Embedding rapid reviews in health policy and systems decision-making: Impacts and lessons learned from four low- and middle-income countries.

BACKGROUND: Demand for rapid evidence-based syntheses to inform health policy and systems decision-making has increased worldwide, including in low- and middle-income countries (LMICs). To promote use of rapid syntheses in LMICs, the WHO's Alliance for Health Policy and Systems Research (AHPSR) created the Embedding Rapid Reviews in Health Systems Decision-Making (ERA) Initiative. Following a call for proposals, four LMICs were selected (Georgia, India, Malaysia and Zimbabwe) and supported for 1 year to embed rapid response platforms within a public institution with a health policy or systems decision-making mandate. METHODS: While the selected platforms had experience in health policy and systems research and evidence syntheses, platforms were less confident conducting rapid evidence syntheses. A technical assistance centre (TAC) was created from the outset to develop and lead a capacity-strengthening program for rapid syntheses, tailored to the platforms based on their original proposals and needs as assessed in a baseline questionnaire. The program included training in rapid synthesis methods, as well as generating synthesis demand, engaging knowledge users and ensuring knowledge uptake. Modalities included live training webinars, in-country workshops and support through phone, email and an online platform. LMICs provided regular updates on policy-makers' requests and the rapid products provided, as well as barriers, facilitators and impacts. Post-initiative, platforms were surveyed. RESULTS: Platforms provided rapid syntheses across a range of AHPSR themes, and successfully engaged national- and state-level policy-makers. Examples of substantial policy impact were observed, including for COVID-19. Although the post-initiative survey response rate was low, three quarters of those responding felt confident in their ability to conduct a rapid evidence synthesis. Lessons learned coalesced around three themes - the importance of context-specific expertise in conducting reviews, facilitating cross-platform learning, and planning for platform sustainability. CONCLUSIONS: The ERA initiative successfully established rapid response platforms in four LMICs. The short timeframe limited the number of rapid products produced, but there were examples of substantial impact and growing demand. We emphasize that LMICs can and should be involved not only in identifying and articulating needs but as co-designers in their own capacity-strengthening programs. More time is required to assess whether these platforms will be sustained for the long-term.

Invited Commentary: Some Social Epidemiologic Lessons From the COVID-19 Pandemic.

In their recent article, Dimitris et al. (Am J Epidemiol. 2022;191(6):980-986) presented a series of challenges modern epidemiology has faced during the coronavirus disease 2019 (COVID-19) pandemic, including challenges around the scientific progress, epidemiologic methods, interventions, equity, team science, and training needed to address these issues. Here, 2 social epidemiologists who have been working on COVID-19 inequities reflect on further lessons with an added year of perspective. We focus on 2 key challenges: 1) dominant biomedical individualistic narratives around the production of population health, and 2) the role of profit in policy-making. We articulate a need to consider social epidemiologic approaches, including acknowledging the importance of considering how societal systems lead to health inequities. To address these challenges, future (and current) epidemiologists should be trained in theories of population health distribution and political structures of governance. Last, we close with the need for better investment in public health infrastructure as a crucial step toward achieving population health equity.

Decision making under deep uncertainty for pandemic policy planning.

Policymakers around the world were generally unprepared for the global COVID-19 pandemic. As a result, the virus has led to millions of cases and hundreds of thousands of deaths. Theoretically, the number of cases and deaths did not have to happen (as demonstrated by the results in a few countries). In this pandemic, as in other great disasters, policymakers are confronted with what policy analysts call Decision Making under Deep Uncertainty (DMDU). Deep uncertainty requires policies that are not based on 'predict and act' but on 'prepare, monitor, and adapt', enabling policy adaptations over time as events occur and knowledge is gained. We discuss the potential of a DMDU-approach for pandemic decisionmaking.

Policy actors' perceptions of public participation to tackle health inequalities in Scotland: a paradox?

