Research for policy: A study on improving the contribution of scientific knowledge to evidence-informed health policy

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Tilburg University

Research for policy

Hegger, Ingrid

Publication date: 2017

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Citation for published version (APA):

Hegger, I. (2017). Research for policy: A study on improving the contribution of scientific knowledge to evidence-informed health policy. Gildeprint.

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Take down policy

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Resear

ch f

or P

olicy

A s tudy on impr oving the c on tribution of scien tific kno wledg e t o e vidence-in

formed health policy

Ingrid Heg

Research for Policy

A study on improving the contribution of

scientific knowledge to evidence-informed health policy

Evidence-informed health policy-making is generally considered as an important approach for safeguarding public health: governments should take into account the best available research evidence in health policy-making. Most countries have established a National Public Health Institute to support their government in essential public health operations by activities such as health protection, population health assessment and research to produce evidence for policy-making. However, researchers experience that achieving contributions to health policy-making appears to be more difficult than one would expect in view of the institute’s mission. In the body of scientific literature on knowledge utilization, alignment between researchers and policy-makers is recognized as an important key for enhancing contributions of scientific knowledge to policy-making.

This thesis describes a study investigating how alignment is achieved and can be improved in research projects conducted by a National Public Health Institute in commission of governmental organizations.

Uitnodiging

voor het bijwonen van de openbare verdediging

van mijn proefschrift

Research for Policy

A study on improving the contribution of scientific knowledge to evidence-informed

health policy

op woensdag 6 september 2017 om 16:00 precies in de aula van de Universiteit van Tilburg, Warandelaan 2 te Tilburg

Aansluitend bent u van harte welkom op de receptie ter plaatse

Ingrid Hegger Soestdijkseweg Zuid 19 3732 HC De Bilt ingridhegger@gmail.com 06-38464916 Paranimfen: Thomas Bakker Promotie06092017@gmail.com Esther Bakker Promotie06092017@gmail.com

De aula bevindt zich in het Cobbenhagengebouw, te bereiken via het Koopmansgebouw.

Bij de universiteit is voldoende parkeergelegenheid. Station Tilburg Universiteit is op

10 minuten loopafstand. https://www.tilburguniversity.edu/nl/

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Research for Policy

A study on improving the contribution of

scientific knowledge to evidence-informed health policy

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Colofon

The research for this thesis was supported by the Strategic Research Programme 2011-2014 of the Dutch National Institute for Public Health and the Environment (RIVM) (project number S/270206).

The printing was financially supported by Tilburg University and the National Institute for Public Health and the Environment (RIVM).

ISBN

978-94-6233-673-5 Cover

‘Connections’ by Louise van Terheijden, Tilburg

http://louisevanterheijden.com/ Lay-out

Nicole Nijhuis - Gildeprint, Enschede Printed by

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Research for Policy

A study on improving the contribution of

scientific knowledge to evidence-informed health policy

Proefschrift

ter verkrijging van de graad van doctor aan Tilburg University op gezag van de rector magnificus, prof.dr. E.H.L. Aarts,

in het openbaar te verdedigen ten overstaan van een

door het college voor promoties aangewezen commissie in de aula van de Universiteit op woensdag 6 september 2017 om 16.00 uur

door

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Promotiecommissie

Promotores

Prof.dr.ing. J.A.M. van Oers Prof.dr.ir. A.J. Schuit Copromotor Dr. S.W.J. Janssen Overige leden

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Mijn proefschrift draag ik op aan

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Chapter 1 9 Introduction Chapter 2 29 The complex relationship between research and health policy: a comprehensive overview of theoretical approaches Chapter 3 43 Analyzing the contributions of a government-commissioned research project: a case study Chapter 4 75 Enhancing the contributions of research to healthcare policy-making: a case study on the Dutch Health Care Performance Report

Chapter 5 91

Contributions of knowledge products to health policy: a case study on the Public Health Status and Forecasts Report 2010

Chapter 6 105

Research for Policy (R4P): Development of a reflection tool for researchers to improve knowledge utilization

Appendix Chapter 6: Research for Policy tool

Chapter 7 151

Discussion and Conclusion

Summary 179

Samenvatting 189

Dankwoord 201

About the author 205

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Chapter 1

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R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 R23 R24 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38

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Public health for a healthy population

‘The Netherlands healthy and well.’ These words represent the motto of the Ministry of Health, Welfare and Sport in the Netherlands. On its website, the Ministry declares to have the ambition of keeping everyone as healthy as possible, as long as possible. Furthermore, the Ministry intends to support people with a disability and promote societal participation [1]. This short ministerial mission statement reflects the Dutch implementation of the worldwide responsibility for all national governments to maintain and enhance the health of its population as defined in the Universal Declaration of Human Rights [2]. Guaranteeing public health and maintaining effective health services is a demanding task with many difficult issues and a major impact on the national budget, asking for wise national and local policies. In order to ensure the population’s health, governments need to invest in a health system comprising a public health infrastructure and a well performing health care system. The World Health Organization (WHO) defined ten Essential Public Health

Operations (EPHOs) for the public health infrastructure to assure detecting, measuring, and

tackling health challenges through population-based measures [3]. The health care system has to offer health services such as preventive, curative and palliative interventions directed to individuals or to populations [4]. Many countries have established knowledge institutes for providing support in these governmental tasks, the so-called National Public Health

Institutes (NPHIs) [5, 6].

