Archive | September 2013

A Different Perspective?

My thesis revolves around an experience that I had when I worked as a nurse. A certain medication delivery device with which I worked presented difficulties that constituted a safety problem for nurses, and potential dosing issues for patients. A related issue was the fact that this went on for years, and around the world, without acknowledgement from the producer. Some nurses even perceived bad faith on behalf of the producer, believing that their concerns where not being listened to. Because the device was only used in psychiatric settings, there were allegations that more would have been done if the client base had been more affluent and socially audible.

As I come to grapple with what kind of background such a project might need, and how best to frame my question for a review of that background, I find myself wondering what is truly salient here? So far, I have found hundreds of articles related to various faulty, or reportedly faulty clinical implements. They tend to focus on what the issues were, and how they were mechanically fixed. Studies looking at how healthcare settings reacted to these situations are harder to find, and critical examinations of the power relationships between the pharmaceutical industry, nurses, psychiatric patients and other players don’t seem to be presented with these types of practical contexts. Am I exploring a perspective on our pharmaceutical system that hasn’t been explored before? Surely not – but even when I find something that seems promising, it generally seems that the approach is very different.

Aside from individual articles, this seems to happen more broadly in the way we look at pharmaceutical products. Take, for example, the Therapeutics Initiative (TI) at the University of British Columbia. It had, on several occasions, been suggested to me as a possible partner for my research. During the actual struggle with the device, a possible ally in teasing out the best evidence around the situation. On its website the TI (2010) purports that “To reduce bias as much as possible the TI is an independent organization, separate from government, pharmaceutical industry and other vested interest groups.” It goes on to say that practical, unbiased information about medication is a critical part of its role. Looking through its reviews, however, there is somewhat little in the way of critical analysis. Rather than exploring effectiveness, the studies explore pharmacological efficacy. And instead of searching for a broader understanding of effects, most available studies on the TI website are meta-analyses of efficacy studies, most of which would have been conducted by the pharmaceutical companies themselves.

I look forward to exploring this issue in more depth. I’m concerned that instead of an informative review of the subject, I will be writing a patchwork of understanding originating from no central theoretical framework.

References:

Therapeutics Initiative, (2020). Therapeutics Initiative Home. Retrieved From : http://www.ti.ubc.ca

 

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We thought about it a little and think it should work…

Still stuck on the question of adaptation (so vague!), I explored a little more…

Clinical guidelines are often irrelevant in LMICs due to the fact that they are not commonly developed for or in these types of settings (Ehrhardt et al, 2012). The evidence on which many of these guidelines are based does not come from trials conducted in LMICs either because the research isn’t being done in these settings or there is an issue with study quality. Low quantity and quality of trials in LMICs is often the result of technical and infrastructure constraints, ethical issues, overburdened health systems, and lack of funding (Ehrhardt et al, 2012). Clinical guidelines based on evidence from high-income countries are thus not necessarily appropriate or applicable in LMICs and site-specific adaptation of guidelines might actually be less efficient and possibly harmful. Ehrhardt and Meyer (2012) argue for the mandatory, rigorous evaluation of guidelines in LMICs because, in their opinion, ‘adaptation without evaluation by use of adequate study designs is not good enough’.

This call for rigorous evaluation (i.e. using meaningful study methods such as clinical trials) is an important aspect of the the adaptation phase of the knowledge to action cycle that is missing from the framework presented by Graham et al (2006). It does make reference to the “activities that [individuals or groups] may engage in to tailor or customize the knowledge to their particular situation” (Graham et al, 2006, p. 20), but the language used to described how this is done (i.e. The process by which knowledge is adapted to a local setting “may be more or less formal”…; Some sort of “vetting or tailoring to the local context” is required…) leaves one believing that the ‘how’ is not overly important.

To address the issue of poor adaptability of clinical guidelines across settings, Ehrhardt and Meyer (2012) recommend that we pay more attention to: The setting in which a guideline has been developed and evaluated; the design processes addressing the question whether or not a guideline developed in HICs may also be suitable for LMICs; local adaptation of guidelines, and timely inclusion of relevant stakeholders and experts; and local evaluation of modified guidelines through either cost-effective implementation research or rigorous clinical trials. The issue of adaptability is not unique to the ‘knowledge’ contained in clinical guidelines. Spoth et al (2013) stress the importance of studying the adaptations of evidence-based prevention interventions and identify the need for strategies and methods for updating and adapting EBIs to local circumstances. This kind of implementation research will help in understanding whether adaptations affect outcomes, and if so, how (Spoth et al, 2013).

