This review seeks to explore and explain what health policy research is and why it matters, through pooling the evidence and providing case examples. Alongside examining the types of research involved, and their rationale the paper identifies the challenges taking part in this sort of research may create. Finally the paper suggests how to make clinical research more accessible to policy makers.
- General Paediatrics
- Health Service
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There is an increasing recognition of the role of health policy in prioritising and implementing changes in public health and clinical practice and the translation of research findings into practice. Arguably, the greatest revolutions in improving health in modern times, certainly in the UK, have come either from public health policy, such as smoking or seat belt legislation, or in the effective reorganisation of the way health services are delivered (eg, networked reconfiguration of acute stroke services).1 Health policy research is simply research that informs or evaluates health policy: that is, higher level decision-making by policy makers about structures, laws or processes related to health.
There can be considerable confusion and overlap between the terms health policy research, health systems research and health services research, 2 although health policy research frequently involves sectors outside health. There are two separate but related concepts in health policy research: ‘research for policy’—the identification of key policy elements through epidemiological or other traditional clinical, public health or qualitative research methods; and ‘research about policy’—which analyses policy decisions, including evaluating their outcomes and effectiveness.
What is ‘evidence-based policy’?
Medicines are carefully tested with laboratory research and clinical trials before they can be licensed and prescribed for patients. By contrast, health policies affect whole populations and have the potential for great benefit or harm, but they are often designed and implemented without transparent and balanced use of evidence or thorough evaluation of their impact.
Evidence-based policy (EBP) making is about the transparent and balanced use of evidence in public policy making.3 The purpose of EBP is to ensure accountability and promote the conditions for securing improvements in health and well-being. So the question is: what is needed to promote EBP? Many of the answers lie in health policy research.
Science is important for effective policy making, but it is insufficient. Policy making is a complex, non-linear, and often non-rational process that uses scientific evidence, but which is also dependent on the political, economic, legal and ethical environments, diffracted through the prism of key decision-makers’ personal and political values. Successful policy making depends on three essential conditions: problem recognition, politics, and policy formulation and evaluation.4 Greater understanding of each of these components is needed to promote EBP, and policy research makes important contributions in each of these three areas.
Tobacco control provides an interesting example of the complex relation between evidence and policy making. Problem recognition happened decades ago when the harmful effects of tobacco were convincingly described in scientific terms. But policies and politics were slow to catch up, and still lag behind. Major policy changes such as the Framework Convention on Tobacco Control and the prohibition of smoking in public places were achieved, not through convincing evidence alone, but through advocacy, legal action and public pressure.5 ,6 The process of effecting policy change is indeed still ongoing, and tobacco-related illness and death remains a significant problem despite overwhelming evidence of harm.
Research for policy is about obtaining evidence, through primary or clinical research, about interventions that work in health. Translating research findings about effective interventions into actionable policy is comparatively poorly developed. Health policy research can strengthen this important step in securing health gain from basic research, for example through knowledge brokering to facilitate effective communication between researchers and policy makers.
Research about policy, or policy analysis, is about understanding the policy process and the institutions, stakeholders, ideas and political processes around policy.7 Indeed, the policy content is often not the most important factor. First, it may be the system in which that policy is implemented which may have the greatest influence on its success. Second, the effectiveness and cohesion of the various policy ‘actors’ in the process: from formal ‘policymakers’ (politicians, public sector officials), to those with pivotal system roles (healthcare workers and managers, patients) to external agencies with informal influence over policy making and implementation (eg, non-governmental organisations, charities, private sector, civil society or lobbyists).8
Research on policy is about evaluating the process of policy development and implementation, and measuring the health outcomes and wider impact of that policy. Evaluative policy research is about learning lessons from policy successes and failures, and is part of a wider comparative effectiveness agenda. Health policy research in this sense is about investigating and explaining health patterns and their link to policy. Examples include studying political, economic and social policies and their influence on health—such as describing the relations between child mortality and income inequality, family policy or the type of political system in which those policies are embedded. More familiar perhaps are examples of policy research on healthcare, such as describing the relation between health spending and mortality. Finally, there are more indirect policy research areas such as on healthcare amenable mortality, which may generate more questions than answers. For instance, where an outcome is thought likely to be influenced by a specific policy, such as access to or organisation of health services, deeper examination of trends or geographical variations in outcomes may suggest where to direct further enquiry.
