Getting evidence into practice: what works in developing countries?

Global Barriers to the Diagnosis of Multiple Sclerosis: Data From the Multiple Sclerosis International Federation Atlas of MS, Third Edition

BACKGROUND AND OBJECTIVES

Recent data suggest increasing global prevalence of multiple sclerosis (MS). Early diagnosis of MS reduces the burden of disability-adjusted life years and associated health care costs. Yet diagnostic delays persist in MS care and even within national health care systems with robust resources, comprehensive registries, and MS subspecialist referral networks. The global prevalence and characteristics of barriers to expedited MS diagnosis, particularly in resource-restricted regions, have not been extensively studied. Recent revisions to MS diagnostic criteria demonstrate potential to facilitate earlier diagnosis, but global implementation remains largely unknown.

METHODS

The Multiple Sclerosis International Federation third edition of the Atlas of MS was a survey that assessed the current global state of diagnosis including adoption of MS diagnostic criteria; barriers to diagnosis with respect to the patient, health care provider, and health system; and existence of national guidelines or national standards for speed of MS diagnosis.

RESULTS

Coordinators from 107 countries (representing approximately 82% of the world population), participated. Eighty-three percent reported at least 1 "major barrier" to early MS diagnosis. The most frequently reported barriers included the following: "lack of awareness of MS symptoms among general public" (68%), "lack of awareness of MS symptoms among health care professionals" (59%), and "lack of availability of health care professionals with knowledge to diagnose MS" (44%). One-third reported lack of "specialist medical equipment or diagnostic tests." Thirty-four percent reported the use of only 2017 McDonald criteria (McD-C) for diagnosis, and 79% reported 2017 McD-C as the "most commonly used criteria." Sixty-six percent reported at least 1 barrier to the adoption of 2017 McD-C, including "neurologists lack awareness or training" by 45%. There was no significant association between national guidelines pertaining to MS diagnosis or practice standards addressing the speed of diagnosis and presence of barriers to early MS diagnosis and implementation of 2017 McD-C.

DISCUSSION

This study finds pervasive consistent global barriers to early diagnosis of MS. While these barriers reflected a lack of resources in many countries, data also suggest that interventions designed to develop and implement accessible education and training can provide cost-effective opportunities to improve access to early MS diagnosis.

Barriers to Gait Training among Stroke Survivors: An Integrative Review

Gait recovery is vital for stroke survivors' ability to perform their activities associated with daily living. Consequently, a gait impairment is a significant target for stroke survivors' physical rehabilitation. This review aims to identify barriers to gait training among stroke survivors. An integrative review was conducted following Whittemore and Knafl's methodology. The research was carried out on the electronic databases Scopus, PubMed, and B-on, applying a time span of 2006 to 2022. A total of 4189 articles were initially identified. After selecting and analyzing the articles, twelve studies were included in the sample. This review allowed for the identification of several barriers to gait training among stroke survivors, which can be grouped into three categories: individual, environmental, and rehabilitation workforce-related barriers. These findings highlight that participation in gait training is not solely dependent on the stroke survivor. Instead, the uptake of rehabilitation programs may also depend on environmental and rehabilitation workforce-related factors.

Strengthening capacity in hospitals to reduce perinatal morbidity and mortality through a codesigned intervention package: protocol for a realist evaluation as part of a stepped-wedge trial of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project

INTRODUCTION

Despite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge-implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project aims to overcome these gaps through strengthening the capacity of multidisciplinary teams that provide maternity care. The intervention includes competency-based midwife training, community engagement for study design, mentoring and quality improvement cycles. The realist process evaluation of ALERT aims at identifying and testing the causal pathway through which the intervention achieves its impact.

METHODS AND ANALYSIS

This realist process evaluation complements the effectiveness evaluation and the economic evaluation of the ALERT intervention. Following the realist evaluation cycle, we will first elicit the initial programme theory on the basis of the ALERT theory of change, a review of the evidence on adoption and diffusion of innovations and the perspectives of the stakeholders. Second, we will use a multiple embedded case study design to empirically test the initial programme theory in two hospitals in each of the four intervention countries. Qualitative and quantitative data will be collected, using in-depth interviews with hospital staff and mothers, observations, patient exit interviews and (hospital) document reviews. Analysis will be guided by the Intervention-Actors-Context-Mechanism-Outcome configuration heuristic. We will use thematic coding to analyse the qualitative data. The quantitative data will be analysed descriptively and integrated in the analysis using a retroductive approach. Each case study will end with a refined programme theory (in-case analysis). Third, we will carry out a cross-case comparison within and between the four countries. Comparison between study countries should enable identifying relevant context factors that influence effectiveness and implementation, leading to a mid-range theory that may inform the scaling up the intervention.

ETHICS AND DISSEMINATION

In developing this protocol, we paid specific attention to cultural sensitivity, the do no harm principle, confidentiality and non-attribution. We received ethical approval from the local and national institutional review boards in Tanzania, Uganda, Malawi, Benin, Sweden and Belgium. Written or verbal consent of respondents will be secured after explaining the purpose, potential benefits and potential harms of the study using an information sheet. The results will be disseminated through workshops with the hospital staff and national policymakers, and scientific publications and conferences.

TRIAL REGISTRATION NUMBER

PACTR202006793783148.

Community pharmacists’ attitudes toward practice-based research and their perceived utilization of scientific evidence

Background

Enhancing the contribution of practicing pharmacists into scientific evidence via practice-based research (PBR) is crucial in maintaining high-quality clinical practice and healthcare delivery. Involving community pharmacists in PBR can potentially can also help break barriers to the utilization of the current best evidence in everyday pharmacy practice. The impact of pharmacists’ attitude towards PBR on their utilization of current best evidence in pharmacy practice is understudied.

Objectives

The aim of the study was to investigate the impact of community pharmacists’ attitudes toward PBR on their utilization of current best evidence, barriers for conducting PBR in clinical practice were also investigated.

Methods

In this cross-sectional study, 169 community pharmacists working across Jordan filled a questionnaire to assess their attitudes towards PBR, barriers to PBR, and their utilization of the current best evidence in clinical practice.

Results

Pharmacists in this study showed a positive attitude toward PBR (attitude mean score >3.5). A positive attitude towards PBR was associated with high utilization of the best current scientific evidence. We also investigated several barriers to PBR and their association with utilization those included; the lack of perceived benefits, lack of institutional support, and lack of self-engagements of community pharmacists to PBR. The lack of perceived benefit was found to be negatively associated with pharmacists’ utilization of the current best scientific evidence.

Conclusion

In this study, pharmacists’ utilization of current best evidence was found to be significantly impacted by their attitude toward PBR. The current study findings highlight the importance of supporting, promoting, and facilitating PBR among community pharmacists which can potentially enhance their utilization of the current best evidence in their everyday pharmacy practice.

Action leveraging evidence to reduce perinatal mortality and morbidity (ALERT): study protocol for a stepped-wedge cluster-randomised trial in Benin, Malawi, Tanzania and Uganda

Background

Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period.

