Evidence-Informed Oral Health Policy Making: Opportunities and Challenges.

Despite a clear need for improvement in oral health systems, progress in oral health systems transformation has been slow. Substantial gaps persist in leveraging evidence and stakeholder values for collective problem solving. To truly enable evidence-informed oral health policy making, substantial "know-how" and "know-do" gaps still need to be overcome. However, there is a unique opportunity for the oral health community to learn and evolve from previous successes and failures in evidence-informed health policy making. As stated by the Global Commission on Evidence to Address Societal Challenges, COVID-19 has created a once-in-a-generation focus on evidence, which has fast-tracked collaboration among decision makers, researchers, and evidence intermediaries. In addition, this has led to a growing recognition of the need to formalize and strengthen evidence-support systems. This article provides an overview of recent advancements in evidence-informed health policy making, including normative goals and a health systems taxonomy, the role of evidence-support and evidence-implementation systems to improve context-specific decision-making processes, the evolution of learning health systems, and the important role of citizen deliberations. The article also highlights opportunities for evidence-informed policy making to drive change in oral health systems. All in all, strengthening capacities for evidence-informed health policy making is critical to enable and enact improvements in oral health systems.

Support mechanisms for research generation and application for postgraduate students in four universities in Uganda.

BACKGROUND: A large proportion of postgraduate students the world over complete a research thesis in partial fulfilment of their degree requirements. This study identified and evaluated support mechanisms for research generation and utilization for masters' students in health institutions of higher learning in Uganda. METHODS: This was a self-administered cross-sectional survey using a modified self-assessment tool for research institutes (m-SATORI). Postgraduate students were randomly selected from four medical or public health Ugandan universities at Makerere, Mbarara, Nkozi and Mukono and asked to circle the most appropriate response on a Likert scale from 1, where the "situation was unfavourable and/or there was a need for an intervention", to 5, where the "situation was good or needed no intervention". These questions were asked under four domains: the research question; knowledge production, knowledge transfer and promoting use of evidence. Mean scores of individual questions and aggregate means under the four domains were computed and then compared to identify areas of strengths and gaps that required action. RESULTS: Most of the respondents returned their questionnaires, 185 of 258 (71.7%), and only 79 of these (42.7%) had their theses submitted for examination. The majority of the respondents were male (57.3%), married or cohabiting (58.4%), and were medical doctors (71.9%) from Makerere University (50.3%). The domain proposal development for postgraduate research project had the highest mean score of 3.53 out of the maximum 5. Three of the four domains scored below the mid-level domain score of 3, that is, the situation is neither favourable nor unfavourable. Areas requiring substantial improvements included priority-setting during research question identification, which had the lowest mean score of 2.12. This was followed by promoting use of postgraduate research products, tying at mean scores of 2.28 each. The domain knowledge transfer of postgraduate research products had an above-average mean score of 2.75. CONCLUSIONS: This study reports that existing research support mechanisms for postgraduate students in Uganda encourage access to supervisors and mentors during proposal development. Postgraduate students' engagement with research users was limited in priority-setting and knowledge transfer. Since supervisors and mentors views were not captured, future follow-on research could tackle this aspect.

Evidence brief: supporting rapid learning and improvement across Ontario's health system

Ontario has both a health system and a research system that are increasingly aiming to support rapid learning and improvement. Yet, Ontario's health system still faces complex challenges, such as reducing emergency-room wait times, ending hallway medicine, improving support for people with mental health and substance-use problems, and providing optimal care to a growing aging population. To contend with these challenges, the government recently introduced The People's Health Care Act, which will enact the Connecting Care Act and amend and repeal a number of existing acts and regulations.This redesign provides a unique opportunity to take stock of the health and research system assets that exist within each of these agencies, at each level of health system and across the different parts of the health system to determine how they can best be joined up to maximize their value. The redesign also provides an opportunity to ask how a rapid-learning health-system approach if 'baked into' the redesign and its implementation from the beginning, could assist with ensuring that the redesign (and course corrections based on rapid feedback and real-time learning) continually 'moves the needle' in ways that matter most to patients and families.

Use of post-graduate students' research in evidence informed health policies: a case study of Makerere University College of Health Sciences, Uganda.

