Implementing healthy food environment policies in New Zealand: nine years of inaction

Background The INFORMAS [International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support] Healthy Food Environment Policy Index (Food-EPI) was developed to evaluate the degree of implementation of widely recommended food environment policies by national governments against international best practice, and has been applied in New Zealand in 2014, 2017 and 2020. This paper outlines the 2020 Food-EPI process and compares policy implementation and recommendations with the 2014 and 2017 Food-EPI. Methods In March–April 2020, a national panel of over 50 public health experts participated in Food-EPI. Experts rated the extent of implementation of 47 “good practice” policy and infrastructure support indicators compared to international best practice, using an extensive evidence document verified by government officials. Experts then proposed and prioritized concrete actions needed to address the critical implementation gaps identified. Progress on policy implementation and recommendations made over the three Food-EPIs was compared. Results In 2020, 60% of the indicators were rated as having “low” or “very little, if any” implementation compared to international benchmarks: less progress than 2017 (47%) and similar to 2014 (61%). Of the nine priority actions proposed in 2014, there was only noticeable action on one (Health Star Ratings). The majority of actions were therefore proposed again in 2017 and 2020. In 2020 the proposed actions were broader, reflecting the need for multisectoral action to improve the food environment, and the need for a mandatory approach in all policy areas. Conclusions There has been little to no progress in the past three terms of government (9 years) on the implementation of policies and infrastructure support for healthy food environments, with implementation overall regressing between 2017 and 2020. The proposed actions in 2020 have reflected a growing movement to locate nutrition within the wider context of planetary health and with recognition of the social determinants of health and nutrition, resulting in recommendations that will require the involvement of many government entities to overcome the existing policy inertia. The increase in food insecurity due to COVID-19 lockdowns may provide the impetus to stimulate action on food polices.

Policy options for strengthening evidence-informed health policy-making in Iran: overall SASHA project findings

Background The institutionalization of evidence-informed health policy-making (EIHP) is complex and complicated. It is complex because it has many players and is complicated because its institutionalization will require many changes that will be challenging to make. Like many other issues, strengthening EIHP needs a road map, which should consider challenges and address them through effective, harmonized and contextualized strategies. This study aims to develop a road map for enhancing EIHP in Iran based on steps of planning. Methods This study consisted of three phases: (1) identifying barriers to EIHP, (2) recognizing interventions and (3) measuring the use of evidence in Iran's health policy-making. A set of activities was established for conducting these, including foresight, systematic review and policy dialogue, to identify the current and potential barriers for the first phase. For the second phase, an evidence synthesis was performed through a scoping review, by searching the websites of benchmark institutions which had good examples of EIHP practices in order to extract and identify interventions, and through eight policy dialogues and two broad opinion polls to contextualize the list of interventions. Simultaneously, two qualitative-quantitative studies were conducted to design and use a tool for assessing EIHP in the third phase. Results We identified 97 barriers to EIHP and categorized them into three groups, including 35 barriers on the “generation of evidence” (push side), 41 on the “use of evidence” (pull side) and 21 on the “interaction between these two” (exchange side). The list of 41 interventions identified through evidence synthesis and eight policy dialogues was reduced to 32 interventions after two expert opinion polling rounds. These interventions were classified into four main strategies for strengthening (1) the education and training system (6 interventions), (2) the incentives programmes (7 interventions), (3) the structure of policy support organizations (4 interventions) and (4) the enabling processes to support EIHP (15 interventions). Conclusion The policy options developed in the study provide a comprehensive framework to chart a path for strengthening the country’s EIHP considering both global practices and the context of Iran. It is recommended that operational plans be prepared for road map interventions, and the necessary resources provided for their implementation. The implementation of the road map will require attention to the principles of good governance, with a focus on transparency and accountability.

