Mental health research priorities in Australia: a consumer and carer agenda

Background

The perspectives of mental health consumers and carers are increasingly recognised as important to the development and conduct of research. However, research directions are still most commonly developed without consumer and carer input. This project aimed to establish priorities for mental health research driven by the views of consumers and carers in Australia.

Method

The project was conducted in two studies. Firstly, a face-to-face discussion forum held in the Australian Capital Territory (Study 1; n?=?25), followed by a national online survey (Study 2; n?=?70). Participants in both studies were members of the community who identified as a mental health consumer, carer or both. In Study 1, participants developed topics for mental health research in small group discussions, then voted on which topics, developed across all groups and sorted into thematic areas, were a priority. An online survey was developed from these research topics. Study 2 participants were asked to rate topics on a 5-point priority scale and rank the relative importance of the highest-rated topics.

Results

At the forum, 79 topics were generated and grouped into 14 thematic areas. Votes on priorities were spread across a large number of topics, with the greatest overall support for research relating to integrating care that is sensitive to past experiences of trauma into mental health service delivery (trauma-informed care). Survey responses were similarly spread, with the majority of research topics rated as important by at least 50% of participants and no clear individual priorities for research identified. Amongst items rated as important by approximately 80% of participants, key research areas included the delivery of services, and consumer and carer involvement.

Conclusions

Australian mental health consumers and carers demonstrate a strong understanding of the mental health system and its inadequacies. Although clear specific priorities are difficult to establish, consistent areas of focus are services and the role consumers and carers can play in their improvement. However, for consumer and carer views to be at the forefront of research, it is important to regularly update research agendas and work in partnership across the whole research process.

     

Neonatal survival in complex humanitarian emergencies: setting an evidence-based research agenda

Background

Over 40% of all deaths among children under 5 are neonatal deaths (0–28 days), and this proportion is increasing. In 2012, 2.9 million newborns died, with 99% occurring in low- and middle-income countries. Many of the countries with the highest neonatal mortality rates globally are currently or have recently been affected by complex humanitarian emergencies. Despite the global burden of neonatal morbidity and mortality and risks inherent in complex emergency situations, research investments are not commensurate to burden and little is known about the epidemiology or best practices for neonatal survival in these settings.

Methods

We used the Child Health and Nutrition Research Initiative (CHNRI) methodology to prioritize research questions on neonatal health in complex humanitarian emergencies. Experts evaluated 35 questions using four criteria (answerability, feasibility, relevance, equity) with three subcomponents per criterion. Using SAS 9.2, a research prioritization score (RPS) and average expert agreement score (AEA) were calculated for each question.

Results

Twenty-eight experts evaluated all 35 questions. RPS ranged from 0.846 to 0.679 and the AEA ranged from 0.667 to 0.411. The top ten research priorities covered a range of issues but generally fell into two categories– epidemiologic and programmatic components of neonatal health. The highest ranked question in this survey was “What strategies are effective in increasing demand for, and use of skilled attendance?”

Conclusions

In this study, a diverse group of experts used the CHRNI methodology to systematically identify and determine research priorities for neonatal health and survival in complex humanitarian emergencies. The priorities included the need to better understand the magnitude of the disease burden and interventions to improve neonatal health in complex humanitarian emergencies. The findings from this study will provide guidance to researchers and program implementers in neonatal and complex humanitarian fields to engage on the research priorities needed to save lives most at risk.

     

Developing the design of a continuous national health survey for New Zealand

Background

A continuously operating survey can yield advantages in survey management, field operations, and the provision of timely information for policymakers and researchers. We describe the key features of the sample design of the New Zealand (NZ) Health Survey, which has been conducted on a continuous basis since mid-2011, and compare to a number of other national population health surveys.

Methods

A number of strategies to improve the NZ Health Survey are described: implementation of a targeted dual-frame sample design for better Māori, Pacific, and Asian statistics; movement from periodic to continuous operation; use of core questions with rotating topic modules to improve flexibility in survey content; and opportunities for ongoing improvements and efficiencies, including linkage to administrative datasets.

