Sources of Evidence of Effectiveness for Work in Low and Middle-Income Countries:
Using interventions that do not work is a waste of valuable resources (money, time, energy) and creates a false promise to those for whom they are provided.
Sources of Evidence and Guidelines
Using local and country guidelines is good practice, and these are usually based on WHO guidelines.
Other guidelines may be useful for some settings such as the guidelines from Medecins Sans Frontieres.
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Translating Evidence into Practice in Low and Middle Income Countries
There can be a huge impact on health outcomes of using evidence-based practice.The issue is less about knowing what to do and more about actually implementing what is known e.g. reducing malnutrition, using bed nets to reduce malaria.
The barriers to using evidence-based practice in low-middle income countries include the following:
- Access to information : The problems lower income countries face getting access to the databases and searching for evidence
- Local applicability : The applicability of using global evidence to make local decisions (a) : Because of the deficit in evidence specific to their settings and lack of resources for research, lower income countries must defer to international studies which will differ in many ways (e.g. genetic & environmental differences, cultural mores, organisational contexts). However, where strong evidence for an intervention strengthens its universal application, unless there is good reason to think the evidence would not be applicable locally.
- Lack of generalisability :As a result of cultural, behaviour, lifestyle & environmental differences, evidence-based practice may lack generalisability to low income countries in areas such as health promotion. (b)
- Translation to local relevance : The fact that evidence-based knowledge has to be adapted to the local setting and then translated into understandable guidelines with local relevance.
- Professionalism : The lack of professional regulation (and accountability) that affects whether best evidence will be used at all
- Training : The lack of training in using audit cycles to implement evidence-based practice, standardise care and increase efficiency of resource use
- Resource implications, equity and efficiency : There may be issues related to these that are specific to low and middle income countries
Learning to critically appraise
Learning about is how to critically appraise the validity, completeness and transferability of public health evidence for low income countries can be helped by using Richard Heller's critical appraisal checklist: the Population Health Evidence Cycle ('ask', 'collect', 'understand', 'use') as an initial appraisal tool. This tool is particularly useful for public health policy issues or studies where the populations and/or interventions are not similar to those where the policy is to be implemented (c).
(a) Garner P, Meremikuwu M, Volmink J, Qian X, Smith H. Putting evidence into practice: how middle and low income countries "get it together". BMJ 2004;329(473):1036-39.
(b) Tang, K; Choi, B, Beaglehole, R. Grading of evidence of the effectiveness of health promotion interventions J Epidemiol. Community Health, 2008; 62: 832-34
(c) Heller RF, Verma A, Gemmell I, Harrison R, Hart J, Edwards R. Critical appraisal for public health: a new checklist. Public Health 2008; 122: 1: 92-98
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