The qualitative experience of telehealth access and clinical encounters in Australian healthcare during COVID-19: implications for policy

Background Adaptive models of healthcare delivery, such as telehealth consultations, have rapidly been adopted to ensure ongoing delivery of essential healthcare services during the COVID-19 pandemic. However, there remain gaps in our understanding of how clinicians have adapted to telehealth. This study aims to explore the telehealth experiences of specialists, based at a tertiary hospital in the Hunter Region, and general practitioners (GP), including barriers, enablers and opportunities. Methods An interpretative qualitative study involving in-depth interviews explored the telehealth experiences of specialists, based at a tertiary hospital in the Hunter Region of Australia, and GPs, including barriers, enablers and opportunities. Data were analysed using an inductive thematic approach with constant comparison. Results Individual interviews were conducted with 10 specialists and five GPs. Key themes were identified: (1) transition to telehealth has been valuable but challenging; (2) persisting telehealth process barriers need to be addressed; (3) establishing when face-to-face consults are essential; (4) changes in workload pressures and potential for double-up; (5) essential modification of work practices; and (6) exploring what is needed going forward. Conclusions While there is a need to rationalize and optimize health access during a pandemic, we suggest that more needs to be done to improve telehealth going forward. Our results have important policy implications. Specifically, there is a need to effectively train clinicians to competently utilize and be confident using this telehealth and to educate patients on necessary skills and etiquette.

Repairing boundaries along pathways to tuberculosis case detection: a qualitative synthesis of intervention designs

Background Tuberculosis case-finding interventions often involve several activities to enhance patient pathways, and it is unclear which activity defines the type of case-finding intervention. When conducting studies to identify the most effective case-finding intervention it is important to have a clear understanding of these interventions for meaningful comparisons. This review aimed to construct a systems-based logic model of all pathways to tuberculosis case detection through a synthesis of intervention designs. Methods We identified an existing systematic review on the effectiveness of interventions to increase tuberculosis case detection and updated the search from December 2016 to October 2020. We included randomized controlled trials, as these designs encourage detailed description of interventions. Taking each study in turn, intervention descriptions were read in detail. The texts were analysed qualitatively by constantly comparing emerging codes to construct patient journeys, visualized as logical chains. Actions taken as part of interventions were positioned along patient journeys to theorize the sequence of outcomes. Patient journeys formed the basis of the model, which was refined through discussion. Results Based on intervention descriptions from 17 randomized controlled trials, our model distinguishes two care-seeking pathways and four screening pathways. An open invitation to people with tuberculosis symptoms creates care-seeking pathways. On care-seeking pathways, systematic screening can be conducted at general health services, but not at specific TB care services. People invited to tuberculosis services regardless of symptoms follow tuberculosis screening pathways and may be identified with presumptive tuberculosis even if they do not seek care for tuberculosis symptoms. Tuberculosis screening pathways include screening offered to all people accessing care at general health services, screening at a mobile clinic or health facility with open invitation to a whole population or tuberculosis contacts, screening personally offered to a whole population or tuberculosis contacts at home, work or school, and screening offered to people receiving care for human immunodeficiency virus or other clinical risk-group care. Conclusion This systems-based logic model of tuberculosis case-finding pathways may support standardized terminology, consistency, transparency and improved communication among researchers, policy-makers, health workers and community members when implementing and evaluating interventions to improve tuberculosis case detection.

“There hasn’t been a career structure to step into”: a qualitative study on perceptions of allied health clinician researcher careers

Background There are many demonstrated benefits for health service organizations engaging in research. As a result, growing numbers of clinicians are being encouraged to pursue research as part of their clinical roles, including in allied health (AH). However, while the benefits of having clinician researchers embedded in AH services have been well established, the career needs of those engaged in these dual roles are poorly understood. The aim of this study was to examine perspectives of the career pathway for AH clinicians engaged in “clinician researcher” roles within Australian health services. Methods A qualitative descriptive study was conducted, utilizing semi-structured interviews. Purposive sampling was used to ensure selection of varied locations, professions and role types. Results were analysed using thematic analysis. Trustworthiness was established using regular peer debriefing during theme development, and respondent validation of final themes. Results Fifty-seven AH clinician researchers, including those who did and did not have research as a formal component of their current role, participated in semi-structured interviews. Key themes were as follows: (1) clinician researchers prefer roles which are embedded in health services; (2) current opportunities for clinician researcher roles in health are insufficient; (3) there are deficiencies in the pathway for clinician researcher careers; (4) clinician researchers are not always valued or incentivized by health services; (5) the current career challenges impair the viability of clinician researcher careers; and (6) the clinician researcher career path has been improving, and there is hope it will continue to improve. Conclusion This study outlines a number of weaknesses in the current career structure and opportunities for AH clinician researchers in Australian health services. In particular, while there are strong intrinsic drivers to pursue this dual career, extrinsic drivers are poorly developed, including a lack of job opportunities, an unstable career pathway and a lack of valuing or incentivizing this career choice within health services. This often means that clinician researchers feel compelled to choose between a research or clinical career, leading to loss of this valuable combined skill set. The findings of this research may assist health services in developing and supporting improved clinician researcher career pathways.

