Putting evidence into practice: how middle and low income countries "get it together"
http://www.100md.com
《英国医生杂志》
1 International Health Research Group, Liverpool School of Tropical Medicine, Liverpool L3 5QA, 2 Institute of Tropical Diseases Research and Prevention, University of Calabar, Calabar, PMB 1115, Cross River State, Nigeria, 3 Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925 Cape Town, South Africa, 4 Department of Maternal and Child Health, School of Public Health, Medical Center of Fudan University, Shanghai, People's Republic of China
Correspondence to: P Garner pgarner@liv.ac.uk
The scarcity of resources in poorer countries means that ensuring health care is evidence based is particularly important. A group of workers active in the field describe their experiences of trying to do just that
Introduction
It seems reasonable to communicate the principles of evidence based medicine to healthcare staff to help them use the information from systematic reviews. The principles are relatively new to many people, so we believe that engaging people in the ideas is a prerequisite to achieving changes in clinical practice based on understanding.
Policy makers participating in seminars about evidence based approaches often agree with the principles but are unsure what to do next. We developed a dissemination framework, based on work at the Centre for Reviews and Dissemination at the University of York, to guide policy makers and clinicians in understanding research summaries and in using them to change practice. The framework outlines different levels of dissemination with activities to engage different target groups; from passive dissemination, to engaging clinicians in change, to projects to highlight the potential for change, to institutionalising evidence based approaches in training and ministries (see box). We have used this framework in an international programme of research and development, the Effective Health Care Alliance, to promote evidence based practice with collaborators across the world including in China, Thailand, Nigeria, South Africa, Ghana, Tanzania, and Chile.
We experienced the many constraints facing clinicians considering practice change through the "better births initiative"—a low cost educational programme started in South Africa to communicate best practice to midwives and doctors on labour wards in low and middle income settings.11 The initiative was a pilot innovation project (level 3 in the box) to improve policies and practice in labour rooms through the use of evidence from systematic reviews packaged in an interactive workshop delivered by a local opinion leader.12 It encouraged uptake of practices known to be beneficial (such as social support in labour) and discouraged painful practices with little evidence of benefit (such as routine episiotomy).
Accompanying qualitative research in South Africa helped elucidate possible pathways for change. Any chance of change required mobilising the social structure within the health facilities, but even then change was often random—it might depend on just one person or on a team consensus to bypass the traditional staff hierarchy. Although resource constraints are often cited as a barrier to change, the reality is often more complicated: the high turnover of staff seen in one pilot site in Gauteng province, South Africa, clearly mitigated against any sustained practice change.13 Change on the ground is clearly a complex process, and enthusiasts seem important in the early stages: a particular respected obstetrician was the driving force for the spread of the better births initiative in Eastern and Western Cape and Kwa-Zulu Natal, with provincial government support.
In Shanghai we examined similar issues in institutional care some five years ago, when WHO and others were disseminating ideas about evidence based reproductive health. With respected leaders at Fudan University, we developed an awareness raising package (level 1 in the box) to communicate the concepts of evidence based reproductive health to a wide audience and to stimulate debate on how to use review findings in practice. An audit of practice in Shanghai maternity hospitals highlighted areas where practice was inconsistent with available evidence,14 and a repeat audit four years later showed some change in some hospitals. However, there was no policy shift at national level until recently. In the past few months, after much lobbying and advocacy, a national level training programme to apply evidence based care in obstetrics, gynaecology, and paediatrics has been planned and held. Some hospitals have rewritten their own service guidelines based on current evidence, and the Ministry of Health has agreed to use evidence based guidelines for obstetric care for basic health services in its "safe motherhood programme."
Framework for dissemination and implementation of evidence based medicine
Level 1: Awareness raising
Purpose
? Increase awareness about effective interventions and the potential gains from using research based knowledge in policy and practice
Activities
Produce and publish relevant systematic reviews in a variety of professional and consumer publications
Communicate potential relevance of systematic reviews to current practice, with examples through commentaries
Level 2: Targeting groups and individuals responsible for implementation
Purpose
? Identify target groups and individuals with specific roles in implementing research based knowledge in practice
Activities
Identify target groups, such as health ministry policy makers, donor aid advisers, professional groups, managers with responsibility for clinical and public health policy
Communicate results from systematic reviews and their implications for practice face to face and with short summaries
Give examples of how others have used systematic reviews combined with audit to change practice for the better in their own hospital or practice.
