A protocol for a systematic review of the use of process evaluations in knowledge translation research

Primary health care roles of community pharmacists in low- and middle-income countries: A protocol for a mixed methods systematic review

BACKGROUND

The roles of community pharmacists in primary health care cannot be overemphasized, these professionals have evolved from the traditional dispensing to providing health promotion, vaccination services, and medication therapy management as well as other areas of patient care needs. The objectives of this review are to explore evidence of the provision of primary health care services by community pharmacists in low- and middle-income countries (LMICs) and identify barriers to these services and how these barriers can be mitigated.

METHOD

A systematic search will be conducted in Medline, CINAHL, Google scholar, Global Index Medicus, LILACS, and CENTRAL to identify potentially relevant primary literature for inclusion. Also, ProQuest Dissertations and Theses will be search to identify relevant gray literature. The review will be guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist for systematic reviews. All primary research articles regardless of study design exploring or reporting on community pharmacists' involvement in primary health care in LMICs will be considered for possible inclusion. A summary of the included studies will be provided and a quality assessment will be conducted using the 2018 version of the mixed methods analytical tool.

EXPECTED RESULTS

Findings from this review will add to the evidence in the literature and cause the need for policy change to empower the community pharmacy practice by providing a friendlier legal framework for delivering services in tandem with international best practices. PROSPERO registration ID: CRD42023357312.

What do we want to get out of this? a critical interpretive synthesis of the value of process evaluations, with a practical planning framework

BACKGROUND

Process evaluations aim to understand how complex interventions bring about outcomes by examining intervention mechanisms, implementation, and context. While much attention has been paid to the methodology of process evaluations in health research, the value of process evaluations has received less critical attention. We aimed to unpack how value is conceptualised in process evaluations by identifying and critically analysing 1) how process evaluations may create value and 2) what kind of value they may create.

METHODS

We systematically searched for and identified published literature on process evaluation, including guidance, opinion pieces, primary research, reviews, and discussion of methodological and practical issues. We conducted a critical interpretive synthesis and developed a practical planning framework.

RESULTS

We identified and included 147 literature items. From these we determined three ways in which process evaluations may create value or negative consequences: 1) through the socio-technical processes of 'doing' the process evaluation, 2) through the features/qualities of process evaluation knowledge, and 3) through using process evaluation knowledge. We identified 15 value themes. We also found that value varies according to the characteristics of individual process evaluations, and is subjective and context dependent.

CONCLUSION

The concept of value in process evaluations is complex and multi-faceted. Stakeholders in different contexts may have very different expectations of process evaluations and the value that can and should be obtained from them. We propose a planning framework to support an open and transparent process to plan and create value from process evaluations and negotiate trade-offs. This will support the development of joint solutions and, ultimately, generate more value from process evaluations to all.

Process Evaluation of an Implementation Trial: Design, Rationale, and Early Lessons Learnt From an International Cluster Clinical Trial in Intracerebral Hemorrhage

Background

The third INTEnsive care bundle with blood pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT3) is an ongoing, international, multicenter, stepped-wedge cluster, prospective, randomized, open, blinded endpoint assessed trial evaluating the effectiveness of a quality improvement “care bundle” for the management of patients with acute spontaneous intracerebral hemorrhage (ICH) in low- and middle-income countries (LMICs). An embedded process evaluation aims to explore the uptake and implementation of the intervention, and understand the context and stakeholder perspectives, for interpreting the trial outcomes.

Methodology

The design was informed by Normalization Process Theory and the UK Medical Research Council process evaluation guidance. Mixed methods are used to evaluate the implementation outcomes of fidelity, reach, dose, acceptability, appropriateness, adoption, sustainability, and relevant contextual factors and mechanisms affecting delivery of the care bundle. Semi-structured interviews and non-participant observations are conducted with the primary implementers (physicians and nurses) and patients/carers to explore how the care bundle was integrated into routine care. Focus group discussions are conducted with investigators and project operational staff to understand challenges and possible solutions in the organization of the trial. Data from observational records, surveys, routine monitoring data, field notes and case report forms, inform contextual factors, and adoption of the intervention. Purposive sampling of sites according to pre-specified criteria is used to achieve sample representativeness.

Discussion

Implementation outcomes, and relevant barriers and facilitators to integrating the care bundle into routine practice, will be reported after completion of the process evaluation. The embedded process evaluation will aid understanding of the causal mechanisms between care bundle elements and clinical outcomes within complex health systems across diverse LMIC settings.

