Civil society engagement in innovation and research through the European Public Health Association

Background: The European Public Health Association (EUPHA) proposed and led PHIRE (Public Health Innovation and Research in Europe), with co-financing by the European Commission, to assess public health innovation and research at national level in Europe. PHIRE was also designed to promote organizational development and capacity building of EUPHA. We assess the success and limitations of using EUPHA’s participative structures. Methods: In total, 30 European countries were included—27 EU countries, Iceland, Norway and Switzerland. EUPHA thematic section presidents were asked to identify country informants to report, through a web-based questionnaire, on eight public health innovations. National public health associations (EUPHA member organiza- tions) were requested to identify their national public health research programmes and calls, review the health research system, coordinate a stakeholder workshop and provide a national report. The section and national reports were assessed for responses and completeness. Results: Half of the final responding CIs were members of EUPHA sections and the other half gained from other sources. Experts declined to respond for reasons including lack of time, knowledge of the innovation or funding. National public health associations held PHIRE workshops with Ministries of Health in 14 countries; information for 10 countries was gained through discussions within the national association, or country visits by PHIRE partners. Six countries provided no response. Some national associations had too weak organizational structures for the work or insufficient financial resources or criticism of the project. Conclusion: EUPHA is the leading civil society organization giving support to public health research in Europe. PHIRE created new knowledge and supported organizational development. EUPHA sections gained expert reports on public health innovations in European countries and national public health associations reported on national public health research systems. Significant advances could be made if the European Commission worked more directly with EUPHA’s expert members and with the national public health associations.

Background: The European Public Health Association (EUPHA) proposed and led PHIRE (Public Health Innovation and Research in Europe), with co-financing by the European Commission, to assess public health innovation and research at national level in Europe. PHIRE was also designed to promote organizational development and capacity building of EUPHA. We assess the success and limitations of using EUPHA's participative structures. Methods: In total, 30 European countries were included-27 EU countries, Iceland, Norway and Switzerland. EUPHA thematic section presidents were asked to identify country informants to report, through a web-based questionnaire, on eight public health innovations. National public health associations (EUPHA member organizations) were requested to identify their national public health research programmes and calls, review the health research system, coordinate a stakeholder workshop and provide a national report. The section and national reports were assessed for responses and completeness. Results: Half of the final responding CIs were members of EUPHA sections and the other half gained from other sources. Experts declined to respond for reasons including lack of time, knowledge of the innovation or funding. National public health associations held PHIRE workshops with Ministries of Health in 14 countries; information for 10 countries was gained through discussions within the national association, or country visits by PHIRE partners. Six countries provided no response. Some national associations had too weak organizational structures for the work or insufficient financial resources or criticism of the project. Conclusion: EUPHA is the leading civil society organization giving support to public health research in Europe. PHIRE created new knowledge and supported organizational development. EUPHA sections gained expert reports on public health innovations in European countries and national public health associations reported on national public health research systems. Significant advances could be made if the European Commission worked more directly with EUPHA's expert members and with the national public health associations.

Introduction
Civil society makes important contributions to governance at national and European levels. 2 EUPHA is a civil society organization established to promote public health research and practice in Europe. It brings together national public health associations, scientists, practitioners and policy makers. It holds an annual scientific meeting each year, rotating across different European countries, owns and manages the scientific content of the European Journal of Public Health and links researchers and practitioners through 20 thematic sections. EUPHA has promoted the development of national public health associations in partnership with the Open Society Institute. 3 As part of a reform of its governance and constitution in 2008, EUPHA created an internal structure of 'pillars' for four areas of work-policy, practice, training and research-and individual leaders were appointed for these areas. 4 To take forward the research pillar, EUPHA developed PHIRE (Public Health Innovation and Research in Europe) to extend knowledge on European public health research gained in previous collaborative projects Strengthening Public Health Research in Europe (SPHERE) and Strengthening Engagement in Public Health Research (STEPS). 5,6 The European Commission Health Programme, 7 initiated in 2003, supports demonstration, implementation and dissemination of projects rather than primary research. An interim evaluation of the first programme 8 identified cross-Europe networking for health as one of the main achievements. PHIRE proposed to assess how far public health innovations, supported as European projects by the Health Programme, had achieved uptake and impact within European countries and assess how far national public health research systems link with European research and innovation developments.