Make people aware of the evidence base for effective practice change
Level 3: Pilot and innovation projects
Purpose
? Support individuals in specific pilot projects to evaluate potential ways to implement change in practices that seem to run contrary to current available evidence
Activities
Identify collaborators engaged in or interested in developing pilot projects to implement research findings and where they perceive there is an opportunity to make care more evidence based
Help them in to stimulate change (such as by audit and feedback or by means of opinion leaders) to practices for which there is reliable evidence from systematic reviews of effectiveness
Ensure collaborators monitor change in policy and practice
Level 4: National or institutional policies for evidence based decisions
Purpose
? Encourage national governments, institutions, or donors to commit to evidence based approaches, with effective implementation and monitoring systems
Activities
Work with government and donors in establishing or strengthening health technology assessment offices or similar bodies at national level
Encourage national policies for evidence based guidelines, with management systems to ensure that guidelines are implemented and monitored
Help institutions to train doctors, nurses, and other health staff to deliver training in evidence based approaches
Collaborators in Cross River State in Nigeria used a strategy that engaged key policy makers and practitioners in producing guidelines (level 4 in the box) in response to a request from the state government to help ensure practice was evidence based for some common conditions. During collaboration with four government and 10 private hospitals, it became clear that there was no experience or understanding of audit or management processes to standardise care. The project, which was recently discussed at Nigeria's National Council on Health (a policy forum) recently, recognised the utility of simple guidelines for increasing the efficiency of the hospital service, and central to this was introducing the basic principles of audit and management processes. Clearly evidence based approaches need people and institutions to have the skills and motivation to evaluate how they do things and how they can improve their practice.
Reflections
Adjuik M, Babiker A, Garner P, Olliaro P, Taylor W, White N for the International Artemisinin Study Group. Artesunate combinations for treatment of malaria: meta-analysis. Lancet 2004;363: 9-17.
Attaran A, Barnes KI, Curtis C, d'Alessandro U, Fanello CI, Galinski MR, et al. WHO, the Global Fund, and medical malpractice in malaria treatment. Lancet 2004;363: 237-40.
Eisenberg JM. Globalize the evidence, localize the decision: evidence-based medicine and international diversity. Health Aff 2002;21: 166-8.
Clarke M, Chalmers I. Discussion sections in reports of controlled trials published in general medical journals: islands in search of continents? JAMA 2000;284: 1785-6.
Global Programme on Evidence for Health Policy. Guidelines for WHO guidelines (EIP/GPE/EQC/2003.1.). Geneva: WHO, 2003 (www.who.int/medicines/organization/par/edl/expcom14/guid_for_guid.pdf)
GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328: 1490.
Kim Y, Hahn S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev 2001(2): CD002847. Update in:Cochrane Database Syst Rev 2002;(1): CD002847.
Child and Adolescent Health Development, WHO. Oral rehydration salts (ORS): a new reduced osmolarity formulation. www.who.int/child-adolescent-health/New_Publications/NEWS/Statement.htm (accessed 28 Jul 2004).
Olliaro P, Mussano P. Amodiaquine for treating malaria. Cochrane Database Syst Rev 2003(2): CD000016.
McIntosh HM, Olliaro P. Artemisinin derivatives for treating uncomplicated malaria. Cochrane Database Syst Rev 2000(2): CD000256.
Smith H. Better Births Initiative in South Africa. British Journal of Midwifery 2003;11(8): 502-6.
Thomson O'Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000(2): CD000125.
Smith H, Brown H, Hofmeyr GJ, Garner P. Evidence-based obstetric care in South Africa—influencing practice through the `Better Births Initiative.' S Afr Med J 2004;94: 117-20.
Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2003(3): CD000259.
Plsek P, Wilson T. Complexity, leadership, and management in healthcare organisations. BMJ 2001;323: 746-9.
