define recommendations in research

Implications or Recommendations in Research: What's the Difference?

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High-quality research articles that get many citations contain both implications and recommendations. Implications are the impact your research makes, whereas recommendations are specific actions that can then be taken based on your findings, such as for more research or for policymaking.

Updated on August 23, 2022

That seems clear enough, but the two are commonly confused.

This confusion is especially true if you come from a so-called high-context culture in which information is often implied based on the situation, as in many Asian cultures. High-context cultures are different from low-context cultures where information is more direct and explicit (as in North America and many European cultures).

Let's set these two straight in a low-context way; i.e., we'll be specific and direct! This is the best way to be in English academic writing because you're writing for the world.

Implications and recommendations in a research article

The standard format of STEM research articles is what's called IMRaD:

• Introduction
• Discussion/conclusions

Some journals call for a separate conclusions section, while others have the conclusions as the last part of the discussion. You'll write these four (or five) sections in the same sequence, though, no matter the journal.

The discussion section is typically where you restate your results and how well they confirmed your hypotheses. Give readers the answer to the questions for which they're looking to you for an answer.

At this point, many researchers assume their paper is finished. After all, aren't the results the most important part? As you might have guessed, no, you're not quite done yet.

The discussion/conclusions section is where to say what happened and what should now happen

The discussion/conclusions section of every good scientific article should contain the implications and recommendations.

The implications, first of all, are the impact your results have on your specific field. A high-impact, highly cited article will also broaden the scope here and provide implications to other fields. This is what makes research cross-disciplinary.

Recommendations, however, are suggestions to improve your field based on your results.

These two aspects help the reader understand your broader content: How and why your work is important to the world. They also tell the reader what can be changed in the future based on your results.

These aspects are what editors are looking for when selecting papers for peer review.

Implications and recommendations are, thus, written at the end of the discussion section, and before the concluding paragraph. They help to “wrap up” your paper. Once your reader understands what you found, the next logical step is what those results mean and what should come next.

Then they can take the baton, in the form of your work, and run with it. That gets you cited and extends your impact!

The order of implications and recommendations also matters. Both are written after you've summarized your main findings in the discussion section. Then, those results are interpreted based on ongoing work in the field. After this, the implications are stated, followed by the recommendations.

Writing an academic research paper is a bit like running a race. Finish strong, with your most important conclusion (recommendation) at the end. Leave readers with an understanding of your work's importance. Avoid generic, obvious phrases like "more research is needed to fully address this issue." Be specific.

The main differences between implications and recommendations (table)

Now let's dig a bit deeper into actually how to write these parts.

What are implications?

Research implications tell us how and why your results are important for the field at large. They help answer the question of “what does it mean?” Implications tell us how your work contributes to your field and what it adds to it. They're used when you want to tell your peers why your research is important for ongoing theory, practice, policymaking, and for future research.

Crucially, your implications must be evidence-based. This means they must be derived from the results in the paper.

Implications are written after you've summarized your main findings in the discussion section. They come before the recommendations and before the concluding paragraph. There is no specific section dedicated to implications. They must be integrated into your discussion so that the reader understands why the results are meaningful and what they add to the field.

A good strategy is to separate your implications into types. Implications can be social, political, technological, related to policies, or others, depending on your topic. The most frequently used types are theoretical and practical. Theoretical implications relate to how your findings connect to other theories or ideas in your field, while practical implications are related to what we can do with the results.

Key features of implications

• State the impact your research makes
• Helps us understand why your results are important
• Must be evidence-based
• Written in the discussion, before recommendations
• Can be theoretical, practical, or other (social, political, etc.)

Examples of implications

Let's take a look at some examples of research results below with their implications.

The result : one study found that learning items over time improves memory more than cramming material in a bunch of information at once .

The implications : This result suggests memory is better when studying is spread out over time, which could be due to memory consolidation processes.

The result : an intervention study found that mindfulness helps improve mental health if you have anxiety.

The implications : This result has implications for the role of executive functions on anxiety.

The result : a study found that musical learning helps language learning in children .

The implications : these findings suggest that language and music may work together to aid development.

What are recommendations?

As noted above, explaining how your results contribute to the real world is an important part of a successful article.

Likewise, stating how your findings can be used to improve something in future research is equally important. This brings us to the recommendations.

Research recommendations are suggestions and solutions you give for certain situations based on your results. Once the reader understands what your results mean with the implications, the next question they need to know is "what's next?"

Recommendations are calls to action on ways certain things in the field can be improved in the future based on your results. Recommendations are used when you want to convey that something different should be done based on what your analyses revealed.

Similar to implications, recommendations are also evidence-based. This means that your recommendations to the field must be drawn directly from your results.

The goal of the recommendations is to make clear, specific, and realistic suggestions to future researchers before they conduct a similar experiment. No matter what area your research is in, there will always be further research to do. Try to think about what would be helpful for other researchers to know before starting their work.

Recommendations are also written in the discussion section. They come after the implications and before the concluding paragraphs. Similar to the implications, there is usually no specific section dedicated to the recommendations. However, depending on how many solutions you want to suggest to the field, they may be written as a subsection.

Key features of recommendations

• Statements about what can be done differently in the field based on your findings
• Must be realistic and specific
• Written in the discussion, after implications and before conclusions
• Related to both your field and, preferably, a wider context to the research

Examples of recommendations

Here are some research results and their recommendations.

A meta-analysis found that actively recalling material from your memory is better than simply re-reading it .

• The recommendation: Based on these findings, teachers and other educators should encourage students to practice active recall strategies.

A medical intervention found that daily exercise helps prevent cardiovascular disease .

• The recommendation: Based on these results, physicians are recommended to encourage patients to exercise and walk regularly. Also recommended is to encourage more walking through public health offices in communities.

A study found that many research articles do not contain the sample sizes needed to statistically confirm their findings .

The recommendation: To improve the current state of the field, researchers should consider doing power analysis based on their experiment's design.

What else is important about implications and recommendations?

When writing recommendations and implications, be careful not to overstate the impact of your results. It can be tempting for researchers to inflate the importance of their findings and make grandiose statements about what their work means.