Although it seems to be accepted that adapting knowledge to local setting or context is an important part of the KT process, the rigor and formality with which this should be done is debatable. Ehrhardt and Meyer (2012) and Spoth et al (2013) both argue for the meticulous evaluation of modified/adapted interventions. Failure to do so can result in wasted resources, ineffective (or less effective) interventions, and possibly even harm. I think that the importance of this type of evaluation studies should not be glossed over, but I am left with these questions: What are the ethical implications of conducting clinical trials of interventions modified and/or adapted to LMIC settings when ‘best practices’ already exist? What are the ethical implications of not doing so?

References:

Ehrhardt, S et al. (2012). Transfer of evidence-based medical guidelines to low- and middle-income countries. Tropical Medicine and International Health, 17(2): 144-146.

Graham, ID et al. (2011). Lost in knowledge translation: time for a map?. The Journal of Continuing ducation in the Health Profession, 26(1), 13-24.

Spoth, R et al. (2013). Addressing core challenges for the next generation of type 2 translation research and systems: The translation science to population impact (Tsci Impact) Framework. Prev Sci, 14: 319-351.

The role of judgment in turning evidence into guidance

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I came across a sentence about risk assessment in another class that I am taking that struck me as particularly relevant to knowledge translation (KT). In the textbook chapter on Risk Assessment, there is a section titled “Is Risk Assessment a Science?”. It reads:

Although it relies heavily on science-based information, risk assessment does not generate new empirical evidence on health effects in the way that toxicology and epidemiology do. Instead risk assessment can be viewed as a synthesis of existing scientific information, often aimed at addressing specific regulatory or policy issues. This is why risk assessment has been referred to as a mixture of “science and judgment.” (Frumkin, 2010, p. 1038).

I think this quote illustrates well the tension that sometimes (often?) exists between scientists and decision-makers. Scientists work in a systematic and rigorous way to obtain empirical evidence, but where does that leave us? What can be done with this evidence? It is the role of the environmental health risk assessor to apply “a quantitative framework for evaluating and combining evidence from toxicology, epidemiology, and to other disciplines with the goal of providing a basis for decision-making” (Frumkin, 2010, p. 1038). That is, to turn the empirical evidence the scientists have provided into guidance.

While I may be reading into it, I find the quote reflects certain uneasiness around the fact that risk assessment involves judgment and therefore strays away from “science”. And it is easy to see why the presence of judgment in risk assessment could make people uneasy.  Obviously, when faced with a hazard that is potentially very harmful to human health, one should be wary about who is making the call on how safe it is for people to be exposed to it; what are the values of the risk assessor and whose interests might they be taking into consideration is the assessment?

Still one cannot very well just eliminate judgment. As we saw last week in our class discussion of different types of reviews, each method required the reviewer to make judgments – how will the research question be framed, what are the inclusion and exclusion criteria, what counts as evidence. In his article on indifference towards research-based evidence, Lewis (2007) points out some of the ways evidence and judgment interact to complicate evidence-based decision making. In particular two propositions struck me as particularly relevant to risk assessment: “Proposition 5: Everyday life is normative, but there is no science to human values” and “Proposition 6: Evidence often makes decision-making more difficult, not less”. With these two propositions, Lewis points out that judgments involve not only technical, but also social and philosophical considerations  – who’s needs are most important, do we think of the collective or of the individual.

The process of turning evidence into guidance is clearly not always straightforward. Yet it is necessary to ensure that research does make its way to policies that can improve people’s lives. So given that judgment is inevitable in taking evidence and turning it into guidance for decision-makers, what is the best way to make those whose role it is to evaluate and combine evidence the best possible judges?

Resources:

Frumkin, H. (2010). Environmental Health: From Global to Local (2nd Ed). John Wiley & Sons.

Lewis, S. (2007). Towards a general theory of indifference to research-based evidence. Journal of Health Services Research & Policy.

