The study takes its point of departure in a widespread notion that decisions should be based on the ‘facts of the matter’. Normative theories of organizational choice, in particular, encourage organizations to base decisions on facts. Many organizations also face explicit requirements to justify their decision-making with factual knowledge. But what if ‘the facts’ are ambiguous? How do organizations make justifiable decisions with ambiguous knowledge? A study of efforts on the part of the Swedish Pharmaceutical Benefits Board to decide whether prescription drugs are ‘reasonable’ to subsidize, suggests that organizations can employ various methods to remove ambiguity of knowledge. However, such attempts at achieving coherent knowledge on which to base decisions often fail. In these cases, though a decision can be made, the choice of one future action to the exclusion of others is delegated – along with the unresolved ambiguity of knowledge. Thus, the study argues that rationalistic demands for ‘knowledgeable’ and ‘justifiable’ decision outcomes, when taken seriously, make it difficult to make choices. Such demands lead to more decisions and fewer choices, since the difficulty in achieving coherence between multiple knowledge claims will delegate the actual choices to practice. Knowledge-based decision-making could therefore tend to be conservative vis-à-vis the practices that it seeks to control. This has, for instance, implications for the possibility of using ‘evidence-based policy-making’ as a means of setting priorities in healthcare. / Diss. Stockholm : Handelshögskolan i Stockholm, 2006

In this thesis, priority setting to the form of the Swedish parliamental decision on priority setting, 1997, is considered an innovation for implementation in health care. The features of this innovation are investigated. The practical implications of implementation are identified by investigating the user organisation, ie, Swedish health care organisations and management systems. Also, a case of a three-stage process for macro-level priority setting that engaged the entire organisation in the Västerbotten County Council (VCC) is presented. This is done against a background of preceding implementation efforts in the VCC. Four specific research efforts and papers are presented. In Paper I, priority setting is operationalised into a multi-dimensional resource allocation task. On that basis, with the help of interviews (1998) and surveys (2002 and 2005) primarily of VCC health care managers, the impact of implementation is measured by prioritisation structures, processes and decisions. Survey response rates were low. Results were used as qualitative data, internally compared, and interpreted as: a) responses reflected mainly “early adopters’” opinions; b) priority setting is an ambiguous concept; c) indicating limited overall implementation; d) reinterpretation of the prioritisation task occurred over time among respondents; and, e) this group took increasingly personal responsibility as stakeholders in priority setting. Paper II reports a case study intervention of explicit, departmental level priority setting with the aim of improving cost-effectiveness in in vitro fertilization resource use and a rationing of services perceived legitimate by all stakeholders. The intervention combined priority setting and structured quality improvement techniques. Results were: a) improved operational efficiency of diagnostic procedures that allowed resources to be reallocated to treatment; and b) patients were prioritized and treatment resources were rationed based on evidence of treatment effect among subgroups. Evaluation showed that the procedure met stated criteria for legitimacy. In Paper III, a full-format test of the macro level prioritisation process is described and evaluated by participants with the help of surveys after each completed stage. Participants report the need for improvement of elements in the overall process and of procedural specifics. However, overall there was a strong commitment to the initiative and satisfaction with the process and the resulting decisions. In Paper IV, procedural specifics of the prioritisation process are evaluated. They are also compared to the Program Budgeting and Marginal Analysis (PBMA) framework when used for macro level purposes. Procedures provided intended results such as vertical and horizontal priority setting and a consistent process. However, economic targets were not fully achieved in any of the stages. Conclusions include that health care management systems are not prepared for priority setting and need profound restructuring and that the prioritisation process described in Papers III and IV was successful because: a) the process satisfied politicians’ directives; b) participants were satisfied with the procedures and perceived the subsequent reallocation decisions as legitimate; and, c) methods resulted in the intended outcome. Factors suggested as the basis of success include: long-term overall preparations; broad and deep participation; a readiness for change among participants; a stage for horizontal priority setting that added to the quality, feasibility and perceived validity of the knowledge base; a strong process leadership; and politicians determined to protect the process from opportunistic disturbances.