What are the challenges of health policy research?
The challenges of health policy research are threefold: its complexity, which necessitates a widely multidisciplinary approach; its methodology, requiring a combination of empirical, social and anthropological approaches with quantitative and qualitative methods, and inductive with deductive techniques; and in accounting for political cycles, whereby many policies are not given sufficient time to embed and be evaluated comprehensively.
Health policy research is multidisciplinary and cross-sectoral. It involves the tools and techniques of public health and epidemiology but also health economics, and social and political science. It encompasses health services research, health systems and organisational effectiveness studies, and other emerging disciplines such as translational research; research on the prioritisation, development, and implementation of policies and their impact on population health; and implementation science (a narrower, more technical aspect of policy and systems research related to identifying and tackling implementation gaps for clinically effective interventions, within the context of complex human and organisational factors.)9
The rich multidisciplinarity of health policy research is one of its strengths, but inevitably it means that it is sometimes considered ‘dirty’ science. Attributing causality is challenging, and often impossible. For health researchers trained in biomedicine and epidemiology, the randomised controlled trial is usually the gold standard of evidence. However it is rare for a policy to be examined in a controlled environment or in isolation. More usually, policy happens as part of a complex set of inter-related measures and in a broad and rapidly changing landscape. Although randomised trials are desirable and possible in many situations, it would be simplistic given the nature of health policy always to rely on trials to substantiate policy making. Cluster-randomised trials—where the unit of allocation is a group of people for example, in a hospital, a community or a school—are frequently used to evaluate policy interventions.
Observational multidisciplinary research makes important contributions to understanding and improving health policy: they should not be considered inferior to interventional research, but rather as an important adjunct. Indeed, the recommendations that follow from health policy research findings are more likely to be a construct based on best available evidence, rather than a fully tested hypothesis with a definable margin of error around the result of controlled trials.10
Furthermore, although one should always aim towards EBP, much of policy making by necessity happens in the context of incomplete evidence. As with evidence-based medicine, absence of evidence of effect should not be confused with absence of effect. This should of course be acknowledged in line with the important concept of transparency in the policy process, but can also be useful as a driver for evaluation of the process of policy implementation. While evaluation rightly focuses on outcomes, health policy is about the human condition, and so it is important to remember that processes often matter as much as outcomes: compassionate, humane health policy must be about more than proven outcomes and cost effectiveness alone.
Finally, policy making is inextricably entwined with politics and advocacy. The impact of powerful commercial lobbies cannot be ignored, as the ongoing experience in tobacco, alcohol and food legislation attests. Economic considerations play a significant part in prioritising new initiatives, or discontinuing existing ones, based primarily on cost and short-term benefit: the reduction of the successful and evidence-based Sure Start initiative in early years’ development is one such example. It is no secret that political ideologies affect health policy making, and influences how policy makers select, interpret and use existing evidence to support or disinvest in certain policies based on political dogma. This political influence is not static but dynamic: political cycles rather than evidence can often dictate the pace and direction of policy making, which means that policies are often given inadequate time fully to develop and embed. Instead, often there is a tendency to the reactionary, with strategy, direction and implementation of policy being driven by yesterday's anecdote or headline, rather than best evidence. The all-too-frequent reorganisations of the National Health Service are an example of how policies can change tack, not with objective high quality evidence alone, but with evidence as viewed through a highly politicised and ideological lens.
Box 1 outlines three examples illustrating the impact of some of these factors on the success, or otherwise, of recent UK child health policies.
Evidence and policy: three contrasting examples
An effective and research-driven policy initiative—the Teenage Pregnancy Strategy
Given mounting concern over the UK's position as the country with the highest rate of teenage conceptions in Europe, the Labour government's Social Exclusion Unit in the late 1990s undertook a widespread evidence-gathering exercise, and developed a comprehensive multicomponent strategy to reduce teenage conceptions that was very strongly based on evidence. The Department of Health and the Department for Education commissioned new research, to correct deficiencies in the evidence base as identified by the original research review. Lasting up to 2010, the strategy was effective in reducing England's teenage conception rate by 41% between 1998 and 2012.11 The strategy's reliance on research, its multicomponent nature and the cross-government ownership of the strategy were key to its early success. Indeed, it may have been the very controversial and sensitive nature of the debate around interventions on teenage sexuality that led strategy architects to lay the policy foundations so strongly on evidence.
