How to get research into practice: first get practice into research

Strengthening the Operational Research Capacity of National Tuberculosis Control Programs: Necessity or Luxury?

'How to get research into practice: first get practice into research [...].

Quality, Equity and Partnerships in Mixed Methods and Qualitative Research during Seven Years of Implementing the Structured Operational Research and Training Initiative in 18 Countries

Introduction: Qualitative studies are often inadequately reported, making it difficult to judge their appropriateness for decision making in public health. We assessed the publication characteristics and quality of reporting of qualitative and mixed-method studies from the Structured Operational Research and Training Initiative (SORT IT), a global partnership for operational research capacity building. Methods: A cross-sectional analysis of publications to assess the qualitative component using an adapted version of the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results: In 67 publications involving 18 countries, 32 journals and 13 public health themes, 55 were mixed-methods studies and 12 were qualitative studies. First authorship from low-and-middle-income (LMIC) countries was present in 64 (96%), LMIC last authorship in 55 (82%), and female first authorship in 30 (45%). The mean LMIC institutions represented per publication was five (range 1–11). Sixty-three (94%) publications were open access. Reporting quality was graded as ‘good’ to ‘excellent’ in 60 (89%) publications, ‘fair’ in five (8%) and ‘poor’ in two (3%). Conclusion: Most SORT IT publications adhered to COREQ standards, while supporting gender equity in authorship and the promotion of LMIC research leadership. SORT IT plays an important role in ensuring quality of evidence for decision making to improve public health.

How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean

Innovative strategies are needed to improve the delivery of evidence-informed health interventions. Embedded implementation research (EIR) seeks to enhance the generation and use of evidence for programme improvement through four core features: (1) central involvement of programme/policy decision-makers in the research cycle; (2) collaborative research partnerships; (3) positioning research within programme processes and (4) research focused on implementation. This paper examines how these features influence evidence-to-action processes and explores how they are operationalized, their effects and supporting conditions needed. We used a qualitative, comparative case study approach, drawing on document analysis and semi-structured interviews across multiple informant groups, to examine three EIR projects in Bolivia, Colombia and the Dominican Republic. Our findings are presented according to the four core EIR features. The central involvement of decision-makers in EIR was enhanced by decision-maker authority over the programme studied, professional networks and critical reflection. Strong research-practice partnerships were facilitated by commitment, a clear and shared purpose and representation of diverse perspectives. Evidence around positioning research within programme processes was less conclusive; however, as all three cases made significant advances in research use and programme improvement, this feature of EIR may be less critical than others, depending on specific circumstances. Finally, a research focus on implementation demanded proactive engagement by decision-makers in conceptualizing the research and identifying opportunities for direct action by decision-makers. As the EIR approach is a novel approach in these low-resource settings, key supports are needed to build capacity of health sector stakeholders and create an enabling environment through system-level strategies. Key implications for such supports include: promoting EIR and creating incentives for decision-makers to engage in it, establishing structures or mechanisms to facilitate decision-maker involvement, allocating funds for EIR, and developing guidance for EIR practitioners.

Bridging the gap between real estate research and professional practice in Nigeria

Purpose

Beyond contributing to literature, research findings are expected to reinforce existing best practices while also serving as a springboard for formulating new and more efficient methods of undertaking economic activities. However, academic research is sometimes divorced from implementation and research findings are not always translated into practice. This study, therefore, assesses the impact of real estate research activities and findings on the practice of real estate surveying and valuation in Nigeria as the largest real estate market in Africa.

Design/methodology/approach

An online questionnaire survey was conducted to obtain relevant data from Estate Surveyors and Valuers across the country. The survey questions cover reading of academic papers from the field of real estate and the reasons for doing so; whether they have made any changes to their professional practice based on findings from academic papers; and possible barriers to adoption academic research findings in your practice. Mean score ranking and principal component analysis were employed for data analysis.

Findings

Out of a total of 61 participants, only 35 have made a change to their professional practice based on findings from academic papers they have read. “Personal development and enlightenment” ranks first on the list of reasons for reading academic papers among the participants while barriers to the adoption of academic research findings relate mainly to education, dissemination and lack of guidance on how to apply research findings.

Practical implications

The study demonstrates how findings from real estate research are being applied and identifies possible barriers that must be addressed to improve the level of application and consequently, the value of academic studies.

Originality/value

The study provides evidence on barriers to the adoption of academic research and contributes to the global effort to bridge the gap between academia and practice.

