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A software tool to help tackle global health inequality: Health Equity Assessment Toolkit (HEAT)

In an effort to fight global poverty, the United Nations has launched the Sustainable Development Goals project to encourage countries to ‘mobilize efforts to end all forms of poverty, fight inequalities and tackle climate change, while ensuring that no one is left behind’. A major part of this process is ensuring the availability of data on key development indicators to assess inequalities between and within countries and determine how these change over time. Monitoring health inequalities can uncover the effect of health policies, programs and interventions on specific disadvantaged subgroups and involves collecting, analysing, interpreting and reporting various types of health data. This article describes a toolkit developed by the World Health Organisation (WHO) to display and assess the health inequalities in any given country: the Health Equity Assessment Toolkit (HEAT).

HEAT contains data from the WHO’s Health Equity Monitor database which includes information from 94 low- or middle-income countries. The software allows the assessment of inequalities within a country using over 30 reproductive, maternal, new-born and child health indicators and five dimensions of inequality (economic status, education, place of residence, sub-national region and child’s sex) providing information about health interventions and health outcomes. The development of the toolkit marks a huge step forward in the monitoring of health inequalities which could in the future help to inform policy makers and national priority-setting for healthcare.

How does the choice of database affect the results of a meta-analysis?

Systematic reviews are considered the gold standard for knowledge synthesis on healthcare interventions. One of the most important methodological considerations is how the literature is searched, including how many and which bibliographic databases should be used. There is limited quantitative evidence to guide this process, so the authors of this study set out to investigate the effect of selective database searching on the results of meta-analyses. Their study revealed that meta-analysis results generally did not differ significantly when different combinations of databases were searched and that the majority of relevant studies can be found within a limited number of databases. The study provides information which can be used to increase the efficiency of systematic reviews, and provides further guidance for the assessment and development of more recent forms of knowledge synthesis such as rapid reviews.

Why sex and gender matter in implementation science

Researchers are being encouraged more and more to take sex and gender into account when carrying out medical research. This debate article considers the progress that has been made in taking sex and gender into account in implementation science, which considers how research findings are put into practice. A review of the current literature, including assessment of the top ten articles published in the journal Implementation Science in 2015, revealed that few studies mention sex and gender as a consideration. This is despite the fact that there is now guidance on these considerations available from groups such as the Cochrane Collaboration’s Methods Equity group.

The article then goes on to define the difference between sex and gender; the former being a classification based on the biology of the individual (according to genetics, anatomy and physiology) and the latter being a construct that is fluid and influenced by social and cultural context. Whilst biological sex is generally simple to measure, the measurement of an individual’s gender is more nuanced with the authors separating it into four constructs: gender roles, gender identity, gender relations and institutionalised gender. They highlight the need for both the qualitative and quantitative measurement of these factors in order to inform implementation research methods. They describe their importance at multiple points along the implementation process, from the content and messaging surrounding an intervention, to decision making around the uptake of an intervention.

Guidance for evidence mapping methodology

Evidence synthesis methods are used to analyse the literature and gain an overall summary of the results obtained from multiple studies on a specific topic or intervention. The classic methods of meta-analysis and systematic review can be labour intensive and so researchers are investigating ways to simplify this process whilst still maintaining accuracy and rigour. An emerging evidence synthesis method is evidence mapping which can be used as a first step in conducting a broad systematic review and can clarify where there is sufficient evidence to inform policy makers as well as identify research dense areas where systematic reviews could be pursued. Areas where there is a lack of evidence can also be identified, known as research gaps, where further studies may be needed.

There are currently no methodological standards for evidence mapping which led the authors of this study to describe the process and methodology of creating an evidence map database using the topic of low-calorie sweeteners (LCS) and selected health outcomes of interest as an example. With the help of a stakeholder panel, a comprehensive literature search strategy was developed and refined. Outcomes from the studies identified in this search were classified into clinically and biologically meaningful outcome categories which were then analysed to identify how data have been reported on each outcome and where there are research gaps. Assessment of the frequency of publications in each outcome category revealed areas where research outputs increased over specific periods of time. An example of a research gap that was uncovered was the assessment of appetite and dietary intake outcomes using a LCS intervention with a sugar intake comparison in people with diabetes.

The steps presented in this article can be applied to create an evidence map database for any research topic of interest. Through the creation of this database, researchers and practitioners can easily acquire information necessary for decision-making, such as directions for future research and the basis for evidence synthesis, in a fraction of the time needed to conduct comprehensive literature reviews.

How to be both a clinician and a researcher

Health research is frequently carried out in a clinical setting with clinicians being directly involved in the research process. This brings many benefits including increasing the clinical relevance of research questions, gaining access to clinical settings for research, and bringing clinical expertise and insider perspectives. However, there are ethical and methodological implications that should be considered when clinicians undertake a research role. In this study, the authors systematically reviewed published articles looking at the clinician-researcher dual-role and summarise the key findings from the literature.

The main finding was that clinician-researchers cannot adopt a wholly non-clinical research identity. This was attributed to the fact that it was not possible to maintain a strict researcher-participant relationship when the participant had previously been treated as a patient by the clinician-researcher. Consciously and subconsciously, the clinician and patient roles are present in the research setting, creating shared ground and a connection that resembles a clinician-patient relationship. Clinicians also described their struggles with separating themselves from the clinical role when carrying out research, suggesting that there are deep rooted characteristics which cannot be shed when a clinician moves into a research context. The authors recommend that clinician-researchers should be encouraged to accept and explore the factors surrounding the dual-role phenomenon, consider both roles throughout the research process, and ensure that clinical and research roles are not artificially separated in research protocols, ethics applications, and research practice.