变革理论在卫生政策与体系研究领域的应用

变革理论是主流的项目理论之一,其描述了干预措施在特定背景下产生预期效果的因果逻辑,为干预设计、实施和评价以及经验推广提供理论基础,有利于提高政策干预的有效性和系统性。然而目前国内卫生政策与体系领域应用变革理论的研究相对较少,本文探讨了变革理论的基本概念,并对国内外相关研究进行了综述,促进变革理论在我国卫生政策与体系研究领域中的应用。     

Operational research capacity building in Asia: innovations,successes and challenges of a training course

A structured training course on operational research (OR) based on the model created by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières was conducted in the South Asian region in 2012. Many innovations were introduced into the administration, structure and content of the course. Of 12 participants, 11 successfully completed all pre-defined milestones. Several challenges were identified. The main challenges included shortage of time, especially for data analysis and interpretation, and insufficient numbers of experienced facilitators. Appropriate modifications have been made to the structure and processes of the next course scheduled for 2013. We describe these modifications and the innovations, successes and challenges of this model of training.     

1978-2007年卫生政策研究论文文献计量学分析

对1978-2007年《中国生物医学文献光盘数据库》收录的有关卫生政策研究的论文进行文献计量学分析,发现我国的卫生政策研究发展迅速,核心期刊初显雏形,虽然核心著者群体尚未出现但已有了一定数量的高产作者,除卫生部外,大学院校为卫生政策研究论文的主要产出单位。     

制定并落实目标全面的国家药物政策：印度经验与教训

中国和印度同为经济崛起中的大国,在全球医药市场中起着举足轻重的作用。世界上绝大多数价格低廉的通用名药都是由这两个国家生产供应的,但这两个国家的国民却在不同程度上面临着获得有质量保证基本药物的挑战。药品的经济学和社会学属性,医药领域的健康目标和经济发展目标,如何平衡医药产业的发展对经济和社会作出的贡献等问题,在这两个国家都存在着热议。本文回顾印度国家药物政策的历史演变过程,剖析其产生的矛盾效果：培育了强大的民族医药产业,但本国多数民众基本用药仍得不到保障。文章还分析印度德里地区制定、贯彻和落实区域药物政策的成功经验,希望为中国制定目标全面的国家药物政策和建立国家基本药物制度提供有益的经验和教训。     

Fortification of selected foodstuffs with folic acid in the UK: consumer research carried out to inform policy recommendations

BACKGROUND: The UK Food Standards Agency Board identified four options to increase folate intake in women of reproductive age in order to reduce the risk of neural tube defect (NTD) affected pregnancies; these ranged from continuing with current policy, to mandatory fortification of bread or flour with folic acid. In order to appraise these options, the agency carried out a consultation, and also commissioned four pieces of research. This paper provides detailed information about two of the research studies, which used qualitative research approaches to gather consumer evidence. METHODS: Study 1: This was carried out with people from a wide range of demographic backgrounds. A 'reconvened group' methodology was used, with five groups convened twice, in five geographical locations. In addition paired, in depth face-to-face interviews were conducted with female black and ethnic minority consumers. Study 2: This was carried out with young mothers living in deprived communities. The approach used for this study was in depth face-to-face interviews (n = 24). In addition, discussions were held in seven friendship groups. RESULTS: Study 1: only a minority of participants knew about a link between spina bifida and folic acid, and these tended to be women with young families. After the provision of some information about the causes and impacts of NTDs, the majority were in favour of action to tackle the issue. Support for mandatory fortification increased considerably during the study, and at the final discussion, this option was most preferred. Study 2: In this group, there was a fatalistic approach to pregnancy and to health. The women were less likely to change established habits if this required effort, money or doing something unfamiliar. They tended to actively avoid thinking about risks, by rationalizing them. Mandatory fortification was preferred by the majority of respondents. CONCLUSIONS: In this research, mandatory fortification was the preferred option. There were outstanding concerns about risk, and the maintenance of consumer choice, which would need to be addressed in policy recommendations.     

