Mustafa Afifi 1, Abdulbari Bener 2,3*

1 Dept. of Non- Communicable Diseases, Ministry of Health, Muscat, Sultanate of Oman
2 Dept. of Medical Statistics and Epidemiology, Hamad Medical Corporation
3 Dept. Evidence for Population Health Unit, School of Epidemiology and Health Sciences,
The University of Manchester, Manchester, UK

*Correspondence to:
Prof. Abdulbari Bener
Advisor to WHO
Consultant & Head,
Dept. of Medical Statistics and Epidemiology
Hamad Medical Corporation
Weill Cornell Medical College Qatar
PO Box 3050, Doha -State of Qatar
Office Tel: + 974- 439 3765
Office Tel: + 974- 439 3766
Email: abener@hmc.org.qa
Email: abaribener@hotmail.com

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ABSTRACT Research alone is no silver bullet for health development in the Arab world. In our countries, health research is fragmented where there is little communication between research producers, users, and policy makers. It is long debated whether policy process runs well ahead of research-based evidence or researchers are not selecting the appropriate "horses for courses". In this current short review we will explore why does research evidence have little influence on health policies? We also would point to some factors that could promote the linkage and integration of researchers and policy makers. We also explain the expected role and goals of health research departments or units in the Arab world, along with the different strategies to be adopted for health research dissemination and communication. This is followed by recommendations for promoting research integrity and the quality of studies; which, in its turn, would help in increasing policy makers' trust, develop their interest in research-informed policy making, and work on fostering the research- policy link. Accordingly, the role of ethics' committees and sub-committees, the importance of developing or adopting health research guidelines, and the role of medical associations would be explained. Finally, answers to two important questions would be figured out. Firstly, how do the medical journals constitute a crucial part of research process? Secondly how could medical journals ensure the quality of the published research as well as the effectiveness of its peer review process?

Key words: Research, policy, communication, integrity, dissemination, Arab world
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Research is a structured process of collecting, analyzing, synthesizing, and interpreting (explaining or describing) data to answer theoretical questions not visible in data themselves. Policies are governmental or organizational guidelines about allocation of resources and principles of desired behavior.1 Policy making is the process by which governments translate their political vision into programs and actions to deliver outcomes - desired changes in the real world.
Health policies are of three categories: governance policy which relates to organizational and financial structures; service policies which cover resource allocation issues and pattern of services, and practice policies which relate to the use of resources by practitioners in delivering patient care. For each category, analysis of the link between policy-making and of research utilization, often identifies at least three broad areas of activity: policy agenda setting, policy formulation, and policy implementation. 2

The phases of the policy-making process are 3:

• Policy formulation (creating a common vision, goals and objectives, setting the agenda, information and data on existing conditions, engaging key interest groups)
  
• Policy alternatives (generate and evaluate alternatives, research)
  
• Policy decision (agreement, approval processes, enactment)
  
• Policy implementation (regulations, plan, budget, competency, capacity, monitoring)
  
• Policy review (adaptation or change)
  

1. Nature of processes: e.g. core versus secondary issues, early intervention within the policy formulation phase could have greater influence than at the end of the legislative process.

2. Links between decision making and level of scrutiny: Decision taking has been divided into three main types - routine, incremental and fundamental. At each stage, the level of data, information and knowledge becomes more complex.

• Routine decisions are regular with a focus on keeping the status quo with minimal amendments to design and no changes to principles or values. At this level of decision-making, data and analysis are sufficient to understand and to modify the current situation.
  
• Incremental decisions deal with selective issues as they occur, but do not deal systematically or comprehensively with constituents. Consequently a level of policy analysis is sufficient to identify alternatives and compromises on the selected issues.
  