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In the Netherlands, the National Institute for Public Health and the Environment (RIVM), functions as a typical NPHI for already more than a century. RIVM has an important role in the EPHOs during the entire policy cycle for public health and environmental health. RIVM conducts research and knowledge synthesis in order to support national and international governmental organizations in the field of public health, health care, medical products, food and environmental health. Its operational tasks include population health monitoring, prevention by vaccination, infectious disease management, and population screening [9]. Most NPHIs are (partly) financed by national government funding, whether or not supplemented with other financial sources. As part of the Ministry of Health or being an autonomous governmental organization, NPHIs often have to account to the Minister of Health in some way. For policy advice issues, these characteristics can result in a position of the NPHI on the nexus of science and policy, where both scientific quality and policy relevance are at stake.

Research evidence for health policy-making

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Science, research, knowledge and evidence

In the first part of this introduction, the terms science, research, knowledge and evidence have already appeared without further clarification. These terms are easily used as synonyms, but their meaning is different. To clarify the term science we refer to the definition by the Science Council, UK: ‘Science is the pursuit and application of knowledge and understanding of the natural and social world following a systematic methodology based on evidence’ [26]. In NPHIs, a significant proportion of the scientists have been educated in natural sciences, in which a positivist view on science is dominant. From a positivist perspective, science is considered a rational system creating objective, value-free facts by measuring and observation. These facts reflect the objective single reality. However, for studying the dynamics of knowledge utilization in policy-making, this perspective does not offer sufficient understanding. In this thesis, we used the constructivist perspective that considers reality not a single truth, but a social construct. In this view, science is considered a dynamic social institution where norms, ideologies, practices, networks and power play a role [27,28]. Where science is the complete system, research is the systematic methodology to investigate and explain phenomena. As put forward by Hanney, health research can roughly be divided into basic, clinical and applied research [15]. Clinical research is basically conducted in a health care setting outside knowledge institutes. A characteristic of basic research is that the researchers mainly determine priorities; these research findings will generally not directly be utilized in policy-making. In applied research, other stakeholders, such as commissioners, governmental organizations and funding organizations, will generally also play a part in determining the research agenda. Although one could expect that this involvement will enhance scientific knowledge utilization, reality shows that this is not a guarantee for research impact and utilization of the findings [15]. In this thesis, we focus on applied research as conducted by NPHIs commissioned by governmental organizations. We now come to knowledge, another broad concept closely related to science and research. Knowledge encompasses all forms of knowing such as scientific findings, theories, data, experiences and practical skills [17, 29]. From a constructivist perspective, knowledge is a social construct depending on individuals and organizations involved and created when people interpret and process different information, such as research findings, theories and experiences. In this thesis, the term knowledge refers to scientific knowledge based

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science as dynamic social institution, the interpretation and processing of information into knowledge is also influenced by social processes [28]. Scientific knowledge is neither solely determined by scientific facts nor value free, which makes it impossible to draw a sharp line between scientific knowledge and non-scientific knowledge. This also implies that the boundary between the systems science and policy is not predetermined and more difficult to set than is (often implicitly) expected [8, 17, 30]. In Chapter 2, we further explore the complex relationship between science and policy.

Although in scientific literature the term evidence often refers to evidence from scientific

research [31], evidence for policy-making can be different types of information next to

findings from research and scientific knowledge. As described by Bowen and Zwi, types of evidence can be ideas, interests and information from politics and economics, anecdotal evidence, knowledge and expertise of experts as well as lay persons, judgements, history, analogies, local knowledge and culture (table 1.1) [24, 25]. Following the next explanation on

health policy, we return to the issue of evidence types in the section on evidence-informed health policy.

Table 1.1 Types of evidence and how they are used in policy making [24] Type of Evidence Information and Influence on Decision-Making

Research Empirical evidence from randomized control trials and other trials Analytic studies such as cohort or case control studies

Time series analyses

Observations, experiences, and case reports Qualitative research Before and after studies Knowledge and information Results of consultation processes with networks/groups Internet Published documents/reports (including policy evaluations and statistical analyses)

Ideas and interests Opinion and view- “expert knowledge” of individuals, groups, networks (shaped by pas personal and professional experiences, beliefs, values, skills)

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Policy, policy-makers, health policy and the policy process

In this part of the introduction, we explain how we interpret the concepts public policy,

policy-makers, health policy and the policy process.

In general, policy is a very broad concept related to the rational control and governance of society; we focus on public policy made by government and governmental organizations as a guide to action and for making choices on goals in a specified area and allocating resources and capacities to achieve these goals in a specified timeframe [32, 33]. The goals of public policy are inherently related to public interest and frequently aim to solve so-called ‘common problems’ that comprise the conflict between public and private interest [34]. The term

policy-makers is used when we refer to the professionals of government / governmental

organizations, who develop policies, often under the authority of a political official [35]. In the context of this thesis, we limit health policy to public policy made by the Ministry of Health or governmental organizations on an national level with the aim to impact positively on population health and including both health care policy and public health policy [32].

Agenda setting Policy formulation Decision making Policy implementation Policy evaluation

Figure 1.1 Policy cycle

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alternatives and select policy solutions; and those solutions get implemented, evaluated and revised’ [36]. The policy-making process is often represented as the policy cycle that includes the steps agenda setting, policy formulation, decision making, policy implementation and

policy evaluation in a logical, rational sequence.