Results and discussion

The use of disproportionate area sampling and a dual frame design resulted in reductions of approximately 19%, 26%, and 4% to variances of Māori, Pacific and Asian statistics respectively, but at the cost of a 17% increase to all-ethnicity variances. These were broadly in line with the survey’s priorities. Respondents provided a high degree of cooperation in the first year, with an adult response rate of 79% and consent rates for data linkage above 90%.

Conclusions

A combination of strategies tailored to local conditions gives the best results for national health surveys. In the NZ context, data from the NZ Census of Population and Dwellings and the Electoral Roll can be used to improve the sample design. A continuously operating survey provides both administrative and statistical advantages.

     

A review of selected research priority setting processes at national level in low and middle income countries: towards fair and legitimate priority setting

Background

It is estimated that more than $130 billion is invested globally into health research each year. Increasingly, there is a need to set priorities in health research investments in a fair and legitimate way, using a sound and transparent methodology. In this paper we review selected priority setting processes at national level in low and middle income countries. We outline a set of criteria to assess the process of research priority setting and use these to describe and evaluate priority setting exercises that have taken place at country level. Based on these insights, recommendations are made regarding the constituents of a good priority setting process.

Methods

Data were gathered from presentations at a meeting held at the World Health Organization (WHO) in 2008 and a web-based search. Based on this literature review a number of criteria were developed to evaluate the priority setting processes.

Results

Across the countries surveyed there was a relative lack of genuine stakeholder engagement; countries varied markedly in the extent to which the priority setting processes were documented; none of the countries surveyed had a systematic or operational appeals process for outlined priorities; and in all countries (except South Africa) the priorities that were outlined described broad disease categories rather than specific research questions.

Conclusions

Country level priority setting processes differed significantly in terms of the methods used. We argue that priority setting processes must have in-built mechanisms for publicizing results, effective procedures to enforce decisions as well as processes to ensure that the revision of priorities happens in practice.

     

An analysis of research priority-setting at the World Health Organization – how mapping to a standard template allows for comparison between research priority-setting approaches

Background

A review of research priorities completed by WHO technical units was undertaken. Results of the mapping were recorded in a database that was used to generate analysis and compare research priorities and the different methodological approaches used in their development.

Methods

A total of 116 documents were reviewed for this study. The documents were published between 2002 and 2017 by the technical programmes of WHO headquarters and deposited in the institutional repository, IRIS. Research priorities were extracted from documents into a standard template and mapped to a five-category research cycle type framework defined in the WHO Strategy on Research for Health covering research to describe the research problem, identifying the cause and risk factors, developing solutions and new interventions, understanding the barriers to implementation, and evaluation of the impact of response. Details of the research priority methods were recorded. A database with user interface was created using Microsoft Excel 2010.

Results

A total of 2145 research priorities were extracted from the 116 documents meeting the inclusion criteria. The priorities specifically address 73 diseases/health topics. The document types were 26% Report, 22% WHO Guideline, 26% Research Prioritisation publication and 11% Meeting Notes. The most widely reported method used to identify priorities was expert consultation. Expert consultation was used to identify 86% of the priorities categorised here, with 26% (561) reporting it as the sole method; 52% (1111) explicitly listed a literature review as contributing to the identification of priorities. When the 2145 priorities were categorised across the research cycle framework, the largest portion (43%) addressed implementation challenges. The database is published here under an open access licence.

Conclusion

Comparing research priorities between diseases/health topics requires standardisation and the research cycle type framework is one approach that can be applied across all the health topics found in public health. There is great variation in the use of research priority-setting methodology at WHO Headquarters. Therefore, a standard reporting approach, linked to established good practice, should be an area for future development by the WHO Global Health R&D Observatory. The database reported here can also be used to quickly access and analyse the research priorities for a specific health topic or to compare across a range of health topics.

     

Visual and participatory research techniques: photo-elicitation and its potential to better inform public health about physical activity and eating behavior in underserved populations

Aim

A healthier America depends on the development of strategies and interventions that are inclusive of and attentive to the needs of at-risk groups. This commentary seeks to contribute to the discussion of such interventions by advocating for the use of photo-elicitation (PE) as a research tool that can enhance the impact of studies targeting health behaviors such as physical activity and diet.