Methods

This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial’s primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention.

Discussion

There is evidence that each of the ALERT intervention components improves health providers’ practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions.

Trial registration

Pan African Clinical Trial Registry (www.pactr.org): PACTR202006793783148. Registered on 17th June 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07155-z.

Evidence-based practice in primary healthcare from the managerial point of view - a national survey

Background

The vast availability of and demand for evidence in modern primary healthcare force clinical decisions to be made based on condensed evidence in the form of policies and guidelines. Primary healthcare managers play a key role in implementing these governing documents. Thus, the aim of this article is to investigate the use and availability of evidence-based practice resources from the perspective of first-line primary healthcare managers.

Methods

The study is based on a national survey of primary healthcare managers, consisting of 186 respondents, recruited nationally from Sweden. The data was analysed using empirically constructed concepts and validated using factor analysis. A chi-square test was utilized to determine the statistical significance of comparisons. Associations between variables were calculated using Spearman’s correlation coefficients. All tests were two-sided, and the significance level was set to 0.05.

Results

A majority (97 %) of managers stated that guidelines and policy documents impacted primary healthcare; 84 % of managers observed a direct effect on daily practices. Most of the managers (70 %) stated that some adaptation was needed when new evidence was introduced. The managers emphasized the importance of keeping themselves updated and open to new information about work routines (96 %).

Conclusions

The study illustrates a nearly unanimous response about the influence of clinical evidence on daily practice. The emphasis on the importance of all staff members keeping their professional knowledge up to date is viewed as a direct result of this effect on daily practice. An information-dense organization such as a primary healthcare organization would have much to gain from increased cooperation with regional information resources such as clinical libraries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07023-w.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

From Passive Surveillance to Response: Suriname's Efforts to Implement Maternal Death Surveillance and Response

Implementation of maternal death surveillance and response (MDSR) is crucial to reduce maternal deaths. In Suriname, MDSR was not implemented until 2015. We describe the process of MDSR implementation in Suriname and share the "lessons learned," as experienced by the health care providers, national maternal death review committee members, and public health experts. Before 2015, maternal deaths were identified using death certificates and by active surveillance in the hospitals. Based on the recommendations from a 2010-2014 Reproductive Age Mortality Survey in Suriname, a maternal death review committee has improved the identification of maternal deaths and has audited every death since 2015. Although this review committee initiated several actions to implement MDSR together with health care providers, the involvement of the Ministry of Health (MOH) was crucial. Therefore, the Maternal Health Steering Committee was recently installed as a direct working arm of MOH to guide MDSR implementation. One of the main barriers to implementing MDSR in Suriname has been the lack of action following recommendations. Delineating roles and responsibilities for action, establishing accountability mechanisms, and influencing stakeholders in a position to act are critical to ensure a response to the recommendations. To implement MDSR, the 5 Cs-commitment, "no blame, no shame" culture, coordination, collaboration, and communication-are crucial.

A systematic approach to context-mapping to prepare for health interventions: development and validation of the SETTING-tool in four countries

Effectiveness of health interventions can be substantially impaired by implementation failure. Context-driven implementation strategies are critical for successful implementation. However, there is no practical, evidence-based guidance on how to map the context in order to design context-driven strategies. Therefore, this practice paper describes the development and validation of a systematic context-mapping tool. The tool was cocreated with local end-users through a multistage approach. As proof of concept, the tool was used to map beliefs and behaviour related to chronic respiratory disease within the FRESH AIR project in Uganda, Kyrgyzstan, Vietnam and Greece. Feasibility and acceptability were evaluated using the modified Conceptual Framework for Implementation Fidelity. Effectiveness was assessed by the degree to which context-driven adjustments were made to implementation strategies of FRESH AIR health interventions. The resulting Setting-Exploration-Treasure-Trail-to-Inform-implementatioN-strateGies (SETTING-tool) consisted of six steps: (1) Coset study priorities with local stakeholders, (2) Combine a qualitative rapid assessment with a quantitative survey (a mixed-method design), (3) Use context-sensitive materials, (4) Collect data involving community researchers, (5) Analyse pragmatically and/or in-depth to ensure timely communication of findings and (6) Continuously disseminate findings to relevant stakeholders. Use of the tool proved highly feasible, acceptable and effective in each setting. To conclude, the SETTING-tool is validated to systematically map local contexts for (lung) health interventions in diverse low-resource settings. It can support policy-makers, non-governmental organisations and health workers in the design of context-driven implementation strategies. This can reduce the risk of implementation failure and the waste of resource potential. Ultimately, this could improve health outcomes.

Older Adults' Perceived Barriers to Participation in a Falls Prevention Strategy

There is a need to increase older adults’ access and adherence to falls prevention strategies. This study aims to explore older adults’ perceived barriers to participation in a fall prevention strategy. A qualitative descriptive approach was used. Semi-structured interviews were conducted with 18 older adult users of a Day Care Unit from a Private Institution of Social Solidarity in the region of Lisbon and Tagus Valley in Portugal. The recruitment was made in September 2019. The interviews were recorded transcribed verbatim and analysed thematically using the method of constant comparisons. The barriers to participation in a fall prevention strategy are healthcare system gaps, social context, economic context, health status, psychological capability, and lack of knowledge to demystify myths and misconceptions about falls. There are different barriers to participate in a fall prevention strategy. It is urgent to eliminate or reduce the effect of these barriers to increase older adults’ participation in fall prevention strategies.

Factors critical to implementation success of cleaner cooking interventions in low-income and middle-income countries: protocol for an umbrella review

INTRODUCTION

Over a third of the world's population relies on solid fuels as their primary energy source. These fuels have damaging effects on health, air quality and forest resources. Interventions to promote access to cleaner solid fuel cookstoves and clean fuels have existed for decades. However, the adoption by local communities has largely failed, which led to a waste of resources and suboptimal outcomes. Therefore, the objective of this umbrella review is to identify factors that determine implementation success for cleaner cooking interventions in low-resource settings and weigh their level of confidence in the evidence.

METHODS AND ANALYSIS

We identified systematic and narrative reviews examining factors that influence the acquisition, initial adoption or sustained use of cleaner solid fuel cookstoves and clean fuels at any scale by a literature search in PubMed, Embase, Global Health Database, Cochrane, PsycINFO, Emcare, Web of Science and CINAHL, without date or language restrictions. The search was conducted on 23 October 2017 and updated on 10 July 2019. Reviews based on qualitative, quantitative or mixed-methods studies were included and will be appraised using the Meta Quality Appraisal Tool combined with the Assessment of Multiple Systematic Reviews. Data will be extracted and factors affecting implementation will be coded using the Consolidated Framework for Implementation Research. The Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative Research tool will be used to determine the level of confidence in the coded factors. Two researchers will independently conduct these steps.

