Evidence synthesis to policy: development and implementation of an impact-oriented approach from the Eastern Mediterranean Region.

BACKGROUND: Despite the importance of evidence syntheses in informing policymaking, their production and use remain limited in the Eastern Mediterranean region (EMR). There is a lack of empirical research on approaches to promote and use policy-relevant evidence syntheses to inform policymaking processes in the EMR. OBJECTIVE: This study sought to describe the development of an impact-oriented approach to link evidence synthesis to policy, and its implementation through selected case studies in Lebanon, a middle-income country in the EMR. METHODS: This study followed a multifaceted and iterative process that included (i) a review of the literature, (ii) input from international experts in evidence synthesis and evidence-informed health policymaking, and (iii) application in a real-world setting (implementation). We describe four selected case studies of implementation. Surveys were used to assess policy briefs, deliberative dialogues, and post-dialogue activities. Additionally, Kingdon's stream theory was adopted to further explain how and why the selected policy issues rose to the decision agenda. RESULTS: The approach incorporates three interrelated phases: (1) priority setting, (2) evidence synthesis, and (3) uptake. Policy-relevant priorities are generated through formal priority setting exercises, direct requests by policymakers and stakeholders, or a focusing event. Identified priorities are translated into focused questions that can be addressed via evidence synthesis (phase 1). Next, a scoping of the literature is conducted to identify existing evidence syntheses addressing the question of interest. Unless the team identifies relevant, up-to-date and high-quality evidence syntheses, it proceeds to conducting SRs addressing the priority questions of interest (phase 2). Next, the team prepares knowledge translation products (e.g., policy briefs) for undertaking knowledge uptake activities, followed by monitoring and evaluation (phase 3). There are two prerequisites to the application of the approach: enhancing contextual awareness and capacity strengthening. The four case studies illustrate how evidence produced from the suites of activities was used to inform health policies and practices. CONCLUSIONS: To our knowledge, this is the first study to describe both the development and implementation of an approach to link evidence synthesis to policy in the EMR. We believe the approach will be useful for researchers, knowledge translation platforms, governments, and funders seeking to promote evidence-informed policymaking and practice.

Knowledge management tools and mechanisms for evidence-informed decision-making in the WHO European Region: a scoping review.

BACKGROUND: Knowledge management (KM) emerged as a strategy to promote evidence-informed decision-making. This scoping review aims to map existing KM tools and mechanisms used to promote evidence-informed health decision-making in the WHO European Region and identify knowledge gaps. METHODS: Following the Joanna Briggs Institute (JBI) guidance for conducting scoping reviews, we searched Medline, PubMed, EMBASE, the Cochrane library, and Open Grey. We conducted a descriptive analysis of the general characteristics of the included papers and conducted narrative analysis of the included studies and categorized studies according to KM type and phase. RESULTS: Out of 9541 citations identified, we included 141 studies. The KM tools mostly assessed are evidence networks, surveillance tools, observatories, data platforms and registries, with most examining KM tools in high-income countries of the WHO European region. Findings suggest that KM tools can identify health problems, inform health planning and resource allocation, increase the use of evidence by policymakers and stimulate policy discussion. CONCLUSION: Policymakers and funding agencies are called to support capacity-building activities, and future studies to strengthen KM in the WHO European region particularly in Eastern Europe and Central Asia. An updated over-arching strategy to coordinate KM activities in the WHO European region will be useful in these efforts.

Stereotactic radiotherapy for oligoprogressive ER-positive breast cancer (AVATAR).