Evidence on how to practice intersectoral collaboration for health equity: a scoping review

The persistence of health inequities is reflected in repeated calls for intersectoral collaboration on the social determinants of health, specifically through public policy action. Yet, how to do intersectoral collaboration specifically for policy action toward health equity is articulated rather scarcely in the scientific literature. With this scoping review, we intended to generate insight into current peer-reviewed literature to identify gaps about evidence-based approaches to practices of intersectoral collaboration for health equity-oriented policy action. Seven search engines were used: Proquest, Web of Science, CINAHL, Pubmed, Sociological Abstracts, Project Muse and ERIC. Social determinants of health, including public policy and intersectoral collaboration, are related concepts for the health equity agenda and were used as a conceptual framework to map selected literature. Out of 227 articles, our review identified 64 articles describing intersectoral collaboration specifically in relation to public policy. Of those articles with a policy topic, 10 had a focus on broad public policy areas, while 51 publications articulated specific policies relevant to the determinants of health and only three articles examined effective practices of intersectoral collaboration in public policy through phenomenology, literature review and case study research. The majority of policy-focused publications described that collaboration was used as a strategy to address intersectoral public policy issues, but failed to report how the process of collaboration unfolded. Perhaps it is time to re-direct the gaze onto collaborative teams to generate evidence of effective intersectoral collaboration practices in public policy.     

Muddling through the middle ground: theoretical concerns in intersectoral collaboration and health promotion

This paper considers the conceptual basis of intersectoral collaboration(ISC) in health promotion. It summarises concepts and perspectiveswithin literature loosely labelled as ‘interorganisationalrelations’. These are applied to health promotion, specificallythe development of healthy public policy at local level. Whilethe importance of collaboration and working together at practitionerlevel is acknowledged, the main emphasis is on strategic levelcollaboration and policy coordination. The aim is to consolidateunderstanding of the concept, its features and its ‘determinants’.Ways in which collaboration might be fostered are considered.     

Operational research training: the course and beyond

Insufficient operational research (OR) is generated within programmes and health systems in low- and middle-income countries, partly due to limited capacity and skills to undertake and publish OR in peer-reviewed journals. To address this, a three-module course was piloted by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières in 2009–2010, with 12 participants. Five received mentorship and financial support as OR Fellows. Eleven of 12 participants submitted a paper to a peer-reviewed journal within 4 weeks of the end of the course. Evaluation shows that participants continued OR activities beyond the course. During the subsequent year, they submitted and/or published 19 papers, made 10 posters and/or presentations, and many participated in training, mentoring and/or paper reviewing. Some described changes in policy and practice influenced by their research, and changes in their organisation’s approach to OR. They provided recommendations for improving and expanding OR. We conclude that participants can, with certain enabling conditions, take research questions through to publication, use skills gained to undertake and promote OR thereafter and contribute to improvement in policy and practice. An internet-based network will provide participants and graduates with a platform for collection of course outcomes and ongoing mentor- and peer-based support, resources and incentives.     

High time to use rapid tests to detect multidrug resistance in sputum smear-negative tuberculosis in Belarus

Setting: Belarus (Eastern Europe) is facing an epidemic of multidrug-resistant tuberculosis (MDR-TB). In 2012, rapid molecular diagnostics were prioritised for sputum smear-positive pulmonary tuberculosis (PTB) patients to diagnose MDR-TB, while pulmonary sputum smear-negative pulmonary TB (SN-PTB) patients were investigated using conventional methods, often delaying the diagnosis of MDR-TB by 2–4 months.Objective: To determine the proportion of MDR-TB among SN-PTB patients registered in 2012 and associated clinical and demographic factors.Design: Retrospective cohort study using countrywide data from the national electronic TB register.Results: Of the 5377 TB cases registered, 2960 (55%) were SN-PTB. Of the latter, 1639 (55%) were culture-positive, of whom 768 (47%) had MDR-TB: 33% (363/1084) were new and 73% (405/555) previously treated patients. Previous history of treatment, age, region, urban residence, human immunodeficiency virus (HIV) status and being a pensioner were independently associated with MDR-TB.Conclusion: About half of culture-positive SN-PTB patients have MDR-TB and this rises to over 7/10 for retreatment cases. A national policy decision to extend rapid molecular diagnostics universally to all PTB patients, including SN-PTB, seems justified. Steps need to be taken to ensure implementation of this urgent priority, given the patient and public health implications of delayed diagnosis.     

