Getting research findings into practice: implementing research findings in developing countries

Security vulnerabilities in healthcare: an analysis of medical devices and software

The integration of IoT in healthcare has introduced vulnerabilities in medical devices and software, posing risks to patient safety and system integrity. This study aims to bridge the research gap and provide valuable insights for addressing healthcare vulnerabilities and their mitigation mechanisms. Software vulnerabilities related to health systems from 2001 to 2022 were collected from the National Vulnerability Database (NVD) systematized by software developed by the researchers and assessed by a medical specialist for their impact on patient well-being. The analysis revealed electronic health records, wireless infusion pumps, endoscope cameras, and radiology information systems as the most vulnerable. In addition, critical vulnerabilities were identified, including poor credential management and hard-coded credentials. The investigation provides some insights into the consequences of vulnerabilities in health software products, projecting future security issues by 2025, offers mitigation suggestions, and highlights trends in attacks on life support and health systems are also provided. The healthcare industry needs significant improvements in protecting medical devices from cyberattacks. Securing communication channels and network schema and adopting secure software practices is necessary. In addition, collaboration, regulatory adherence, and continuous security monitoring are crucial. Industries, researchers, and stakeholders can utilize these findings to enhance security and safeguard patient safety.

mHealth Phone Intervention to Reduce Maternal Deaths and Morbidity in Cameroon: Protocol for Translational Adaptation

Purpose

The purpose of this NIH-funded protocol is to adapt (Aim 1) and pilot test (Aim 2) an mHealth intervention to improve maternal and child health in Cameroon. We will adapt the 24/7 University of Alabama at Birmingham Medical Information Service via Telephone (MIST) provider support system to mMIST (mobile MIST) for peripheral providers who provide healthcare to pregnant and postpartum women and newborns in Cameroon.

Methods

In Aim 1, we apply qualitative and participatory methods (in-depth interviews and focus groups with key stakeholders) to inform the adaptation of mMIST for use in Cameroon. We use the sequential phases of the ADAPT-ITT framework to iteratively adapt mMIST incorporating qualitative findings and tailoring for local contexts. In Aim 2, we test the adapted intervention for feasibility and acceptability in Ndop, Cameroon.

Results

This study is ongoing at the time that this protocol is published.

Conclusion

The adaptation, refinement, and pilot testing of mMIST will be used to inform a larger-scale stepped wedged cluster randomized controlled effectiveness trial. If successful, this mHealth intervention could be a powerful tool enabling providers in low-resource settings to deliver improved pregnancy care, thereby reducing maternal and fetal deaths.

Intrasphincteric anastomotic urethroplasty allows preservation of continence in men with bulbomembranous urethral strictures following benign prostatic hyperplasia surgery

PURPOSE

Injury to the external sphincter during urethroplasty at or near the membranous urethra can result in incontinence in men whose internal sphincter mechanism has been compromised by previous benign prostatic hyperplasia (BPH) surgery. We present outcomes of a novel reconstructive procedure, incorporating a recent anatomic discovery revealing a connective tissue sheath between the external sphincter and membranous urethra, which provides a surgical plane allowing for intrasphincteric bulbo-prostatic urethroplasty (ISBPA) with continence preservation.

METHODS

Stricture at or near the membranous urethra after transurethral resection (TURP) or open simple prostatectomy (OSP) was reconstructed with ISBPA. The bulbomembranous junction is approached dorsally with a bulbar artery sparing approach and the external sphincter muscle is carefully reflected, exposing the wall of the membranous urethra. Gentle blunt dissection along this connective tissue plane allows separating the muscle away up to the prostatic apex, where healthy urethra is found for anastomosis.

RESULTS

From January 2010 to August 2019, 40 men (18 after TURP and 22 after OSP) underwent ISBPA at a single institution. Mean age was 67 years (54-82). Mean stricture length was 2.6 cm (1-6) with obliterative stricture identified in 10 (25%). At a mean follow-up of 53 months (10-122), 36 men (90%) are free of stricture recurrence and 34 (85%) were completely dry or using one security pad.

CONCLUSION

This novel intrasphincteric urethroplasty technique for stricture following BPH surgery is feasible and safe, allowing successful reconstruction with continence preservation in most patients. A larger series and reproduction in other centers is needed.

Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis

BACKGROUND

Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles.

OBJECTIVES

(1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review.

SEARCH METHODS

We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed.

SELECTION CRITERIA

We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively.

DATA COLLECTION AND ANALYSIS

We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness.

MAIN RESULTS

We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses.

AUTHORS' CONCLUSIONS

Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.

Risk and benefits of Bubble Continuous Positive Airway Pressure for neonatal and childhood respiratory diseases in Low- and Middle-Income countries

Over 80% of the global burden of childhood deaths occur in Low- and Middle-Income Countries (LMIC). Of the leading causes of death, respiratory failure is common to the top three. Bubble Continuous Positive Airway Pressure (bCPAP) is a standard therapy considered safe and cost effective in high resource settings. Although high-quality trials from LMIC are few, pooled available trial data considered alongside studies from high-income countries suggest that bCPAP: (i) reduces mortality; (ii) reduces the need for mechanical ventilation; and (iii) prevents extubation failure. Wider availability and optimal use at all levels of the health care system in LMIC are important steps to improve childhood survival. Studies aimed at effectively implementing, and sustaining safe use of bCPAP in the resource limited setting of LMIC are required.

