Getting research findings into practice

Implementing research findings in developing countries

BMJ 1998; 317 doi: (Published 22 August 1998)
Cite this as: BMJ 1998;317:531.1

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EDITOR - The paper on implementing research findings in developing countries (1) sets out a clear framework for getting research findings into practice. With the creation of systematic reviews and guidelines, and implementation programmes through workshops and published work, this is very much in line with the process in western countries. However one element that we would add into this is the development of skills to find and appraise the scientific evidence. We know that as a single intervention the dissemination of guidelines and other educational materials has only a small impact on practice (2) and approaches have to be multifaceted to work. Yet for many parts of the developing world access to evidence will be through literature in one form or another, and there may be little opportunity for getting together with colleagues. This means that the acquisition of skills to find and appraise evidence must be central to all programmes designed to help get research into practice. Even in the United Kingdom there are still many clinical staff who have not got the basic skills in finding and appraising evidence and this is now being remedied through comprehensive educational programmes in many parts of the country. To ensure clinicians are equipped with skills to find and appraise evidence is an enormous challenge for developing countries, but has to be tackled. This will need to be through methods taylored for the particular needs of clinicians in developing countries and to be successful will no doubt need to include distance learning techniques.

1. Garner P, Kale R, Dickson R, Dans T, Salinas R. Implementing research findings in developing countries. BMJ 1998;317:531-5

2. Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educational materials to improve the behaviour of healthcare professionals and patient outcomes. Cochrane Library 1998: Issue 3.

Alison Hill Director of Public Health and Primary Care Buckinghamshire Health Authority Verney House Gatehouse Road Aylesbury Buckinghamshire HP19 3ET

Katie Enock CASP Manager Critical Appraisal Skills Programme Public Health Resource Unit Institute of Health Sciences Old Road, Headington, Oxford OX3 7LF

Catherine Brogan Consultant in Public Health Medicine Public Health Resource Unit Institute of Health Sciences Headington Oxford OX3 7LF

Competing interests: None declared

Alison Hill

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We agree with Garner et al(1) that the medical profession is the main constraint to getting research into policy and practice in many developing countries. This is especially the case where user fees finance health services. In China the mark-up on drugs is used as the main source of income generation in health services, creating perverse incentives which makes knowledge of evidence-based practice virtually irrelevant. We have explored the gap between knowledge and practice in three provinces in China. Through a questionnaire survey we investigated knowledge and practice relating to the management of uncomplicated diarrhoea in a one year old and upper respiratory tract infection in a three year old. Of 182 doctors questioned at village, township and county levels all knew that Oral Rehydration Therapy should be used for the management of the diarrhoea and 95% knew that antibiotics should not be used for the URTI. However, 90% said they used Intraveneous fluids routinely for diarrhoea and 92% used antibiotics routinely for URTIs. Of the latter 52% said they gave intramuscular antibiotics, from which larger profits can be made. The main reason for this discrepancy was the need for income generation (stated by 85%) with parental demand given as the second explanation (78%).

While substantial profits can be made from drugs, especially parenteral drugs, this situation will not change, irrespective of the evidence that these practices are unncessary and potentially dangerous. It will require fundamental changes to the way health care is financed in many countries before research in many spheres can be implemented.

Therese Hesketh, Research Fellow in International Child Health, Institute of Child Health, London, WC1N 1EH

Zhu Wei Xing, Regional Manager, Health Unlimited, Albert Embankment, London SE1

1. Garner P, Kale R, Dickson R, Dans T, Salinas R. Implementing research findings in developing coutries BMJ 1998;317:531-5

Competing interests: None declared

Therese Hesketh

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The excellent article by P. Garner et al.1 has been commented on by T. Gibbs 2, who explained the educational roots of difficulties in implementing research evidence in medical practice, using the example of Ukraine.

Problems described by Garner et al. are relevant to all countries with old fashioned medicine. For example, in Russia in medical practice and in medical education the importance of scientific understanding of pathology is indisputable. It is the foundation for the prized 'individualization' of treatment of the patient.

Another 'educational' barrier for the implementation of the research findings in practice in Russia is the old fashioned state of epidemiology. Russian epidemiology is still the science of the spread of infectious diseases. It is the point defended by the powerful Dr. V. Pokrovskiy, head of the Academy of Medical Sciences and the head of the major Moscow research institute of epidemiology. He insists that 'epidemiology is a Russian science' and is a science of the spread of infectious diseases 3. As a result no medical school teaches students epidemiological methods and modern biostatistics, and there was no textbook on epidemiology until this spring, when the first book 4 was translated. Most physicians do not understand study design and the possibilities of critical appraisal, believe information from drug company representatives, and do not understand the biases of unethical advertisements in medical journals. In one major medical journal in Russia recently the advertisement and the telephone number of the drug company representative were published in the middle of a 'scientific' report of a drug trial!