Image: http://vecto.rs/designs/judgment

Change v. The Managers

The theme of “innovation” has been recurring in this and another course I’m taking at the moment and I think it’s interesting to continue to compare this KT rhetoric with its corporate parallels. In the text from outside of the course we read a recent article from GE’s Jeffrey Immelt explaining business’ need to push toward “reverse innovation”. In other words, to give emerging markets the freedom and power to produce more inexpensive products relevant to local contexts (sound familiar?). In the dog-eat-dog business world this seemingly polite proposal is of course however, a profit-making strategy for maintaining the interdependency of these developing nations and preempting the creation of their own competing companies.  The challenge businesses are facing in executing this mandate is much like our own in pushing for new models and innovation in the field of public health: “changing the mind-set of managers who’ve spent their careers excelling at the (old model)” (Immelt et al, 2009).

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This is an interesting point that is implicit in much that we’ve been reading but it raises for me another issue with these models for innovation that is, the structure of large organizations themselves and the basic fact that those in positions of power are those with more experience in the field and thus often guilty of this tendency to resist change because it counters what’s been done before. In my recent field experience with a large international public health organization in Nicaragua, I found this to be entirely the case. At the end of my term my supervisor in so many words confirmed this by confiding that he had recently told his son not to aspire to starting his career with a job in his organization and would tell me the same thing, because it was not the place for young people, that young people should get experience in environments where innovation is applauded and politics don’t stifle their every move. If deep, lasting change is to promulgate though, I think that the biggest challenge truly is convincing managers to change. We the up and comers of public health are easy to convince that change is the way of the future and we want a job in the future, so we’re hopping on board with innovation! That is, until the next innovation comes along and we are comfortably sitting in our offices practicing our innovation. Peschl’s plea for us to remain open and aware and attentive and enable processes rather than forcing them (2008) is appropriate and though abstract I see it’s integration into our practice as the key to sustaining these processes.

(Click on the photo for a quick glimpse into the art of profiting off of resistance to change, KT consulting firm anyone?)

References

Immelt, J. et al. (2009, October). How GE is Disrupting Itself. Harvard Business Review. 

Peschl, M.F., et al. (2008). Emergent Innovation and Sustainable Knowledge Co-Creation. A Socio-Epistemological Approach to “Innovation from within”. The Open Knowledge Society: A Computer Science and Information Systems Manifesto. Springer, New York.

Health Systems and Physician Behaviour

I was very interested in the article by Lawrence Brass on Health Systems and Physician Behaviour (2003) and the introductory quote, ‘take it from me; it is not easy to change a physician’s behavior’ (Lori-Ann Brass). The author describes acknowledged medication errors and their 243% increase over 15 years (1983 to 1998) in the US increasing from 2876 to 9856 per year. One supposes that these were not the ones picked up as errors by nurses and pharmacists and tragedy avoided.

We learn that medical errors in hospitals kill up to 98,000 people per year, a higher number than motor vehicle accidents.  Clearly the quality of health care needs improvement and monitoring and measuring care will lead to that improvement. He goes on to state that physicians are the leaders in focussing on delivery of high quality care to patients and thus have an obligation to lead. However, according to Brass (2003) physicians in the US anyways, seem at least in many cases, unable to take appropriate evidence-based decisions for treatment of patients. The author reflects on the fact that patients with stroke were not treated appropriately half the time, and that there was much variance in treatment. However, he points out that the complex treatment does not involve just one doctor but a whole team, with new technologies and diverse skills pointing out the need for good coordination of the interdisciplinary team. Team members other than physicians, who are knowledgeable about evidence for treatments, may be appropriate leaders to manage care. Quality and cost of treatment must also be discussed and in some cases highly technical care is not the best use of resources.

The author suggests that to change physician behaviour, some methods work well and others so not work at all. Physicians needing continuing medical education (CME) points to continue with licensure may receive all their points from ‘traditional continuing education’ such as conferences or lectures, found to be ineffective for changing behaviour (Brass, 2003), but fun to attend, especially if at a ski resort or on a cruise. Interactive interventions, especially with local opinion leaders, such as the Managing Obstetrical Risk Efficiently Program (MORE OB) team hands-on obstetrical course would be in the ‘effective category.’

Lewis (2007) in his essay on ‘Towards a general theory of indifference to research-based evidence’ discusses the dilemma of setting aside biases and hunches in favour of using evidence-based medicine and guidelines with decision-making for each individual patient. This is juxtaposed with the caveat of the need to ‘use your judgement… an inalienable right, the hallmark of a professional.’ The author proposes another problem; that the practices based on understanding the evidence will provide superior care to practitioners who rely on understanding of basic mechanisms and their own clinical experience. So far there is no evidence to confirm this assumption.