Methods
Working with the EUPHA sections PHIRE worked with the EUPHA thematic sections to assess the uptake and impact of public health innovations in Europe. The Chair of the section council led the work package on tracking the uptake and impact of European public health innovations with the EUPHA sections. To ensure feasibility within the size of the overall project, PHIRE initially proposed to investigate around six innovations. A list of 198 projects whose funding by the Public Health Programme commenced in 2003-05, was sorted according to the section themes. The Chair of the section council wrote to each section president individually, asking each to choose public health projects from the list supplied and to discuss participation in PHIRE with their section members.
At the European Public Health conference in Amsterdam, November 2010, PHIRE was discussed at the section council meeting and at the individual meetings of the sections. Seven section presidents responded positively and one proposed to assess two projects-so eight projects overall were selected. Three meetings were held (in Amsterdam, Stockholm and Copenhagen) between PHIRE partners and EUPHA section presidents, followed by three telephone conferences. There were also bilateral telephone meetings and email contact with all parties concerned.

Identifying country informants
EUPHA section presidents were invited to identify one or more innovation projects relevant to their Section that had been implemented by the European Union Public Health Programme and started in 2003-2005. Eight projects were chosen: CHOB-Children, obesity and associated avoidable chronic diseases (Section of Food and Nutrition). CSAP-Child safety action plans (Section of Injury Prevention and Safety Promotion). EAAD-European alliance against depression (Section of Public Mental Health). ENHIS-Implementing environmental and health information systems in Europe (Section of Environment Related Diseases). EUCID-European core indicators in diabetes mellitus (Section of Chronic Diseases). HA-Healthy ageing, (Section of Public Mental Health). URHIS-European system of urban health indicators (Section of Urban Public Health). VENICE-Vaccine European new integrated collaboration effort (Section of Public Health Epidemiology).
Individuals with an interest in any EUPHA section can apply electronically to be a member. Section membership ranges from 300 to 800 registered individuals. The section presidents asked their members to identify one Country Informant (CI) for their chosen innovation project for each of the 27 EU member states plus Iceland, Norway and Switzerland. Where the section did not have any member from a country, other EUPHA sections or other existing networks were used.
The initial email invitations for CIs were sent by the work package lead, signed by the respective EUPHA section presidents. This letter gave a link to the web-based questionnaire, which the CI was asked to complete (more detail in the PHIRE work package report). 9 The process of inclusion and invitation to the CIs to participate in the web survey was thereafter developed by the section presidents. A web-based questionnaire was developed for each CI to report their perceptions on national uptake and impact of each of the eight innovation projects. The first requests to respond were sent to CIs in March 2011, and the last responses were received by December 2011.

Working with national public health associations
The initial PHIRE proposal budgeted funding for a national 'expert' in each country. However, with the reduction of the budget for PHIRE during the proposal negotiation, PHIRE was revised by shortening the overall time of the project and reducing the national allocation to each country for their work and report. To manage the project within more limited funds, PHIRE was organized into four regional groupings, with each regional coordinator managing seven to eight countries. The regional coordinator initially contacted the representative of the NPHA in the EUPHA Governing Council, or the secretariat of the NPHA. A letter, signed by the EUPHA president, explained that PHIRE had been approved by the Governing Council and asked for national participation.
The approach followed by regional coordinators included the following steps: Address initial email to national public health association contact given by EUPHA office. Offer to contact by telephone (ask for a time, date and number to establish the contact). Ask the first contact to suggest another person to be contacted if the first contact was unable to provide information.
Offer assistance in organizing the information and fulfilling the forms. If no answer, use alternative contacts in the same country.
Two sets of data were requested: In the first year, information was collected describing national public health research calls and programmes and public health research structures. The protocol for programmes and calls was developed iteratively. The focus was restricted to programmes and calls opened in 2010 only, to standardize the task and to improve feasibility. Public health research, as defined for the study 10 was sought within the different national research commissioning frameworks. Information sought on public health structures built on previous work for STEPS, which had prepared reports on country research structures within a specified form. National public health associations and other contacts were asked to review the existing country reports and advise on revisions or updates. More than 242 emails were sent and 60 phone calls made, data are available in Table 5.
In the second year, the national public health associations were sent in a standardized format: (i) the country analysis of programmes and calls in 2010; (ii) the country analysis of the CIs' responses for the eight innovation projects and (iii) revised country public health research structures. Each national public health association was asked to hold workshops based on these documents and to prepare a national report.