Quality, Equity and Utility of Observational Studies during 10 Years of Implementing the Structured Operational Research and Training Initiative in 72 Countries

Introduction: Observational studies are often inadequately reported, making it difficult to assess their validity and generalizability and judge whether they can be included in systematic reviews. We assessed the publication characteristics and quality of reporting of observational studies generated by the Structured Operational Research and Training Initiative (SORT IT). Methods: A cross-sectional analysis of original publications from SORT IT courses. SORT IT is a global partnership-based initiative aimed at building sustainable capacity for conducting operational research according to country priorities and using the generated evidence for informed decision-making to improve public health. Reporting quality was independently assessed using an adapted version of ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) checklist. Results: In 392 publications, involving 72 countries, 50 journals, 28 publishers and 24 disease domains, low- and middle-income countries (LMICs) first authorship was seen in 370 (94%) and LMIC last authorship in 214 (55%). Publications involved LMIC-LMIC collaboration in 90% and high-income-country-LMIC collaboration in 87%. The majority (89%) of publications were in immediate open access journals. A total of 346 (88.3%) publications achieved a STROBE reporting quality score of >85% (excellent), 41 (10.4%) achieved a score of 76–85% (good) and 5 (1.3%) a score of 65–75% (fair). Conclusion: The majority of publications from SORT IT adhere to STROBE guidelines, while also ensuring LMIC equity and collaborative partnerships. SORT IT is, thus, playing an important role in ensuring high-quality reporting of evidence for informed decision-making in public health.

Investing in Operational Research Capacity Building for Front-Line Health Workers Strengthens Countries' Resilience to Tackling the COVID-19 Pandemic

(1) Introduction. The Structured Operational Research and Training IniTiative (SORT IT) supports countries to build operational research capacity for improving public health. We assessed whether health workers trained through SORT IT were (1) contributing to the COVID-19 pandemic response and if so, (2) map where and how they were applying their SORT IT skills. (2) Methods. An online questionnaire survey of SORT IT alumni trained between 2009 and 2019. (3) Results. Of 895 SORT IT alumni from 93 countries, 652 (73%) responded to the survey and 417 were contributing to the COVID-19 response in 72 countries. Of those contributing, 307 (74%) were applying their SORT IT skills to tackle the pandemic in 60 countries and six continents including Africa, Asia, Europe, South Pacific and North/South America. Skills were applied to all the pillars of the emergency response with the highest proportions of alumni applying their skills in data generation/analysis/reporting (56%), situation analysis (55%) and surveillance (41%). Skills were also being used to mitigate the health system effects of COVID-19 on other diseases (27%) and in conducting research (26%). (4) Conclusion. Investing in people and in research training ahead of public health emergencies generates downstream dividends by strengthening health system resilience for tackling pandemics. It also strengthens human resources for health and the integration of research within health systems.

A process for developing a sustainable and scalable approach to community engagement: community dialogue approach for addressing the drivers of antibiotic resistance in Bangladesh

Background

Community engagement approaches that have impacted on health outcomes are often time intensive, small-scale and require high levels of financial and human resources. They can be difficult to sustain and scale-up in low resource settings. Given the reach of health services into communities in low income countries, the health system provides a valuable and potentially sustainable entry point that would allow for scale-up of community engagement interventions. This study explores the process of developing an embedded approach to community engagement taking the global challenge of antibiotic resistance as an example.

Methods

The intervention was developed using a sequential mixed methods study design. This consisted of: exploring the evidence base through an umbrella review, and identifying key international standards on the appropriate use of antibiotics; undertaking detailed formative research through a) a qualitative study to explore the most appropriate mechanisms through which to embed the intervention within the existing health system and community infrastructure, and to understand patterns of knowledge, attitudes and practice regarding antibiotics and antibiotic resistance; and b) a household survey – which drew on the qualitative findings - to quantify knowledge, and reported attitudes and practice regarding antibiotics and antibiotic resistance within the target population; and c) drawing on appropriate theories regarding change mechanisms and experience of implementing community engagement interventions to co-produce the intervention processes and materials with key stakeholders at policy, health system and community level.

Results

A community engagement intervention was co-produced and was explicitly designed to link into existing health system and community structures and be appropriate for the cultural context, and therefore have the potential to be implemented at scale. We anticipate that taking this approach increases local ownership, as well as the likelihood that the intervention will be sustainable and scalable.

Conclusions

This study demonstrates the value of ensuring that a range of stakeholders co-produce the intervention, and ensuring that the intervention is designed to be appropriate for the health system, community and cultural context.

Health system decision-makers at the helm of implementation research: development of a framework to evaluate the processes and effectiveness of embedded approaches

Background

Embedded approaches to implementation research (IR), whereby health system decision-makers participate actively in the research process, are gaining traction as effective approaches to optimise the delivery of health programmes and policies. However, the evidence base on the processes and effectiveness of such collaborative research remains inchoate. Standardised approaches to evaluate these initiatives are needed to identify core elements of ‘embeddedness’, unveil the underlying pathways of change, and assess contribution to evidence uptake in decision-making and overall outcomes of effect. The framework presented in this paper responds to this need, designed to guide the systematic evaluation of embedded IR.

