Pivotal points of change: various factors can facilitate or hinder research utilization.
* Straightforward research findings can speed changes in clinical practices.
* Research findings that are extensively disseminated are most likely to be used.
* Political support for and timeliness of research findings can be essential for moving them into practice.
* Increasing interactions among researchers, policy-makers, and practitioners can further hasten research utilization.
Many factors can facilitate the speed and ease with which research results are incorporated into practice. The presence of these factors does not guarantee implementation of research findings, but the more factors that are in place, the greater the chances of success.
One key factor is the nature and complexity of the research question, which often determines how easily it can be investigated and how straightforward the study conclusions will be. Various study designs are used to evaluate different types of research questions pertaining to reproductive health. One of two basic categories of studies--observational--is commonly used to answer questions about disease prevalence, natural history, cause, and risk groups. Observational studies may appropriately be used for ethical, financial, or logistical reasons, or because the research question requires this approach. However, these studies--while identifying associations among variables--are less able to identify direct causal relationships than are randomized controlled trials. Such trials, involving an intervention to prevent or change the course of a disease, are especially well suited to test the safety and efficacy of drugs or devices. (1)
Particularly straightforward findings from a randomized controlled trial in Uganda are among several unique factors that recently contributed to rapid and positive changes in clinical practice (see article, page 9).
The trial determined the effectiveness of single-dose nevirapine versus a specific regimen of short-course zidovudine (AZT) to prevent mother-to-child transmission of HIV. (2) Enrollment of some 600 women and their infants occurred quickly, and rates of adherence to the drug regimens were high. The proportion of women and infants who remained in the trial through completion, the most important component of avoiding study bias, was also high. "After eight weeks, 98 percent of mother-infant pairs had been followed-up, and at 16 weeks, 97 percent," says Dr. Willard Cates Jr., president of FHI's Institute for Family Health. "In any setting, especially in a resource-poor setting like Uganda, these are phenomenal study vital statistics," he says.
The results of the study were also highly significant, demonstrating that nevirapine was nearly 50 percent more effective than this AZT regimen at preventing transmission. Moreover, the research had a strong potential to make a highly desired public health impact of saving the lives of babies, which it eventually did.
Like the strength of research results, specific ways of disseminating results can help facilitate their use. Most research findings are passively disseminated through academic seminars and publication in peer-reviewed journals, but more active dissemination involving a broad range of stakeholders--key decision-makers, health professionals, and the community--can increase their acceptance.
Type and scale of dissemination are among the best predictors of research utilization, according to a review of eight operations research projects conducted between 1988 and 1993 by the Population Council's Africa Operations Research and Technical Assistance Project I. (3) (Operations research seeks to assess factors contributing to programmatic success or failure and to test new and potentially better approaches to service delivery.) Studies with the most extensive dissemination efforts were the most utilized, this operations research in Africa showed.
One study disseminated and utilized most extensively was a pilot project of community-based distribution of contraceptives, conducted from 1990 to 1993 by the Ministry of Health in Mali (see article, page 10). Dissemination activities included development and distribution of reports on five different aspects of the study; dissemination seminars during the study; an international workshop on the final results; and presentation of study findings at regional and international meetings. Communicating results with messages, and through channels, appropriate to specific audiences was an important dissemination strategy, says Dr. Ian Askew, a Population Council senior program associate and coauthor of the review of the eight operations research projects. "This requires many more resources, but is also much more effective," he says.
Another factor that can facilitate or hinder research utilization is the economic, political, or programmatic environment in which the research is conducted and eventually implemented. The timeliness of research in any of these contexts can be important, as is depicted in a case study regarding IUD provision in Turkey (see article, page 13).
In some cases, however, compatibility of research with existing cultural beliefs may be even more important. Lessons learned from interventions and operations research to eradicate female genital cutting (FGC) throughout Africa demonstrate this point. Multiple factors facilitating research utilization have been present in the settings where this research is being conducted (including Egypt, Burkina Faso, Mali, and Kenya). Research clearly shows that FGC has negative health consequences, including hemorrhage, infections, complications during childbirth, and psychological scarring. And the political environment is supportive of eradication: Burkina Faso, Ghana, and Senegal all have national laws banning FGC. Nevertheless, utilization of the FGC research has been slow.