BACKGROUND: Health inequalities are persistent and widening with transformative policy change needed. Radically shifting policy to tackle upstream causes of inequalities is likely to require public participation to provide a mandate, evidence and to address questions of co-design, implementation and acceptability. The aim of this paper is to explore perceptions among policy actors on why and how the public should be involved in policymaking for health inequalities. METHODS: In 2019-2020, we conducted exploratory, in-depth, semi-structured interviews with 21 Scottish policy actors from a range of public sector bodies and agencies and third sector organisations that work in, or across, health and non-health sectors. Data were analysed thematically and used to examine implications for the development of participatory policymaking. RESULTS: Policy actors viewed public participation in policymaking as intrinsically valuable for democratic reasons, but the main, and more challenging, concern was with how it could affect positive policy change. Participation was seen as instrumental in two overlapping ways: as evidence to improve policies to tackle health inequalities and to achieve public acceptance for implementing more transformative policies. However, our analysis suggests a paradox: whilst policy actors place importance on the instrumental value of public participation, they simultaneously believe the public hold views about health inequalities that would prevent transformative change. Finally, despite broad agreement on the need to improve public participation in policy development, policy actors were uncertain about how to make the necessary changes due to conceptual, methodological and practical challenges. CONCLUSIONS: Policy actors believe in the importance of public participation in policy to address health inequalities for intrinsic and instrumental reasons. Yet, there is an evident tension between seeing public participation as a route to upstream policies and a belief that public views might be misinformed, individualistic, short-term or self-interested and doubts about how to make public participation meaningful. We lack good insight into what the public think about policy solutions to health inequalities. We propose that research needs to shift from describing the problem to focusing more on potential solutions and outline a potential way forward to undertake effective public participation to tackle health inequalities.

Key factors influencing paediatric COVID-19 vaccine hesitancy: a brief overview and Decision-making Trial and Evaluation Laboratory analysis.

OBJECTIVES: The purpose of this study was to examine the current literature on paediatric COVID-19 vaccine hesitancy among parents and identify key influencing factors, thus enabling targeted policy development and implementation. STUDY DESIGN: This was a systematic literature review and Decision-making Trial and Evaluation Laboratory (DEMATEL) analysis. METHODS: A review of the quantitative and qualitative literature focusing on factors influencing paediatric COVID-19 vaccine hesitancy was conducted. Searches were performed in PubMed, ScienceDirect, SpringerLink and Embase. Because of the immediacy of the topic, commentaries were included in addition to research and review articles. Influencing factors were categorised according to the Health Ecology Theory and screened using the DEMATEL method. RESULTS: A total of 44 articles were included in the study, and 44 factors influencing paediatric COVID-19 vaccine hesitancy were identified. Of these, 18 were categorised as key factors using the DEMATEL method, including a history of COVID-19 infection in parents and perceived safety of the paediatric COVID-19 vaccine. CONCLUSIONS: Policymakers and public health personnel should pay more attention to the key factors influencing paediatric COVID-19 vaccine hesitancy. The outcome of this research will benefit and motivate decision-makers to consider strategies to overcome various challenges of COVID-19 vaccine hesitancy.

Decision-makers' experiences with rapid evidence summaries to support real-time evidence informed decision-making in crises: a mixed methods study.

BACKGROUND: There is a clear need for research evidence to drive policymaking and emergency responses so that lives are saved and resources are not wasted. The need for evidence support for health and humanitarian crisis is even more pertinent because of the time and practical constraints that decision-makers in these settings face. To improve the use of research evidence in policy and practice, it is important to provide evidence resources tailored to the target audience. This study aims to gain real-world insights from decision-makers about how they use evidence summaries to inform real-time decision-making in crisis-settings, and to use our findings to improve the format of evidence summaries. METHODS: This study used an explanatory sequential mixed method study design. First, we used a survey to identify the views and experiences of those who were directly involved in crisis response in different contexts, and who may or may not have used evidence summaries. Second, we used the insights generated from the survey to help inform qualitative interviews with decision-makers in crisis-settings to derive an in-depth understanding of how they use evidence summaries and their desired format for evidence summaries. RESULTS: We interviewed 26 decision-makers working in health and humanitarian emergencies. The study identified challenges decision-makers face when trying to find and use research evidence in crises, including insufficient time and increased burden of responsibilities during crises, limited access to reliable internet connection, large volume of data not translated into user friendly summaries, and little information available on preparedness and response measures. Decision-makers preferred the following components in evidence summaries: title, target audience, presentation of key findings in an actionable checklist or infographic format, implementation considerations, assessment of the quality of evidence presented, citation and hyperlink to the full review, funding sources, language of full review, and other sources of information on the topic. Our study developed an evidence summary template with accompanying training material to inform real-time decision-making in crisis-settings. CONCLUSIONS: Our study provided a deeper understanding of the preferences of decision-makers working in health and humanitarian emergencies about the format of evidence summaries to enable real-time evidence informed decision-making.