Remember that implications and recommendations must be coming directly from your results. Therefore, they must be straightforward, realistic, and plausible.

Another good thing to remember is to make sure the implications and recommendations are stated clearly and separately. Do not attach them to the endings of other paragraphs just to add them in. Use similar example phrases as those listed in the table when starting your sentences to clearly indicate when it's an implication and when it's a recommendation.

When your peers, or brand-new readers, read your paper, they shouldn't have to hunt through your discussion to find the implications and recommendations. They should be clear, visible, and understandable on their own.

That'll get you cited more, and you'll make a greater contribution to your area of science while extending the life and impact of your work.

The AJE Team

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Research Recommendations Process and Methods Guide [Internet]

• PMID: 27466642
• Bookshelf ID: NBK310373

The foundation of NICE guidance is the synthesis of evidence primarily through the process of systematic reviewing and, if appropriate, modelling and cost effectiveness decision analysis. The results of these analyses are then discussed by independent committees. These committees include NHS staff, healthcare professionals, social care practitioners, commissioners and providers of care, patients, service users and carers, industry and academics. Stakeholders have the opportunity to comment on draft recommendations before they are finalised. Not only does this process explicitly describe the evidence base, it also identifies where there are gaps, uncertainties or conflicts in the existing evidence.

Many of these uncertainties, although interesting to resolve, are unlikely to affect people’s care or NICE’s ability to produce guidance. However, if these uncertainties may have an effect on NICE’s recommendations it is important for NICE to liaise with the research community to ensure they are addressed. NICE does this by making recommendations for research, which are communicated to researchers and funders. At the time guidance is issued, NICE’s staff and committees have a thorough understanding of the current evidence and valuable insights into uncertainties that need to be resolved. It is important that these are capitalised on.

To undertake its national role effectively, NICE needs to ensure that:

the process of developing the research recommendations is robust, transparent and involves stakeholders

we identify research priorities

we make all research recommendations clearly identifiable in the guidance

the research recommendations provide the information necessary to support research commissioning

the research recommendations are available to researchers and funders by promoting them (for example through the research recommendations database)

the research recommendations are relevant to current practice

we communicate well with the research community.

This process and methods guide has been developed to help guidance-producing centres make research recommendations. It describes a step-by-step approach to identifying uncertainties, formulating research recommendations and research questions, prioritising them and communicating them to the NICE Science Policy and Research (SP&R) team, researchers and funders. It has been developed based on the SP&R team’s interactions with research funders and researchers, as well as with guidance developers.

Keywords: research gaps; uncertainties; research recommendations; NICE Process and Methods Guides.

Copyright © 2015 National Institute for Health and Clinical Excellence, unless otherwise stated. All rights reserved.

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• A Research Guide
• Research Paper Guide

How to Write Implications in Research

• Implications definition
• Recommendations vs implications
• Types of implications in research
• Step-by-step implications writing guide

Research implications examples

What the implications of the research definition?

• Theoretical implications stand for all the new additions to theories that have already been presented in the past. At the same time, one can use a totally new theory that provides a background and a framework for a study.
• Practical implications are about potential consequences that show the practical side of things.

Recommendations VS Implications

• Implied content versus proposed writing. It means that an implication should provide an outcome from your study. The recommendation is always based on the outcome, along with your words as a personal opinion.
• Potential impact a study may have versus a specific act. When you are composing your research paper, your implications have the purpose of discussing how the findings of the study matter. They should tell how your research has an impact on the subject that you address. Now, unlike the implications section of the research paper, recommendations refer to peculiar actions or steps you must take. They should be based on your opinion precisely and talk about what must be done since your research findings confirm that.

What are the types of implications in research?

• Political implications. These are mostly common for Law and Political Sciences students basing implications on a certain study, a speech, or legislative standards. It is a case when implications and recommendations can also be used to achieve an efficient result.
• Technological implications. When dealing with a technological implication, it serves as special implications for future research manuals where you discuss the study with several examples. Do not use a methodology in this section, as it can only be mentioned briefly.
• Findings related to policies. When you have implemented a special policy or you are dealing with a medical or legal finding, you should add it to your policy. Adding an implications section is necessary when it must be highlighted in your research.
• Topical (subject) implications. These are based on your subject and serve as a way to clarify things or as a method to narrow things down by supporting the finding before it is linked to a thesis statement or your main scientific argument.

Step-by-step implications in research writing guide

Step 1: talk about what has been discovered in your research., step 2: name the differences compared to what previous studies have found., step 3: discuss the implications of your findings., step 4: add specific information to showcase your contributions., step 5: match it with your discussion and thesis statement..

Green energy can benefit from the use of vertical turbines versus horizontal turbines due to construction methods and saving costs. 

The use of AI-based apps that contain repetition and grammar-checking will help ESL students and learners with special needs. 

Most studies provide more research on the social emphasis that influences the problem of bullying in the village area. It points out that most people have different cultural behavior where the problem of bullying is approached differently.

If you encounter challenges in terms of precise replication, you can use a CR genetic code to follow the policies used in 1994. Considering the theoretical limitations, it is necessary to provide exact theories and practical steps. It will help to resolve the challenge and compare what has been available back then. It will help to trace the temporal backline. 

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Research Process – Steps, Examples and Tips

Table of Contents

Research Process

Definition:

Research Process is a systematic and structured approach that involves the collection, analysis, and interpretation of data or information to answer a specific research question or solve a particular problem.

Research Process Steps

Research Process Steps are as follows:

Identify the Research Question or Problem

This is the first step in the research process. It involves identifying a problem or question that needs to be addressed. The research question should be specific, relevant, and focused on a particular area of interest.

Conduct a Literature Review

Once the research question has been identified, the next step is to conduct a literature review. This involves reviewing existing research and literature on the topic to identify any gaps in knowledge or areas where further research is needed. A literature review helps to provide a theoretical framework for the research and also ensures that the research is not duplicating previous work.

Formulate a Hypothesis or Research Objectives

Based on the research question and literature review, the researcher can formulate a hypothesis or research objectives. A hypothesis is a statement that can be tested to determine its validity, while research objectives are specific goals that the researcher aims to achieve through the research.