In Mali, where FGC prevalence is more than 90 percent, several nongovernmental organizations (NGOs) have been working to eradicate this practice. In particular, three local NGOs have educated traditional practitioners on FGC's negative health effects, trained them to advocate discontinuation of the practice, and suggested alternative sources of income. But an evaluation of the work of these three NGOs in 1996 showed that many practitioners were not convinced that FGC is a harmful practice and were continuing to perform it, despite the interventions. (4)
Many of these early efforts by NGOs to eradicate FGC emphasized the adverse health effects of the practice, says Dr. Askew, who is also an associate director of the Frontiers in Reproductive Health Program (carried out by the Population Council, FHI, and Tulane University), which conducted the evaluation in Mali. But the original emphasis on health did not sufficiently address the fact that FGC is essentially a cultural practice. "So several groups are now trying different and innovative ways of addressing the practice from a sociocultural perspective," he says.
In Kenya, for example, where FGC is practiced as a traditional rite of passage for young women, the local NGO Maendeleo Ya Wanawake (MYWO) has been working for years to encourage communities to abandon FGC. As an alternative to this tradition, MYWO suggests that families hold similar ceremonies that do not include genital cutting. An assessment in 2000 of this "alternative rite" program showed that families who took part in alternative ceremonies were more likely than others to know about the negative health consequences of FGC and to attribute to MYWO some of their decisions to abandon FGC. (5)
Research utilization mediators
Those who have a stake in utilization of research findings can provide essential support to move research findings into practice. But different stakeholders do not always have the same views on whether or how to push findings forward. A mediator--such as an influential political leader, a researcher, an entire organization, or an advocate or "champion" for utilization--can also help.
"Anything that can bridge the gap between research and practice is important," says Matthew Tiedemann, senior program manager and research utilization expert at FHI. "Use of mediators, which increases interaction between researchers, policy-makers, and practitioners, can help ensure that stakeholders are aware of the others' needs and contributions. That can reduce the time lag between research and its utilization."
In an ongoing project to implement a new single-visit approach for cervical cancer prevention in rural Thailand (see article, page 14), an influential member of the medical community is acting as a mediator, says Dr. Paul Blumenthal, director of JHPIEGO's Cervical Cancer Prevention Program. JHPIEGO is collaborating with the Royal Thai College of Obstetricians and Gynaecologists (RTCOG) on the project.
This single-visit approach, involving visual inspection of the cervix with acetic acid and a light source and then immediate treatment of precancerous lesions with cryotherapy, is safe, acceptable, and feasible in rural Thailand, a recent study has shown. (6) The mediator--Dr. Khunying Kobchitt Limpaphayom, who is a well-known professor at Chulalongkorn University in Bangkok, the project director of JHPIEGO's Cervical Cancer Prevention Program in Thailand, and a member of the research team--will continue to be especially important as the project is expanded. "Because she is well respected and well connected, and because many people recognize that women's health issues are important to her, Dr. Limpaphayom can draw attention to the topic," says Dr. Blumenthal. "It is also clear that without her, we would not have been able to garner as much collaboration and support as we have."
As president of RTCOG during the project's conception, Dr. Limpaphayom was instrumental in developing an initial RTCOG/JHPIEGO collaboration. She was also pivotal in gaining the support of the Ministry of Public Health and in creating a project advisory board. That board helps convey project information to Ministry members who can consider further project implementation.
"This single-visit approach is important for my country," says Dr. Limpaphayom. "It can help save many lives, since, for the time being, we cannot offer Pap smear screening for all women. My goal is to decrease mortality from cervical cancer, so I want to get this research into practice as quickly as possible. There is no time to waste."
(1) Stephenson JM, Babiker A. Overview of study design in clinical epidemiology. Sex Transm Inf 2000;76(4):244-47.
(2) Guay LA, Musoke P, Fleming T, et al Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999;354(9181):795-802.
(3) Solo J, Cerulli A, Miller R, et al. Strengthening the utilization of family planning operations research: findings from case studies in Africa. Unpublished paper. New York, NY: Population Council, 1998.
(4) Frontiers in Reproductive Health. Mali Female Genital Cutting. FGC Excisors Persist Despite Entreaties, OR Summary 2. Washington, DC: Population Council. Frontiers in Reproductive Health, 2000.
(5) Frontiers in Reproductive Health. Kenya Female Genital Cutting. Community Sensitization Must Precede Alternative Coming-of-Age Rite, OR Summary 27. Washington, DC: Population Council, Frontiers in Reproductive Health. 2002; Chege JN, Askew I, Liku J. An Assessment of the Alternative Rites Approach for Encouraging Abandonment of Female Genital Mutilation in Kenya. Nairobi, Kenya: Population Council, 2001.
(6) Royal Thai College of Obstetricians and Gynaecologists (RTCOG) and the JHPIEGO Corporation Cervical Cancer Group. Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project. Lancet 2003;361(9360):814-20.
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|Author:||Wright, Kerry L.|
|Date:||Sep 22, 2003|
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