low baseline risk of CVD (70 per 1000 over 10 years), both positive and negative framing resulted in significantly more people deciding to take medication compared to what participants decided after being shown all three of the presentations.
Trial Registration
International Standard Randomised Controlled Trial Number Register ISRCTN 33771631
doi:10.1371/journal.pone.0009469
PMCID: PMC2830888  PMID: 20209127
10.  SUPPORT Tools for evidence-informed health Policymaking (STP) 16: Using research evidence in balancing the pros and cons of policies 
Health Research Policy and Systems  2009;7(Suppl 1):S16.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
In this article, we address the use of evidence to inform judgements about the balance between the pros and cons of policy and programme options. We suggest five questions that can be considered when making these judgements. These are: 1. What are the options that are being compared? 2. What are the most important potential outcomes of the options being compared? 3. What is the best estimate of the impact of the options being compared for each important outcome? 4. How confident can policymakers and others be in the estimated impacts? 5. Is a formal economic model likely to facilitate decision making?
doi:10.1186/1478-4505-7-S1-S16
PMCID: PMC2809501  PMID: 20018106
11.  SUPPORT Tools for evidence-informed health Policymaking (STP) 
This article is the Introduction to a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Knowing how to find and use research evidence can help policymakers and those who support them to do their jobs better and more efficiently. Each article in this series presents a proposed tool that can be used by those involved in finding and using research evidence to support evidence-informed health policymaking. The series addresses four broad areas: 1. Supporting evidence-informed policymaking 2. Identifying needs for research evidence in relation to three steps in policymaking processes, namely problem clarification, options framing, and implementation planning 3. Finding and assessing both systematic reviews and other types of evidence to inform these steps, and 4. Going from research evidence to decisions. Each article begins with between one and three typical scenarios relating to the topic. These scenarios are designed to help readers decide on the level of detail relevant to them when applying the tools described. Most articles in this series are structured using a set of questions that guide readers through the proposed tools and show how to undertake activities to support evidence-informed policymaking efficiently and effectively. These activities include, for example, using research evidence to clarify problems, assessing the applicability of the findings of a systematic review about the effects of options selected to address problems, organising and using policy dialogues to support evidence-informed policymaking, and planning policy monitoring and evaluation. In several articles, the set of questions presented offers more general guidance on how to support evidence-informed policymaking. Additional information resources are listed and described in every article. The evaluation of ways to support evidence-informed health policymaking is a developing field and feedback about how to improve the series is welcome.
doi:10.1186/1478-4505-7-S1-I1
PMCID: PMC3271819  PMID: 20018098
12.  SUPPORT Tools for evidence-informed health Policymaking (STP) 1: What is evidence-informed policymaking? 
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
In this article, we discuss the following three questions: What is evidence? What is the role of research evidence in informing health policy decisions? What is evidence-informed policymaking?
Evidence-informed health policymaking is an approach to policy decisions that aims to ensure that decision making is well-informed by the best available research evidence. It is characterised by the systematic and transparent access to, and appraisal of, evidence as an input into the policymaking process. The overall process of policymaking is not assumed to be systematic and transparent. However, within the overall process of policymaking, systematic processes are used to ensure that relevant research is identified, appraised and used appropriately. These processes are transparent in order to ensure that others can examine what research evidence was used to inform policy decisions, as well as the judgements made about the evidence and its implications. Evidence-informed policymaking helps policymakers gain an understanding of these processes.
doi:10.1186/1478-4505-7-S1-S1
PMCID: PMC3271820  PMID: 20018099
13.  SUPPORT Tools for evidence-informed health Policymaking (STP) 10: Taking equity into consideration when assessing the findings of a systematic review 
Health Research Policy and Systems  2009;7(Suppl 1):S10.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
In this article we address considerations of equity. Inequities can be defined as "differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust". These have been well documented in relation to social and economic factors. Policies or programmes that are effective can improve the overall health of a population. However, the impact of such policies and programmes on inequities may vary: they may have no impact on inequities, they may reduce inequities, or they may exacerbate them, regardless of their overall effects on population health.
We suggest four questions that can be considered when using research evidence to inform considerations of the potential impact a policy or programme option is likely to have on disadvantaged groups, and on equity in a specific setting. These are: 1. Which groups or settings are likely to be disadvantaged in relation to the option being considered? 2. Are there plausible reasons for anticipating differences in the relative effectiveness of the option for disadvantaged groups or settings? 3. Are there likely to be different baseline conditions across groups or settings such that that the absolute effectiveness of the option would be different, and the problem more or less important, for disadvantaged groups or settings? 4. Are there important considerations that should be made when implementing the option in order to ensure that inequities are reduced, if possible, and that they are not increased?