• However, fundamental decisions occur rarely and aim at re-examining the policy in its entirety. The level of scrutiny of the issues is intense, backed up with research, debate and comprehensive consultation. 4,5

3. Role of research
Various methodologies exist and are promoted by research units in developing countries to influence policy decisions. Examples are dissemination of research results, interaction between researchers and policy makers during each phase, public dissemination of research results in mass media, or strengthening capacity of researchers who will develop future policy. Based on research into the policy-making process by the IDRC in 2001, the literature review 6 identifies issues related to the role of research in policy making. These include the use of knowledge, and the type of policy framework.

A. Use of knowledge
In the process of policy-making, data, information and knowledge are imperative for rigorous decision making. However, a distinction in the perception of researchers and policy makers regarding knowledge makes the use of research more complex. For policy makers, research is one source of knowledge in the policy-making process.

B. Policy frameworks
To comprehend the policy-making process, the frameworks (such as linear, incremental, interactive, agenda-setting, policy networks, policy narratives and policy transfer) 6 provide a way of explaining the factors contributing to the process. The frameworks also provide ways of planning interventions to influence policy outcomes and to provide an analysis of when and how stakeholders may or may not be consulted.

Policy should be based on evidence; either the context free evidence which concerns what works in general, or the context sensitive evidence which deals with the conditions of implementation. The Canadian Health Service Research Foundation defined evidence as "[the] information that comes closest to the facts of a matter. The form it takes depends on context. The findings of high-quality, methodologically appropriate research are the most accurate evidence. Because research is often incomplete and sometimes contradictory or unavailable, other kinds of information are necessary supplements to or stand-ins for research. The evidence base for a decision is the multiple forms of evidence combined to balance rigor with expedience, while privileging the former over the latter" 7.The evidence from research should be broadened to anticipate the dynamics of the process and the involvement of an appropriate range of actors, but without compromising on rigor of knowledge or exclusion of stakeholders. 5

The existence of relevant health research, though necessary, is not sufficient. Research alone is no "silver bullet" for health in developing countries. To be of benefit, research should legitimize some polices and throw doubts on others. The study of the role of research in child health policy and programs in Pakistan found some examples of immediate clear-cut linkage between research and decisions. However it shows that research was under-utilized.8 Similarly, in the Arab world, health research is fragmented; there is little communication between research producers, users and policy makers. Moreover, there is virtually no information on the linkages between health research and health policy in developing countries. 9

Researchers and decision makers tend only to connect, if they connect at all, around the products of their process. This is a less than opportune time to insert research into the policy process, which is actually not an event. Researchers' view to decision making as an event fails to do justice to the nature of policy making process. Equivalently, research is viewed by policy makers as a retail store, where products from not processes within the research community are what concerns decision makers. 10 Actually, researchers and policy makers fail to face three challenges; what are the best solutions to the most burdensome health problems, what are the best ways to fit these solutions into the complex health system, and what are the best ways to bring about the desired changes in the health systems. 11

Abdur Rab 12 investigated the utilization of research results in five EMRO countries namely Egypt, Morocco, Iran, Sudan, and Pakistan. He found that, in some of these countries, research reports are sent to health authorities for information. A formal mechanism does not appear to exist in any of the five countries for scrutinizing research reports to select those where the results may have policy or program implications. The heads of institutions who were interviewed in Egypt, felt that results of research on communicable disease and on health systems are more likely to be used by authorities. In Sudan, interviews with senior health managers indicated that results of research are more likely to be used when the Ministry has specifically commissioned it. The decree for establishing policy-making councils for applicable research in all the medical universities in Iran, is an interesting innovation for promoting 'utilizable research'. The close links between the researchers and health service personnel in Iran, both belonging to the same Ministry, may account to some extent for this positive experience. Abdur Rab 12 concluded that the need of a much improved linkage between the demand side (users of research) and the supply side (the producers of research) has emerged very clearly from his study. In other words the inter-linkage of research to policy, needs to be developed and strengthened. He added that (?)we will need a new orientation for health researchers and as well as for policy makers and managers in the health ministries. The capacity of users to articulate their research needs and to critically appraise research findings (sadly lacking at the moment) need to be developed as a priority. 12

