Health Policy Proposal Analysis Paper

Health Policy Proposal Analysis Paper

Health Policy Proposal Analysis Paper

A policy brief is defined as a succinct summary of a specific issue that also contains the policy options to address it and a number of recommendations on the most appropriate option. Policy briefs target government legislators and other individuals interested in formulating or influencing policies. Besides, they propose evidence-based recommendations that enable policymakers to make informed decisions during legislation (Arnautu & Dagenais, 2021). A policy brief should provide an adequate background for the legislator to understand the magnitude of the problem, offer information on available alternatives, and offer evidence to support the most preferred alternative. The purpose of this paper is to outline a policy brief on the recommendation chosen from the Institute of Medicine (IOM) report.

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Selected Recommendation

The chosen IOM recommendation is: “Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.” 

Background

The IOM recommendation stresses the need for an improved education system for nurses. This is to ensure that the present and future generations of nurses can provide safe, high-quality, patient-centered care across all patient settings, particularly in primary care and community and public health. The US healthcare system is dynamic, and it will need significant changes in nursing education before and after licensing and certification (Sullivan, 2018). The nursing profession has experienced dramatic growth in the past years owing to the economic recession and the reasonable stability the health care sector offers. According to the American Association of Colleges of Nursing (AACN) (2019), the applications to entry-level baccalaureate nursing programs increased by over 70% in the past five years. Although nursing schools across the US have responded to this increase in the number of nursing students, they experience challenges, like insufficient numbers of nursing educators to teach nurses at all levels (Daniel & Smith, 2018). These constraints reduce the capacity of nursing schools to take in all the qualified applicants. As a result, thousands of interested students are turned away annually.

The methods used to train nurses in the 20th century are no longer adequate to teach the current and future nurses how to deliver care and make clinical decisions in the 21st century. There is a need for nursing schools to delve into research and generate knowledge crucial to providing health care in a healthcare system that is progressively becoming complex (Daniel & Smith, 2018). The education system ought to provide nursing students with the tools they require to assess and enhance standards of patient care and the quality and safety of care. The education system should ensure nurses are adaptable and flexible with regard to changes in population demographics, science, and technology, which significantly influence the delivery of care. Furthermore, nursing education at all levels should promote a better insight on the approaches to work and foster change within health care delivery systems, as well as approaches for quality improvement and reducing patient risk.

Current Characteristics

Nursing in the US is a mix of education, credentials, and practice, which often causes confusion even among people in healthcare. Even with a common licensure exam, the educational pathways to becoming an RN are different and often confusing to students.

For one to become a practicing registered nurse (RN) in the US, they must graduate from an approved educational program, pass a licensure exam (NCLEX-RN), and meet licensure requirements in the state they wish to practice in (Morris, 2019). Diploma nursing programs generally take three years and are based at an institution, like a hospital-based educational program where they train Licensed practical nurses (LPN). Associate degree in nursing (ADN) programs take 18 months or two years and are provided at junior colleges, community colleges, or hospital-based schools of nursing (Fang, 2019). Baccalaureate programs are usually provided in colleges or universities offering a Bachelor of Science in Nursing (BSN) degree, which usually takes four years for direct entry. However, it takes less time for nurses to upgrade from AND to BSN.

Various programs previously viewed as graduate education are now offering entry to practice graduate degrees, including Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), and Philosophy Doctorate (Ph.D.). It is worth noting that most healthcare organizations, including Magnet hospitals, prefer BSN-prepared nurses when hiring (Sullivan, 2018). Although most LPNs and ADNs express an interest in advancing their education, various barriers limit them, including financial concerns and difficulty getting into ADN and BSN programs. Online education programs have increased access to advanced nursing education. However, the high cost of pursuing a BSN degree is a major barrier for prospective students. The LPN degree is the cheapest to attain, followed by ADN, BSN (accelerated program), BSN, MSN, and Ph.D./ DNP degrees (Morris, 2019). The high costs are attributed to the increasing trend by healthcare facilities to charge learning institutions for access to clinical sites for nursing students.

The Impact of the Recommendation

The basis of the IOM recommendation on the need to transform nursing education was to increase the number of BSN nurses in the workforce. This would transform nursing education to accommodate the needs of the evolving and transforming healthcare system and practice environments. The IOM recommendation can potentially increase the proportion of BSN nurses and ultimately improve the delivery of healthcare care and patient outcomes. According to the AACN (2019), enhanced patient outcomes reduced mortality, and decreased healthcare costs will be attained owing to a workforce having a higher proportion of BSN-prepared nurses. In addition, a study by Harrison et al. (2019) established that each 10% point increase in the hospital number of BSN nurses was associated with 24% higher odds of surviving up to discharge among patients who got a cardiac arrest.