Design a Research Plan and Methodology

This step involves designing a research plan and methodology that will enable the researcher to collect and analyze data to test the hypothesis or achieve the research objectives. The research plan should include details on the sample size, data collection methods, and data analysis techniques that will be used.

Collect and Analyze Data

This step involves collecting and analyzing data according to the research plan and methodology. Data can be collected through various methods, including surveys, interviews, observations, or experiments. The data analysis process involves cleaning and organizing the data, applying statistical and analytical techniques to the data, and interpreting the results.

Interpret the Findings and Draw Conclusions

After analyzing the data, the researcher must interpret the findings and draw conclusions. This involves assessing the validity and reliability of the results and determining whether the hypothesis was supported or not. The researcher must also consider any limitations of the research and discuss the implications of the findings.

Communicate the Results

Finally, the researcher must communicate the results of the research through a research report, presentation, or publication. The research report should provide a detailed account of the research process, including the research question, literature review, research methodology, data analysis, findings, and conclusions. The report should also include recommendations for further research in the area.

Review and Revise

The research process is an iterative one, and it is important to review and revise the research plan and methodology as necessary. Researchers should assess the quality of their data and methods, reflect on their findings, and consider areas for improvement.

Ethical Considerations

Throughout the research process, ethical considerations must be taken into account. This includes ensuring that the research design protects the welfare of research participants, obtaining informed consent, maintaining confidentiality and privacy, and avoiding any potential harm to participants or their communities.

Dissemination and Application

The final step in the research process is to disseminate the findings and apply the research to real-world settings. Researchers can share their findings through academic publications, presentations at conferences, or media coverage. The research can be used to inform policy decisions, develop interventions, or improve practice in the relevant field.

Research Process Example

Following is a Research Process Example:

Research Question : What are the effects of a plant-based diet on athletic performance in high school athletes?

Step 1: Background Research Conduct a literature review to gain a better understanding of the existing research on the topic. Read academic articles and research studies related to plant-based diets, athletic performance, and high school athletes.

Step 2: Develop a Hypothesis Based on the literature review, develop a hypothesis that a plant-based diet positively affects athletic performance in high school athletes.

Step 3: Design the Study Design a study to test the hypothesis. Decide on the study population, sample size, and research methods. For this study, you could use a survey to collect data on dietary habits and athletic performance from a sample of high school athletes who follow a plant-based diet and a sample of high school athletes who do not follow a plant-based diet.

Step 4: Collect Data Distribute the survey to the selected sample and collect data on dietary habits and athletic performance.

Step 5: Analyze Data Use statistical analysis to compare the data from the two samples and determine if there is a significant difference in athletic performance between those who follow a plant-based diet and those who do not.

Step 6 : Interpret Results Interpret the results of the analysis in the context of the research question and hypothesis. Discuss any limitations or potential biases in the study design.

Step 7: Draw Conclusions Based on the results, draw conclusions about whether a plant-based diet has a significant effect on athletic performance in high school athletes. If the hypothesis is supported by the data, discuss potential implications and future research directions.

Step 8: Communicate Findings Communicate the findings of the study in a clear and concise manner. Use appropriate language, visuals, and formats to ensure that the findings are understood and valued.

Applications of Research Process

The research process has numerous applications across a wide range of fields and industries. Some examples of applications of the research process include:

• Scientific research: The research process is widely used in scientific research to investigate phenomena in the natural world and develop new theories or technologies. This includes fields such as biology, chemistry, physics, and environmental science.
• Social sciences : The research process is commonly used in social sciences to study human behavior, social structures, and institutions. This includes fields such as sociology, psychology, anthropology, and economics.
• Education: The research process is used in education to study learning processes, curriculum design, and teaching methodologies. This includes research on student achievement, teacher effectiveness, and educational policy.
• Healthcare: The research process is used in healthcare to investigate medical conditions, develop new treatments, and evaluate healthcare interventions. This includes fields such as medicine, nursing, and public health.
• Business and industry : The research process is used in business and industry to study consumer behavior, market trends, and develop new products or services. This includes market research, product development, and customer satisfaction research.
• Government and policy : The research process is used in government and policy to evaluate the effectiveness of policies and programs, and to inform policy decisions. This includes research on social welfare, crime prevention, and environmental policy.

Purpose of Research Process

The purpose of the research process is to systematically and scientifically investigate a problem or question in order to generate new knowledge or solve a problem. The research process enables researchers to:

• Identify gaps in existing knowledge: By conducting a thorough literature review, researchers can identify gaps in existing knowledge and develop research questions that address these gaps.
• Collect and analyze data : The research process provides a structured approach to collecting and analyzing data. Researchers can use a variety of research methods, including surveys, experiments, and interviews, to collect data that is valid and reliable.
• Test hypotheses : The research process allows researchers to test hypotheses and make evidence-based conclusions. Through the systematic analysis of data, researchers can draw conclusions about the relationships between variables and develop new theories or models.
• Solve problems: The research process can be used to solve practical problems and improve real-world outcomes. For example, researchers can develop interventions to address health or social problems, evaluate the effectiveness of policies or programs, and improve organizational processes.
• Generate new knowledge : The research process is a key way to generate new knowledge and advance understanding in a given field. By conducting rigorous and well-designed research, researchers can make significant contributions to their field and help to shape future research.

Tips for Research Process

Here are some tips for the research process:

• Start with a clear research question : A well-defined research question is the foundation of a successful research project. It should be specific, relevant, and achievable within the given time frame and resources.
• Conduct a thorough literature review: A comprehensive literature review will help you to identify gaps in existing knowledge, build on previous research, and avoid duplication. It will also provide a theoretical framework for your research.
• Choose appropriate research methods: Select research methods that are appropriate for your research question, objectives, and sample size. Ensure that your methods are valid, reliable, and ethical.
• Be organized and systematic: Keep detailed notes throughout the research process, including your research plan, methodology, data collection, and analysis. This will help you to stay organized and ensure that you don’t miss any important details.
• Analyze data rigorously: Use appropriate statistical and analytical techniques to analyze your data. Ensure that your analysis is valid, reliable, and transparent.
• I nterpret results carefully : Interpret your results in the context of your research question and objectives. Consider any limitations or potential biases in your research design, and be cautious in drawing conclusions.
• Communicate effectively: Communicate your research findings clearly and effectively to your target audience. Use appropriate language, visuals, and formats to ensure that your findings are understood and valued.
• Collaborate and seek feedback : Collaborate with other researchers, experts, or stakeholders in your field. Seek feedback on your research design, methods, and findings to ensure that they are relevant, meaningful, and impactful.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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• How to write actionable policy recommendations

By Nyasha Musandu 16/07/2013

When writing a policy brief, there are many things one has to consider: The language has to be just right, not too technical but professional. The length has to be brief yet informative and most of all it needs to speak to a pre-identified and targeted audience.