Subject and Methods

This commentary discusses the extent to which PE may enhance the quality and outcomes of research studies that aim to understand health behavior in underserved groups. We describe some of the advantages and disadvantages of the application of PE in public health research. This analysis is timely because public health researchers and practitioners are currently engaged in efforts to better understand health behaviors in specific racial and ethnic groups in an attempt to mitigate health disparities.

Results

Participatory research techniques (PRTs) such as PE are promising tools for elucidating an individual’s knowledge and perceptions of his or her socio-cultural context. As a participant-centered method, it can directly benefit individuals and their communities. Within the behavioral health sciences, it has the potential to advance knowledge of the determinants of physical activity and healthy eating habits as well as of the enablers and deterrents of these key health behaviors.

Conclusion

The new insights that investigators can acquire by employing PRTs such as PE may help public health researchers to develop culturally sensitive strategies and culturally meaningful intervention programs that have a better chance of reaching and benefiting at-risk populations.

     

Budgeting for a billion: applying health technology assessment (HTA) for universal health coverage in India

Background

India recently launched the largest universal health coverage scheme in the world to address the gaps in providing healthcare to its population. Health technology assessment (HTA) has been recognised as a tool for setting priorities as the government seeks to increase public health expenditure. This study aims to understand the current situation for healthcare decision-making in India and deliberate on the opportunities for introducing HTA in the country.

Methods

A paper-based questionnaire, adapted from a survey developed by the International Decision Support Initiative (iDSI), was administered on the second day of the Topic Selection Workshop that was conducted as part of the HTA Awareness Raising Workshop held in New Delhi on 25–27 July, 2016. Participants were invited to respond to questions covering the need, demand and supply for HTA in their context as well as the role of their organisation vis-à-vis HTA. The response rate for the survey was about 68% with 41 participants having completed the survey.

Results

Three quarters of the respondents (71%) stated that the government allocated healthcare resources on the basis of expert opinion. Most respondents indicated reimbursement of individual health technologies and designing a basic health benefit package (93% each) were important health policy areas while medical devices and screening programmes were cited as important technologies (98% and 92%, respectively). More than half of the respondents noted that relevant local data was either not available or was limited. Finally, technical capacity was seen as a strength and a constraint facing organisations.

Conclusion

The findings from this study shed light on the current situation, the opportunities, including potential topics, and challenges in conducting HTA in India. There are limitations to the study and further studies may need to be conducted to inform the role that HTA will play in the design or implementation of universal health coverage in India.

     

Health care facility vulnerability in developing nations: strengthening health care policy-making and implementation

Background

In developing countries such as India, inadequate importance and consideration given to assessment of health care facilities negatively affects progress towards achieving health targets. India has focused on developing Primary Health Centres (PHCs) for rural basic laboratory and curative services. The local decision-makers do not have any national-level framework to evaluate the vulnerability of PHCs which are not meeting national PHC standards, nor do they have resources to meet national PHC standards.

Aim

The study proposed a framework to assess the public health care facilities for vulnerability.

Methods

A cross-sectional questionnaire survey was performed. The study used PHC laboratory services of 42 PHCs of Osmanabad District, India as a case study for proposed framework. The data assessment was carried out at district level, block level, PHC cluster level, and PHC level to provide flexibility to local decision-makers in taking remedial measures.

Results

Staff workload (73.17%), physician’s need (51.22%), and organization structure (36.59%) are the most prevalent challenges across PHCs. Multiple challenges are prevalent in the PHCs across districts. The PHCs with poor medical doctor (MD) capability or many challenges have shown poor laboratory performance.

Conclusion

Governance need to be strengthened in PHCs, followed by sustained support in resources and financing. Poor health status in developing nations necessitates a public health response based on health systems. Therefore, an assessment of health facility vulnerability in the form of laboratory services is essential in primary health care facilities.

     

Prioritizing health services research: an economic perspective

Introduction

Given limited resources policymakers need to decide about how much and in what areas of health services research (HSR) to invest. The purpose of this study is to provide guidance for priority setting of HSR projects based on economic theory.

Methods

The conceptual analysis starts from the premise that competition in health care is valuable—a position that seems to predominate among Western policymakers. The principle of competition rests on economic theory and, in particular, its branch of welfare economics.