Methods

This evaluation framework for embedded IR approaches is based on the experience of a joint initiative by the Pan American Health Organization/Alliance for Health Policy and Systems Research, which has supported 19 IR grants in 10 Latin American and Caribbean countries from 2014 to 2017. The conceptualisation of this framework drew on various sources of information, including empirical evidence and conceptual insights from the literature, interviews with content experts, and a prospective evaluation of the 2016 cohort that included semi-structured key informant interviews, document analysis, and a research team survey to examine key aspects of embedded research.

Results

We developed a widely applicable conceptual framework to guide the evaluation of embedded IR in various contexts. Focused on uncovering how this collaborative research approach influences programme improvement, it outlines expected processes and intermediate outcomes. It also highlights constructs with which to assess ‘embeddedness’ as well as critical contextual factors. The framework is intended to provide a structure by which to systematically examine such embedded research initiatives, proposing three key stages of evidence-informed decision-making – co-production of evidence, engagement with research, and enactment of programme changes.

Conclusion

Rigorous evaluation of embedded IR is needed to build the evidence on its processes and effectiveness in influencing decision-making. The evaluation framework presented here addresses this gap with consideration of the complexity of such efforts. Its applicability to similar initiatives is bolstered by virtue of being founded on real-world experience; its potential to contribute to a nuanced understanding of embedded IR is significant.

Cost-effectiveness analysis of a multi-dimensional intervention to reduce inappropriate antibiotic prescribing for children with upper respiratory tract infections in China

BACKGROUND

We developed a multifaceted intervention to reduce antibiotic prescription rate for children with upper respiratory tract infections (URTIs) among primary care doctors in township hospitals in China. The intervention achieved a 29% (95% CI 16-42) absolute risk reduction in antibiotic prescribing. This study was to assess the cost-effectiveness of our intervention at reducing antibiotic prescribing in rural primary care facilities as measured by the intervention's effect on the antibiotic prescription rates for childhood URTIs.

METHODS

We took a healthcare provider perspective, measuring costs of consultation (time cost of doctor), prescription monitoring process and peer-review meetings (time cost of participants) and medication costs. Costs on provider side were collected through a bespoke questionnaire from all 25 township hospitals in December 2016, while medication costs were collected prospectively in the trial. Incremental cost-effectiveness ratios were calculated by dividing the mean difference in cost of the two trial arms by the mean difference in antibiotic prescribing rate.

RESULTS

This showed an incremental cost of $0.03 per percentage point reduction in antibiotic prescribing. In addition to this incremental cost, the cost of implementing the intervention, including training and materials delivered by township hospitals, was $390.65 (SD $145.68) per healthcare facility.

CONCLUSIONS

This study shows that a multifaceted intervention programme, when embedded into routine practice, is very cost-effective at reducing antibiotic prescribing in primary care facilities and has the potential of scale up in similar resource limited settings.

Embedded health service development and research: why and how to do it (a ten-stage guide)

In a world of changing disease burdens, poor quality care and constrained health budgets, finding effective approaches to developing and implementing evidence-based health services is crucial. Much has been published on developing service tools and protocols, operational research and getting policy into practice but these are often undertaken in isolation from one another. This paper, based on 25 years of experience in a range of low and middle income contexts as well as wider literature, presents a systematic approach to connecting these activities in an embedded development and research approach. This approach can circumvent common problems such as lack of local ownership of new programmes, unrealistic resource requirements and poor implementation.We lay out a ten-step process, which is based on long-term partnerships and working within local systems and constraints and may be tailored to the context and needs. Service development and operational research is best prioritised, designed, conducted and replicated when it is embedded within ministry of health and national programmes. Care packages should from the outset be designed for scale-up, which is why the piloting stage is so crucial. In this way, the resulting package of care will be feasible within the context and will address local priorities. Researchers must be entrepreneurial and responsive to windows of funding for scale-up, working in real-world contexts where funding and decisions do not wait for evidence, so evidence generation has to be pragmatic to meet and ensure best use of the policy and financing cycles. The research should generate tested and easily usable tools, training materials and processes for use in scale-up. Development of the package should work within and strengthen the health system and other service delivery strategies to ensure that unintended negative consequences are minimised and that the strengthened systems support quality care and effective scale up of the package.While embedded development and research is promoted in theory, it is not yet practiced at scale by many initiatives, leading to wasted resources and un-sustained programmes. This guide presents a systematic and practical guide to support more effective engagements in future, both in developing interventions and supporting evidence-based scale-up.

Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster-randomised controlled trial

BACKGROUND

Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, and is particularly common in China. We assessed the effectiveness of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients by targeting providers and caregivers in primary care hospitals in rural China.