Trial Registration

The INTERACT3 study is registered at ClinicalTrials.gov (NCT03209258).

The use of theory in process evaluations conducted alongside randomized trials of implementation interventions: A systematic review

Interventions to implement changes into health care practice (i.e., implementation interventions) are critical to improving care but their effects are poorly understood. Two strategies to better understand intervention effects are conducting process evaluations and using theoretical approaches (i.e., theories, models, frameworks). The extent to which theoretical approaches have been used in process evaluations conducted alongside trials of implementation interventions is unclear. In this study context, we reviewed (a) the proportion of process evaluations citing theoretical approaches, (b) which theoretical approaches were cited, and (c) whether and how theories were used. Systematic review (PROSPERO: CRD42016042789). MEDLINE, PsycINFO, Embase, CINAHL, and Cochrane CENTRAL were searched up to July 31, 2017. For all studies, data extraction included names and types of theoretical approaches cited. For studies citing a theory, data extraction included study characteristics and extent of theory use (i.e., "informed by," "applied," "tested," "built/created" theory). We identified 123 process evaluations. Key findings: (a) 77 (63%) process evaluations cited a theoretical approach; (b) the most cited theory was normalization process theory; (c) 32 (26%) process evaluations used theory: 7 (22%) were informed by, 18 (56%) applied, 7 (22%) tested, and none built/created theory. Although nearly two thirds of process evaluations cited a theoretical approach, only a quarter were informed by, applied, or tested a theory-despite the potential complementarity of these strategies. When theory was used, it was primarily applied. Using theory more substantively in process evaluations may accelerate our understanding of how implementation interventions operate.

Systematic review of the use of process evaluations in knowledge translation research

BACKGROUND

Experimental designs for evaluating knowledge translation (KT) interventions can provide strong estimates of effectiveness but offer limited insight into how the intervention worked. Consequently, process evaluations have been used to explore the causal mechanisms at work; however, there are limited standards to guide this work. This study synthesizes current evidence of KT process evaluations to provide future methodological recommendations.

METHODS

Peer-reviewed search strategies were developed by a health research librarian. Studies had to be in English, published since 1996, and were not excluded based on design. Studies had to (1) be a process evaluation of a KT intervention study in primary health, (2) be a primary research study, and (3) include a licensed healthcare professional delivering or receiving the intervention. A two-step, two-person hybrid screening approach was used for study inclusion with inter-rater reliability ranging from 94 to 95%. Data on study design, data collection, theoretical influences, and approaches used to evaluate the KT intervention, analysis, and outcomes were extracted by two reviewers. Methodological quality was assessed with the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Of the 20,968 articles screened, 226 studies fit our inclusion criteria. The majority of process evaluations used qualitative forms of data collection (43.4%) and individual interviews as the predominant data collection method. 72.1% of studies evaluated barriers and/or facilitators to implementation. 59.7% of process evaluations were stand-alone evaluations. The timing of data collection varied widely with post-intervention data collection being the most frequent (46.0%). Only 38.1% of the studies were informed by theory. Furthermore, 38.9% of studies had MMAT scores of 50 or less indicating poor methodological quality.

CONCLUSIONS

There is widespread acceptance that the generalizability of quantitative trials of KT interventions would be significantly enhanced through complementary process evaluations. However, this systematic review found that process evaluations are of mixed quality and lack theoretical guidance. Most process evaluation data collection occurred post-intervention undermining the ability to evaluate the process of implementation. Strong science and methodological guidance is needed to underpin and guide the design and execution of process evaluations in KT science.

REGISTRATION

This study is not registered with PROSPERO.

A typology of systematic reviews for synthesising evidence on health care

OBJECTIVES

The objectives of this paper are to (a) Review published references to systematic reviews; (b) offer a typology of systematic reviews for synthesising evidence on health care; and (c) summarise the guides for designing, reporting and appraising the reviews.

BACKGROUND

Systematic reviews play a role in finding, synthesising, transferring and implementing evidence for healthcare policy, practice guidelines and allocation of health resources. They have been particularly successful in confirming or synthesising evidence for health care by meta-analysing aggregated data from multiple randomised controlled trials. However, concerns about the limitations of evidence from controlled trials have prompted interest in other review methods capable of locating and appraising evidence from more diverse, and possibly more realistic, healthcare situations.

