Jenny Woodman

A systematic review of barriers to and facilitators of the use of evidence by policymakers

BackgroundThe gap between research and practice or policy is often described as a problem. To identify new barriers of and facilitators to the use of evidence by policymakers, and assess the state of research in this area, we updated a systematic review.MethodsSystematic review. We searched online databases including Medline, Embase, SocSci Abstracts, CDS, DARE, Psychlit, Cochrane Library, NHSEED, HTA, PAIS, IBSS (Search dates: July 2000 - September 2012). Studies were included if they were primary research or systematic reviews about factors affecting the use of evidence in policy. Studies were coded to extract data on methods, topic, focus, results and population.Results145 new studies were identified, of which over half were published after 2010. Thirteen systematic reviews were included. Compared with the original review, a much wider range of policy topics was found. Although still primarily in the health field, studies were also drawn from criminal justice, traffic policy, drug policy, and partnership working. The most frequently reported barriers to evidence uptake were poor access to good quality relevant research, and lack of timely research output. The most frequently reported facilitators were collaboration between researchers and policymakers, and improved relationships and skills. There is an increasing amount of research into new models of knowledge transfer, and evaluations of interventions such as knowledge brokerage.ConclusionsTimely access to good quality and relevant research evidence, collaborations with policymakers and relationship- and skills-building with policymakers are reported to be the most important factors in influencing the use of evidence. Although investigations into the use of evidence have spread beyond the health field and into more countries, the main barriers and facilitators remained the same as in the earlier review. Few studies provide clear definitions of policy, evidence or policymaker. Nor are empirical data about policy processes or implementation of policy widely available. It is therefore difficult to describe the role of evidence and other factors influencing policy. Future research and policy priorities should aim to illuminate these concepts and processes, target the factors identified in this review, and consider new methods of overcoming the barriers described.

The views of young children in the UK about obesity, body size, shape and weight: a systematic review

BackgroundThere are high levels of concern about childhood obesity, with obese children being at higher risk of poorer health both in the short and longer terms. Childrens attitudes to, and beliefs about, their bodies have also raised concern. Children themselves have a stake in this debate; their perspectives on this issue can inform the ways in which interventions aim to work.This systematic review of qualitative and quantitative research aimed to explore the views of UK children about the meanings of obesity and body size, shape or weight and their own experiences of these issues.MethodsWe conducted sensitive searches of electronic databases and specialist websites, and contacted experts. We included studies published from the start of 1997 which reported the perspectives of UK children aged 4-11 about obesity or body size, shape or weight, and which described key aspects of their methods. Included studies were coded and quality-assessed by two reviewers independently.Findings were synthesised in two analyses: i) an interpretive synthesis of findings from open-ended questions; and ii) an aggregative synthesis of findings from closed questions. We juxtaposed the findings from the two syntheses. The effect of excluding the lowest quality studies was explored. We also consulted young people to explore the credibility of a subset of findings.ResultsWe included 28 studies. Instead of a focus on health, children emphasised the social impact of body size, describing experiences and awareness of abuse and isolation for children with a greater weight. Body size was seen as under the individuals control and children attributed negative characteristics to overweight people. Children actively assessed their own size; many wished their bodies were different and some were anxious about their shape.Reviewers judged that childrens engagement and participation in discussion had only rarely been supported in the included studies, and few study findings had depth or breadth.ConclusionsInitiatives need to consider the social aspects of obesity, in particular unhelpful beliefs, attitudes and discriminatory behaviours around body size. Researchers and policy-makers should involve children actively and seek their views on appropriate forms of support around this issue.

Using mixed methods in health research.