Longitudinal study of the impact of three major regulations on the Korean pharmaceutical industry in the last 30 years

Background The pharmaceutical industry is heavily regulated. Partly for this reason, new drugs generally take over 10 years from the product development stage to market entry. Although regulations affect the pharmaceutical industry over a long period, previous studies investigating the impact of new regulatory policies have usually focused on the short period before and after implementing that policy. Therefore, the purpose of this study is to examine whether and how significantly regulatory policies affect long-term innovation in the pharmaceutical industry in Korea. Methods This study focused on three significant regulatory policies: the introduction of the product patent system, changes in the Good Manufacturing Practice (GMP) system, and the Drug Expenditure Rationalization Plan (DERP). The study used interrupted time series (ITS) analysis to investigate the long-term impacts of the policies before and after implementation. Results Our results show that introducing the product patent system in 1987 significantly increased the number of Korean patent applications. The effect of the revised GMP policies was also statistically significant, both before and after implementation and between pre-emptive companies and non-pre-emptive ones. However, due to the companies' negotiations with the regulatory authorities or the regulatory system that links drug approval and price evaluation, the DERP did not significantly delay new drug registration in Korea. Conclusion This study showed that the policies of the product patent system, GMP policies, and DERP regulations have significantly encouraged pharmaceutical companies to strive to meet regulatory requirements and promote innovation in Korea. The study suggests that it is necessary for companies to pre-emptively respond to systemic changes in development and production strategies to deal with regulatory changes and achieve sustainable growth. Also, our study results indicate that since government policies motivate the innovative system of the pharmaceutical industry, governmental authorities, when formulating pharmaceutical policies, need to consider the impact on the long-term innovation of the industry.

Assessing the impact of the Good Samaritan Law in the state of Connecticut: a system dynamics approach

Background Although Good Samaritan laws (GSLs) have been widely adopted throughout the United States, their efficacy in individual states is often unknown. This paper offers an approach for assessing the impact of GSLs and insight for policy-makers and public health officials who wish to know whether they should expect to see outcomes from similar policy interventions. Methods Utilizing a system dynamics (SD) modeling approach, the research team conducted a policy evaluation to determine the impact of GSLs on opioid use disorder (OUD) in Connecticut and evaluated the GSL based upon the following health outcomes: (1) emergency department (ED) visits for overdose, (2) behavioral changes of bystanders, and (3) overdose deaths. Results The simulation model suggests that Connecticut’s GSL has not yet affected overdose deaths but has resulted in bystander behavioral changes, such as increased 911 calls for overdose. ED visits have increased as the number of opioid users has increased. Conclusions The simulation results indicate that the number of opioid-related deaths will continue to increase and that the GSL alone cannot effectively control the crisis. However, the SD approach that was used will allow policymakers to evaluate the effectiveness of the GSL over time using a simulation framework. This SD model demonstrates great potential by producing simulations that allow policymakers to assess multiple strategies for combating the opioid crisis and select optimal public health interventions.

Health technology assessment-informed pricing negotiation in China: higher negotiated price for more effective targeted anticancer medicines?