Results

Based on economic theory, the role of HSR is to detect and alleviate information asymmetry, negative externalities, and harm caused by competition and inappropriate incentives for competition. A hierarchy of HSR projects is provided; following the ethical principle of harm (‘do not harm’), the detection and prevention of harm would receive highest priority among HSR projects.

Conclusions

Agreeing that competition is valuable in achieving efficiency and quality of care (and therefore agreeing to the assumptions of economic theory) implies accepting the role of HSR in detecting market failure and the HSR hierarchy as suggested. Disagreement would require an alternative coherent concept of improving efficiency and quality of care.

     

Mode differences in a mixed-mode health interview survey among adults

Background

Health interview surveys are important data sources for empirical research in public health. However, the diversity of methods applied, such as in the mode of data collection, make it difficult to compare results across surveys, time, or countries. The aim of this study was to explore whether the prevalence rates of health-related indicators amongst adults differ when self-administered paper mail questionnaires (SAQ-Paper), self-administered web surveys (SAQ-Web), and computer-assisted telephone interviews (CATI) are used for data collection in a health survey.

Methods

Data were obtained from a population-based mixed-mode health interview survey of adults in Germany carried out within the ‘German Health Update’ (GEDA) study. Data were collected either by SAQ-Paper (n?=?746), SAQ-Web (n?=?414), or CATI (n?=?411). Predictive margins from logistic regression models were used to estimate the prevalence rates of chronic conditions, subjective health, mental health, psychosocial factors, and health behaviours, adjusted for the socio-demographic characteristics of each mode group.

Results

Socio-demographic characteristics were found to differ significantly between study participants who responded by SAQ-Paper, SAQ-Web, and CATI. Crude prevalence rates for health-related indicators also showed significant variation across all three survey modes. After adjusting for socio-demographic factors though, significant differences in prevalence rates between the two self-administered modes (SAQ-Paper and SAQ-Web) were found in only 2 out of the 19 health-related indicators studied. The differences between CATI and the two self-administered modes remained significant however, especially for indicators of mental and psychosocial health and self-reported sporting activity.

Conclusions

The findings of this study indicate that prevalence rates obtained from health interview surveys can vary with the mode of data collection, primarily between interviewer and self-administered modes. Hence, the type of survey mode used should be considered when comparing results from different health surveys. Mixing self-administered modes, such as paper-based questionnaires and web surveys, may be a combination to minimize mode differences in mixed-mode health interview surveys.

     

Concepts of social epidemiology in health services research

Background

Social epidemiologists aim to identify social characteristics that affect the pattern of disease and health distribution in a society and to understand its mechanisms. Some important concepts of social epidemiology are: social inequalities, social relationships, social capital, and work stress.

Discussion

Concepts used in social epidemiology can make a useful contribution to health services research because the underlying social factors do not only influence health but are also related to health care. Social inequality indicators like education or income have an impact on access to health care as well as on utilization and quality of health care. Social relationships influence adherence to medical treatment, help-seeking behavior, utilization of health services, and outcomes. Social capital in health care organizations is an important factor for the delivery of high-quality coordinated care. Job stress is highly prevalent among health care providers and can not only affect their health but also their performance.

Summary

The theoretical considerations behind factors like social inequalities, social relationships, social capital and work stress can enrich health services research because theory helps to specify the research question, to clarify methodological issues, to understand how social factors are related to health care, and to develop and implement interventions.

     

Setting priorities for knowledge translation of Cochrane reviews for health equity: Evidence for Equity

Background

A focus on equity in health can be seen in many global development goals and reports, research and international declarations. With the development of a relevant framework and methods, the Campbell and Cochrane Equity Methods Group has encouraged the application of an ‘equity lens’ to systematic reviews, and many organizations publish reviews intended to address health equity.The purpose of the Evidence for Equity (E4E) project was to conduct a priority-setting exercise and apply an equity lens by developing a knowledge translation product comprising summaries of systematic reviews from the Cochrane Library. E4E translates evidence from systematic reviews into ‘friendly front end’ summaries for policy makers.