BACKGROUND: The enhanced knowledge of cancer biology has led to considerable advancement in systemic therapy for advanced breast cancer. Recently, studies showed that cyclin-dependent kinase (CDK) 4/6 inhibitor, when added to endocrine therapy, had improved the outcomes of patients with advanced ER-positive HER2-negative breast cancer. However, the disease often progresses following a period of treatment response. In a subset of patients, disease progression may occur at limited sites, i.e., oligoprogressive disease (OPD). In the past few years, stereotactic radiotherapy (SRT) has emerged as a safe and effective treatment for advanced cancer when delivered to limited metastatic sites. Hence, it is worth investigating the role of SRT in the setting of oligoprogressive breast cancer. METHOD: AVATAR is a multicentre phase II registry trial of SRT with endocrine therapy and CDK 4/6 inhibitor for the management of advanced ER-positive HER2-negative breast cancer. The study aims to enrol 32 patients with OPD limited to 5 lesions. The primary endpoint of the study is time to change systemic therapy measured from the commencement of SRT to change in systemic therapy. Secondary objectives include overall survival, progression free survival and treatment related toxicity. The exploratory objective is to describe the time to change in systemic therapy by the site (bone only vs. non-bone lesions) and number (1 vs. > 1) of OPD. DISCUSSION: This study aims to explore the effect of SRT in maximising the benefit of systemic therapy in patients with oligoprogressive ER-positive HER2-negative breast cancer. This approach might help reduce the burden of disease and improve the life quality in these patients. TRIAL REGISTRATION: ACTRN, ACTRN12620001212943 . Date of registration 16 November 2020- Retrospectively registered.

Amplifying the role of knowledge translation platforms in the COVID-19 pandemic response.

The COVID-19 pandemic presents the worst public health crisis in recent history. The response to the COVID-19 pandemic has been challenged by many factors, including scientific uncertainties, scarcity of relevant research, proliferation of misinformation and fake news, poor access to actionable evidence, time constraints, and weak collaborations among relevant stakeholders. Knowledge translation (KT) platforms, composed of organisations, initiatives and networks supporting evidence-informed policy-making, can play an important role in providing relevant and timely evidence to inform pandemic responses and bridge the gap between science, policy, practice and politics. In this Commentary, we highlight the emerging roles of KT platforms in light of the COVID-19 pandemic. We also reflect on the lessons learned from the efforts of a KT platform in a middle-income country to inform decision-making and practice during the COVID-19 pandemic. The lessons learned can be integrated into strengthening the role, structures and mandates of KT platforms as hubs for trustworthy evidence that can inform policies and practice during public health crises and in promoting their integration and institutionalisation within the policy-making processes.

Prioritization approaches in the development of health practice guidelines: a systematic review.

BACKGROUND: Given the considerable efforts and resources required to develop practice guidelines, developers need to prioritize what topics and questions to address. This study aims to identify and describe prioritization approaches in the development of clinical, public health, or health systems guidelines. METHODS: We searched Medline and CINAHL electronic databases in addition to Google Scholar. We included papers describing prioritization approaches in sufficient detail allowing for reproducibility. We synthesized findings in a semi-quantitative way. We followed an iterative process to develop a common framework of prioritization criteria that captures all of the criteria reported by each included study. RESULTS: Our search captured 33,339 unique citations out of which we identified 10 papers reporting prioritization approaches for guideline development. All of the identified approaches focused on prioritizing guideline topics but none on prioritizing recommendation questions or outcomes. The two most frequently reported steps of the development process for these approaches were reviewing the grey literature (9 out of 10, 90%) and engaging various stakeholders (9 out of 10, 90%). We derived a common framework of 20 prioritization criteria that can be used when prioritizing guideline topics. The most frequently reported criteria were the health burden of disease which was included in all of the approaches, practice variation (8 out of 10, 80%), and impact on health outcomes (7 out of 10, 70%). Two of the identified approaches stood out as being comprehensive and detailed. CONCLUSIONS: We described 10 prioritization approaches in the development of health practice guidelines. There is a need to assess the effectiveness, efficiency and transparency of the identified approaches and to develop standardized and validated priority setting tools.

Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria.

The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care-a strategy of using people's need for health care as a weapon against them by violently depriving them of it-has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.

Public health journals' requirements for authors to disclose funding and conflicts of interest: a cross-sectional study.