Avoidable waste related to inadequate methods and incomplete reporting of interventions: a systematic review of randomized trials performed in Sub-Saharan Africa

Background

Randomized controlled trials (RCTs) are needed to improve health care in Sub-Saharan Africa (SSA). However, inadequate methods and incomplete reporting of interventions can prevent the transposition of research in practice which leads waste of research. The aim of this systematic review was to assess the avoidable waste in research related to inadequate methods and incomplete reporting of interventions in RCTs performed in SSA.

Methods

We performed a methodological systematic review of RCTs performed in SSA and published between 1 January 2014 and 31 March 2015. We searched PubMed, the Cochrane library and the African Index Medicus to identify reports. We assessed the risk of bias using the Cochrane Risk of Bias tool, and for each risk of bias item, determined whether easy adjustments with no or minor cost could change the domain to low risk of bias. The reporting of interventions was assessed by using standardized checklists based on the Consolidated Standards for Reporting Trials, and core items of the Template for Intervention Description and Replication. Corresponding authors of reports with incomplete reporting of interventions were contacted to obtain additional information. Data were descriptively analyzed.

Results

Among 121 RCTs selected, 74 (61%) evaluated pharmacological treatments (PTs), including drugs and nutritional supplements; and 47 (39%) nonpharmacological treatments (NPTs) (40 participative interventions, 1 surgical procedure, 3 medical devices and 3 therapeutic strategies). Overall, the randomization sequence was adequately generated in 76 reports (62%) and the intervention allocation concealed in 48 (39%). The primary outcome was described as blinded in 46 reports (38%), and incomplete outcome data were adequately addressed in 78 (64%). Applying easy methodological adjustments with no or minor additional cost to trials with at least one domain at high risk of bias could have reduced the number of domains at high risk for 24 RCTs (19%). Interventions were completely reported for 73/121 (60%) RCTs: 51/74 (68%) of PTs and 22/47 (46%) of NPTs. Additional information was obtained from corresponding authors for 11/48 reports (22%).

Conclusion

Inadequate methods and incomplete reporting of published SSA RCTs could be improved by easy and inexpensive methodological adjustments and adherence to reporting guidelines.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2034-0) contains supplementary material, which is available to authorized users.

A systematic comparison of key features of ischemic stroke prevention guidelines in low- and middle-income vs. high-income countries

BACKGROUND AND PURPOSE

Implementation of contextually appropriate, evidence-based, expert-recommended stroke prevention guideline is particularly important in Low-Income Countries (LMICs), which bear disproportional larger burden of stroke while possessing fewer resources. However, key quality characteristics of guidelines issued in LMICs compared with those in High-Income Countries (HICs) have not been systematically studied. We aimed to compare important features of stroke prevention guidelines issued in these groups.

METHODS

We systematically searched PubMed, AJOL, SciELO, and LILACS databases for stroke prevention guidelines published between January 2005 and December 2015 by country. Primary search items included: "Stroke" and "Guidelines". We critically appraised the articles for evidence level, issuance frequency, translatability to clinical practice, and ethical considerations. We followed the PRISMA guidelines for the elaboration process.

RESULTS

Among 36 stroke prevention guidelines published, 22 (61%) met eligibility criteria: 8 from LMICs (36%) and 14 from HICs (64%). LMIC-issued guidelines were less likely to have articulation of recommendations (62% vs. 100%, p=0.03), involve high quality systematic reviews (21% vs. 79%, p=0.006), have a good dissemination channels (12% vs 71%, p=0.02) and have an external reviewer (12% vs 57%, p=0.07). The patient views and preferences were the most significant stakeholder considerations in HIC (57%, p=0.01) compared with LMICs. The most frequent evidence grading system was American Heart Association (AHA) used in 22% of the guidelines. The Class I/III and Level (A) recommendations were homogenous among LMICs.

CONCLUSIONS

The quality and quantity of stroke prevention guidelines in LMICs are less than those of HICs and need to be significantly improved upon.

Organizational culture in cardiovascular care in Chinese hospitals: a descriptive cross-sectional study

Background

Organizational learning, the process by which a group changes its behavior in response to newly acquired knowledge, is critical to outstanding organizational performance. In hospitals, strong organizational learning culture is linked with improved health outcomes for patients. This study characterizes the organizational learning culture of hospitals in China from the perspective of a cardiology service.

Methods

Using a modified Abbreviated Learning Organization Survey (27 questions), we characterized organizational learning culture in a nationally representative sample of 162 Chinese hospitals, selecting 2 individuals involved with cardiovascular care at each hospital. Responses were analyzed at the hospital level by calculating the average of the two responses to each question. Responses were categorized as positive if they were 5+ on a 7-point scale or 4+ on a 5-point scale. Univariate and multiple regression analyses were used to assess the relationship between selected hospital characteristics and perceptions of organizational learning culture.

Results

Of the 324 participants invited to take the survey, 316 responded (98 % response rate). Perceptions of organizational learning culture varied among items, among domains, and both among and within hospitals. Overall, the median proportion of positive responses was 82 % (interquartile range = 59 % to 93 %). “Training,” “Performance Monitoring,” and “Leadership that Reinforces Learning” were characterized as the most favorable domains, while “Time for Reflection” was the least favorable. Multiple regression analyses showed that region was the only factor significantly correlated with overall positive response rate.

