Background
The physiological mechanisms behind PTB remain largely unknown, although a number of risk factors have been described. Medical risk factors include infections, non-communicable diseases and their risk factors (diabetes, hypertension), and multiple pregnancies; social risk factors include low or high maternal age, poverty, and receiving antenatal care for the first time at a late stage in the pregnancy; and behavioral risk factors include tobacco, alcohol, substance use, and stress. |
The Born Too Soon report summarized the key evidence-based interventions for preventing PTB and for reducing mortality among those born prematurely [2]. |
Prevention focuses on prenatal care (e.g., education, nutrition, treatment of sexually transmitted infections, family planning); antenatal care; obstetric care; and policies to tackle risk factors, such as smoking in pregnancy. |
Reducing mortality focuses on newborn care (e.g., feeding, thermal care); kangaroo care; neonatal resuscitation if needed; management of complications; and neonatal intensive care, if needed. |
Managing preterm labor can both prevent PTB and reduce mortality among premature babies. Such management includes antenatal corticosteroids; antibiotics for premature rupture of the membranes; and tocolytics to slow down preterm labor. |
Broader social, financial, agricultural and other policies that are being investigated for their potential role in reducing the burden of PTB include measures to improve household food security; conditional cash transfers to increase patient uptake of services; and performance-based financing to improve quality of care. |
KTE with policymakers: a global imperative for reducing PTB
Empirical research on improving KTE with policymakers
Facilitators and barriers to KTE
A 2014 systematic review of studies examining facilitators and barriers to the use of evidence in health policymaking identified 145 studies, including 13 systematic reviews [11]. The most commonly identified facilitators to the use of scientific evidence by policymakers are listed below (n refers to the number of studies that reported any given factor): |
• Good availability of and access to research and improved dissemination of research (n = 63 studies) |
• Strong collaboration between researchers and policymakers (n = 49) |
• Clear, relevant, and reliable research findings (n = 46) |
• Strong personal relationships between researchers and policymakers (n = 39). |
The most commonly identified barriers to the uptake of evidence by policymakers were: |
• Poor availability of and access to research and poor dissemination of research (n = 63) |
• Unclear research findings of little relevance and poor reliability (n = 54) |
• Evidence not available at the time when policymakers needed it most, i.e., the windows of opportunity for getting evidence into policy were missed (n = 42) |
• Lack of research skills among policymakers (n = 26) |
• Economic costs involved in dissemination activities (n = 25). |
Two key approaches to KTE with policymakers
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using multiple forms of evidence, not just systematic reviews (e.g., including the “lived experience” of the populations affected by the policy);
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acknowledging and understanding the political processes, vested interests, and ethical dimensions that shape policymaking;
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encouraging scientists and experts to support “open reflection and debate” about the evidence; and
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encouraging policymakers to routinely question their own roles, relationships, and values in relation to their use of research evidence—for example, by reflecting on whether they include, exclude, or perhaps do not “hear” different bodies of evidence.
Evidence on the effectiveness of different KTE strategies targeting policymakers
• Providing policymakers with evidence briefs: short, accessible summaries of systematic review and local evidence, describing the context, problem and policy options, and paying attention to issues such as policy implementation, equity, local applicability and the quality of the underlying evidence. |
• Deliberative dialogues: these are in-person discussions between researchers and policymakers, typically followed by a year-long service in which policymakers receive evidence updates; the dialogues are based on evidence briefs. |
• Providing policymakers with systematic review-derived products: summaries of reviews, overviews of reviews, and policy briefs. |
• “One-stop shops” of optimally-packaged online systematic review-derived products. An example of a one-stop shop is Health Evidence (www.healthevidence.org), which allows users to find evidence on the effectiveness of public health interventions; the resource can be searched by topic (e.g. premature birth, maternal depression, etc.). |
• “Rapid response units,” which provide policymakers written summaries, telephone consultations or in-person consultations about best evidence. |
• SUPPORT tools for evidence-informed health policy making. A set of tools developed by the Supporting Policy Relevant Reviews and Trials (SUPPORT) project aimed at helping decision makers in health to make decisions informed by evidence. The tools cover topics such as identifying evidence needs, finding the evidence, and applying the evidence. |
Strategy | Outcome | Type of supportive evidence |
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Collective impact: a collaborative, multi-sectoral approach to achieving policy change, with five characteristics: “a common agenda; shared measurement systems, mutually reinforcing activities, continuous communication, and the presence of a backbone organization” [21] | ||
Learning collaboratives: these bring policymakers together in an ongoing way to share knowledge about how to improve a specific health outcome. Common characteristics of learning collaboratives are: • An explicit mission • Routine learning activities (e.g. continuous learning groups) • Relationship-building (e.g. through social networking) | Modest benefits in improving quality of care | A systematic review identified 9 studies using a controlled design (two were RCTs); these measured the effects of collaboratives on care processes or care outcomes. The evidence for quality improvement was “positive but limited and the effects cannot be predicted with great certainty” [24]. Other case studies have suggested positive outcomes [22, 23]. |
Proposed research agenda for engaging policymakers in KTE
Underlying principles
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Context matters. KTE never happens in a social, political, and economic vacuum. For example, the capacity for policymaking will vary according to all aspects of the local environment, including the economic, financial, regulatory, and social environments, which can vary at both local and country levels. For these reasons, effective KTE cannot follow a “one size fits all” approach. A key avenue of research will be to study how the political, economic, cultural and social environments in targeted areas come into play in designing effective KTE interventions and policies to enact them.