BACKGROUND: Public health journals need to have clear policies for reporting the funding of studies and authors' personal financial and non-financial conflicts of interest (COI) disclosures. This study aims to assess the policies of public health journals on reporting of study funding and the disclosure of authors' COIs. METHODS: This is a cross-sectional study of "Public, Environmental & Occupational Health" journals. Teams of two researchers abstracted data in duplicate and independently using REDCap software. RESULTS: Of 173 public health journals, 155 (90%) had a policy for reporting study funding information. Out of these, a majority did not require reporting of the phase of the study for which funding was received (88%), nor the types of funding sources (87%). Of the 173 journals, 163 (94%) had a policy requiring disclosure of authors' COI. However, the majority of these journals did not require financial conflicts of interest disclosures relating to institutions (75%) nor to the author's family members (90%) while 56% required the disclosure of at least one form of non-financial COI. CONCLUSIONS: The policies of the majority of public health journals do not require the reporting of important details such as the role of the funder, and non-financial COI. Journals and publishers should consider revising their editorial policies to ensure complete and transparent reporting of funding and COI.

The reporting of funding in health policy and systems research: a cross-sectional study.

BACKGROUND: Major research-reporting statements, such as PRISMA and CONSORT, require authors to provide information about funding. The objectives of this study were (1) to assess the reporting of funding in health policy and systems research (HPSR) papers and (2) to assess the funding reporting policies of journals publishing on HPSR. METHODS: We conducted two cross-sectional surveys for papers published in 2016 addressing HPSR (both primary studies and systematic reviews) and for journals publishing on HPSR (both journals under the 'Health Policy and Services' (HPS) category in the Web of Science, and non-HPS journals that published on HPSR). Teams of two reviewers selected studies and abstracted data in duplicate and independently. We conducted descriptive analyses and a regression analysis to investigate the association between reporting of funding by papers and the journal's characteristics. RESULTS: We included 400 studies (200 systematic reviews and 200 primary studies) that were published in 198 journals. Approximately one-third (31%) of HPSR papers did not report on funding. Of those that did, only 11% reported on the role of funders (15% of systematic reviews and 7% of primary studies). Of the 198 journals publishing on HPSR, 89% required reporting of the source of funding. Of those that did, about one-third (34%) required reporting of the role of funders. Journals classified under the HPS category (n = 72) were less likely than non-HPS journals that published HPSR studies (n = 142) to require information on the role of funders (15% vs. 32%). We did not find any of the journals' characteristics to be associated with the reporting of funding by papers. CONCLUSIONS: Despite the majority of journals publishing on HPSR requiring the reporting of funding, approximately one-third of HPSR papers did not report on the funding source. Moreover, few journals publishing on HPSR required the reporting of the role of funders, and few HPSR papers reported on that role.

Health research institutional mapping: an Eastern Mediterranean Regional perspective.

BACKGROUND: Research-conducive environments are mandatory for planning, implementing and translating research findings into evidence-informed health policies. AIM: This study aimed at comprehensive situation analysis of health research institutions in the Region. METHODS: We collected data on: institutional characteristics, research scope, capacity building, ethics, governance and resources. RESULTS: We contacted 575 institutions, of which, 223 (38.8%) responded, indicating that they conducted population research (82%). Reported studies were mostly in medicine, public health and epidemiology, while reported capacity building mainly focused on scientific writing (20.6%), research proposal writing (18%) and quantitative research methods (17%). Most institutions reported having collaborating partners (82%) - predominantly national (77%). Sixty-four percent of institutions received their own funding, with 48% reporting always having access to national databases. CONCLUSION: Governments in the Eastern Mediterranean Region and international funding agencies are called upon to support health research production through increasing allocated support and capacity building in health research.

Requirements of health policy and services journals for authors to disclose financial and non-financial conflicts of interest: a cross-sectional study.