ETHICS AND DISSEMINATION

This umbrella review does not require the approval of an ethical review board. Study results will be published in an international peer-reviewed journal. The outcomes will be converted into two practical tools: one for cleaner solid fuel cookstoves and one for clean fuels. These tools can guide the development of evidence-based implementation strategies for cleaner cooking interventions in low-income and middle-income countries to improve implementation success. These tools should be pilot-tested and promoted among regional and global initiatives.

PROSPERO REGISTRATION NUMBER

CRD42018088687.

Effective strategies to improve health worker performance in delivering adolescent-friendly sexual and reproductive health services

Background Despite recognition of the important role of health workers in providing adolescent-friendly sexual and reproductive health services (AFSRHS), evidence on strategies for improving performance is limited. This review sought to address: (1) which interventions are used to improve health worker performance in delivering AFSRHS? and (2) how effective are these interventions in improving AFSRHS health worker performance and client outcomes? Methods Building on a 2015 review, a search for literature on 18 previously identified programs was conducted to identify updated literature and data relevant to this review. Data was systematically extracted and analyzed. Results Due to the parent review's eligibility criteria, all programs included health worker training. Otherwise, supervision was the most frequently reported intervention used (n=10). Components and methods related to quality of trainings and supervision varied considerably in program reports. Nearly half of programs described employing processes to ensure availability of basic medicines and supplies (n=7). Other interventions (policies, standards, and job descriptions [n=5]; refresher trainings [n=5]; job aids or other reference material [n=3]) were less commonly reported to have been employed. No discernible patterns emerged in the relationship between interventions and outcomes of interest. Conclusions Multi-faceted complementary strategies are recommended to improve health worker performance to deliver AFSRHS; however, this was uncommonly reported in the programs that we reviewed. Effectiveness and cost-effectiveness evaluations of interventions and intervention packages are needed to guide efficient use of limited resources to enhance health worker capacity to deliver AFSRHS. In the interim, programs should be developed and implemented based on available existing evidence on improving health worker performance within and outside adolescent health. Implications and contribution This review is the first to examine the interventions commonly used to improve health worker performance in delivering AFSRHS. The findings indicate a need for additional effectiveness and cost-effectiveness evaluations of such interventions. In the meantime, existing evidence on improving health worker performance within and outside adolescent health must be integrated more thoughtfully into program planning and implementation.

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.

Implementing lung health interventions in low- and middle-income countries: a FRESH AIR systematic review and meta-synthesis

The vast majority of patients with chronic respiratory disease live in low- and middle-income countries (LMICs). Paradoxically, relevant interventions often fail to be effective particularly in these settings, as LMICs lack solid evidence on how to implement interventions successfully. Therefore, we aimed to identify factors critical to the implementation of lung health interventions in LMICs, and weigh their level of evidence.

This systematic review followed Cochrane methodology and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting standards. We searched eight databases without date or language restrictions in July 2019, and included all relevant original, peer-reviewed articles. Two researchers independently selected articles, critically appraised them (using Critical Appraisal Skills Programme (CASP)/Meta Quality Appraisal Tool (MetaQAT)), extracted data, coded factors (following the Consolidated Framework for Implementation Research (CFIR)), and assigned levels of confidence in the factors (via Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)). We meta-synthesised levels of evidence of the factors based on their frequency and the assigned level of confidence (PROSPERO:CRD42018088687).

We included 37 articles out of 9111 screened. Studies were performed across the globe in a broad range of settings. Factors identified with a high level of evidence were: 1) “Understanding needs of local users”; 2) ensuring “Compatibility” of interventions with local contexts (cultures, infrastructures); 3) identifying influential stakeholders and applying “Engagement” strategies; 4) ensuring adequate “Access to knowledge and information”; and 5) addressing “Resource availability”. All implementation factors and their level of evidence were synthesised in an implementation tool.

To conclude, this study identified implementation factors for lung health interventions in LMICs, weighed their level of evidence, and integrated the results into an implementation tool for practice. Policymakers, non-governmental organisations, practitioners, and researchers may use this FRESH AIR (Free Respiratory Evaluation and Smoke-exposure reduction by primary Health cAre Integrated gRoups) Implementation tool to develop evidence-based implementation strategies for related interventions. This could increase interventions’ implementation success, thereby optimising the use of already-scarce resources and improving health outcomes.

This systematic review and meta-synthesis shows why implementation of lung health interventions often fails in low- and middle-income countries, and it provides critical factors to prevent failure with their level of evidencehttps://bit.ly/2UYJOSa

Continued nursing education in low-income and middle-income countries: a narrative synthesis

Introduction

Continued nursing education and development can reduce mortality and morbidity of patients and can alleviate the shortage of healthcare workers by training of nurses for high-demand skill sets. We reviewed patterns of educational interventions and strategies in initiating behaviour change, improving patient outcomes or knowledge for nurses in low- and middle-income countries (LMICs).

Methods

The study searched the MEDLINE (PubMed), Embase, CINAHL, Google Scholar and Web of Science databases. The study included interventional studies on continued nursing education from 2007 to 2017. Of the 6216 publications retrieved, 98 articles were included and analysed by three independent reviewers.

Results

Of the 98 studies that met inclusion criteria, five were randomised controlled trials, two were qualitative in design and the remaining 91 were quasi-experimental, before-and-after studies. Of these studies, the median sample size of participants was 64, and the majority were conducted in Asia (53.1%). During the 10-year study period, 20.4% was conducted in 2015, the highest proportion, with a general increase in number of studies over time from 2007 to 2017. Main themes that arose from the review included train-the-trainer models, low-dose/high-frequency models, use of multiple media for training, and emphasis on nurse empowerment, strong international partnerships, and the integration of cultural context. Overall, the studies were limited in quality and lacked rigorous study design.

Conclusion

Continued nursing education in LMICs is essential and effective in improving nurses’ knowledge base, and thus patient outcomes and quality of care. Long-term, randomised studies are needed to understand how training strategies compare in impact on nurses and patients.

A condom uterine balloon device among referral facilities in Dar Es Salaam: an assessment of perceptions, barriers and facilitators one year after implementation

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal death in Tanzania. The Every Second Matters for Mothers and Babies- Uterine Balloon Tamponade (ESM-UBT) device was developed to address this problem in women with atonic uterus. The objective of this study was to understand the barriers and facilitators to optimal use of the device, in Dar es Salaam Tanzania 1 year after implementation.

METHODS

Semi-structured interviews of skilled-birth attendants were conducted between May and July 2017. Interviews were recorded, coded and analyzed for emergent themes.

RESULTS

Among the participants, overall there was a positive perception of the ESM-UBT device. More than half of participants reported the device was readily available and more than 1/3 described ease and success with initial use. Barriers included fear and lack of refresher training. Finally, participants expressed a need for training and device availability at peripheral hospitals.

CONCLUSION

The implementation and progression to optimal use of the ESM-UBT device in Tanzania is quite complex. Ease of use and the prospect of saving a life/preserving fertility strongly promoted use while fear and lack of high-level buy-in hindered utilization of the device. A thorough understanding and investigation of these facilitators and barriers are required to increase uptake of the ESM-UBT device.