It should be noted that although the above presented straightforward and rational policy-cycle provides a helpful overview, this model rather reflects the ideal policy-making process [34]. In the complex reality of policy-making, the stages are linked but ideas, interests, actors and value interact in a non-linear fashion [34]. As already recognized by Lindblom (1959), policy-making has a complex and incremental nature, which he characterized as ‘muddling through’ [37]. By taking incremental steps, policy-makers can manage the extremely complex set of interacting elements that is involved in the policy-making process and avoid mistakes. These characteristic elements include the involvement of many different actors with different interests, the long lead-time to come from agenda setting to policy evaluation, the simultaneous action on the same policy issue by different programs at different government levels, the influence of very technical disputes and the determining role of power elements, such as interests, money and authoritative coercion [36].

The complex reality of policy-making is important for understanding the use of scientific knowledge in policy-making, where information, knowledge and evidence have a specific role. In the political context, the interpretation of information is more powerful for attaining political goals than the correctness of information, as explained by Stone [34]. For policy-makers, it is crucial to put efforts in strategically controlling the interpretation of information. Some practices that could be regarded questionable in a scientific context can be important tools of political strategy, such as selecting the most wanted information, ignoring information, delaying publication of information and rephrasing information. Framing of information in a narrative is an important tool for creating the necessity of a proposed policy; a method that has a different logic than the linear scientific description of a problem, its cause and solution.

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what extent? From a political point of view, the outcome could be undesirable. Measuring and monitoring can reveal (new) problems, which is not always politically opportune since identification of a problem always raises the question of who has to account for it or even who is to blame for it. This policy-making logic may conflict with the logic pursued by scientists, who operate on the principle of accepting research findings as they are.

In next chapters, we will often refer to the complexity of the policy-making process and the consequences for enhancing knowledge contributions.

From evidence-based medicine to evidence-informed health policy

Medicine and health policy-making are naturally closely related worlds influencing each other. Evidence-informed health policy is a concept coming from Evidence Based Medicine

(EBM) that gained influence by the end of the 20th_{century [20]. EBM is ‘the conscientious,}

explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ and integrates ‘the best external evidence with individual clinical expertise and patients’ choice’ [31]. In this context, the best external evidence is considered to be ‘clinical evidence from systematic research’ such as randomized controlled trials (RCTs) [31]. EBM implies that the best clinical decisions need three types of knowledge: research evidence, clinical experience and the patient’s preferences. In line with EBM, the idea of evidence-based health policy (EBHP) came to the forefront over the past decade as an important way to improve health systems performance worldwide [38]. In the EBHP concept, robust research evidence should have an important role as basis for making and justifying political choices. However, the problems in public health and health systems, such as health inequalities or lifestyle consequences, are complex, though and persistent; they are so-called ‘wicked problems’ Wicked problems are difficult to understand and describe, since they have many causes, uncertainties and levels. They cannot be solved in a finite time-period by applying straightforward approaches such as an RCT. Many possible outcomes of a wicked problem exist and the desirability of an outcome depends on values and interests making the concept of EBHP a wicked problem in turn [21, 39-41].

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Know the place of evidence.

Rebecca Armstrong et al. J Public Health 2006;28:168-172

Figure 1.2 Know the place of evidence; Armstrong et al (2006) [13]

Putting the role of research evidence in policy-making into perspective clarifies why the term evidence-informed policy-making (EIPM) is nowadays preferred instead of the term

evidence-based policy-making [40]. Evidence-based could unjustly suggest that policy

decisions should be largely determined by research evidence preferably from RCTs [13, 24, 42]. According to Oxman et al, evidence-informed health policy-making is ‘an approach to policy decisions that aims to ensure that decision making is well-informed by the best available research evidence’ [42].

Role of national public health institutes in evidence-informed health policy

To act in accordance with the EIPM concept, policy-makers have to be able to find and appraise research evidence and acknowledge its possible limitations [42]. NPHIs have the task to produce knowledge based on research evidence in order to make research evidence readily available for use in policy-making. Graham et al describe primary scientific information as first-generation knowledge that is ‘in its natural state and largely unrefined, like diamonds in the rough’ [29]. Next to first-generation knowledge, they also distinguish

second- and third-generation knowledge. Second-generation knowledge is created by using

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is practically an impossible, time-consuming task if they have to turn to first-generation and second-generation knowledge (of variable quality) outside their own expertise field. The NPHI weighs and translates relevant information for the purpose of policy-making and the knowledge is often presented in a way that specifically meets the needs of the users, such as tools, websites, infographics, reports or other knowledge products. These knowledge products represent third-generation knowledge and aim at improving knowledge utilization.

Third-generation knowledge could also intend to influence the behavior of stakeholders by

providing decision tools, guidelines or recommendations [29].

