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Director & Co-Directors' Blog
This issue we invite Yen-Fu Chen, Senior Research Fellow, to deliver a Guest Blog
From CAHRD to Campbell
After two days of an intensive consultation meeting at the Collaboration for Applied Health Research and Delivery (CAHRD), where the focus was on learning from stakeholders about the future direction of applied health research in low- and middle-income countries, I set off to Belfast to attend the 2014 Campbell Collaboration Colloquium. Having been a traditional ‘Cochraner’ for some time, it was a bizarre experience for me to meet so many people who, while doing the same type of work (systematic reviews) for the same purpose (informing policy and practice), are doing it in quite different contexts (education, crime and justice, and international development). It is somewhat like travelling to a different country in the modern world – you see people doing the same thing, such as going to a restaurant, but they have quite different menus and speak a different language.
Talking of language, one common issue that emerged from both meetings is terminology. In the CAHRD meeting we talked about the need for a standardised terminology in health service delivery research. As an example, the term “health system” means different things for different people and is often used when people want to describe something about health care, but know relatively little about it. In the Campbell conference I joined a session of the Knowledge Translation and Implementation (KTI) group where we were tasked with consolidating the definition of ‘knowledge translation’. The group leaders presented no less than 15 related terms (such as knowledge mobilisation and technical assistance) and identified 61 different frameworks or models of KTI through preliminary research. The tasks of resolving differences and reaching a consensus seem daunting.
While differences appear to be ubiquitous, many of them need not be a cause of concern so long as they do not lead to misunderstanding and ignorance. In the world of Campbell I soon got used to the term “moderator analysis,” which had only been known to me in the context of subgroup analysis and meta-regression for exploring potential sources of heterogeneity; and “impact evaluation for a development programme,” which appears somewhat similar to health technology assessments for new drugs, with which I am more familiar. I realised that although the names may be different and the techniques and emphasis may (quite rightly) vary to some extent to suit a different context, the principles are the same.
With my unease dissipated, I quickly started to enjoy exploring the new territory – as expected at such a conference there are many interesting things to be uncovered. For example, Professor Paul Connolly talked about how randomised controlled trials (RCTs) are depicted negatively in research methods textbooks as an unrealistic method advocated by positivists ignorant of the complex world of teaching and learning. He also detailed how the team at the Centre for Effective Education, based in the Queen’s University Belfast, have managed to conduct more than 30 RCTs in education settings since 2007. My recent task of sifting through nearly 10,000 records for a systematic review is easily dwarfed by the efforts of international colleagues who have trawled through over 60,000 records for a review of youth crime and violence. However, against the rather gloomy prospect of soon getting lost in the ever expanding sea of information, comes the welcome news that the Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre (a major player in the field of evidence synthesis in education and social policy) has developed smart software that utilises text mining and machine learning to automatically ‘prioritise’ references that are most likely to be relevant for a review based on the input of a few key words.
One of the most inspiring talks was delivered by Dr Howard White, who illustrated that the lack of permanent changes backed up by solid evidence has rendered education and social policy vulnerable to the influence of short-term political cycles. The example he quoted is the resurfacing of the debate on the merit of pay-for-performance based on exam results in school settings – an issue that was claimed to be resolved in a book concerning the education system in West Africa in the 1920s.
For people like me who have mainly been involved in evidence synthesis and evaluation in health care, but are curious about their application in the wider world, the International Initiative for Impact Evaluation (3ie), of which Dr White is the Executive Director, is well worth looking into. They are a US-based, not-for-profit organisation that commissions and carries out in-house systematic reviews and impact evaluations of development programmes for developing countries. They have offices in Washington, New Delhi and London and have commissioned or carried out more than 130 impact evaluations and 30 systematic reviews since 2009. Topics have been diverse, ranging from the more familiar, such as a systematic review of community-based intervention packages for reducing maternal morbidity and mortality and improving neonatal outcomes, to the less familiar, for example, impact evaluation of export processing zones on employment, wages and labour conditions in developing countries. All reports are available from their website, which also includes a wealth of other resources such as evidence ‘Gap Maps’, methodological working papers, a prospective registry for international development impact evaluations, and a searchable database of evaluation experts.
My final reflections upon the journey through both meetings is that to achieve the common aspiration of evidence-informed policy and practice, we need to break any boundary of disciplines and ideologies; and understand and embrace differences rather than exclude or ignore them, so that the diverse strength from individual persons and organisations can be harvested to the greatest extent to expedite the progress. Perhaps science has its own cycles, just like politics, and after a period of phenomenal advances in increasingly divided subject areas, the time has come to focus on how to integrate and synergise specialised knowledge.
Yen-Fu Chen with Martina Vojtkova, Evaluation Specialist from the 3ie,
at the Campbell Collaboration Colloquium 2014.