The effect of leadership on public service motivation: a multiple embedded case study in Morocco

OBJECTIVES

We aimed at exploring the underlying mechanisms and contextual conditions by which leadership may influence 'public service motivation' of health providers in Moroccan hospitals.

DESIGN

We used the realist evaluation (RE) approach in the following steps: eliciting the initial programme theory, designing the study, carrying out the data collection, doing the data analysis and synthesis. In practice, we adopted a multiple embedded case study design.

SETTINGS

We used purposive sampling to select hospitals representing extreme cases displaying contrasting leadership practices and organisational performance scores using data from the Ministry of Health quality assurance programmes from 2011 to 2016.

PARTICIPANTS

We carried out, on average, 17 individual in-depth interviews in 4 hospitals as well as 7 focus group discussions and 8 group discussions with different cadres (administrators, nurses and doctors). We collected relevant documents (eg, performance audit, human resource availability) and carried out observations.

RESULTS

Comparing the Intervention-Context-Actor-Mechanism-Outcome configurations across the hospitals allowed us to confirm and refine our following programme theory: "Complex leaders, applying an appropriate mix of transactional, transformational and distributed leadership styles that fit organisational and individuals characteristics [I] can increase public service motivation, organisational commitment and extra role behaviours [O] by increasing perceived supervisor support and perceived organizational support and satisfying staff basic psychological needs [M], if the organisational culture is conducive and in the absence of perceived organisational politics [C]".

CONCLUSIONS

In hospitals, the archetype of complex professional bureaucracies, leaders need to be able to balance between different leadership styles according to the staff's profile, the nature of tasks and the organisational culture if they want to enhance public service motivation, intrinsic motivation and organisational commitment.

Daily versus weekly evidence reports for orthopaedic surgeons in India: A mixed-methods study

BACKGROUND

There is a dearth of research regarding the impact of evidence-based medicine (EBM) tools, such as evidence summaries, in developing countries. The goals of this study were to: investigate accessibility, use, and impact of an online EBM knowledge dissemination portal in orthopaedic surgery in India; explore whether receiving daily targeted evidence summaries results in more frequent use of an EBM tool compared with receiving general weekly reports; and identify and explain the barriers and benefits of an online EBM resource in the Indian context.

METHODS

Forty-four orthopaedic surgeons in Pune, India, were provided free access to OrthoEvidence (OE), a for-profit, online EBM knowledge dissemination portal. Participants were subsequently randomized into 2 groups-1 group received daily targeted evidence summaries while the other received general weekly summaries. This study employed an explanatory sequential mixed methods design that incorporated 2 questionnaires, OE usage data, and semi-structured interviews to gain insight into the surgeons' usage, perceptions, and impact of OE.

RESULTS

There were no observable differences in OE usage between groups. OE was deemed to be comprehensive, practical, useful, and applicable to clinical practice by the majority of surgeons. The exit survey data revealed no differences between groups' perceptions of the OE tool. semi-structured interviews revealed barriers to keeping up with evidence that included limited access to relevant medical literature and limited incentive to keep up with current evidence.

CONCLUSIONS

Neither frequency of delivery (daily versus weekly) nor targeted versus general content affected the use of evidence summaries. Facilitating uptake of current evidence into clinical practice among Indian orthopedic surgeons may require additional components beyond dissemination of evidence summaries.

A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results

BACKGROUND

Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR's methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes.

METHODS

The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy's effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch.

RESULTS

We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958-2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness.

CONCLUSIONS

Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.

Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique

Background: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

The role of context in implementation research for non-communicable diseases: Answering the 'how-to' dilemma

Introduction

Understanding context and how this can be systematically assessed and incorporated is crucial to successful implementation. We describe how context has been assessed (including exploration or evaluation) in Global Alliance for Chronic Diseases (GACD) implementation research projects focused on improving health in people with or at risk of chronic disease and how contextual lessons were incorporated into the intervention or the implementation process.

Methods

Using a web-based semi-structured questionnaire, we conducted a cross-sectional survey to collect quantitative and qualitative data across GACD projects (n = 20) focusing on hypertension, diabetes and lung diseases. The use of context-specific data from project planning to evaluation was analyzed using mixed methods and a multi-layered context framework across five levels; 1) individual and family, 2) community, 3) healthcare setting, 4) local or district level, and 5) state or national level.

Results

Project teams used both qualitative and mixed methods to assess multiple levels of context (avg. = 4). Methodological approaches to assess context were identified as formal and informal assessments, engagement of stakeholders, use of locally adapted resources and materials, and use of diverse data sources. Contextual lessons were incorporated directly into the intervention by informing or adapting the intervention, improving intervention participation or improving communication with participants/stakeholders. Provision of services, equipment or information, continuous engagement with stakeholders, feedback for personnel to address gaps, and promoting institutionalization were themes identified to describe how contextual lessons are incorporated into the implementation process.

Conclusions

Context is regarded as critical and influenced the design and implementation of the GACD funded chronic disease interventions. There are different approaches to assess and incorporate context as demonstrated by this study and further research is required to systematically evaluate contextual approaches in terms of how they contribute to effectiveness or implementation outcomes.

Standard treatment guidelines: Perception and utilization in a tertiary health care facility in South-South, Nigeria

Background:

The Nigerian National Standard Treatment Guidelines (NSTG) was introduced in 2008 and the second edition was launched in 2017. This study evaluated the level of awareness, acceptance, and use of this tool within the Nigerian health-care system.

Methodology:

This study was carried out at the University of Benin Teaching Hospital, Benin City, Nigeria. A semistructured questionnaire was administered to doctors in the hospital. Information sought included the biodata, awareness of the STG, publication and use of the STG, the perceived advantages and disadvantages, and suggestions on how to improve its use.

Results:

There were 155 respondents with a mean age of 34.1 ± 6.4 years and response rate of 77.5%. The level of awareness was 46.5%, with 21.9% having received lessons on the subject; 53.0% received lessons as students. Awareness of the date of the initial introduction of the STG at the national level was 4.5% with 1.3% aware of the current edition of the NSTG. The description of the STG was satisfactory in 27.7% participants. Again only 20.6% currently use the NSTG, with 12.3% rating the entire STG utilization as successful.

Conclusion:

There is low awareness and poor utilization of the STG among doctors in the facility which may be a reflection of the situation in other health facilities in the country. There is need to encourage the use of this clinical tool to ensure appropriate use of medicines and delivery of health care in resource-limited settings.