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patient care. Lancet 2003;362: 1225-30.
Harvey G, Wensing M. Methods for evaluation of small scale quality improvement projects. Qual Saf Health Care 2003;12: 210-4.(Paul Garner, professor1, )
Correspondence to: P Garner pgarner@liv.ac.uk
The scarcity of resources in poorer countries means that ensuring health care is evidence based is particularly important. A group of workers active in the field describe their experiences of trying to do just that
Introduction
It seems reasonable to communicate the principles of evidence based medicine to healthcare staff to help them use the information from systematic reviews. The principles are relatively new to many people, so we believe that engaging people in the ideas is a prerequisite to achieving changes in clinical practice based on understanding.
Policy makers participating in seminars about evidence based approaches often agree with the principles but are unsure what to do next. We developed a dissemination framework, based on work at the Centre for Reviews and Dissemination at the University of York, to guide policy makers and clinicians in understanding research summaries and in using them to change practice. The framework outlines different levels of dissemination with activities to engage different target groups; from passive dissemination, to engaging clinicians in change, to projects to highlight the potential for change, to institutionalising evidence based approaches in training and ministries (see box). We have used this framework in an international programme of research and development, the Effective Health Care Alliance, to promote evidence based practice with collaborators across the world including in China, Thailand, Nigeria, South Africa, Ghana, Tanzania, and Chile.
We experienced the many constraints facing clinicians considering practice change through the "better births initiative"—a low cost educational programme started in South Africa to communicate best practice to midwives and doctors on labour wards in low and middle income settings.11 The initiative was a pilot innovation project (level 3 in the box) to improve policies and practice in labour rooms through the use of evidence from systematic reviews packaged in an interactive workshop delivered by a local opinion leader.12 It encouraged uptake of practices known to be beneficial (such as social support in labour) and discouraged painful practices with little evidence of benefit (such as routine episiotomy).
Accompanying qualitative research in South Africa helped elucidate possible pathways for change. Any chance of change required mobilising the social structure within the health facilities, but even then change was often random—it might depend on just one person or on a team consensus to bypass the traditional staff hierarchy. Although resource constraints are often cited as a barrier to change, the reality is often more complicated: the high turnover of staff seen in one pilot site in Gauteng province, South Africa, clearly mitigated against any sustained practice change.13 Change on the ground is clearly a complex process, and enthusiasts seem important in the early stages: a particular respected obstetrician was the driving force for the spread of the better births initiative in Eastern and Western Cape and Kwa-Zulu Natal, with provincial government support.
In Shanghai we examined similar issues in institutional care some five years ago, when WHO and others were disseminating ideas about evidence based reproductive health. With respected leaders at Fudan University, we developed an awareness raising package (level 1 in the box) to communicate the concepts of evidence based reproductive health to a wide audience and to stimulate debate on how to use review findings in practice. An audit of practice in Shanghai maternity hospitals highlighted areas where practice was inconsistent with available evidence,14 and a repeat audit four years later showed some change in some hospitals. However, there was no policy shift at national level until recently. In the past few months, after much lobbying and advocacy, a national level training programme to apply evidence based care in obstetrics, gynaecology, and paediatrics has been planned and held. Some hospitals have rewritten their own service guidelines based on current evidence, and the Ministry of Health has agreed to use evidence based guidelines for obstetric care for basic health services in its "safe motherhood programme."
Framework for dissemination and implementation of evidence based medicine
Level 1: Awareness raising
Purpose
? Increase awareness about effective interventions and the potential gains from using research based knowledge in policy and practice
Activities
Produce and publish relevant systematic reviews in a variety of professional and consumer publications
Communicate potential relevance of systematic reviews to current practice, with examples through commentaries
Level 2: Targeting groups and individuals responsible for implementation
Purpose
? Identify target groups and individuals with specific roles in implementing research based knowledge in practice
Activities
Identify target groups, such as health ministry policy makers, donor aid advisers, professional groups, managers with responsibility for clinical and public health policy
Communicate results from systematic reviews and their implications for practice face to face and with short summaries
Give examples of how others have used systematic reviews combined with audit to change practice for the better in their own hospital or practice.