BACKGROUND: World over, stakeholders are increasingly concerned about making research useful in public policy-making. However, there are hardly any reports linking production of research by students at institutions of higher learning to its application in society. We assessed whether and how post-graduate students' research was used in evidence-informed health policies. METHODS: This is a multiple case study of master's students' dissertations at Makerere University College of Health Sciences (MakCHS) produced between 1996 and 2010. In a structured review, we applied a theoretical framework of 'research use' and used content analysis to map how research was used in public policy documents. We categorised content of these documents according to the health-related Millennium Development Goals (MDG). We defined a case of 'use' as citation of research products from a master's student's dissertation in a public policy-related document. RESULTS: We found 22 cases of research use in policy-related documents (0.5%) out of a total 4230 citations from 16 of 1172 total dissertations (1.4%). Additionally, research was mostly cited in primary studies (95.4%), systematic reviews (3%), narrative reviews (0.8%) and cost-effectiveness analyses (0.2%). Research was predominantly used instrumentally, to either frame the problem (burden of disease or health condition) or select an intervention (treatment or diagnostic option) and rarely symbolically to justify strategies already selected. The bulk of the cases of research use addressed child health (MDG 4), focusing on infectious diseases (MDG 6), mainly in international clinical or public health guidelines, working papers, a consensus statement and a global report. We distilled 'synergistic relationships' among organisations or interest groups, 'globalisation of local evidence', 'trade-offs' in the use of research and use of 'negative results' from the documents and text content. CONCLUSIONS: Research from dissertations of post-graduate students at MakCHS is used in evidence-informed health policies, particularly for infectious diseases in child health. Further, we have delineated pathways of research use in the global arena and highlighted the importance of 'negative results' from dissertations of post-graduate students at MakCHS.

A systematic review on academic research productivity of postgraduate students in low- and middle-income countries.

BACKGROUND: While several individual studies addressing research productivity of post-graduate students are available, a synthesis of effective strategies to increase productivity and the determinants of productivity in low-income countries has not been undertaken. Further, whether or not this research from post-graduate students' projects was applied in evidence-informed decision-making was unknown. Therefore, we conducted a systematic review of literature to identify and assess the effectiveness of approaches that increase productivity (proportion published) or the application (proportion cited) of post-graduate students' research, as well as to assess the determinants of post-graduate students' research productivity and use. METHODS: We conducted a systematic review as per our a priori published protocol, also registered in PROSPERO (CRD42016042819). We searched for published articles in PubMed/MEDLINE and the ERIC databases through to July 2017. We performed duplicate assessments for included primary studies and resolved discrepancies by consensus. Thereafter, we completed a structured narrative synthesis and, for a subset of studies, we performed a meta-analysis of the findings using both fixed and random effects approaches. We aligned our results to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: We found 5080 articles in the PubMed (n = 3848) and ERIC (n = 1232) databases. After excluding duplicates (n = 33), we screened 5047 articles, of which 5012 were excluded. We then retrieved 44 full texts and synthesised 14, of which 4 had a high risk of bias. We did not find any studies assessing effectiveness of strategies for increasing publication nor citations of post-graduate research projects. We found an average publication proportion of 7% (95% CI 7-8%, Higgins I-squared 0.0% and Cochran's Q p < 0.01) and 23% (95% CI 17-29%, Higgins I-squared of 98.4% and Cochran's Q, p < 0.01) using fixed effects and random effects models, respectively. Two studies reported on the citation of post-graduate students' studies, at 17% (95% CI 15-19%) in Uganda and a median citation of 1 study in Turkey (IQR 0.6-2.3). Only one included study reported on the determinants of productivity or use of post-graduate students' research, suggesting that younger students were more likely to publish and cohort studies were more likely to be published. CONCLUSIONS: We report on the low productivity of post-graduate students' research in low- and middle-income countries, including the citation of post-graduate students' research in evidence-informed health policy in low- and middle-income countries. Secondly, we did not find a single study that assessed strategies to increase productivity and use of post-graduate students' research in evidence-informed health policy, a subject for future research.

Academic research productivity of post-graduate students at Makerere University College of Health Sciences, Uganda, from 1996 to 2010: a retrospective review.