Health policies, not infrequently, do not reflect research evidence to the extent in theory that they could. Policy makers sometimes need unequivocal and rapid research, or want final answers (or covers for their decisions), not predictable conclusions that "more research is needed". 1 Whether policy process runs well ahead of research, or researchers are not selecting the appropriate "Horses for Courses" i.e. conducting the right research in the right place at the right time, is difficult to answer. 13 Sometimes the researchers might be unprepared or unwilling to communicate their results to the public or to decision makers; they accept that publication of results in scientific journals is sufficient to bring them into eventual use. 1

Black 14 mentioned some reasons why research evidence has little influence on service policies: policy makers have goals other than clinical effectiveness, research evidence dismissed as irrelevant, complexity of research evidence or scientific controversy, other types of competing evidence as personal experience, social environment not conducive to policy change, or poor quality of knowledge purveyors. 14

Troslte et al. 1 looked for factors that promoted or impeded exchanges between researchers and policy makers. These were in turn divided into emphasis on content, actors, process, and context, summarized in table 1. 1

Promoting responsible conduct of research fosters the research-policy link:
Responsible conduct of research (RCR) is the responsibility of individuals, the research institution, and the medical journals as well. Training on research methodology and biomedical ethics, mentoring, developing research policy, adopting guidelines for the conduct of research, availability and functioning of ethics committee, research integrity-oriented information to authors in medical journals, are some of the strategies to promote research integrity (RI) and responsible conduct of research in the Arab world.

Promoting research integrity and RCR would increase policy-makers' trust, develop their interest in research-informed policy making and work on strengthening or fostering the research - policy link. Moreover, managing research integrity is a part of the research institutions' responsibilities to the general public, which in turn certainly affect the later perception to the institutions' commitment with this regard. Ethics committees, developing or adopting research guidelines, the national medical associations, the role of medical journals, constitutes crucial tools to promote RI and will be discussed hereafter.

1. Ethics' committee:

The most important body in promoting RI is the ethics committees on the national level and the institutional review boards (IRBs) on the institutional level. Ethics committees and IRBs should apply the common principles of autonomy, non-maleficence, beneficence and justice to research proposals but with variable weighting as the ethical requirements differ markedly between the various countries. In ensuring that ethical standards are met and research has scientific merit, ethics committees have obligations to participants (to meet their rights and protect them from harm); to society (to ensure good quality research is conducted); and to researchers (to treat their proposals with just consideration and respect). 15 Ethics committees scrutinize research proposals to ensure that they are scientifically valid with rigorous methodology. Scientific validity of the study, fair selection of the study participants, favorable risk-benefit ratio, independent reviewing process, informed consent, respect for recruited participants and the study community, collaborative partnership and the social value of the study are the ethical principles of biomedical studies. 16 Moreover, a sub-committee for fieldwork monitoring is required to ensure the researcher's adherence to their proposals as well as to the ethical principles.

2. Health research guidelines

Developing or adopting research guidelines is crucial to promote RI. In 1990, Nobel surveyed medical schools regarding research guidelines and found that only 13% had general institutional guidelines and 19% were considering developing guidelines, whereas 68% stated that they neither had nor were considering developing or adopting guidelines. 17 In the United States, the Office of Research Integrity (ORI) is responsible for protecting the integrity of the research supported by the grants awarded for the Public Health Services (PHS) extra-mural research program.18 After ten years of Nobel 17 study, the Office of Research Integrity (ORI) conducted a study questioning : how many accredited U.S. medical school have guidelines that relate to the conduct of research and what topics are addressed by the guidelines. Of 125 accredited medical schools, 98 (78.4%) had some form of research conduct guidelines. However, most individual institutional guidelines suffer to some extent from limited focus and fragmentation in the development of guidelines. Table 2 shows the different topics, which should be included in an ideal guideline for conduct of research, fitting into clusters. Only 46% had guidelines relating to data management; 37% had guidelines relating to publications and data dissemination; 56% (partially) covered investigator's role and 94% discussed legal issues. Thus, more than half of current guidelines cover no more than two of the four clusters in table 2. Accordingly, it was concluded that there is still a great need for development of more comprehensive written guiding principles.19 Similarly, Ministries of Health in the Arab countries should be encouraged to develop or adopt guidelines for responsible conduct of research to promote research integrity within its national program that aim to improve the quality and effectiveness of health care.