Conclusions

This nationally representative survey demonstrated variation in hospital organizational learning culture among hospitals in China. The variation was not substantially explained by hospital characteristics. Organizational learning culture domains with lower positive response rates reveal important areas for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1211-7) contains supplementary material, which is available to authorized users.

Utilization of research findings for health policy making and practice: evidence from three case studies in Bangladesh

Background

In striving to contribute towards improved health outcomes, health research institutions generate and accumulate huge volumes of relevant but often underutilized data. This study explores activities undertaken by researchers from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), an international research institution that promotes the utilization of their findings in the policymaking processes in Bangladesh.

Methods

The study used an exploratory case study design and employed qualitative methods to explore activities implemented to promote research utilization and the extent to which researchers felt that their findings contributed to the policymaking process. Data were collected between September and December 2011 through key informant interviews, focus group discussions with study investigators, and database and document reviews. We reviewed findings from 19 reproductive health studies conducted and completed by icddr,b researchers between 2001 and 2011. We interviewed 21 key informants, including 13 researchers, two policy makers, and six programme implementers. Data were entered into Microsoft Word and analyzed manually following a thematic framework approach. Following the World Health Organization/Turning Research into Practice (WHO/TRIP) framework, three case studies of how research findings were utilized in the policymaking processes in Bangladesh were documented.

Results

Activities implemented to promote research utilization included conducting dissemination workshops, publishing scientific papers, developing policy briefs, providing technical assistance to policymakers and programme implementers, holding one-on-one meetings, and joining advocacy networks. The majority of the researchers (12 of 13) reported that their study findings were utilized to influence policymaking processes at different levels. However, some researchers reported being unaware of whether and how their findings were utilized. As regards actual utilization of research findings, the evidence from the three case studies indicate that research findings can be utilized instrumentally, conceptually and symbolically, and at different stages within the policymaking process, including agenda setting and policy formulation and implementation.

Conclusions

The results show that research findings from icddr,b were promoted and utilized in health policymaking processes in Bangladesh using a variety of utilization approaches. These results suggest a need for using multiple approaches to promote utilization of research findings in health policymaking processes.

The first center for evidence-based medicine in Lithuania: an opportunity to change culture and improve clinical practice

In post-Soviet countries, where medical practice largely relies on experience alone, the incorporation of the best research evidence in clinical practice is limited. In order to promote the awareness and utilization of evidence-based medicine (EBM) among Lithuanian doctors, we organized EBM conferences in each of the two Lithuanian medical schools. More than 500 medical professionals and students attended the conferences in Vilnius (2013) and Kaunas (2014) demonstrating that there is a high demand for formal EBM teaching. Building on the success of these seminal conferences, and to start addressing the lack of EBM practice in the country, the first Lithuanian Centre for Evidence-Based Medicine was established at Vilnius University Medical Faculty in 2014. The Centre will focus on the implementation of EBM teaching in medical school curriculum, formulating management guidelines, writing systematic reviews and supporting Lithuanian authors in doing so.

Dimensions of Learning Organizations Questionnaire (DLOQ) in a low-resource health care setting in Nepal

Background

Knowledge-based organizations, such as health care systems, need to be adaptive to change and able to facilitate uptake of new evidence. To be able to assess organizational capability to learn is therefore an important part of health systems strengthening. The aim of the present study is to assess context using the Dimensions of the Learning Organization Questionnaire (DLOQ) in a low-resource health setting in Nepal.

Methods

DLOQ was translated and administered to 230 employees at all levels of the hospital. Data was analyzed using non-parametric tests.

Results

The DLOQ was able to detect variations across employee’s perceptions of the organizational context. Nurses scored significantly lower than doctors on the dimension “Empowerment” while doctors scored lower than nurses on “Strategic leadership”. These results suggest that the hospital’s organization carries attributes of a centralized, hierarchical structure that might hinder a progress towards a learning organization.

Conclusions

This study demonstrates that, despite the designing and developing of the DLOQ in the USA and its main utilization in company settings, it can be used and applied in hospital settings in low-income countries. The application of DLOQ provides valuable insights and understanding when designing and evaluating efforts for healthcare improvement.

Effective strategies for global health research, training and clinical care: a narrative review

The purpose of this narrative review was to synthesize the evidence on effective strategies for global health research, training and clinical care in order to identify common structures that have been used to guide program development. A Medline search from 2001 to 2011 produced 951 articles, which were reviewed and categorized. Thirty articles met criteria to be included in this review. Eleven articles discussed recommendations for research, 8 discussed training and 11 discussed clinical care. Global health program development should be completed within the framework of a larger institutional commitment or partnership. Support from leadership in the university or NGO, and an engaged local community are both integral to success and sustainability of efforts. It is also important for program development to engage local partners from the onset, jointly exploring issues and developing goals and objectives. Evaluation is a recommended way to determine if goals are being met, and should include considerations of sustainability, partnership building, and capacity. Global health research programs should consider details regarding the research process, context of research, partnerships, and community relationships. Training for global health should involve mentorship, pre-departure preparation of students, and elements developed to increase impact. Clinical care programs should focus on collaboration, sustainability, meeting local needs, and appropriate process considerations.