Scaling up a tobacco control intervention in low resource settings: a case example for school teachers in India

Research on processes of bringing effective tobacco control interventions to scale to increase quit rates among tobacco users is uncommon. This study examines processes to bring to scale one such intervention for school teachers, i.e. Tobacco Free Teacher-Tobacco Free Society (TFT-TFS). This intervention provides a foundation for an effective and low cost approach to promote cessation through schools. The present study was conducted in the states of Bihar and Maharashtra in 2014 using quantitative and qualitative methods. Focus group discussions (FGDs) were analysed using immersion crystallization method. The data presented are from a survey of 291 principals and seven FGDs. This study examined characteristics of principals and teachers, organizational environment, external environmental factors and program characteristics to determine facilitators and barriers for successful dissemination and implementation of the TFT-TFS program. Some facilitators were, incorporation of the program in existing channels like staff meetings and trainings, certification and recognition by the department of education; while some barriers were routine time bound duties (mainly teaching) of teachers and prevalence of tobacco use among teachers and administrators. Principals and teachers expressed a need and high level of interest in the adoption and implementation of the TFT-TFS program in their schools.

When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out": justification of disrespectful and abusive care during childbirth among midwifery students in Ghana

Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation. Key Messages •Midwifery students in Ghana’s public midwifery schools report witnessing and participating in many forms of disrespect and abuse during deliveries as part of their education. While they are clear as to why respectful care is important and necessary, they are able to justify and explain reasons for disrespectful and abusive care. This poor treatment of labouring women was explicitly and tacitly supported by these students’ teachers and preceptors. •All study materials and methods were reviewed and approved by the Ghana Health Service Ethical Review Committee, the Kwame Nkrumah University of Science and Technology Committee on Publication and Human Ethics, and the University of Michigan Institutional Review Board. •This research was made possible through a grant from the African Studies Center, University of Michigan. For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana’s regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data. While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse. Although midwifery students in Ghana’s public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.

Reducing stigma among healthcare providers to improve mental health services (RESHAPE): protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal

Background

Non-specialist healthcare providers, including primary and community healthcare workers, in low- and middle-income countries can effectively treat mental illness. However, scaling-up mental health services within existing health systems has been limited by barriers such as stigma against people with mental illness. Therefore, interventions are needed to address attitudes and behaviors among non-specialists. Aimed at addressing this gap, REducing Stigma among HealthcAre Providers to ImprovE mental health services (RESHAPE) is an intervention in which social contact with mental health service users is added to training for non-specialist healthcare workers integrating mental health services into primary healthcare.

Methods

This protocol describes a mixed methods pilot and feasibility study in primary care centers in Chitwan, Nepal. The qualitative component will include key informant interviews and focus group discussions. The quantitative component consists of a pilot cluster randomized controlled trial (c-RCT), which will establish parameters for a future effectiveness study of RESHAPE compared to training as usual (TAU). Primary healthcare facilities (the cluster unit, k = 34) will be randomized to TAU or RESHAPE. The direct beneficiaries of the intervention are the primary healthcare workers in the facilities (n = 150); indirect beneficiaries are their patients (n = 100). The TAU condition is existing mental health training and supervision for primary healthcare workers delivered through the Programme for Improving Mental healthcarE (PRIME) implementing the mental health Gap Action Programme (mhGAP). The primary objective is to evaluate acceptability and feasibility through qualitative interviews with primary healthcare workers, trainers, and mental health service users. The secondary objective is to collect quantitative information on health worker outcomes including mental health stigma (Social Distance Scale), clinical knowledge (mhGAP), clinical competency (ENhancing Assessment of Common Therapeutic factors, ENACT), and implicit attitudes (Implicit Association Test, IAT), and patient outcomes including stigma-related barriers to care, daily functioning, and symptoms.

Discussion

The pilot and feasibility study will contribute to refining recommendations for implementation of mhGAP and other mental health services in primary healthcare settings in low-resource health systems. The pilot c-RCT findings will inform an effectiveness trial of RESHAPE to advance the evidence-base for optimal approaches to training and supervision for non-specialist providers.

Trial registration

ClinicalTrials.gov identifier, NCT02793271

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

BACKGROUND

Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.

METHODS

We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.

RESULTS

Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.

CONCLUSIONS

We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

Implementing maternal death surveillance and response: a review of lessons from country case studies

Background

Maternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation.

Methods

A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful.

Results

MDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a ‘no shame, no blame’ culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs.

Conclusions

Case studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.

Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach.

MAIN RESULTS

We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.

Improving prehospital trauma care in Rwanda through continuous quality improvement: an interrupted time series analysis

INTRODUCTION

Injury is a major cause of premature death and disability in East Africa, and high-quality pre-hospital care is essential for optimal trauma outcomes. The Rwandan pre-hospital emergency care service (SAMU) uses an electronic database to evaluate and optimize pre-hospital care through a continuous quality improvement programme (CQIP), beginning March 2014.

MATERIALS AND METHODS

The SAMU database was used to assess pre-hospital quality metrics including supplementary oxygen for hypoxia (O2), intravenous fluids for hypotension (IVF), cervical collar placement for head injuries (c-collar), and either splinting (splint) or administration of pain medications (pain) for long bone fractures. Targets of >90% were set for each metric and daily team meetings and monthly feedback sessions were implemented to address opportunities for improvement. These five pre-hospital quality metrics were assessed monthly before and after implementation of the CQIP. Met and unmet needs for O2, IVF, and c-collar were combined into a summative monthly SAMU Trauma Quality Scores (STQ score). An interrupted time series linear regression model compared the STQ score during 14 months before the CQIP implementation to the first 14 months after.

RESULTS

During the 29-month study period 3,822 patients met study criteria. 1,028 patients needed one or more of the five studied interventions during the study period. All five endpoints had a significant increase between the pre-CQI and post-CQI periods (p<0.05 for all), and all five achieved a post-CQI average of at least 90% completion. The monthly composite STQ scores ranged from 76.5 to 97.9 pre-CQI, but tightened to 86.1-98.7 during the post-CQI period. Interrupted time series analysis of the STQ score showed that CQI programme led to both an immediate improvement of +6.1% (p=0.017) and sustained monthly improvements in care delivery-improving at a rate of 0.7% per month (p=0.028).

CONCLUSION

The SAMU experience demonstrates the utility of a responsive, data-driven quality improvement programme to yield significant immediate and sustained improvements in pre-hospital care for trauma in Rwanda. This programme may be used as an example for additional efforts engaging frontline staff with real-time data feedback in order to rapidly translate data collection efforts into improved care for the injured in a resource-limited setting.

Teaching Splinting Techniques Using a Just-in-Time Training Instructional Video

OBJECTIVE

Splinting is a multistep procedure that is seldom performed by primary care physicians. Just-in-time training (JITT) is an emerging teaching modality and can be an invaluable asset for infrequently performed procedures or in locations where teaching resources and trained professionals are limited. Our objective was to determine the utility of JITT for teaching medical students the short-arm (SA) volar splinting technique.

METHODS

This was a prospective randomized controlled pilot study. An instructional video on SA volar splinting was produced. Students viewed the video or had access to standard medical textbooks (control group) immediately before applying an SA volar splint. The students were assessed for the quality of the splint via a standard 6-point skills checklist. The times required for presplinting preparation and for completion of the splint were also measured.

