Presentation given at the Canadian Conference on Global Health in 2015 in Montreal, with Federica Fregonese, Pierre Minn, Emilie Robert and Georges -Chalers Thiebaut

1. Innovative research approaches to !
improve evidence in global health
22nd Canadian Conference in Global Health,
Montreal 5 Nov 2015
Federica Fregonese
Pierre Minn
Emilie Robert
Georges-Charles Thiebaut

2. Outline of the Presentation
• Introduction of the problem and need for different and integrated
approaches (Federica Fregonese)
Presentation of three possible approaches:
• The role of “slow research” in global health (Pierre Minn)
• The realist approach for evidence-based decision making in global
health (Émilie Robert)
• Enhancing organizational performance: configurational and
deliberative approaches to translate evidence into knowledge
(Georges-Charles Thiebaut)
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3. Introduction !
The limits of quantitative research from a quantitative
researcher’s perspective!
The example of prevention of mother to child transmission of HIV
infection (PMTCT)
• Ground-breaking trials in the 1990s (on use of zidovudine in
pregnant women), in early 2000s (combination of zidovudine and
nevirapine), and subsequently on possibilities to avoid transmission
using therapy during breastfeeding
• Combination intervention for PMTCT: proven efficacy in RCT of
reducing transmission of HIV during pregnancy, delivery or
neonatal period to less than 2% (from about 30-40% with no
intervention)
3

4. Based on this evidence, National and International Guidelines with
recommendations to offer one of the combinations of interventions
which has been proven to work in Prevention of MTCT (PMTCT)
What is happening in reality…
4

5. • In 2010, only ~50% of pregnant women living with HIV in SSA
region, received effective drug regimens to prevent MTCT
• An estimated 390 000 children were infected with HIV
WHO Global Report 2011
Estimated percentage of pregnant women living with HIV, who received
antiretrovirals for preventing MTCT (WHO, 2013)
5

6. “[…] most pregnant women wait for hours in hot crowded
conditions for a brief consultation that lasts on average about 7
minutes—just a few minutes to do a battery of tests, conduct
counseling for HIV testing, treat malaria, test for and treat
syphilis, and deliver other services in integrated antenatal care.”
Pfeiffer J, The Lancet, 2015
Context of PMTCT implementation
6

7. Translating research into practice
• This is just one of many examples of the gap between evidence
produced by high-quality research and its translation into practice
(Dobrow 2004, Glasgow 2007, Green 2015, Lenfant 2003 ...)
• Barriers can develop at production, utilization and transferability
levels
• Many reasons why research does not translate into practice
(economic, political, social, scientific, etc.)
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8. Methods for “contextualized” evidence
• Different methods can be used to take into account the
“organizational, clinical, and social environments” that
affect translation of research into practice (Green 2015)
• Qualitative and mixed methods (interviews,
ethnographic methods, case studies), as well as
practical trials have been used in approaches as Action-
Driven Participatory Research or Program Science
8

9. Three innovative methods
• “Slow research” for research in global health
• Realist approach for evidence-based decision making in
global health
• Enhancing organizational performance: configurational
and deliberative approaches to translate evidence into
knowledge
9

10. The Role of “Slow Research” in Global
Health
Pierre Minn
Département d’anthropologie
Université de Montréal

11. What’s at stake in GH research?
• Improved health outcomes and quality of life
• Potential to reduce health (and other) inequalities
• Economic costs of morbidity/mortality and of health interventions
• Career advancement, publications, funding, reputations…
• Academic trajectories, accreditation, certification,
professionalization…

12. Global health interventions…
• Operating in the logic of emergencies and crises
• Humanitarian biomedicine + global health security = imperative to
act (Lakoff, 2010)

13. Global health research…
• Emerging in a context of accelerated globalization (time and
distance)
• Tendency towards quantification (DALYs/QALYs, BoD, etc.)
• Influence of administrative and managerial sciences (lessons
learned, best practices, leadership…)
• Pressures and demands for data at multiple levels