-- Yen-Fu Chen, Senior Research Fellow
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Contraception – a Huge Cause of Controversy Around the World
We at CLAHRC WM are very interested in not just differences, but similarities, across the globe. Access to contraception is an important issue in both rich and poor countries – for example, it is currently one of the main causes of controversy in both the USA and Uganda.
Two years ago, the Patient Protection and Affordable Care Act (commonly known as Obamacare) was upheld in the Supreme Court, mandating that organisations above a certain size offer their employees health insurance, including access to free contraception and to family planning services.[1] However, this mandate was modified last month when a controversial decision [2] was passed through the Supreme Court ruling that organisations with religious owners do not have to pay for their employee’s contraception as religious objection trumps federal law.[3]
Making contraception freely and easily available in order to promote choice and family planning is as controversial in the USA as it is in many countries in Africa. Some say that contraception promotes extramarital sex and abortion, but the evidence does not support this. In fact, religious beliefs in Uganda have led to the country having the highest unmet need for contraception.[4] Unplanned pregnancies are common, leading to high levels of unplanned births, unsafe abortion and maternal injuries and death.[5]
From a teleological point of view, the important thing for human societies is not to maximise the number of children born, but to capitalise on the numbers of successful and happy families.
It has been argued that Africa seems to be experiencing a rather attenuated dividend from economic emancipation and “CLAHRC Africa” (Warwick Centre for Applied Health Research and Delivery W-CAHRD) is currently studying the availability and demand for contraception in many African countries.
-- Jo Sartori, CLAHRC WM Head of Programme Delivery
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References
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Director's Choice - From the Journals
World's First Randomised Trial of Public Involvement
in Health Care and Policy Decisions
Evaluating the effects of public and patient involvement in priority setting in health care is notoriously tricky. However, two recent studies reported on a cluster RCT of enhanced public involvement among six health authorities in Canada.[1] [2] The results favoured the intervention, in that the priorities selected were different across the two groups and “Professionals’ choices moved toward indicators prioritized by the public (eg, access), and public representatives’ choices moved toward indicators prioritized by professionals (eg, self-care support).” A great strength of the study is the use of mixed methods advocated by CLAHRC WM – actually by all CLAHRCs. The public involvement was very carefully implemented with thorough induction of public representatives and moderation of the discussions, and the public representatives were selected because they were thought to have legitimacy and to represent different interests. These are landmark papers. In CLARHC WM what gets studied is what is implemented. The corollary is that there is no point in asking people what they want to research without also asking them what they think should be implemented. We therefore ensure that the members of the public who advise on the research are largely the same as those advising on the service.
-- Richard Lilford, Director CLAHRC WM
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Director's Choice - From the Journals
Birth Interval and Birth Weight
Short gaps (less than two years) between pregnancies have been shown again and again to be associated with poorer birth outcomes (particularly smaller babies) than medium length gaps (3-5 years), even after controlling for identifiable confounders such as maternal age. This result was replicated by Ball et al.,[1] but they made a further analysis in which mothers who had had at least three children acted as their own controls. The association between short birth interval and low birth weight disappears. So it would appear that both events – birth interval and birth weight – are linked by underlying biological factors. The lesson – whenever possible look for differences within person, before comparing the differences across people, and remain very sceptical about cause and effect associations based on cross-sectional risk-adjustment alone.
-- Richard Lilford, Director CLAHRC WM
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PPI Advisors - Recruitment
CLAHRC WM has recently conducted a number of interviews to recruit PPI (Patient and Public Involvement) Advisors. The field was incredibly strong, with candidates demonstrating a wide diversity of skills and experience. The recruitment panel were spoilt for choice, and, in the end, at least two candidates were selected for each theme. We hope that the PPI Advisors will bring their wealth of skills, qualities, experience and diversity to the themes, and complement one another to enrich the CLAHRC and its research projects.
Magdalena Skrybant, a PPI representative of the CLAHRC and part of the interview panel, said afterwards that she felt “really enthused and optimistic about PPI engagement and involvement in projects in the future. Such an excellent pool of candidates from diverse backgrounds reflects the promotion of the CLAHRC, the reputation of PPI within the CLAHRC WM, and that it champions meaningful Patient and Public engagement and involvement – I do hope that this work will continue to flourish as CLAHRC WM grows and develops. The Theme Leaders, I am sure, will benefit from the experience and skills the PPI Advisors will bring to the themes and I hope they recognise and appreciate the effort that has gone into the recruitment and selection processes. I gained a lot from the experience, and I consider it a real privilege to be involved in CLAHRC WM. During the interviews, I had the opportunity to answer some questions about the CLAHRC, and I found myself extolling its virtues: meaningful research practice; translating research findings into improving services; and, importantly, meaningful Patient and Public involvement. The office in Birmingham is an incredibly warm and friendly environment and I do feel that PPI representatives are valued and nurtured. I am confident that PPI Advisors we recruit will flourish in the warm, inclusive and supportive environment that the team have worked so hard to create.”