RESULTS

Just-in-time training group students scored higher on the splint checklist (mean [SD], 5.45 [1.06]; 95% confidence interval [CI], 4.99-5.92 vs mean [SD], 1.58 [1.12]; 95% CI, 1.04-2.12; P < 0.0001), had higher pass rates (73%; 95% CI, 53%-93% vs 0%; P < 0.0001), and required less time (minutes) for presplinting preparation (mean [SD], 7.86 [2.45]; 95% CI, 6.78-8.94 vs mean [SD], 9.89 [0.46]; 95% CI, 9.67-10.12; P < 0.0001) compared with the control group. No difference was seen in the time required to complete a splint, successful or not.

CONCLUSIONS

In comparison with reading standard textbooks, watching a brief JITT instructional video before splinting yielded faster learning times combined with more successful procedural skills. The use of a JITT instructional video may have potential applications, including globally, as an alternative resource for teaching and disseminating procedural skills, such as SA volar splinting.

Effects of a worksite tobacco control intervention in India: the Mumbai worksite tobacco control study, a cluster-randomised trial

OBJECTIVES

We assessed a worksite intervention designed to promote tobacco control among workers in the manufacturing sector in Greater Mumbai, India.

METHODS

We used a cluster-randomised design to test an integrated health promotion/health protection intervention, the Healthy, Safe, and Tobacco-free Worksites programme. Between July 2012 and July 2013, we recruited 20 worksites on a rolling basis and randomly assigned them to intervention or delayed-intervention control conditions. The follow-up survey was conducted between December 2013 and November 2014.

RESULTS

The difference in 30-day quit rates between intervention and control conditions was statistically significant for production workers (OR=2.25, p=0.03), although not for the overall sample (OR=1.70; p=0.12). The intervention resulted in a doubling of the 6-month cessation rates among workers in the intervention worksites compared to those in the control, for production workers (OR=2.29; p=0.07) and for the overall sample (OR=1.81; p=0.13), but the difference did not reach statistical significance.

CONCLUSIONS

These findings demonstrate the potential impact of a tobacco control intervention that combined tobacco control and health protection programming within Indian manufacturing worksites.

TRIAL REGISTRATION NUMBER

NCT01841879.

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

BACKGROUND

In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity.

OBJECTIVES

Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines.

METHODS

This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review.

RESULTS

Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews).

CONCLUSION

The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Implementing a nationwide quality improvement approach in health services

PURPOSE

The purpose of this paper is to present an innovative quality improvement intervention developed in Morocco and discuss its implementation. Until 2004, the Moroccan Ministry of Health (MoH) encouraged pilots of quality improvement approaches but none of them were revealed to be sustainable. Internal assessments pinpointed factors such as lack of recognition of the participating team's efforts and lack of pressure on managers to become more accountable. In 2005, Morocco opted for an intervention called "Quality Contest" (QC) targeting health centres, hospitals and health district offices and combining quality measurement with structures ranking, performance disclosure and reward system.

DESIGN/METHODOLOGY/APPROACH

The QC is organized every 18 months. After the self-assessment and external audit step, the participating structures are ranked according to their scores. Their performances are then disseminated and the highest performing structures are rewarded.

FINDINGS

The results showed an improvement in performance among participating structures, constructive exchange of successful experiences between structures, as well as communication of constraints, needs and expectations between MoH managers at central and local levels; the use of peer-auditors was appreciated as it enabled an exchange of best practices between auditors and audited teams but this was mitigated by the difficulty of ensuring their neutrality; and the recognition of efforts was appreciated but seemed insufficient to ensure a sense of justice and maintain motivation.

ORIGINALITY/VALUE

This intervention is an example of MoH leadership that has succeeded in introducing transparency and accountability mechanisms (ranking and performance disclosure) as leverage to change the management culture of the public health services; setting up a reward system to reinforce motivation and adapting continuously the intervention to enhance its sustainability and acceptability.

Evidence-based guideline implementation in low and middle income countries: lessons for mental health care

Background

There is a significant treatment gap in provision of effective treatment for people with mental disorders globally. In some Low and Middle Income Countries (LMICs) this gap is 90% or more in terms of untreated cases. Clinical practice guidelines (CPGs) are one tool to improve health care provision. The aim of this review is to examine studies of the effectiveness of evidence-based CPG implementation across physical and mental health care, to inform mental healthcare provision in low and middle income countries (LMICs), and to identify transferable lessons from other non-communicable diseases to mental health.

Methods

A systematic literature review employing narrative synthesis and utilising the tools developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group was conducted. Experimental studies of CPG implementation relating to non-communicable diseases, including mental disorders, in LMICs were retrieved and synthesised.

Results

Few (six) studies were identified. Four cluster randomised controlled trials (RCTs) related to the introduction of CPGs for non-communicable diseases in physical health; one cluster-RCT included CPGs for both a non-communicable disease in physical health and mental health, and one uncontrolled before and after study described the introduction of a CPG for mental health. All of the included studies adopted multi-faceted CPG implementation strategies and used education as part of this strategy. Components of the multi-faceted strategies were sometimes poorly described. Results of the studies included generally show statistically significant improvement on some, but not all, outcomes.

Conclusion

Evidence for the effectiveness of interventions to improve uptake of, and compliance with, evidence-based CPGs in LMICs for mental disorders and for other non-communicable diseases is at present limited. The sparse literature does, however, suggest that multifaceted CPG implementation strategies that involve an educational component may be an effective way of improving guideline adherence and therefore of improving clinical outcomes. Further work is needed to examine cost-effectiveness of CPG implementation strategies in LMICs and to draw conclusions on the transferability of implementation experience in physical health care to mental health practice settings. Strategies to ensure that CPGs are developed with clear guidance for implementation, and with explicit, methods to evaluate them should be a priority for mental health researchers and for international agencies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13033-016-0115-1) contains supplementary material, which is available to authorized users.

Enhancing Nurses' Oral Therapy Practice in 4 Latin American Countries: A Collaborative and Participatory Approach

BACKGROUND

Oral therapy (OT) use for cancer is increasing globally. Yet, nurses in 4 Latin American countries lacked knowledge and educational opportunities to safely care for people receiving OTs. Global partnerships to contextualize education and create local capacity may enhance nursing practice.

OBJECTIVE

Within 4 Latin American countries, this study aims to (1) develop, deliver, and evaluate an OT cancer nursing education program and (2) evaluate the feasibility and efficacy of using an integrated knowledge translation (iKT) framework to develop the program and foster nurses' capacity for OT care.

METHODS

Using the iKT framework, a "train the trainer" model was used to develop, contextualize, pilot test, implement, and evaluate the OT education program. An online survey evaluated nurses' perceived benefits, ease of use, barriers, facilitators, and recommendations for improvement. Nurses' self-reported OT practices were evaluated 9 months after the final workshop.