doi:10.1186/1478-4505-7-S1-S10
PMCID: PMC3271821  PMID: 20018100
14.  SUPPORT Tools for evidence-informed Policymaking in health 11: Finding and using evidence about local conditions 
Health Research Policy and Systems  2009;7(Suppl 1):S11.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Evidence about local conditions is evidence that is available from the specific setting(s) in which a decision or action on a policy or programme option will be taken. Such evidence is always needed, together with other forms of evidence, in order to inform decisions about options. Global evidence is the best starting point for judgements about effects, factors that modify those effects, and insights into ways to approach and address problems. But local evidence is needed for most other judgements about what decisions and actions should be taken. In this article, we suggest five questions that can help to identify and appraise the local evidence that is needed to inform a decision about policy or programme options. These are: 1. What local evidence is needed to inform a decision about options? 2. How can the necessary local evidence be found? 3. How should the quality of the available local evidence be assessed? 4. Are there important variations in the availability, quality or results of local evidence? 5. How should local evidence be incorporated with other information?
doi:10.1186/1478-4505-7-S1-S11
PMCID: PMC3271822  PMID: 20018101
15.  SUPPORT Tools for evidence-informed health Policymaking (STP) 12: Finding and using research evidence about resource use and costs 
Health Research Policy and Systems  2009;7(Suppl 1):S12.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
In this article, we address considerations about resource use and costs. The consequences of a policy or programme option for resource use differ from other impacts (both in terms of benefits and harms) in several ways. However, considerations of the consequences of options for resource use are similar to considerations related to other impacts in that policymakers and their staff need to identify important impacts on resource use, acquire and appraise the best available evidence regarding those impacts, and ensure that appropriate monetary values have been applied. We suggest four questions that can be considered when assessing resource use and the cost consequences of an option. These are: 1. What are the most important impacts on resource use? 2. What evidence is there for important impacts on resource use? 3. How confident is it possible to be in the evidence for impacts on resource use? 4. Have the impacts on resource use been valued appropriately in terms of their true costs?
doi:10.1186/1478-4505-7-S1-S12
PMCID: PMC3271823  PMID: 20018102
16.  SUPPORT Tools for evidence-informed health Policymaking (STP) 13: Preparing and using policy briefs to support evidence-informed policymaking 
Health Research Policy and Systems  2009;7(Suppl 1):S13.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Policy briefs are a relatively new approach to packaging research evidence for policymakers. The first step in a policy brief is to prioritise a policy issue. Once an issue is prioritised, the focus then turns to mobilising the full range of research evidence relevant to the various features of the issue. Drawing on available systematic reviews makes the process of mobilising evidence feasible in a way that would not otherwise be possible if individual relevant studies had to be identified and synthesised for every feature of the issue under consideration. In this article, we suggest questions that can be used to guide those preparing and using policy briefs to support evidence-informed policymaking. These are: 1. Does the policy brief address a high-priority issue and describe the relevant context of the issue being addressed? 2. Does the policy brief describe the problem, costs and consequences of options to address the problem, and the key implementation considerations? 3. Does the policy brief employ systematic and transparent methods to identify, select, and assess synthesised research evidence? 4. Does the policy brief take quality, local applicability, and equity considerations into account when discussing the synthesised research evidence? 5. Does the policy brief employ a graded-entry format? 6. Was the policy brief reviewed for both scientific quality and system relevance?
doi:10.1186/1478-4505-7-S1-S13
PMCID: PMC3271824  PMID: 20018103
17.  SUPPORT Tools for evidence-informed health Policymaking (STP) 14: Organising and using policy dialogues to support evidence-informed policymaking 
Health Research Policy and Systems  2009;7(Suppl 1):S14.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Policy dialogues allow research evidence to be considered together with the views, experiences and tacit knowledge of those who will be involved in, or affected by, future decisions about a high-priority issue. Increasing interest in the use of policy dialogues has been fuelled by a number of factors: 1. The recognition of the need for locally contextualised 'decision support' for policymakers and other stakeholders 2. The recognition that research evidence is only one input into the decision-making processes of policymakers and other stakeholders 3. The recognition that many stakeholders can add significant value to these processes, and 4. The recognition that many stakeholders can take action to address high-priority issues, and not just policymakers. In this article, we suggest questions to guide those organising and using policy dialogues to support evidence-informed policymaking. These are: 1. Does the dialogue address a high-priority issue? 2. Does the dialogue provide opportunities to discuss the problem, options to address the problem, and key implementation considerations? 3. Is the dialogue informed by a pre-circulated policy brief and by a discussion about the full range of factors that can influence the policymaking process? 4. Does the dialogue ensure fair representation among those who will be involved in, or affected by, future decisions related to the issue? 5. Does the dialogue engage a facilitator, follow a rule about not attributing comments to individuals, and not aim for consensus? 6. Are outputs produced and follow-up activities undertaken to support action?