The BSN program exposes nursing students to a myriad of competencies in areas like leadership, health policy, health care financing, quality improvement, and systems thinking. Consequently, other healthcare professionals believe that having more nurses with knowledge in these areas will significantly improve leadership practices and increase the number of nurses involved in policy formulation in the country. Besides, it will promote increased participation of nurses in quality improvement initiatives, which will be crucial in improving the healthcare delivery process and patient outcomes leading to healthier populations (Harrison et al., 2019). BSN-prepared nurses have markedly higher levels of knowledge and skills in evidence-based practice (EBP), research, and evaluation of gaps in areas like interprofessional collaboration, teamwork, and practice.

The IOM recommendation will ensure that the next generation of nurses will possess more than the basic knowledge of patient care. They will be involved in EBP and research activities to find solutions to issues they encounter in clinical practice (Sullivan, 2018). In addition, it will set a stronger basis for the expansion of nursing science. A workforce of BSNs will be geared up to attain higher levels of education at the MSN, DNP, and Ph.D. levels, which are needed for nurses to take roles as nurse researchers, primary care providers, and nurse faculty (Daniel & Smith, 2018). Lastly, the recommendation will enable nurses to be imparted with knowledge and skills needed to be effective change agents and to adapt to the dynamic models of healthcare effectively.

Current Solutions

The current solutions to transforming nursing education include the introduction of online nursing educational programs, competency-based education, and education programs in which students are given credit for licensure and professional work experience. Technologies, like distance and simulation learning through online courses, are being used to facilitate LPN and ADN nurses to advance their education in ADN and BSN courses, respectively (Fang et al., 2019). Online education programs have created flexibility and provide an extra skill set to nurses who will apply technology in the future nursing practice. Furthermore, the online programs have been increased to make upgrading courses available to all students despite where they live. Various hospitals have also partnered with local universities and colleges to provide onsite classes.

Healthcare organizations are providing stipends to nursing staff as an incentive to advance their education. Solutions for prospective nursing students include the traditional four-year BSN programs provided in universities, but community colleges are also offering four-year baccalaureate degrees in various states (Fang et al., 2019). In addition, important education programs have been introduced to promote academic progression to higher levels of education, such as the LPN-to-BSN and ADN-to-MSN programs. The ADN-to-MSN program is creating a significant path to advanced practice and faculty positions, particularly at the community college level.

Current Status in the Health Policy Arena

The Council on Physician and Nurse Supply recommended a policy (Title VIII) to increase graduations from nursing schools by 30%. Title VIII is usually considered the major source of federal support for nursing education. It also proposes that public support to promote increased output of nursing schools be targeted to inspire more nurses to take up BSN degrees (Schaeffer & Haebler, 2019). In addition, policies have been proposed to fund four-year colleges and universities to help compensate for the budget cuts affecting the learning institutions that have caused limitations in the uptake of undergraduate BSN applicants. Title VIII act also proposes a capitation method of funding to support colleges and universities to increase nursing admissions (Schaeffer & Haebler, 2019). Various states have approved community colleges to offer baccalaureate BSN programs, and they will be eligible to be given the new targeted Title VIII funds should the policy be enacted.

Conclusion

The IOM recommendation proposes that nurses should advance effortlessly through the education system to higher education levels, including graduate degrees. However, nursing institutions have faced constraints like inadequate educators training nurses at all levels, limiting the number of students enrolled annually. The IOM recommendation can improve health outcomes and decrease healthcare costs and mortality rates. Besides, it will increase the number of MSN, DNP, and Ph.D. nurses who will replenish the pool of nurse educators. Solutions currently implemented include online nursing programs for nurses advancing to BSN and the introduction of BSN programs in community colleges. The Title VIII policy proposes funding colleges and universities offering BSN programs to increase the admissions of prospective students.

References

American Association of Colleges of Nursing. (2019). Creating a more highly qualified workforce. Retrieved from https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Workforce

Arnautu, D., & Dagenais, C. (2021). Use and effectiveness of policy briefs as a knowledge transfer tool: a scoping review. Humanities and Social Sciences Communications, 8(1), 1-14. https://doi.org/10.1057/s41599-021-00885-9

Daniel, K. M., & Smith, C. Y. (2018). Present and future needs for nurses. Journal of Applied Biobehavioral Research, 23(1), e12122. https://doi.org/10.1111/jabr.12122

Fang, D., Li, Y., Turinetti, M. D., & Trautman, D. E. (2019). 2018-2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. American Association of Colleges of Nursing.

Harrison, J. M., Aiken, L. H., Sloane, D. M., Brooks Carthon, J. M., Merchant, R. M., Berg, R. A., … & American Heart Association’s Get With The Guidelines–Resuscitation Investigators. (2019). In hospitals with more nurses who have baccalaureate degrees, better outcomes for patients after cardiac arrest. Health Affairs, 38(7), 1087-1094. https://doi.org/10.1377/hlthaff.2018.05064

Morris, T. L. (2019). The Landscape of Nursing Education in the United States. In Forum on Public Policy Online (Vol. 2019, No. 1). Oxford Round Table. 406 West Florida Avenue, Urbana, IL 61801.

Schaeffer, R., & Haebler, J. (2019). Nurse leaders: extending your policy influence. Nurse Leader, 17(4), 340-343. https://doi.org/10.1016/j.mnl.2019.05.010

Sullivan, T. (2018). Institute of Medicine Report, The future of nursing: leading change, advancing health. Policy and Medicine.