Summary Mixed methods research is the use of quantitative and qualitative methods in a single study or series of studies. It is an emergent methodology which is increasingly used by health researchers, especially within health services research. There is a growing literature on the theory, design and critical appraisal of mixed methods research. However, there are few papers that summarize this methodological approach for health practitioners who wish to conduct or critically engage with mixed methods studies. The objective of this paper is to provide an accessible introduction to mixed methods for clinicians and researchers unfamiliar with this approach. We present a synthesis of key methodological literature on mixed methods research, with examples from our own work and that of others, to illustrate the practical applications of this approach within health research. We summarize definitions of mixed methods research, the value of this approach, key aspects of study design and analysis, and discuss the potential challenges of combining quantitative and qualitative methods and data. One of the key challenges within mixed methods research is the successful integration of quantitative and qualitative data during analysis and interpretation. However, the integration of different types of data can generate insights into a research question, resulting in enriched understanding of complex health research problems.

Screening injured children for physical abuse or neglect in emergency departments: a systematic review

BACKGROUND Screening markers are used in emergency departments (EDs) to identify children who should be assessed for possible physical abuse and neglect. We conducted three systematic reviews evaluating age, repeat attendance and injury type as markers for physical abuse or neglect in injured children attending EDs. METHODS We included studies comparing markers in physically abused or neglected children and non-abused injured children attending ED or hospital. We calculated likelihood ratios (LRs) for age group, repeat attendance and injury type (head injury, bruises, fractures, burns or other). Given the low prevalence of abuse or neglect, we considered that an LR of 10 or more would be clinically useful. RESULTS All studies were poor quality. Infancy increased the risk of physical abuse or neglect in severely injured or admitted children (LRs 7.7-13.0, 2 studies) but was not strongly associated in children attending the ED (LR 1.5, 95% CI: 0.9, 2.8; one study). Repeat attendance did not substantially increase the risk of abuse or neglect and may be confounded by chronic disease and socio-economic status (LRs 0.8-3.9, 3 studies). One study showed no evidence that the type of injury substantially increased the risk of physical abuse or neglect in severely injured children. CONCLUSIONS There was no evidence that any of the markers (infancy, type of injury, repeated attendance) were sufficiently accurate (i.e. LR >or= 10) to screen injured children in the ED to identify those requiring paediatric assessment for possible physical abuse or neglect. Clinicians should be aware that among injured children at ED a high proportion of abused children will present without these characteristics and a high proportion of non-abused children will present with them. Information about age, injury type and repeat attendances should be interpreted in this context.

Variation in recording of child maltreatment in administrative records of hospital admissions for injury in England, 1997–2009

Background Information on variation in the recording of child maltreatment in administrative healthcare data can help to improve recognition and ensure that services are able to respond appropriately. Objective To examine variation in the recording of child maltreatment and related diagnoses. Design Cross-sectional analyses of administrative healthcare records (Hospital Episode Statistics). Setting and participants Acute injury admissions to the National Health Service in England of children under 5 years of age (1997–2009). Outcome measure Annual incidence of admission for injury recorded by International Classifications of Diseases 10 codes for maltreatment syndrome (child abuse or neglect) or maltreatment-related features (assault, undetermined cause or adverse social circumstances). Proportion of all admissions for injury coded for maltreatment syndrome or maltreatment-related features. Results From 1997 to 2009, the annual incidence of injury admissions coded for maltreatment syndrome declined in infants and in 1–3-year-old children while admissions coded for maltreatment-related features increased in all age groups. The combined incidence of these categories remained stable. Overall, 2.6% of injury admissions in infants, and 0.4–0.6% in older age groups, had maltreatment syndrome recorded. This prevalence more than doubled when maltreatment-related codes were added (6.4% in infants, 1.5–2.1% in older age groups). Conclusion Despite a shift from maltreatment syndrome to codes for maltreatment-related features, the overall burden has remained stable. In combination, the cluster of codes related to maltreatment identify children likely to meet thresholds for suspecting or considering maltreatment and taking further action, as recommended in recent National Institute of Health and Clinical Excellence guidance, and indicate a considerable burden to which hospitals should respond.