doi:10.1186/1478-4505-7-S1-S14
PMCID: PMC3271825  PMID: 20018104
18.  SUPPORT Tools for evidence-informed health Policymaking (STP) 15: Engaging the public in evidence-informed policymaking 
Health Research Policy and Systems  2009;7(Suppl 1):S15.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
In this article, we address strategies to inform and engage the public in policy development and implementation. The importance of engaging the public (both patients and citizens) at all levels of health systems is widely recognised. They are the ultimate recipients of the desirable and undesirable impacts of public policies, and many governments and organisations have acknowledged the value of engaging them in evidence-informed policy development. The potential benefits of doing this include the establishment of policies that include their ideas and address their concerns, the improved implementation of policies, improved health services, and better health. Public engagement can also be viewed as a goal in itself by encouraging participative democracy, public accountability and transparency. We suggest three questions that can be considered with regard to public participation strategies. These are: 1. What strategies can be used when working with the mass media to inform the public about policy development and implementation? 2. What strategies can be used when working with civil society groups to inform and engage them in policy development and implementation? 3. What methods can be used to involve consumers in policy development and implementation?
doi:10.1186/1478-4505-7-S1-S15
PMCID: PMC3271826  PMID: 20018105
19.  SUPPORT Tools for evidence-informed health Policymaking (STP) 17: Dealing with insufficient research evidence 
Health Research Policy and Systems  2009;7(Suppl 1):S17.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
In this article, we address the issue of decision making in situations in which there is insufficient evidence at hand. Policymakers often have insufficient evidence to know with certainty what the impacts of a health policy or programme option will be, but they must still make decisions. We suggest four questions that can be considered when there may be insufficient evidence to be confident about the impacts of implementing an option. These are: 1. Is there a systematic review of the impacts of the option? 2. Has inconclusive evidence been misinterpreted as evidence of no effect? 3. Is it possible to be confident about a decision despite a lack of evidence? 4. Is the option potentially harmful, ineffective or not worth the cost?
doi:10.1186/1478-4505-7-S1-S17
PMCID: PMC3271827  PMID: 20018107
20.  SUPPORT Tools for Evidence-informed Policymaking in health 18: Planning monitoring and evaluation of policies 
Health Research Policy and Systems  2009;7(Suppl 1):S18.
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
The term monitoring is commonly used to describe the process of systematically collecting data to inform policymakers, managers and other stakeholders whether a new policy or programme is being implemented in accordance with their expectations. Indicators are used for monitoring purposes to judge, for example, if objectives are being achieved, or if allocated funds are being spent appropriately. Sometimes the term evaluation is used interchangeably with the term monitoring, but the former usually suggests a stronger focus on the achievement of results. When the term impact evaluation is used, this usually implies that there is a specific attempt to try to determine whether the observed changes in outcomes can be attributed to a particular policy or programme. In this article, we suggest four questions that can be used to guide the monitoring and evaluation of policy or programme options. These are: 1. Is monitoring necessary? 2. What should be measured? 3. Should an impact evaluation be conducted? 4. How should the impact evaluation be done?
doi:10.1186/1478-4505-7-S1-S18
PMCID: PMC3271828  PMID: 20018108
21.  SUPPORT Tools for evidence-informed health Policymaking (STP) 2: Improving how your organisation supports the use of research evidence to inform policymaking 
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
In this article, we address ways of organising efforts to support evidence-informed health policymaking. Efforts to link research to action may include a range of activities related to the production of research that is both highly relevant to – and appropriately synthesised for – policymakers. Such activities may include a mix of efforts used to link research to action, as well as the evaluation of such efforts. Little is known about how best to organise the range of activity options available and, until recently, there have been relatively few organisations responsible for supporting the use of research evidence in developing health policy. We suggest five questions that can help guide considerations of how to improve organisational arrangements to support the use of research evidence to inform health policy decision making. These are: 1. What is the capacity of your organisation to use research evidence to inform decision making? 2. What strategies should be used to ensure collaboration between policymakers, researchers and stakeholders? 3. What strategies should be used to ensure independence as well as the effective management of conflicts of interest? 4. What strategies should be used to ensure the use of systematic and transparent methods for accessing, appraising and using research evidence? 5. What strategies should be used to ensure adequate capacity to employ these methods?