3. The role of medical associations

The Medical Associations in our Arab world could also play an important role in leverage of the professional strengths of their members by adopting research methodology and ethical issues in its continuous medical education programs. Members who violate research ethics deliberately could be subjected to disciplinary actions for their deeds as well as those with medical ethics violations or malpractice. Altman 20 raised the question: "what should we think about a doctor who uses the wrong treatment, either willfully or through ignorance, or who uses the right treatment wrongly? " He answered that most people would agree that such behavior is unprofessional, arguably unethical and certainly unacceptable. Similarly, he concluded, that we should think about researchers who use the wrong techniques, use the right techniques wrongly, misinterpret their results, report their results selectively, cite the literature selectively, and draw unjustified conclusions. He added that numerous studies of the medical literature in both general and specialist journals, have shown that all of the above phenomena of violating research integrity or research misconduct are common, concluding that this is surely a scandal. 20

4. The role of medical journals

Because of what Altman20 said, medical journals, by providing credible information medium for the scientific community, constitute a crucial part of the research process. Information published in the Uniform Requirements, the most frequently cited Instructions to Authors, in the PubMed indexed medical journals include topics that are related to research integrity besides those that are related to manuscript preparation. Copyrights, authorship, reference practice, publishing practice, financial disclosure, peer review, human subject research, animal research, correcting the literature, research misconduct were the ten primary topics investigated by Scheetz 21 in his study analyzing the degree to which integrity issues are addressed in Instruction to Authors (IA) of 41 medical journals. Scheetz 21 found that the above ten topics were found only in 7% of the journals and 58% of the IA contained four or fewer of these primary topics. He concluded that there is a lack of uniformity and frequency of primary topic categories and integrity measures. He added that editors and publishers are in a unique position to help cultivate a scientific culture that promotes research integrity through instruction they provide to authors and enhance the research cycle by educating their readers about research integrity. 21 Thus, managing and promoting the integrity of research should be the future goals for every Arab biomedical journal. Learning from the Croatian experience where the Croatian Medical Journal introduces, what it believes to be, the first Research Integrity Editor. Moreover, the Croatian Medical Journal intends to facilitate the development of an Office of Research Integrity, based on the ORI model, to develop regulations to define scientific misconduct, investigate, and develop administrative actions against those found to have committed scientific misconduct. 22

5. The authorship credit and research integrity

Given the association between authorship credit and responsibility from one side and research misconduct and scientific fraud in the other side, we can not deal with one leaving the other.23 A frequently encountered challenge in Arab world is the authorship credit and the disputes around such credit and authorship order. An existing situation, despite not scientifically-grounded by studies in our countries, leads to the emergence of either guest authors added to the list without fulfilling the criteria of authorship, or ghost authors who are deleted from the list albeit fulfilling such criteria. 23 Many people accept or confer gift authorship, detection is unlikely, and the rewards are obvious: tenure, promotion, research grants, and fame, especially in a society that measures worth by the weight of papers produced rather than their quality. 24 Authorship credit should be based on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3. Collection of data, technical help, general supervision of the research group or department chair, alone, does not justify authorship. The order of authorship on the byline should be a joint decision of the co-authors. All contributors who do not meet the criteria for authorship should be listed in an acknowledgments section. 25 COPE 26 prepared some guidelines which could help researchers to handle authorship disputes. They recommended three principles: 1) encourage a culture of ethical authorship where researchers should not simply follow local customs and practice but they need to be aware of the views of editors, 2) start discussing authorship when planning the study, so researchers have to raise the subject right from the start at a face to face meeting and continue to discuss ideas about authorship as the project evolves keeping a written record of discussions, and 3) decide authorship before starting each article as many authorship difficulties arise because of misplaced expectations and poor communication. Before starting to write the project, confirm in writing who will do what and when. Ideally this should be face to face and keep everyone informed of any changes with a written note. 26