Methods

The following topic areas with high burdens of disease globally, were selected for the pilot: diabetes/obesity, HIV/AIDS, malaria, nutrition, and mental health/depression. For each topic area, a “stakeholder panel” was assembled that included policymakers and researchers. A systematic search of Cochrane reviews was conducted for each area to identify equity-relevant interventions with a meaningful impact. Panel chairs developed a rating sheet which was used by all panels to rank the importance of these interventions by: 1) Ease of Implementation; 2) Health System Requirements; 3)Universality/Generalizability/Share of Burden; and 4) Impact on Inequities/Effect on equity.The ratings of panel members were averaged for each intervention and criterion, and interventions were ordered according to the average overall ratings.

Results

Stakeholder panels identified the top 10 interventions from their respective topic areas. The evidence on these interventions is being summarized with an equity focus and the results posted online, at http://methods.cochrane.org/equity/e4e-series.

Conclusions

This method provides an explicit approach to setting priorities by systematic review groups and funders for providing decision makers with evidence for the most important equity-relevant interventions.

     

Priority setting in health: development and application of a multi-criteria algorithm for the population of New Zealand’s Waikato region

Background

Priority setting in a climate of diverse needs and limited resources is one of the most significant challenges faced by health care policymakers. This paper develops and applies a comprehensive multi-criteria algorithm to help determine the relative importance of health conditions that affect a defined population.

Methods

Our algorithm is implemented in the context of the Waikato District Health Board (WDHB) in New Zealand, which serves approximately 10% of the New Zealand population. Strategic priorities of the WDHB are operationalized into five criteria along which the algorithm is structured—scale of disease, household financial impact of disease, health equity, cost-effectiveness, and multimorbidity burden. Using national-level data and published literature from New Zealand, the World Health Organization, and other high-income Commonwealth countries, 25 health conditions in Waikato are identified and mapped to these five criteria. These disease-criteria mappings are weighted with data from an ordered choice survey administered to the general public of the Waikato region. The resulting output of health conditions ranked in order of relative importance is validated against an explicit list of health concerns, provided by the survey respondents.

Results

Heart disease and cancerous disorders are assigned highest priority rankings according to both the algorithm and the survey data, suggesting that our model is aligned with the primary health concerns of the general public. All five criteria are weighted near-equal across survey respondents, though the average health equity preference score is 9.2% higher for Māori compared to non-Māori respondents. Older respondents (50 years and above) ranked issues of multimorbidity 4.2% higher than younger respondents.

Conclusions

Health preferences of the general population can be elicited using ordered-choice surveys and can be used to weight data for health conditions across multiple criteria, providing policymakers with a practical tool to inform which health conditions deserve the most attention. Our model connects public health strategic priorities, the health impacts and financial costs of particular health conditions, and the underlying preferences of the general public. We illustrate a practical approach to quantifying the foundational criteria that drive public preferences, for the purpose of relevant, legitimate, and evidence-based priority setting in health.

     

Evaluation of regional project to strengthen national health research systems in four countries in West Africa: lessons learned

Background

Since the Commission on Health Research for Development (COHRED) published its flagship report, more attention has been focused on strengthening national health research systems (NHRS). This paper evaluates the contribution of a regional project that used a participatory approach to strengthen NHRS in four post-conflict West African countries – Guinea-Bissau, Liberia, Sierra Leone and Mali.

Methods

The data from the situation analysis conducted at the start of the project was compared to data from the project’s final evaluation, using a hybrid conceptual framework built around four key areas identified through the analysis of existing frameworks. The four areas are governance and management, capacities, funding, and dissemination/use of research findings.

Results

The project helped improve the countries’ governance and management mechanisms without strengthening the entire NHRS. In the four countries, at least one policy, plan or research agenda was developed. One country put in place a national health research ethics committee, while all four countries could adopt a research information management system. The participatory approach and support from the West African Health Organisation and COHRED were all determining factors.

Conclusion

The lessons learned from this project show that the fragile context of these countries requires long-term engagement and that support from a regional institution is needed to address existing challenges and successfully strengthen the entire NHRS.

     

Mental health problems among university students and the impact of structural conditions

Aim

Mental health among university students represents an important and growing public health concern. International research has shown a high prevalence of depression and anxiety among university students. The aim of this study was to determine the prevalence of depression as well as anxiety among German university students and to assess gender differences and discrepancies between fields of study as well as class years. Additionally, an important public health issue—the impact of structural conditions at the university on depression and anxiety—was addressed.