BACKGROUND: The requirements of the health policy and services journals for authors to report their financial and non-financial conflicts of interest (COI) are unclear. The present article aims to assess the requirements of health policy and services journals for authors to disclose their financial and non-financial COIs. METHODS: This is a cross-sectional study of journals listed by the Web of Science under the category of 'Health Policy and Services'. We reviewed the 'Instructions for Authors' on the journals' websites and then simulated the submission of a manuscript to obtain any additional relevant information made available during that step. We abstracted data in duplicate and independently using a standardised form. RESULTS: Out of 72 eligible journals, 67 (93%) had a COI policy. A minority of policies described how the disclosed COIs of authors would impact the editorial process (34%). None of the policies had clear-cut criteria for rejection based on the content of the disclosure. Approximately a fifth of policies (21%) explicitly stated that inaccurate or incomplete disclosures might lead to manuscript rejection or retraction. No policy described whether the journal would verify the accuracy or completeness of authors' disclosed COIs. Most journals' policies (93%) required the disclosure of at least one form of financial COI. While the majority asked for specification of source of payment (71%), a minority asked for the amount (18%). Overall, 81% of policies explicitly required disclosure of non-financial COIs. CONCLUSION: A majority of health policy and services journal policies required the disclosure of authors' financial and non-financial COIs, but few required details on disclosed COIs. Health policy journals should provide specific definitions and instructions for disclosing non-financial COIs. A framework providing clear typology and operational definitions of the different types of COIs will facilitate both their disclosure by authors and reviewers and their assessment and management by the editorial team and the readers.

Systematic reviews addressing identified health policy priorities in Eastern Mediterranean countries: a situational analysis.

BACKGROUND: Systematic reviews can offer policymakers and stakeholders concise, transparent, and relevant evidence pertaining to pressing policy priorities to help inform the decision-making process. The production and the use of systematic reviews are specifically limited in the Eastern Mediterranean region. The extent to which published systematic reviews address policy priorities in the region is still unknown. This situational analysis exercise aims at assessing the extent to which published systematic reviews address policy priorities identified by policymakers and stakeholders in Eastern Mediterranean region countries. It also provides an overview about the state of systematic review production in the region and identifies knowledge gaps. METHODS: We conducted a systematic search of the Health System Evidence database to identify published systematic reviews on policy-relevant priorities pertaining to the following themes: human resources for health, health financing, the role of the non-state sector, and access to medicine. Priorities were identified from two priority-setting exercises conducted in the region. We described the distribution of these systematic reviews across themes, sub-themes, authors' affiliations, and countries where included primary studies were conducted. RESULTS: Out of the 1,045 systematic reviews identified in Health System Evidence on selected themes, a total of 200 systematic reviews (19.1%) addressed the priorities from the Eastern Mediterranean region. The theme with the largest number of systematic reviews included was human resources for health (115) followed by health financing (33), access to medicine (27), and role of the non-state sector (25). Authors based in the region produced only three systematic reviews addressing regional priorities (1.5%). Furthermore, no systematic review focused on the Eastern Mediterranean region. Primary studies from the region had limited contribution to systematic reviews; 17 systematic reviews (8.5%) included primary studies conducted in the region. CONCLUSIONS: There are still gaps in the production of systematic reviews addressing policymakers' and stakeholders' priorities in the Eastern Mediterranean region. Efforts should be directed towards better aligning systematic review production with policy needs and priorities. Study findings can inform the agendas of researchers, research institutions, and international funding agencies of priority areas where systematic reviews are required.

The making of nursing practice law in Lebanon: a policy analysis case study.

BACKGROUND: Evidence-informed decisions can strengthen health systems, improve health, and reduce health inequities. Despite the Beijing, Montreux, and Bamako calls for action, literature shows that research evidence is underemployed in policymaking, especially in the East Mediterranean region (EMR). Selecting the draft nursing practice law as a case study, this policy analysis exercise aims at generating in-depth insights on the public policymaking process, identifying the factors that influence policymaking and assessing to what extent evidence is used in this process. METHODS: This study utilized a qualitative research design using a case study approach and was conducted in two phases: data collection and analysis, and validation. In the first phase, data was collected through key informant interviews that covered 17 stakeholders. In the second phase, a panel discussion was organized to validate the findings, identify any gaps, and gain insights and feedback of the panelists. Thematic analysis was conducted and guided by the Walt & Gilson's "Policy Triangle Framework" as themes were categorized into content, actors, process, and context. RESULTS: Findings shed light on the complex nature of health policymaking and the unstructured approach of decision making. This study uncovered the barriers that hindered the progress of the draft nursing law and the main barriers against the use of evidence in policymaking. Findings also uncovered the risk involved in the use of international recommendations without the involvement of stakeholders and without accounting for contextual factors and implementation barriers. Findings were interpreted within the context of the Lebanese political environment and the power play between stakeholders, taking into account equity considerations. CONCLUSIONS: This policy analysis exercise presents findings that are helpful for policymakers and all other stakeholders and can feed into revising the draft nursing law to reach an effective alternative that is feasible in Lebanon. Our findings are relevant in local and regional context as policymakers and other stakeholders can benefit from this experience when drafting laws and at the global context, as international organizations can consider this case study when developing global guidance and recommendations.

