ARTÍCULO DE REVISIÓN / REVIEW
A systematic review of nursing research priorities on health system and services in the Americas
Revisión sistemática de las prioridades de investigación de enfermería en sistemas y servicios de salud en la Región de las Américas
Alessandra Bassalobre GarciaI; Silvia Helena De Bortoli CassianiI; Ludovic ReveizII
IHealth Systems and Services Department, Human Resources for Health Pan American Health Organization, Washington DC, United States of America. Send correspondence to Silvia Helena De Bortoli Cassiani, firstname.lastname@example.org
IIKnowledge Management, Bioethics, and Research Department, Pan American Health Organization, Washington DC, United States of America
OBJECTIVE: To systematically review literature on priorities in nursing research on health systems and services in the Region of the Americas as a step toward developing a nursing research agenda that will advance the Regional Strategy for Universal Access to Health and Universal Health Coverage.
METHOD: This was a systematic review of the literature available from the following databases: Web of Science, PubMed, LILACS, and Google. Documents considered were published in 2008-2014; in English, Spanish, or Portuguese; and addressed the topic in the Region of the Americas. The documents selected had their priority-setting process evaluated according to the "nine common themes for good practice in health research priorities." A content analysis collected all study questions and topics, and sorted them by category and subcategory.
RESULTS: Of 185 full-text articles/documents that were assessed for eligibility, 23 were selected: 12 were from peer-reviewed journals; 6 from nursing publications; 4 from Ministries of Health; and 1 from an international organization. Journal publications had stronger methodological rigor; the majority did not present a clear implementation or evaluation plan. After compiling the 444 documents' study questions and topics, the content analysis resulted in a document with 5 categories and 16 subcategories regarding nursing research priorities on health systems and services.
CONCLUSIONS: Research priority-setting is a highly important process for health services improvement and resources optimization, but implementation and evaluation plans are rarely included. The resulting document will serve as basis for the development of a new nursing research agenda focused on health systems and services, and shaped to advance universal health coverage and universal access to health.
Key words: Health research agenda; health services research; health systems; nursing staff; public health; Americas.
OBJETIVO: Revisar sistemáticamente la bibliografía sobre las prioridades de investigación de enfermería en materia de sistemas y servicios de salud en la Región de las Américas, como un paso más en la elaboración de un programa de investigación de enfermería que impulse la Estrategia Regional para el Acceso Universal a la Salud y la Cobertura Universal de Salud.
MÉTODOS: Se llevó a cabo una revisión sistemática de la bibliografía disponible en las siguientes bases de datos: Web of Science, PubMed, LILACS y Google. Se tuvieron en cuenta los documentos publicados del 2008 al 2014 en inglés, español o portugués, y que trataran del tema en el ámbito de la Región de las Américas. En los documentos seleccionados se evaluaron los procesos de establecimiento de prioridades según los "nueve temas comunes para buenas prácticas en establecimiento de prioridades de investigación de salud". Mediante un análisis de los contenidos se recopilaron todas las preguntas y temas de estudio, y se clasificaron los documentos por categorías y subcategorías.
RESULTADOS: De los 185 artículos o documentos de texto completo evaluados, se seleccionaron 23: 12 procedían de revistas con revisión por pares, 6 de publicaciones de enfermería, 4 de ministerios de salud y 1 de una organización internacional. Las publicaciones de las revistas mostraron un mayor rigor metodológico; la mayoría no presentaba un plan definido de ejecución o evaluación. Después de compilar las 444 preguntas y temas de estudio de los documentos, el análisis de los contenidos dio lugar a un documento con 5 categorías y 16 subcategorías con respecto a las prioridades de investigación de enfermería en materia de sistemas y servicios de salud.
CONCLUSIONES: El establecimiento de prioridades de investigación es un proceso muy importante para la mejora de los servicios de salud y la optimización de los recursos, pero raramente se incluyen planes de ejecución y evaluación. El documento resultante servirá de base para la elaboración de una nueva agenda de investigación de enfermería centrada en los sistemas y servicios de salud, y configurada para impulsar la cobertura universal de salud y el acceso universal a la salud.
Palabras clave: Agenda de investigación en salud; investigación sobre servicios de saud; sistemas de salud; personal de enfermería; salud pública; Américas.
At the October 2014 meeting of the Directing Council of the Pan American Health Organization (PAHO), Member States approved the "Regional Strategy for Universal Access to Health and Universal Health Coverage" (1). The Strategy defined universal access as "the absence of geographical, economic, sociocultural, organizational, or gender barriers," and health coverage as "the capacity of the health system to serve the needs of the population, including the availability of infrastructure, human resources, health technologies (including medicines) and financing" (1). The approved document would guide the transformation of health systems toward universal coverage. In addition, the Strategy stated that "developing an adequately financed research agenda and better knowledge management are essential elements in order to address social determinants of health, ensure access to quality services, incorporate technology, and evaluate the effectiveness of implemented actions and programs" (1). It is important to understand the concepts of Universal Access to Health (UAH) and Universal Health Coverage (UHC) in this context because success is contingent upon public health leaders fairly and equitably prioritizing health actions (2).