Identifying CIs
An overview of how the CIs were selected is shown in Table 1. The section presidents were asked initially to identify the CIs from their section members. This was used for five of the eight innovation projects (five of the seven sections). To widen the invitations, four section presidents made contact with the original innovation project partners, although the other section presidents chose not to because of possible bias. Personal contact was used by five section presidents for six projects (for one section, this was the primary method of approach). Informants were also identified from publications, conference lists and internet sources by three section presidents. Half of the invited informants were members of a EUPHA section (Table 2).

Public health innovation and research through EUPHA 13
The section on food and nutrition provided information on the 'success' rate between methods. Members of the section provided 11 of 18 CIs, snowball contacts provided 3 CIs and personal contacts together with experts identified through PubMed and internet search engines gained 4 CIs. In contrast, the section on urban health compiled a list of 321 people across all 30 countries using members of the sections and professional contacts from previous research projects including URHIS 1 and EURO-URHIS 2. Of 47 CIs invited, representing 20 countries, 19 responses were gained for 15 countries.
Although the response rate was limited, the quality of the answers was considered good and in some cases, also very detailed. Phone call follow-up was reported to be difficult because of languages. Some prospective informants asked to look at the questions to be answered for the survey and then declined. Some CIs found that a more senior colleague was required to answer the PHIRE questions and the section president needed to establish contact with a new CI and begin the procedure again.

Completing the survey
At the outset, PHIRE recognized that it would not be possible to achieve country responses for all the innovations, because of the known coverage by country of EUPHA section members. The target set was to achieve responses for two-thirds of the countries. This goal was reached for CHOB (67%) followed by CSAP and URHIS 1 with 60% and 50%, respectively, of the countries represented (Table 3).
Some of the CIs found it difficult to report the rather specific and complex information using the web-based survey. The type of information asked for was not always formally documented and not necessarily known to the expert despite being in their general field. For only two of the innovations did more than half of the contacted CIs respond.
About 30% of the CIs who were not involved in the innovation projects could not answer the questions about the level of impact of the project in their country. This was only the case for <10% of the CIs who themselves were involved in these projects.

Performance of national public health associations
In the first phase of PHIRE, contact was made with informants of 25 countries. Of these, 16 countries identified at least one public health research programme or call opened in 2010 (Table 4). Two countries provided the majority of the responses-25 for France and 14 for UK. Germany, the Netherlands and Denmark also had differentiated research programmes, although this was not only a function of programme size as Spain and Romania each reported single large programmes. Four countries with national associations-Austria, Czech Republic, Estonia and Hungary-did not   In coordinating the second phase of data gathering from NPHAs, there were 249 emails sent and 127 replies were received. Fifteen NPHAs held workshops with Ministries of Health (Table 5), with altogether 195 (range 5-45 per country) participants. The workshop meetings were held in the national language and reported in English. In one country, an official at the national health research board provided a full report. Four countries organized internal meetings within their national association. Reports for four countries were made through country visits and discussions in English by the PHIRE work package lead. No response was provided for six countries.