The emergence and regression of political priority for refugee integration into the Jordanian health system: an analysis using the Kingdon's multiple streams model.

BACKGROUND: The prolonged presence of Syrian refugees in Jordan has highlighted the need for sustainable health service delivery models for refugees. In 2012, the Jordanian government adopted a policy that granted Syrian refugees access, free of charge, to the national health system. However since 2012, successive policy revisions have limited refugee access. This paper seeks to understand factors that initially put refugee integration into the health system on the policy agenda, as well as how these same factors later affected commitment to sustain the policy. METHODS: This paper draws on data from a document review of 197 peer-reviewed and grey literature publications, a media analysis of newspaper articles retrieved from four officially recognized newspapers in Jordan, and 33 semi-structured key informant interviews. We used Kingdon's Multiple Streams Model - a well-established tool for analyzing policy adoption - to understand how political priority developed for integration of refugees into the health system. RESULTS: We find that several factors helped bring attention to the issue, namely concerns over infectious disease transmission to host communities, high rates of chronic conditions among the refugee population and the increasingly urban and dispersed nature of refugees. At the outset of the conflict, the national mood was receptive to refugees. Politicians and government officials quickly recognized the crisis as an opportunity to secure material and technical support from the international humanitarian community. At the same time, global pressures for integrating refugees into national health systems helped move the integration agenda forward in Jordan and the region more broadly. Since 2012, there were several modifications to the policy that signal profound changes in national views around the continued presence of Syrian refugees in the country, as well as reduced external financial support which has undermined the sustainability of the policy. CONCLUSION: This case study underscores the dynamic nature of policymaking and the challenge of sustaining government commitment to the right to health among refugees. Our analysis has important implications for advocates seeking to advance and maintain momentum for the integration of refugees into national health systems.

Assessing the integration of refugee health data into national health information systems in Jordan, Lebanon, and Uganda.

BACKGROUND: With the increasing number of protracted refugee crises globally, it is essential to ensure strong national health information systems (HIS) in displacement settings that include refugee-sensitive data and disaggregation by refugee status. This multi-country study aims to assess the degree of integration of refugee health data into national HIS in Jordan, Lebanon, and Uganda and identify the strengths and weaknesses of their national HIS in terms of collecting and reporting on refugee-related health indicators. METHODS: The study employs a comparative country analysis approach using a three-phase framework. The first phase involved reviewing 4120 indicators compiled from global health organizations, followed by a multi-stage refinement process, resulting in 45 indicators distributed across five themes. The second phase consisted of selecting relevant criteria from the literature, including data sources, annual reporting, disaggregation by refugee status, refugee population adjustments, accuracy, and consistency. The third phase involved assessing data availability and quality of the selected indicators against these criteria. RESULTS: Our analysis uncovered significant challenges in assessing the health status of refugees in Jordan, Lebanon, and Uganda, primarily stemming from limitations in the available health data and indicators. Specifically, we identified significant issues including incomplete local data collection with reliance on international data sources, fragmented data collection from various entities leading to discrepancies, and a lack of distinction between refugees and host populations in most indicators. These limitations hinder accurate comparisons and analyses. In light of these findings, a set of actionable recommendations was proposed to guide policymakers in the three countries to improve the integration of refugee health data into their national HIS ultimately enhancing refugees' well-being and access to healthcare services. CONCLUSION: The current status of refugee-related health data in Jordan, Lebanon, and Uganda indicates the need for improved data collection and reporting practices, disaggregation by refugee status and better integration of refugee health data into national HIS to capture the health status and needs of refugees in host countries. Key improvement strategies include establishing a centralized authority for consistent and efficient data management, fostering transparent and inclusive data governance, and strengthening workforce capacity to manage refugee health data effectively.

