GLOBAL HEALTH WRITES
Citizen Journalist: Jess O’Dowd
The gap between evidence and practice
Evidence-based practice is seen as the benchmark of good healthcare. The use of scientific evidence combined with clinical expertise and patient preference is the gold standard. However, despite the push for evidence-based practice the majority of healthcare interventions being used may not be based on current evidence. A mere 14% of evidence-based interventions are estimated to make it into real world healthcare settings. The importance of implementation science to bridge this evidence to practice gap is beginning to come to the fore, although how best to carry out implementation studies remains unclear.
With developments in science and technology the wealth of knowledge for healthcare interventions is continually building. The 3rd Global Implementation Conference took place in Dublin at the end of May, and explored how to support the uptake and use of evidence in healthcare.
The labyrinth of choice
Within implementation science there are many theories, frameworks and models to assist this process. However the sheer number of these, addressing different aspects of the implementation process, can make their selection and use overwhelming and unappealing.
Arguments have been made as to whether these theories, frameworks or models are better than a common sense approach. Those supporting common sense propose that you have an awareness of what barriers and facilitators are in your setting and you can then address these as needed. However if the common sense approach has been mainly used to this point, with many of these theories and frameworks only developed in the last number of years, it can be argued that common sense has not worked and it is time to try something new and with more transparency.
When deciding which theory, framework or model to use in your setting you are faced with a wide variety. There is a choice between; classic theories, implementation theories (developed specifically for implementation science), determinant frameworks (designed to assess the situation for which the intervention is to be applied), process models (step-by-step guidelines of stages to bring evidence into practice) and evaluation frameworks (used to evaluate the success of implementation). Within each of these categories there are many to choose from, and some are more relevant to different stages in the process than others. However after reading through all and hearing the input of the experts at the Global Implementation Conference it was clear that there was no stand out theory/model/framework among them all. With large amounts of overlap between each other – it leaves the choice up to the user as to which would be most useful to use in their context.
Shifting the context towards areas of greatest need
Although there is an abundance of theories, frameworks and models, one major issue raised was the bias towards high-income country contexts. Melanie Barwick from SickKids Research Institute, Ontario, Canada, discussed the use of the Consolidated Framework for Implementation Research (CFIR) in Ethiopia and Mali for exploration of implementation of strategies supporting exclusive breastfeeding. Through this research it was found that numerous items relevant to Low and Middle Income Country (LMIC) contexts were not present on the original CFIR framework. These included contextual issues around supervision and remuneration for community health workers, individual patient factors such as belief systems, role within family, economic status and level of education. All of which were found to be contextual factors affecting implementation of the exclusive breastfeeding intervention in these settings. It was clear from this study that contextual factors affecting LMICs need also be included in development of these theories, frameworks and models.
Implementation science is growing and can assist in addressing the evidence to practice gap. The use of theories, frameworks and models as opposed to a “common sense” approach can be argued to lead to a more comprehensive and transparent approach to implementation. Allowing for shared learning across contexts. However there is no clear answer on which is best to use. The large volume of methods to address implementation can be overwhelming and use depends on context and stage of implementation of the intervention. BuyTermPapersOnline contextual factors that may be more common in LMICs need to be incorporated into these frameworks and models to allow for a global inclusive approach to implementation science. With the current emphasis on evidence-based practice the role of implementation science to bridge the evidence to practice gap is becoming clear.
As the science grows it is hoped that far greater than 14% of evidence will eventually be realised in healthcare settings.
Jessica O’Dowd is a Doctoral student at the Centre for Global Health, Trinity College Dublin and the HRB TMRN. Jessica holds an MSc Global Health and BSc Physiotherapy. Her research interests include disability, assistive health technologies and how context affects implementation of healthcare interventions in low resource settings.