We now reach the point where the inherent tension between usefulness of knowledge in policy-making and the border between science and policy-making emerges. The more a knowledge product contains political sensitive findings and recommendations on how to translate the knowledge into action, the more it comes close to policy-making. As we explained before, knowledge and research findings have a complex role in policy-making determined by the actual political context. Such a close-to-policy advice could very well meet the policy-maker’s need if in line with the actual political view, but could just as well give rise to concerns about political interference by the NPHI, particularly in case it does not fit in. The NPHI’s role depends on its legal position, authority and distance to the policy-making process and its staff has to be aware of their role. A NPHI being part of the Ministry of Health has to act in a different way than an independent agency not accountable to the Ministry. Researchers should know what the respective roles are of their institute and the government department, what their own role should be, how to handle uncertainty in expertise and how to interact with the policy-makers involved, for example by installing advisory committees for commissioned research. In order to prevent troubling situations, NPHIs researchers should also be aware of possible barriers in research utilization that may relate to expectations placed at the start of the research, the (in)effective transfer of research findings and the acceptance and interpretation of research findings by individual policy-makers [11]. They have to negotiate the boundary of their advice by finding the right balance in wording, format and presentation [43]. This also implies that achieving optimal knowledge utilization requires a two-way process that includes the policy-makers’ involvement as well [25]. Joint efforts will create knowledge products representing a

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For researchers at NPHIs, it is very satisfactory when contributions of knowledge to policy-making are smoothly attained and become clearly visible, specifically when the outside world recognizes the role of knowledge as basis for the policy choices. However, even contributions of carefully balanced, third-generation knowledge to policy-making often appear not to be that straightforward raising the question of what researchers can do to enhance contributions.

When we consider the differences in the role of information, knowledge, numbers and measurements in the policy-making context compared to the scientific context and the need to address wicked problems, the complexity of providing relevant research evidence for policy-making emerges. In fact, researchers and policy-makers have to align the political context and the scientific findings [25, 28]. According to Kok and Schuit (2012), the term

alignment, a state of being aligned, ‘emphasizes that accommodation can take place on

the side of research and/or on the side of action, instead of a one-way research to action dynamic’ [28]. In our study, the side of action was the policy-making context of the Ministry of Health. We consider alignment as a state in which all actors involved consider the knowledge products acceptably balanced to the policy-making needs. This balance can be reached after deliberately bringing together the research context and political context and by accommodation on either side. Alignment increases the likelihood that beneficial contributions to health policy can be obtained [28]. Kok and Schuit (2012) propose to call the specific anticipatory efforts to enhance the contributions to policy-making alignment

efforts [28]. In our study, we also distinguish alignment areas, meaning subject areas where

alignment efforts may focus on.

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Aim of the study

The aim of our study was to acquire insights in how knowledge institutes such as NPHIs can enhance the contributions to evidence-informed health policy of knowledge produced in commission of governmental organizations. To investigate this issue, we formulated the following research questions:

1. What alignment areas are important for enhancing the contributions to health policy of government commissioned research commissioned by National Public Health Institutes?

2. Based on the empirical findings gained in this study, what is a practical approach to enhance knowledge contributions from NPHIs to evidence-informed health policy-making at national level?

These research questions rendered specific objectives for this study:

• To map in detail the process of three RIVM projects, the alignment efforts in the projects and the projects’ contributions to health policy-making at national level; • To identify the most decisive alignment areas for knowledge contributions to

health policy-making;

• To prepare and evaluate a draft tool based on the theoretical framework and empirical findings for supporting researchers in alignment.

Study design and outline of the thesis

For answering exploratory questions such as “Why is available knowledge (not) used?” or “What factors play a role in knowledge utilization ?” qualitative research is often seen as the most suitable research design, because it pays appropriate attention to the contemporary and contextual conditions in relation to the topic under research. For this study, we choose an approach that offered insights into the processes of research projects at the level of daily practice. Therefore, the study-design was organized along the case study methodology [45]. We selected three cases of research projects according to the following criteria:

• The research projects jointly cover the scope of the RIVM health domain, i.e. public health, health care and health products, such as medicines, medical devices and consumer products;

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• The research projects render third generation knowledge products typical for a NPHI institute;

• The research projects have different status and size

The first case in the multiple case study was a new project commissioned by the Health Care Inspectorate in the domain of health products. The project Risk Model started in 2007 and was relatively small in terms of budget and number of researchers involved. The commissioner’s question was to develop a risk-based approach for stratified selection of high-risk clinical trials. The Inspectorate intended to implement a risk–based selection of inspection objects and the risk model aimed to facilitate the selection of the high-risk trials from the large number of clinical trials conducted every year in the Netherlands. As an inspection tool, the risk model developed had to remain confidential and could not be published by RIVM. Although the project started as a one-year project, the Inspectorate continued the commission in following years.

The second case was the development of the Dutch Health Care Performance Report 2010 (DHCPR) during the period 2008-2010. The Dutch Ministry of Health, Welfare and Sport commissioned this long-term health care performance monitor initially biannually (editions in 2006, 2008 and 2010). The last edition was published in 2014, four years after the 2010 edition. The DHCPR had the aim to contribute to strategic health care policy-making, but was not officially embedded in the policy cycle of the Ministry. Both team and budget were substantial and many stakeholders outside RIVM were involved. The DHCPR was considered one of the RIVM flagship-products in the health care domain and was sent to parliament for informing the members of parliament.

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For analyzing the data collected in the case studies, the Contribution Mapping approach developed by Kok and Schuit offered a useful model and method to analyze the processes [28]. Contribution Mapping conceptualizes the utilization and impact of knowledge through so-called contributions, which are activities that enable the conversion of knowledge into a component of policies and practices or in innovation. This concept reflects that knowledge conversion into policy-making can take many, even very subtle, shapes and forms, already during the research process. For the realization of meaningful contributions, Kok and Schuit consider specific actions, called alignment efforts, essential to attune research and use. The qualitative nature of the method and detailed analysis provided in depth understanding of the alignment processes (or lack of alignment) in research projects and the contributions of the created knowledge to health policy-making.