Integrating Syrian refugees into Lebanon's healthcare system 2011-2022: a mixed-method study.

INTRODUCTION: The Lebanese government estimates the number of Syrian refugees to be 1.5 million, representing 25% of the population. Refugee healthcare services have been integrated into the existing Lebanese health system. This study aims to describe the integration of Syrian refugee health services into the Lebanese national health system from 2011 to 2022, amid an ongoing economic crisis since 2019 and the COVID-19 pandemic. METHODS: This paper employs a mixed-methods approach drawing upon different data sources including: 1- document review (policies, legislation, laws, etc.); 2- semi-structured interviews with policymakers, stakeholders, and health workers; 3- focus group discussions with patients from both host and refugee populations; and 4- health systems and care seeking indicators. RESULTS: Although the demand for primary health care increased due to the Syrian refugee crisis, the provision of primary health care services was maintained. The infusion of international funding over time allowed primary health care centers to expand their resources to accommodate increased demand. The oversupply of physicians in Lebanon allowed the system to maintain a relatively high density of physicians even after the massive influx of refugees. The highly privatized, fragmented and expensive healthcare system has impeded Syrian refugees' access to secondary and tertiary healthcare services. The economic crisis further exacerbated limits on access for both the host and refugee populations and caused tension between the two populations. Our findings showed that the funds are not channeled through the government, fragmentation across multiple financing sources and reliance on international funding. Common medications and vaccines were available in the public system for both refugee and host communities and were reported to be affordable. The economic crisis hindered both communities' access to medications due to shortages and dramatic price increases. CONCLUSION: Integrating refugees in national health systems is essential to achieve sustainable development goals, in particular universal health coverage. Although it can strengthen the capacity of national health systems, the integration of refugees in low-resource settings can be challenging due to existing health system arrangements (e.g., heavily privatized care, curative-oriented, high out-of-pocket, fragmentation across multiple financing sources, and system vulnerability to economic shocks).

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review.

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Digital health in fragile states in the Middle East and North Africa (MENA) region: A scoping review of the literature.

INTRODUCTION: Conflict, fragility and political violence, that are taking place in many countries in the Middle East and North Africa (MENA) region have devastating effects on health. Digital health technologies can contribute to enhancing the quality, accessibility and availability of health care services in fragile and conflict-affected states of the MENA region. To inform future research, investments and policy processes, this scoping review aims to map out the evidence on digital health in fragile states in the MENA region. METHOD: We conducted a scoping review following the Joanna Briggs Institute (JBI) guidelines. We conducted descriptive analysis of the general characteristics of the included papers and thematic analysis of the key findings of included studies categorized by targeted primary users of different digital health intervention. RESULTS: Out of the 10,724 articles identified, we included 93 studies. The included studies mainly focused on digital health interventions targeting healthcare providers, clients and data services, while few studies focused on health systems or organizations managers. Most of the included studies were observational studies (49%). We identified no systematic reviews. Most of the studies were conducted in Lebanon (32%) followed by Afghanistan (13%) and Palestine (12%). The first authors were mainly affiliated with institutions from countries outside the MENA region (57%), mainly United Kingdom and United States. Digital health interventions provided a platform for training, supervision, and consultation for health care providers, continuing education for medical students, and disease self-management. The review also highlighted some implementation considerations for the adoption of digital health such as computer literacy, weak technological infrastructure, and privacy concerns. CONCLUSION: This review showed that digital health technologies can provide promising solutions in addressing health needs in fragile and conflict-affected states. However, rigorous evaluation of digital technologies in fragile settings and humanitarian crises are needed to inform their design and deployment.

Combining Radiotherapy and Immunotherapy in Metastatic Breast Cancer: Current Status and Future Directions.

