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EDITORIALS

If not now, when? Time to focus on “evidence to impact”

Pilla, Bianca1; Scott, Anna M.2; Jordan, Zoe1

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doi: 10.11124/JBIES-20-00373
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The current year will be etched into our collective memories forever. A year in which we have witnessed and experienced one of the deadliest viruses in recent history resulting in hundreds of thousands of deaths. A year where countries across the world closed their borders, but opened their hearts. The health care and health research communities in particular have rallied in impressive fashion in an endeavor to protect those at risk, to care for those who suffer, to develop a vaccine, and to identify evidence to inform policy and practice decisions for COVID-19.

We have, however, in many instances, been forced to detour or pivot our activities this year, to make difficult choices about where to place our focus, and perhaps not surprisingly, a significant proportion of our energies have been redirected toward the current COVID-19 crisis. It is important not to lose sight of that fact that other equally devastating global health priorities remain, and it would be remiss of us to discontinue our efforts to address them. Diseases like tuberculosis, Ebola, yellow fever, and even measles continue to ravage vulnerable populations, so there is a risk in pivoting too far. Ischemic heart disease continues to be one of the leading causes of death globally, along with stroke, Alzheimer disease, and diabetes, to name a few. As a global evidence-based health care (EBHC) community, the efforts to scale up the immediate health response to address COVID-19 cannot be disconnected from other global health priorities.

As we have observed this year, it is not always feasible (or indeed appropriate) to wait for what has historically been deemed “gold-standard” evidence. Now, more than ever, we see the value, the necessity, of having access to the best available research evidence. “Best available” is an important distinction to make. This year, the need to embrace multiple epistemic frameworks and methods to cope with the uncertainty and unpredictability of situations, such as the global pandemic we are currently living through, has been highlighted.1 It is of critical importance that we collectively acknowledge the limitations of evidence in situations where it simply does not exist. However, taking a more nuanced approach to appraising the utility of diverse types of evidence is also required, as the difficult decisions being faced by health professionals and policymakers currently are questions that the evidence does not address with certainty.2 Not all types of evidence can answer the same questions, and in the absence of what is typically deemed the highest-quality evidence, other sources simply must be consulted. We have never been better positioned to drive the evidence-based agenda forward.

World EBHC Day (https://worldebhcday.org/) is an opportunity to keep evidence, and the role it plays, front of mind as we move forward in navigating new ways of solving old problems. There are many who are cynical about the value of EBHC, but perhaps this cynicism flows from outdated constructions of what EBHC means in today's context. In 2020, we continue to face considerable health challenges globally; we continue to conduct research in an attempt to overcome the burden of diseases, inefficient health systems, and other health issues; and there is a persistent need to be able to evaluate and collate the results of research to inform clinical, policy, and community decisions. The importance of having the ability to utilize the best available evidence has not diminished. This has never been more evident than with the implementation of more robust handwashing and use of personal protective equipment (PPE) in the community, which has not simply helped to fight the spread of COVID-19, but also other influenza and seasonal viruses more broadly.

Of equal importance is the ever-increasing need to establish impact measures in relation to EBHC, hence the theme for this year. Internationally, there is increasing pressure to demonstrate the impact of EBHC, including the synthesis, transfer, and implementation of research evidence through improvements in health care policy, practice, and patient outcomes to substantiate value to funding organizations and the wider community.3

While progress has been made in measuring the outcomes of EBHC and the processes and activities through which these are achieved, it has not been without its critics.4 Traditional impact assessment frameworks that consider the linear progression of inputs (funding), activities (research), outputs (guidelines, policy), and outcomes (changes to practice) leading to impact are increasingly viewed as overly simplistic.5 This is because the evidence ecosystem is a complex and unstable network of people and technologies,6 with different processes, individuals, and organizations involved.7 Ultimately, outcomes are often slow to emerge, hard to quantify, and sometimes unexpected.

There are emerging frameworks that adopt the concept of contribution rather than attribution, acknowledging the numerous complex, nonlinear factors influencing outcomes, including the transfer and implementation of research evidence. Contribution frameworks provide a practical way of looking at how research and knowledge translation activities interact with other drivers to create change, including contextual factors that help or hinder research impact.6,8 They also acknowledge that impact can be measured at various points, creating opportunities for ongoing learning and evaluation, as opposed to the traditional view that impact is only visible at the end of the pathway, which can be long and winding.

While traditional metrics tend to focus on direct, causal impacts, there are also indirect and diffuse elements of the evidence-to-impact link that can and should be measured4 (ie, in a low- to middle-income country context, where the process of doing research may itself have positive externalities, for example, related to capacity-building for research or building the skills of the health workforce).

Most, if not all of us, are motivated by the aspiration that our research will make a real difference in the world we live in. To achieve this, we have our work cut out for us and sometimes it seems a Herculean challenge to ensure that research is relevant, timely, and conducted in ways that produce trustworthy, reliable evidence. Nevertheless, the pursuit of better health cannot be achieved without the contribution of those discerning researchers who seek to find answers and those who hold them accountable for demonstrating impact. So the question remains, if we do not choose to make impact (and impact measurement) a critical area of focus now, then when?

References

1. Greenhalgh T. Will evidence-based medicine survive COVID-19? [Internet] Boston Review; 2020 [cited 2020 Aug 24]. Available from: http://bostonreview.net/science-nature/trisha-greenhalgh-will-evidence-based-medicine-survive-covid-19
2. Porritt K, Lockwood C. Does facing the challenges of a global pandemic require more than evidence? JBI Evid Synth 2020; 18 (5):857–858.
3. Milat AJ, Bauman AE, Redman S. A narrative review of research impact assessment models and methods. Health Res Policy Syst 2015; 13 (1):18.
4. Greenhalgh T, Raftery J, Hanney S, Glover M. Research impact: a narrative review. BMC Med 2016; 14 (1):78.
5. Greenhalgh T, Snow R, Ryan S, Rees S, Salisbury H. Six ‘biases’ against patients and carers in evidence-based medicine. BMC Med 2015; 13 (1):200.
6. Kok MO, Schuit AJ. Contribution mapping: a method for mapping the contribution of research to enhance its impact. Health Res Policy Syst 2012; 10 (1):21.
7. Cohen G, Schroeder J, Newson R, King L, Rychetnik L, Milat AJ, et al. Does health intervention research have real world policy and practice impacts: testing a new impact assessment tool. Health Res Policy Syst 2015; 13 (1):3.
8. Morton S. Progressing research impact assessment: a ‘contributions’ approach. Res Eval 2015; 24 (4):405–419.
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