How delay in research connecting to policy has cost lives—the ‘Back to Sleep’ campaign
The example of the impact of the ‘Back to Sleep’ campaign in the early 1990s on reducing rates of sudden unexplained death in infancy (SUDI), by nearly 75% since implementation, is rightly heralded as a health policy success story. However, this was not a tale of overnight success in the translation of research into policy. The path to policy implementation and improving outcomes was a tortuous one, with early epidemiological evidence contradicting the widely accepted practice of sleeping babies in the prone position being published as far back as 1944.12
The evidence continues to accumulate, and indeed the Dutch Department of Health had instituted their own campaign 4 years earlier than the UK. Taking a conservative estimate that SUDI rates declined by 50% in countries following adoption of the public health campaign13 (although UK-only data suggest reductions were much greater, of up to 65% after implementation in 199114), if the UK had instituted its campaign at the same time as the Netherlands, the intervention may have prevented further deaths of over 1800 infants in those 4 years. And the UK was by no means the tardiest—Australia adopted the policy in the same year, while the USA did not formally approve sleep guidance until 1992, and never instituted a publically funded national public health campaign to promote it.
Of course, successful implementation of policy is not simply about public health campaigns. Deeper examination of the ways in which the UK and other European countries changed population behaviours reveals important lessons. In the Netherlands a public lecture and research presentation caught media attention and led to significant changes in parenting practices. Nearly half (46%) of Dutch babies born before the lecture slept face down, but afterwards less than one in five babies (19%) slept in a prone position.15 The mortality rate from SUDI fell from 1.04 to 0.44 per 1000 live births in the 5 years that followed the public lecture.16 In effect, a successful public health campaign happened almost by stealth. By contrast, public health and information campaigns were planned in France and Germany, but there were weak public health structures in place at the time and they were therefore less successful. In France, a planned national education campaign never happened because efforts were distracted by an upcoming election, while Germany's highly devolved system of regional government resulted in public health action to reduce SUDI being implemented in only two regions.
The UK had a comparatively strong public health system, so why then was there a delay in action, and what lessons can be drawn from European examples? Problem recognition, the first of the Kingdom's essential preconditions, was slow to happen because the problem was difficult to elucidate4 There were doubts about the strength and generalisability of the policy evidence that came from other countries. Indeed it took many years before sufficient agreement was reached about the diagnosis, risk factors and intervention: only then was successful policy implemented in the UK. Visible participants outside government were important in the success of the Dutch and British examples, illustrating the importance of partnerships between governmental and non-governmental stakeholders working in a coherent national public health system.17
B+ for effort: The Free School Meals policy and the gulf between evidence and ideology
In 2008, the Government announced a pilot of increasing coverage of free school meals for children in primary schools. Two mechanisms, supported by an accompanying communication campaign, were tested: one local authority piloted an extension of the inclusion criteria for access to free school meals, and two local authorities piloted a scheme for universal access. This was based on evidence suggesting that school lunches were healthier, and that there was some positive impact on children's health, behaviour and concentration.
The 2-year pilots showed some benefits, including increased uptake of school meals, particularly among those previously eligible but not making use of free meals. However, take-up was higher among the newly entitled under the universal access scheme, compared with the extended inclusion criteria scheme. There was a change in food intake: however, the change was small, and there was very limited impact on eating habits, and no change in health measures such as body mass index. There was an increase in educational attainment, especially among the less affluent, in the universal access scheme as compared with the extended benefit schemes.
So, then, some success was achieved within the limited pilot. However, as the Department for Education's own evaluation states: “The evidence suggests that the universal entitlement pilot provides better value for money than the extended entitlement pilot, but raises questions over its value for money compared with some other initiatives.18”
Despite the limited nature of the evidence in favour, funding for the Free School Meals policy was announced by the Coalition Government on 23 January 2014. From September 2014, all Reception, year 1 and year 2 pupils will receive universal access to free school meals, with a Government commitment for 2 years’ funding, at a cost of £1 billion. This translates to £2.30 per meal, and additional monies were confirmed to allow capital works to school kitchens and dining areas.