Implementation in Indonesia of the WHO Pocket Book of Hospital Care for Children

BACKGROUND

Effective implementation of evidence-based practice guidelines has the potential to improve quality of hospital care for children. To achieve this in Indonesia, a locally adapted version of the WHO Pocket Book of Hospital Care for Children was published in 2009.

OBJECTIVES

To document implementation of the Pocket Book in Indonesia and to compare uptake in health facilities in which there has been a quality-improvement approach involving audit and feedback with uptake in settings in which there has been only passive dissemination.

METHODS

Indonesian district health offices, district hospitals, health centres with beds, and medical schools were surveyed by telephone, and an online and telephone survey of paediatricians was conducted. Health facilities in four provinces were visited, and key stakeholders were interviewed. Health facilities were assessed on availability of the guidelines, use by staff, and their incorporation into hospital procedures and activities.

RESULTS

There was evidence of use of the Pocket Book across Indonesia, despite limited funding for implementation. Its distribution had reached all provinces; 61% (33/54) of health facilities surveyed had a copy of the guidelines. Hospitals involved in a related quality audit were more likely to report use of the guidelines than hospitals exposed to passive dissemination, although this difference was not significant. Of 150 paediatricians sampled, 109 (73%) reported referring to the guidelines in their clinical practice. The guidelines have been incorporated into the postgraduate paediatric curriculum in four of 13 universities sampled.

CONCLUSION

There was encouraging evidence of uptake of the Pocket Book in Indonesia following local adaptation, nationwide mailing distribution and small-scale local implementation activities.

Understanding the investigators: a qualitative study investigating the barriers and enablers to the implementation of local investigator-initiated clinical trials in Ethiopia

OBJECTIVES

Clinical trials provide 'gold standard' evidence for policy, but insufficient locally relevant trials are conducted in low-income and middle-income countries. Local investigator-initiated trials could generate highly relevant data for national governments, but information is lacking on how to facilitate them. We aimed to identify barriers and enablers to investigator-initiated trials in Ethiopia to inform and direct capacity strengthening initiatives.

DESIGN

Exploratory, qualitative study comprising of in-depth interviews (n=7) and focus group discussions (n=3).

SETTING

Fieldwork took place in Ethiopia during March 2011.

PARTICIPANTS

Local health researchers with previous experiences of clinical trials or stakeholders with an interest in trials were recruited through snowball sampling (n=20).

OUTCOME MEASURES

Detailed discussion notes were analysed using thematic coding analysis and key themes were identified.

RESULTS

All participants perceived investigator-initiated trials as important for generating local evidence. System and organisational barriers included: limited funding allocation, weak regulatory and administrative systems, few learning opportunities, limited human and material capacity and poor incentives for conducting research. Operational hurdles were symptomatic of these barriers. Lack of awareness, confidence and motivation to undertake trials were important individual barriers. Training, knowledge sharing and experience exchange were key enablers to trial conduct and collaboration was unanimously regarded as important for improving capacity.

CONCLUSIONS

Barriers to trial conduct were found at individual, operational, organisational and system levels. These findings indicate that to increase locally led trial conduct in Ethiopia, system wide changes are needed to create a more receptive and enabling research environment. Crucially, the creation of research networks between potential trial groups could provide much needed practical collaborative support through sharing of financial and project management burdens, knowledge and resources. These findings could have important implications for capacity-strengthening initiatives but further research is needed before the results can be generalised more widely.

The emergence of maternal health as a political priority in Madhya Pradesh, India: a qualitative study

BACKGROUND

Politics plays a critical role in agenda setting in health affairs; therefore, understanding the priorities of the political agenda in health is very important. The political priority for safe motherhood has been investigated at the national level in different countries. The objective of this study was to explore why and how maternal health became a political priority at sub-national level in the state of Madhya Pradesh in India.

METHODS

This study followed a qualitative design. Data were collected by carrying out interviews and review of documents. Semi-structured interviews were carried out with twenty respondents from four stakeholder groups: government officials, development partners, civil society and academics. Data analysis was performed using thematic analysis. The analysis was guided by Kingdon's multiple streams model.

RESULTS

The emergence of maternal health as a political priority in Madhya Pradesh was the result of convergence in the developments in different streams: the development of problem definition, policy generation and political change. The factors which influenced this process were: emerging evidence of the high magnitude of maternal mortality, civil society's positioning of maternal mortality as a human rights violation, increasing media coverage, supportive policy environment and launch of the National Rural Health Mission (NRHM), the availability of effective policy solutions, India's aspiration of global leadership, international influence, maternal mortality becoming a hot debate topic and political transition at the national and state levels. Most of these factors first became important at national level which then cascaded to the state level. Currently, there is a supportive policy environment in the state for maternal health backed by greater political will and increased resources. However, malnutrition and population stabilization are the competing priorities which may push maternal health off the agenda.

CONCLUSIONS

The influence of the events and factors evolving from international and national levels significantly contributed to the development of maternal health as a priority in Madhya Pradesh. This led to several opportunities in terms of policies, guidelines and programmes for improving maternal health. These efforts were successful to some extent in improving maternal health in the state but several implementation challenges still require special attention.

Development of a Farsi translation of the AGREE instrument, and the effects of group discussion on improving the reliability of the scores

OBJECTIVE

We aimed to develop a formal Farsi (Persian) translation of the Appraisal of Guidelines for Research and Evaluation (AGREE) clinical guideline appraisal instrument. We considered the effect of group discussion in improving the reliability of scores.