The policy brief has become the ‘go to’ tool in facilitating evidence based policies. The policy brief seeks to inform the decision maker of policy options that are evidence based, robust and will achieve the desired result in various scenarios. With the creation of each policy brief we hope that maybe, just maybe, we will get the right policy maker to read our compelling arguments, experience a eureka moment and spearhead the process of creating sound and effective policies with our research as their sword.  Unfortunately, policy influence rarely happens in this manner. What you have to try to do is identify your policy makers’ problems and give him/her actionable policy recommendations.

Here are some simple things to consider to ensure that your recommendations are practical and actionable.

1 .   Ensure that you have identified your target audience beforehand. Understanding who your audience is and what their job entails is crucial. What is their sphere of influence and what change can they implement?

2.   Be very clear about what the current policy you want to change is.

3.   Set the scene: Identify the shortfalls of the current policy. Where is this policy failing, why and how can your recommendations improve the status quo?

4.   Be aware of how policies are made: remember that government policy actors are interested in making decisions that are practical, cost-effective and socially acceptable.

5.   If you are suggesting change ask yourself: What specifically needs to be changed? How will this change come about? What resources will be needed? Where will these resources come from? What is the overall benefit to both the policy maker and society in general? If your recommendations include these components they are much more likely to garner the required change.

6.   The word actionable suggests that your recommendations should be active. Try using language that is active rather than passive. Words such as use, engage, incorporate etc.

7 .   Keep your policy recommendations short. Identify 3 recommendations and elaborate on these. Pick the three that are most practical and relevant for your target audience then focus on presenting these in the most actionable way.

8 .   Make sure your research supports your recommendations. This may sound very obvious but policy makers will want to know that the evidence supports your assertions. Where you are providing an opinion, not supported by research, make this very clear.

9.   Ask yourself, is my recommendation viable? Does the recommendation seem feasible?

References:

·       Global HIV/AIDS Initiatives Network, 2008. Policy Brief Guidelines.

·       Community – Based Monitoring System (CBMS) Network Coordinating Team. Guidelines for writing a policy brief.

·       FAO. Food Security Communications Toolkit .

·       MEASURE Evaluation, 2009. Making Research Findings Actionable: A quick reference to communicating health information for decision making .

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Summary, Conclusion, and Recommendations

• First Online: 01 November 2022

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• Yasir Alenazi 3  

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This chapter presents the conclusions reached in this study, acknowledging some limitations and suggestions for further research. The chapter is presented in seven sections. The first section (7.2) provides a brief overview of the research project. The second section (7.3) demonstrates a summary of the major findings based on the research questions and analysis. The third section (7.4) presents the contributions of the study. The fourth section (7.5) offers two pedagogical frameworks as a set of recommendations to improve ESL/EFL teaching/learning with respect to language errors and writing skills. The chapter concludes (sections 7.6 and 7.7) by presenting the limitations of the study and suggesting areas for further research.

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Al-Jabri, S. M. H. (1998). An analysis of lexical errors in written English of Saudi college freshman female students [Unpublished Master’s thesis], Girls College of Education.

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Alenazi, Y. (2022). Summary, Conclusion, and Recommendations. In: Exploring Lexical Inaccuracy in Arabic-English Translation. New Frontiers in Translation Studies. Springer, Singapore. https://doi.org/10.1007/978-981-19-6390-2_7

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Definition of recommendation

Examples of recommendation in a sentence.

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'recommendation.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

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15th century, in the meaning defined at sense 1a

Phrases Containing recommendation

• on someone's recommendation

Dictionary Entries Near recommendation

recommended

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“Recommendation.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/recommendation. Accessed 23 Apr. 2024.

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Meaning of recommendation in English

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• advice Let me give you some advice.
• help I didn't know who to turn to for help.
• a piece of advice Let me give you a piece of advice.
• counsel I will miss his wise counsel.
• guidance Young people don't always appreciate the guidance offered by their parents and teachers.
• counseling US Victims of abuse usually need expert counseling.
• They were accused of trying to emasculate the report's recommendations.
• The National Executive is expected to endorse these recommendations.
• I'd like to see the research that these recommendations are founded on.
• This committee can make recommendations but it has no real teeth .
• I don't know what to choose . What's your recommendation?
• affirmation
• ally yourself to/with someone
• argumentation
• flag-waving
• provide for someone
• recommended
• stick together

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recommendation | Intermediate English

Recommendation | business english, examples of recommendation, collocations with recommendation, recommendation.

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Institute of Medicine (US) Committee on Community-Based Drug Treatment; Lamb S, Greenlick MR, McCarty D, editors. Bridging the Gap between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington (DC): National Academies Press (US); 1998.

Bridging the Gap between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment.

• Hardcopy Version at National Academies Press

6 Findings and Recommendations

The committee's review of current research, models for collaboration between research and practice, community-based organizations, and dissemination strategies led to findings and recommendations in six areas: (1) strategies for linking research and practice, (2) strategies for linking research findings, policy development, and implementation, (3) strategies for knowledge development, (4) strategies for dissemination and knowledge transfer, (5) strategies for consumer participation, and (6) training strategies for community-based research collaboration. The committee believes that attention to its recommendations will lead to improvements in clinical practices and will enhance the value of treatment research to clinicians, investigators, policymakers, clients, and to the general public.

• STRATEGIES FOR LINKING RESEARCH AND PRACTICE

The committee found some striking examples of strong collaborations between community-based drug and alcohol abuse treatment programs and academic research institutions. It was apparent, however, that relatively few investigators work closely with community treatment programs and even fewer programs participate actively in research.