In Chapter 2, we provide a concise overview of the theoretical background for the complex relationship between research and health policy. It describes an influential typology of knowledge use and successive theoretical models on knowledge utilization [11, 46]. Chapter 3 describes the case study ‘Risk Model’. It contains an outline of Contribution Mapping as theoretical framework and method for analysis [28]. We analyzed the process of an RIVM project in which risk ranking models for clinical trials were developed in co-creation with and in commission of the Health Care Inspectorate. This case study provided information on important categories of alignment efforts.

In a second case study (Chapter 4), we analyzed the developmental process of the Dutch Health Care Performance Report 2010 (DHCPR 2010). The DHCPR monitors health care performance in the Netherlands by using indicators for quality, accessibility and affordability. This study focused specifically on the process at project level of RIVM researchers and policy-makers of the Ministry of Health. The study revealed several areas where alignment is relevant for enhancing the contributions of future reports.

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revealed insights on alignment issues in projects that already include several alignment efforts.

In Chapter 6, the findings of the three case studies are integrated for identifying the most decisive areas for alignment. The development of the practical tool Research for Policy tool

(R4P tool), based on the decisive alignment areas and intended for researchers, is described.

The R4P tool is presented as an Annex to this chapter.

In Chapter 7, the study as a whole is discussed including a reflection on the methods applied. Conclusions are drawn in relation to the initial research questions and are completed with recommendations on practical follow-up and further research opportunities.

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39. Green LW, Ottoson JM, Garcia C, Hiatt RA. Diffusion Theory, and Knowledge Dissemination, Utilization, and Integration in Public Health. Annu Rev Public Health. 2009; 30:151-174. 40. Lomas J, Brown A. Research and advice giving: a functional view of evidence-informed policy

advice in a Canadian ministry of health. Milbank Q. 2009;87:903-926.

41. Pielke RA, Jr. The honest broker: Making sense of science in policy and politics. Cambridge: Cambridge University Press; 2007.

42. Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 1: What is evidence-informed policymaking? Health Res Policy Syst. 2009;7 Suppl 1:S1.

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45. Yin RK. Case Study Research Design and Methods. 4th rev ed. Thousand Oaks: SAGE Publications Inc; 2008.

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Chapter 2

The complex relationship between research and health

policy: a concise overview of theoretical approaches

Submitted for publication

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R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 R23 R24 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 Abstract

It often appears difficult to realize the integration of scientific knowledge and research evidence into health policy; a problem which has been subject of extended scientific research in social sciences for several decades. This article provides a comprehensive overview of the different theoretical approaches in the complex relationship between science and policy-making. It describes successive theoretical models on knowledge utilization to inform researchers who intend to contribute to health policy about their own position in this complex constellation.

The influential typology of knowledge use provided by Weiss makes a division between

instrumental, conceptual and symbolic use of knowledge. Positivist, interactive and constructivist models have been developed to explain actual knowledge use and to identify

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Introduction

Researchers producing knowledge to support policy-makers have to deal with the complex relationship between science and health policy. In this paper, we intend to provide these researchers with a concise overview of the different theoretical approaches to make them aware of their own position in this relationship and to provide them with insights that can be of help in cross-disciplinary co-creation processes and in making research relevant and usable for policy-makers. After all, the awareness of researchers about the sensitive social issues arising at the nexus of science and policy has been found a decisive factor for the impact of research in policy-making [1-5].

Different perspectives on knowledge utilization

When aiming at integration of scientific evidence into health policy, researchers should realize that different perspectives on the use of scientific knowledge in policy-making exist, depending on the concepts for knowledge production, policy processes and knowledge use taken as starting points [6].

Knowledge production

In traditional knowledge production, scientists produce knowledge within their own discipline. Their focus is on science and knowledge in the first place and not necessarily on the usability of the knowledge produced.

Gibbons et al. described this as ‘Mode 1 knowledge production’ [7]. In the last decades,

Mode 1 knowledge production moved to ‘Mode 2 knowledge production’ in which academics

from different disciplines co-create knowledge together with other partners in a multi-disciplinary way [7].

Typology of knowledge use

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Instrumental use means that knowledge is considered as technical, objective data and

findings that are utilized in a direct and specific way to solve a particular problem [11]. Instrumental use of knowledge is mostly present in situations in which there is consensus, both in science and in policy [8].

Research is used in a conceptual way when it delivers ideas that ‘enlighten’ policy-makers [11]. From the original research, a more or less ‘layman story’ remains which can change people’s perceptions about problems and can frame those problems for the policy agenda. This indirect way of use can be observed in cases of high uncertainty about a problem or in the early stages of a policy discussion [8].

Research influences policy in a symbolic way when it is used as arguments to take an advocacy position. In this case, politicians and policy-makers may use research data selectively and strategically to support or strengthen their own position [8]. The knowledge is not used to inform decision-making, but to justify a pre-chosen position (political use) or to legitimize (in)action (tactical use) [11]. This type of research use can be observed in conflict situations [8].

In addition to the typology of Weiss, agenda-setting is sometimes named as a fourth way of research impact for cases where the research findings itself gives rise to social or political debate [12]. This however shows large overlap with the conceptual function of knowledge use.