METHODS

We followed a multi-step process of translation including independent translations of the instrument and extensive assessment of face validity and fluency. We used the instruments to appraise 11 guidelines from three specialities. After the first appraisal, the raters discussed about each guideline in groups, and had the opportunity to revise their scores individually. In total 96 appraisals were conducted. The intra-class correlations (1,1) were calculated for domain scores obtained by two versions at each time point.

RESULTS

We observed no statistically significant differences between the mean values obtained from the English and the translated versions of AGREE, and the scores at two time points. The average domain scores, as well as the reliability rose significantly after discussion.

CONCLUSION

The Farsi version of the AGREE instrument yields in the scores comparable to the original version, despite a lower reliability. Revision of scores after group discussion leads to higher reliability, probably by helping the raters recognize what they might have overlooked during the short time of assessment.

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.

Application of standard treatment guidelines in rural community health centres, Timor-Leste

OBJECTIVE

To analyse nurses' and midwives' knowledge of and attitudes towards standard treatment guidelines (STGs), which were developed to help their practices at rural community health centres (CHCs) in Timor-Leste.

METHODS

Fifty-five nurses and midwives were individually interviewed. Data were analysed qualitatively using the Framework approach.

RESULTS

Overall, the standard treatments for acute respiratory tract infections, malaria and diarrhoea were well known by the respondents. Clinical nurses showed precise and detailed knowledge, especially for antibiotic use. The respondents were willing to use STGs and believed that they 'should' follow them. This feeling arose due to their self-awareness as frontline health workers and, at the same time, as peripheral civil servants. The changes brought about by the introduction of STGs were positively perceived. Three components of the change were observed: the concept, daily practice and perceived patient satisfaction. The respondents had previously felt a lack of confidence and hoped to improve their capacity as health care workers; they became confident in their practices by using STGs. Self-confidence was identified more clearly in the clinical nurse interviews. Few difficulties in using STGs were indicated, and the respondents suggested ways to deal with these difficulties.

DISCUSSION

By using the STGs, the nurses/midwives gained knowledge and self-confidence. The positive perception of the changes promoted further use of the STGs. Clinical nurse training positively influenced the knowledge of and attitudes towards the STGs. Few difficulties in applying STGs in daily practice were identified, which is contrary to previous studies that targeted physicians in the Western world. Development of STGs within a health policy framework was considered a key factor. The STGs exist across related policies and various programmes, which are interconnected. The Timor-Leste experience indicates the value of STGs for non-physician health care providers at the primary health care level.

Where there is no evidence: use of expert consensus methods to fill the evidence gap in low-income countries and cultural minorities

BACKGROUND

In both developing countries and in relation to cultural minorities there have been calls to scale up mental health services and for evidence-informed policy and practice.

EVIDENCE BASED MEDICINE

The evidence based medicine movement has had a major influence in improving practice. However, implementation of this approach has some major difficulties. One that has been neglected is the situation where there is no relevant evidence. This situation is more likely to occur for healthcare decisions in developing countries or for cultural minorities within developed countries, because resources do not exist for expensive research studies.

CONSENSUS METHODS

Consensus methods, such as the Delphi process, can be useful in providing an evidence base in situations where there is insufficient evidence. They provide a way of systematically tapping the expertise of people working in the area and give evidence that is readily applicable for a particular country and culture. Although consensus methods are often thought of as low in the hierarchy of evidence, consensus is central to the scientific process. We present four examples where the Delphi method was used to assess expert consensus in situations where no other evidence existed: estimating the prevalence of dementia in developing countries, developing mental health first aid guidelines in Asian countries, mental health first aid guidelines for Australian Aboriginal people, and modification of the concept of 'recovery' for Australian immigrant communities.

CONCLUSION

Consensus methods can provide a basis for decision-making and considered action when there is no evidence or when there are doubts about the applicability of evidence that has been generated from other populations or health system settings.

Mental health services for children in public care and other vulnerable groups: implications for international collaboration

Children in public care and other vulnerable young groups (homeless, adopted, refugees) are increasingly becoming the focus of policy and service planning. There is strong evidence that all these client populations have high rates of mental health problems which are closely associated with other needs. We also have good knowledge on the factors that predispose individuals to and maintain mental health problems, as well as on the reasons for their not easily accessing and engaging with services. There is less evidence on the effectiveness of interventions or service models, although some interesting patterns are beginning to emerge. These include the need for inter-agency commissioning, clear care pathways, designated provision, applied therapeutic interventions, training for carers and frontline practitioners, and multi modal programmes. This paper discusses these issues, as well as ways forward, both for systems with relatively well developed child mental health services and for low-income countries. Service quality can be greatly strengthened by international collaboration on policy, practice and research networks, training and research.