PAHO is committed to promoting and fostering further development of a research agenda for health systems and services that is based on both UAH and UHC (3). The 2013 World Health Report by the World Health Organization (WHO) focused precisely on research for UHC. Such research could develop and strengthen health systems by investigating, for example, financial risk protection or coverage and quality of health services, which would also contribute to the Millennium Development Goals (MDG) and the post-2015 Development Agenda (4-5). Since there are still many more questions than there are answers, it is profoundly important to set priorities (4). Furthermore, both the WHO Strategy on Research for Health and the PAHO Regional Policy on Research for Health have made setting research standards one of their main goals (6-7).
The science of nursing has been the subject of rigorous research, yet there are some important inequalities regarding the capacity of nurses to conduct research and to implement new evidence into their everyday practice. Nonetheless, while the number of publications on nursing research has importantly increased in the last decade, a lower proportion was produced regarding health services and systems research (8-11). Public health services and systems research is a field of investigation that has progressively gained more attention during the last decade (12-14). Nursing health professionals will play an important role in strengthening health systems and services performance and advancing UAH and UHC, people-centered health care, and workforce management and partnerships (15).
The study objective was to systematically identify and evaluate literature on priorities in nursing research on health systems and services in the Region of the Americas. This is a first step toward developing a nursing research agenda focused on health systems and services that will advance the Regional Strategy for Universal Access to Health and Universal Health Coverage.
MATERIALS AND METHODS
Sources and search strategies
A systematic search was conducted in March-June 2014 and followed the methods proposed by Whittemore and Knafl (16). To guide the systematic review, the study question set was: "Are there priority nursing research agendas focused on health systems and services or public health?"
The literature search included the following databases: PubMed (National Library of Medicine, Bethesda, Maryland, United States); Web of Science (Thomson Reuters, New York City, New York, United States) and LILACS (Latin American and Caribbean Center on Health Sciences Information, São Paulo, Brazil) for peer-reviewed literature; and Google (Google Incorporated, Mountain View, California, United States) for gray literature. The search terms for PubMed and Web of Science were based on MeSH (Medical Subject Headings) and text terms, and for LILACS on DeCS (Descritores em Ciências da Saúde) terms (see Appendix 1). For Google searches, the terms used were "Nursing Research Priorities" (in English, Spanish, and Portuguese), "Agenda Nacional de Prioridades de Investigación en Salud" (in Spanish and Portuguese), and "Agenda de Investigación en Salud Pública" (in Spanish and Portuguese). In addition, an Internet-based search of the official websites of health-related institutions was conducted to identify national health research policies and priority agendas in Latin American and the Caribbean (LAC) countries; documents in the bibliographies of existing materials were also reviewed. The search strategy limits were restricted to studies published in the last 5 years (2008-2013) and in English, Spanish, or Portuguese; however, for the Google searches, a date range was not applied.
In the first screening, the titles and abstracts of all the resulting documents were read. To decide which documents and papers would be read in their entirety, and which would be included in the final sample, the researchers applied the following inclusion criteria to each report or paper: 1) It addresses nursing research priorities focused on primary health care systems and services or public health; AND 2) It explicitly formulates research priorities on nursing and/or health systems and services; AND 3) It is related to the Region of the Americas, or on a global scale that includes the Region. If a document met these criteria, the bibliography was reviewed to ensure that all pertinent material was being examined.
Information gathered through the systematic review was managed in Microsoft ExcelTM (Microsoft Corp., Redmond, Washington, United States) and is described according to the database, year of publication, title of the document, and journal/source of publication.
The final sample of documents was analyzed using "the nine common themes of good practices for health research priority setting" (17). The quality of the domains was identified based on: preparatory work (context, use of a comprehensive approach, inclusiveness, information gathering, and planning for implementation); deciding on priorities (criteria and methods for deciding on priorities); and after priorities have been set (evaluation and transparency).
To gather information on priorities for health systems and services research, each document's study questions and topics were compiled and a content analysiswas conducted. Documents were then read thoroughly and a brainstorming session followed to sort them into categories and subcategories.
The database searches resulted in 1 796 documents, as shown in Figure 1. The title and abstract of each document were screened, resulting in 185 full-text articles/documents that were assessed for eligibility. The final selection of 23 documents (12, 14, 18-38) was examined thoroughly.