This thesis examined factors that influence three Canadian Nursing Associations’ priority setting and policy advocacy for community environmental health (CEH). The research questions that guided the study were: (a) how do the nature and scope of nursing organizations’ engagement for CEH policies differ according to provincial and federal contexts? and (b) how do nursing organizational factors and external system factors influence the priority-setting and policy advocacy choices for CEH policy? To answer these questions I undertook a qualitative comparative case study. The research was guided by epistemological and methodological principles of interpretative description and informed by whole-systems socio-ecological theory and institutional theory. Data were collected through participant interviews (n=41) and document review. Guided by framework analysis and the use of descriptive and conceptually-oriented matrices, cases were analyzed using an iterative and inductive approach to identify case patterns. These case patterns were then compared to identify cross-cutting factors that influence the Nursing Associations’ priority setting and policy advocacy for CEH. Key findings are represented in an integrated conceptual framework. Nursing Associations’ priority setting and policy advocacy are embedded in a dynamic policy field whereby structures and institutional pressure both create opportunities and narrow the Nursing Associations’ options for engaged CEH advocacy. The findings lead to recommendations for practice, policy, and research that have relevance for the profession, nursing associations, and policy decision-makers.

Background During the 1990s, Tanzania, like many other developing countries, adopted health sector reforms. The most common policy change under health sector reforms has been decentralisation, which involves the transfer of power and authority from the central levels to the local governments. However, while decentralisation of health care planning and priority-setting in Tanzania gained currency in the last decade, its performance has, so far, been less than satisfactory. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority-setting in district health management were studied through action research. As part of this overall project, this doctoral thesis aims to analyse the existing health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness approach to priority setting in Tanzania. Methods A qualitative case study in Mbarali district formed the basis of exploring the socio-political and institutional contexts within which health care decision-making takes place. The thesis also explores how the Accountability for Reasonableness intervention was shaped, enabled and constrained by the interaction between the contexts and mechanisms. Key informant interviews were conducted with the Council Health Management Team, local government officials, and other stakeholders, using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting processes in the district were observed. Main findings The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The findings showed that decentralisation, in whatever form, does not automatically provide space for community engagement. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. In addition, the thesis found that while the Accountability for Reasonableness approach to priority setting was perceived to be helpful in strengthening transparency, accountability, stakeholder engagement and fairness, integrating the innovation into the current district health system was challenging.   Conclusion This thesis underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context, can lead to better prediction of the effects of the innovation, pinpoint stakeholders’ concerns, and thereby illuminate areas requiring special attention in fostering sustainability. Additionally, the thesis stresses the need to recognise and deal with power asymmetries among various actors in priority-setting contexts.

Systematic reviews - appraisal and synthesis of all primary research - are increasingly being used to inform policy and practice in health care. Therefore, it is important to understand how the key questions in systematic reviews are identified and prioritised and whether they are relevant to policy makers, practitioners and members of the public. Research priority setting (RPS) is usually defined as any interpersonal activity that leads to the selection of topics and/or choices of key questions to investigate . Diverse approaches to setting research priorities are used in different countries, regions and organisations. There is no consensus in the literature on the most effective processes with which to set these priorities. However, these decisions define the quality and implications of the evidence, and syntheses of it, available to patients, public and policy makers to help them make informed decisions. My initial scoping work, was to design and conduct a survey across an influential international systematic review organisation (Cochrane Collaboration ) on how they set priorities for their reviews. We identified 13 structured approaches to setting priorities. As part of the project, we developed an evaluation framework that demonstrated whether the priority setting processes meet the values and principles of the Cochrane Collaboration. Subsequently, we developed an equity lens for research priority setting exercises to inform the design of research priority setting processes to ensure that they consider the priorities of disadvantaged groups along with advantaged groups. We used the equity lens to do a second evaluation on the priority setting processes in the Cochrane Collaboration. Both evaluation frameworks demonstrated that the Cochrane Collaboration requires better designed priority setting approaches and must be more transparent in reporting those processes. The evaluation of research priority setting exercises in the Cochrane Collaboration, along with the wider literature, demonstrates that research priority setting exercises cannot be evaluated in isolation from organisational cultures, values and context. Therefore, the next step of the project focused on a specific stakeholder group (major research funders) with significant influence on research, including support for systematic reviews. We selected 11 national research agencies in the UK, Netherlands, France, Norway, Denmark, Germany, Australia, Canada, and the USA. We devised and used a checklist based on Chalmers and Glasziou’s “avoidable research waste” framework (and evaluated the processes and policies of these agencies using this checklist). As previous evaluations had demonstrated, this second evaluation found a lack of transparency in the process of setting priorities for research and other related organisational and policy issues. Increased funding is needed for methodological research to evaluate research practices and to monitor how funding research projects is done and reported. My evaluation of funding agencies and the Cochrane Collaboration found a similar lack of transparency and accountability in the context of conflicting values among stakeholders that decreases accountability and scrutiny of researchers and their institutions. However, the projects have led to organisational and policy changes in the two key stakeholder groups (the Cochrane Collaboration and selected funding agencies). Officials of national health research funding agencies have approached me to collaborate with them to address the issues raised by my work on reducing research waste. This led to the establishment of Funders Forum - the Ensuring Value in Research (EViR) Funders’ Collaboration and Development Forum - to enable agencies in various countries to exchange their experience in addressing issues and creating work groups to address them. The Forum is chaired by individuals from three major research funders: NIHR (UK), ZonMW (Netherlands) and Patient-Centered Outcomes Research Institute (PCORI; USA). The Forum organises several meetings to establish common principles, standards and work plans to achieve the common objective around reducing research waste and adding value for research for a national research funder.