METHODS

We did a pragmatic, cluster-randomised controlled trial with a 6-month intervention period. Clusters were primary care township hospitals in two counties of Guangxi province in China, which were randomly allocated to the intervention group or the control group (in a 1:1 ratio in Rong county and in a 5:6 ratio in Liujiang county). Randomisation was stratified by county. Eligible participants were children aged 2-14 years who attended a township hospital as an outpatient and were given a prescription following a primary diagnosis of an upper respiratory tract infection. The intervention included clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief caregiver education. In hospitals allocated to the control group, usual care was provided, with antibiotics prescribed at the individual clinician's discretion. Patients were masked to their allocated treatment group but doctors were not. The primary outcome was the antibiotic prescription rate in children attending the hospitals, defined as the cluster-level proportion of prescriptions for upper respiratory tract infections in 2-14-year-old outpatients, issued during the final 3 months of the 6-month intervention period (endline), that included one or more antibiotics. The outcome was based on prescription records and analysed by modified intention-to-treat. This study is registered with the ISRCTN registry, number ISRCTN14340536.

FINDINGS

We recruited all 25 eligible township hospitals in the two counties (14 hospitals in Rong county and 11 in Liujiang county), and randomly allocated 12 to the intervention group and 13 to the control group. We implemented the intervention in three internal pilot clusters between July 1, 2015, and Dec 31, 2015, and in the remaining nine intervention clusters between Oct 1, 2016 and March 31, 2016. Between baseline (the 3 months before implementation of the intervention) and endline (the final 3 months of the 6-month intervention period) the antibiotic prescription rate at the individual level decreased from 82% (1936/2349) to 40% (943/2351) in the intervention group, and from 75% (1922/2548) to 70% (1782/2552) in the control group. After adjusting for the baseline antibiotic prescription rate, stratum (county), and potentially confounding patient and prescribing doctor covariates, this endline difference between the groups represented an intervention effect (absolute risk reduction in antibiotic prescribing) of -29% (95% CI -42 to -16; p=0·0002).

INTERPRETATION

In China's primary care setting, pragmatic interventions on antimicrobial stewardship targeting providers and caregivers substantially reduced prescribing of antibiotics for childhood upper respiratory tract infections.

FUNDING

Department of International Development (UKAID) through Communicable Diseases Health Service Delivery.

The role of NGOs' service delivery experience in developing relevant research agendas: experience and challenges among NGOs in Malawi

Background

There has been growing interest in the contribution of non-governmental organisations (NGOs) to international health research. One strength that NGOs may bring to research involves the potential value of service delivery experience for indicating relevant research questions, namely through their involvement in service delivery, NGO staff may be aware of frontline knowledge gaps, allowing these staff to identify questions that lead to research with immediate relevance. However, there is little empirical evidence on research agendas within NGOs to assess whether their service delivery experience does lead to relevant research or conditions that affect this. This article examines the identification and selection of research questions within NGOs to explore the role of their service delivery experience in generating relevant research agendas.

Methods

The article reports comparative case study research on four NGOs in Malawi, including two international and two Malawian organisations. Each NGO conducts research and undertakes service delivery and advocacy. Data collection included interviews, focus groups, observation and document review. Analysis involved thematic coding and use of diagrams.

Results

The case NGOs’ experiences suggest that using service delivery to identify research questions does not always match NGOs’ aims or capacities, and does not guarantee relevance. First, NGOs do not want to rely only on service delivery when developing research agendas; they consider other criteria and additional sources of ideas when selecting questions they see as relevant. Second, service delivery staff are not always well-placed to identify research topics; indeed, involvement in hectic, target-driven service delivery can hinder input to research agendas. Third, NGOs’ ability to pursue questions inspired by service delivery depends on control over their research agendas; relationships with external actors and financial autonomy affect NGOs’ capacity to undertake the research they see as relevant. Finally, the perceived relevance of research findings varies between audiences and depends on more than the research question.

Conclusions

The findings suggest limits to the value and feasibility of a research agenda based on service delivery experience. Based on the analysis, the conclusion outlines strategies to support an effective role for NGOs’ service delivery experience in development of research agendas.

Ten tips to improve the visibility and dissemination of research for policy makers and practitioners

Effective dissemination of evidence is important in bridging the gap between research and policy. In this paper, we list 10 approaches for improving the visibility of research findings, which in turn will hopefully contribute towards changes in policy. Current approaches include using social media (Facebook, Twitter, LinkedIn); sharing podcasts and other research outputs such as conference papers, posters, presentations, reports, protocols, preprint copy and research data (figshare, Zenodo, Slideshare, Scribd); and using personal blogs and unique author identifiers (ORCID, ResearcherID). Researchers and funders could consider drawing up a systematic plan for dissemination of research during the stage of protocol development.