Unfolding and modeling the recovery process after COVID lockdowns.

Lockdown is a common policy used to deter the spread of COVID-19. However, the question of how our society comes back to life after a lockdown remains an open one. Understanding how cities bounce back from lockdown is critical for promoting the global economy and preparing for future pandemics. Here, we propose a novel computational method based on electricity data to study the recovery process, and conduct a case study on the city of Hangzhou. With the designed Recovery Index, we find a variety of recovery patterns in main sectors. One of the main reasons for this difference is policy; therefore, we aim to answer the question of how policies can best facilitate the recovery of society. We first analyze how policy affects sectors and employ a change-point detection algorithm to provide a non-subjective approach to policy assessment. Furthermore, we design a model that can predict future recovery, allowing policies to be adjusted accordingly in advance. Specifically, we develop a deep neural network, TPG, to model recovery trends, which utilizes the graph structure learning to perceive influences between sectors. Simulation experiments using our model offer insights for policy-making: the government should prioritize supporting sectors that have greater influence on others and are influential on the whole economy.

Taiwan's National Health Insurance at the Emergency Department following the COVID-19 outbreak.

Taiwan's National Health Insurance (NHI) is a widely acclaimed universal healthcare system. In the past few years, particularly following the COVID-19 outbreak, challenges related to maintaining the NHI system have surfaced. Since 2020, NHI has faced a series of challenges, including excessive patient visits to the hospital emergency department, a lack of an effective primary care and referral system, and a high turnover rate of healthcare workers. We review major problems related to Taiwan's NHI, emphasizing input from frontline healthcare workers. We provide recommendations for potential policies addressing the concerns around NHI, for example, strengthening the role of primary care services under the NHI administration, reducing the high turnover rate of healthcare workers, and increase the premium and copayments. We hope that this policy analysis may allow policymakers and scholars to understand both the merits and critical problems related to NHI from the clinical perspective.

Rethinking the path from evidence to decision-making.

Evidence-informed decision-making is increasingly recognized as a standard for policymaking in many fields, including public health. However, many challenges exist in identifying the appropriate evidence, disseminating it to different stakeholders, and implementing it in various settings. The Israel Implementation Science and Policy Engagement Centre (IS-PEC) was established at Ben-Gurion University of the Negev to "bridge the gap" between scientific research and policy. As an illustrative case study, IS-PEC is conducting a scoping review on strategies to engage senior citizens in Israel when developing health policy. In May 2022, IS-PEC brought together international experts and Israeli stakeholders to increase knowledge in the field of evidence-informed policy, develop a research agenda, strengthen international collaborations, and create a community for sharing experience, research, and best practices. Panelists presented the importance of communicating clear, accurate bottom-line messages with the media. Also, they highlighted the once-in-a-generation opportunity to promote the uptake of evidence in public health due to the increased public interest in evidence-informed policymaking post-COVID-19 pandemic and the need to build systems and centers to support the systematic use of evidence. Group discussions focused on various aspects of communication, including challenges and strategies when communicating to policymakers, understanding the nuances of communication between scientists, journalists, and the public, and some ethical issues surrounding data visualization and infographics. Panelists participated in a passionate debate regarding whether and how values play a role when conducting, analyzing, and communicating evidence. Takeaway lessons from the workshop included that going forward, Israel must create lasting systems and a sustainable environment for evidence-informed policy. Novel and interdisciplinary academic programs must be developed to train future policymakers in various fields, including public health, public policy, ethics, communication, social marketing, and infographics. Sustainable professional relationships between journalists, scientists, and policymakers must be fostered and strengthened based on mutual respect and a shared commitment to creating, synthesizing, implementing, and communicating high-quality evidence to serve the public and individual wellbeing.

A risk-based decision framework for policy analysis of societal pandemic effects.