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SUPPORT Tools for evidence-informed health Policymaking (STP) 13: Preparing and using policy briefs to support evidence-informed policymaking
John N Lavis*1, Govin Permanand2, Andrew D Oxman3, Simon Lewin4 and Atle Fretheim5

Address: 1Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, and Department of Political Science, McMaster University, 1200 Main St. West, HSC-2D3, Hamilton, ON, Canada, L8N 3Z5, 2Health Evidence Network, World Health Organization Regional Office for Europe, Scherfigsvej 8, Copenhagen, Denmark DK-2100, 3Norwegian Knowledge Centre for the Health Services,
P.O. Box 7004, St. Olavs plass, N0130 Oslo, Norway, 4Norwegian Knowledge Centre for the Health Services, P.O. Box 7004, St. Olavs plass, N0130 Oslo, Norway; Health Systems Research Unit, Medical Research Council of South Africa and 5Norwegian Knowledge Centre for the Health Services,
P.O. Box 7004, St. Olavs plass, N0130 Oslo, Norway; Section for International Health, Institute of General Practice and Community Medicine, Faculty of Medicine, University of Oslo, Norway
Email: John N Lavis* – lavisj@mcmaster.ca; Govin Permanand – gop@euro.who.int; Andrew D Oxman – oxman@online.no; Simon Lewin – simon.lewin@nokc.no; Atle Fretheim – atle.fretheim@nokc.no
* Corresponding author

Published: 16 December 2009
Health Research Policy and Systems 2009, 7(Suppl 1):S13 doi:10.1186/1478-4505-7-S1-S13 This article is available from: http://www.health-policy-systems.com/content/7/S1/S13
© 2009 Lavis et al; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.
Policy briefs are a relatively new approach to packaging research evidence for policymakers. The first step in a policy brief is to prioritise a policy issue. Once an issue is prioritised, the focus then turns to mobilising the full range of research evidence relevant to the various features of the issue. Drawing on available systematic reviews makes the process of mobilising evidence feasible in a way that would not otherwise be possible if individual relevant studies had to be identified and synthesised for every feature of the issue under consideration. In this article, we suggest questions that can be used to guide those preparing and using policy briefs to support evidence-informed policymaking. These are: 1. Does the policy brief address a high-priority issue and describe the relevant context of the issue being addressed? 2. Does the policy brief describe the problem, costs and consequences of options to address the problem, and the key implementation considerations?
3. Does the policy brief employ systematic and transparent methods to identify, select, and assess synthesised research evidence? 4. Does the policy brief take quality, local applicability, and equity considerations into account when discussing the synthesised research evidence? 5. Does the policy brief employ a graded-entry format? 6. Was the policy brief reviewed for both scientific quality and system relevance?

About STP
This article is part of a series written for people responsible for

making decisions about health policies and programmes and for those who support these decision makers. The series is intended

to help such people ensure that their decisions are well-informed by the best available research evidence. The SUPPORT tools and the ways in which they can be used are described in more detail in the Introduction to this series [1]. A glossary for the entire series is attached to each article (see Additional File 1). Links to Spanish, Portuguese, French and Chinese translations of this series can be found on the SUPPORT website http:// www.support-collaboration.org. Feedback about how to improve the tools in this series is welcome and should be sent to: STP@nokc.no.

Scenarios
Scenario 1: You are a senior civil servant and have been sent a policy brief that describes the research evidence about an issue that is of growing concern to the Minister. You are responsible for ensuring that the policy brief profiles research evidence in a way that informs different elements of the issue and recognises the importance of drawing on both local and global evidence. You want to ensure that the policy brief won’t place the Minister in an awkward position by making a recommendation that is not politically or economically feasible.

Scenario 2: You work in the Ministry of Health and have been given a few hours to prepare an assessment of a policy brief that has been sent to the Ministry on a high-priority issue. All that you have been told is that this policy brief is different in a number of ways to the type of policy brief that you have pro- duced in the past including the way in which it profiles research evidence about a problem, the options and implementation con- siderations, and the fact that it does not conclude with a specific recommendation.

Scenario 3: You work in an independent unit that supports the Ministry of Health in its use of research evidence in policymak- ing. You are preparing a policy brief for both the Ministry and key stakeholders to profile what is known and not known about a problem, options for addressing it, and implementation con- siderations. You have been told to prepare the brief in a system- atic way and to report the methods and findings in a transparent and readily understandable way, but you want guidance on how to be both thorough and efficient in your work.

Background
For policymakers (Scenario 1), this article suggests a number of questions that they might ask themselves or their staff to consider when assessing a policy brief. For those who support policymakers (Scenarios 2 and 3), this article suggests a number of questions to guide the assess- ment of a policy brief or the preparation of one.