Subject and methods

A Web-based survey was conducted at two German universities, employing data from 1,707 students. Anxiety and depressive disorders were assessed with the 4-item Patient Health Questionnaire (PHQ-4), and structural conditions at the universities were also determined.

Results

During the 2 weeks prior to the survey, 14.2 % of the students showed depressive and 16.3 % anxiety symptoms; symptoms of both disorders were experienced by 8.4 %. Gender differences and differences correlated with study year and field were found, but the effect size showed that these were not empirically relevant. Structural conditions, such as study demands, time latitude, social support by students, qualification potential and decision latitude, proved to be significant predictors for depression and accounted for 18 % of the total variance. Demands, time latitude and social support by students were proven to be significant predictors for anxiety, contributing to 16 % of the total variance.

Conclusions

These findings highlight the need to address mental health problems among university students and to initiate interventions. Furthermore, the findings implicate that study demands placed on students should be adjusted, and study resources, especially time latitude and social support by other students, should be promoted.

     

Reasons for self-testing—beyond the passive users. Results from a nationwide sample in Germany

Objectives

The aims of this study were to investigate (1) the personal reasons for using a self-test, (2) the decisive motives for self-testing, and (3) why a self-test was preferred over a conventional diagnosis by a health professional.

Subject and methods

Participants were invited to an online survey in batches representative of the age and gender distribution in Germany. The research questions were investigated with open questions and questions with given responses. Qualitative content analysis was conducted based on the method described by Mayring.

Results

Overall, 980 personal reasons for conducting 709 self-tests were indicated by 505 self-testers, which were assigned to 13 main categories with 32 sub-categories. The two most frequently stated personal reasons for self-testing were ‘uncertainty/reassurance’ and ‘risk perception’ (e.g. hereditary risks, previous diseases). The decisive reason for self-testing was strongly associated with the disease the user expected to detect. Self-tests were preferred over a diagnosis by a health professional because of practical advantages.

Conclusions

The majority of the German testers actively sought a self-test. Self-testers’ follow-up behaviour and their emotional perceptions need to be investigated.

     

Attitudes of developing world physicians to where medical research is performed and reported

Background

Little is known about the influence of the site of research or publication on the impact of the research findings on clinical practice, particularly in developing countries. The International Clinical Epidemiology Network (INCLEN) is dedicated to improving the quality of health research in the Developing World through institutional capacity building for evidence based medicine, and provided the opportunity to examine the likely impact of research location and journal location on physicians' practice in a number of the participating countries.

Methods

Physicians from secondary and tertiary hospitals in six cities located in China, Thailand, India, Egypt and Kenya were enrolled in a cross-sectional questionnaire survey. The primary outcome measures were scores on a Likert scale reflecting stated likelihood of changing clinical practice depending on the source of the research or its publication.

Results

Overall, local research and publications were most likely to effect change in clinical practice, followed by North American, European and regional research/publications respectively, although there were significant variations between countries. The impact of local and regional research would be greater if the perceived research quality improved in those settings.

Conclusion

Conducting high quality local research is likely to be an effective way of getting research findings into practice in developing countries.

     

Key Aspects of a Sustainable Health Insurance System in Germany

Background

The main goals of health-care systems are to improve the health of the population they serve, respond to people’s legitimate expectations, and offer fair financing. As a result, the health system in Germany is subject to continuous adaption as well as public and political discussions about its design.

Objective

This paper analyzes the key challenges for the German health-care system and the underlying factors driving these challenges. We aim to identify possible solutions to put the German health-care system in a better position to face these challenges.

Methods

We utilize a broad array of methods to answer these questions, including a review of the published and grey literature on health-care planning in Germany, semi-structured interviews with stakeholders in the system, and an online questionnaire.

Results

We find that the most urgent (and manageable) aspects that merit attention are holistic hospital planning, initiatives to increase (administrative) innovation in the health-care system, incentives to increase prevention, and approaches to increase analytical quality assurance.

Conclusion

We found that hospital planning, innovation, quality control, and prevention, are considered to be the topics most in need of attention in the German health system.