For her MPH thesis research, Alex Kent conducted secondary analysis of data from the Equity Lens in Public Health (ELPH) research program to explore whether and how Indigenous health equity is prioritized within one regional health authority [HA100] in British Columbia’s public health system. Her thesis addresses the question: How has Indigenous health equity been identified and prioritized within HA100 as reflected in core documents and plans as well as interviews with key decision makers in the health authority? Using the Xpey’ Relational Environments Framework, a theoretical framework designed by Drs. Charlotte Loppie and Jeannine Carriere, Alex identifies and discusses the physical and theoretical settings where Indigenous health equity is and is not manifested in the public health system. Her findings highlight a number of examples of how HA100 has implemented successful strategies aimed at enhancing Indigenous health equity as well as several areas for improvement across the relational environments. Alex concludes that improving Indigenous health equity through human, non-human and symbolic interactions in institution, system and community settings appears to be a current priority for HA100; whereas reconciling historical relationships and creating equitable social, cultural and political conditions that promote optimal health and wellbeing for Indigenous peoples is positioned as a long-term and indirect goal. / Graduate

This thesis examined factors that influence three Canadian Nursing Associations’ priority setting and policy advocacy for community environmental health (CEH). The research questions that guided the study were: (a) how do the nature and scope of nursing organizations’ engagement for CEH policies differ according to provincial and federal contexts? and (b) how do nursing organizational factors and external system factors influence the priority-setting and policy advocacy choices for CEH policy? To answer these questions I undertook a qualitative comparative case study. The research was guided by epistemological and methodological principles of interpretative description and informed by whole-systems socio-ecological theory and institutional theory. Data were collected through participant interviews (n=41) and document review. Guided by framework analysis and the use of descriptive and conceptually-oriented matrices, cases were analyzed using an iterative and inductive approach to identify case patterns. These case patterns were then compared to identify cross-cutting factors that influence the Nursing Associations’ priority setting and policy advocacy for CEH. Key findings are represented in an integrated conceptual framework. Nursing Associations’ priority setting and policy advocacy are embedded in a dynamic policy field whereby structures and institutional pressure both create opportunities and narrow the Nursing Associations’ options for engaged CEH advocacy. The findings lead to recommendations for practice, policy, and research that have relevance for the profession, nursing associations, and policy decision-makers.