Models for knowledge utilization

Most people will recognize the different types of knowledge use as described by Weiss from their own experience. From this typology, several questions naturally follow, such as ‘What factors determine the actual knowledge use and how can we influence the (type of) use?’. To handle the complex area of knowledge utilization, successive theoretical models have been developed which may help to find an answer to these questions. Some of these models— more specifically the constructivist ones—also challenge the distinction made by Weiss. In the next sections, we give a brief outline of three approaches: positivist, interactive and

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Positivist approach models

Positivism is an approach of reality that assumes the existence of a reality driven by natural laws and mechanisms and of research studying objects without influencing them [13].

Traditional or positivist models on knowledge utilization assume two separate worlds of

science and policy with a strict boundary in between and a one-way relationship [14]. The positivist perspective regards knowledge as a product for use in policy-making at a certain point in time. Consequently, these models take the boundaries of both domains as a starting point to improve knowledge utilization and to look for solutions that try to bridge the so-called ‘gap’ between these worlds. (Figure 2.1)

Science

_making

Policy-Figure 2.1 The gap between the world of science and policy-making

A first example of a positivist model is the classic knowledge-driven (or push) model. In this model, there is a sequence from research to policy utilization with the assumption that knowledge existence automatically presses to its use [15, 16]. Besides attributes of the research content, such as complexity and validity, and the type of research, such as method and domain, high quality research automatically leads to better use by policy makers according to this model [17].

Another example of a positivist model is the problem solving (or demand pull) model. Instead of the researchers, the initiative to start research is now shifted to the policy-makers [17]. Policy-makers identify a particular problem and ask researchers to help formulate alternatives and solutions to make a policy choice [15].

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R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 R23 R24 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 Agenda setting Policy formulation Decision making Policy implementation Policy evaluation

Figure 2.2 Policy cycle

After identifying the problem (agenda setting), policy-makers gather and consider data on all possible solutions or alternatives relevant for the public interest (policy formulation). Thereafter, they select a solution depending on predefined goals (decision making). After the solution has been put into practice (policy implementation), the results are monitored (policy evaluation) and adjusted when necessary [18]. Assuming that research evidence easily finds its way to policy-makers and offers ‘neutral’ and ‘objective’ facts, this rational policy cycle also reflects the different possible roles for research that offers objective and value-free facts.

However, this model of a one-way policy cycle has been criticized for not corresponding with the complex and incremental nature of policy-making including many different stakeholders with their own interests and preferences [19]. In an incremental model of policy-making, research has a weaker contribution and in comparison with the rational policy cycle,

symbolic use of research is more likely.

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account the organizational and social contexts that may influence the uptake and production of research. The science-policy model that researchers have (often implicitly) in their mind is often the rational model. It may be helpful for them to learn about alternative models and the implications of these models for their own work if taken as a starting point.

Interactive approach models

In response to the drawbacks of the rational models, interactive models of science-policy relations pay extra attention to context, communication and interaction between researchers and policy-makers. ‘Socio-organizational explanations’ of knowledge utilization include organizational interest explanations, ‘two communities’ explanations and interaction explanations [20]. According to the organizational interest explanation, researchers have to pay specific attention to the knowledge users’ needs, which depend on their policy domain or organization. In these models, knowledge use increases when policy-makers consider the research findings relevant, credible, timely and fitting in with their needs [21].

A model that gained a lot of influence is the ‘two communities’ model [10, 22, 23]. This model explains the lack of research use by policy-makers as a consequence of a cultural gap in norms and values between science and policy; both researchers and policy-makers have their own language and different ways of communication.

Although maybe difficult to achieve, effective interaction to better understand each other’s worlds is a starting point for increasing the use of research by policy-makers [22]. The ‘linkage and exchange’ model extended this view by focusing on the broader institutional and political context and acknowledges both research and policy-making to be ‘processes’ [23, 24]. Consequently, the use of research by policy-makers is higher when the research supports an existing policy or corresponds with the ideological environment, values or interest [10]. In this perspective, adaptation from both researchers and policy-makers, is necessary to increase research use [9]. For instance, researchers can invest in the presentation of the research (more readable and understandable) and present specific (policy) recommendations. At the same time, users can try to influence the topics on the research agenda in order to get research outcomes that fit with their needs [17].

The interaction model further bridges the gap between the ‘two communities’ by considering

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users and researchers [16, 21]. Relationships between researchers and policy-makers at different stages of the research process (from formulation to interpretation) have priority in this model and more investment in different types of linkage mechanisms result in higher use of research [21]. To analyze knowledge utilization in local policy-making, De Goede et al. for example developed a model that consists of a policy network and a research network and identified four categories of barriers in knowledge utilization: expectation, transfer, acceptance and interpretation [17]. (Figure 2.3) In their model, both networks may overlap when, for example, policy-makers get involved into the research process by formulating research questions or researchers in the policy process by communicating or presenting their results.

Barriers:

Expectation, Transfer, Acceptance, Interpretation

Policy network Research network

Research Use

Context

Figure 2.3 Interaction model de Goede [17]

Constructivist approach models

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Another way to look at knowledge utilization is the constructivist view that emphasizes the

co-construction of knowledge in a social process and considers boundaries between research

and policy as the outcome of negotiation processes between researchers and policy-makers [1, 25, 26]. The idea of separate worlds is replaced by the concept of ‘hybrids’ where policy-makers and researchers co-create knowledge in mutual interaction. In this view, science is not value-free and only producing facts but is, instead, another social institution with its own social norms and practices and no conclusive boundaries. In the constructivist perspective, the notion of knowledge use is problematized, as the positions of producer and user of knowledge are seen as intertwined.