14. Slow science / Slow research
• Critical perspectives in philosophy and social sciences
• Building on slow food movement
• Attentive to the conditions through which research and knowledge
is produced
• Research can reinforce or challenge existing hierarchies (resource
allocation, priorities, stakeholder involvement, use of results)

15. Research as relationships
• Ethics compromised or abbreviated with pressure to move studies
forward
• Rewarding mobility, universality, innovation and production over
engagement, transformation, specificity and “what already works”
• Finding “brakes” for global health research without condoning
paralysis or disengagement

16. References:
• Stengers, Isabelle, 2013 Une autre science est possible! Manifeste
pour un ralentissement des sciences, Paris, Les Empêcheurs de
penser en rond
• Adams, V, N. Burke and I. Whitmarsh, 2014, “Slow research:
thoughts for a movement in global health”, Medical Anthropology
33(3): 179-197
• Loyola, R, 2013, “Developing nations should avoid slow science”,
www.scidev.net
• http://slow-science.org/

17. The realist approach for evidence-based
decision-making in global health
Emilie Robert, Ph.D."
Université McGill, Canada
emilierobert.udem@gmail.com 17

18. To sum up…
Relevant scientific evidence for decision-
making in global health"
Theory"
Causation"
Context"
18

19. Taking the context into account in natural
experiments
• Pawson & Tilley, 1997: “spatial
and institutional locations of
social situations together,
crucially, with the norms, values,
and interrelationships found in
them”
• The context influences
implementation of interventions,
and thus expected outcomes.
• The context only exists as a
result of interacting with the
intervention.
19
Context
OutcomeIntervention
Controlled experiment
Natural experiment
Expected
outcome
Intervention
Unexpected
outcome

20. Aknowledging causation in series of events
Generative vision of causation : "
Regular patterns – though not
systematic – in the production of
outcomes, in a specific context,
through the triggering of a
mechanism
Mechanism : "
“element of reasoning and reactions
of (an) individual or collective agent
(s) in regard of the resources
available in a given context to bring
about changes through the
implementation of an
intervention” (Lacouture et al, 2015)
20
Outcome
Mechanism
Context

21. Proposing a theory that showcases levers for
action
Theory-driven approach: "
Program theory as the starting point
Explanatory realist middle range
theory as the output
Theory as a way to ensure validity:"
Internal validity: in-depth study of the
theoretical articulation between
C-M-O through an iterative process
between empirical data and theory
External validity: explanation of how
context interacts with outcomes
21
C M O
Realist epistemology
C1 M1 O1
C2 M2 O2
C3 M3 O3
Middle-range theory
C1 M1 O1 C2 M1 O1 C3 M1 O1
C4 M1 O2 C3 M1 O2
Empirical C-M-O configurations
Abstraction
Specification
THEORY
DATA

22. Why useful to global health research?
• Realist evaluation and realist review promoted in the field of health
policy and systems research (HPSR)
• 2 main observations :
 Similar implementation challenges and weaknesses of health
systems accross low- and middle-income countries (LMICs)
 Similar interventions promoted at the international level and
targeting LMICs
• Goals of HPSR:
 To understand challenges and successes in implementing health
policies and complex interventions in health systems (mixed methods)
 To produce relevant and actionable evidence to decision-makers
accross low- and middle-income countries
22

23. Why useful for decision-making?
• Understanding context to
allow for adaptation to
local challenges and
propose context-specific
policy action
• Acknowledging causation
for accountability of
policy action
• Theory-based research to
ensure validity of
evidence
23
How to foster / create the condition(s) that trigger the
mechanisms leading to expected outcomes?
Relevant scientific evidence for decision-making in
global health"
Theory"
Causation"
Context"