BACKGROUND: Research is a core business of universities globally, and is crucial in the scientific process as a precursor for knowledge uptake and use. We aimed to assess the academic productivity of post-graduate students in a university located in a low-income country. METHODS: This is an observational retrospective documentary analysis using hand searching archives, Google Scholar and PubMed electronic databases. The setting is Makerere University College of Health Sciences, Uganda. Records of post-graduate students (Masters) enrolled from 1996 to 2010, and followed to 2016 for outcomes were analysed. The outcome measures were publications (primary), citations, electronic dissertations found online or conference abstracts (secondary). Descriptive and multivariable logistic regression analyses were performed using Stata 14.1. RESULTS: We found dissertations of 1172 Masters students over the 20-year period of study. While half (590, 50%) had completed clinical graduate disciplines (surgery, internal medicine, paediatrics, obstetrics and gynaecology), Master of Public Health was the single most popular course, with 393 students (31%). Manuscripts from 209 dissertations (18%; 95% CI, 16-20%) were published and approximately the same proportion was cited (196, 17%; 95% CI, 15-19%). Very few (4%) policy-related documents (technical reports and guidelines) cited these dissertations. Variables that remained statistically significant in the multivariable model were students' age at enrolment into the Masters programme (adjusted coefficient -0.12; 95% CI, -0.18 to -0.06; P < 0.001) and type of research design (adjusted coefficient 0.22; 0.03 to 0.40; P = 0.024). Cohort studies were more likely to be published compared to cross-sectional designs (adjusted coefficient 0.78; 95% CI, 0.2 to 1.36; P = 0.008). CONCLUSIONS: The productivity and use of post-graduate students' research conducted at the College of Health Sciences Makerere University is considerably low in terms of peer-reviewed publications and citations in policy-related documents. The need for effective strategies to reverse this 'waste' is urgent if the College, decision-makers, funders and the Ugandan public are to enjoy the 'return on investment' from post-graduate students research.

Where is students' research in evidence-informed decision-making in health? Assessing productivity and use of postgraduate students' research in low- and middle-income countries: a systematic review.

BACKGROUND: Investing in research that is not accessible or used is a waste of resources and an injustice to human subject participants. Post-graduate students' research in institutions of higher learning involves considerable time, effort and money, warranting evaluation of the return on investment. Although individual studies addressing research productivity of post-graduate students are available, a synthesis of these results in low-income settings has not been undertaken. Our first aim is to identify the types of approaches that increase productivity and those that increase the application of medical post-graduate students' research and to assess their effectiveness. Our second aim is to assess the determinants of post-graduate students' research productivity. METHODS: We propose a two-stage systematic review. We will electronically search for published and grey literature in PubMed/MEDLINE and the ERIC databases, as well as contact authors, research administration units of universities, and other key informants as appropriate. In stage one, we will map the nature of the evidence available using a knowledge translation framework adapted from existing literature. We will perform duplicate screening and selection of articles, data abstraction, and risk of bias assessments for included primary studies as described in the Cochrane handbook for systematic reviews. Our primary outcome is publication output as a measure of research productivity, whilst we defined research use as citations in peer-reviewed journals or policy-related documents as our secondary outcome. In stage two, we will perform a structured narrative synthesis of the findings and advance to quantitative meta-analysis if the number of studies are adequate and their heterogeneity is low. Adapting the Grading, Recommendations, Assessment, Development and Evaluation (GRADE) approach, we will assess the overall quality of evidence for effects, and report our results in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. DISCUSSION: We will share our findings with universities, other training institutions, civil society, funders as well as government departments in charge of education and health particularly in low- and middle-income countries.

Optimizing clinical practice in Ontario based on data, evidence and guidelines

Optimizing clinical practice based on data, evidence and guidelines is a challenge faced in every health system around the world. The way the challenge manifests itself at the level of the patient has been remarkably consistent over time: tough decisions made at the intersection of clinical expertise, patient values and preferences, and the best available data, evidence and guidelines.(1) Rigid clinical decision support systems, insufficient attention to patient goals of care and shared decision-making (particularly in the face of multimorbidity), and the large volume of available data, evidence and guidelines (of variable reliability and clinical significance) are variations on a now twodecades-old theme about just how tough these decisions can be

Supporting the use of research evidence in the Americas through an online "one-stop shop": the EVIPNet VHL.