Three major shifts have occurred recently in the focus of many efforts to package research evidence for policymak- ers. Firstly, there has been a shift from packaging single studies to packaging systematic reviews of studies that

address typical policy-relevant questions. A number of research groups, including the SUPPORT collaboration http://www.support-collaboration.org/, now produce policymaker-friendly summaries of systematic reviews. These summaries always highlight the key messages from the review but some of them, like SUPPORT summaries, also address considerations related to quality, local appli- cability, and equity [2]. This shift has made it easier for policymakers to scan broadly across large bodies of research evidence. And it has also enabled them to extract what they need to know easily from particular systematic reviews that directly address key features of any policy issue of interest.

Secondly, there have been more recent complementary efforts to package systematic reviews (together with local research evidence) in the form of a new product – the pol- icy brief – which mobilises the best available research evi- dence on high-priority issues [3]. For policy briefs, the starting point is the issue and not the related research evi- dence that has been produced or identified. Once an issue is prioritised, the focus then turns to mobilising the full range of research evidence addressing the different fea- tures of the issue concerned. These include the underlying problem, options to address the problem, and key imple- mentation considerations. Drawing on available system- atic reviews makes the process of evidence mobilisation feasible in a way that would not otherwise be possible if single studies had to be identified and synthesised for all the features of the issue. In this article, we have restricted our use of the term ‘policy brief’ to those products match- ing this description exactly. But the term has also been applied elsewhere to many other types of products pre- pared by those supporting policymakers. The appropria- tion of this term by those involved in producing and supporting the use of research evidence reflects perhaps their increasing orientation to the needs and contexts of policymakers.

Evidence-packaging mechanisms and policy briefs in par- ticular have been developed largely as a response to the findings of systematic reviews of factors influencing the use of research evidence in policymaking [4,5]. Three fac- tors in particular have emerged as significant. These are: 1. Timing or timeliness, 2. Accordance between the research evidence and the beliefs, values, interests, or political goals and strategies of policymakers and stakeholders, and 3. Interactions between researchers and policymakers.

Having access to both a stock of the summaries of system- atic reviews and policy briefs helps to address the need that policymakers have for timely inputs to policymaking processes [6]. Review summaries and policy briefs can typ- ically be produced in days and weeks rather than the months or years required to prepare a systematic review

from scratch. Undertaking primary research (i.e. original studies) can be similarly and often more time intensive. Evidence-packaging mechanisms, and policy briefs in par- ticular, can also make it easier for policymakers and other stakeholders to determine whether and how the available research evidence accords with their own beliefs, values, interests, or political goals and strategies. With a problem clarified, what is known and not known about the options clearly described, and key implementation considerations clearly flagged, policymakers may be more readily able to identify viable ways forward.

Thirdly, changes have occurred in the purpose for which packaged research evidence has typically been produced. Policy briefs are increasingly used as an input into policy dialogues involving individuals drawn from those who will be involved in, or affected by, decisions about a par- ticular issue. These dialogues provide the opportunity for greater interaction between researchers and policymakers. Dialogues in which research evidence is just one input in a policy discussion form the focus of Article 14 in this series [7].

The formats used for evidence-packaging have often been developed in response to the few available empirical stud- ies of the preferences of health policymakers for different kinds of mechanisms (and not their usage or effects, which typically have not been evaluated) [4,8]. These studies have revealed a need amongst policymakers to have for- mats that both provide graded entry to the full details of a review and facilitate assessment of decision-relevant infor- mation [4]. A graded-entry format of one page of take- home messages, a three-page executive summary that summarises the full report, and a 25-page report (i.e. a 1:3:25 format) has shown to be particularly promising [9]. Presumably, either the one- or three-page summary should follow a structured format [10]. Structured abstracts have been found to have an effect on intermedi- ate outcomes such as searchability, readability and recall among healthcare providers. However, no studies have compared full text to structured abstracts and no studies have examined the impact of format features on policy- makers [11]. Decision-relevant information can include the important impacts (both benefits and harms) and costs (i.e. resources used) of policy and programme options, as well as local applicability and equity consider- ations [4].

Questions to consider
The following questions can be used to guide the prepara- tion and use of policy briefs to support evidence-informed policymaking:

1. Does the policy brief address a high-priority issue and describe the relevant context of the issue being addressed?

2. Does the policy brief describe the problem, costs and consequences of options to address the problem, and the key implementation considerations?

3. Does the policy brief employ systematic and transpar- ent methods to identify, select, and assess synthesised research evidence?

4. Does the policy brief take quality, local applicability, and equity considerations into account when discussing the research evidence?

5. Does the policy brief employ a graded-entry format?

6. Was the policy brief reviewed for both scientific quality and system relevance?

1. Does the policy brief address a high-priority issue and describe the relevant context of the issue being addressed? Policy briefs are distinguished most clearly from other packaged evidence summaries by the fact that they begin with the explicit identification of a high-priority issue. In instances where an issue has been on the agenda of key stakeholders for some time, policy briefs may act as a way to spur progress. This is highlighted in the example shown in Table 1 of low coverage rates for artemisinin-based combination therapies (ACT) to treat uncomplicated fal- ciparum malaria in sub-Saharan African countries. Alter- natively, if the issue is relatively new, the policy brief may play an agenda-setting role. Either way, it is critical that the issue is deemed a priority by at least some key stake- holders. Ideally the prioritisation process should also be systematic and transparent and Article 3 in this series out- lines an approach for achieving this [12].