METHODS

An iterative citation-tracking process with Google Search and grey literature identified 204 papers on previous typologies and methods of systematic reviews.

RESULTS AND CONCLUSIONS

There are six types of systematic reviews: narrative; meta-analysis; scoping; qualitative; umbrella; and realist. Each type has distinct objectives, characteristics and attributes, but with much overlapping of methods and guides. Sensitivity to the need for qualitative evidence on complex human responses to ill-health and health care has broadened the objectives and methods of health-related systematic reviews to find, appraise and synthesis useful evidence for practice guidelines, healthcare policy and allocation of health resources.

A Web-Based Knowledge Translation Resource for Families and Service Providers (The "F-Words" in Childhood Disability Knowledge Hub): Developmental and Pilot Evaluation Study

BACKGROUND

The "F-words in Childhood Disability" (Function, Family, Fitness, Fun, Friends, and Future) are an adaptation and an attempt to operationalize the World Health Organization's (2001) International Classification of Functioning, Disability and Health (ICF) framework. Since the paper was published (November 2011), the "F-words" have attracted global attention (>12,000 downloads, January 2018). Internationally, people have adopted the "F-words" ideas, and many families and service providers have expressed a need for more information, tools, and resources on the "F-words".

OBJECTIVE

This paper reports on the development and pilot evaluation of a Web-based knowledge translation (KT) resource, the "F-words" Knowledge Hub that was created to inform people about the "F-words" and to provide action-oriented tools to support the use of the "F-words" in practice.

METHODS

An integrated research team of families and researchers at CanChild Centre for Childhood Disability Research collaborated to develop, implement, and evaluate the Knowledge Hub. A pilot study design was chosen to assess the usability and utility of the Web-based hub before implementing a larger evaluation study. Data were collected using a brief anonymous Web-based survey that included both closed-ended and open-ended questions, with the closed-ended responses being based on a five-point Likert-type scale. We used descriptive statistics and a summary of key themes to report findings.

RESULTS

From August to November 2017, the Knowledge Hub received >6,800 unique visitors. In 1 month (November 2017), 87 people completed the survey, of whom 63 completed the full survey and 24 completed 1 or 2 sections. The respondents included 42 clinicians and 30 family members or individuals with a disability. The majority of people visited the Knowledge Hub 1-5 times (n=63) and spent up to 45 minutes exploring (n=61) before providing feedback. Overall, 66 people provided information on the perceived usefulness of the Knowledge Hub, of which 92% (61/66) found the Knowledge Hub user-friendly and stated that they enjoyed exploring the hub, and a majority (n=52) reported that the Knowledge Hub would influence what they did when working with others. From the open-ended responses (n=48), the "F-words" videos (n=21) and the "F-words" tools (n=15) were rated as the best features on the Knowledge Hub.

CONCLUSIONS

The "F-words" Knowledge Hub is an evidence-informed Web-based KT resource that was useful for respondents, most of whom were seen as "early adopters" of the "F-words" concepts. Based on the findings, minor changes are to be made to improve the Knowledge Hub before completing a larger evaluation study on the impact at the family, clinician, and organizational levels with a wider group of users. Our hope is that the "F-words" Knowledge Hub will become a go-to resource for knowledge sharing and exchange for families and service providers.

Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative

PURPOSE

This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients.

MATERIALS AND METHODS

This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach.

RESULTS

Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group.

CONCLUSIONS

The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature

BACKGROUND

Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa.

METHODS

Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings.

RESULT

The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff.

CONCLUSIONS

A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074102.

The new roles of medical librarians in medical research

Purpose

This study aims to highlight the role of librarians as an essential element in medical research. For this purpose, the primary research process was divided into three phases: before, during and after. Then, the roles of librarians associated with each phase were separated and the viewpoint of researchers and librarians on the importance of these roles were considered and compared.

Design/methodology/approach

This comparative, descriptive-causal research was conducted using the census method. Birjand University, a type-2 university in the field of Medical Sciences according to the rating of the Iranian Ministry of Health and Medical Education, was selected for the study. The participants were all faculty members and all librarians working in the university’s libraries. The data collection tool was a questionnaire made by authors. Its validity was confirmed by four professors of Library Science, and questionnaire design expert and its reliability was confirmed with a Cronbach's alpha of 0.89. Data were analyzed with the Statistical Package for the Social Sciences, using descriptive statistics.