Despite the broad search of scientific databases, Google results offered the greatest number of important documents regarding health research priorities (Table 1); and although most of these were not peer-reviewed, they shared worthy points of view and strong research expertise from Ministries of Health, nursing associations, councils, and networks. In terms of peer-reviewed publications, LILACS database held the greater number compared to PubMed and Web of Science, in part because its is specific to Latin America and the Caribbean, a fact favored by this study's selection criteria.
As expected, many of the studies and nursing associations' documents were related to North America. Of the 23 documents, 10 (43.5%) regarded or discussed North America, mainly nursing associations and networks. Surprisingly, only 4 documents were related to national agendas and focused specifically on health systems and services research: those of Bolivia, Brazil, Guatemala, and Panama (25, 33, 35, 36).
Regarding assessment of research agendas using the "nine common themes of good practices for health research priority setting" (17) displayed in the Table 2, there were a variety of methods used by journal publications and non-peer-reviewed ones. The former presented a higher level of rigor and frequently combined consensus and metrics approaches when setting priorities; the latter were generally related to consensus methods, sometimes not clearly described.
Equally importantly, most of the agendas did not include adequate implementation and evaluation plans, even those that were peer-reviewed. This was the most important gap found regarding priority-setting methods. Furthermore, 13 of the 23 documents analyzed did not report or were unclear regarding their criteria for the priority-setting process. Yet, one positive finding was that the national agendas and policy strategies (25, 33, 35, 36) and the international organization document (22) involved a wide range of stakeholders in the priority-setting process. Additionally, two references (21, 23), whose objectives did not include setting an agenda, were included despite not meeting some of the instrument evaluation domains because they discussed research priorities on health systems and services in the Americas and displayed its topics, thus meeting all the inclusion criteria.
It became evident during the content analysis that most of the 23 selected documents addressed topics with common themes, making the categorization process relatively straightforward. In addition, the number of research topics and questions retrieved allowed the researches to carry out a wide analysis of health systems and services research priorities. The study questions and topics extracted from the selected documents resulted in a new document with 444 study questions and topics sorted into five categories and 16 subcategories (Table 3).
As expected, articles published through a peer-reviewing process, such as a journal employs, demonstrated a higher level of scientific rigor than others. Almost all of these included complete descriptions of the context and methods-related characteristics (comprehensive approach, inclusiveness, information gathering, criteria, and priority-setting method) (17). On the other hand, most of the nursing association, council, and network documents lacked several important methodological factors, such as selection criteria, information gathering, and priority-setting method (17).
Selection criteria plays an important role in setting priorities, and most of the documents were similar in this regard. In brief, they each included characteristics of the problem (magnitude, severity, burden, quantity, and quality of scientific evidence available on the topic); reality of the context (ethical, cultural, political, financial feasibility, and cost-effectiveness of the proposed research); and possible impact (level of resulting evidence and to what extent the answers to certain study questions would add to social well-being and contribute to the development of solutions for health system and services issues). Nonetheless, more than 50% of the documents presented unclear selection criteria and some did not report any at all, which undermines evidence of their priority-setting methods (39).
Another important observation was that most agendas did not present an implementation and/or evaluation plan, obviously creating a challenge for effectively launching its recommendations or monitoring progress. Given that health systems and services are extremely complex social structures-multi-layered, nonlinear, and highly sophisticated-linear approaches, such as cause-effect analysis, are often useless; furthermore, research is often conducted in a continuously changing and politically affected environment (40).
An agenda that lacks planning will face enormous barriers when applied, and some broadly recognized health systems' issues are ineffectively addressed for this reason. For example, human resources for health, considered to be a central issue to health systems and services research, have often failed to address the nursing profession. The unequal distribution and lack of nurses in some LAC countries (34) urge researchers to seek effective solutions for dealing with this deficit.
The documents related to national research agendas (25, 33, 35, 36) showed greater stakeholder involvement by including health institutions, universities, research centers, and practitioners from both public and private sectors, governmental entities, and community and/or civil society representatives in their priority-setting processes. Stakeholder participation is pivotal for successfully implementing a research agenda and for securing financial support from research funding agencies.
Even so, two (35, 36) of the four national agendas lacked important methodological items, such as information gathering strategies and a complete description of priority-setting methods and criteria. A study comparing LAC countries' research agendas indicated that there is no gold standard for setting health research priorities and that the quality of priority setting methods could be improved in future agendas (41).
Moreover, low- and middle-income countries should be encouraged to use standard approaches to priority-setting, yet shape them specifically to their context (42). Any improvement in their priority-setting method could greatly contribute to international cooperation between countries with shared research priorities and health systems arrangement (41). To do so, national capacity for health systems research (40) should be bolstered-one of the main strategies that WHO has in place for developing health research (43).