Development of a Patient-Centred, Psychosocial Support Intervention for Multi-Drug-Resistant Tuberculosis (MDR-TB) Care in Nepal

Multi-drug-resistant tuberculosis (MDR-TB) poses a major threat to public health worldwide, particularly in low-income countries. The current long (20 month) and arduous treatment regime uses powerful drugs with side-effects that include mental ill-health. It has a high loss-to-follow-up (25%) and higher case fatality and lower cure-rates than those with drug sensitive tuberculosis (TB). While some national TB programmes provide small financial allowances to patients, other aspects of psychosocial ill-health, including iatrogenic ones, are not routinely assessed or addressed. We aimed to develop an intervention to improve psycho-social well-being for MDR-TB patients in Nepal. To do this we conducted qualitative work with MDR-TB patients, health professionals and the National TB programme (NTP) in Nepal. We conducted semi-structured interviews (SSIs) with 15 patients (10 men and 5 women, aged 21 to 68), four family members and three frontline health workers. In addition, three focus groups were held with MDR-TB patients and three with their family members. We conducted a series of meetings and workshops with key stakeholders to design the intervention, working closely with the NTP to enable government ownership. Our findings highlight the negative impacts of MDR-TB treatment on mental health, with greater impacts felt among those with limited social and financial support, predominantly married women. Michie et al's (2011) framework for behaviour change proved helpful in identifying corresponding practice- and policy-level changes. The findings from this study emphasise the need for tailored psycho-social support. Recent work on simple psychological support packages for the general population can usefully be adapted for use with people with MDR-TB.

Building Global Capacity for Conducting Operational Research Using the SORT IT Model: Where and Who?

Setting

Research capacity is weakest in low and middle-income countries (LMICs) where operational research is highly relevant and needed. Structured Operational Research and Training Initiative (SORT IT) courses have been developed to train participants to conduct and publish operational research and influence policy and practice. Twenty courses were completed in Asia, Africa, Europe and the South Pacific between 2009 and 2014.

Objectives

In the 20 completed SORT IT courses, to assess where the research was conducted, who was trained, who became facilitators in subsequent courses and course outcomes.

Design

A cohort study of completed SORT IT courses

Results

There were 236 participants (41% female) including 64 nationalities who conducted research in 59 countries, mostly from Asia and Africa (mean course duration = 9.7 months). Most participants (68%) were from government health programs and non-governmental agencies. A total of 213(90%) participants completed all milestones successfully with 41(19%) becoming subsequent course facilitators, 88% of whom were from LMICs. Of 228 manuscripts submitted to scientific journals, 197(86%) were either published or in press; in 86%, the principal investigator (first author) was a LMIC national. Papers were published in 23 scientific journals (impact factor 0.5–4.4) and covered 21 disease categories (median publication time = 5.7 months). Published papers (186) had 94,794 cumulative article views/downloads. Article views/downloads for immediate open access articles were double those from closed access journals.

Conclusion

The SORT IT model has been effective in training personnel to produce relevant operational research in LMICs. It merits continued commitment and support for further scale-up and development.

Which health research gets used and why? An empirical analysis of 30 cases

BACKGROUND

While health research is considered essential for improving health worldwide, it remains unclear how it is best organized to contribute to health. This study examined research that was part of a Ghanaian-Dutch research program that aimed to increase the likelihood that results would be used by funding research that focused on national research priorities and was led by local researchers. The aim of this study was to map the contribution of this research to action and examine which features of research and translation processes were associated with the use of the results.

METHODS

Using Contribution Mapping, we systematically examined how 30 studies evolved and how results were used to contribute to action. We combined interviews with 113 purposively selected key informants, document analysis and triangulation to map how research and translation processes evolved and contributions to action were realized. After each case was analysed separately, a cross-case analysis was conducted to identify patterns in the association between features of research processes and the use of research.

RESULTS

The results of 20 of the 30 studies were used to contribute to action within 12 months. The priority setting and proposal selection process led to the funding of studies which were from the outset closely aligned with health sector priorities. Research was most likely to be used when it was initiated and conducted by people who were in a position to use their results in their own work. The results of 17 out of 18 of these user-initiated studies were translated into action. Other features of research that appeared to contribute to its use were involving potential key users in formulating proposals and developing recommendations.

CONCLUSIONS

Our study underlines the importance of supporting research that meets locally-expressed needs and that is led by people embedded in the contexts in which results can be used. Supporting the involvement of health sector professionals in the design, conduct and interpretation of research appears to be an especially worthwhile investment.

Insights into Global Health Practice from the Agile Software Development Movement

Global health practitioners may feel frustration that current models of global health research, delivery, and implementation are overly focused on specific interventions, slow to provide health services in the field, and relatively ill-equipped to adapt to local contexts. Adapting design principles from the agile software development movement, we propose an analogous approach to designing global health programs that emphasizes tight integration between research and implementation, early involvement of ground-level health workers and program beneficiaries, and rapid cycles of iterative program improvement. Using examples from our own fieldwork, we illustrate the potential of 'agile global health' and reflect on the limitations, trade-offs, and implications of this approach.