24. Key ressources
In English:"
RAMESES mailing list: https://www.jiscmail.ac.uk/cgi-bin/webadmin?A0=RAMESES
MENDELEY group: Critical realism and realist evaluation
Dieleman, M., et al. 2009. Human resource management interventions to improve health
workers’ performance in low and middle income countries: A realist review. Health
Research Policy and Systems, 2009, 7:7.
Marchal, B., et al. 2012. Is realist evaluation keeping its promise? A review of published
empirical studies in the field of health systems research. Evaluation, 18(2): 192-212.
Pawson, R, & Tilley, N. 1997. Realistic evaluation, London, UK: SAGE, 256.
Wong, G., Westhorp, G., Pawson, R. & Greenhalgh, T. 2013. Realist synthesis: RAMESES
training materials, London, UK: RAMESES, 54.
In French:"
Atelier de formation : samedi 7 novembre (de 10h30 à 12h00, Fontaine E)
Groupe ICARES (Initiative collective sur l’approche réaliste pour l’évaluation et la synthèse)
Robert, E. & Ridde, V. 2013. L’approche réaliste pour l’évaluation de programmes et la
revue systématique : de la théorie à la pratique. Mesure et évaluation en éducation, 36:
79-108.
Robert, E., Samb, O.M., Marchal, B., Ridde, V. 2015. Recours aux soins gratuits en Afrique
subsaharienne : Une revue réaliste. Cahiers REALISME (N°1).
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25. Enhancing organizational performance:
configurational and deliberative approaches to
translate evidence into knowledge
Georges-Charles Thiebaut Ph.D
LG35 Inc Evaluation & Management

26. Starting point
• How to improve evidence translation, relevance and use by health
managers to improve organizational performance?
• What are the approaches that could support organizations in
analysing problems and building innovative solutions?

27. The configurational approach
• This approach underscores commonalities across organizations
and classifies them into categories (Meyers, 1993, McKelvey, 1975,
1982).
• In performance analysis, a configuration is an evidence-based
description of the interrelations between performance dimensions
(Thiebaut, Champagne, Contandriopoulos, 2015).
• Configurations aim to synthesize, combine and analyse
performance dimensions, as well as their measurements, into one
comprehensive model (Champagne et al, 2014).

28. Configuration example: the case of absenteeism in hospitals
Resources
availability
• Employee
with
a
regular
posi<on
Staff
alloca2on
according
to
workload
• Pa<ents/nurse
ra<o
Equipment
availability
• Pa<ent
li@ers
/bed
ra<o
Resources
organiza2on
• Percentage
of
full-­‐
<me
posi<ons
• Work
organiza<on
Working
2me
• Percentage
of
over<me
Organiza2onal
support
• Training
opportuni<es
Working
environment
Organiza2onal
climat
• Accomplishment
through
work
• collabora<on
• communica<on
• Organiza<onal
leadership
Managerial
leadership
Behavioral
reac2ons
• Turnover
rate
Employee
health
status
/
Absenteeism
• Absenteism
ra<o
• Percentage
of
injuries
and
occupa<onal
diseases
with
absence
Pa2ent
safety
• Adverse
events
ra<o
Efficiency
• Average
hours
worked
per
day
presence
Humanism
• Pa<ent
–
provider
rela<on
Employee
safety
• Percentage
of
occupa<onal
injuries
with
no
absence

29. The deliberative approach
• Process allowing a group to receive and exchange information, to
critically examine a problem and create a rational understanding
that supports decision making (Abelson, 2011)
• Deliberation is a process through which actors share their
perceptions and understanding of a situation, come to an
agreement on situation analysis, and ways of action (Habermas,
1987).

30. To use a deliberative approach
Group analysis with stakeholders at tactical and operational levels:
1. Diagnosis
• Confron<ng
configura<on
and
data
to
personal
experiences
• Reaching
consent
on
the
root
causes
of
absenteeism
2. Building solutions
• Support
emergence
of
appropriate
solu<ons
• Reaching
consent
on
an
ac<on
plan
(priority,
role
and
task)

31. Why are such approaches needed?
• To synthesize evidence into a comprehensive model and confront
them to actors’ experiences
• To foster problem solving and solution building through deliberative
processes.
• To strengthen analytical capacities of organizations (learning
organizations)

32. Thank you
Discussion is open
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33. Conclusions
• The production, transfer and and utilization of evidence are parts of
a cycle, in which each step is not separated, but contributes to the
process
• There is a role for the researcher in promoting interdisciplinary and
participative research, which has higher potential for translation
high-quality evidence into practice
• …
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