In my years of working in the health sector, in maternity care in various low-resource countries, I have seen extreme variations in practices and wonder why physicians are making the decisions they are. Is it because they do not know the evidence, or because they have other clinical ideas of what works better, or some other reason? I was interested to read that there was a new article on ‘HIFA2015 – Healthcare Information For All by 2015’ list serve on the challenges of translation of the Cochrane reviews into languages other than English, supposedly to reach more policy makers and practitioners. Will physicians, policy makers, researchers and allied health professionals take more seriously the challenge of using evidence in practice? The principal reason for being concerned about physician behaviour change and evidence medicine is its positive impact on health outcomes; therefore we should study the intervention and the KT as part of a package to improve the people’s health.

Brass, L. (2003). Health Systems and Physician Behavior. Seminars in Cerebrovascular Diseases and Stroke Vol. 3 No. 2.

Lewis, S. (2007). Toward a general theory of indifference to research-based evidence. Journal of Health Research Policy. 12(3):166-72

‘MORE OB’ retrieved from http://sogc.org/continuing-medical-education-cme/more-ob/

von Elm E, Ravaud P, MacLehose H, Mbuagbaw L, Garner P, et al. (2013) Translating Cochrane Reviews to Ensure that Healthcare Decision-Making is Informed by High-Quality Research Evidence. PLoS Med 10(9): e1001516. doi:10.1371/journal.pmed.1001516 http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001516

 

Performing arts as a method of sharing knowledge: The role of dance in KT strategy

Despite the CIHR’s mandate that knowledge translation (KT) be a necessary part of research funding, and thus requiring that researchers and scientists take an approach to their work that reflects KT values, the implementation of KT methods external to conference presentations and journal publications has been slow.  However, contemporary methods in KT have come to incorporate nonconventional representations of KT, as seen in the following example.

In pursuing a nonconventional KT strategy, Boydell and Jackson (2010) have pushed the boundaries of existing KT methods with the notion that the performing arts is not only able to, but also suitable for, sharing knowledge.  Using dance as a KT strategy, Boydell and Jackson aimed to disseminate research evidence and by extension educate target audiences about first-episode psychosis in youth and the difficulties associated with seeking help, as well as other barriers to treatment.

According to CIHR (2010), “Arts based research provides a platform from which to begin a dialogue with young people, families and the public, to move them toward new ways of understanding and knowing.  In representing the experiences of mental illness in a new evocative, illuminating and memorable way, viewers are challenged to engage with the work and consider the cultural stereotypes that surround those with mental illness.  The evocative representation of textual research results through dance can communicate moods as well as facts, which has the advantage of allowing the audience to engage in the phenomena in a deeper, more sensitive, open and meaningful way” (Boydell & Jackson, 2010, p. 6).

Under such terms, using dance to impart information has the potential to encourage dialogue among target audiences.  Further, it is of significance to consider the effect that performing arts may have on certain groups (e.g., youth) and such groups’ responses to the performing arts.  The roles that the performing arts could possibly play, as well as the benefits it could potentially have for KT strategy, are infinite.

It is important to note that although the use of performing arts as a method of imparting knowledge and encouraging dialogue among audiences may not be applicable to the multitude of shapes and sizes health research may take, it’s very nature has the tendency to be suitable to various venues, from conferences to film festivals and beyond, as well as the ability to be featured in both contemporary and traditional media.

An essential component of any KT strategy is evaluation, and indeed, Boydell and Jackson’s (2010) experiment with this particular KT method has been evaluated.  A number of methods were used to assess audience engagement and elicit dialogue, including: in-theatre observation of audience response, moderated post-performance large audience discussions, audience feedback in the form of ‘post-it’ notes, and researcher field notes.  Evaluations of the data collected from these processes appear to suggest that dance is an effective way to share research findings and to enhance awareness and engagement among audience groups.

Although there is limited research on the effectiveness of research-based dance (or other performing arts) as a knowledge translation strategy, such endeavors certainly appear to be fruitful.  KT efforts should certainly consider the possibility of using such methods to involve the community, and future research should address in increased detail the application of performing arts as a KT strategy in other health-related fields.  (For an interesting take on how theatre may be useful to KT efforts, see https://tspace.library.utoronto.ca/bitstream/1807/17578/1/StagingData-FINAL_June_13.pdf.)