Introduction: In this article, we summarize our findings from an EU-supported project for policy analyses applied to pandemics such as Covid-19 (with the potential to be applied as well to other, similar hazards) while considering various mitigation levels and consequence sets under several criteria. Methods: It is based on our former development for handling imprecise information in risk trees and multi-criteria hierarchies using intervals and qualitative estimates. We shortly present the theoretical background and demonstrate how it can be used for systematic policy analyses. In our model, we use decision trees and multi-criteria hierarchies extended by belief distributions for weights, probabilities and values as well as combination rules to aggregate the background information in an extended expected value model, taking into criteria weights as well as probabilities and outcome values. We used the computer-supported tool DecideIT for the aggregate decision analysis under uncertainty. Results: The framework has been applied in three countries: Botswana, Romania and Jordan, and extended for scenario-building during the third wave of the pandemic in Sweden, proving its feasibility in real-time policy-making for pandemic mitigation measures. Discussion: This work resulted in a more fine-grained model for policy decision that is much more aligned to the societal needs in the future, either if the Covid-19 pandemic prevails or for the next pandemic or other society-wide hazardous emergencies.

How gender is socially constructed in policy making processes: a case study of the Adolescent and Youth Health Policy in South Africa.

BACKGROUND: Gender equality remains an outstanding global priority, more than 25 years after the landmark Beijing Platform for Action. The disconnect between global health policy intentions and implementation is shaped by several conceptual, pragmatic and political factors, both globally and in South Africa. Actor narratives and different framings of gender and gender equality are one part of the contested nature of gender policy processes and their implementation challenges. The main aim of this paper is to foreground the range of policy actors, describe their narratives and different framings of gender, as part exploring the social construction of gender in policy processes, using the Adolescent Youth Health Policy (AYHP) as a case study. METHODS: A case study design was undertaken, with conceptual underpinnings combined from gender studies, sociology and health policy analysis. Through purposive sampling, a range of actors were selected, including AYHP authors from government and academia, members of the AYHP Advisory Panel, youth representatives from the National Department of Health Adolescent and Youth Advisory Panel, as well as adolescent and youth health and gender policy actors, in government, academia and civil society. Qualitative data was collected via in-depth, semi-structured interviews with 30 policy actors between 2019 and 2021. Thematic data analysis was used, as well as triangulation across both respondents, and the document analysis of the AYHP. RESULTS: Despite gender power relations and more gender-transformative approaches being discussed during the policy making process, these were not reflected in the final policy. Interviews revealed an interrelated constellation of diverse and juxtaposed actor gender narratives, ranging from framing gender as equating girls and women, gender as inclusion, gender as instrumental, gender as women's rights and empowerment and gender as power relations. Some of these narrative framings were dominant in the policy making process and were consequently included in the final policy document, unlike other narratives. The way gender is framed in policy processes is shaped by actor narratives, and these diverse and contested discursive constructions were shaped by the dynamic interactions with the South Africa context, and processes of the Adolescent Youth Health Policy. These varied actor narratives were further contextualised in terms of reflections of what is needed going forward to advance gender equality in adolescent and youth health policy and programming. This includes prioritising gender and intersectionality on the national agenda, implementing more gender-transformative programmes, as well as having the commitments and capabilities to take the work forward. CONCLUSIONS: The constellation of actors' gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. Understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda.

Reconnecting the Patient: Why Telehealth Policy Solutions Must Consider the Deepening Digital Divide.

This Article attempts to untangle the complicated web of providing telehealth to those populations it is potentially capable of further alienating from access to healthcare including: 1) race/minority populations, 2) aging adults, 3) individuals with disabilities, 4) non-English speakers, 5) individuals living in rural areas, 6) socioeconomic class, and 7) children, in order to advance the argument that telehealth can be successful in providing healthcare access to these populations. Rather than suggesting that telehealth simply "cannot work" for these populations, instead this Article considers how telehealth can and must meet the needs of these individuals through technology, access, and policy developments. First, this Article explains how telehealth is defined and how the definition has and can continue to influence policy development. Next, this Article explores the issues surrounding the "digital divide" and how this relates to telehealth use. Then this Article discusses how access to technology impacts particular populations. This Article then considers legislation and policy developments both at the federal and state level that have emerged thus far that could help overcome challenges of accessibility, affordability, and usability. Finally, this Article offers policy recommendations for ensuring that the delivery of telehealth can be accessible to those populations with potentially less access to technology to ensure telehealth's successful availability and use for these populations can continue beyond Covid-19.

Health and Safety Regulations for COVID-19: A Policy Analysis.