Treatment programs benefit from being part of a learning culture that, among other characteristics, values knowledge development and hypothesis testing. Research collaboration can provide tangible and intangible benefits that improve an agency's competitive position—enhanced information systems, education and mentoring for clinical staff, contributions to overhead costs, access to state-of-the-art treatment interventions, staff pride, and more informed consumers.

Research participation becomes a possibility for treatment providers when community-based organizations are compensated for the true costs of research participation, and when program staff and investigators collaborate in construction of hypotheses, research design, and data collection, analysis, and interpretation.

Only a small proportion of community-based agencies currently have the capacity to participate fully in long-term partnerships with teams of investigators. The level of participation in research collaborations depends on an agency's stage of organizational development, the compatibility of the studies with the organization's mission and culture, and its financial stability. Thus, participation may vary from relatively passive participation (completing surveys and submitting data to state databases) to involvement as a partner in the development of research questions, data collection, and data interpretation. However, incentives must change for all parties if real progress is to be made.

The trust necessary for long-term collaboration is generally based on a history of increasing involvement. Successful collaborative programs from other health fields include support for a permanent infrastructure that facilitates long-term development. The National Cancer Institute's Community Clinical Oncology Program (CCOP) uses this strategy to bring state-of-the-art oncology research to community-based cancer treatment programs. CCOP facilitates research collaborations and enhances the ability of treatment programs to apply research findings to the general patient population. Development of a similar mechanism for use in community-based drug abuse treatment programs could catalyze research/practice collaborations and stimulate improvements in practice. The CCOPs are not inexpensive and they present a significant managerial challenge. The infrastructure alone at each clinical site can exceed $200,000. However, the infrastructure recommendation that follows does not necessarily require a model with that complexity. It could begin as a demonstration project involving a basic infrastructure enhancement of perhaps one full-time equivalent staff person and some computer support to a small set of diverse treatment sites. This level of support would be the target, whichever of the various network collaboration models is finally implemented.

Based on these findings, the committee offers two recommendations and identifies certain key characteristics that will facilitate their successful implementation.

RECOMMENDATION 1. The National Institute on Drug Abuse and the Center for Substance Abuse Treatment should support the development of an infrastructure to facilitate research within a network of community-based treatment programs, similar to the National Cancer Institute's Community Clinical Oncology Program (CCOP) networks.

To be successful, the infrastructure and network development will depend on commitment from the community-based treatment programs and researchers. Certain key areas will need to be addressed to foster partnership. For the community-based treatment programs, these include:

• encouraging and, when appropriate, participating in biomedical, social-behavioral, treatment effectiveness, and services research;
• seeking collaboration with researchers to build information systems that enhance the delivery of clinical services, improve program management and operations, and contribute to research databases;
• enhancing quality improvement strategies and fostering the development of organizational learning; and
• promoting staff education on current research and creating strategies to encourage adoption of clinical protocols that hold promise to improve treatment services.

Likewise, for treatment researchers, the following approaches are suggested:

• encouraging and, when appropriate, seeking collaborative opportunities with community-based drug treatment organizations (CBOs);
• recognizing the burdens of research on programs and consumers and providing fair compensation for the time and resources required to participate in studies;
• remaining sensitive to any potential their work has to harm consumers or treatment programs;
• guarding against the misuse of their research findings and the findings of other researchers in the development of funding and regulatory policies and the design of clinical protocols;
• supporting, through their work and their policy participation, consumer education on state-of-the-art clinical services; and
• recognizing the value of consumer participation by providing information accessible to consumers about the benefits of research, by including consumers on study advisory groups and by integrating informed consumer opinion in research proposals and study designs.

RECOMMENDATION 2. The National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism should develop research initiatives to foster studies that include community-based treatment programs as full partners.

Issues to be addressed by these initiatives are:

• including representatives from the treatment community in the development of the research initiative and in the review of proposals;
• showing sensitivity to the needs and constraints of community-based programs;
• requiring, in the proposal, an assessment of the study's burden and impact on the treatment program and its clients, as well as its potential relevance and practicality for CBO implementation;
• requiring active, early, and permanent participation of treatment staff in the development, implementation, and interpretation of the study;
• emphasizing the consideration of gender, gender identity, race, and urban/rural issues in research priorities; and
• providing a rapid funding mechanism to promote small research projects on emerging issues affecting treatment (e.g., managed care, welfare reform, performance measurement).
• STRATEGIES FOR LINKING RESEARCH FINDINGS, POLICY DEVELOPMENT, AND TREATMENT IMPLEMENTATION

State and federal policies sometimes hinder the diffusion of knowledge flowing from research relevant to drug abuse treatment. Selective prohibitions on the use of state and federal funds can inhibit the application of proven research findings. Language in the Substance Abuse Prevention and Treatment Block Grant, for example, prohibits the use of federal funds for needle exchange, despite studies demonstrating this improves the effectiveness of outreach to the population at highest risk for HIV infection. A similar restriction on the use of funds for client payments inhibits the implementation of behavioral reinforcement strategies. Local laws and policies restrict the development and operation of methadone services. Moreover, state and federal officials have generally not used funding mechanisms to facilitate collaboration between treatment programs and researchers, to foster adoption of new and effective treatments, or to improve the design of clinical research.

The committee believes that the coordination of state and federal programs is important to facilitate active collaboration and improvement of drug and alcohol treatment. Two recommendations are offered emphasizing the role of states in this collaboration, accompanied by approaches to undergird needed support.

RECOMMENDATION 3. State authorities should provide financial incentives for collaborative investigations between CBOs and academically oriented research centers; and should support structures to foster broad participation among researchers, practitioners, consumers, and payers in the development of a treatment research agenda, including studies to measure outcomes and program operations.

RECOMMENDATION 4. CSAT and the states need to cooperate in the development of financial incentives that encourage the inclusion of proven treatment approaches into community-based treatment programs. This approach should include making additional funds available for implementing targeted treatment approaches.