The role of radiotherapy and immunotherapy with immune checkpoint inhibitors (ICI) is of emerging interest in many solid tumours, including breast cancer. There is increasing evidence that the host's immune system plays an important role in influencing the response to treatment and prognosis in breast cancer. Several pre-clinical studies and clinical trials have reported on the 'abscopal effect-regression of distant untreated tumour sites, mediated by an immunological response following ionizing radiation to a targeted tumour site. Stereotactic Ablative Body Radiotherapy (SABR) is a non-invasive technique used to augment various immune responses with an ablative tumoricidal dose when compared to conventional radiotherapy. SABR is characterized by typically 1-5 precision radiotherapy treatments that simultaneously deliver a high dose, whilst sparing normal tissues. Following SABR, there is evidence of systemic immune activation in patients with increased PD1 expression on CD8+ and CD4+ T cells. Studies continue to focus on metastatic triple-negative disease, a highly immunogenic subtype of breast cancer with poor prognosis. In this review, we discuss the immunological effect of SABR, alone and in combination with immunotherapy, and the importance of dose and fractionation. We also propose future strategies for treating oligometastatic disease, where this approach may be most useful for producing durable responses.

Approaches to prioritising primary health research: a scoping review.

OBJECTIVE: To systematically identify and describe approaches to prioritise primary research topics in any health-related area. METHODS: We searched Medline and CINAHL databases and Google Scholar. Teams of two reviewers screened studies and extracted data in duplicate and independently. We synthesised the information across the included approaches by developing common categorisation of relevant concepts. RESULTS: Of 44 392 citations, 30 articles reporting on 25 approaches were included, addressing the following fields: health in general (n=9), clinical (n=10), health policy and systems (n=10), public health (n=6) and health service research (n=5) (10 addressed more than 1 field). The approaches proposed the following aspects to be addressed in the prioritisation process: situation analysis/ environmental scan, methods for generation of initial list of topics, use of prioritisation criteria, stakeholder engagement, ranking process/technique, dissemination and implementation, revision and appeal mechanism, and monitoring and evaluation. Twenty-two approaches proposed involving stakeholders in the priority setting process. The most commonly proposed stakeholder category was 'researchers/academia' (n=17, 77%) followed by 'healthcare providers' (n=16, 73%). Fifteen of the approaches proposed a list of criteria for determining research priorities. We developed a common framework of 28 prioritisation criteria clustered into nine domains. The criterion most frequently mentioned by the identified approaches was 'health burden' (n=12, 80%), followed by 'availability of resources' (n=11, 73%). CONCLUSION: We identified and described 25 prioritisation approaches for primary research topics in any health-related area. Findings highlight the need for greater participation of potential users (eg, policy-makers and the general public) and incorporation of equity as part of the prioritisation process. Findings can guide the work of researchers, policy-makers and funders seeking to conduct or fund primary health research. More importantly, the findings should be used to enhance a more coordinated approach to prioritising health research to inform decision making at all levels.

Preventing Unintentional Injuries in School-Aged Children: A Systematic Review.

BACKGROUND AND OBJECTIVES: Unintentional injuries constitute the leading causes of death and long-term disabilities among children aged 5 to 15 years. We aimed to systematically review published literature on interventions designed to prevent unintentional injuries among school-aged children. METHODS: We searched MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO and screened the reference lists of included studies and relevant reviews. We included randomized controlled trials, controlled before-and-after studies, and interrupted time series studies. The focus of included studies was on primary prevention measures. Two reviewers collected data on type of study design, setting, population, intervention, types of injuries, outcomes assessed, and statistical results. RESULTS: Of 30 179 identified studies, 117 were included in this review. Most of these studies were conducted in high-income countries and addressed traffic-related injuries. Evidence from included studies reveals that multicomponent educational interventions may be effective in improving safety knowledge, attitudes, and behaviors in school-aged children mainly when coupled with other approaches. Laws/legislation were shown to be effective in increasing cycle helmet use and reducing traffic-related injury rates. Findings reveal the relevance of infrastructure modification in reducing falls and improving pedestrian safety among children. CONCLUSIONS: Additional studies are needed to evaluate the impact of unintentional injury prevention interventions on injury, hospitalizations, and mortality rates and the impact of laws and legislation and infrastructure modification on preventing unintentional injuries among school-aged children.