Scaling up of physical activity interventions in Brazil: how partnerships and research evidence contributed to policy action

The global health burden due to physical inactivity is enormous and growing. There is a need to consider new ways of generating evidence and to identify the role of government in promoting physical activity at the population level. In this paper, we summarize key findings from a large-scale cross-national collaboration to understand physical activity promotion in Brazil. We describe the main aspects of the partnership of Project GUIA (Guide for Useful Interventions for Activity in Brazil and Latin America) that sustained the collaborative effort for eight years and describe how the evidence gathered from the collaboration triggered political action in Brazil to scale up a physical activity intervention at the national level. Project GUIA is a cross-national multidisciplinary research partnership designed to understand and evaluate current efforts for physical activity promotion at the community level in Latin America. This example of scaling up is unprecedented for promoting health in the region and is an example that must be followed and evaluated.

Physical activity interventions in Latin America: expanding and classifying the evidence

CONTEXT

Systematic reviews of public health interventions are useful for identifying effective strategies for informing policy and practice. The goals of this review were to (1) update a previous systematic review of physical activity interventions in Latin America which found that only school-based physical education had sufficient evidence to recommend widespread adoption; (2) assess the reporting of external validity elements; and (3) develop and apply an evidence typology for classifying interventions.

EVIDENCE ACQUISITION

In 2010-2011, community-level, physical activity intervention studies from Latin America were identified, categorized, and screened based on the peer-reviewed literature or Brazilian theses published between 2006 and 2010. Articles meeting inclusion criteria were evaluated using U.S. Community Guide methods. External validity reporting was assessed among a subset of articles reviewed to date. An evidence rating typology was developed and applied to classify interventions along a continuum based on evidence about their effectiveness in the U.S. context, reach, adoption, implementation, institutionalization, and benefits and costs.

EVIDENCE SYNTHESIS

Thirteen articles published between 2006 and 2010 met inclusion criteria and were abstracted systematically, yet when combined with evidence from articles from the previous systematic review, no additional interventions could be recommended for practice. Moreover, the reporting of external validity elements was low among a subset of 19 studies published to date (median=21% of elements reported). By applying the expanded evidence rating typology, one intervention was classified as evidence-based, seven as promising, and one as emerging.

CONCLUSIONS

Several physical activity interventions have been identified as promising for future research and implementation in Latin America. Enhanced reporting of external validity elements will inform the translation of research into practice.

Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact

INTRODUCTION

Evidence exists that community-based intervention packages can have substantial child and newborn mortality impact, and may help more countries meet Millennium Development Goal 4 (MDG 4) targets. A non-governmental organization (NGO) project using such programming in Mozambique documented an annual decline in under-five mortality rate (U5MR) of 9.3% in a province in which Demographic and Health Survey (DHS) data showed a 4.2% U5MR decline during the same period. To test the generalizability of this finding, the same analysis was applied to a group of projects funded by the US Agency for International Development. Projects supported implementation of community-based intervention packages aimed at increasing use of health services while improving preventive and home-care practices for children under five.

METHODS

All projects collect baseline and endline population coverage data for key child health interventions. Twelve projects fitted the inclusion criteria. U5MR decline was estimated by modelling these coverage changes in the Lives Saved Tool (LiST) and comparing with concurrent measured DHS mortality data.

RESULTS

Average coverage changes for all interventions exceeded average concurrent trends. When population coverage changes were modelled in LiST, they were estimated to give a child mortality improvement in the project area that exceeded concurrent secular trend in the subnational DHS region in 11 of 12 cases. The average improvement in modelled U5MR (5.8%) was more than twice the concurrent directly measured average decline (2.5%).

CONCLUSIONS

NGO projects implementing community-based intervention packages appear to be effective in reducing child mortality in diverse settings. There is plausible evidence that they raised coverage for a variety of high-impact interventions and improved U5MR by more than twice the concurrent secular trend. All projects used community-based strategies that achieved frequent interpersonal contact for health behaviour change. Further study of the effectiveness and scalability of similar packages should be part of the effort to accelerate progress towards MDG 4.

Is operational research delivering the goods? The journey to success in low-income countries

Operational research in low-income countries has a key role in filling the gap between what we know from research and what we do with that knowledge-the so-called know-do gap, or implementation gap. Planned research that does not tangibly affect policies and practices is ineffective and wasteful, especially in settings where resources are scarce and disease burden is high. Clear parameters are urgently needed to measure and judge the success of operational research. We define operational research and its relation with policy and practice, identify why operational research might fail to affect policy and practice, and offer possible solutions to address these shortcomings. We also propose measures of success for operational research. Adoption and use of these measures could help to ensure that operational research better changes policy and practice and improves health-care delivery and disease programmes.

Early experiences on the feasibility, acceptability, and use of malaria rapid diagnostic tests at peripheral health centres in Uganda-insights into some barriers and facilitators

Background

While feasibility of new health technologies in well-resourced healthcare settings is extensively documented, it is largely unknown in low-resourced settings. Uganda's decision to deploy and scale up malaria rapid diagnostic tests (mRDTs) in public health facilities and at the community level provides a useful entry point for documenting field experience, acceptance, and predictive variables for technology acceptance and use. These findings are important in informing implementation of new health technologies, plans, and budgets in low-resourced national disease control programmes.