Double trouble: tuberculosis and substance abuse in Nagaland,India

The diagnosis and treatment of tuberculosis (TB) in people who use and/or inject illicit drugs (PWUIDs) remains a barrier to achieving universal coverage for TB in India and globally. This report describes treatment outcomes in PWUIDs who received treatment for drug-susceptible TB at the Mon District Hospital in Nagaland, India, during 2012–2013. The median age of the patients was 39 years, and most (92%) were male. Two thirds (33/49) of the patients had a successful TB treatment outcome. A previous TB episode and residence in a semi-urban area were associated with unsuccessful treatment outcomes. Separate diagnostic and treatment algorithms, including regular adherence counselling and opioid substitution therapies, should be considered for PWUIDs.     

卫生政策研究特点及信息资源利用

本文从卫生政策研究的主要特点出发，分析了卫生政策研究信息除具有自然科学与社会科学文献信息的基本特点之外，还具有信息资源丰富、来源渠道广泛、检索方法复杂、获取难度大等特点，对决策者和政策研究者获取卫生政策研究信息造成了一定困难，并在此基础上提出了进行卫生政策研究信息资源整合的重要意义。     

Fostering interest in research: evaluation of an introductory research seminar at hospitals in rural Rwanda

Settings: Partners In Health Rwanda, in collaboration with the Ministry of Health, leads a multipronged approach to develop research capacity among health workers, particularly in rural areas.Objectives: To describe the characteristics of participants and to assess the impact of an introductory research seminar series in three district hospitals in rural Rwanda.Design: This was a retrospective cohort study of seminar participants. Data were sourced from personnel records, assessment sheets and feedback forms.Results: A total of 126 participants, including 70 (56%) clinical and 56 (44%) non-clinical staff, attended the research seminar series; 61 (48%) received certification. Among those certified, the median assessment score on assignments was 79%. Participants read significantly more articles at 6 and 12 months (median 2 and 4 respectively, compared to 1 at baseline, P < 0.01). There was also a significant increase (P ⩽ 0.05) in self-reported involvement in research studies (28%, baseline; 59%, 12 months) and attendance at other research training (36%, baseline; 65%, 12 months).Conclusion: The introductory research seminar series provided an important opportunity for engagement in research among clinical and non-clinical staff. Such an activity is a key component of a comprehensive research capacity building programme at rural sites, and serves as an entry point for more advanced research training.     

The effects of a national policy to reduce c-sections in Brazil

In this paper, we assess the effects of a national policy implemented in Brazil to avoid unnecessary cesareans. The policy has a supply-side component that prohibits elective c-sections before the 39th gestational week and a demand-side awareness component. Since the policy is not binding for cases with a strong medical c-section indication, we use births of breech- and transverse-positioned babies as a counterfactual for births of cephalic-positioned babies in a difference-in-differences framework. Our results reveal that the policy decreases the rate of c-sections by 1.6 percentage point, and slightly increases gestational time, birthweight, and first-minute APGAR scores. There is evidence that policy effectiveness is driven by its demand-side component.     

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 5: Needs and implications for future research and policy

Abstract

The recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and highlights related needs and implications for future research and policy. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In three subsequent, articles the results for the six core competencies of the European Definition of GP/FM were presented. This article formulates the common aims for further research and appropriate research methodologies, based on the missing evidence and research gaps identified form the comprehensive literature review. In addition, implications of this research agenda for general practitioners/family doctors, researchers, research organizations, patients and policy makers are presented. The concept of six core competencies should be abandoned in favour of a model with four dimensions, including clinical, person related, community oriented and management aspects. Future research and policy should consider more the involvement and rights of patients; more attention should be given to how new treatments or technologies are effectively translated into routine patient care, in particular primary care. There is a need for a European ethics board. The promotion of GP/FM research demands a good infrastructure in each country, including access to literature and databases, appropriate funding and training possibilities.     