A second key feature of policy briefs is that they are typi- cally context-specific. Describing the key features of a con- text in the policy brief is important as a way of creating a level playing field among policy brief readers. Table 2 highlights issues related to limited or inequitable access to sustainable, high-quality community-based primary healthcare in Canada. There, as the policy brief explained, the issue could only be understood in the context of the particular features of Canadian primary healthcare and the existence of ‘private delivery/public payment’ arrange- ments with physicians. These are of particular importance in this context for they have meant historically that most primary healthcare in Canada is delivered by physicians working in private practice with first-dollar, public (typi- cally fee-for-service) payment [13]. Improving access in creative ways, including the use of collaborative practice models, requires an understanding that: 1. Physicians tend to be wary of potential infringements on their profes- sional and commercial autonomy, 2. No other healthcare providers at this time can secure the public payment

 

Table 1: Outline of a policy brief about supporting the widespread use of a new, highly effective treatment for malaria in an African country
What problem has been identified?
• The overarching problem is one of low coverage rates for artemisinin-based combination therapies (ACT) to treat uncomplicated falciparum malaria in sub-Saharan Africa. Key features of the problem include:
• A high incidence of, and death rates from, malaria
• Existing treatments have much lower cure rates than ACT. However, patients often favour existing treatments because of their past experiences and the higher price of ACT
• The national malaria control policy, treatment guidelines, and drug formulary in many countries do not all support the prescription, dispensing and use of ACT
• Delivery arrangements for ACT often rely primarily on physicians but not everyone has regular access to them and many are comfortable receiving care from community health workers. Financial arrangements favour existing treatments over ACT (which is much more expensive) yet some patients are sceptical about heavily subsidised medication. Governance arrangements often do not allow community health workers to prescribe ACT and do not protect against counterfeit or substandard drugs

What information do systematic reviews provide about three viable options to address the problem?
• Each of the following three options was assessed in terms of the likely benefits, harms, costs (and cost-effectiveness), key elements of the policy option if it was tried elsewhere, and the views and experiences of relevant stakeholders:
• Enlarge the scope of practice for community health workers to include the diagnosis of malaria and prescription of ACT (governance arrangements), introduce target payments for achieving a defined coverage rate for ACT treatment (financial arrangements), and provide them with training and supervision for the use of both rapid diagnostic tests and prescribing (delivery arrangements)
• Introduce partial subsidies for both rapid diagnostic tests and ACT within the private sector where much care is provided in urban areas (financial arrangements)
• Restrict the types of anti-malaria drugs that can be imported and introduce penalties for those found dispensing counterfeit or substandard drugs (governance arrangements) and make changes to the national malaria control policy and drug formulary to ensure that ACT is the recommended first-line treatment
• Important uncertainties about each option’s benefits and potential harms were flagged in order to give them particular attention as part of any monitoring and evaluation plan put into place

What key implementation considerations need to be borne in mind?
• A number of barriers to implementation were identified, among which were the familiarity of some patients and healthcare providers with existing treatment options and their resistance to change. Systematic reviews about the effects of mass media campaigns, the effects of strategies for changing healthcare provider behaviour generally, and for influencing prescribing and dispensing specifically, all proved helpful in deciding how to address these barriers

Notes about the supporting evidence base:
• Six systematic reviews about anti-malarial drugs had been published since the release of the World Health Organization guidelines in 2006, all of which lent further support to ACT as the recommended first-line treatment
• Of the systematic reviews identified: two addressed relevant governance arrangements, six addressed financial arrangements, five addressed specific configurations of human resources for health, and fifteen addressed implementation strategies, many of which could be supplemented by local studies

required to function independently as primary healthcare providers on a viable scale, and 3. Many forms of care (including prescription drugs and home care services) would still not be covered [14].

2. Does the policy brief describe the problem, costs and consequences of options to address the problem, and the key implementation considerations?
A policy brief would ideally describe different features of a problem, what is known (and not known) about the costs and consequences of options for addressing the problem, and key implementation considerations. As out- lined in Article 4, a problem can be understood in one or more of the following terms [15]:

1. The nature and burden of the actual common diseases and injuries that the healthcare system must prevent or treat

2. The cost-effective programmes, services and drugs that are needed for prevention and treatment, and

3. The broader health system arrangements that deter- mine access to, and the use of, cost-effective programmes, services and drugs, including how they affect particular groups.

A policy brief would help to clarify the problem by diag- nosing it in one or more of these terms.