References

CIHR. (2010). Research-based dance as a knowledge translation strategy. In Knowledge to action: An end-of-grant knowledge translation casebook. Retrieved from http://www.cihr-irsc.gc.ca/e/documents/cihr_kt_casebook_2010_e.pdf

CIHR. (2013). About knowledge translation. Retrieved from http://www.cihr-irsc.gc.ca/e/29418.html.

Rossiter, K., Kontos, P., Colantonio, A., Gilbert, J., Gray, J., & Keightley, M. (2008). Staging data: Theatre as a tool for analysis and knowledge transfer in health research. Retrieved from https://tspace.library.utoronto.ca/bitstream/1807/17578/1/StagingData-FINAL_June_13.pdf

Chatter in the virtual schoolyard: youth, sex ed, and the Internet

Given the pervasiveness of social media and the significant amount of time that youth spend online, the digital domain represents a new frontier for sex education. While these developments present a great opportunity for public health practitioners to reach a wide audience, they also present threats. A great deal of inaccurate information circulates online; therefore, the challenge is to ensure that youth have the resources they need to distinguish the good from the bad. Researchers and public health practitioners have paid heed to this phenomenon. In one review, Simon and Danebeck (2013) conclude that teens rely heavily on the Internet for information about sex. They argue that it represents an important supplement to school-based sex education, which does not adequately address sexual experiences in addition to sexual health. There are also sexual health interventions that have sought reach teens through digital media. A systematic review by Guse et al. (2012) provides an overview of some of these efforts.

This work is not without its shortcomings. The pace with which the Internet and social media evolve poses a challenge to traditional research. Several years can pass between data collection and publication in a scholarly journal. In the case of Jones and Biddlecom this gap was three years. During that period, Facebook took off and eclipsed Myspace as the most-visited social networking site.  Although we can consider this article recent by academic standards, the digital domain has changed significantly since 2011. Smartphone use has steadily increasedand there has been a dramatic jump in popularity for theTumblr blogging network. Most of the studies Guse et al. (2012) included in their review were published prior to 2010 (one as early as 2006). In light of these issues, it is not clear that scholarly publications are the best venue for explorations of how youth use digital media to seek out information about sex and sexuality.

However great the incentives to publish in academic journals, researchers should consider alternate venues where they can share their findings: websites and blogs, grey literature, and social media. Along with public health practitioners, they might also consider meeting youth in the Internet spaces they frequent. Yahoo Answers, Tumblrs (personal blogs), forums and message boards are just a few of the venues where adolescents seek out information about sex and sexuality. Some Tumblrs represent a new frontier in peer sex education: sex and relationship advice interspersed with pornography are a significant departure from putting condoms on bananas during gym class.

Works cited:

Guse, K., Levine, D., Martins, S., Lira, A., Gaarde, J., Westmorland, W., & Gilliam, M. (2012). Interventions using new digital media to improve adolescent sexual health: A systematic review. Journal of Adolescent Health51(6), 535-543.

Jones, R. K., & Biddlecom, A. E. (2011). Is the internet filling the sexual health information gap for teens? An exploratory study. Journal of health communication16(2), 112-123.

Simon, L., & Daneback, K. (2013). Adolescents’ use of the Internet for sex education: A thematic and critical review of the literature. International Journal of Sexual Health, (just-accepted).

 

End of Grant vs Integrated KT

One of the greatest pains to human nature is the pain of a new idea – Walter Bagehot (169)

Canadian research is heavily impacted by funding sources, the Canadian Institute for Health Research (CIHR) requires grant applicants to address their requirement for a KT plan. This requirement is forcing research to at least consider how their research will impact their field and how it will be disseminated to help improve the health of Canadians (CIHR, 2013). CIHR makes an important distinction between ‘end of grant’ and ‘integrated’ KT (CIHR, 2013). In ‘end of grant’ KT the onus is on the researcher to engage in dissemination by providing their finding to their peers, as well as to the public in general. They are encouraged to hold seminars, engage media, go to conferences, etc. (CIHR, 2013). For the ‘integrated’ KT researchers are expected to engage end users throughout the research process (CIHR, 2013). A more collaborative approach that requires a researcher to identify end users during the proposal phase, and consider significant ways that they can engage and participate in the research process.