RESULTS

One hundred nineteen nurses across 4 countries participated in a pilot and/or final OT educational workshop, facilitated by 6 local nurse champions. The nurse champions found the program easy to use and modify. Participants reported using the curriculum to teach other nurses and patients and networking opportunities for problem solving. Barriers included nurses' role clarity and time for education.

CONCLUSIONS

The iKT approach was an effective method to develop the OT curriculum and build OT capacity among nurses and leaders within the 4 countries.

IMPLICATIONS FOR PRACTICE

The iKT approach may be useful in low- or middle-income countries to enhance nursing education and practice. Future OT education projects should strengthen strategies for ongoing support after education intervention.

Tuberculosis screening in patients with HIV: use of audit and feedback to improve quality of care in Ghana

BACKGROUND

Tuberculosis screening of people living with HIV (PLHIV) can contribute to early tuberculosis diagnosis and improved patient outcomes. Evidence-based guidelines for tuberculosis screening are available, but literature assessing their implementation and the quality of clinical practice is scarce.

OBJECTIVES

To assess tuberculosis screening practices and the effectiveness of audit and performance feedback to improve quality of tuberculosis screening at HIV care clinics in Ghana.

DESIGN

Healthcare providers at 10 large HIV care clinics prospectively registered patient consultations during May and October 2014, before and after a performance feedback intervention in August 2014. The outcomes of interest were overall tuberculosis suspicion rate during consultations and provider adherence to the International Standards for Tuberculosis Care and the World Health Organizations' guidelines for symptom-based tuberculosis screening among PLHIV.

RESULTS

Twenty-one healthcare providers registered a total of 2,666 consultations; 1,368 consultations before and 1,298 consultations after the feedback intervention. Tuberculosis suspicion rate during consultation increased from 12.6 to 20.9% after feedback (odds ratio, OR 1.83; 95% confidence interval, CI: 1.09-3.09). Before feedback, sputum smear microscopy was requested for 58.7% of patients with suspected tuberculosis, for 47.2% of patients with cough ≥2 weeks, and for 27.5% of patients with a positive World Health Organization (WHO) symptom screen (any of current cough, fever, weight loss or night sweats). After feedback, patients with a positive WHO symptom screen were more likely to be suspected of tuberculosis (OR 2.21; 95% CI: 1.19-4.09) and referred for microscopy (OR 2.71; 95% CI: 1.25-5.86).

CONCLUSIONS

A simple prospective audit tool identified flaws in clinical practices for tuberculosis screening of PLHIV. There was no systematic identification of people with suspected active tuberculosis. We found low initial tuberculosis suspicion rate compounded by low referral rates of relevant patients for sputum smear microscopy. Adherence to recommended standards and guidelines for tuberculosis screening improved after performance feedback.

Smart Patient, Smart Community: Improving Client Participation in Family Planning Consultations through a Community Education and Mass-Media Program in Indonesia

In health care consultations, patients often receive insufficient information from providers and communicate little with providers about their needs or concerns. This study evaluated a combined community education and mass media intervention to improve clients' participation in family planning consultations. A household survey was conducted with 1,200 women in three sub-districts (two intervention and one control) of West Java province in Indonesia. A comparison of post-campaign findings among family planning clients suggests that the intervention as a whole had a positive effect on client participation, specifically the number of clients who prepared questions to ask the service provider prior to a family planning visit in the past year. Multivariate analyses showed that the “Smart Card” intervention and elements of the “Sahabat” (Friend) mass media campaign were positively associated with clients' preparation of questions and question asking behavior during family planning consultations, indicating that a combined community education and mass-media approach can improve client communication with providers and improve the quality of family planning counseling.

Response process and test-retest reliability of the Context Assessment for Community Health tool in Vietnam

BACKGROUND

The recently developed Context Assessment for Community Health (COACH) tool aims to measure aspects of the local healthcare context perceived to influence knowledge translation in low- and middle-income countries. The tool measures eight dimensions (organizational resources, community engagement, monitoring services for action, sources of knowledge, commitment to work, work culture, leadership, and informal payment) through 49 items.

OBJECTIVE

The study aimed to explore the understanding and stability of the COACH tool among health providers in Vietnam.

DESIGNS

To investigate the response process, think-aloud interviews were undertaken with five community health workers, six nurses and midwives, and five physicians. Identified problems were classified according to Conrad and Blair's taxonomy and grouped according to an estimation of the magnitude of the problem's effect on the response data. Further, the stability of the tool was examined using a test-retest survey among 77 respondents. The reliability was analyzed for items (intraclass correlation coefficient (ICC) and percent agreement) and dimensions (ICC and Bland-Altman plots).

RESULTS

In general, the think-aloud interviews revealed that the COACH tool was perceived as clear, well organized, and easy to answer. Most items were understood as intended. However, seven prominent problems in the items were identified and the content of three dimensions was perceived to be of a sensitive nature. In the test-retest survey, two-thirds of the items and seven of eight dimensions were found to have an ICC agreement ranging from moderate to substantial (0.5-0.7), demonstrating that the instrument has an acceptable level of stability.

CONCLUSIONS

This study provides evidence that the Vietnamese translation of the COACH tool is generally perceived to be clear and easy to understand and has acceptable stability. There is, however, a need to rephrase and add generic examples to clarify some items and to further review items with low ICC.

The effect of registry-based performance feedback via short text messages and traditional postal letters on prescribing parenteral steroids by general practitioners--A randomized controlled trial

BACKGROUND

It is conjectured that providing feedback on physicians' prescribing behavior improves quality of drug prescriptions. However, the effectiveness of feedback provision and mode of feedback delivery is not well understood. The objective of this study was to assess and compare the effect of traditional paper letters (TPL) and short text message (STM) feedback on general practitioners' prescribing behavior of parenteral steroids (PSs).

METHODS

In a single-blind randomized controlled trial, 906 general practitioners (GPs) having at least 10 monthly prescriptions were randomly recruited into two interventions and one control study arms with 1:1 allocation, stratified by percentage of prescriptions. The intervention was the provision of 3 feedback messages containing prescribing indices in TPL and STM (in the first two arms) versus the control arm (CG) with an interval of 3 months between these messages. We calculated the PS Defined Daily Dose (DDD) for every GP, every month, and compared between the 3 arms, before and after the interventions. The expected primary outcome was to reduce prescription of parenteral steroids by participants. The study was performed in the Kerman Social Security Organization in Iran.

RESULTS

A total of 906 GPs were selected for the trial, but only 721 of them (TPL=191, STM=228, CG=302) were recruited for the 1st feedback. The mean age of GPs was 44 and 59% of them were male. The prescribed parenteral steroid DDDs at baseline were similar (TPL=121.62, STM=127.49, CG=115.68, P>0.5). At the end of the study, DDDs in the TPL and STM arms were similar (TPL=104.38, STM=101.90, P>0.9) but DDDs in each intervention arm was statistically significantly lower than in CG (CG=156.17, P<0.0001). Being in TPL and STM arms resulted in 36.1 and 41.7 units of decrease in DDD respectively, compared to the control arm (P<0.02 and P<0.005) after the one-year duration of the study.