6. The pre and post-publication peer review process

Smith 27 stated that "the problem of peer review is that we have good evidence on its deficiencies and poor evidence on its benefits" 27 The medical journals could promote the quality of published articles and the effectiveness of their peer-review process by adopting many strategies. "Asking first" protocol by querying potential reviewers before sending manuscripts is an alternative protocol to "just send" where reviewers are allowed to opt out. Pitkin and Burmeister concluded in their study 28 that assenting "ask first" referees completed reviews faster. However, they found no indication that soliciting in advance affected review quality. 28 Schroter et al.29 found that one full day of a face to face training package had only a slight impact on the quality of peer review in terms of quality of reviews and detection of deliberate major errors. However, the training did influence reviewers' recommendations to editors. Hence, they recommended that the value of longer interventions needs to be assisted.29 Baxt et al. 30 found that peer-reviewers failed to identify two thirds of the major errors in a fictitious manuscript. Therefore, they concluded that the use of a preconceived manuscript into which purposeful errors are placed may be a viable approach to evaluate reviewer performance. 30

Scientific discourse occurs in many forms among colleagues, at scientific meetings, during peer review and after publication. Such discourse is essential to interpreting studies and guiding future research. There are mainly two categories of letter to editor in medical journals; the critical letter which provides a forum for readers to comment about articles recently published in the journal and the research letter which reports concise research. 31,32 the critical letter is an essential part of post-publication peer review. 31 Many readers seem to assume that articles published in peer reviewed journals are scientifically sound, despite much evidence to the contrary. It is important, therefore, that misleading work be identified after publication. 33 Through the letters, scientific articles published are subject to continuing scrutiny. Letters also document discussions and debate. Moreover, it helps make a journal accountable to the scientific community 34 Therefore, journals welcome and encourage the submission of letters to editors. 31,35 Mayberry stated that any editor is glad to know that his or her journal is being read and that articles have prompted a response. 36

The poor linkage between research and policy results in directing only 10% of research and development spending at the health problems that cause 90% of the world's disease burden. 9 Therefore, research units and departments in the Arab Ministries of Health should assist with the formulation of assessment tools that reveal the full picture of the way research is used in policy making. Research units should first draw on the research policies in their countries. Research policy comprising goals to be achieved, strategies to be taken and health and health related priorities should be developed by and implemented in research institutions. Then, units have to set defined research policies' goals as disseminating the research culture, capacity building of health workers and researchers, and evidence-based policy and planning. Such goals would facilitate implementing the research strategies and knowing the strengths, weaknesses, opportunities and threats in any health research system (HRS). Defining a sound health research system would censor how responsible the research is conducted; the aforementioned point, and what are the incentives or disincentives influencing research finding utilization. HRS functions are stewardship, financing, building resources, and conducting studies. One of the main elements that distinguish a HRS is the attempt to develop mechanisms and networks to facilitate the greater use of health research. Researchers, by conceptualizing the utilization process, could definitely help in developing the interest in research-informed policy making and work on strengthening or fostering the research - policy link. 2,9

The research units could adopt many research communication and dissemination strategies to facilitate the use of research findings. These strategies include: maximizing press and media exposure, widespread distribution of brochures and pamphlets, increasing the use of the internet and other electronic means of dissemination, publishing research papers, disseminating policy briefs, engaging with policy makers through policy debates, and holding open seminar presentations. 37

