Using equitable impact sensitive tool (EQUIST) and knowledge translation to promote evidence to policy link in maternal and child health: report of first EQUIST training workshop in Nigeria

The Equitable Impact Sensitive Tool (EQUIST) designed by UNICEF and knowledge translation (KT) are important strategies that can help policymakers to improve equity and evidence-informed policy making in maternal, newborn and child health (MNCH). The purpose of this study was to improve the knowledge and capacity of an MNCH implementation research team (IRT) and policy makers to use EQUIST and KT. A modified “before and after” intervention study design was used in which outcomes were measured on the target participants both before the intervention (workshop) is implemented and after. A 5-point likert scale according to the degree of adequacy was employed. A three -day intensive EQUIST and KT training workshop was organized in Edo State, Nigeria with 45 participants in attendance. Some of the topics covered included: (i) Knowledge translation models, measures & tools; (ii) Policy review, analysis and contextualization; (iii) Policy formulation and legislation process; (iv) EQUIST Overview & Theory of change; (v) EQUIST's situation analysis, scenario analysis and scenario comparison. The pre-workshop mean of understanding of use of KT ranged from 2.02-3.41, while the post-workshop mean ranged from 3.24-4.30. Pre-workshop mean of understanding of use of EQUIST ranged from 1.66-2.41, while the post-workshop mean ranged from 3.56-4.54 on the 5point scale. The percentage increase in mean of KT and EQUIST at the end of the workshop ranged from 8.0%-88.1% and 65.6%-158.4% respectively. Findings of this study suggest that policymakers' and researchers KT and EQUSIT use competence relevant to evidence-informed policymaking can be enhanced through training workshop.


Introduction
Throughout the world especially in low and middle-income countries (LMICs), policymakers often face difficult decisions about how to allocate scarce resources, balancing equity (eliminating inequality in health outcomes between groups), effectiveness (maximizing results for the country as a whole) and efficiency (making the most rational use of resources) [1]. In many LMICs, including Nigeria, among the most important health policy areas where decision making is increasingly becoming challenging are those related to maternal, newborn and child health (MNCH). In Nigeria, maternal and child health outcome is reportedly poor with more than 1 million newborn, infant, and child deaths and more than 50,000 maternal deaths every year [2,3]. However, in recent years there has been a noteworthy reduction in maternal and child mortality in Nigeria. The national maternal mortality ratio reduced from 800/100,000 in 2005 [4] to 576/100,000 in 2013 [5], while the under-five mortality rate (U5MR) reduced from 201 per 1000 live births in 2003 [6, 7] to 117 per 1000 live births in 2013 [8]. It is pertinent to state that the decrease in U5MR in Nigeria and in most LMICs for instance has been accompanied by increased inequity in health outcomes between the poor and those better off [9]. This explains why the United Nations Children's Fund (UNICEF) argues for abandoning the "mainstream approach" where scaling-up of child health interventions is first provided to more readily accessible (and typically wealthier) groups in society. Instead, an "equity-focused" approach is suggested, contending that it is more cost-effective to target interventions at the poorest in society, resulting in a greater U5MR decrease while also positively impacting upon equity [10]. It is based on this premise that the UNICEF designed the EQUitable Impact Sensitive Tool (EQUIST) to help governments and the global health community improve equity in maternal, newborn and child health [11]. EQUIST is an online tool, designed to help health policymakers and program managers to sharpen health plans and policies and make responsible decisions about how to strengthen their health systems. The explicit goal of EQUIST is to reduce health disparities between the most marginalized mothers and young children and the better-off [12].
It is a medium-term strategic planning, modelling and monitoring platform that serves to improve child and maternal health as well as nutrition equity in developing and middle-income countries [11,12].
Equist, was developed in partnership with the Community Systems Foundation (CSF), with funding from the Bill and Melinda Gates Foundation and builds on previously-existing platforms including the Lives Saved Tool (John Hopkins Bloomberg School of Public Health) and the Marginal Budgeting for Bottleneck tool (a cost estimator used by the World Bank) and on globally available data including demographic health surveys DHS [11]. A key difference between EQUIST and previous tools is that EQUIST is considerably simpler and more user-friendly, with most of the calculations happening automatically [12]. EQUIST contains three modules: situation analysis, scenario development using bottleneck analysis and cost and impact projections [11]. Incorporating EQUIST in the knowledge translation (KT) process will definitely improve the evidence to policy link. The Canada Institutes of Health Research (CIHR) had earlier defined KT as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of people, provide more effective health services and products and strengthen the health care system [13]. A research team with a robust KT competence will be able to use research to inspire stakeholders to think and/or act differently because the KT process is achieved through transmission and exchange of reliable information and through extensive dialogue between the producers and users of the research [14]. EQUIST is therefore is very critical to both KT and evidence-informed policy processes as it can provide very reliable information for example to calculate the impacts and costs of intervention strategies as well as the reduction of disparities in access to and quality coverage of, essential health services [1].
Despite the importance of EQUIST to the evidence informed policymaking process, the knowledge and capacity to use the tool are essentially lacking among policymakers and health researchers in Nigeria. This report is the first EQUIST training workshop in Nigeria.

Workshop report
Aim of the workshop: The aim of this study was to improve the knowledge and capacity of Nigerian MNCH implementation research team (IRT) and policymakers to use EQUIST and KT to promote evidence-informed policymaking in MNCH. This was achieved via a training workshop on EQUIST and KT. A modified "before and after" intervention study design was used in which outcomes were measured on the eligible population (target participants) both before the programme (intervention) is implemented and after [15].
The difference between the before and after measurements was Page number not for citation purposes 3 taken to be the impact of the intervention. (In this instance, the "before"-or "baseline"-measurements served as the control measurements).   Table 2, Table 3 [20] had argued that policymaking does not take place in a vacuum but political, economic and social factors all affect how policies are made, and who makes them, at all levels. According to Jones and Walsh [21], the integration of evidence into policy decision making is a complex process of multiple, frequently competing and/or intertwined sets of influences in which evidence plays just one of many roles.

Study area and participants: This study was conducted in
A major milestone in this study was the introduction of EQUIST as an important tool to help the participants especially the policymakers and program managers to sharpen health plans and policies and make responsible decisions about how to strengthen the health systems [12]. This study was the very first report of EQUIST training workshop in Nigeria. It is worthy of note to state that of all the aspects of this training, the improvement in the participants' understanding of the EQUIST module was tremendous and ranged from 104.0% to 158.4%. Interestingly, the EQUIST enabled the participants to create an accurate picture of the health status of the most deprived children and women in Nigeria, identify which populations are at greatest risk, why they are at risk and how many lives can be saved with appropriate action. This is one of the most important benefits of EQUIST [11]. In addition to this, the tool also helped the participants to practice how to confidently plan health interventions by identifying the highest impact, most costeffective strategies to level disparities and project the impact of health systems strategies and measure the potential effects in terms of lives saved and costs [11]. The improved understanding of knowledge translation and EQUIST gained by the participants in this study will undoubtedly impact positively on the evidence-to-policy process regarding the MNCH outcomes. A major limitation of this study was the limited duration of the workshop which made adequate impact assessment not to be possible. To assess the real impact of the training, a follow-up may be necessary to assess the extent the participants will use the skill acquired in the policymaking process. This limitation notwithstanding, this workshop is an important first step to bridging the divide between research and policy and understanding how to address equity concerns in the MNCH interventions in Nigeria.

Competing interests
Authors declare no competing interests.  Tables   Table 1: Profile and official designation attributes of participants who completed the questionnaire at the workshop