CONCLUSION

Feedback by TPLs and STMs on prescribing performance effectively reduced prescribing PSs by GPs. STM, being a cheap and fast tool, is potentially powerful and efficient for drug prescription rationalization.

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

BACKGROUND

The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose.

METHODS

The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries.

RESULTS

The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge.

CONCLUSIONS

Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

Urban-rural inequality regarding drug prescriptions in primary care facilities - a pre-post comparison of the National Essential Medicines Scheme of China

Objective

To assess the impact of the National Essential Medicines Scheme (NEMS) with respect to urban-rural inequalities regarding drug prescriptions in primary care facilities.

Methods

A stratified two-stage random sampling strategy was used to sample 23,040 prescriptions from 192 primary care facilities from 2009 to 2010. Difference-in-Difference (DID) analyses were performed to test the association between NEMS and urban-rural gaps in prescription patterns. Between-Group Variance and Theil Index were calculated to measure urban-rural absolute and relative disparities in drug prescriptions.

Results

The use of the Essential Medicines List (EML) achieved a compliance rate of up to 90 % in both urban and rural facilities. An overall reduction of average prescription cost improved economic access to drugs for patients in both areas. However, we observed an increased urban-rural disparity in average expenditure per prescription. The rate of antibiotics and glucocorticoids prescription remained high, despite a reduced disparity between urban and rural facilities. The average incidence of antibiotic prescription increased slightly in urban facilities (62 to 63 %) and reduced in rural facilities (67 % to 66 %). The urban-rural disparity in the use of parenteral administration (injections and infusions) increased, albeit at a high level in both areas (44 %-52 %).

Conclusion

NEMS interventions are effective in reducing the overall average prescription costs. Despite the increased use of the EML, indicator performances with respect to rational drug prescribing and use remain poor and exceed the WHO/INRUD recommended cutoff values and worldwide benchmarks. There is an increased gap between urban and rural areas in the use of parenteral administration and expenditure per prescription.

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.

Prescribing for acute childhood infections in developing and transitional countries, 1990-2009

BACKGROUND

Evidence of global progress in treating acute paediatric infections is lacking.

OBJECTIVES

To assess progress over two decades in prescribing for childhood infections and interventions to improve treatment by reviewing empirical evidence in developing and transitional countries.

METHODS

Data were systematically extracted on the use of medicines for diarrhoea, respiratory infections and malaria from published and unpublished studies (1990-2009) in children under 5 years of age. Medians of each indicator were calculated across studies by study year, geographic region, sector, country income level and prescriber type. To estimate intervention effects from studies meeting methodologically accepted design criteria [randomised controlled trials (RCTs), pre-post with control, and time series studies], the medians of the median effect sizes (median MES) were calculated across outcome measures.

RESULTS

Data were extracted from 344 studies conducted in 78 countries with 394 distinct study groups in public (64%), private (22%) and other facilities to estimate trends over time. Of 226 intervention studies, only the 44 (19%) with an adequate study design were used to estimate intervention effects. Over time, use of anti-diarrhoeals for acute diarrhoea decreased significantly (P<0.01). However, treatment of malaria and acute respiratory infection remained largely sub-optimal. Multi-component interventions resulted in larger improvements than single-component ones. The median MES indicated a 28% improvement with community case-management, an 18% improvement with provider education combined with consumer education, but only 9% improvement with provider education alone.

CONCLUSIONS

While diarrhoea treatment has improved over the last 20 years, treatment of other childhood illnesses remains sub-optimal. Multi-component interventions demonstrated some success in improving management of acute childhood illness.

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.

Evaluation of capacity-building program of district health managers in India: a contextualized theoretical framework

Performance of local health services managers at district level is crucial to ensure that health services are of good quality and cater to the health needs of the population in the area. In many low- and middle-income countries, health services managers are poorly equipped with public health management capacities needed for planning and managing their local health system. In the south Indian Tumkur district, a consortium of five non-governmental organizations partnered with the state government to organize a capacity-building program for health managers. The program consisted of a mix of periodic contact classes, mentoring and assignments and was spread over 30 months. In this paper, we develop a theoretical framework in the form of a refined program theory to understand how such a capacity-building program could bring about organizational change. A well-formulated program theory enables an understanding of how interventions could bring about improvements and an evaluation of the intervention. In the refined program theory of the intervention, we identified various factors at individual, institutional, and environmental levels that could interact with the hypothesized mechanisms of organizational change, such as staff’s perceived self-efficacy and commitment to their organizations. Based on this program theory, we formulated context–mechanism–outcome configurations that can be used to evaluate the intervention and, more specifically, to understand what worked, for whom and under what conditions. We discuss the application of program theory development in conducting a realist evaluation. Realist evaluation embraces principles of systems thinking by providing a method for understanding how elements of the system interact with one another in producing a given outcome.

Effectiveness of the tailored Evidence Based Practice training program for Filipino physical therapists: a randomized controlled trial

BACKGROUND

This study evaluated the effectiveness of the contextualized EBP training program for Filipino physical therapists in terms of knowledge, skills, attitudes and behavior.

METHODS

A randomized controlled trial was designed to assess the effectiveness of the EBP training program. Fifty four physical therapists were randomly allocated to the EBP group (intervention) and waitlist (control) group. The EBP group had a one day face-to-face training with an online support, whilst the control was waitlisted. There were three measurement points which were pre, post, and three months post intervention for knowledge, skills and attitudes. Activity diaries were used to measure behavior. The diaries were collected after three months. Data analysis was by intention to treat in EBP domains of knowledge, skills and attitudes.

RESULTS

Fifty-four physical therapists were included in the study. Fifty two (52) completed the post training assessment and 26 completed the 3 months post training assessment for EBP knowledge, skills and attitudes. There were significant improvements in these domains in the EBP group from pre to post training and over a period of three months (p < 0.05) compared with the waitlist control group. Thirty seven (37) physical therapists completed their activity diaries over three months. Behavior significantly improved in the EBP group in terms of EBP behaviors (formulating PICO, searching, appraising and applying the evidence) when faced with both new/unique and usual case scenarios (p < 0.05). More physical therapists in the waitlist control group significantly performed non-EBP behaviors (asking doctors and reading textbooks) when faced with new/unique cases compared with the EBP group (p < 0.05). No differences were noted between groups regarding non-EBP behaviors (asking colleagues and doctors and reading textbooks) particularly when faced with usual cases.

CONCLUSION

The contextually designed EBP training program for Filipino physical therapists was effective in improving knowledge, skills and attitudes to EBP from pre to post training. Improvements were also observed at three months post training in knowledge, skills, attitudes and behavior to EBP. This model of training can be modified as needed based on the needs of the local context. Findings need to be interpreted with caution due to study limitations.

CURRENT CONTROLLED TRIALS

ISRCTN74485061 (Registration date: February 9, 2011).