The main source of information on evidence based medicine for Russia is the pages of the Russian version of Evidence Based Medicine (Russian title 'International Journal of Medical Practice', published since December 1996). In 1997, the Ministry of Health started the program of 'standardization' in health care. In Moscow and in all regions of Russia health officials initiated the writing and official approval of 'standards' or 'medico-technological protocols' for all frequent conditions. These documents, usually two pages long, have no references and have nothing similar to the modern trend to 'evidence based guidelines'. They reflect the opinions of the authors and textbooks available to them. It is an example of how the implementation process of research findings may be erroneously reflected in the medicine of specific countries.

My Russian colleagues will condemn me for discussing Russian problems in the context of discussion of the medicine in developing countries. They have good arguments: e.g. in Russia there are more computer tomographs per million population than in England. I understand these arguments only as proof that the article by P. Garner et al. 1 relates not only to developing countries but to all countries where medicine is outdated. V. Vlassov -- Vasiliy Vlassov Dr. Med. Sci., Professor Saratov State Medical University e-mail: snail mail: P.O.Box 1528, Saratov, 410601 Russia

Reference List

1. Garner P, Kale R, Dickson R, Dans T, Salinas R. Implementing research findings in developing countries. Br.Med.J. 1998;317:531-535.

2. Gibbs T. Implementing research findings in developing countries. Br.Med.J. 1998;317:

3. Pokrovskiy VI. Epidemiology - Russian science [Russian]. Zdravoohranenie Ross. Federatsii. 1993;3-5.

4. Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology [Russian]. íoscow: MediaSphera, 1998;

Competing interests: None declared

Vasiliy Vlassov, Professor, Saratov Medical University

Saratov, Russia

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EDITOR------- Very few people who have worked in developing countries would argue with Garner et al in their excellent summary of how to encourage research in such areas and the difficulties and obstacles encountered. 1 However, experience from Ukraine suggests that the solution may not just be the provision of financial resource, but may lie deeper in basic medical education.

The Royal College of General Practitioners has been working, through its International Fellowship Programme, on the facilitation of a system of primary care in Ukraine, based upon the European model of general practice. This programme is now in its forth year and substantial progress has been made 2 . One positive outcome has been the ability to observe the delivery of health care and although the numbers are at this point in time are small, interesting observations are emerging which appear to affect long term planning.

Observing consultations in primary care suggest that there is a strong tendency to medicalise non-clinical problems. Multi-drug prescribing is often the rule and health promotion is rarely discussed . Further enquiry demonstrates an absence from both the undergraduate or postgraduate medical curricula of teaching related to either health promotion or to the diagnosis and management of psycho-social disorders. 3 This has to be taken into the context of Ukraine having the worst morbidity and mortality figures in the whole of Eastern Europe, with most illness being a result of a poor understanding of personal and social effects on disease.4

Ukraine is ready for the introduction of primary care research and evidence based medicine, but this must be accompanied by a change in medical education, a change that has to be driven by a central Government order with its associated complexities.

Ukraine similarly shares with other developing countries the perception that a good doctor is judged by the items of equipment and number of tests he performs. Hence computers are becoming increasingly common in medical practices and should be accessible for research. However since there are no educational initiatives to encourage the wider use of Information Technology, specifically to either access data or as a data collecting tool, facilities lie fallow and become items of status rather than practicality.

Medical personnel must recognise that this deficiency in basic medical education will impede the development of standard and progressive medical care and research, even if accompanied by vast financial resources.

Dr Trevor Gibbs Director of Community Studies RCGP International Adviser Department of Primary Care University of Liverpool Liverpool L69 3GB

1 Garner P, Kale R, Dickson R, Dans T, Salinas R. Implementing research findings in developing countries. Brit Med J 1998;317: 531-535

2 Gibbs T, Mulka O, Zaremba E. The Royal College of General Practitioners Ukraine Fellowship Programme 1993-1997 European Journal of General Practice. 1998 ; 4: 84-87

3 Gibbs T, Mulka O, Zaremba E, Lysenko G. Ukrainian General Practitioners- an observational study European Journal of General Practice Awaiting review.

4 Kromhout D, Bloemberg B, Doornbos G Reversibility of rise in Russian mortality rates Lancet. 1997; 350: 379

Competing interests: None declared

Trevor Gibbs

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