The COVID-19 pandemic spurred some regulators in the USA to require occupational health and safety programs to prevent COVID-19 transmission in workplaces. The objective of this study was to describe such state and federal regulations enacted between January 2020 and January 2022. Regulations, including emergency temporary standards (ETS) and permanent standards, were identified through a search of Nexis Uni and Bloomberg Law and review of US OSHA websites and the Federal Register. Full texts were reviewed for regulatory scope, hazard and exposure definitions, determination of exposure or risk levels, and control strategies. Four state (California, Michigan, Virginia, and Oregon) and two federal regulations were identified. All regulations described respiratory aerosols as the primary source of SARS-CoV-2 and recognized person-to-person transmission by droplet, airborne, and contact routes. Only the US OSHA ETS for healthcare explicitly stated that inhalation of respiratory particles was the most likely method of COVID-19 transmission. The Virginia, Michigan, and Oregon regulations described different categories of risk defined by exposure frequency and duration or specific workplace activities. California described exposure as places and times when employees come into contact or congregate with other people. The US OSHA ETS for healthcare described exposure as involving close contact with suspected or confirmed COVID-19 patients. While all of the state regulations required strategies from across the hierarchy, only the Virginia regulations specifically incorporated the hierarchy of controls. Only the California and Virginia regulations explicitly linked control strategies to the transmission route, while Virginia demarcated control strategies by risk level. Oregon linked risk level to occupancy levels and physical distancing requirements and referred to the use of a layered approach for transmission control. The US OSHA ETS for healthcare defined droplet and airborne precautions but made no mention of the hierarchy of controls or risk levels. Respirators were discussed in most of the regulations. The first Michigan regulation explicitly required respirators appropriate to exposure risk. The California regulations noted that respirators protect the wearer while face coverings protect people around the wearer. These regulations offer insights for a permanent US OSHA infectious disease regulation, such as the need to consider a range of transmission modes including near- and far-range aerosol inhalation, endemic and novel pathogens, workplaces beyond healthcare settings, factors that contribute to exposure and risk, the hierarchy of controls, the role of vaccination, and the importance of written exposure assessment and infection prevention plans.

Navigating complex trade-offs in public health interventions.

Public health, just as any policy-related field, faces the evergreen problem of turning knowledge into action. Among other problems, there is a clash between the inherent complexity of public health problems and the inevitable push, by decision-makers and the public, to simplify them. The Covid-19 pandemic has shown the insufficiencies of our current epistemological, methodological and normative apparatus to handle such crises in a timely manner. Despite this, several authors have been arguing for the importance of engaging global crises such as Covid-19 in ways that do not oversimplify key dimensions of the issues involved. In this paper, we contribute to this emerging scholarship. Building on existing work in the field of environmental problem-solving, we propose an integrative approach to navigating complex trade-offs in public health interventions. Briefly put, we propose that decision making should be informed by an analysis of any given problem from four distinct, but interrelated, lenses: (i) values and valuation, (ii) process and governance, (iii) power and inequalities and (iv) scientific evidence, methods and concepts. This normative framework, we argue, can help with spelling out the complexity of public health problems and with spelling out the rationale behind public health decision making to non-specialists and the general public. We illustrate our approach using the controversy over wearing face masks in the Covid-19 pandemic.

Virology under the Microscope-a Call for Rational Discourse.

Viruses have brought humanity many challenges: respiratory infection, cancer, neurological impairment and immunosuppression to name a few. Virology research over the last 60+ years has responded to reduce this disease burden with vaccines and antivirals. Despite this long history, the COVID-19 pandemic has brought unprecedented attention to the field of virology. Some of this attention is focused on concern about the safe conduct of research with human pathogens. A small but vocal group of individuals has seized upon these concerns - conflating legitimate questions about safely conducting virus-related research with uncertainties over the origins of SARS-CoV-2. The result has fueled public confusion and, in many instances, ill-informed condemnation of virology. With this article, we seek to promote a return to rational discourse. We explain the use of gain-of-function approaches in science, discuss the possible origins of SARS-CoV-2 and outline current regulatory structures that provide oversight for virological research in the United States. By offering our expertise, we - a broad group of working virologists - seek to aid policy makers in navigating these controversial issues. Balanced, evidence-based discourse is essential to addressing public concern while maintaining and expanding much-needed research in virology.