Workshop reports
The full National Reports are presented on the PHIRE web pages (www.eupha.org/phire).
Leading themes from the workshops are shown in Table 6. Conclusions for three contrasting countries-the Netherlands, Romania and Slovakia-are given in Table 7.
The workshop in Austria noted that a public health group is to develop a national public health research strategy. The Czech Republic workshop considered 'public health research and promotion and its financing are hot issues' and proposed regular meetings. France emphasized existing involvement in European FP7 and DG Health projects. Italy, Latvia, Poland and Romania discussed more effective collaboration between the Ministry of Health and the Ministry of Education and Science to increase financial resources for public health research. In Malta, the workshop 'helped us review our public health research systems and identify areas which need to be further developed and improved'. Slovakia circulated a two-page summary of the workshop to all important stakeholders within the country. Sweden and the UK confirmed the strength of public health research within their countries and the importance of public health research also in the EU programmes.
Difficulties in developing interest within the NPHAs were also reported, with various explanations. Some respondents cited internal organizational challenges-because 'the Secretary was changing', members of the board 'have been sick' or difficulty in agreeing which national representative would contribute. 'Collaboration with PHIRE was discussed several times in the executive board and we tried but we were unable to identify a member that could answer the questionnaire'. Some NPHAs presented this in terms of resources needed, either for the organization or to pay an individual directly. The new EU member states particularly reflected on financial difficulties due to the economic recession. Some respondents expressed direct criticism of the project's objectives or methods and thus declined to participate, although two suggested that NPHAs would have participated if they had been more closely involved in the original design.

Dissemination
PHIRE's consortium management meetings and dissemination Platform meetings were structured around the European Public Health scientific conferences (led by EUPHA) held in November each year and the associated conference planning meetings in June.
PHIRE was presented both at the yearly EUPHA Governing Council meetings, with representatives of the member national public health associations and at the yearly section council meeting, held respectively before and after the European Public Health Conference. PHIRE was also presented at each conference through Europe-themed workshops and PHIRE publicity (leaflets and a banner) was provided at each conference at the EUPHA exhibition stand.
For wider dissemination, the summary report was written and presented to stakeholders made available on the EUPHA website and published in this the supplement of the European Journal of Public Health presents learning from the project.

Discussion
Capacity building for health research should be a high priority of EUPHA, through its Governing Council and Section Council. This has been achieved by some national health research systems, 11 and for research in policy making. 12 PHIRE has contributed to understanding country contexts, identifying appropriate partners and strengthening relationships through field contacts. Capacity building at national level should consider individuals (researchers and teams); for research organizations (institutes and universities) and the institutional 'rules of the game'. There is a need to address the incentive structures, the regulatory context and the resource base in which research is undertaken and used by policy makers. 13 At present, there is little sense of cross-national collaboration-or competition-between countries in public health research at the structural level. Significant advances could be made if the

EUPHA sections
Membership of EUPHA sections is open to all interested researchers and practitioners in the topic, but it does not automatically create an active and engaged network. The EUPHA section presidents were able to gain about half of all PHIRE CIs through their section members. Rather specific and complex information was sought. Although they were experts in their field, the CIs sometimes had to search for information which was not widely known, and needed knowledge of the European public health projects. The web survey covered a range of topics and its length proved challenging to some potential CIs. Telephoning the CIs before getting the web survey seemed to lead to more responses; sending the survey to known colleagues did not have the same positive effect. Information was not collected systematically about non-response or drop-out, but some members were unable to help because of the workload or because they considered they were not the right person to answer all the questions. Demonstrating and investigating public health research programmes and calls was a new activity for EUPHA, although Initial long discussion: 'public health research and promotion and its financing are hot issues'. Many participants expressed the view that regular meetings of persons (institutions) interested in public health research would be beneficial. France, Inserm (national health research agency and provider) May 2012 (6 people) The Agence nationale de la recherche and Inserm organized a workshop on French involvement in European public health research. In 40 FP7 projects, France was leader in 3 and partner in 37. For 26 SANCO Health Programme projects with a clear research component, France was leader in 9 projects and partner in 17. 'European projects more often concern information and policy, whereas public health research in France is more often oriented towards and/or closer to clinical issues'. Equally, not every national public health association was well equipped to inform on public health research. Although PHIRE simplified the NPHAs' work through providing the workshop materials and reporting template, the NPHAs found challenges to identify and bring together the right people, to discuss reports written in English and to provide the final report within the requested time. About half of the NPHAs held workshop meetings. In some countries, the discussion was welcome-for example, the national reports by Cyprus, Latvia, Romania and UK-but in other countries the response was limited (e.g. France and Norway). There were only internal discussions in some NPHAs and three countries (Finland, Germany and Ireland) only provided reports through the viewpoint of a single person. EUPHA national associations in several countries declined to participate entirely. There was no clear pattern to this at national level: it seemed related to the internal perspectives and priorities of each NPHA.
A template for the workshop reports was developed collectively by the PHIRE partners. Yet, country informants (CIs) did not readily accept this structure-perhaps it did not fit the perception of the NPHAs of their own situation, or because the concept of finding their 'gaps and needs' in public health research was new. Several respondents wanted to revise the organogram of the national health research system, but they had not been involved in its earlier development and the limitations of cross-national reporting. Some reports did not address all three parts of the template. There is a trend towards fewer, but bigger research programmes. New knowledge and innovations are not only coming out of the R&D pipelines from the universities, but also more bottom up, e.g. the municipal health services are developing their own R&D departments. The development of academic workplaces for public health was considered as a good practice, potentially interesting for other countries.

