Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective ...interventions. To meet this challenge, WHO's Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael's Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these.
We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers).
Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators.
This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.
Abstract Objective To explore similarities and differences in challenges to maternal health and evidence implementation in general across several low- and middle-income countries (LMICs) and to ...identify common and unique themes representing barriers to and facilitators of evidence implementation in LMIC healthcare settings. Study Design Secondary analysis of qualitative data. Setting Meeting reports and manuscripts describing projects undertaken by the authors in five LMICs on three continents were analyzed. Projects focused on identifying barriers to and facilitators of implementation of evidence products: five World Health Organization maternal health guidelines, and a knowledge translation strategy to improve adherence to tuberculosis treatment. Data were analyzed using thematic content analysis. Results Among identified barriers to evidence implementation, a high degree of commonality was found across countries and clinical areas, with lack of financial, material, and human resources most prominent. In contrast, few facilitators were identified varied substantially across countries and evidence implementation products. Conclusion By identifying common barriers and areas requiring additional attention to ensure capture of unique barriers and facilitators, these findings provide a starting point for development of a framework to guide the assessment of barriers to and facilitators of maternal health and potentially to evidence implementation more generally in LMICs.
The outcome of well-performed clinical research is essential for evidence-based patient management during pandemics. However, conducting clinical research amidst a pandemic requires researchers to ...balance clinical and research demands. We seek to understand the values, experiences, and beliefs of physicians working at the onset of the COVID-19 pandemic in order to inform clinical research planning. We aim to understand whether pandemic settings affect physician comfort with research practices, and how physician experiences shape their understanding of research in a pandemic setting.
A survey tool was adapted to evaluate familiarity and comfort with research during a pandemic. A cross-sectional, online questionnaire was distributed across Canadian research networks early in the COVID-19 outbreak. The survey was administered between March 11th and 17th, 2020, during a time of local transmission but prior to the surge of cases. We aimed to recruit into the survey physicians in infectious disease and critical care research networks across Canada.
Of the 133 physician respondents, 131 (98%) considered it important to conduct clinical research during the COVID-19 pandemic. Respondents were more accepting of adaptations to the research process in during a pandemic compared to in a non-pandemic setting, including conducting research with deferred consent (χ2 = 8.941, 95% CI: -0.264, -0.085, p = 0.003), using non-identifiable observational data with a waiver of consent with a median score of 97 out of 100 (IQR: 79.25-100) vs median 87 out of 100 (IQR: 63-79) (95% CI: -12.43, 0.054, p = 0.052). The majority felt that research quality is not compromised during pandemics.
Physicians consider it important to conduct research during a pandemic, highlighting the need to expedite research activities in pandemic settings. Respondents were more accepting of adaptations to the research process for research conducted during a pandemic, compared to that conducted in its absence of a pandemic.
Purpose
Healthcare workers must ensure effective infection prevention and control (IPC) to prevent nosocomial spread of SARS-CoV-2, the virus that causes COVID-19. This questionnaire study aims to ...evaluate Canadian critical care and emergency department nurses’ readiness to follow IPC guidelines in their workplace, and to understand their perceptions of trust in organizational preparedness, communication, and infection risk.
Methods
We adapted an internationally distributed survey for the Canadian context. This cross-sectional questionnaire, incorporating validated scales for items including institutional trust, was distributed by email to nurses via the Canadian Association of Critical Care Nurses and the Canadian Association of Emergency Physicians networks between 16 March and 25 May 2020. We evaluated intensive care unit and emergency department nurses’ adherence to IPC protocols, barriers and facilitators to IPC guideline adherence, and their level of institutitonal trust.
Results
Three hundred and nineteen nurses responded to the survey. There was higher trust in organizational preparedness among nurses who were older (B = 0.31,
P
< 0.001) and more experienced (F = 18.09,
P
< 0.001), and particularly among those with previous experience working in outbreak settings (F = 7.87,
P
= 0.005). Compared with those without experience working in outbreak settings, respondents with this experience reported higher levels of fear of becoming ill and fear of providing care for COVID-19 patients (χ
2
= 21.48,
P
= 0.002 and χ
2
= 12.61,
P
= 0.05, respectively). Older and more experienced nurses reported greater comfort with IPC skills and easier access to personal protective equipment. While the vast majority (96%) of respondents reported using masks and gloves, only 83% had access to isolation facilities for suspected or confirmed COVID-19 cases.
Conclusion
Canadian nurses had strong self-reported adherence to IPC measures and personal protective equipment use. There were high levels of trust in health system leadership to ensure protective measures are present and reliable. Trust was particularly high among older and more experienced nurses despite these populations reporting higher levels of fear of personal illness.