CLAHRC WM Director in the Press
The CLAHRC WM Director, Richard Lilford, was recently quoted in both Nature and Scientific American regarding release of interim results from clinical trials. Even though it might prompt patients to abandon a trial, he argues, it should be their choice. See this previous blog post for more information.
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17 Sep 2014, 09:30-11:30
Induction Event for Leadership & Diffusion Fellows
University of Birmingham
An induction event for all Leadership and Diffusion Fellows working in our partner health and social care organisations to improve health and social care services for patient benefit. The agenda will include capacity development and the role and expectations of Leadership and Diffusion Fellows, and working with the West Midlands AHSN.
If you are interested in attending, then please email Alan Hargreaves.
15 Oct 2014, 11:00-15:00
National CLAHRC Workshop: Chronic Diseases and Integrated Care
The Studio, Cannon Street, Birmingham
A workshop for CLAHRC Theme leads and researchers who are working in the area of chronic diseases and integrated care to develop synergies, look for opportunities for collaboration, and share current work, challenges and methodological issues. Delegates should arrive ready to talk for 10 minutes on their programme of work. NB three delegates per CLAHRC.
You can register for this workshop, and view further details, here.
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CLAHRC Personality of the Issue
Jo Sartori
Jo Sartori is currently Head of Programme Delivery for CLAHRC WM. Jo is an experienced programme manager with a speciality in communications, stakeholder relations and engagement. She has worked for the University of Birmingham since 2011 and her previous roles have included Knowledge, Communications and Engagement Manager, and Programme Manager of CLAHRC for Birmingham and Black Country.
Jo graduated from the University of Manchester in 2007 with a BA in Economics and Social Science degree, specialising in politics and sociology. Since graduating, she has held a variety of public sector roles, such as supporting organisations in the West Midlands to apply for European Funding and the programme management of a £6.8 million regional portfolio of health and wellbeing projects funded by the BIG Lottery.
Last year, Jo managed and coordinated the successful £30 million application for CLAHRC West Midlands, which included collaborative working with three Universities and over 15 NHS organisations and Local Authorities.
On 1st September 2014, Jo is joining the University of Warwick to manage the Centre for Applied Health Research and Delivery (W-CAHRD). Her new role will oversee the expansion of “CLAHRC for Africa,” with the aim to build the centre to excellent international standing with a focus on international research and improving the health of poor and vulnerable populations. Therefore, keep your eyes peeled on the CLAHRC International section of these blogs to see how things are progressing.
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Barber CM, Burton CM, Hendrick DJ, Pickering AC, Robertson AS, Robertson W, Sherwood Burge P. Hypersensitivity pneumonitis in workers exposed to metalworking fluids. Am J Ind Med. 2014. [ePub].
Bowater RJ, Hartley LC, Lilford RJ. Are cardiovascular trial results systematically different between North America and Europe? A study based on intra-meta-analysis comparisons. Arch Cardiovasc Dis. 2014; pii: S1875-2136(14)00061-8.
Jagielski AC, Jiang CQ, Xu L, Taheri S, Zhang WS, Cheng KK, Lam TH, Thomas GN. Glycaemia is associated with cognitive impairment in older adults: the Guangzhou Biobank Cohort Study. Age Ageing. 2014. [ePub].
Taylor-Phillips S, Elze MC, Krupinski EA, Dennick K, Gale AG, Clarke A, Mello-Thomas C. Retrospective Review of the Drop in Observer Detection Performance Over Time in Lesion-enriched Experimental Studies. J Digit Imaging. 2014. [ePub].
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Challenges of Implementing Routine Behaviour Change Support
in a Children's Hospital Setting
Lifestyle behaviours, such as smoking, poor diet etc., are the main causes of mortality and morbidity worldwide, and evidence shows that brief advice given during routine consultations can produce improvements in lifestyle. To this end, a policy has been introduced in the UK to instruct healthcare professionals to provide routine health advice. However, changing staff practice often requires more than official instruction. Furthermore, with regards to young children, the advice is targeted at the parents, not the patient.
CLAHRC WM carried out a qualitative study of semi-structured interviews with health professionals to look at barriers to implementation of routine health behaviour change in a children's hospital setting.
Most health professionals acknowledged they had a duty of care to promote overall health and wellbeing, and that parents' behaviour affected children. However, a number of barriers were identified, for example, low level of confidence in starting conversations, and concern that families may feel criticised - especially if the advice was not directly related to why the child was there.
Staff expressed a desire to receive training and improve their skills - as a result, a training video has been produced for all staff training and induction, and can be viewed online at: http://youtu.be/6yF8YGfZmJQ
More information
CLAHRC BITEs (Brokering Innovation Through Evidence) - accessible bite-sized pieces of research that aim to summarise findings from our published work and make recommendations for practice for health and social staff locally and beyond. Previously published BITEs can be found here.
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