Bobby Ramakant and Shobha Shukla, CNS
When scientists produce evidence that a public health intervention works (or not works), why does it takes years of delay to implement these learnings into programmes on the ground? Dr Taryn Young, Director, Centre for Evidence-Based Health Care at Stellenbosch University, South Africa, said to Citizen News Service (CNS) at the 22nd Cochrane Colloquium in Hyderabad, India: "We see a gap between the evidence being ready and actually
being implemented. Because whole evidence-informed policy making and
practice takes some time as there are many other factors, costing,
feasibility, acceptability, politics, etc."
Dr Young added: "There is a need for researchers and policy makers to work closely together. There needs to be more engagement of policy makers with researchers when basic research or systematic reviews begin. Researchers need to understand the policy environment, and also know where are the 'policy windows'. If policy is being formulated researchers need to know that it is happening so that they can contribute meaningfully. They also need to know what questions policy makers are grappling with, so that if research needs to be conducted to get those answers then they can do that in a timely way and findings made available when the policy makers need it. That will speed up the process of evidence getting into policy, and eventually into practice."
PEP: Preventing HIV acquisition after exposure
Dr Young and her colleagues were involved in a Cochrane systematic review which looked at using antiretroviral post-exposure prophylaxis (PEP) by occupational healthcare workers if they had occupational injury exposing them to a risk of HIV acquisition. The evidence showed that antiretroviral PEP works to reduce the risk of HIV acquisition in an event of occupational injury such as needle prick injury (but protection against HIV is not 100%). Researchers could only find one case-control study on this subject. But conducting a definitive randomised placebo-controlled trial now will be unethical because there is strong evidence already that antiretroviral therapy (ART) works. Dr Young's and her colleagues' review recommended the use of PEP in case of occupational injury exposing healthcare workers to risk of HIV acquisition.
Home-based care
Dr Young's another important work has been with her colleague on conducting a systematic review to look at the home-base care approaches for people living with HIV (PLHIV). She lamented that very few studies were done in low- and middle- income countries and most studies related to home-based care were from the richer nations. "We looked at any form of HIV care, treatment or support that was given at home. When we did this review few years back, it was disappointing to realize that most studies we could find were conducted in high income countries. When we talk of home-base care, it could refer to delivering ART and promoting adherence in the home, support services, psychological support, nutritional support, and care services even before we start ART. Lot of questions need to be considered such as who is providing the care, how often it is being provided, are the providers trained, etc. When we first did the review, we found all the studies from high income countries looked at some interventions that were not feasible in our setting. There were some interventions that promoted social support by using computers. In settings like Africa where we do not even have regular electricity how can we have computers in every house? There were some studies that promoted exercise in the house which made the person feel better. This worked but these types of interventions do not make much sense for low- or middle- income countries because these brought fitness flyers into homes too and perhaps may not be practical and feasible interventions in our contexts."
On the way forward regarding more evidence in the context of low- and middle- income countries, Dr Young informed: "Now we are proceeding with a systematic review update that is in progress and I am happy to be able to say that we found 8 new studies done in low- and middle- income countries. We are busy going through these at the moment. The outcome should be out early next year."
Partner notification strategy
Dr Young and her colleagues' work around systematic review on "Strategies for partner notification for sexually transmitted infections (STIs) including HIV" needs a special mention too. Researchers looked at several studies documenting partner notification strategies for STIs such as: sending leaflets etc to partners, doctors or nurses phoning the partner to inform about the infection and requesting them to come in for checkup and treatment, among others. "The partner notification strategy that worked best was patient-delivered partner medication. Depending upon the infection the patient had been diagnosed with, the healthcare workers would ask if the partner is allergic to certain type of medications, and give the appropriate medication to the indexed patient to give it to the partners. There were fewer studies that looked at this strategy but when we did the meta-analysis it clearly showed that this strategy was superior than other strategies. In this patient-delivered partner medication strategy, it is also easier for the partner to get treatment, they do not have to wait to get an appointment or find the time to go to the clinic. We should remember that the key thing one wants to prevent is reinfection which these studies looked at – and they actually found a reduction in the reinfection rate of the indexed patients."
Including evidence-based medicine in medical education
Although surprising but it is a reality that most health education schools do not include training in evidence-based medicine in low- and middle- income countries. Dr Young stressed that: "If you consider the health education as a whole (for doctors, nurses, physiotherapy, dentists, occupational therapists, among other healthcare providers) everybody needs to practice evidence-informed way. Everyone is not going to conduct research, but all healthcare professionals should be able to use research while decision-making. They need to know if the evidence they found is useful, relevant and then apply it to their local settings." Researchers found that if evidence-based medicine is part of their learning and considered into their decision making, it yields positive public health outcomes.
Dr Young reflected that "Role of medical teachers is critical as students look up to them. If those role models are not showing that 'it is okay that you do not know all the answers, in which case you should go and find what the right answer is' then similar trends will continue. Senior doctors need to show young professionals that it is okay to say 'you do not know' and go and look for evidence and practice medicine in an evidence informed way. It is happening in some institutions but not as often as it should be. As the Cochrane Collaboration is often working with senior academicians it can play a key role in this regard."