Negative
Research seems to follow the interests of vested professions and institution. As a consequence, the programmed research is relatively unable to address the questions and information needs of specific groups or institutions. There is a mismatch between the problem holder (professional, institute in need of new knowledge or an innovation), the researchers who are producing the new knowledge/innovation and the financiers who program and commission. Scientific researchers must publish and maximize their impact factors: there should be greater 'valorization' of societal impacts. There is much new knowledge and innovations developed, but it is insufficiently used in practice. There is little room for research aiming at disruptive innovations and/or paradigm shifts. There is a lack of overview in R&D programmes for healthcare, including public health.

Future R&D policies
Earlier attempts to initiate 'paradigm' shifts have not been successful. Why? And what lessons? Research methodology should extend to use action research, qualitative research, inter-and multi-disciplinary research methodologies. Complexity may need to be managed, rather than reduced in research designs. Translate and link health to other public goods such as welfare, participation, and sustainability.
A framework for R&D would distinguish: a Content: describe the themes that need targeted research funding and/or technology development. b Methodology: a new epistemology (e.g. systems thinking, complexity science), new methods (e.g. action research, qualitative methods, mixed methods) and inter-and multi-disciplinary theories are needed. c Programming: how to organize R&D, including commissioning

Romania
The workshop participants concluded: The visibility of Romania in the EU research field related to health should be increased. This is a joint responsibility between public bodies, researchers, academic institutions and civil society organisations. Connections between the Ministry for Education, Research and Science and the Ministry of Health should be strengthened in deciding priorities. The legal frame for research in the National Institute of Public Health (three national and six regional centres) should be strengthened, along with universities, for young researchers to build careers. Public health links with the medical universities should be strengthened Civil society organisations, including the Romanian Public Health Association have an important contribution in coordination and support.

Slovakia
Slovak conclusions and recommendations. Strengthening public health research at national level: Public health research should be included among other health research areas. National priorities of public health research have to be clearly defined. A defined amount of the public health budget should be spent on public health research. The Ministry of Health should establish an administrative department to coordinate health/public health research. Partnerships should be supported among public health research stakeholders (universities, Slovak Academy of Sciences, NGOs, etc.).

Strengthening national public health research within European research:
Promote translation of experience and knowledge, through transfer of European research to national level. Provide additional financing for follow-up dissemination of research projects deliverables. Raise interest in European research projects (European Commission Directorate for Health, Research Framework Programmes and Structural Funds). Motivate researchers at their institutions towards European activities. Support co-financing of European grants.

Funding of PHIRE
Both at the level of NPHAs as well as CIs, the lack of sufficient funding for all the activities limited PHIRE's success. There was insufficient European Commission co-funding for the several tasks the national public health associations were asked to performfinding national programmes and calls for 2010, commenting on national public health research structures, organizing the stakeholder workshop and providing the final national report. A more complete set of data, for all 30 countries, could perhaps have been achieved with the original requested budget for PHIRE.

Conclusion
EUPHA is the leading civil society organization giving support to public health research across European countries. There is a strong need for capacity building of public health research at all levels, which should be fostered and supported by EU Member States directly and through the European Commission in the coming period 2014-20. Significant advances could be made if the European Commission worked more directly with EUPHA's expert members and with the national public health associations.