Assessing and understanding quality of care in a labour ward: a pilot study combining clinical and social science perspectives in Gondar, Ethiopia

Ensuring high quality intrapartum care in developing countries is a crucial component of efforts to reduce maternal and neonatal mortality and morbidity. Conceptual frameworks for understanding quality of care have broadened to reflect the complexity of factors affecting quality of health care provision. Yet, the role of social sciences within the assessment and understanding of quality of care in this field has focused primarily on seeking to understand the views and experiences of service users and providers. In this pilot study we aimed to combine clinical and social science perspectives and methods to best assess and understand issues affecting quality of clinical care and to identify priorities for change. Based in one referral hospital in Ethiopia, data collection took place in three phases using a combination of structured and unstructured observations, interviews and a modified nominal group process. This resulted in a thorough and pragmatic methodology. Our results showed high levels of knowledge and compliance with most aspects of good clinical practice, and non-compliance was affected by different, inter-linked, resource constraints. Considering possible changes in terms of resource implications, local stakeholders prioritised five areas for change. Some of these changes would have considerable resources implications whilst others could be made within existing resources. The discussion focuses on implications for informing quality improvement interventions. Improvements will need to address health systems issues, such as supply of key drugs, as well as changes in professional practice to promote the rational use of drugs. Furthermore, the study considers the need to understand broader organizational factors and inter-professional relationships. The potential for greater integration of social science perspectives as part of currently increasing monitoring and evaluation activity around intrapartum care is highlighted.

Evidence-based medicine knowledge, attitudes, and practices among doctors in Sri Lanka

OBJECTIVE

To assess knowledge, attitudes, and practices on evidence-based medicine (EBM) among doctors in selected hospitals in Sri Lanka.

METHODS

A cross-sectional descriptive study was conducted among 315 doctors in five government hospitals in Sri Lanka between December 2007 and January 2008. A pre-tested self-administered questionnaire was used to gather information on knowledge, attitudes, and practices.

RESULTS

Of the 407 invited, 315 doctors participated, among whom, 87% (271) had heard the term EBM, 30% (n= 94) were aware of the Cochrane Library, and 8.5% (n= 27) were current users of it. Forty-seven per cent (n= 148) claimed to understand the terms systematic review and 37% (n= 115) meta-analysis. Twenty-four per cent (n= 77) had been exposed to some form of EBM training. All three components of EBM were known by 18% (n= 56) of participants. Attitudes toward EBM were positive among 76% (n= 239), 80% (n= 251) believed the practice of EBM would lead to improved patient care, and 77% (n= 243) considered EBM to be fundamental to professional practice. Just 3% (n= 13) considered it unimportant. EBM was used in clinical practice by 54% (n= 169) of participants. Thirty-six per cent (n= 114) referred to EBM sources when relevant. Available clinical guidelines were referred to by 56% (n= 176), and 34% (n= 107) thought that available guidelines provide sufficient support for the practice of EBM. The main barriers to practicing EBM were insufficient resources, overwork, lack of exposure to EBM, and lack of time and lack of endorsement of the need to practice EBM.

CONCLUSIONS

Knowledge and practices of EBM among Sri Lanka doctors were poor. However, attitudes toward EBM were relatively good.

Treatment of infection: a cross-sectional survey of antibiotic drug utilisation in the Ramallah district of Palestine

Objective

To characterise the use of antibiotics in outpatients treated for infection in the Ramallah district of Palestine.

Setting

A purposive sample of general and specialist outpatient clinics in the public and private sector in Ramallah.

Method

A prospective, cross-sectional survey over 3 months (February-May 2000) of patients diagnosed with infection, conducted through questionnaires to treating physicians (n = 25) and patients (n = 575).

Key findings

Infection associated with the respiratory tract was the most common type of infection diagnosed, accounting for over 80% of all infections, followed by urinary tract infection and otitis media (14% and 10%, respectively). Amoxicillin was the antibiotic prescribed most often, prescribed for 44% of all patients and for infection of all types and across all age groups. A wide variety of other antibiotics was prescribed, and in the private sector there was more use of newer, more expensive antibiotics. Antibiotic use was rated as appropriate in only 35% of patients, with inappropriate prescribing largely resulting from inappropriate indication (73%) and to a lesser extent choice of drug (17%) or cost (9%). Duration of therapy was seldom specified by the prescriber and depended on pack size dispensed. Seventy-six per cent of patients followed up at 1 week had recovered partially or completely, but lack of compliance was noted in 30%.

Conclusions

There was considerable evidence of inappropriate use of antibiotics, including prescribing for likely self-limiting or non-bacterial infection and failure to specify duration of therapy. A number of patients failed to complete the course. Strategies to promote optimal antibiotic use should be targeted initially to respiratory tract infection, and both physicians and patients require educational input. The community pharmacist can play a lead role on account of both drug expertise and ability to advise health professionals and patients.

Implementing family practice research in countries with limited resources: a stepwise model experienced in Crete, Greece

The need for a cost-effective decision-making process is increasingly seen as a challenge within modern family practice. The role of family practice research is well recognized in countries with readily available resources and capacity. However, the situation is different in a number of countries with limited financial resources and current low research capacity. This article reports on an empirical model of 10 steps developed and applied in Crete, Greece. It aims to exchange views on how to better design and undertake actions in order to develop future family practice research in countries with limited resources.

Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries

BACKGROUND

Little is known about the process of knowledge translation in low- and middle-income countries. We studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomized control trials (RCTs). We examined two cases: the use of magnesium sulphate (MgSO(4)) in the treatment of eclampsia in pregnancy (a clinical case); and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control (a public health case).

METHODS

We used a qualitative case-study methodology to explore the policy making process. We carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Using an iterative approach, we undertook a thematic analysis of the data.