Since the release of the 'World Report on Knowledge for Better Health' in 2004, a transformation has occurred in the field of health policy and systems research that has brought with it an increased emphasis on supporting the use of research evidence in the policy process. There has been an identified need for comprehensive online "one-stop shops" that facilitate the timely retrieval of research evidence in the policy process. This report highlights the EVIPNet VHL, a recently established project that was developed to meet the need for online repositories of relevant evidence to support knowledge translation efforts in the Americas, which can help contribute to strengthening health systems in the region.

Evidence brief: strengthening public and patient engagement in health technology assessment in Ontario

This evidence brief and the stakeholder dialogue it was prepared to inform were designed to guide the actions of those involved in strengthening public and patient engagement in HTA in Ontario. In this section of the brief, we propose key definitions to ensure a common conceptual understanding. We also highlight key goals for public and patient engagement in HTA, as well as describe the health policy and HTA context in Ontario. The second section focuses on the key challenges associated with strengthening public and patient engagement in HTA, with an emphasis on the Ontario context. In the third section we propose three elements of a potentially comprehensive approach to address the problem. Lastly, we highlight key implementation considerations for moving forward.

Evidence brief: supporting optimal screening approaches in Canada

This evidence brief mobilizes both global and local research evidence about a problem, three elements of a comprehensive approach for addressing the problem, and key implementation considerations. Whenever possible, the evidence brief summarizes research evidence drawn from systematic reviews of the research literature and occasionally from single research studies. A systematic review is a summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select and appraise research studies and to synthesize data from the included studies. The evidence brief does not contain recommendations, which would have required the authors of the brief to make judgments based on their personal values and preferences, and which could pre-empt important deliberations about whose values and preferences matter in making such judgments.

Evidence brief: creating community-based specialty clinics in Ontario

Ontario's Action Plan for Health Care called for "right care, right time, right place" (p. 10) and specifically for "moving procedures into the community" (p. 13).(1) To support the implementation of this commitment, the ministry of health has taken several steps. The ministry has supported one midwifery-led birth centre in Ontario (on Six Nations of the Grand River territory) and announced in March 2012 plans for two more. The ministry may also announce another type of community-based specialty clinic in the coming months.

How can knowledge brokering be advanced in a country's health system?

There is a general lack of attention given to 'what to do next' to advance knowledge brokering in many European countries' health systems. Four sets of interrelated issues can contribute to this problem within any given country's health system.

Evidence brief: Improving end-of-life communication, decision-making and care in Ontario

Improving end-of-life communication, decision-making and care has been identified as a pressing health issue in Ontario (and in Canada more generally), as evidenced by recent research,(1;2) public opinion polls,(3) expert panels and commissions,(4-6) and a high-profile legal case,(7) which have revealed many challenges in this area. The importance of this issue is also reflected by a strong push from various organizations to support citizens in having informed conversations about end-oflife issues and engaging in formalized advance care planning,(8) large advocacy coalitions dedicated to quality end-of-life care,(9;10) numerous initiatives to support high-quality integrated palliative and end-of-life care, including implementation of the 2011 Declaration of Partnership and Commitment to Action,(11) as well as an active research community dedicated to this issue.

Issue brief: designing integrated approaches to support people with multimorbidity in Ontario

Managing multiple medical conditions is part of the daily life of a growing number of Ontarians. As Fortin et al. observed, "patients with multiple conditions are the rule rather than the exception in primary care."(2) Multimorbidity (living with three or more medical conditions) has attracted significant attention among health system policymakers and stakeholders in Ontario, in part because adults with multimorbidity account for more than two-thirds of healthcare costs.(3) Multimorbidity not only has a significant impact on healthcare utilization and costs, but affects quality of life, ability to work, employability, disability, processes of care and mortality.(4) Despite the burden of multimorbidity, patients often receive care that is "fragmented, incomplete, inefficient, and ineffective."(4) Thus, there have been growing calls for changes to health systems and clinical decision-making processes to more effectively and efficiently provide the complex care required by those with multimorbidity.(5;6) One such response in Ontario has been Health Links, which was launched in December 2012 and now includes 26 'early adopters'. Health Links are designed to support local patient-care networks, led by a coordinating partner, and attempt to coordinate and optimize access to needed services, initially with a particular focus on the 5% of patients who consume about 66% of healthcare costs.(3;7) However, primary care, community care and other providers, whether working as part of or separate from Health Links, need support to achieve measurable successes in caring for patients with multimorbidity and preventing multimorbidity in those at risk, and to achieve health system transformation more broadly for this patient group.

