MALARIA RESEARCH IN MALAWI FROM 1984 TO 2016: A LITERATURE REVIEW AND BIBLIOMETRIC ANALYSIS

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CHAPTER TWO LITERATURE REVIEW

Introduction

This chapter presents a review of literature based on the study objectives. The first section explores the meaning of evidence and the various types of research categories of health research that provide new knowledge and evidence for decision making, followed by a discussion on how evidence can be utilised in the process of policy making. This stage brings up the section of understanding the policy making process and how the various types of evidence can be used in this process, which also incorporates the challenges of utilising evidence in this process. The following section is a discussion about the promotion of evidence in policy development through the understanding of the roles of theories, models and frameworks. This discussion highlights examples of frameworks that guided the development of the research-to-policy framework in this study. Further recognition is made of the need to take into consideration the challenges of policy implementation, which hinder the realisation of policy objectives.

What constitutes evidence?

Understanding how evidence is defined is critical on how it is used for decision-making. The meaning of evidence is understood differently between researchers and non-researchers. Non-researchers broadly define evidence colloquially as “anything that establishes a fact or gives reason for believing in something.¹ This evidence can constitute professional or expert opinion and experiences, political judgement, habits and traditions, and values. Utilising this kind of evidence requires strict judgement because it is not gathered through rigorous means and the experiences may not be replicated. This should be of great concern when dealing with human life. On the other hand, researchers have a restrictive description of what constitutes evidence. They view evidence as information originating from explicit and systematic approaches that are universally accepted and replicable.² The credibility of scientific research evidence depends on the methodology tests while relevance applies to colloquial evidence.³ Decision makers such as policy makers are more inclined to take into consideration colloquial evidence while challenged to practice evidence-based decision making which highly considers research evidence.
However, as the more acceptable research evidence is considered for decision-making, colloquial evidence can be assimilated into the picture by conducting multidisciplinary research. Proponents of scientific research evidence have further categorised evidence as either context-free or context-sensitive.⁴ Context-free evidence originates from rigorous controlled scientific methods that reveal the universal truth or effectiveness of the issues under study while context-sensitive evidence is highly rooted in social science as it reveals the applicability of findings from context-free evidence.³ Therefore, these two approaches of gathering scientific evidence should be viewed as complementary because context-free provides evidence on ‘what works’ while context-sensitive provides evidence on how ‘what works’ can be implemented in the real setting and this can include factors such as organizational capacity, socio-economical, and population dynamics.

Sources of evidence for health care – health research

Decision making and policy development for the improvement of public health needs to be supported by scientific evidence,⁵ which is provided through health research. One of the most important aspects in the promotion of research utilisation for decision-making is understanding the various types of research since it will guide the strategies taken for its utilisation. Describing types of research has been confusing since it may come from different research backgrounds such as social science, biomedical, health economics.⁶ Various definitions have been used showing inconsistency in the scientific world, creating confusion and hence affecting its credibility and how it is sought.⁷ Evidence for decision making in health care can originate from primary or secondary health research.⁸ Primary research, which is also referred to as original research, is concerned with the collection and analysis of primary data from tools such as experiments, interviews, surveys, and questionnaires.^8,9 On the other hand, secondary research, which is also called desk research, focuses on analysing and interpreting primary research findings. It involves the synthesis of existing two or more primary research to answer a specific topical question.^8,10 Review papers or articles can be written from secondary research and these can be in the form of a narrative review, systematic review, and meta-analysis.⁸ A simple narrative review involves appraising and summarising existing literature on an existing topic to identify gaps and guide in conducting a primary research. This approach can be subjective and lead to bias in order to support the researcher’s position. A systematic review addresses most of the challenges encountered in the ordinary narrative review. A systematic review involves a definite, rigorous, and comprehensive approach in identifying and synthesising two or more primary research fitting an eligibility criteria that is pre-defined in order to answer a specific topical question. Meta-analyses combine and compare the findings of two or more primary quantitative research in order to assess the effectiveness of a particular intervention or type of treatment by using standardised statistical procedures.¹¹ Reviews have become popular for planning, decision making and policy development in health. With a growing body of primary research evidence, managers, policy makers, and health practitioners do not have the time and expertise to search for particular studies and yet interpret such findings, in addition to the fact that one study cannot provide the basis of a final decision,¹² hence systematic reviews and meta-analysis serve this purpose.