Ideally, the number of options described in a brief that is to be presented to senior policymakers would conform to local document conventions. Three-option models, for instance, are familiar to many policymakers. But regard- less of the number selected, each option in the policy brief can be characterised in terms of:

• The benefits of each option

Table 2: Outline of a policy brief about improving access to high quality primary healthcare in Canada
What problem has been identified?
• The problem is limited or inequitable access to sustainable, high-quality community-based primary healthcare in federal, provincial, and territorial publicly-funded health systems in Canada. Key characteristics of the problem include:
• Chronic diseases represent a significant share of the common conditions that must be prevented or treated by the primary healthcare system
• Access to cost-effective programmes, services and drugs in Canada is not ideal. This is the case both when Canadians identify their own care needs or (more proactively on the part of healthcare providers) when they have an indication (or need) for prevention or treatment, particularly for chronic disease prevention and treatment
• Health system arrangements have not always supported the provision of cost-effective programmes, services and drugs. Many Canadians do not:
1. Have a regular physician or place of care
2. Receive effective chronic-disease management services, or
3. Receive care in a primary healthcare practice that uses an electronic health record, faces any financial incentive for quality, or provides nursing services
What is more difficult to determine is the proportion of physicians who receive effective continuing professional development for chronic disease management and the proportion of primary healthcare practices that:
1. Are periodically audited for their performance in chronic disease management
2. Employ physician-led or collaborative practice models, and
3. Adhere to a holistic primary healthcare model’s (the Chronic Care Model’s) key features [21]

What information do systematic reviews provide about three viable options to address the problem?
• Each of the following three options was assessed in terms of its likely benefits, harms, costs (and cost-effectiveness), its key elements if it had been tried elsewhere, and stakeholder views about and experiences with it:
• Support the expansion of chronic disease management in physician-led care through a combination of electronic health records, target payments, continuing professional development, and auditing of their primary healthcare practices
• Support the targeted expansion of inter-professional, collaborative practice primary healthcare
• Support the use of the Chronic Care Model in primary healthcare settings. This model entails the combination of self-management support, decision support, delivery system design, clinical information systems, health system, and community
• Important uncertainties about each option’s benefits and potential harms were flagged. This was done in order to give these issues particular attention within any monitoring and evaluation plan put into place

What key implementation considerations need to be borne in mind?
• Little empirical research evidence could be identified about implementation barriers and strategies. Four of the implementation barriers identified were:
1. Initial wariness amongst some patients of potential disruptions to their relationship with their primary healthcare physician
2. Wariness on the part of physicians (particularly older physicians) of potential infringements on their professional and commercial autonomy
3. The organisational scale required for some of the options is not viable in many rural and remote communities, and
4. Hesitancy on the part of governments about broadening the breadth and depth of public payment for primary healthcare, particularly during a recession

Notes about the supporting evidence base:
• Dozens of relevant systematic reviews were identified, some of which addressed an option directly and others of which addressed elements of one or more options [14]

• The harms of each option

• The costs of each option or their relative cost-effective- ness (if possible)

• The degree of uncertainty related to these costs and con- sequences (so that monitoring and evaluation can focus on particular areas of uncertainty if any given option is pursued)

• Key elements of the policy option if it has been tried elsewhere and adaptation is being considered, and

• Stakeholder views about and experiences with each option

A policy brief would help to make clear the trade-offs involved in selecting one option over others. If the options are not designed to be mutually exclusive, a policy brief would also help to make clear the benefits of com- bining particular elements of the different options and which combination of options might bring about positive synergies. Alternatively, the elements from one or more individual options could be presented first, followed by ‘bundles’ of options combining different elements in var- ious ways.

Barriers to implementation (outlined in further detail in Article 6 in this series) are located at different levels, rang- ing from the consumer (citizen or healthcare recipient) level through to healthcare providers, organisations, and broader systems [16]. Policy briefs would help to identify

these barriers and describe what can reasonably be expected (again, in terms of benefits, harms, and costs) as a result of pursuing alternative implementation strategies to address these barriers. A policy brief could also identify considerations related to the preparation of a monitoring and evaluation plan. Table 3 provides a possible outline for a policy brief.

Table 3: Possible outline of a policy brief

Title (possibly in the form of a compelling question)
Key messages (possibly as bullet points)
• What is the problem?

3. Does the policy brief employ systematic and transparent methods to identify, select, and assess synthesised research evidence?
Policymakers and a wide range of stakeholders who will be involved in or affected by a decision, are the main audi- ence of a policy brief. Research language should therefore be kept to a minimum as most people will be unfamiliar with it. A policy brief, nevertheless, should still ideally describe how synthesised research evidence was identi-

• What do we know (and not know) about viable options to address the problem?
• What implementation considerations need to be borne in mind?
Report
• Introduction that describes the issue and the context in which it will be addressed
• Definition of the problem such that its features can be understood in one or more of the following terms:
1. The nature and burden of common diseases and injuries that the healthcare system must prevent or treat
2. The cost-effective programmes, services and drugs that are needed for prevention and treatment, and
3. The health system arrangements that determine access to and use of cost-effective programmes, services and drugs, including how they affect particular groups
• Options for addressing the problem, with each one assessed in a table (an example is shown below)

Category of finding Nature of findings from systematic reviews and other available research evidence

