Chapter 2: Phase 2 – Design the solution

Design solutions

Once the problem is identified and framed as part of phase 1, relevant evidence to address the problem is searched for and critically appraised to determine its validity and usefulness in responding to the problem at hand. To enable efficient searching of the research evidence, one or more PICO questions (population, interventions, comparisons and outcomes)^b will need to be developed to guide the search and inclusion criteria [39]. These questions are usually discussed and agreed with key stakeholders. The search should start at the top of the evidence funnel to identify existing evidence products (tertiary research) to address the problem. This approach saves time, human resources and costs, and minimizes the effect of bias because fewer, more synthesized evidence products will be found. If nothing is found, the search proceeds to evidence syntheses (secondary research) and finally to primary research if a new evidence synthesis is needed. The evidence is accessed and evaluated to ensure that it meets the inclusion criteria and its quality appraised. The evidence is then synthesized, which can include both narrative syntheses as well as meta-analysis where appropriate.

The results of the search and assessment of the evidence will guide the next steps:

1. If an existing evidence product (e.g. guideline) that addresses the problem of interest is identified, it can be assessed for its applicability and transferability [85]. If the product is acceptable and recent, e.g. published in the past 2 years, no further work is needed at this step.

2. If an existing evidence product is found, which is not specific to the context or problem of interest or just needs updating, it can be considered for adaptation. There are a number of tools available to help. For example, if an international guideline needs to be adapted to the local context to ensure uptake and sustained use, consider the Pan American Health Organization ADAPTE or ADOLOPMENT tools [86]^,[87][88]. A tool also exists for the adaptation of HTAs [89]. If adaptation of the evidence product is not appropriate, it still may be possible to use the same systematic reviews as a source of evidence provided that they are up to date.

3. If no useful evidence products are found but recent evidence syntheses (secondary research) are identified, they can be used to develop a new evidence product, provided that they are of sufficient quality [90] and their findings are applicable and transferrable to the problem and context of interest [27]^,[91]^,[92].

4. Finally, if no suitable evidence syntheses are found, there may be a need to conduct or commission a new systematic review or other type of evidence synthesis, but care should be taken to ensure that it is of high quality [90].

In times of emergency and crisis or to inform local policy decisions, accelerating the systematic review process and fast-tracking knowledge synthesis to enable pressing policy and systems decisions may prove valuable [84]^,[93]. For example, in emerging disease outbreaks, such as the COVID-19 pandemic, rapid reviews and rapid advice guidelines can provide strategic evidence to allow crucial decisions to be made about health systems responses at both global and local levels [39]^,[84]^,[93]. In these situations, some methodological aspects and stakeholder engagement processes may need to be streamlined to ensure timeliness and relevance of evidence. Options for accelerating methodological procedures for rapid evidence synthesis include reducing the scope of the question; limiting the study types, publication dates and language of eligible studies; limiting the number of sources searched; avoiding duplicate selection or analysis of studies and synthesizing narratively rather than quantitatively [93]^,[94]. Living reviews is another methodology that can help improve timeliness and quality as they use systematic review quality methods but are frequently updated to ensure that they are also current [95]^,[96].

When deciding on interventions/options for addressing health problems, a variety of information is needed to help decision-makers come to an informed decision, including the anticipated benefits and harms, impact on health equity, resource implications, and cost–effectiveness, acceptability and feasibility (Fig. 2.4) [35].

Design implementation

When considering how to implement an intervention or policy option, it is important to consider the local context using the local evidence that was gathered as part of step 1 (Identify high-priority issue). Successful implementation of an intervention/option also requires consideration of any potential barriers to (and facilitators for) the implementation of the option in the local context. These are known as implementation considerations. For example, potential barriers might be individuals (e.g. due to lack of awareness of a programme), health workers (e.g. due to lack of adherence to guidelines) or organizational (e.g. lack of high-level support for the intervention). There may also be facilitators or supports that can be taken advantage of. Implementation considerations can be framed using a series of five questions [97]:

An assessment of the barriers to and facilitators for successful implementation of the intervention/option will allow appropriate strategies to be designed to address them. These strategies could include education, linkage and exchange, audit and feedback, informatics, organizational interventions, and financial incentives, among others [63].

Five questions to frame implementation considerations:

1. What are the barriers to implementation?

2. What are the strategies used in planning the implementation of a new policy to facilitate behavioural changes among users?

3. … and behavioural changes of providers?

4. … and organizational changes?

5. … and system changes?

For interventions that are implemented for the first time or where there is little evidence available, it is advisable to first conduct or commission a pilot project that includes a formal evaluation, which can be performed under the routine operating conditions and existing resource constraints of the health system. This allows testing of how the intervention works in the local context, and develop and evaluate potential implementation strategies (e.g. educational programmes, determine necessary equipment, assess the impact on staffing). If successful, the pilot can be scaled up. Nonetheless, the process should ideally “begin with the end in mind” [98], designing the pilot in ways that enhance its potential for sustainability and future large-scale impact. If the implementation/scaling up of the evidence-informed intervention seems feasible, the organization responsible needs to plan and design the implementation, taking into account the local context and the implementation considerations identified (Fig. 2.5).

Communicate and engage

Potential solutions to high-priority problems, however, will achieve impact only if they are adopted and implemented by policy-makers. This requires a sustained communication and engagement strategy to bring the solution to their attention and to achieve their buy-in and ownership to implement the solution. Passive dissemination of solutions, even when packaged as evidence products (e.g. as a guideline) does not always work [99]. Instead, active dissemination/ communication and education/training are more likely to succeed. To effectively communicate, the target audience(s) needs to be identified and analysed to tailor messages and strategically select communication channels to potential users. This can be done by considering the questions of what, to whom, by whom, how, and with what effect should the evidence product be transferred to decision-makers [100].

To foster uptake, the evidence needs to be packaged in user-friendly formats (e.g. media bytes) and strategically distributed to organizations and individuals that help with its application. This often includes advocating with donors to identify seed funding and other sources of funding for financial support to ensure implementation, scaling up and sustainability. It is also important to engage with the media as they are often interested in EIDM and play an important role in influencing health policy processes and informing the public [101]^,[102].

Key questions for strategic communication

• What is the objective and desired effect of communicating evidence and research findings? (With what aim should research knowledge be transferred?)

• What are the key messages to be communicated to decision-makers?

• Who is the target audience? (To whom should research knowledge be transferred?)

• Who is the target audience? (To whom should research knowledge be transferred?)

• Who is the target audience? (To whom should research knowledge be transferred?)

For evidence syntheses and other evidence products to be used, they will need to address the following characteristics:

Characteristics of policy-friendly synthesis

Informed by the best available evidence	Concise
In context	Understandable
Relevant	Objective
Practical	Accessible
Timely	Aesthetic

Source: adapted from Eklund Karlsson, Takahashi 2017 [103].

While linkages and exchange between evidence producers and users are encouraged along the entire evidence creation and policy/action cycle (using different KT approaches), it is particularly useful to convene all stakeholders affected or affecting the issue and deliberate the suggested way forward once the research evidence is available [84]. This can take place in the form of a policy dialogue [25]^,[104][105] or a citizen panel [102]^,[106]. Policy dialogues enable interactions between multidisciplinary and multisectoral stakeholders for the timely identification of the points of intersection between the research evidence, and the values and goals of the policy-makers and stakeholders [25]. The active participation and collaboration of stakeholders who can mobilize resources and influence systems to change policies, programmes, and practices is crucial to ensure successful implementation and impact (Fig. 2.6).

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