Policy decisions are not necessarily made based on a single study. On the other hand, a single research study can have multiple policy implications. Best use of the research results starts with ensuring relevance to the potential users. This requires research that fits within national priorities rather than externally imposed agenda. The various groups of people who are concerned by the issues being studied, the stakeholders, should be identified and become involved at various steps of the process of research planning, management and dissemination. Interaction among all the stakeholders needs to be intensive and take place at multiple overlapping stages of the research and decision making process. A common pitfall made by researchers in raising recommendations based on study findings, is not to involve all stakeholders. Researchers attempt to do this on their own belief that they are more neutral to the situation and will not bias the recommendations. The role of mediators is perhaps the most crucial component in fostering the linkage of research to policy. They could be researchers themselves, academic groups that support evidence-based decision-making, national research coordinating bodies, or international agencies.8

Troslte et al. 1 recommended improving communication between researchers and policy makers via training of both parties: assisting researchers to communicate their findings in an understandable and stimulating way, or synthesizing policy makers about the usefulness of research results as an input to decision making. They also recommended that research should be evaluated in terms of its cost and effectiveness before it is considered as the basis for a policy or program. However, this type of evaluation is still under-developed internationally. 1

The Canadian Heath Service Research Foundation has a two-page guidance note on how to present and communicate research findings for policy makers. This principle has been used to good effect in departments and agencies in Canada, Australia, the USA, the UK and other countries. Known as the 1:3:25 method, it refers to the number of pages in:

• The summary in bulleted form (1 page)
  
• Executive Summary (3 pages)
  
• Full length report (a maximum of 25 pages). 7

Knowledge Translation is the exchange, synthesis and ethically sound application of knowledge within a complex system of interactions among researchers and users, to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system." 38

It is time to extend the meaning of evidence, argues Dr. Dennis Willms (McMaster University, Hamilton, Ontario, Canada), beyond the results of traditional academic or scientific research to a broader definition encompassing experiential, intuitive, spiritual, practical and expert knowledge. Such a definition would facilitate the involvement of multiple stakeholders in a participatory process of dialogue and negotiation to arrive at a shared framework for understanding and seeking solutions to priority health problems. 39 This participatory process is a defining feature of what he calls translational research.

Translational research entails the systematic eliciting of, and building on, evidential and experiential stories from a wide range of stakeholders. The many actors engage in a process of structured reflection and action. Intentionally organized forums provide an opportunity for sharing understandings of the determinants of, and evidence for, a specific health problem, agreeing on a mutual language for framing these understandings and negotiating joint solutions. Referred to as "conceptual events" by Willms, these forums give equal time and voice to dissonant perspectives. They have the potential to form the basis for the design, dissemination, and evaluation of health interventions that are equitable, sustainable, culturally appropriate, and psychologically compelling. 39 Lomas 40 suggests three types of knowledge translation activities:

• Diffusion: These include activities that are passive and where the actual "translation" effect is relatively unplanned. The objective is simply to promote awareness. Examples include journal or newsletter publications, information on a
  website, or in the mass media.
  
• Dissemination: Interventions here include more intentional strategies, such as
  direct mailing of results to intended audiences, workshops, and conferences. The goal is both awareness creation and attitude change.
  
• Implementation: Here the interventions are even more active, with the intent of adding behavior change to awareness and attitude change. Efforts are directed to systematically identifying and overcoming barriers. Examples include specific meetings with opinion leaders, audit and feedback or reminder procedures, and administrative or economic interventions. 40
  

A number of important components of effective research dissemination are identified, including: 41-43

1. distillation of research findings,
   
2. the use of plain and clear language rather than academic style (implying a reduced methodological and theoretical content),
   
3. using a range of formats appropriately tailored to different audiences,
   
4. using multiple media channels;
   
5. paying attention to timing.
   