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Effective KTE does not stop once the knowledge has been transferred. Transferring research evidence is a necessary but insufficient condition for achieving sustainable impacts on PTB. Sustained follow-up, continued engagement with policymakers, and tracking the fidelity of the evidence-to-policy process is likely needed to achieve optimal outcomes. Thus, a key avenue of research should be to study the required duration of researcher engagement needed to support “stickiness” and sustainability of knowledge in policy formation, implementation, and short and longer term outcomes.
Proposed framework for KTE targeting policymakers
Research questions and methods to optimize KTE with policymakers
Goal of the research | Research question | Examples of studies in different contexts: |
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Understanding and improving elements of the context in which KTE occurs | What are the political, economic, cultural, and social contextual factors that influence PTBI policymaking? | Compare and contrast the influence that key stakeholders have had in PTB policy formation and implementation in developing countries (for example, Kenya, Uganda) to those in underserved communities in developed countries (for example, Fresno, California). Understand how the social context has influenced the degree to which stakeholder groups are able to influence policy formation. |
What are the specific barriers and facilitators to the uptake of evidence by policymakers in the research site under study? | Qualitative research with policymakers in the research site under study; document analysis; case studies | |
In the site being studied, who are the key policymakers, how much power do they have to shape policy, and what is their current position towards PTB? | Stakeholder analysis | |
In the research site being studied, how much priority does PTB currently receive on the health agenda? | Political prioritization analysis e.g., using the Shiffman and Smith framework for assessing the position of a health issue on the national policy agenda [25] | |
How do material conditions in the research sites under study (e.g., physical safety, access to clean water, food supply) impact PTB outcomes? | Community-engaged participatory research, ethnography | |
What are the most important PTB outcomes for people living within each research site, and what are their views on the optimal path forward for changing policies to affect those outcomes? | Community-engaged participatory research, ethnography | |
What is the role of community advisory boards (CABs) in the policy making process? CABs are comprised of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings. Involving them optimizes the potential for KTE [26, 27] | Qualitative methods | |
What strategies are associated with optimal KTE? | In the research sites under study, do evidence briefs for policymakers on preventing and treating PTB increase the likelihood that policies will be informed by the evidence? | Review of existing policy resource materials to examine how evidence briefs are used and whether they result in successful outcomes; case studies of examples of previous policymaker decision making, what evidence was used, and with what level of success (in the area of PTBI or parallel areas, e.g., HIV/AIDS); interventional studies that test whether evidence briefs affect policy decisions |
In the research sites under study, could an online “one stop shop” on evidence-based interventions for PTB increase the likelihood that policies will be informed by the evidence? | Landscape analyses of which resources currently exist, the availability of any repositories of information, policymaker preference and current use of tools to assure that this resource is useful and tailored to needs; interventional studies that test whether “one-stop shops” affect policy decisions | |
In the research sites under study, could “deliberative dialogues” (Table 3) with policymakers on evidence-based interventions for PTB increase the likelihood that policies will be informed by the evidence? | Conduct a randomized study in which some sites are randomized to participate in a “deliberate dialogue” (control sites receive an evidence brief (Table 3) but do not participate in a dialogue about this brief) | |
In the research sites under study, could “rapid response services” (Table 3) with policymakers on evidence-based interventions for PTB increase the likelihood that policies will be informed by the evidence? | Incorporate a rapid response service as part of the randomized study mentioned above | |
In the research sites under study, could capacity building with policymakers on how to use evidence increase the likelihood that policies will be informed by the evidence? | Incorporate capacity building of policy makers as part of the randomized study | |
In the research sites under study, could community engagement tools help policymakers to consider new perspectives? | Incorporate community engagement as part of the randomized study | |
In the research sites under study, could the cultivation of learning collaboratives among policymakers on evidence-based interventions for PTB increase the likelihood that policies will be informed by the evidence? | Incorporate learning collaboratives as part of the randomized study | |
Participant observation; key informant interviews with participants | ||
What components of post-transfer engagement are associated with KTE strength and durability? | What is the duration of post-transfer engagement that is needed to support “stickiness” and sustainability of knowledge transfer? | Monitor and study research sites as part of the randomized study |
What levels of ongoing KTE support were required to achieve tangible policy change outcomes? | Process evaluation of the KTE efforts | |
How might one improve KTE to create better sustainability in post-transfer engagement? | Exit interviews with participants in KTE efforts to assess “what worked” and “what didn’t” | |
Evaluation | Did policymakers use the evidence transferred? If they did use it, how did they use the evidence? | Qualitative key informant interviews of how evidence was used, and surveys of policymakers’ knowledge of scientific evidence pre/post KTE |
Did KTE efforts result in tangible changes in policies that promote improved PTB outcomes? | Case studies that track KTE from knowledge transfer to policy drafting and implementation to assess changes in funding levels, regulations, etc. | |
Do KTE efforts, when they have successfully informed policymaking, have a measureable impact on PTB health outcomes? | Natural experiments, ideally using comparison sites, to track PTB outcomes before and after evidence-informed policies were implemented |