Enhancing communication between research and policy: systems and strategies
One strategy to address the need for research to assist policy is through the Policy Research Units of the Department of Health in England, of which one has a specific focus on child and adolescent health. These units carry out a mixture of functions from pursuing policy research relevant questions to providing a reactive function, that is, answering civil servant or ministerial questions.
Researchers are often frustrated at the apparent inability, or even intransigence, of policy makers to use the wealth of evidence available to inform the policy making process. While it is often true that policy makers are not as willing to engage with researchers as they might be, the onus should not simply be on them to become better versed in the language and intricacies of interpreting research evidence. Researchers can maximise their effectiveness in translating research into health policy by understanding and embracing the vagaries of the political context in which policy is being made, and by reframing the interaction with policy makers to one of collaboration.
To this end, some key principles can be gleaned among examples of successful strategies:
Understand the political context
It is worth emphasising again how much of policy making, by its nature, is influenced by the political and socioeconomic climate. The impact of research findings on policy for child health, for instance, will be dependent on the priorities of the Government as a whole, and also specifically on how it might impact other policies in the government departments responsible for health, education, social care and the Treasury. The chances of successful translation of research to policy will be increased by aligning policy recommendations from research evidence to cross-sectoral priorities, and articulating the benefits in health, social and financial terms.
Prioritise the need for research knowledge translation from the outset
The translation of research to policy is about more than simply communicating the results of a research study to a policy audience. Too often, it is seen almost as an afterthought, not considered until the research is near completion. To effectively influence and shape policy, researchers should frame and articulate at the outset a clear policy message that would result from their research, and plan a strategy to engage policy makers and stakeholders. Efforts to improve this are already starting to happen, and at a system level. For example, while broader policy research is the responsibility of the Policy Research Programme, the National Institute of Health Research has a very strong focus on translational research, and clearly articulating the potential policy implications of any research is key to obtaining National Institute of Health Research funding.
Context is everything
In clinical trials, it is taken for granted that any results are potentially generalisable only within the context of the study parameters: they may be applied to patient groups which are similar to the study population, and that the outcome may be dependent on the intensity of treatment tested. The context in which policy evaluation occurs is equally vital. The success or otherwise of a piece of policy research cannot and should not support or preclude its widespread adoption in different settings, and this message should be explicitly communicated in the policy making dialogue. However, as exemplified by the sudden unexplained death in infancy example above, lessons in the process of policy implementation (as distinct from content) can be invaluable, and may be generalisable across different policy areas.
Prepare data and evidence for the policy audience
There is much evidence to show that policy makers do not have the same understanding or training in academic research and evidence appraisal, and that much of academic research never reaches their consciousness.19 ,20 Brownson et al outline key principles for the preparation of data for a policy audience, to maximise the likelihood of creating impact to influence change21 (see box 2). Briefing papers, written largely in lay language and outlining the breadth of evidence and their relative strengths and limitations, can be a useful way to communicate with policy audiences.
Seeking out opportunities to engage with policy officials
Many policy makers and officials are keen to form links with academics: reaching out from government may be as hard as reaching in. Indeed, there may be reciprocal benefits: the Department of Health's Policy Research Programme has a responsibility to consider research requests made to it from a number of arms’ length bodies in health such as NHS England and Public Health England, and opening a dialogue with policy officials may help researchers to formulate and fund policy-relevant research projects.
Data preparation to maximise policy influence (from Brownson et al)21
Shows public health burden
Demonstrates priority of an issue over others
Relevance at local (voting) level
Shows benefit/harm from intervention
Personalises the issue through personal/patient stories
Estimates the cost of an intervention
Delivered in short concise formats
That practice should be evidence based is now, after many years of hard advocacy, largely a given in the health community. Evidence-based policy is evolving. This paper has examined what policy research is, provided examples of where policy research has succeeded and failed, and suggested some ways in which researchers can improve the policy relevance of their work and connection to policy makers. Without a better understanding of policy formation by researchers, a better understanding of research by policy makers and, most crucially, improved connections between these communities, using evidence to shape policy will continue to lag behind evidence-based clinical practice.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.