To improve treatment, the following are considered critical areas to address:

• Creating mechanisms to ensure the adoption of treatments proven to be effective and development of requests for proposals that support implementations of specific treatments within local community-based settings.
• Supporting the development of management information systems within community-based drug treatment programs, including consultation for system planning. These data systems should not be a one-way conduit to a state database but should also provide information to the treatment programs in a usable format and become the basis of public reports on outcomes.
• Expanding researcher, provider, and consumer participation in the development of licensing standards, staff development requirements, and initiatives to enhance consumer participation. State licensing standards provide the basis for monitoring treatment outcomes and processes and for managing progress toward desired patient outcomes. The best staff development standards require ongoing staff training and education (e.g., through publications, seminars, enrollment in continuing education, and attendance at training sessions that disseminate information on emerging developments in clinical care). Consumer participation standards provide consumers with information on state-of-the-art treatment techniques, and outcomes measurement systems are best developed with input from families and patients.
• STRATEGIES FOR KNOWLEDGE DEVELOPMENT

Drug and alcohol abuse treatment providers were often critical of treatment research. At the same time, there was considerable support for collaborating on research projects that had immediate application to problems faced in patient care. Practitioners and policymakers requested more research on treatment effectiveness—studies that help programs operate more effectively and identify interventions that serve clients more effectively.

The committee's findings suggest that expanding the range of studied treatment settings, treatment modalities, and treatment populations may result in more broadly applicable treatment research findings. These observations led the committee to make two specific recommendations in this area.

RECOMMENDATION 5. CSAT and NIDA should develop mechanisms to enable state policymakers to monitor service delivery in community-based treatment programs and to determine if consumers receive services empirically demonstrated as effective and to ascertain if the treatment dosage and intensity are sufficient to be effective.

RECOMMENDATION 6. NIDA and NIAAA should continue to support ''real world" services research and cost-effectiveness studies and include the development of services research in their strategic plans.

• STRATEGIES FOR DISSEMINATION AND KNOWLEDGE TRANSFER

The committee found at least four factors that inhibit diffusion of drug abuse treatment knowledge: (1) the structure of treatment delivery systems; (2) the diversity of the clients, providers, and other stakeholders; (3) the stigmatization of people who are dependent on alcohol and other drugs; and (4) an inadequate base of knowledge about technology transfer specific to the field. Differences in perspective among consumers, clinicians, researchers, and policymakers also inhibit knowledge dissemination and use.

While there is a general knowledge base about technology transfer, there has been little research on information exchange in the drug abuse treatment field. Research findings about technology transfer specific to drug abuse treatment are needed to help overcome the critical barriers to information exchange and reduce the knowledge gaps in this field.

Treatment programs are underutilizing research findings in the area of psychosocial interventions, pharmacotherapy, and integrated service delivery approaches. Several approaches have been shown in other fields to successfully close the gaps between treatment, research, and policy and there are models that could be applied more widely in the future.

Because providers and payers are often unaware of the latests research, the committee found a pressing need to create consensus in the field about which treatments have been proven to be effective and which have been proven to be ineffective. Further, the research agendas of the federal agencies should continue to be fueled by agreement in the field on which models have not received adequate study. The fruits of this consensus process should be widely distributed.

Key to improving knowledge dissemination will be cooperation and collaboration across federal agencies, states, professional organizations, and consumer groups, among others. The committee recommends two general approaches to establish the needed collaboration.

RECOMMENDATION 7. CSAT, NIDA, NIAAA, and AHCPR are the federal agencies that should develop formal collaborations, where appropriate, to synthesize research, reduce the barriers to knowledge transfer, and provide updated information about drug and alcohol treatment strategies to purchasers of health care.

A variety of approaches could be utilized to accomplish these goals. For example, expert panels of investigators, practitioners, program administrators, policymakers, and consumers could be convened by NIDA, NIAAA, and CSAT to generate up-to-date consensus recommendations for community-based drug and alcohol treatment programs based on current research. NIDA-, NIAAA-, and AHCPR-sponsored research on drug treatment knowledge dissemination would help to reduce barriers to the transfer of treatment knowledge and encourage treatment programs and policymakers to adopt proven treatments. Research findings need to be prepared in a form, and disseminated within channels, that enhance availability and acceptability to community-based treatment programs—especially front-line treatment staff. Continued support for and improvement of electronic and print publications directed to treatment programs and consumers is necessary; and other media, such as public access television, should be considered.

CSAT, NIDA, and NIAAA also have an important role in the development of information to enable purchasers of care to take research findings into account explicitly in making purchasing decisions. At the same time, purchasers should develop treatment criteria that ensure treatments of proven effectiveness are adequately funded and should consider withholding funding when the science base shows the treatment to be unequivocally ineffective.

RECOMMENDATION 8. CSAT, in collaboration with state substance abuse authorities, professional organizations, and consumer organizations in the addiction field, should continue the development of evidence-based treatment recommendations for use by clinicians of all disciplines involved in the treatment of drug and alcohol use disorders.

To ensure that these treatment recommendations have a positive impact on health care, these agencies and groups should work to encourage their use. Measurement of the impact of guidelines on clinical care delivery will optimally include short-, intermediate-, and long-term treatment outcomes.

• STRATEGIES FOR CONSUMER PARTICIPATION

Consumers are rarely involved in the issues of how drug abuse treatment research is supported and conducted. Although many community-based treatment programs were founded by men and women in recovery and counselors in recovery make up a significant portion of the workforce, there are few advocacy groups for patients and their families. In view of the stigma and legal hazards attached to illicit drug abuse, the reluctance to advocate is understandable but unfortunate. Consumer advocacy for state-of-the-art services has improved care for individuals with cancer and with HIV/AIDS. Drug abuse treatment may enjoy similar benefits if drug treatment consumers become informed consumer advocates.

RECOMMENDATION 9. CSAT and NIDA, in collaboration with state substance abuse authorities, should develop public awareness programs to encourage consumers and their families to recognize high-quality treatment programs so they will begin to demand that treatment programs include research-proven treatment approaches within their treatment models.

There are a variety of approaches that can be considered by these groups to accomplish this goal. These include:

• Encouraging provider quality scorecard development to assure that consumer-oriented quality and satisfaction data, including shortand long-term data, are available to the public. Scorecard development is an early stage but growing movement in health care generally and could provide useful information about community-based treatment programs.
• Reviewing and updating the formats and content of communication vehicles to assure that treatment and research information is accessible to consumers and to the community-based treatment organizations.