Regarding UAH and UHC, some of the studies (12, 14, 20, 21, 23-25, 29, 34, 37) touched on health access for the whole population, but only briefly and without addressing issues directly related to these concepts. Only one document assessed presented insights on UHC and its relationship to research priorities (27). In spite of that, the countries' decisions to pursue UHC should be promoted, especially since it directly contributes to a nation's development, and indirectly, to the overall well-being of the population, in addition to beneficial economic effects (2).
Despite the differences among countries in the Region of the Americas, the criteria set in this review allowed for inclusion of studies from all contexts. This permitted gathering a broad range of study topics that would help build a prospective agenda with a high degree of transferability. This is important because transferability is another limitation for health systems and services research agendas given the different social, economic, political, geographical, and cultural contexts among nations (40). In this regard, a wider review approach could bridge, at least in part, this issue, ensuring the proper coverage and quality to the document.
Even though a variety of study questions/topics was identified, it became clear that some documents focused on particular areas of research (14, 22, 24, 27) that seem to be of higher priority, such as "Human Resources for Health" and "Health Systems and Services Financing" (see categories in the Table 3). In addition, even the documents that did not deal directly with these two priorities did tend to touch on them in some way.
Furthermore, other topics shown in Table 3 tended to be broadly discussed by the documents found, including those related to the categories of "Science, Technology, Innovation, and Information Systems," and "Health Systems and Services Structure, Organization, and Dynamics." On the other hand, issues concerning the category of "Health Policies, Governance, and Social Control" were presented as study topics by only a few documents (21, 25, 26, 34, 36).
Besides that, although many of the documents collected in this systematic review were related to the United States, the participation of Latin American experts and well-established criteria for rating, ranking, or changing the study questions might adapt the priority-setting process to the LAC area and focus on UAH and UHC.
Research priority-setting is an important process for health services improvement and resources optimization. However, implementation and evaluation plans are equally important for effective operationalization and enhancement of the research agenda. The findings of this study are expected to encourage best practices on the development of nursing research agendas regarding health systems and services, particularly well-defined impact objectives and assessment possibilities. This document will serve as basis for developing a Regional nursing research agenda focused on health systems and services, yet shaped to advance Universal Access to Health and Universal Health Coverage. Due to the wide variety of research topics and questions captured in this resulting document, the prospective agenda will be suitable to any country of the Region of the Americas, and any country will be able to adjust the agenda to its health systems and services context.
Disclaimer. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the Pan American Health Organization.
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Manuscript received on 4 December 2014
Revised version accepted for publication on 18 February 2015
APPENDIX 1: Search Strategies
(("Health Priorities" OR "Research Priorities" OR agenda [tw] OR Priority [tw] OR Priorities [tw]) AND ("Health Services Research" OR research OR "research topics") AND (Nursing OR Nurses OR "Primary Care Nursing" OR "Public Health Nursing" OR "Nursing Research" OR "Nursing Staff" OR "Faculty, Nursing" OR "Education, Nursing" OR "Community Health Nursing" OR "Continuing Nursing Education" OR "Nursing Education Research" OR "Nursing Services") AND ("Public health" OR "Health Services" OR "Community Health Planning" OR "Community Health Services" OR "Health Personnel" OR "Health Education" OR "Continuing Education" OR "Education, Public Health Professional" OR "Staff Development" OR "Human Resources Development" OR "Health Manpower" OR Manpower OR "Health Services Accessibility" OR "Delivery of Health Care, Integrated" OR "Healthcare Delivery" OR "Health Care Systems" OR "Health Policy" OR "National Health Policy"))
(("Prioridades en Salud" OR "Prioridades de Investigación" OR "Agenda de Prioridades en Salud") AND ("Investigación sobre Servicios de Salud" OR Investigación) AND (Enfermería OR "Atención de Enfermería" OR "Investigación en Enfermería" OR "Enfermería de Atención Primaria" OR Enfermería en Salud Comunitaria" OR "Enfermería en Salud Pública" OR "Enfermeras de Salud Comunitaria" OR "Educación en Enfermería" OR "Educación Continua en Enfermería" OR "Educación de Postgrado en Enfermería" OR "Personal de Enfermería" OR "Investigación en Ed ucación de Enfermería" OR "Servicios de Enfermería") AND ("Salud Pública" OR "Servicios de Salud" OR "Personal de Salud" OR "Recursos Humanos en Salud" OR "Técnicos Medios en Salud" OR "Educación en Salud Pública Profesional" OR "Sistemas de Salud" OR "Servicios Preventivos de Salud" OR "Cobertura de los Servicios de Salud" OR "Servicios Básicos de Salud" OR "Servicios de Salud Comunitaria" OR "Agentes Comunitarios de Salud" OR "Educación en Salud" OR "Planificación en Salud Comunitaria" OR "Prestación de Atención de Salud" OR "Política de Salud" OR "Políticas, Planificación y Administración en Salud" OR "Política de Investigación en Salud" OR "Política de Educación Superior" OR "Políticas Públicas de Salud"))