Make people aware of the evidence base for effective practice change
Level 3: Pilot and innovation projects
Purpose
? Support individuals in specific pilot projects to evaluate potential ways to implement change in practices that seem to run contrary to current available evidence
Activities
Identify collaborators engaged in or interested in developing pilot projects to implement research findings and where they perceive there is an opportunity to make care more evidence based
Help them in to stimulate change (such as by audit and feedback or by means of opinion leaders) to practices for which there is reliable evidence from systematic reviews of effectiveness
Ensure collaborators monitor change in policy and practice
Level 4: National or institutional policies for evidence based decisions
Purpose
? Encourage national governments, institutions, or donors to commit to evidence based approaches, with effective implementation and monitoring systems
Activities
Work with government and donors in establishing or strengthening health technology assessment offices or similar bodies at national level
Encourage national policies for evidence based guidelines, with management systems to ensure that guidelines are implemented and monitored
Help institutions to train doctors, nurses, and other health staff to deliver training in evidence based approaches
Collaborators in Cross River State in Nigeria used a strategy that engaged key policy makers and practitioners in producing guidelines (level 4 in the box) in response to a request from the state government to help ensure practice was evidence based for some common conditions. During collaboration with four government and 10 private hospitals, it became clear that there was no experience or understanding of audit or management processes to standardise care. The project, which was recently discussed at Nigeria's National Council on Health (a policy forum) recently, recognised the utility of simple guidelines for increasing the efficiency of the hospital service, and central to this was introducing the basic principles of audit and management processes. Clearly evidence based approaches need people and institutions to have the skills and motivation to evaluate how they do things and how they can improve their practice.
Reflections
Adjuik M, Babiker A, Garner P, Olliaro P, Taylor W, White N for the International Artemisinin Study Group. Artesunate combinations for treatment of malaria: meta-analysis. Lancet 2004;363: 9-17.
Attaran A, Barnes KI, Curtis C, d'Alessandro U, Fanello CI, Galinski MR, et al. WHO, the Global Fund, and medical malpractice in malaria treatment. Lancet 2004;363: 237-40.
Eisenberg JM. Globalize the evidence, localize the decision: evidence-based medicine and international diversity. Health Aff 2002;21: 166-8.
Clarke M, Chalmers I. Discussion sections in reports of controlled trials published in general medical journals: islands in search of continents? JAMA 2000;284: 1785-6.
Global Programme on Evidence for Health Policy. Guidelines for WHO guidelines (EIP/GPE/EQC/2003.1.). Geneva: WHO, 2003 (www.who.int/medicines/organization/par/edl/expcom14/guid_for_guid.pdf)
GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328: 1490.
Kim Y, Hahn S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev 2001(2): CD002847. Update in:Cochrane Database Syst Rev 2002;(1): CD002847.
Child and Adolescent Health Development, WHO. Oral rehydration salts (ORS): a new reduced osmolarity formulation. www.who.int/child-adolescent-health/New_Publications/NEWS/Statement.htm (accessed 28 Jul 2004).
Olliaro P, Mussano P. Amodiaquine for treating malaria. Cochrane Database Syst Rev 2003(2): CD000016.
McIntosh HM, Olliaro P. Artemisinin derivatives for treating uncomplicated malaria. Cochrane Database Syst Rev 2000(2): CD000256.
Smith H. Better Births Initiative in South Africa. British Journal of Midwifery 2003;11(8): 502-6.
Thomson O'Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000(2): CD000125.
Smith H, Brown H, Hofmeyr GJ, Garner P. Evidence-based obstetric care in South Africa—influencing practice through the `Better Births Initiative.' S Afr Med J 2004;94: 117-20.
Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2003(3): CD000259.
Plsek P, Wilson T. Complexity, leadership, and management in healthcare organisations. BMJ 2001;323: 746-9.
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patient care. Lancet 2003;362: 1225-30.
Harvey G, Wensing M. Methods for evaluation of small scale quality improvement projects. Qual Saf Health Care 2003;12: 210-4.(Paul Garner, professor1, )