doi:10.1186/1478-4505-7-S1-S2
PMCID: PMC3271829  PMID: 20018109
22.  SUPPORT Tools for evidence-informed health Policymaking (STP) 3: Setting priorities for supporting evidence-informed policymaking 
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Policymakers have limited resources for developing – or supporting the development of – evidence-informed policies and programmes. These required resources include staff time, staff infrastructural needs (such as access to a librarian or journal article purchasing), and ongoing professional development. They may therefore prefer instead to contract out such work to independent units with more suitably skilled staff and appropriate infrastructure. However, policymakers may only have limited financial resources to do so. Regardless of whether the support for evidence-informed policymaking is provided in-house or contracted out, or whether it is centralised or decentralised, resources always need to be used wisely in order to maximise their impact. Examples of undesirable practices in a priority-setting approach include timelines to support evidence-informed policymaking being negotiated on a case-by-case basis (instead of having clear norms about the level of support that can be provided for each timeline), implicit (rather than explicit) criteria for setting priorities, ad hoc (rather than systematic and explicit) priority-setting process, and the absence of both a communications plan and a monitoring and evaluation plan. In this article, we suggest questions that can guide those setting priorities for finding and using research evidence to support evidence-informed policymaking. These are: 1. Does the approach to prioritisation make clear the timelines that have been set for addressing high-priority issues in different ways? 2. Does the approach incorporate explicit criteria for determining priorities? 3. Does the approach incorporate an explicit process for determining priorities? 4. Does the approach incorporate a communications strategy and a monitoring and evaluation plan?
doi:10.1186/1478-4505-7-S1-S3
PMCID: PMC3271830  PMID: 20018110
23.  SUPPORT Tools for evidence-informed health Policymaking (STP) 4: Using research evidence to clarify a problem 
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Policymakers and those supporting them often find themselves in situations that spur them on to work out how best to define a problem. These situations may range from being asked an awkward or challenging question in the legislature, through to finding a problem highlighted on the front page of a newspaper. The motivations for policymakers wanting to clarify a problem are diverse. These may range from deciding whether to pay serious attention to a particular problem that others claim is important, through to wondering how to convince others to agree that a problem is important. Debates and struggles over how to define a problem are a critically important part of the policymaking process. The outcome of these debates and struggles will influence whether and, in part, how policymakers take action to address a problem. Efforts at problem clarification that are informed by an appreciation of concurrent developments are more likely to generate actions. These concurrent developments can relate to policy and programme options (e.g. the publication of a report demonstrating the effectiveness of a particular option) or to political events (e.g. the appointment of a new Minister of Health with a personal interest in a particular issue). In this article, we suggest questions that can be used to guide those involved in identifying a problem and characterising its features. These are: 1. What is the problem? 2. How did the problem come to attention and has this process influenced the prospect of it being addressed? 3. What indicators can be used, or collected, to establish the magnitude of the problem and to measure progress in addressing it? 4. What comparisons can be made to establish the magnitude of the problem and to measure progress in addressing it? 5. How can the problem be framed (or described) in a way that will motivate different groups?
doi:10.1186/1478-4505-7-S1-S4
PMCID: PMC3271831  PMID: 20018111
24.  SUPPORT Tools for evidence-informed health Policymaking (STP) 5: Using research evidence to frame options to address a problem 
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Policymakers and those supporting them may find themselves in one or more of the following three situations that will require them to characterise the costs and consequences of options to address a problem. These are: 1. A decision has already been taken and their role is to maximise the benefits of an option, minimise its harms, optimise the impacts achieved for the money spent, and (if there is substantial uncertainty about the likely costs and consequences of the option) to design a monitoring and evaluation plan, 2. A policymaking process is already underway and their role is to assess the options presented to them, or 3. A policymaking process has not yet begun and their role is therefore to identify options, characterise the costs and consequences of these options, and look for windows of opportunity in which to act. In situations like these, research evidence, particularly about benefits, harms, and costs, can help to inform whether an option can be considered viable. In this article, we suggest six questions that can be used to guide those involved in identifying policy and programme options to address a high-priority problem, and to characterise the costs and consequences of these options. These are: 1. Has an appropriate set of options been identified to address a problem? 2. What benefits are important to those who will be affected and which benefits are likely to be achieved with each option? 3. What harms are important to those who will be affected and which harms are likely to arise with each option? 4. What are the local costs of each option and is there local evidence about their cost-effectiveness? 5. What adaptations might be made to any given option and could they alter its benefits, harms and costs? 6. Which stakeholder views and experiences might influence an option's acceptability and its benefits, harms, and costs?
doi:10.1186/1478-4505-7-S1-S5
PMCID: PMC3271832  PMID: 20018112
25.  SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented 
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
After a policy decision has been made, the next key challenge is transforming this stated policy position into practical actions. What strategies, for instance, are available to facilitate effective implementation, and what is known about the effectiveness of such strategies? We suggest five questions that can be considered by policymakers when implementing a health policy or programme. These are: 1. What are the potential barriers to the successful implementation of a new policy? 2. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes among healthcare recipients and citizens? 3. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes in healthcare professionals? 4. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary organisational changes? 5. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary systems changes?
doi:10.1186/1478-4505-7-S1-S6
PMCID: PMC3271833  PMID: 20018113

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