Categories of primary health research

Various approaches have been used to define and understand categories of primary research but in this review the categories adopted are best defined by Rohrig⁸ with an addition of context-sensitive Health Policy and Systems Research (HPSR) that is explained by Remme.⁶ Primary health research can be categorized into basic, clinical, epidemiological and HPSR. Basic research, which is sometimes called fundamental, pure, or curiosity-driven research, is experimental and theoretical in nature with no particular purpose of its application but rather to create new knowledge.¹³ Basic research will include pharmacology, microbiology, biochemistry, physiology, and genetics investigations.⁸ Clinical health research, which can either be interventional or observational, is a type of research that seeks to assess the effectiveness and safety of an intervention such as a drug, vaccine, and diagnostic tool in humans.^8,14 Usually the intervention would have been discovered during basic research. While epidemiological studies involve investigations on the distribution and patterns of health determinants and diseases in a given population with the purpose of understanding their dynamics and devising strategies for prevention and control.¹⁵ Another type of context-sensitive primary research has evolved to understand and improve the delivery of health services in a country and it is called HPSR. HPSR seeks to generate new knowledge for improving the organisation of societies to achieve better health by focusing on health systems.¹⁶ The WHO defines health systems as “all organisations, people and actions whose primary intent is to promote, restore or maintain health”.¹⁷ The building blocks of a health system are illustrated in the WHO framework presented in Figure 2.1 below
Therefore, HPSR will encompass any study on the six building blocks, assessment on accessibility, coverage, quality and safety of health services, and the evaluation on the achievement of outcomes and goals. A study assessing the outcomes of investing in new technology in comparison to improving the utilisation and delivery of health services to prevent deaths in under five children has revealed a shift in the focus to HPSR. The study found out that improving the technology potentially reduced 22% of deaths while improvement of health services delivery prevented 63% of deaths.¹⁸ However, the same study also revealed that much of research funding support is towards developing new technologies rather than improving health delivery.
The responsibility of the government should be to focus on the improvement of health services delivery by showing political will and supporting HPSR, which can be categorised into operational, implementation, and health system as described by Remme et al.⁶ The HPSR domains have been differentiated according to how they are organised, address the research question, and their interaction with the health system although slight overlaps exist.

Operational research

This kind of research is mostly used by health care providers. Operational research tends to be context specific and address a specific local health problem hence its generalisation to other settings is not obvious although the approach taken can be replicated elsewhere. There may be problems that threaten a local disease control programme, hence it is characterised by a stern problem-solving emphasis and its significance for rapid uptake of the research findings. It is also characterised by the specific research designs such as descriptive and analytical, and the usage of mathematical models. The research questions may come from the routine monitoring and evaluation project activities.

Implementation research

This type of research is mainly used by managers of programs in scaling up an intervention. It provides a general strategy of intervention implementation for increased access to the target population. It is important to note that this type of research tries to promote an intervention whose efficacy has been proven by other research, therefore, it explores on innovative strategies for wider implementation. This type of research will complement the rolling out of a new policy. Therefore, some good policies may be developed from quality research but their impact may not be felt due to lack of evidence on how best to implement them. Hence, implementation research further addresses this challenge. Social science research methods such as qualitative research methods are often used and usually undertaken by research from various fields.