Benefits Harms
Costs and cost-effectiveness
Uncertainty regarding benefits and potential harms Key elements of the option (how and why it works) Stakeholders’ views and experiences
• Implementation considerations, with potential barriers to implementing the options assessed in a table (please see example below), each viable implementation strategy also assessed in table (please see example above), and suggestions for a monitoring and evaluation plan

Levels Option 1 Option 2 Option 3

Consumer Healthcare provider Organisation System
Additional content that could appear on a cover page or in an appendix:
• A list of authors and their affiliations
• A list of those involved in establishing the terms of reference for the policy brief and their affiliations
• A list of key informants who were contacted to gain additional perspectives on the issue and to identify relevant data and research evidence, and their affiliations
• A list of funders (for the organisation producing the policy brief and for the policy brief itself)
• A statement about conflicts of interest among authors
Additional content that could appear in boxes or in an appendix
• Methods used to identify, select, and assess synthesised research evidence (including assessments of quality, local applicability and equity considerations)
• Review process used to ensure the scientific quality and system relevance of the policy brief

fied, selected and assessed in ways that are easily under- stood. This objective can be achieved by using techniques such as explanatory ‘boxes’ within the brief to clarify or highlight particular concepts, or through the inclusion of additional appendices. The methods, too, should be sys- tematic in nature and reported in a transparent yet under- standable way. For example, users could be provided with a description of how systematic reviews addressing the benefits and harms of particular health system arrange- ments were identified through a search of continuously updated databases containing reviews in particular domains. This could provide significant reassurance to readers that most, if not all, key reviews had been found and that few, if any, key reviews had been missed.

4. Does the policy brief take quality, local applicability, and equity considerations into account when discussing the research evidence?
Systematic reviews may be of high or low quality, their findings may be highly applicable to a given policy- maker’s setting or of very limited applicability, and they may or may not give consideration to the impacts an option is likely to have on disadvantaged groups, and on equity in a specific setting. Ideally, a policy brief would flag such variations for policymakers and other readers. As outlined in Article 8, explicit criteria are available to assist with quality assessments [17]. Importantly, some data- bases of systematic reviews, such as Rx for Change http:// www.rxforchange.ca, provide quality ratings for all reviews contained in the database. If possible, a policy brief would provide a quality review for all systematic reviews from which key messages have been extracted. Explicit criteria are also available to assist with local appli- cability assessments and these are outlined in further detail in Article 9 [18]. Given that policy briefs are typi- cally context-specific, a policy brief would also ideally comment on the local applicability of the findings of any systematic reviews that are critical to an understanding of the impacts of any options being considered. Equity con- siderations can also be addressed using explicit criteria (see Article 10) [19]. A policy brief should also note in its introduction whether any groups have been given partic- ular attention in the brief. Group-specific key messages could be added to the overall key messages in each sec- tion.

5. Does the policy brief employ a graded-entry format?
A policy brief would ideally allow busy policymakers and other readers to scan the key messages quickly in order to determine whether these corresponded sufficiently closely to their key issue of concern and context to warrant read- ing the entire document. A graded-entry format could take a number of forms. These could be achieved, for example, through a 1:3:25 format – i.e. one page of take-home mes- sages, a three-page executive summary, and a 25page

report [9]. Or a brief may take the form of a 1:12 format, with one page of take-home messages followed by a 12- page report. Whatever form is chosen, the minimum that a policy brief should contain is a list of key messages, a report, and a reference list for those who wish to read more. The key messages would range from the identifica- tion of the problem through what is known about the options, and the key considerations for implementation.

A number of other features of a policy brief could engage potential readers and facilitate assessments of who was involved in preparing, informing and funding it. The title of a policy brief could be worded in a way that would engage policymakers and other stakeholders. This could be achieved, for example, by using a compelling question as a title. The cover and/or the acknowledgements section of a policy brief could provide a list of authors and their affiliations. It could also include a list of those involved in establishing the terms of reference of the policy brief, a list of the key informants contacted for additional perspec- tives on the issue and to identify relevant data and research evidence, and their affiliations. A list of funders for both the organisation producing the policy brief and the policy brief itself, and a statement about any conflicts of interest among authors could also form part of the pol- icy brief document.

6. Was the policy brief reviewed for both scientific quality and system relevance?
Policy briefs need to meet two standards: scientific quality and system relevance. To ensure this, the review process could involve at least one policymaker, at least one other stakeholder, and at least one researcher. This so-called merit review process differs from a typical peer review proc- ess that would typically only involve researchers in the review process, and hence focus primarily on scientific quality. Involving policymakers and other stakeholders can help to ensure the brief’s relevance to the health sys- tem.

Conclusion
Policy briefs are a new approach to supporting evidence- informed policymaking. Their preparation and use con- tinues to evolve through practical experience. Evaluations of this new approach are needed in order to improve our understanding of which particular design features are well received for particular types of issues and in particular contexts. Describing the different features of a problem may, for example, be perceived as being particularly important for highly politicised topics where the very nature of the problem is contentious. Taking equity con- siderations into account through a focus on only one group may be perceived as inappropriate in political sys- tems that may have a long tradition of either addressing all major ethnocultural groups in policy documents or

perhaps of focusing on no groups in particular. Evalua- tions are also necessary as a way of improving our under- standing of whether, and how, policy briefs influence policymaking. Table 4 provides a description of one approach to the formative evaluation of policy briefs.

