Policy & practice An approach for setting evidence-based and stakeholder-informed research priorities in low- and middle-income countries Eva A Rehfuess,a Solange Durão,b Patrick Kyamanywa,c Joerg J Meerpohl,d Taryn Younge & Anke Rohwere on behalf of the CEBHA+ consortium Abstract To derive evidence-based and stakeholder-informed research priorities for implementation in African settings, the international research consortium Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA+) developed and applied a pragmatic approach. First, an online survey and face-to-face consultation between CEBHA+ partners and policy-makers generated priority research areas. Second, evidence maps for these priority research areas identified gaps and related priority research questions. Finally, study protocols were developed for inclusion within a grant proposal. Policy and practice representatives were involved throughout the process. Tuberculosis, diabetes, hypertension and road traffic injuries were selected as priority research areas. Evidence maps covered screening and models of care for diabetes and hypertension, population-level prevention of diabetes and hypertension and their risk factors, and prevention and management of road traffic injuries. Analysis of these maps yielded three priority research questions on hypertension and diabetes and one on road traffic injuries. The four resulting study protocols employ a broad range of primary and secondary research methods; a fifth promotes an integrated methodological approach across all research activities. The CEBHA+ approach, in particular evidence mapping, helped to formulate research questions and study protocols that would be owned by African partners, fill gaps in the evidence base, address policy and practice needs and be feasible given the existing research infrastructure and expertise. The consortium believes that the continuous involvement of decision-makers throughout the research process is an important means of ensuring that studies are relevant to the African context and that findings are rapidly implemented. Introduction Evidence-based approaches to address health problems are recognized as best practice. Evidence-based public health Mortality in sub-Saharan Africa is still predominantly caused draws on the principles of evidence-based health care10 and is by human immunodeficiency virus/acquired immunodefi- defined as the“ integration of the best available evidence with ciency syndrome (HIV/AIDS), malaria and other infectious the knowledge and considered judgments from stakeholders diseases. However, premature deaths due to noncommunicable and experts to benefit the needs of a population”.11 diseases and unintentional injuries are increasing.1 Further- When allocating resources, policy-makers and health-care more, Africa is facing significant challenges in the provision practitioners need to consider the significance of the health of preventative and curative health care. This is the result problem; the potential benefits and harms of the interven- of a combination of factors – including insufficient human tion and the quality of evidence on effectiveness. The cost resources, poor health system infrastructure, limited sup- and cost–effectiveness must also be weighed up, along with plies of essential medication and technology and suboptimal personal values and preferences, feasibility, acceptability and health-care seeking.2–4 equity. To achieve evidence-based decision-making, data from While there has been a significant increase in health rigorous primary research and evidence syntheses relevant to research conducted in the region in recent years,5 the overall the African context must expand and translation of evidence research has not been commensurate with the challenges in into policy and practice must be enhanced.12,13 terms of quantity or quality.6 Much of the research under- The Collaboration for Evidence-Based Healthcare and taken is less informative than it should be, often because of a Public Health in Africa (CEBHA+) emerged from the Collabo- mismatch between research required by decision-makers and ration for Evidence Based Healthcare in Africa (www.cebha. that conducted by academic institutions. In some instances, org). CEBHA+ promotes evidence-based health care principles the research agenda is driven by funders (including industry) through (i) identifying relevant and context-sensitive research and thus concerned with international rather than national priorities; (ii) conducting robust, internationally competitive or local problems. Furthermore, usability of findings tends research; and (iii) linking primary research with evidence to be hampered by limitations in quality of conduct, analysis synthesis, implementation research, policy and practice. and reporting of studies. Thus there is a need in the research Currently, the consortium comprises eight African part- field “to increase value and to reduce waste”,7–9 especially in ners in five countries (Ethiopia, Malawi, Rwanda, South Africa resource-constrained settings such as Africa. and Uganda), two German partners and two associate part- a Institute for Medical Informatics, Biometry and Epidemiology, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany. b Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa. c University of Rwanda, Butare, Rwanda. d Cochrane Germany, Freiburg, Germany. e Centre for Evidence-based Health Care, Stellenbosch University, Cape Town, South Africa. Correspondence to Eva A Rehfuess (email: [email protected]). (Submitted: 20 August 2015 – Revised version received: 9 December 2015 – Accepted: 9 December 2015 – Published online: 12 February 2015 ) Bull World Health Organ 2016;94:297–305 | doi: http://dx.doi.org/10.2471/BLT.15.162966 297 Policy & practice Setting research priorities Eva A Rehfuess et al. ners. As part of the preparatory phase, waiver from the Ethics Committee of research to be conducted would be able the consortium developed a pragmatic the LMU Munich, Germany, given the to answer a policy-relevant question and approach for setting evidence-based and low-risk nature of the survey. All data to decide on the most appropriate way to stakeholder-informed research priori- were handled anonymously. The survey do so. In addition, researchers involved ties to ensure that the research would was conducted in March and early April in relevant activities were consulted to be: (i) unique – to avoid unnecessary 2014 using Survey Monkey (https:// check that priority research questions duplication and fill a gap in the African www.surveymonkey.com/). Survey data would build on existing research and and/or international evidence base; were analysed descriptively. not duplicate current research by other (ii) relevant – to address pressing ques- An initial shortlist of priority re- groups. Between June and October 2014, tions asked by African decision-makers; search areas derived from the online evidence maps were created by cross- (iii) context-sensitive – to facilitate us- survey provided the starting point national research teams with method- ability in African settings; (iv) feasible for face-to-face consultations during ological support from the LMU Munich. – to ensure that research can be con- a three-day meeting in Addis Ababa, Step 3 ducted with existing interest, expertise Ethiopia, in April 2014. Participants and resources; and (v) high quality – to included one or more representatives We developed study protocols towards minimize limitations in quality of con- of all partners and high-level health a full grant proposal. The cross-national duct, analysis and reporting of studies. policy-makers from Rwanda, South Af- research teams engaged with policy- This paper describes the development rica and Uganda. A two-stage interactive makers to jointly develop protocols and application of this approach and group process was followed to achieve using email, voice calls and a two-day discusses its strengths and limitations. consensus, with participants from a face-to-face meeting. Depending on the given country initially selecting their specific content and methodological ex- Developing research first choice, a subsequent grouping of pertise required, we involved additional priority research areas and in-depth dis- scientists within partner institutions or priorities cussions regarding those selected by at recruited additional partner institutions. least three countries. With reference to Study protocols were developed between We followed a three-step participatory existing checklists,15,16 participants were September and December 2014. process. Representatives of the policy asked to consider four criteria in pri- and practice community were involved oritizing: (i) magnitude or seriousness throughout, as continuous interaction can of the health problem; (ii) research and Identified research priorities help identify challenges in need of solu- other strengths of the consortium in the tions and increase the chances of research Priority research areas respective area; (iii) requirements by the findings being translated into policy. funder and related strategic advantages The online survey was completed by sev- Step 1 and/or disadvantages; and (iv) feasibility en out of eight partner institutions in six of achieving meaningful results given countries (Burundi, Ethiopia, Malawi, Through an online survey and face-to- available resources and timelines. Rwanda, South Africa and Uganda) and face consultations we developed