Methods

A cross-sectional qualitative descriptive study at 21 health centres in Uganda was undertaken in 2007 to elucidate the barriers and facilitators in the introduction of mRDTs as a new diagnostic technology at lower-level health facilities. Pre-tested interview questionnaires were administered through pre-structured patient exit interviews and semi-structured health worker interviews to gain an understanding of the response to this implementation. A conceptual framework on technology acceptance and use was adapted for this study and used to prepare the questionnaires. Thematic analysis was used to generate themes from the data.

Results

A total of 52 of 57 health workers (92%) reported a belief that a positive mRDT result was true, although only 41 of 57 (64%) believed that treatment with anti-malarials was justified for every positive mRDT case. Of the same health workers, only 49% believed that a negative mRDT result was truly negative. Factors linked to these findings were related to mRDT acceptance and use, including the design and characteristics of the device, availability and quality of mRDT ancillary supplies, health worker capacity to investigate febrile cases testing negative with the device and provide appropriate treatment, availability of effective malaria treatments, reliability of the health commodity supply chain, existing national policy recommendations, individual health worker dynamism, and vitality of supervision.

Conclusions

mRDTs were found to be acceptable to and used by the target users, provided clear policy guidelines exist, ancillary tools are easy to use and health supplies beyond the diagnostic tools are met. Based on our results, health workers' needs for comprehensive case management should be met, and specific guidance for managing febrile patients with negative test outcomes should be provided alongside the new health technology. The extent, to which the implementation process of mRDT-led, parasite-based diagnosis accommodates end user beliefs, attitudes, perceptions, and satisfaction, as well as technology learnability and suitability, influences the level of acceptance and use of mRDTs. The effectiveness of the health system in providing the enabling environment and the integration of the diagnostic tool into routine service delivery is critical.

Relevance or excellence? Setting research priorities for mental health and psychosocial support in humanitarian settings

BACKGROUND

Humanitarian crises are associated with an increase in mental disorders and psychological distress. Despite the emerging consensus on intervention strategies in humanitarian settings, the field of mental health and psychosocial support (MHPSS) in humanitarian settings lacks a consensus-based research agenda.

METHODS

From August 2009 to February 2010, we contacted policymakers, academic researchers, and humanitarian aid workers, and conducted nine semistructured focus group discussions with 114 participants in three locations (Peru, Uganda, and Nepal), in both the capitals and remote humanitarian settings. Local stakeholders representing a range of academic expertise (psychiatry, psychology, social work, child protection, and medical anthropology) and organizations (governments, universities, nongovernmental organizations, and U.N. agencies) were asked to identify priority questions for MHPSS research in humanitarian settings, and to discuss factors that hamper and facilitate research.

RESULTS

Thematic analyses of transcripts show that participants broadly agreed on prioritized research themes in the following order: (1) the prevalence and burden of mental health and psychosocial difficulties in humanitarian settings, (2) how MHPSS implementation can be improved, (3) evaluation of specific MHPSS interventions, (4) the determinants of mental health and psychological distress, and (5) improved research methods and processes. Rather than differences in research themes across countries, what emerged was a disconnect between different groups of stakeholders regarding research processes: the perceived lack of translation of research findings into actual policy and programs; misunderstanding of research methods by aid workers; different appreciation of the time needed to conduct research; and disputed universality of research constructs.

CONCLUSIONS

To advance a collaborative research agenda, actors in this field need to bridge the perceived disconnect between the goals of "relevance" and "excellence." Research needs to be more sensitive to questions and concerns arising from humanitarian interventions, and practitioners need to take research findings into account in designing interventions.

Nurse led, primary care based antiretroviral treatment versus hospital care: a controlled prospective study in Swaziland

Background

Antiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting.

Methods

We undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience.

Results

Those receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0·37, p < 0·0001). Average travel cost was half that of those receiving hospital care (p = 0·001). Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1·23, p = 0·003). There was no significant difference in loss to follow-up or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation.

Conclusions

Clinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.

Health research strengthening and operational research needs for improving child survival in India

Health research can be utilized to improve the policies, interventions and outputs of the health systems, and ultimately the health of individuals and population. This requires systematic evaluation of evidence and its integration into national policies and programs after suitable adoption at the local level. It has been noted that there has been limited focus upon strengthening health research in India, due to weak research systems or institutional mechanisms, lack of trained human resources and enabling environment, absence of well defined priorities, perceived low quality of research, and inadequate funding. Though various vertical and integrated health programs for improving child survival in the country have been introduced, the decline in child mortality has been excessively slow. Operational research, a sub theme of health research, which uses systematic research techniques to provide evidence to the policymakers and program managers, can be used to assess programmatic issues and improve their effectiveness. This article analyzes the current situation of health research in India, describes briefly the process of operational research, and summarizes the areas of programmatic concern and priority topics for future research in five key fields of child health (Newborn health, Immunization, Malnutrition, Disease prevention and control, health systems strengthening). Finally, it outlines the immediate need of strengthening health research system in the country for improving child survival through increased funding, development of institutional mechanisms, building pool of talented researchers and provision of an enabling environment, to facilitate health and operational research in a scientifically credible manner and to ensure wider dissemination of results.