制定和落实国家药物政策的国际进展及启示

通过参加第二届国家药物政策国际大会获得的信息及文献,回顾国际社会推行国家药物政策的发展历程及最新进展,总结欧洲、澳大利亚及相关国家和地区的典型经验,从中提炼我国可借鉴的经验如下:制定和执行国家药物政策,首先是一个政治过程,然后才是技术过程;确定执行主体,规定清晰的权利和义务,在健全的卫生体系下,制定可操作的执行策略是国家药物政策焕发活力的关键;活跃的社会团体可以帮助表达各方意愿,使国家药物政策代表更广泛的民意;国家药物政策服务的主体是消费者,以消费者为中心、让消费者的意见不被忽略,可以提高消费者对政策的认同感;国家药物政策是国家卫生政策的一部分,需要全面、细致的政策设计,平衡健康目标与医药产业发展目标。     

The process of changing national malaria treatment policy: lessons from country-level studies

Widespread resistance of Plasmodium falciparum parasites to commonly used antimalarials, such as chloroquine, has resulted in many endemic countries considering changing their malaria treatment policy. Identifying and understanding the key influences that affect decision-making, and factors that facilitate or undermine policy implementation, is critical for improving the policy process and guiding resource allocation during this process. A historical review of archival documents from Mala?i and data obtained from in-depth policy studies in four countries (Tanzania, South Africa, Kenya and Peru) that have changed malaria treatment policy provides important lessons about decision-making, the policy cycle and complex policy environment, while specifically identifying strategies successfully employed to facilitate policy-making and implementation. Findings from these country-level studies indicate that the process of malaria drug policy review should be institutionalized in endemic countries and based on systematically collected data. Key stakeholders need to be identified early and engaged in the process, while improved communication is needed on all levels. Although malaria drug policy change is often perceived to be a daunting task, using these and other proven strategies should assist endemic countries to tackle this challenge in a systematic fashion that ensures the development and implementation of the rational malaria drug policy.     

卫生政策与体系研究:界定范围，辨别方法

从中低收入国家到高收入国家,卫生服务和体系研究术语的使用混乱状况普遍存在。在卫生服务研究文献和近期卫生政策与体系研究成果的基础上,本文将讨论卫生政策与体系研究方法。本文初稿在卫生政策与体系研究联盟的会议上讨论过。该联盟成立于1998年,旨在促进和支持中低收入国家的卫生政策与体系研究。本文评价卫生政策与体系研究方法,建议优先发展策略,并指出了卫生政策与体系研究所面临的挑战。     

Promoting healthy vision in students: progress and challenges in policy, programs, and research

Background:  An estimated 1 in 5 American children has a vision problem. Children living in poor urban environments have twice the normal rate of vision problems. Uncorrected vision problems can worsen over time and result in permanent vision loss. Early detection and treatment of vision problems is therefore essential in optimizing children's health and development. Federal-, state-, and school-based prevention efforts continue to evolve to identify and serve children with vision problems.
Methods:  Review of current literature on (1) major vision problems among children, (2) unique problems faced by low-income children with poor vision, and (3) the rise in health policy and program efforts to support the goal of healthy vision for each child. The preliminary relationship established between vision and academic performance is also discussed.
Results:  Low-income children have a disproportionate amount of vision problems and face several barriers to acquiring vision care. Varied actions among states include legislation requiring screening and follow-up before entry into elementary school.
Conclusions:  States and schools can take concrete steps to increase the number of children identified and treated for vision problems. Health policy and programs should also address common barriers to children receiving and wearing their glasses at home and in the classroom. Further research is necessary to assess the relationship between children's vision and educational outcomes. To the extent that vision is associated with academic success, policies and programs can be shaped to address the achievement gap that exists among our nation's youth and to support the goal of healthy vision for each child.