            Rogers (2003) introduced the theory of Diffusion of Innovation, which states that new ideas are dependent on 4 factors in order to be widely adapted: the innovation, communication channels, time, and a social system (11). Considering these 4 dynamic elements one would think that when considering KT in the development of a research proposal, a researcher would need to consider how they will present their research to facilitate the KT process as much as possible. Rogers (2003) uses the term innovation to describe a new idea or concept. This is basically the aim of a research project, why is this project worth doing and how will it impact the population I am working with. The point when “interpersonal networks” (Rogers, 11) become activated is an important step in multiple people recognizing the importance of the innovation. Communication channels are ways in which the research is discussed and passed along from research to community (Rogers, 2003). In the sense of ‘end of grant’ KT it is publishing papers and presenting at conferences. For ‘integrated’ KT we could think about involving community stakeholders throughout the research and then looking at how they are disseminating the info to the community. Time is the how long it takes for a new idea to be widely adopted (Rogers, 2003), and we can all think of countless examples when uptake is swift or where flow of a concept has been incrementally slow. And lastly is the social system which consists of several points of intersectionality which inherently play a role in the spread of information (Rogers, 2003). In each of these steps we can think about ways that we would address the CIHR requirements for KT into our research.

            The question that comes to mind for is that is this requirement simply tokenism? Is there a way that CIHR can follow-up on the KT plans of previously funded projects to better understand what strategies worked and which did not? KT is a dynamic process which requires much effort, and although the intention of including KT in a grant proposal is supposed to support this process there is still much work to be done about what or how KT actually is playing out in publically funded research in Canada.

 References

Bagehot, W. (1873). Physics and politics. New York: Appleton-Century.

CIHR. (2013). More About Knowledge Translation at CIHR. Retrieved from: http://www.cihr-irsc.gc.ca/e/39033.html

Rogers, E. (2003). Diffusion of Innovation, 5th edition. Free Press: New York.

 

TSci Impact Framework and Pain Management

What Spoth et al’s designed as the Translation Science to Population Impact (TSci Impact) framework is a kind of road map for planning an effective KT strategy in different health related fields.

Although I am struggling with the broadness of this model, I found it helpful to identify multi-level contributors/factors to any KT plan. 

I liked the framework because it is broad enough to encompass any research/individual/society related elements. My only concern is that how a researcher would assess  role-players performance in any four phases of KT function. For instance, Broth et al. state that pre-adoption phase “focuses on intervention, consumer, provider, and organizational characteristics that could influence the ultimate adoption of EBIs” (p. 323). They also assert that “wide-ranging factors” should been systematically investigated for the fulfillment of each phase goals. My question here is how?

What I liked the most about this model was dedicating a specific phase for “sustainability” that examines “how EBIs are maintained or institutionalized over the long term, or expanded within and across specific settings or services delivery systems” (p. 324). This is the most complicated process and if attains, that would be an incredible success.

I also find Table 1 of this article very useful, particularly in terms of “examples of key research questions”. Depending on at what stage a researcher is more interested, she can use the example questions as a very good start.

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Based on this framework, I would like to develop a model for KT in the field of pain management. According to Statistic Canada in 2012, 14.1% of BC population aged 12 and over reported having pain or discomfort that prevents activities, plus 11.5 % of British Colombians complained of moderate or severe pain or discomfort. Therefore, from every 4 BC residents, one experienced pain in 2012. This number is gradually increasing from 2003 every year.

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According to Pain in Canada Fact Sheet, Chronic pain costs more than cancer, heart disease and HIV combined. “Estimates place direct health care costs for Canada to be more than $6 billion per year and productivity costs related to job loss and sick days at $37 billion per year” (Phillips and Schopflocher 2008; Schopflocher, Jovey et al. 2010).

Therefore, I would like to work on KT strategies for managing pain.

Using Table 2 of Spoth’s article, I would set my “high priority research questions”:

  1. Pre-adoption: how do various preferences about evidence-based interventions attributes influence ultimate patients’ choices and demand who are struggling with pain?
  2. Adoption: how are various types of evidence used by patients in their adoption decision making?
  3. Implementation: which systems factors are most important in quality implementation of specific evidence-based interventions for patients in pain?
  4. Sustainability: what funding models and financing systems are most conductive to sustainability? (I would probably change my approach here, and try to answer the sustainability question for patients in pain by employing motivational theories and frameworks)

I would work on those questions for the rest of the semester.