FINDINGS

Prior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. Key differences across the two case studies included the nature of the evidence, with clear evidence of efficacy for MgSO(4 )and ongoing debate regarding the efficacy of bed nets compared with spraying; local researcher involvement in international evidence production, which was stronger for MgSO(4 )than for malaria vector control; and a long-standing culture of evidence-based health care within obstetrics. Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO(4), and regional networks and political interests for malaria control. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries.

CONCLUSION

Translating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.

Promoting development and use of systematic reviews in a developing country

INTRODUCTION

One major barrier to develop health systems is the limited capacity for conducting research and implementation of research findings. We assessed the views of researchers, decision makers and research policy makers on how the development and usage of evidence from systematic reviews can be promoted in a country with limited resources.

METHODS

We surveyed 131 participants in six systematic review workshops for their views on important items influencing the production and usage of systematic reviews in a developing country. They were also asked to propose interventions to deal with potential barriers. We analysed the quantitative data using multidimensional scaling methods, and the qualitative data using content analysis approach.

RESULTS

We identified seven clusters of items that contribute to the promotion of conducting and using systematic reviews. For each cluster a set of interventions are proposed that health care decision makers and research policy makers may use for promoting conduct and use of systematic reviews. The clusters are 'importance for policy makers', 'access to international research', 'priority and support for systematic reviews', 'competency and willingness of researchers to conduct reviews', 'importance for end-users', 'quality of local primary research' and 'visibility and access to local research'.

DISCUSSION

The proposed interventions focus on national level initiatives for making the systematic reviews 'wanted' and improving the capacity to conduct research. Our findings emphasize the essential role of policy makers for promoting systematic reviews. They demonstrate that many barriers stem from the lower quality of and lack of access to primary research originating from developing countries.

Translating research into maternal health care policy: a qualitative case study of the use of evidence in policies for the treatment of eclampsia and pre-eclampsia in South Africa

Background

Few empirical studies of research utilisation have been conducted in low and middle income countries. This paper explores how research information, in particular findings from randomised controlled trials and systematic reviews, informed policy making and clinical guideline development for the use of magnesium sulphate in the treatment of eclampsia and pre-eclampsia in South Africa.

Methods

A qualitative case-study approach was used to examine the policy process. This included a literature review, a policy document review, a timeline of key events and the collection and analysis of 15 interviews with policy makers and academic clinicians involved in these policy processes and sampled using a purposive approach. The data was analysed thematically and explored theoretically through the literature on agenda setting and the policy making process.

Results

Prior to 1994 there was no national maternal care policy in South Africa. Consequently each tertiary level institution developed its own care guidelines and these recommended a range of approaches to the management of pre-eclampsia and eclampsia. The subsequent emergence of new national policies for maternal care, including for the treatment of pre-eclampsia and eclampsia, was informed by evidence from randomised controlled trials and systematic reviews. This outcome was influenced by a number of factors. The change to a democratic government in the mid 1990s, and the health reforms that followed, created opportunities for maternal health care policy development. The new government was open to academic involvement in policy making and recruited academics from local networks into key policy making positions in the National Department of Health. The local academic obstetric network, which placed high value on evidence-based practice, brought these values into the policy process and was also linked strongly to international evidence based medicine networks. Within this context of openness to policy development, local researchers acted as policy entrepreneurs, bringing attention to priority health issues, and to the use of research evidence in addressing these. This resulted in the new national maternity care guidelines being informed by evidence from randomised controlled trials and recommending explicitly the use of magnesium sulphate for the management of eclampsia.

Conclusion

Networks of researchers were important not only in using research information to shape policy but also in placing issues on the policy agenda. A policy context which created a window of opportunity for new research-informed policy development was also crucial.

Ethics in public health research: minding the gaps: a reassessment of the challenges to safe motherhood

Maternal and perinatal mortality reduction has remained a priority on the international health agenda for nearly 2 decades. During this time, strategies for achieving these goals have shifted in emphasis from prevention of pregnancies to provision of care. Robust evidence is limited, particularly regarding what works best in delivering care in specific health system settings and at the population level. We describe the limited evidence base using a framework that highlights the consequences of the major gaps in measurement, evidence, and action, and we discuss existing opportunities for bridging these gaps at the policy level. Capitalizing on current global policy interests and generating demand-driven evidence is a priority for enabling documentation of progress toward reaching the United Nations Millennium Development Goals for 2015.

Factors influencing the utilization of research findings by health policy-makers in a developing country: the selection of Mali's essential medicines

Background

Research findings are increasingly being recognized as an important input in the formation of health policy. There is concern that research findings are not being utilized by health policy-makers to the extent that they could be. The factors influencing the utilization of various types of research by health policy-makers are beginning to emerge in the literature, however there is still little known about these factors in developing countries. The object of this study was to explore these factors by examining the policy-making process for a pharmaceutical policy common in developing countries; an essential medicines list.

Methods

A study of the selection and updating of Mali's national essential medicines list was undertaken using qualitative methods. In-depth semi-structured interviews and a natural group discussion were held with national policy-makers, most specifically members of the national commission that selects and updates the country's list. The resulting text was analyzed using a phenomenological approach. A document analysis was also performed.

Results

Several factors emerged from the textual data that appear to be influencing the utilization of health research findings for these policy-makers. These factors include: access to information, relevance of the research, use of research perceived as a time consuming process, trust in the research, authority of those who presented their view, competency in research methods, priority of research in the policy process, and accountability.