Findings

From the perspective of researchers, awareness-raising for open access resources, determination of standard subject keywords on the basis of Medical Subject Headings for articles and scientific texts and using scientific research findings as a basis for preventing duplicate studies in future research are the most important roles for librarians in the three stages of medical research. From the perspective of librarians, the use of knowledge management skills, searching scientific information as review of the literature and also selecting standard keywords to search the databases and providing health-care professionals with the findings of latest scientific research have the highest place in the different stages of the research lifecycle.

Originality/value

The difference between the viewpoints of librarians and researchers about the role of medical librarians at the various stages of the research lifecycle shows that there are significant gaps between the librarians’ services and users’ expectations. It is expected that through learning modern professional skills, medical librarians can assume new roles in medical research and make their capabilities known and available to researchers.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa-a systematic review protocol

BACKGROUND

Nearly 15% of all pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labor, and complications of abortion. Between 1990 and 2015, an estimated 10.7 million women died due to obstetric complications. Almost all of these deaths (99%) happened in developing countries, and 66% of maternal deaths were attributed to sub-Saharan Africa. The majority of cases of maternal mortalities can be prevented through provision of evidence-based potentially life-saving signal functions of emergency obstetric care. However, different factors can hinder women's ability to access and use emergency obstetric services in sub-Saharan Africa. Therefore, the aim of this review is to synthesize current evidence on barriers to accessing and utilizing emergency obstetric care in sub-Saharan African. Decision-makers and policy formulators will use evidence generated from this review in improving maternal healthcare particularly the emergency obstetric care.

METHODS

Electronic databases including MEDLINE, CINAHL, Embase, and Maternity and Infant Care will be searched for studies using predefined search terms. Articles published in English language between 2010 and 2017 with quantitative and qualitative design will be included. The identified papers will be assessed for meeting eligibility criteria. First, the articles will be screened by examining their titles and abstracts. Then, two reviewers will review the full text of the selected articles independently. Two reviewers using a standard data extraction format will undertake data extraction from the retained studies. The quality of the included papers will be assessed using the mixed methods appraisal tool. Results from the eligible studies will be qualitatively synthesized using the narrative synthesis approach and reported using the three delays model. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be employed to present the findings.

DISCUSSION

This systematic review will present a detailed synthesis of the evidence for barriers to access and utilization of emergency obstetric care in sub-Saharan Africa over the last 7 years. This systematic review is expected to provide clear information that can help in designing maternal health policy and interventions particularly in emergency obstetric care in sub-Saharan Africa where maternal mortality remains high.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074102 .

Tailoring implementation strategies for evidence-based recommendations using computerised clinical decision support systems: protocol for the development of the GUIDES tools

BACKGROUND

A computerised clinical decision support system (CCDSS) is a technology that uses patient-specific data to provide relevant medical knowledge at the point of care. It is considered to be an important quality improvement intervention, and the implementation of CCDSS is growing substantially. However, the significant investments do not consistently result in value for money due to content, context, system and implementation issues. The Guideline Implementation with Decision Support (GUIDES) project aims to improve the impact of CCDSS through optimised implementation based on high-quality evidence-based recommendations. To achieve this, we will develop tools that address the factors that determine successful CCDSS implementation.

METHODS/DESIGN

We will develop the GUIDES tools in four steps, using the methods and results of the Tailored Implementation for Chronic Diseases (TICD) project as a starting point: (1) a review of research evidence and frameworks on the determinants of implementing recommendations using CCDSS; (2) a synthesis of a comprehensive framework for the identified determinants; (3) the development of tools for use of the framework and (4) pilot testing the utility of the tools through the development of a tailored CCDSS intervention in Norway, Belgium and Finland. We selected the conservative management of knee osteoarthritis as a prototype condition for the pilot. During the process, the authors will collaborate with an international expert group to provide input and feedback on the tools.

DISCUSSION

This project will provide guidance and tools on methods of identifying implementation determinants and selecting strategies to implement evidence-based recommendations through CCDSS. We will make the GUIDES tools available to CCDSS developers, implementers, researchers, funders, clinicians, managers, educators, and policymakers internationally. The tools and recommendations will be generic, which makes them scalable to a large spectrum of conditions. Ultimately, the better implementation of CCDSS may lead to better-informed decisions and improved care and patient outcomes for a wide range of conditions.

PROTOCOL REGISTRATION

PROSPERO, CRD42016033738.