It is also critically important that representatives of consumers and their families, with the support and assistance of the research, treatment, and policy communities, promote local as well as national advocacy groups to work with state funding agencies, insurers, managed care organizations, and self-insured employers to encourage the use of valid and reliable measures of treatment outcomes. Such measures serve as a basis for evaluating the efficacy of specific treatment modalities and the cost effectiveness of treatment programs, individual treatment providers and networks of care. State and federal government and employers and purchasing alliances could then be encouraged to use these data to inform their health care purchasing and contracting decisions. Consumer groups should also advocate for the development of standards of care in community-based clinics, treatment networks, integrated delivery systems, and managed care networks. Such standards could be used in accreditation of treatment programs and are best if based on findings from clinical research as well as broadly accepted clinical consensus.

• TRAINING STRATEGIES FOR COMMUNITY-BASED RESEARCH COLLABORATION

Research collaboration, especially collaboration in services research, requires skills and knowledge not generally provided in most graduate training programs. In order to foster collaborative research, it is necessary to enhance these skills in the next generation of drug abuse researchers. At the same time, despite the plethora of prior recommendations for addressing this problem, clinical training programs often fail to provide the background and orientation for treatment research. Thus, both clinical and research training programs need to be more attentive to the need for collaboration to improve treatment in this field.

The committee made three recommendations specific to preparing trainees for active participation in clinical research studies.

RECOMMENDATION 10. NIDA and other research funding agencies should support predoctoral and postdoctoral research training programs that provide experience in drug abuse treatment research and health services research within community-based treatment programs. Programs funded should have the full and active participation of community-based treatment programs and should include resources to fund the costs of participation for the treatment programs.

RECOMMENDATION 11. University training programs in the health professions should:

• enhance exposure of students to didactic teaching about substance abuse and dependence;
• require didactic teaching as well as supervised clinical experiences in community-based treatment settings;
• teach students to interpret substance abuse treatment research and apply research findings in their clinical practices;
• work with professional organizations to enhance continuing education about the addictions within the residency training curriculum of the various health professions; and
• support researchers seeking to enhance collaborative relationships with treatment programs by offering tuition credit for CBO staff involved in funded collaborative research.

RECOMMENDATION 12. NIDA, CSAT, and other appropriate funding agencies should create research training programs for staff members of community-based treatment programs to strengthen the ability of the treatment programs to include research activities and to adopt the findings of research into their treatment approaches. Training programs should promote research training for clinical staff through fellowships and tuition remission, and incentives for attending professional meetings.

To enhance the likelihood that these recommendations are given serious consideration by the agencies to which they are addressed, the assistance of foundations is also needed. Foundations could play an important role by developing grant programs to:

• Support training in clinical and services research in the addiction disorders. These grants should emphasize skills needed for participating in collaborative research and in the translation and implementation of treatment research into local community settings.
• Support training for consumers and their families in becoming effective advocates and in the development of advocacy organizations to promote state-of-the-art treatment and treatment research, as well as consumer participation in policy areas such as the development of standards of care.
• Cite this Page Institute of Medicine (US) Committee on Community-Based Drug Treatment; Lamb S, Greenlick MR, McCarty D, editors. Bridging the Gap between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington (DC): National Academies Press (US); 1998. 6, Findings and Recommendations.
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Who needs Paxlovid now? New guidelines suggest only highest-risk groups should get COVID drug

Recommendations for provincial drug plans feature narrower definition of who should qualify.

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This story is part of CBC Health's Second Opinion, a weekly analysis of health and medical science news emailed to subscribers on Saturday mornings. If you haven't subscribed yet, you can do that by  clicking here .

If you consider yourself at a higher risk of serious illness from COVID-19 — because of your age, or maybe due to preexisting health issues — you might assume you'll be able to get treatment with Paxlovid when the time comes.

And you might assume the steep cost of the antiviral drug would be automatically covered by your provincial health plan.

But all that might change. There are new Canadian recommendations for who should actually get Paxlovid at this point, guided by a growing body of research suggesting the drug's life-saving benefits now apply to a narrower definition of high-risk individuals.

The expert committee for the Canadian Agency for Drugs and Technologies in Health (CADTH), the body providing advice for the country's publicly funded health care systems, released draft recommendations earlier this year which offer fresh guidance for how drug plans should cover the treatment.

It stipulates Paxlovid should only be reimbursed for patients in two scenarios: If someone is severely immunosuppressed (such as organ transplant recipients) or moderately immunosuppressed (such as someone undergoing cancer treatment, individuals with advanced HIV infections, or anyone with moderate immunodeficiencies).

Simply being older or unvaccinated — both factors long thought to hike someone's risk of serious illness or death from COVID — didn't make the cut.

The recommendations were provided to drug plans on April 11 as part of a negotiation process during which provinces decide whether or not to follow suit.

Multiple medical experts said if provincial decision makers do choose to align with the committee's suggestions, Canadians would only be eligible to get Paxlovid covered if they meet the narrow criteria for severe or moderate immunosuppression. 

Those potential changes may come as a surprise to many Canadians who've long been eligible under broader provincial guidelines — including some that currently allow people as young as 60 to access the drug based on their age and other related risk factors.

But multiple experts told CBC News that who is truly high-risk now, four years into the pandemic, has changed. And narrowed eligibility is based on the latest research into how well the drug works for various groups, said University of British Columbia researcher Colin Dormuth, whose own findings helped inform the CADTH recommendations.

"The risk of something bad happening to you because of COVID-19 is now very low," Dormuth said.

COVID drug Paxlovid may not be reaching enough patients

Who's most at risk has 'changed over time'.

In the early years after SARS-CoV-2 first struck, the arrival of Pfizer's oral antiviral drug — a combination of the medications nirmatrelvir and ritonavir — was hailed as a game-changer. 

But its rollout was marred by controversy. There were reports of symptom "rebound" after the five-day treatment, which was later found to happen whether or not people took the drug . Some physicians also questioned who actually benefited from Paxlovid as the pandemic evolved. And, perhaps not surprisingly given all that debate, there was often low uptake, which left hundreds of thousands of treatments sitting unused across Canada.