Matching form to function: designing organizational models to support knowledge brokering in European health systems

Most existing organizational models for knowledge brokering comprise a set of design features that reflect an evolving effort, typically by researchers and research organizations, to balance a variety of competing objectives such as independence and relevance. These design features are rarely selected to optimize the match between form, function (knowledgebrokering mechanisms used) and the policy-making context.

Citizen brief: Improving access to palliative care in Ontario

For concerned citizens and influential thinkers and doers, the McMaster Health Forum strives to be a leading hub for improving health outcomes through collective problem solving. Operating at the regional/provincial level and at national levels, the Forum harnesses information, convenes stakeholders and prepares action-oriented leaders to meet pressing health issues creatively. The Forum acts as an agent of change by empowering stakeholders to set agendas, take well-considered actions and communicate the rationale for actions effectively.

Issue brief: strengthening national health systems' capacity to respond to future global pandemics

Effective pandemic governance is more important now than ever as pandemic risk factors like urbanization, the hypermobility of persons, trans-border trade, rapid population growth and changes to the environment and food systems all increase in tandem with the demands of globalization.(1) These transformative global shifts have fundamentally changed the way pathogens are spread around the world.(2) The World Health Organization (WHO) estimates that newly emerging infectious disease outbreaks in one country are now only hours away from affecting many others.(3) Pandemics previously spread over years (e.g., bubonic plague in the 14th century), months (e.g., cholera epidemics in 19th century) or weeks (e.g., Spanish influenza of 1918-1919), but in today's globalized world, Severe Acute Respiratory Syndrome (SARS) took only 17 hours to spread half-way around the world from China to Canada. Future disease outbreaks are expected to take similarly short periods before they affect multiple countries across geographically distinct regions.(3) The current outbreak of H7N9 bird influenza in China (which spreads more easily from infected fowl to humans than the H5N1 strain did in 2003, according to Dr. Keiji Fukuda, WHO's top influenza expert) is a stark reminder that the threat of a pandemic exists as an imminent threat to human health and international security.(4) Of notable concern is the fact that more than 30 unexpected outbreaks of previously unknown pathogens and re-emerging diseases were observed in the past two decades alone.(2) Although the great majority of new and re-emerging diseases have not caused pandemics, national health systems that can respond adequately to pandemic threats are fundamental to controlling pandemic-prone local disease outbreaks within a country or a region

Issue brief: building momentum in using the avoidable mortality indicators in Canada

Over the past three decades, Canada has made substantial progress in reducing the national rate of avoidable mortality (deaths that could potentially have been avoided through disease prevention or healthcare services). In fact, the national avoidable mortality rate has decreased by half ­ from 373 per 100,000 in 1979 to 185 per 100,000 in 2008.(1) During this period, avoidable mortality attributed to preventable causes decreased by 47%, while avoidable mortality attributed to treatable causes decreased by 56%. Additionally, Canada is faring well from an international standpoint, ranking the third lowest amongst G7 nations in rates of avoidable mortality, after Japan and France.(1) However, despite the significant gains that Canada has made in reducing avoidable mortality rates, there still exist variations in the distribution of avoidable mortality across provinces and territories, and across different population groups.(1) Additional efforts are needed to reduce avoidable mortality rates both among the jurisdictions and groups being 'left behind', as well as overall.

Policy brief 16: how can knowledge brokering be better supported across European health systems?

While there is a considerable body of health systems information being generated, it is often not being used as a key input in the policy-making process. The BRIDGE systematic review highlights several examples of health systems information: not being used at all, being only partially used, being used to address one feature of an issue, or being used to justify already taken ­ political ­ decisions. In other examples, health systems information is being used instrumentally rather than to change how people think about and approach a problem, potential options to address it and ways to implement any or all options. One reason why health systems information is not being used as frequently or optimally as it might, is that it is just one of many factors that can influence policy-making processes. We must also recognize that policy-makers and stakeholders may not value health systems information or deem it relevant to the issues they face.