Health system research

This type of research is mainly used by policymakers for the improvement of the health system. Health system research will in general be focused on the health system and tends to move away from disease specific concerns, therefore, it will address issues of health financing, governance, and policy in order to solve problems of service delivery and increases the productivity and success of the health system. The type of research is multidisciplinary and case studies can be used to answer context specific health system problems but it can also generate valuable lessons for other similar settings.
The three main categories of HPSR can be related to type of policies that come along with them. Legislative policies can emanate from health system research as they relate to the overall framework of the health system; and administrative policies may originate from implementation research as they focus on the running and the allocation of resources in the health system; while clinical policies arise from operational research that will seek for example alternative interventions to a treatment.¹⁹ Hanney et al.¹⁹ have acknowledged that research evidence is less utilised at the legislative policies and highly needed at the clinical policies. However, at the clinical policies, where research is highly needed, it is delayed to be converted for the improvement of patient care.²⁰
Figure 3.1 and Table 3.1 (in Chapter 3) provide the categories of research type, their definitions and examples as used in this review.

Utilisation of research evidence during policy development

Research utilisation can come in various forms during the policy development process. Lavis et al. ²¹ explain that research can be; instrumental if the research findings have directly led to policy development; conceptual if research is gradually utilised as reference; and symbolic if the research evidence is used to support an already made decision.
However, utilisation of research is based mainly on three factors that need to be working efficiently and these include; availability of research itself which is vigorous and an appropriate knowledge base, regular dialogue between researchers and research users is very critical for research uptake, and the capacity of both the research and users in terms of experiences and qualifications that would enable them to carry out rigorous research and translate it in a form that is well understood to the users, while the users should be able to grasp and understand the findings from research.²² In addition, understanding the policy making process is important as it helps the researchers in strategising on how research can influence the process.

The policy making process

A policy is a plan or a guide that can influence decision making for an organisation and can be broad if it articulates a wide direction, it can be more specific in a particular sector such as health, and it can also be operational for guiding decisions for a programme or project.²³ Policies can also be categorised as public policies if they affect the general population and these are mainly made by the government, or they can be private policies made by private organisations.¹⁹ However, the process of policy formulation involves those in leadership to make the best choice among alternatives and it involves how the policies are instigated, framed, discussed, communicated, executed and evaluated.²⁴ This, hence, calls for thorough research analysis and consultations to make recommendations.²³ Lavis et al.²¹ have described the main stages of policy development process and the role of research in each process, which include policy agenda setting, policy formulation, and policy implementation, while policy evaluation is an ongoing activity that feeds and guides the whole process.
The policy agenda setting involves the initial identification of the area to be addressed, which can be a health problem that has been identified through research and instrumental use of research is prominent at this stage.¹⁹ Policy formulation follows next with the purpose of seeking an approach to solving the problem. At this stage, evidence is sought and examined for alternative options and a choice is made on the best option. This becomes the critical stage in research utilisation because the choice to be made affects the population hence the evidence needs to be of high quality and the intervention developed should be practical while taking into consideration contextual factors. Eventually when the formulated policy is put to practice, research can play an important role in validating the best way of implementation. It is also important to recognise that implementation of the policy might be accomplished by organizations other than those that formulated and adopted it hence, successful implementation depends on the involvement of these institutions in the policy development process.
Finally, policy evaluation pertains to providing evidence on how a policy is performing in achieving its objectives. What needs to be evaluated should be clear because some outcomes can either be short or long term. In health policies, long term results such as reduced morbidity and mortality are the most important outcomes.²¹
It must be acknowledged that the policy making process is intricate²⁵ and hence understanding its challenges is crucial in promoting research for policy development. Various barriers to research utilisation range from institutional set up to individuals.²⁶ Haines et al.²⁰ listed potential barriers that may exist in the health care system, patients, practitioner, and the environments of practice, educational, social, and political to research utilisation. Madjedzadeh et al.²⁷ identified and grouped the barriers into four domains that need improvement to maximise research utilisation; improvement in the context, improvement in knowledge creation, improvement in knowledge transfer, and improvement in knowledge utilisation. Hennik, ²⁸ conducted an assessment of barriers and strategies of using research to inform health policy in developing countries such as Malawi. The study indicated that there are common barriers which highlight the existing gap between researchers and policymakers. The specific barriers included the lack of appreciation by policy makers on the contribution of research to policy and program development, poor communication of research findings by researchers, research evidence not addressing the needs of the country, and the challenge within policymakers to seek and synthesize research findings. The best strategy to promote research uptake for policy formulation was revealed when policymakers were involved in the research process and harboured vested interests in the findings. This was clear for commissioned research but a challenge for non-commissioned research. This study has further informed the need of developing a framework to promote malaria research utilisation in policy development as proposed in the current study. It is clear that researchers conducting non-commissioned research find it challenging to contribute to policy because they do not know which policymakers to involve and where to present their findings, beyond academic circles, if they seek to influence policy.²⁸