As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the ...potential for community health workers to assume a growing role in strengthening health systems. A growing list of tasks, some of them complex, is being shifted to community health workers' job descriptions. Health Surveillance Assistants (HSAs) - as the community health worker cadre in Malawi is known - play a vital role in providing essential health services and connecting the community with the formal health care sector. The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs' perspectives on their roles and responsibilities.
A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre's role and to triangulate collected data.
HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs.
This study provides insights into HSAs' perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre's effectiveness in addressing the country's health priorities.
Abstract Background Over the past three decades, research studies on nurses' engagement in evidence‐based practice (EBP) have been widely reported, particularly in high‐income countries, with studies ...from these countries dominating literature reviews. As low‐ and middle‐income countries (LMICs) continue to join the EBP movement, primary research has emerged over the past decade about nurses' engagement with EBP. Aims The aim of this scoping review was to identify the types and extent of published research regarding nurses' knowledge, skills, attitudes, beliefs, and implementation of EBP in LMICs. Methods The JBI scoping review methodology was used. Eight databases were searched up to November 2023. The review included primary studies (quantitative, qualitative, and mixed methods) that reported the knowledge, skills, attitudes, beliefs, or implementation of EBP among nurses in LMICs. Included studies focused on registered nurses in all healthcare settings within LMICs. Studies published in English were included with no limit on publication date. Two independent reviewers screened titles, abstracts, and full‐text articles of published studies. Data were analyzed quantitatively using frequencies and counts. Textual data from qualitative studies were analyzed using descriptive content analysis. Results Fifty‐three publications were included, involving 20 LMICs. Studies were published between 2007 and 2023, with over 60% published in the past 7 years. Studies that evaluated familiarity/awareness of EBP showed that in general, nurses had low familiarity with or awareness of EBP. Most studies (60%) described nurses' attitudes toward EBP as positive, favorable, or high, and 31% as moderate. However, over 60% of studies described nurses' EBP knowledge/skills as moderate, low, or insufficient. Approximately 84% of studies described EBP implementation in healthcare settings as moderate, low, poor, or suboptimal. Linking Evidence to Action Studies on nursing EBP have been increasing in LMICs for the past two decades, with findings highlighting opportunities for advancing EBP in nursing within LMICs. Health systems and healthcare organization leaders in LMICs should equip nurses with EBP knowledge and skills while providing the needed resources and support to ensure consistent implementation of EBP to improve health outcomes.
Evidence-based clinical algorithms (EBCA) are knowledge tools to promote evidence use by codifying evidence into action plans to facilitate appropriate care. However, their impact on process and ...outcomes of care varies considerably across practice settings and providers, highlighting the need for tailoring of both these knowledge tools and their implementation strategies to target end users and the setting in which EBCAs are to be employed. Leadership at the Tikur Anbessa Specialized Hospital emergency department (TASH-ED) in Addis Ababa, Ethiopia identified a need for context-appropriate EBCAs to improve evidence uptake to mitigate care gaps in this high volume, high acuity setting. We aimed to identify barriers and facilitators to utilization of EBCAs in the TASH-ED, to identify priority targets for development of EBCAs tailored for the TASH-ED context and to understand the process of care in the TASH-ED to inform implementation planning.
We employed a multi-component qualitative design including: semi-structured interviews with TASH-ED clinical, administrative and support services staff, and Toronto EM physicians who had worked in the TASH-ED; direct observation of the process of care in TASH-ED; document review.
Although most TASH-ED participants reported an awareness of EBCAs, they noted little or no experience using them, primarily due to the poor fit of many EBCAs to their practice setting. All participants felt that context-appropriate EBCAs were needed to ensure standardized and evidence-based care and improve patient outcomes for common ED presentations. Trauma, sepsis, acute cardiac conditions, hypertensive emergencies, and diabetic keto-acidosis were most commonly identified as priorities for EBCA development. Lack of medication, equipment and human resources were identified as the primary barriers to use of EBCAs in the TASH-ED. Support from leadership and engagement of stakeholders outside the ED where EBCAs were believed to be less well accepted were identified as essential facilitators to implementation of EBCAs in the TASH-ED.
This study found a perceived need for EBCAs tailored to the TASH-ED setting to support uptake of evidence-based care into routine practice for common clinical presentations. Barriers and facilitators provide information essential to development of both context-appropriate EBCAs and plans for their implementation in the TASH-ED.
To identify candidate quality indicators from existing tools that provide guidance on how to practice knowledge translation and implemenation science (KT practice tools) across KT domains ...(dissemination, implementation, sustainability, and scalability).