Variation in Recorded Child Maltreatment Concerns in UK Primary Care Records: A Cohort Study Using The Health Improvement Network (THIN) Database

Objectives To determine variation over time and between practices in recording of concerns related to abuse and neglect (maltreatment) in childrens primary care records. Design Retrospective cohort study using a United Kingdom representative primary care database. Setting 448 General Practices. Participants In total 1,548, 972 children (<18 y) registered between 1995 and 2010. Main Outcome Measures Change in annual incidence of one or more maltreatment-related codes per child year of registration. Variation between general practices measured as the proportion of registered children with one or more maltreatment-related codes during 3 years (2008–2010). Results From 1995–2010, annual incidence rates of any coded maltreatment-related concerns rose by 10.8% each year (95% confidence interval 10.5, 11.2; adjusted for sex, age and deprivation). In 2010 the rate was 9.5 per 1000 child years (95%CI: 9.3, 9.8), equivalent to a prevalence of 0.8% of all registered children in 2010. Across all practices, the median prevalence of children with any maltreatment-related codes in three years (2008 to 2010) was 0.9% (range 0%–13.4%; 11 practices (2.5%) had zero children with relevant codes in the same period). Once we accounted for sex, age, and deprivation, the prevalence for each practice was within two standard errors of the grand mean. Conclusions General Practitioners (GPs) are far from disengaged from safeguarding children; they are consistently and increasingly recording maltreatment concerns. As these results are likely to underestimate the burden of maltreatment known to primary care, there is much scope for increasing recording in primary care records with implications for resources to respond to concerns about maltreatment. Interventions and policies should build on this evidence that the average GP in the UK is engaged in child safeguarding activity.

Who comes back with what: a retrospective database study on reasons for emergency readmission to hospital in children and young people in England

Objective To determine the proportion of children and young people (CYP) in England who are readmitted for the same condition. Design Retrospective cohort study. Setting National administrative hospital data (Hospital Episode Statistics). Participants CYP (0-year-olds to 24-year-olds) discharged after an emergency admission to the National Health Service in England in 2009/2010. Main outcome measures Coded primary diagnosis classified in six broad groups indicating reason for admission (infection, chronic condition, injury, perinatal related or pregnancy related, sign or symptom or other). We grouped readmissions as ≤30 days or between 31 days and 2 years after the index discharge. We used multivariable logistic regression to determine factors at the index admission that were predictive of readmission within 30 days. Results 9% of CYP were readmitted within 30 days. Half of the 30-day readmissions and 40% of the recurrent admissions between 30 days and 2 years had the same primary diagnosis group as the original admission. These proportions were consistent across age, sex and diagnostic groups, except for infants and young women with pregnancy-related problems (15–24 years) who were more likely to be readmitted for the same primary diagnostic group. CYP with underlying chronic conditions were readmitted within 30 days twice as often (OR: 1.93, 95% CI 1.89 to 1.99) compared with CYP without chronic conditions. Conclusions Financial penalties for readmission are expected to incentivise more effective care of the original problem, thereby avoiding readmission. Our findings, that half of children come back with different problems, do not support this presumption.

Maltreatment or violence-related injury in children and adolescents admitted to the NHS: comparison of trends in England and Scotland between 2005 and 2011