A constructivist way to look at the relationship between science and policy is represented by the concept of ‘boundary work’ conducted by scientists and policy makers. Boundary work is about work done by actors to demarcate science from non-science. Although people use the concept ‘science’ easily in everyday life, it is in fact impossible to demarcate science in an unambiguous way. To handle this problem, Gieryn formulated the concept of boundary

work that has to be understood as ‘creating a social boundary that distinguishes science from intellectual activities that are non-science’ [27]. By conducting boundary work, both

researchers and policy-makers negotiate the boundary between science and policy-making, where science may come close to policy-making, but not too close [28].

Successful co-creation of knowledge heavily depends on the way the co-creation process is organized. In this respect, organizations located on the boundary between science and politics having characteristics of both domains and involving both scientists and policy-makers in knowledge production, play an important role and are sometimes described as

boundary organizations [29]. Although the boundary between science and policy-making

will continuously be the subject of discussion within such a boundary organization, a stable boundary can be presented to the outside world.

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negotiation process and the search for consensus backstage, including informal contacts between researchers and policy-makers, that creates trust and makes knowledge (products) ‘acceptable’ at the frontstage [25].

Frontstage work can be described as the way policy-makers and researchers show their

work and work processes to the public [25]. At the frontstage, they present a clear division of labour and their separated responsibilities. Here, science and policy are seen as two separate domains with their own tasks; science is depicted as objective and neutral to be used for politics to make decisions. This image fits the rational and positivist view of policy-making and science, which is often still a prevalent way to describe the relation between science and policy. It is at the frontstage where the research (process) gains external legitimacy and accountability (as being ‘evidence based’), but it is at the backstage where knowledge utilization is determined. (Figure 2.4)

Knowledge product Governmental organization Knowledge production Research Institute

Front Stage Back Stage

Figure 2.4 Backstage and Front Stage in Knowledge Production

To clarify the constructivist approach, we provide an example.

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policy-makers participate. Both researchers and experts feel the need to include policy recommendations in the final report. However, it becomes clear that some recommendations are politically controversial and unacceptable for the policy-makers who argue that proposing political solutions is their job. The questioned policy recommendations would undermine the acceptance of the report by the Ministry. After exciting negotiations, the group agrees on reformulated recommendations that maintain the research findings but leave room for an adequate political response by the Ministry. The director of the public health institute officially presents the final report to the Minister in presence of the press.

Putting theory into practice

The theoretical models described so far in this article provide useful insights into the complexity of the science- policy relation, but do not offer many practical leads yet to apply at the level of research projects. To fill this gap, researchers have to find approaches that fit their needs while taking into account the theoretical insights into knowledge utilization. Different theoretical approaches resulted in different practices to improve knowledge utilization. Knowledge translation including activities as research priority setting, knowledge distribution and evaluation of uptake is a commonly-used positivist approach [31]. From the interaction perspective, knowledge brokers linking researchers and knowledge users act as valuable intermediates to bridge the gap between the two worlds. Furthermore, a constructivist approach taking into account the complexity of the knowledge production process offers clear understanding of how to improve alignment between researchers and knowledge users. For example, Kok and Schuit developed the Contribution Mapping approach for monitoring research projects [20]. This approach based on constructivism brings up the moments and areas where specific alignment between knowledge producers and knowledge users may improve research contributions to policy and practice [3, 4]. Conclusion

In this paper, we provided an overview of theoretical models for knowledge utilization in health policy-making. All models offer some part of understanding about what is going on in the relationship between science and policy and it is up to researchers to take advantage of these models and concepts in aligning with policy-makers.

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added to the responsibilities of researchers. In everyday work, they probably will need to put flesh on the theoretical concepts described above.

The first step is to become aware of the complexity of science-policy interactions and the possible ways to approach this complexity. Perhaps, alignment may seem an obvious precondition to achieve contributions, but in fact it often proves to be very difficult to achieve [3-5, 17, 32].

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References

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2. Bal R, Bijker WE, Hendriks R. Paradox van Wetenschappelijk Gezag: over de maatschappelijke invloed van adviezen van de Gezondheidsraad. Den Haag: Gezondheidsraad, 2002.

3. Hegger I, Janssen SWJ, Keijsers JFEM, Schuit AJ, van Oers, HAM. Analyzing the contributions of a government-commissioned research project: a case study. Health Res Policy Syst. 2014; 12(1): 8.

4. Hegger I, Marks LK, Janssen SWJ, Schuit AJ, van Oers HAM. Enhancing the contribution of research to health care policy-making: a case study of the Dutch Health Care Performance Report. J Health Serv Res Policy. 2016; 21(1): 29-35.

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6. Sedlačko M, Staroňová K. An Overview of Discourses on Knowledge in Policy: Thinking Knowledge, Policy and Conflict Together. Cent Eur J Public Health. 2016; 9(2): 10-31.

7. Gibbons M, Limoges C, Nowotny H, Schwartzman S, Scott P, Trow M. The new production of knowledge: the dynamics of science and research in contemporary societies. London: Sage; 1994.

8. Weiss C. Policy research: data, ideas or arguments? In: Wagner CHWP, Wittrock B, Wollman H, editors. Social Sciences and modern states. Cambridge: Cambridge University Press; 1991. P. 307–332

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13. Carpiano RM, Daley DM. A guide and glossary on postpositivist theory building for population health. J Epidemiol Community Health. 2006; 60(7):564-570.