DECLARATION 
DEDICATION 
ACKNOWLEDGEMENTS 
ABSTRACT 
LIST OF FIGURES 
LIST OF TABLES 
LIST OF ABBREVIATIONS 
CHAPTER ONE  GENERAL INTRODUCTION 
1.1 Introduction
1.2 Study rationale and significance
1.3 Study motivation
1.4 Research objectives
1.5 PhD study conceptual framework
1.6 Study setting and population
1.7 Methods and study design
1.8 Thesis structure
1.9 References
CHAPTER TWO LITERATURE REVIEW 
2.1 Introduction
2.2 Conclusion
2.3 References
CHAPTER THREE  MALARIA RESEARCH IN MALAWI FROM 1984 TO 2016: A LITERATURE REVIEW AND BIBLIOMETRIC ANALYSIS 
Abstract
3.1 Background
3.2 Methods
3.3 Results
3.4 Discussion
3.5 Limitation(s) of the study
3.6 Conclusion
3.7 References
CHAPTER FOUR  MALARIA RESEARCH AND ITS INFLUENCE ON ANTI-MALARIAL DRUG POLICY IN MALAWI: A CASE STUDY 
Abstract
4.1 Background
4.2 Methods
4.3 Results
4.4 Discussion
4.5 Conclusion
4.6 References
CHAPTER FIVE  CHANGING THE POLICY FOR INTERMITTENT PREVENTIVE TREATMENT WITH SULFADOXINE-PYRIMETHAMINE DURING PREGNANCY IN MALAWI 
Abstract
5.1 Background
5.2 Methods
5.3 Results
5.4 Discussion
5.5 Conclusion
5.6 References
CHAPTER SIX FACILITATING FACTORS AND BARRIERS TO MALARIA RESEARCH UTILISATION FOR POLICY DEVELOPMENT IN MALAWI 
Abstract
6.1 Background
6.2 Methods
6.3 Results
6.4 Discussion
6.5 Limitations of the study
6.6 Conclusion
6.7 References
CHAPTER SEVEN  CHALLENGES TO THE IMPLEMENTATION OF MALARIA POLICIES IN MALAWI
Abstract
8.1 Background
8.2 Methods
8.3 Results
8.4 Discussion
8.5 Limitation of the study
8.6 Conclusion
8.7 References
CHAPTER EIGHT DEVELOPMENT OF A FRAMEWORK TO IMPROVE THE UTILISATION OF MALARIA RESEARCH FOR POLICY DEVELOPMENT IN MALAWI
Abstract
7.1 Introduction
7.2 Methods
7.3 Lessons from case studies
7.4 Assessment of facilitating factors and barriers to malaria research evidence for policy development in Malawi
7.5 The Framework
7.6 Conclusion
7.7 References
CHAPTER NINE  GENERAL DISCUSSION AND CONCLUSION 
Recommendations
Limitations
Areas for further research
References
APPENDICES
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