Resource withdrawal from unnecessary medical services is an important issue as the cost of health care continues to rise. In many countries, resource withdrawal is primarily determined by government policies that remove, restrict, reduce, or limit the availability of publically insured medical services. Ideally, resource withdrawal is the result of a careful assessment of clinical and economic evidence regarding a service’s safety and effectiveness in order to ensure that it is the most efficient use of resources. Despite advocacy for a routinized and systematic approach to the withdrawal of resources from medical services, research has indicated that political and social factors often influence government, resulting in decisions that are neither consistent nor transparent. In this dissertation I seek to understand factors that may influence resource withdrawal decisions in an attempt to promote a more routinized and systematic approach. In order to understand the resource withdrawal landscape and provide greater conceptual clarity, the first study in this dissertation identifies and explores its characteristics (antecedents, attributes, and outcomes). Definitions of two prominent terms, disinvestment, and rationing are proposed. In the second study, a qualitative analysis of two examples of resource withdrawal reveals how the characteristics of problem frames affect the shape and timing of government resource withdrawal policies. Findings support the proposition that the complexity of the story told within the problem frame affects the shape of the policy; while visibility affects the timing. In the third study, I analyzed the perspectives of key informants about the Choosing Wisely Canada (CWC) campaign, which has the aim of reducing unnecessary services by encouraging a discussion between physician and patient. Findings reveal that CWC was designed to address pressures from government, patients, and the public. However, CWC was not designed in a way that is expected to address the underlying reasons unnecessary services are provided, including limited time in the clinical encounter, patient demands, uncertainty in the care pathway, and physician fear of litigation. Results from all three studies help establish a common language, identify influences on government led resource withdrawal and reasons why CWC is unlikely to reduce unnecessary services. Together this thesis provides insights into some of the factors affecting resource withdrawal from medical services, and findings may be used to help assess ways to improve the formulation of resource withdrawal policies. / Dissertation / Doctor of Philosophy (PhD) / Currently several governments pay for unnecessary medical services, leading to suboptimal patient health outcomes and a waste of public resources. Several researchers and organizations have proposed methods to identify and assess medical services to determine if they are unnecessary; however, governments have been slow to adopt such methods on a routine basis. It is clear that evidence is rarely sufficient to motivate governments to withdraw resources from unnecessary medical services. Instead, governments are often influenced by social and political factors when they make such decisions. Through a better understanding of these factors, we may be able to find ways to incorporate evidence into governments’ decisions to withdraw resources from medical services. Qualitative methods were used to investigate how resource withdrawal is defined, factors influencing government resource withdrawal decisions in Ontario, and the effectiveness of Choosing Wisely Canada, an initiative led by the medical community to reduce unnecessary services.

Background: Obesity disproportionately affects Pakistani women and rates of obesity related conditions are high in Bradford. Research priority setting can guide the development of policy and practice, resulting in more relevant research. There are no research prioritisation exercises targeted at obesity in Pakistani women. Aim: To develop an obesity research agenda with Pakistani women living in deprived inner-city areas of Bradford. Methods: Using a feminist participatory action research design, a five stage process was adopted involving the following: (i) A systematic review to identify the gaps in knowledge (ii) face-to-face interviews with 21 Pakistani women to generate their health concerns (iii) focus groups to explore the obesity concerns of 23 Pakistani women (iv) survey to identify unmet obesity needs of Pakistani women according to 160 local, multisectoral stakeholders (v) adapted consensus method involving 32 Pakistani women to rank their identified concerns and unmet needs in order of importance. Results: The study identified needs related to cultural and language constraints, including barriers in obtaining health promotion information and the social isolation of women. Education needs and misconceptions surrounding diet and physical activity were also identified. Highest rankings were given to concerns and needs surrounding the mental health of Pakistani women, education needs for a healthy diet, and the benefits of physical activity. Conclusion: Pakistani women’s unmet obesity needs highlight the existence of wider determinants of health that are structural in nature. Considering these barriers, a research agenda was developed from the findings and reflect the obesity health needs of this population. / Funding through Born in Bradford

Yes / British South Asians have a higher prevalence of overweight and obesity than the wider population. Bradford (UK), with its high Pakistani presence and levels of economic deprivation, has exceptionally high instances, especially in deprived areas where many Pakistanis reside. British Pakistani women in Bradford are more likely to be overweight and obese. There is uncertainty on how these women can be aided to manage their weight. Therefore, the objective of this study was to explore the obesity concerns of Pakistani women living in deprived inner-city areas of Bradford. Three focus groups interviews were carried out with 23 Pakistani women living in deprived areas of Bradford. Data were analysed thematically. This exploratory study identified a wide range of concerns that women had around managing their weight. Participants disclosed distrust in information given around medication, conflicting dietary information and reported low levels of trust in women-only organized physical activities. Cultural barriers were identified, which included the gender role of the woman, the lack of culturally appropriate dietary advice, cultural misunderstandings of what constitutes a healthy diet and healthy weight, the lack of culturally suitable exercise facilities and conforming to family and community expectations. Other concerns were language barriers around a lack of understanding, the inability to read Urdu and reliance on others to translate information. These findings have implications for researchers, local authorities, policy makers and others with an interest in reducing the rates of obesity in this population. Recommendations include training health practitioners to be culturally aware of the diet and eating practices of this community, exploring different ways to support socially isolated women to be more physically active at home, addressing physical activity and diet misconceptions and designing obesity management information materials appropriate for a range of literacy levels. Public contributors were involved in the development of the interview guide and design of the research. A pilot focus group with participants not included in the present paper was used to help test and refine the focus group questions. Interview transcripts were member checked by participants, and participants assisted with data analysis. / UKPRP. Grant Number: MR/S037527/1 NIHR. Grant Number: NIHR200166