14. Gibbons M. Science’s new social contract with society. Nature. 1999. 402(SUPP).

15. Weiss CH. The many meanings of research utilization. Public Adm Rev. 1979; 39(5): 426-431. 16. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in

policy-making: concepts, examples and methods of assessment. Health Res Policy Syst. 2003; 1(1): 2. 17. de Goede J, Putters K, van der Grinten T, van Oers HA. Knowledge in process? Exploring barriers

between epidemiological research and local health policy development. Health Res Policy Syst. 2010; 8(26).

18. Howlett M, Ramesh M. Studying Public Policy: Policy cycles and Policy Subsystems. 1995. Toronto: Oxford University Press.

19. Lindblom CE. The science of “muddling through”. Public Adm Rev. 1959; 19 (2): 79-88.

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21. Landry R, Lamari M, Amara N. The extent and determinants of the utilization of university research in government agencies. Public Adm Rev. 2003; 63(2): 192-205.

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26. Jasanoff S. The fifth branch: Science advisers as policymakers. Cambridge, MA: Harvard University Press; 1990.

27. Gieryn TF. Boundary-work and the demarcation of science from non-science: Strains and interests in professional ideologies of scientists. Am Sociol Rev. 1983; 48(6) 781-795.

28. Bijker WE, Bal R, Hendriks R. The paradox of scientific authority: the role of scientific advice in democracies. Cambridge, MA: MIT Press; 2009

29. Guston DH. Stabilizing the boundary between US politics and science: The role of the Office of Technology Transfer as a boundary organization. Soc Stud Science. 1999; 29(1): 87-111. 30. Goffman E. The presentation of self in everyday life. London: Penguin; 1990.

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Chapter 3

Analyzing the contributions of a

government-commissioned research project: a case study

Published: Health Research Policy and Systems 2014, 12 (1):8

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R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 R23 R24 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 Abstract Background

It often remains unclear to investigators how their research contributes to the work of the commissioner. We initiated the ‘Risk Model’ case study to gain insight into how a Dutch National Institute for Public Health and the Environment (RIVM) project and its knowledge products contribute to the commissioner’s work, the commissioner being the Health Care Inspectorate. We aimed to identify the alignment efforts that influenced the research project contributions. Based on the literature, we expected interaction between investigators and key users to be the most determining factor for the contributions of a research project. Methods

In this qualitative case study, we analyzed the alignment efforts and contributions in the Risk Model project by means of document analysis and interviews according to the evaluation method Contribution Mapping. Furthermore, a map of the research process was drafted and a feedback session was organized. After the feedback session with stakeholders discussing the findings, we completed the case study report.

Results

Both organizations had divergent views on the ownership of the research product and the relationship between RIVM and the Inspectorate, which resulted in different expectations. The RIVM considered the use of the risk models to be problematic, but the inspectors had a positive opinion about its contributions. Investigators, inspectors, and managers were not aware of these remarkably different perceptions. In this research project, we identified six relevant categories of both horizontal alignment efforts (between investigators and key users) as well as vertical alignment efforts (within own organization) that influenced the contributions to the Inspectorate’s work.

Conclusions

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Background

For knowledge institutes such as the Dutch National Institute for Public Health and the Environment (RIVM), it is important to know what factors influence the impact of their research. This article aims to give insight into the process of a government-commissioned RIVM research project and the relevant alignment efforts needed to enhance its contributions to the commissioner’s work.

The RIVM is an independent knowledge institute with expertise in the fields of public health, infectious diseases, health care, medicines, lifestyle, nutrition, and environmental safety. Being a governmental institution, the RIVM conducts research on behalf of other governmental organizations to support them in their policy-making and supervisory tasks. One of the RIVM’s principal contracting agencies is the Health Care Inspectorate (hereafter: Inspectorate), which supervises the quality of health services, prevention measures, and medical products in the Netherlands. In a yearly program cycle, the Inspectorate submits knowledge questions to be answered by research conducted by the RIVM (Additional file 1 Yearly cycle for RIVM research in commission of the Health Care Inspectorate). For commissions to the RIVM, the Minister of Health puts a dedicated budget at the Inspectorate’s disposal, which means that the Inspectorate cannot use this budget for other purposes. Although RIVM investigators and inspectors interact during all phases of the research project, the Inspectorate, as the commissioning body, does not have authority over the research methods used, nor the outcome of studies as is laid down in the Act on the RIVM [1].

These days, the Inspectorate has to account for the effectiveness of its supervisory methods [2]. In its long-range plans, the Inspectorate expresses its objective to develop and use scientific knowledge for evidence-based supervision [3, 4]. Consequently, research projects commissioned to the RIVM are often intended to contribute to the scientific basis of the Inspectorate’s work.

Research for policy: A study on improving the contribution of scientific knowledge to evidence-informed health policy

Tilburg University

Research for policy

Hegger, Ingrid

Resear

ch f

or P

olicy

Research for Policy

A study on improving the contribution of

scientific knowledge to evidence-informed health policy

Uitnodiging

Research for Policy

Research for Policy

A study on improving the contribution of

scientific knowledge to evidence-informed health policy

Colofon

Research for Policy

A study on improving the contribution of

scientific knowledge to evidence-informed health policy

Proefschrift

Promotiecommissie

Contents

Chapter 1

1

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1

1

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Chapter 2

The complex relationship between research and health

policy: a concise overview of theoretical approaches

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Science

making

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Chapter 3

Analyzing the contributions of a

government-commissioned research project: a case study

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_making