Shobha Shukla and Bobby Ramakant
Citizen News Service - CNS
30 September 2014
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| Dr Taryn Young |
Dr Young added: "There is a need for researchers and policy makers to work closely together. There needs to be more engagement of policy makers with researchers when basic research or systematic reviews begin. Researchers need to understand the policy environment, and also know where are the 'policy windows'. If policy is being formulated researchers need to know that it is happening so that they can contribute meaningfully. They also need to know what questions policy makers are grappling with, so that if research needs to be conducted to get those answers then they can do that in a timely way and findings made available when the policy makers need it. That will speed up the process of evidence getting into policy, and eventually into practice."
PEP: Preventing HIV acquisition after exposure
Dr Young and her colleagues were involved in a Cochrane systematic review which looked at using antiretroviral post-exposure prophylaxis (PEP) by occupational healthcare workers if they had occupational injury exposing them to a risk of HIV acquisition. The evidence showed that antiretroviral PEP works to reduce the risk of HIV acquisition in an event of occupational injury such as needle prick injury (but protection against HIV is not 100%). Researchers could only find one case-control study on this subject. But conducting a definitive randomised placebo-controlled trial now will be unethical because there is strong evidence already that antiretroviral therapy (ART) works. Dr Young's and her colleagues' review recommended the use of PEP in case of occupational injury exposing healthcare workers to risk of HIV acquisition.
Home-based care
Dr Young's another important work has been with her colleague on conducting a systematic review to look at the home-base care approaches for people living with HIV (PLHIV). She lamented that very few studies were done in low- and middle- income countries and most studies related to home-based care were from the richer nations. "We looked at any form of HIV care, treatment or support that was given at home. When we did this review few years back, it was disappointing to realize that most studies we could find were conducted in high income countries. When we talk of home-base care, it could refer to delivering ART and promoting adherence in the home, support services, psychological support, nutritional support, and care services even before we start ART. Lot of questions need to be considered such as who is providing the care, how often it is being provided, are the providers trained, etc. When we first did the review, we found all the studies from high income countries looked at some interventions that were not feasible in our setting. There were some interventions that promoted social support by using computers. In settings like Africa where we do not even have regular electricity how can we have computers in every house? There were some studies that promoted exercise in the house which made the person feel better. This worked but these types of interventions do not make much sense for low- or middle- income countries because these brought fitness flyers into homes too and perhaps may not be practical and feasible interventions in our contexts."
On the way forward regarding more evidence in the context of low- and middle- income countries, Dr Young informed: "Now we are proceeding with a systematic review update that is in progress and I am happy to be able to say that we found 8 new studies done in low- and middle- income countries. We are busy going through these at the moment. The outcome should be out early next year."
Partner notification strategy
Dr Young and her colleagues' work around systematic review on "Strategies for partner notification for sexually transmitted infections (STIs) including HIV" needs a special mention too. Researchers looked at several studies documenting partner notification strategies for STIs such as: sending leaflets etc to partners, doctors or nurses phoning the partner to inform about the infection and requesting them to come in for checkup and treatment, among others. "The partner notification strategy that worked best was patient-delivered partner medication. Depending upon the infection the patient had been diagnosed with, the healthcare workers would ask if the partner is allergic to certain type of medications, and give the appropriate medication to the indexed patient to give it to the partners. There were fewer studies that looked at this strategy but when we did the meta-analysis it clearly showed that this strategy was superior than other strategies. In this patient-delivered partner medication strategy, it is also easier for the partner to get treatment, they do not have to wait to get an appointment or find the time to go to the clinic. We should remember that the key thing one wants to prevent is reinfection which these studies looked at – and they actually found a reduction in the reinfection rate of the indexed patients."
Including evidence-based medicine in medical education
Although surprising but it is a reality that most health education schools do not include training in evidence-based medicine in low- and middle- income countries. Dr Young stressed that: "If you consider the health education as a whole (for doctors, nurses, physiotherapy, dentists, occupational therapists, among other healthcare providers) everybody needs to practice evidence-informed way. Everyone is not going to conduct research, but all healthcare professionals should be able to use research while decision-making. They need to know if the evidence they found is useful, relevant and then apply it to their local settings." Researchers found that if evidence-based medicine is part of their learning and considered into their decision making, it yields positive public health outcomes.
Dr Young reflected that "Role of medical teachers is critical as students look up to them. If those role models are not showing that 'it is okay that you do not know all the answers, in which case you should go and find what the right answer is' then similar trends will continue. Senior doctors need to show young professionals that it is okay to say 'you do not know' and go and look for evidence and practice medicine in an evidence informed way. It is happening in some institutions but not as often as it should be. As the Cochrane Collaboration is often working with senior academicians it can play a key role in this regard."
Shobha Shukla and Bobby Ramakant
Citizen News Service - CNS
30 September 2014