Conclusion

Improving the transfer of research to policy will require effort on the part of researchers, policy-makers, and third parties. This will include: collaboration between researchers and policy-makers, increased production and dissemination of relevant and useful research, and continued and improved technical support from networks and multi-national organizations. Policy-makers from developing countries will then be better equipped to make informed decisions concerning their health policy issues.

Translating research into policy and practice in developing countries: a case study of magnesium sulphate for pre-eclampsia

Background

The evidence base for improving reproductive health continues to grow. However, concerns remain that the translation of this evidence into appropriate policies is partial and slow. Little is known about the factors affecting the use of evidence by policy makers and clinicians, particularly in developing countries. The objective of this study was to examine the factors that might affect the translation of randomised controlled trial (RCT) findings into policies and practice in developing countries.

Methods

The recent publication of an important RCT on the use of magnesium sulphate to treat pre-eclampsia provided an opportunity to explore how research findings might be translated into policy. A range of research methods, including a survey, group interview and observations with RCT collaborators and a survey of WHO drug information officers, regulatory officials and obstetricians in 12 countries, were undertaken to identify barriers and facilitators to knowledge translation.

Results

It proved difficult to obtain reliable data regarding the availability and use of commonly used drugs in many countries. The perceived barriers to implementing RCT findings regarding the use of magnesium sulphate for pre-eclampsia include drug licensing and availability; inadequate and poorly implemented clinical guidelines; and lack of political support for policy change. However, there were significant regional and national differences in the importance of specific barriers.

Conclusion

The policy changes needed to ensure widespread availability and use of magnesium sulphate are variable and complex. Difficulties in obtaining information on availability and use are combined with the wide range of barriers across settings, including a lack of support from policy makers. This makes it difficult to envisage any single intervention strategy that might be used to promote the uptake of research findings on magnesium sulphate into policy across the study settings. The publication of important trials may therefore not have the impacts on health care that researchers hope for.

Getting evidence into practice: what works in developing countries?

PURPOSE

We summarize and comment on the available literature on the effectiveness of interventions designed to change professional behaviour in order to bring evidence into practice in developing countries.

DATA SOURCES

We used a strategy adapted from the Effective Practice & Organization Care (EPOC) Cochrane group.

STUDY SELECTION

Forty-four studies met pre-defined selection criteria. Controlled and uncontrolled trials of interventions were included. Studies measured either professional compliance with agreed standards or patients' clinical outcomes. Data extraction. Data were extracted using a pre-defined extraction tool and studies were appraised accordingly.

RESULTS OF DATA SYNTHESIS

Data were synthesized and categorized according to different types of intervention. Audit and feedback was found to be effective, at least in the short term, when combined with other approaches. Similarly, educational interventions were more effective when designed to address local educational needs and organizational barriers. We found insufficient evidence to assess the effectiveness of educational outreach, local opinion leaders, use of mass media, and reminders. Educational materials alone are unlikely to influence change. However, the majority of studies had weak designs and failed to exclude possible biases.

CONCLUSION

Current evidence for the effectiveness of interventions to change health professionals' behaviour in developing countries is either scanty or flawed due to poorly designed research. Given the recent drive to improve quality of care, this should be a priority area for researchers and international agencies supporting health systems development in developing countries. This review provides an insight into some of the methodological issues that interested researchers may face.

Use of research to inform public policymaking

To improve health and reduce health inequalities, public policymakers need to find the best solutions to the most burdensome health problems, the best ways to fit these solutions into complex and often overstretched and underresourced health systems, and the best ways to bring about the desired changes in health systems. Systematic reviews can inform public policymaking by providing research-based answers to these questions. Public policymakers can encourage more informed policymaking by asking to see systematic reviews on priority issues, commissioning reviews when none exists, and placing more value on such work in their deliberations and in their interactions with stakeholders. Donors and international agencies can encourage more informed public policymaking by supporting national and regional efforts to undertake reviews and assess their local applicability, and by supporting regional or worldwide efforts to coordinate review and assessment processes.

The role of research in a technical assistance agency: the case of the 'German Agency for Technical Co-operation'

Technical assistance agencies have a sustainable impact on the health systems of the countries they are operating in. As well as policy-makers at the national level, technical assistance agencies see themselves confronted that their interventions should be based on evidence, usually meaning the results of research. This study has the aim to analyse role of research in the implementation of technical assistance. We sent a questionnaire to all health project managers of the 'German Agency for Technical Co-operation' and performed a qualitative case study in one of the health projects. Forty-seven of 80 (58.8%) of the questionnaires were completed and sent back. The managers considered publications of International Organisations (IOs), scientific articles and local research as most important for their work. The case study showed application problems in the daily work. Research use not only depends on the relevance of the data but also on analytical skills, linguistic barriers and technical access to research by the potential users. The role of knowledge and information management has to be clearly defined in an organisation of technical assistance. The specific needs at the different levels have to be analysed so that skills and resources can be allocated adequately.

Research in family medicine in developing countries

The output of family medicine research in developing countries varies vastly from country to country and also within countries. Most research originates from academic departments of family medicine or from collaborative initiatives with researchers in developed countries. There is generally a paucity of researchers, resources, and expertise. Many factors affecting the research output in primary care internationally applies in developing countries, but there are also factors that are unique to these countries. Solutions require financial resources and international goodwill. Wonca could play a major role in enhancing research in family medicine in the developing world.