Resources
Useful documents and further reading
– Research Matters. Knowledge Translation: A ‘Research Matters’ Toolkit. Ottawa, Canada: International Develop- ment Research Centre: http://www.idrc.ca/research-mat ters/ev-128908-201-1-DO_TOPIC.html – Source of addi- tional examples of policy briefs (Chapter 8) and, most importantly, guidance about effective communication (Chapters 6 and 7)

– Canadian Health Services Research Foundation. Com- munication Notes: Reader-Friendly Writing – 1:3:25. Ottawa, Canada: Canadian Health Services Research Foundation: http://www.chsrf.ca/knowledge_transfer/ pdf/cn-1325_e.pdf – Source of advice about writing for an audience of policymakers and other stakeholders

– Lavis JN, Boyko JA: Evidence Brief: Improving Access to Pri- mary Healthcare in Canada. Hamilton, Canada: McMaster

Health Forum; 2009 [14] – Example of a policy brief for a specific country (Canada)

– Oxman AD, Bjorndal A, Flottorp SA, Lewin S, Lindahl AK: Integrated Health Care for People with Chronic Condi- tions. Oslo, Norway: Norwegian Knowledge Centre for the Health Services; 2008 [20]: http://www.kunnskapssen teret.no/Publikasjoner/5114.cms?threepage=1 – Example of a policy brief that provides an exhaustive review of the potential elements of policy options before bundling them together into three viable options for a specific country (Norway)

Links to websites
– Health Evidence Network/European Observatory on Health Systems and Policies: http://www.euro.who.int/ hen/policybriefs/20070327_1 – Source of policy briefs tar- geted at policymakers in the World Health Organization’s European Region

– Program in Policy Decision-Making (PPD)/Canadian Cochrane Network and Centre (CCNC) database: http:// www.researchtopolicy.ca/search/reviews.aspx – Source of policy briefs as well as systematic reviews and overviews of systematic reviews (with links to policymaker-friendly

Table 4: An example of an approach to the formative evaluation of a policy briefs series
• The McMaster Health Forum surveys those to whom it sends a policy brief, with the long term goal of identifying which design features work best for particular types of issues, and in which particular health system contexts. Participation is voluntary, confidentiality assured, and anonymity safeguarded
• Twelve features of the policy briefs series are the focus of questions in the formative evaluation survey:
• Describes the context of the issue being addressed
• Describes different features of the problem, including (where possible) how it affects particular groups
• Describes three options for addressing the problem
• Describes key implementation considerations
• Employs systematic and transparent methods to identify, select, and assess synthesised research evidence
• Takes quality considerations into account when discussing the research evidence
• Takes local applicability considerations into account when discussing the research evidence
• Takes equity considerations into account when discussing the research evidence
• Does not conclude with particular recommendations
• Employs a graded-entry format (i.e. a list of key messages and a full report)
• Includes a reference list for those who want to read more about a particular systematic review or research study, and
• Is subject to a review by at least one policymaker, at least one stakeholder, and at least one researcher. This process is termed a merit review to distinguish it from a standard peer review which would typically only involve researchers in the review process
• For each design feature, the survey asks:
• How useful did they find this approach (on a scale from 1 = Worthless to 7 = Useful)?
• Are there any additional comments or suggestions for improvement?
• The survey also asks:
• How well did the policy brief achieve its purpose, namely to present the available research evidence on a high-priority issue in order to inform a policy dialogue where research evidence would be just one input to the discussion (on a scale from 1 = Failed to 7 = Achieved)?
• What features of the policy brief should be retained in future?
• What features of the policy brief should be changed in future?
• What key stakeholders can do better or differently to address the high-priority issue and what they personally can do better or differently?
• Their role and background
(so that the McMaster Health Forum can determine if different groups have different views and experiences related to policy briefs)
• The Evidence-Informed Policy Networks (EVIPNet) operating in Africa, Asia and the Americas plan to use a similar approach in the formative evaluation of their policy briefs
summaries of systematic reviews and overviews of system- atic reviews)

– SUPPORT Collaboration: http://www.support-collabo ration.org – Example of a source of policymaker-friendly summaries of systematic reviews relevant to low- and middleincome countries

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
JNL prepared the first draft of this article. GP, ADO, SL and AF contributed to drafting and revising it.

Acknowledegements
Please see the Introduction to this series for acknowledge- ments of funders and contributors. In addition, we would like to acknowledge Sandy Campbell and staff in the Ontario Ministry of Health and Long-Term Care (MoHLTC) Planning Unit for helpful comments on an earlier version of this Article.

This article has been published as part of Health Research Policy and Systems Volume 7 Supplement 1, 2009: SUP- PORT Tools for evidence-informed health Policymaking (STP). The full contents of the supplement are available online at http://www.health-policy-systems.com/con tent/7/S1.

Additional material

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