Objective Legislation to safeguard children from maltreatment by carers or violence by others was advanced in England and Scotland around 2004–2005 and resulted in different policies and services. We examined whether subsequent trends in injury admissions to hospital related to maltreatment or violence varied between the two countries. Setting and participants We analysed rates of all unplanned injury admission to National Health Service (NHS) hospitals in England and Scotland between 2005 and 2011 for children and adolescents aged less than 19 years. Outcomes We compared incidence trends for maltreatment or violence-related (MVR) injury and adjusted rate differences between 2005 and 2011 using Poisson or negative binomial regression models to adjust for seasonal effects and secular trends in non-MVR injury. Infants, children 1–10 years and adolescents 11–18 years were analysed separately. Results In 2005, MVR rates were similar in England and Scotland for infants and 1–10-year-olds, but almost twice as high in Scotland for 11–18-year-olds. MVR rates for infants increased by similar amounts in both countries, in line with rising non-MVR rates in England but contrary to declines in Scotland. Among 1–10-year-olds, MVR rates increased in England and declined in Scotland, in line with increasing non-MVR rates in England and declining rates in Scotland. Among 11–18-year-olds, MVR rates declined more steeply in Scotland than in England along with declines in non-MVR trends. Conclusions Diverging trends in England and Scotland may reflect true changes in the occurrence of MVR injury or differences in the way services recognise and respond to these children, record such injuries or a combination of these factors. Further linkage of data from surveys and services for child maltreatment and violence could help distinguish the impact of policies.

How explicable are differences between reviews that appear to address a similar research question? A review of reviews of physical activity interventions

BackgroundSystematic reviews are promoted as being important to inform decision-making. However, when presented with a set of reviews in a complex area, how easy is it to understand how and why they may differ from one another?MethodsAn analysis of eight reviews reporting evidence on effectiveness of community interventions to promote physical activity. We assessed review quality and investigated overlap of included studies, citation of relevant reviews, consistency in reporting, and reasons why specific studies may be excluded.ResultsThere were 28 included studies. The majority (n = 22; 79%) were included only in one review. There was little cross-citation between reviews (n = 4/28 possible citations; 14%). Where studies appeared in multiple reviews, results were consistently reported except for complex studies with multiple publications. Review conclusions were similar. For most reviews (n = 6/8; 75%), we could explain why primary data were not included; this was usually due to the scope of the reviews. Most reviews tended to be narrow in focus, making it difficult to gain an understanding of the field as a whole.ConclusionsIn areas where evaluating impact is known to be difficult, review findings often relate to uncertainty of data and methodologies, rather than providing substantive findings for policy and practice. Systematic ‘maps’ of research can help identify where existing research is robust enough for multiple in-depth syntheses and also show where new reviews are needed. To ensure quality and fidelity, review authors should systematically search for all publications from complex studies. Other relevant reviews should be searched for and cited to facilitate knowledge-building.

Responses to concerns about child maltreatment: a qualitative study of GPs in England.

Objectives To provide a rich description of current responses to concerns related to child maltreatment among a sample of English general practitioners (GPs). Design In-depth, face-to-face interviews (November 2010 to September 2011). Participants selected and discussed families who had prompted ‘maltreatment-related concerns’. Thematic analysis of data. Setting 4 general practices in England. Participants 14 GPs, 2 practice nurses and 2 health visitors from practices with at least 1 ‘expert’ GP (expertise in child safeguarding/protection). Results The concerns about neglect and emotional abuse dominated the interviews. GPs described intense and long-term involvement with families with multiple social and medical problems. Narratives were distilled into seven possible actions that GPs took in response to maltreatment-related concerns. These were orientated towards whole families (monitoring and advocating), the parents (coaching) and children (opportune healthcare), and included referral to or working with other services and recording concerns. Facilitators of the seven actions were: trusting relationships between GPs and parents, good working relationships with health visitors and framing the problem/response as ‘medical’. Narratives indicated significant time and energy spent building facilitating relationships with parents with the aim of improving the childs well-being. Conclusions These GPs used core general practice skills for on-going management of families who prompted concerns about neglect and emotional abuse. Policy and research focus should be broadened to include strategies for direct intervention and on-going involvement by GPs, such as using their core skills during consultations and practice systems for monitoring families and encouraging presentation to general practice. Exemplars of current practice, such as those identified in our study, should be evaluated for feasibility and acceptability in representative general practice settings as well as tested for efficacy, safety and cost. The seven actions could form the basis for the ‘lead professional’ role in general practice as proposed in the 2013 version of ‘Working Together ’guidance.