We conducted a scoping review using the Joanna Briggs Institute Manual for Evidence Synthesis. We systematically searched multiple electronic databases and the gray literature. Documents were independently screened, selected, and extracted by pairs of reviewers. Data about the included articles, KT practice tools, and candidate quality indicators were analyzed, categorized, and summarized descriptively.
Of 43,060 titles and abstracts that were screened from electronic databases and gray literature, 850 potentially relevant full-text articles were identified, and 253 articles were included in the scoping review. Of these, we identified 232 unique KT practice tools from which 27 unique candidate quality indicators were generated. The identified candidate quality indicators were categorized according to the development (n = 17), evaluation (n = 5) and adaptation (n = 3) of the tools, and engagement of knowledge users (n = 2). No tools were identified that appraised the quality of KT practice tools.
The development of a quality appraisal instrument of KT practice tools is needed. The results will be further refined and finalized in order to develop a quality appraisal instrument for KT practice tools.
With the global shortage of skilled health workers estimated at 7.2 million, outpatient tuberculosis (TB) care is commonly task-shifted to lay health workers (LHWs) in many low- and middle-income ...countries where the shortages are greatest. While shown to improve access to care and some health outcomes including TB treatment outcomes, lack of training and supervision limit the effectiveness of LHW programs. Our objective was to refine and evaluate an intervention designed to address common causes of non-adherence to TB treatment and LHW knowledge and skills training needs.
We employed a pragmatic cluster randomized controlled trial. Participants included 103 health centres (HCs) providing TB care in four districts in Malawi, randomized 1:1 stratified by district and HC funding (Ministry of Health, non-Ministry funded). At intervention HCs, a TB treatment adherence intervention was implemented using educational outreach, a point-of-care reminder tool, and a peer support network. Clusters in the control arm provided usual care. The primary outcome was the proportion of patients with successful TB treatment (i.e., cure or treatment completion). We used a generalized linear mixed model, with district as a fixed effect and HC as a random effect, to compare proportions of patients with treatment success, among the trial arms, with adjustment for baseline differences.
We randomized 51 HCs to the intervention group and 52 HCs to the control group. Four intervention and six control HCs accrued no eligible patients, and 371 of 1169 patients had missing outcome, HC, or demographic data, which left 74 HCs and 798 patients for analysis. Randomization group was not related to missing outcome, however, district, age, and TB type were significantly related and included in the primary analysis model. Among the 1153 patients with HC and demographic data, 297/605 (49%) and 348/548 (64%) in the intervention and control arms, respectively, had treatment success. The intervention had no significant effect on treatment success (adjusted odds ratio 1.35 95% confidence interval 0.93-1.98).
We found no significant effect of the intervention on TB treatment outcomes with high variability in implementation quality, highlighting important challenges to both scale-up and sustainability.
ClinicalTrials.gov NCT02533089 . Registered August 20, 2015.
Abstract
Background
Recent pandemics have provided important lessons to inform planning for public health emergencies. Despite these lessons, gaps in implementation during the COVID-19 pandemic are ...evident. Additionally, research to inform interventions to support the needs of front-line nurses during a prolonged pandemic are lacking. We aimed to gain an understanding of critical care nurses’ perspectives of the ongoing pandemic, including their opinions of their organization and governments response to the pandemic, to inform interventions to improve the response to the current and future pandemics.
Methods
This sub-study is part of a cross-sectional online survey distributed to Canadian critical care nurses at two time points during the pandemic (March–May 2020; April–May 2021). We employed a qualitative descriptive design comprised of three open-ended questions to provide an opportunity for participants to share perspectives not specifically addressed in the main survey. Responses were analyzed using conventional content analysis.
Results
One hundred nine of the 168 (64.9%) participants in the second survey responded to the open-ended questions. While perspectives about effectiveness of both their organization’s and the government’s responses to the pandemic were mixed, most noted that inconsistent and unclear communication made it difficult to trust the information provided. Several participants who had worked during previous pandemics noted that their organization’s COVID-19 response failed to incorporate lessons from these past experiences. Many respondents reported high levels of burnout and moral distress that negatively affected both their professional and personal lives. Despite these experiences, several respondents noted that support from co-workers had helped them to cope with the stress and challenges.
Conclusion
One year into the pandemic, critical care nurses’ lived experiences continue to reflect previously identified challenges and opportunities for improvement in pandemic preparedness and response. These findings suggest that lessons from the current and prior pandemics have been inadequately considered in the COVID-19 response. Incorporation of these perspectives into interventions to improve the health system response, and support the needs of critical care nurses is essential to fostering a resilient health workforce. Research to understand the experience of other front-line workers and to learn from more and less successful interventions, and leaders, is needed.
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