Most recently, the federal government stopped its purchases of Paxlovid as of March 31, leaving future procurement up to the provinces. Most of Canada's remaining inventory also expired at the end of March, with a smaller portion expiring on May 31, said a spokesperson for the Public Health Agency of Canada.

Now multiple studies, including Dormuth's, are shedding light on where Pfizer's drug actually fits into the COVID treatment picture at this point in the pandemic.

• Second Opinion Once touted as a COVID-19 'game changer,' Paxlovid is now a question mark for clinicians
• Prescriptions for COVID-19 antiviral Paxlovid double in Ontario after pharmacists allowed to prescribe

Published in a letter to members of the medical community from the University of British Columbia (UBC) Therapeutics Initiative , Dormuth's observational study looked at more than 6,000 B.C. residents. It showed Paxlovid was associated with reduced chance of severe illness in people at the highest risk, but found no evidence that it made a difference for anyone else. 

"Even just within older people over 70, we didn't find an improvement in terms of reducing one's chance of being hospitalized or dying," Dormuth told CBC News.

"The bottom line is that for most people with COVID-19, Paxlovid will not make you feel better any faster, and will not lower your chance of [serious illness]."

The results, which have not been peer-reviewed, align with Pfizer's own findings. The drugmaker's latest trial data, published in the New England Journal of Medicine earlier this month, looked at standard-risk groups — people who had risk factors and were vaccinated, along with unvaccinated individuals. 

That trial found there weren't any major differences in COVID-related hospitalizations and deaths, nor was there any difference in how long people had symptoms, whether or not people had Paxlovid.

The Pfizer research also included participants of various ages. Age alone "is at best an arbitrary marker for risks … and needs to be contextualized among other risk factors such as vaccination status and comorbidities," wrote the Therapeutics Initiative team at UBC in their latest letter.

The draft CADTH guidelines for the province's drug plans also stressed that the risk factors involved in developing severe COVID once included a wide range of factors including older age, but "have changed over time" as population immunity increased. 

• N.B. use of COVID-19 treatment still low, as hospitals struggle with respiratory illnesses
• A senior says she ended up in the ER after being denied the COVID treatment Paxlovid

Many experts now agree that widespread vaccination and prior infections helped the vast majority of people develop immunity to what was once a brand-new threat, reducing rates of serious illness. Vaccines are also thought to dramatically ward off the possibility of developing long COVID .

And in Canada, the number of patients dying of COVID has plummeted , even among the oldest adults — though they still face highest rates of hospitalizations and ICU stays, which can erode someone's quality of life.

Drug still 'lifesaving' for high-risk individuals

It all paints a reassuring picture of this virus' trajectory. 

Yet the grim reality is that deaths from COVID remain a routine occurrence, with more than 30 Canadians losing their lives in the last week of March . 

The question now is just how many of those deaths could be prevented — and whether the people who could benefit most from Paxlovid are the ones actually getting the drug.

U.S. infectious diseases physician Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security, also stressed Paxlovid was never designed to lessen people's symptoms in the general population, but rather to prevent severe disease. 

• Elderly Canadians remain at higher risk of serious COVID from first infections, study suggests

And while it still works for that purpose, he warned misconceptions around the drug mean it ends up being under-prescribed in high-risk populations.

"'Keeping you alive' isn't resonating with people as much as 'decreasing your sore throat faster' or something like that," said Adalja.

"If people misunderstand what it does and it doesn't deliver on something that it was never designed to do, and people form a negative evaluation of the drug, that creates apprehension around prescribing it, and patients aren't asking their doctors for it."

Thousands of doses of COVID-19 antiviral treatment remain unused

Adelja argued eligibility should remain more broad, allowing anyone with known risk factors — such as being 65 and up, pregnant, obese, or having other health issues or immunodeficiencies — to access the drug.

"Right now… Paxlovid is the best we have and it's really lifesaving for high-risk individuals," he said.

Anyone who considers themselves high risk should speak to their primary care provider about the drug if they do catch COVID, Dormuth said, adding he's concerned that people who truly need the drug might not be the ones accessing it in Canada. 

In B.C. alone, roughly 300 people each week take Paxlovid, according to data cited by UBC's Therapeutics Initiative. 

But with much less PCR testing and collection being done at this point in the pandemic, and no one collecting at-home rapid testing results, Dormuth said we've lost "critical data" to help understand who's getting sick and why.

'Resources aren't infinite' as drug costs $1,200+

The reality, he added, is "resources aren't infinite." 

Pfizer's drug is pricey, costing $1,288.88 per five-day course, CADTH's documents show, prompting some experts to question if widespread purchasing and prescribing would actually save enough lives to justify those costs. (Should provinces no longer cover Paxlovid, it's also possible ineligible people may also have the option of paying out-of-pocket, or through private insurers, but again, it all depends on what each province decides.)

"As soon as we spend a dollar on one thing, we can't spend it on something else," Dormuth added.

With SARS-CoV-2 still circulating, multiple experts agreed that more front line treatments could come down the pike, making further studies into drug efficacy essential. 

• Second Opinion Researchers are still untangling the risks of catching COVID over and over

"We definitely continue to need more research on what treatments actually work for COVID in the acute phase, and we still don't have that evidence," said Unity Health public health specialist Dr. Andrew Pinto, the director of the University of Toronto's Upstream Lab .

Pinto is part of a Canadian team doing ongoing research into Paxlovid and other existing and future treatments through the cross-country CanTreatCOVID trials, which have so far enrolled roughly 450 participants.  The goal, he said, is eventually pooling results with the larger PANORAMIC trials happening in the U.K.

"COVID is still with us, and will likely continue to be with us," he said. "It's still quite a deadly disease compared to other respiratory infections."

ABOUT THE AUTHOR

Senior Health & Medical Reporter

Lauren Pelley covers health and medical science for CBC News, including the global spread of infectious diseases, Canadian health policy, pandemic preparedness, and the crucial intersection between human health and climate change. Two-time RNAO Media Award winner for in-depth health reporting in 2020 and 2022. Contact her at: [email protected]

• @LaurenPelley

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