 

References:

 

Picture: http://news.yale.edu/sites/default/files/imce/beech-interior.jpg

Good Ideas for making childbirth safer?

Comments on the New Yorker ‘How do good ideas spread? By A. Gawand 2013

The public hospital commented on in this article in rural India shows a similar story to many rural public hospitals in other developing countries. Too little funding, too few staff and monitoring and supervision lacking makes providing health care a challenge. The basics for safe childbirth are simple and inexpensive but materials, supplies, staffing and caring may be lacking. Gawande (2013) mentions that even the youngest nurse was very experienced, having done over 1000 deliveries, but once can do many deliveries without keeping up with simple evidenced based procedures such as providing medication to prevent post-partum bleeding, drying and wrapping the baby, and [placing it on the mother’s chest for warmth when it is first born. There may be reasons why the mothers are not putting the babies skin to skin. As a midwife used to working in low resource countries and providing continuing education to nurses, intern and graduate physicians and midwives, I have seen this story play itself out many times. In a recent rural hospital visit in a Asian country, I saw that babies were not placed on the mother’s chest or dried and wrapped well…they were promptly handed to a female companion who lurked outside the door, waiting for the news of the delivery and sex of the baby. There may be a multitude of reasons for this. The mother who has probably birthed on a small delivery table cannot wait to get up, stretch, and move to a cot or bed. The delivery tables are too small for mothers to hold a baby, and they are forced to lie on their backs due to the style of many delivery table. They may not have had a companion to offer food and drink in labour, as no one is allowed to enter the room, so they want to get up, and get some food. As far as warming the baby on her chest, the mother has likely not been told the reason why skin to skin contact is good for newborns.
But the question arises, why does the nurse not educate, promote and active work for changes? Peschl & Fundneider (2008) maintain that to make changes in practice, the core idea of ‘emergent innovation’ would require that a large number of individuals (all staff in the hospital and prenatal public health personnel in the area) have the understanding and skills in the basic thinking of the change for re-framing and re-generating ideas. If few people involved understand and promote the change, it will not happen. To make changes in childbirth practices, which may have been done 1000 times over, requires ‘reflecting and letting-go of predefined patterns of perception and thinking’ (Peschl & Fundneider, 2008).
Sometimes health practitioners do not want to make evidence-based changes and use denial, resistance and passive adaptation (Hanlon et al, 2011). A sense of connectedness is missing, and an ethical sense to reduce harm, such as in this example, harm in childbirth. Whether repeating the message, asking for nurses to change practice, using support supervision to follow-up and re-enforce changes, or using incentives might work depends on the situation. The most important step may be to ask if the intention to make the change is there, explore the attitudes towards change and barriers to making the change, and continue working from there. Graham et al, (2006) in ‘Lost in Knowledge Translation’ describe a cycle and steps where checking back with participants to address additional needs or barriers is a step as well as sustaining the use of knowledge. Many projects are short-lived and once project is over, change is over and participants use other practices that suit them. In health care, many repeat cycles of knowledge translation may be needed, education and ongoing work with health care workers, families and communities.
Years ago, I was teaching new methods of caring for the newly cut umbilical cord with traditional birth attendants (TBA’s). They were to refrain from putting substances on the cord (such as beef tallow). When I travelled to the rural village to see the TBA and found beef tallow on the cord, she told me that the family insisted on it. Our change was to begin community education for all the surrounding villages. Change is slow.
A second example, years later in another country, was to change the practice of holding babies upside down and shaking them to stimulate them to breathe. It took two years working with trainers in one hospital until nearly all staff would point out when they saw someone doing it, “Ah-ah, we don’t do that anymore.” Finding ways to involve the majority will help others make the change.

Atul Gawande: How Do Good Ideas Spread? : The New Yorker (2013) http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gaw

Graham I, Logan J, Harrison M, Straus S, Tetroe J, Caswell W, Robinson N. (2006). Lost in Translation: Time for a Map? Journal of Continuing Education in the Health Professions. 26(13-24).

Hanlon P, Carlisle S, Hannah M, Lyon A, Reilly D. (2011). Journal of Public Health. 33(3)335-42.