6. communicating research results differently to each health policy audience according to the type of the health policy, decision, or program being influenced. There are few examples of systematic reviews of research regarding the effectiveness of diffusion, dissemination and implementation strategies on changing the behavior of policy decision makers. One such review was created to provide guidance to health technology assessment programs in Europe 44 . The project's sub-group on Dissemination and Impact, after reviewing the available literature, concluded that personal contact with policy staff was more effective than distributing printed material. When printed reports are used, they should be short and should be written from the perspective of policy makers, specifically addressing questions that need answering. The style of presentation should be clear and compelling. These insights are now quite generally known, and used in the preparation and presentation of policy briefs. The role of health services research in public policy making have been examined by Lavis and colleagues. 45
   

The publication of the Netherlands Development Assistance Research Council 46 entitled Utilization of Research for Development Cooperation: Linking Knowledge Production to Development Policy and Practice, consists of a collection of papers that draw on the concept of 'knowledge creep', i.e. the notion that research does not necessarily have a direct impact on specific policies or decisions (as proposed in a linear model), but rather has an indirect influence on the policy environment - and hence on policy processes - through gradually introducing new perceptions and understanding. Research has an impact on the policy agenda through interactive, gradual processes and networks. A second publication also by RAWOO 47 repeats the agenda-setting point, arguing that support to capacity development should not just include research activities but also capacities related to agenda-setting ability and policy dialogue.

If there is an actual depression in marketing our research to policy makers in the Arab world, let us think business. First, we have to start with "customer analysis" where we should analyze the nature of policy makers, their educational background, how they perceive policy making process, their decision making capabilities, what factors they consider in policy making and what are their sources of information, the type of decisions made by them and examples of the recent policies made. Then, we have to know "the research share" in the policy making process i.e. to what extent research findings share in policy formulation. PEST analysis used in marketing could be applied in our situation where the Political, Economic, Socio-cultural and Technological factors should be analyzed.

Then, let us think about the marketing variables, which are known as the 4Ps: product development, pricing or economic affordability, promotion of the product, and place of the product or physical accessibility to it. (48) It was mentioned above about the need for ensuring the quality of the research product and responsible conduct of research which would lead to gaining the trust of our customers. As regards the price, our policy makers usually consider research as an expensive product. Unfortunately, we don't know much in our Arab world about the costs of studying a specific health domain and what would be the revenue from it. Therefore, to penetrate the market of policy making, we have to adopt the "demand based method" of pricing our research findings, where we have to respect the other competitive "cheap and fast" sources of information used by policy makers. When the demand on our research is low the price should go down. By that, I mean to start with the short term operational- based research with low integrated funding instead of the long term research of huge funding and slow outcomes. Moreover, in business, intermediaries play an important role in increasing efficiency and reducing costs. There are several different types of intermediary who come together to create different kinds of distribution channels between manufacturer and consumer. Similarly, knowledge brokering is a two-way process that aims to encourage policy makers to become more responsive to research findings and to stimulate researchers to conduct policy relevant research and to translate their findings to be meaningful to policy makers. (49)

Promotion of research has its different strategies including sensitizing our target from policy makers and the public to research findings, and training them to use these findings and increase their demands on it. Incentives and careers to the research producers are also crucial components of such promotion. The deliberate, planned and sustained effort of researchers and research brokers to institute and maintain mutual understanding between different research bodies and their target audience from policy makers and the public is a part of research promotion.

Similarly to the SWOT analysis in business, Innvaer (50) and Aaserud (51) have made attempts to isolate facilitators and barriers to the use of research evidence in policy-making. These points would help to guide researchers in making their research more policy-maker-friendly. Examples of the facilitators to use research are the good quality of research, timeliness and relevance of research, research with a conclusive summary and clear recommendations, community demand on research, good communication between researchers and policy makers and establishing channels with public authorities, and involvement of international and/or professional organizations. Barriers are the opposite of the aforementioned factors plus lack of human or non human resources and financial constraints. (50,51)

To conclude, to foster the link and communication between researchers and policy makers, we have to strengthen researchers' communication skills; to aim for close collaboration between researchers and policy-makers; to construct an appropriate platform from which to communicate; and to strengthen the institutional capacity of policy departments to take up research.