Background In China, health technology assessment (HTA) has recently been adopted in pricing negotiation for medicine listing in the National Reimbursement Drug List. At present, how HTA is applied to inform the decision-making process remains underreported. In order to explore how the adoption of HTA was translated into listing and price negotiation results in light of the confidential nature of the negotiating process, this study aimed to compare the negotiated price and the clinical benefit of selected targeted anticancer medicines (TAMs) involved in the 2019 negotiation. Main text Among 16 TAMs successfully negotiated, only four TAMs representing four indication groups had appropriate reference medicines for comparison and were, therefore, included in the analysis. The price and clinical benefit of the four TAMs were compared against one or two reference medicines with the same initial indications. The sales prices for nine TAMs before and after the negotiation were extracted from the centralized medication procurement system. Clinical benefits were evaluated based on evidence from published articles and clinical guidelines. The results suggested that, despite the application of HTA, both rational and irrational decisions had been made about the reimbursement of TAMs in the 2019 negotiation, warranting further investigation. Conclusion While the development and adoption of HTA has seen significant progress in China, actions are needed to ensure that the adoption of HTA is effectively applied in decisions on the reimbursement of medicines.

Fit for purpose. Co-production of complex behavioural interventions. A practical guide and exemplar of co-producing a telehealth-delivered exercise intervention for people with stroke

Background Careful development of interventions using principles of co-production is now recognized as an important step for clinical trial development, but practical guidance on how to do this in practice is lacking. This paper aims (1) provide practical guidance for researchers to co-produce interventions ready for clinical trial by describing the 4-stage process we followed, the challenges experienced and practical tips for researchers wanting to co-produce an intervention for a clinical trial; (2) describe, as an exemplar, the development of our intervention package. Method We used an Integrated Knowledge Translation (IKT) approach to co-produce a telehealth-delivered exercise program for people with stroke. The 4-stage process comprised of (1) a start-up planning phase with the co-production team. (2) Content development with knowledge user informants. (3) Design of an intervention protocol. (4) Protocol refinement. Results and reflections The four stages of intervention development involved an 11-member co-production team and 32 knowledge user informants. Challenges faced included balancing conflicting demands of different knowledge user informant groups, achieving shared power and collaborative decision making, and optimising knowledge user input. Components incorporated into the telehealth-delivered exercise program through working with knowledge user informants included: increased training for intervention therapists; increased options to tailor the intervention to participant’s needs and preferences; and re-naming of the program. Key practical tips include ways to minimise the power differential between researchers and consumers, and ensure adequate preparation of the co-production team. Conclusion Careful planning and a structured process can facilitate co-production of complex interventions ready for clinical trial. Graphical Abstract

Use of research evidence varied in efforts to expand specific pharmacist autonomous prescriptive authority: an evaluation and recommendations to increase research utilization

Background An expanding body of literature shows that pharmacists’ interventions improve health outcomes and are cost-saving. However, diverse state regulations of pharmacists’ scope of practice create a discrepancy between what pharmacists are trained to do and what they legally can do. This study investigated how stakeholders utilized research evidence when developing expanded scope of practice policies in their respective states. Methods Using autonomous pharmacist prescriptive authority as a surrogate for general pharmacist scope of practice, a general policy document analysis was performed to understand the scope of practice landscape for pharmacists across the United States. Next, semi-structured interviews with policy-makers and pharmacy advocates were conducted to explore how the identified states in the policy document analysis utilized evidence during the policy-making process. Investigators analysed findings from the transcribed interviews through application of the SPIRIT Action Framework. Resulting codes were summarized across themes, and recommendations to researchers about increasing utilization of research evidence were crafted. Results Sixteen states with 27 autonomous pharmacist prescriptive authority policies were identified. Public health need and safety considerations motivated evidence engagement, while key considerations dictating utilization of research included perceptions of research, access to resources and experts, and the successful implementation of similar policy. Research evidence helped to advocate for and set terms for pharmacist prescribing. Barriers to research utilization include stakeholder opposition to pharmacist prescribing, inability to interpret research, and a lack of relevant evidence. Recommendations for researchers include investigating specific metrics to evaluate scope of practice policy, developing relationships between policy-makers and researchers, and leveraging pharmacy practice stakeholders. Conclusions Overall, alignment of researcher goals and legislative priorities, coupled with timely communication, may help to increase research evidence engagement in pharmacist scope of practice policy. By addressing these factors regarding research engagement identified in this study, researchers can increase evidence-based scope of practice, which can help to improve patient outcomes, contain costs, and provide pharmacists with the legal infrastructure to practise at the top of their license.