Primary health care: making Alma-Ata a reality

The principles agreed at Alma-Ata 30 years ago apply just as much now as they did then. "Health for all" by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritisation of health, structural adjustment policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. We propose the following priorities for revitalising primary health care. Health-service infrastructure, including human resources and essential drugs, needs strengthening, and user fees should be removed for primary health-care services to improve use. A continuum of care for maternal, newborn, and child health services, including family planning, is needed. Evidence-based, integrated packages of community and primary curative and preventive care should be adapted to country contexts, assessed, and scaled up. Community participation and community health workers linked to strengthened primary-care facilities and first-referral services are needed. Furthermore, intersectoral action linking health and development is necessary, including that for better water, sanitation, nutrition, food security, and HIV control. Chronic diseases, mental health, and child development should be addressed. Progress should be measured and accountability assured. We prioritise research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalise primary health care.

Adapting a generic tuberculosis control operational guideline and scaling it up in China: a qualitative case study

BACKGROUND

The TB operational guideline (the deskguide) is a detailed action guide for county TB doctors aiming to improve the quality of DOTS, while the China national TB policy guide is a guide to TB control that is comprehensive but lacks operational usability for frontline TB doctors. This study reports the process of deskguide adaptation, its scale-up and lessons learnt for policy implications.

METHODS

The deskguide was translated, reviewed, and revised in a working group process. Details of the eight adaptation steps are reported here. An operational study was embedded in the adaptation process. Two comparable prefectures were chosen as pilot and control sites in each of two participating provinces. In the pilot sites, the deskguide was used with the national policy guide in routine in-service training and supervisory trips; while in the control sites, only the national policy guide was used. In-depth interviews and focus groups were conducted with 16 county TB doctors, 16 township doctors, 17 village doctors, 63 TB patients and 57 patient family members. Following piloting, the deskguide was incorporated into the national TB guidelines for county TB dispensary use.

RESULTS

Qualitative research identified that the deskguide was useful in the daily practice of county TB doctors. Patients in the pilot sites had a better knowledge of TB and better treatment support compared with those in the control sites.

CONCLUSION

The adaptation process highlighted a number of general strategies to adapt generic guidelines into country specific ones: 1) local policy-makers and practitioners should have a leading role; 2) a systematic working process should be employed with capable focal persons; and 3) the guideline should be embedded within the current programmes so it is sustainable and replicable for further scale-up.

Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers

OBJECTIVES

To describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them.

METHODS

In-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach.

RESULTS

IPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp.

CONCLUSION

The benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors.

Implementing Intermittent Preventive Treatment for Malaria in Pregnancy: Review of Prospects, Achievements, Challenges and Agenda for Research

INTRODUCTION: Implementing Intermittent Preventive Treatment for malaria in Pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) through antenatal care (ANC) clinics is recommended for malaria endemic countries. Vast biomedical literature on malaria prevention focuses more on the epidemiological and cost-effectiveness analyses of the randomised controlled trials carried out in selected geographical settings. Such studies fail to elucidate the economic, psychosocial, managerial, organization and other contextual systemic factors influencing the operational effectiveness, compliance and coverage of the recommended interventions. OBJECTIVE: To review literature on policy advances, achievements, constraints and challenges to malaria IPTp implementation, emphasising on its operational feasibility in the context of health-care financing, provision and uptake, resource constraints and psychosocial factors in Africa. RESULTS: The importance of IPTp in preventing unnecessary anaemia, morbidity and mortality in pregnancy and improving childbirth outcomes is highly acknowledged, although the following factors appear to be the main constraints to IPTp service delivery and uptake: cost of accessing ANC; myths and other discriminatory socio-cultural values on pregnancy; target users, perceptions and attitudes towards SP, malaria, and quality of ANC; supply and cost of SP at health facilities; understaffing and demoralised staff; ambiguity and impracticability of user-fee exemption policy guidelines on essential ANC services; implementing IPTp, bednets, HIV and syphilis screening programmes in the same clinic settings; and reports on increasing parasite resistant to SP. However, the noted increase in the coverage of the delivery of IPTp doses in several countries justify that IPTp implementation is possible and better than not. CONCLUSION: IPTp for malaria is implemented in constrained conditions in Africa. This is a challenge for higher coverage of at least two doses and attainment of the Abuja targets. Yet, there are opportunities for addressing the existing challenges, and one of the useful options is the evaluation of the acceptability and viability of the existing intervention guidelines.