Changing Practice with Operational Changing Practice with Operational ResearchResearch

Kate Sadler

Valid International

AimsAimsChanging international practice with

simple operational research and well chosen publications:

– Community-based therapeutic care (CTC)– Know your audience– Demonstrate need for change– Choose the right research tools– Use a range of data collection instruments – Disseminate results widely and effectively

Community based Therapeutic Care (CTC)Community based Therapeutic Care (CTC)

1. Treats acute malnutrition– Marasmus & Kwashiorkor

2. Provide easy access for populations– Decentralised outpatient therapeutic care

(OTP)

3. Care in homes not feeding centres or hospitals– Using existing health infrastructure

4. Community mobilisation– Formal and informal networks– Traditional practitioners

5. Uses Ready to Use Therapeutic Foods

– Medical profession, docs• High science

– Donors• Cost!

– NGOs and implementers• ‘Doable’

• Impact

Your AudienceYour Audience

Demonstrate need for changeDemonstrate need for change

Impact of existing centre-based

programmes poor in nutritional

emergencies:

– Not ‘doable’

– High risks

Demonstrate need for changeDemonstrate need for change

Impact of existing centre-based

programmes poor in nutritional

emergencies:

– Not ‘doable’

– High risks

– Imbalance coverage : intensity

ETHIOPIA 2000ETHIOPIA 2000BOLLOSSO SORIE

One of many highland districts400,000 people - 40 km radius20% < 5 years

= 80,000 children < 5 years10% severe malnutrition

= 8,000 requiring TFCTFC programme duration 4 months

20 TFCs REQUIRED (8000 / 400 = 20)

Choose the right research toolsChoose the right research tools

RCTs– Emergencies - too many external constraints – Humanitarianism? Timely interventions,

ethical– Directed a lot of our high quality research to

outside emergencies and the REAL suffering – Our experience disaster!

Observational studies, retrospective and prospective cohorts– Easily integrated into ongoing programmes

Use a range of data collection Use a range of data collection instruments (1)instruments (1)Quantitative, qualitative, observation

and case studies– Triangulation

OTP EXITS (24 Jun 03 - 23 October 2005)

81%

3% 1%

13%

2%Recovered to SFP

Died.

Default.

Transfers

Moved to other OTP

Quantitative: programme monitoring

Qualitative: programme monitoring

Anthropological studies looking at the acceptability of non-centre based treatment compared to traditional TFC models:– Less disruption to home life– Carers able to fulfil social

responsibilities– Improved access– Carers felt sense of empowerment

being trusted to care for their kids– Tap into community ethos of looking

after each other

Observation & case studies: programme monitoring

Use a range of data collection Use a range of data collection instruments (2)instruments (2)Meta-data with range of partners

– one observational and replicated 20 times. All data comparable and all showed the same thing

Results of CTC programmes: Sep 00-Jun 05Results of CTC programmes: Sep 00-Jun 05

Programme Year No. SAM treated

Recovery (%)

Mortality (%)

Coverage (%)

Ethiopia-Hadiya 2000 170 85 4.1 - N Sudan-Darfur 2002 446 65.1 7.9 >60% Malawi-Dowa 02-05 4920 74.1 6.8 72.6

Malawi-Nkhotakota 03-05 1627 65.8 8.3 - Ethiopia-S Wollo 03-05 2805 80.2 5.7 77.4 Ethiopia-Wolaiyta 03 194 69.6 5.2 - Ethiopia-Wolaiyta 03-05 705 88.4 5.5 - Ethiopia-Sidama 03 1497 84.8 1.2 78.3 Ethiopia-Hararge 03 232 85.8 6.0 80.6 South Sudan-BEG 03-05 2132 73.4 2.5 81.8 Ethiopia-Hararge 04 1086 76.0 2.0 56.0 Ethiopia-Hararge 04 381 69.5 2.4 56.0

Ethiopia-W Hararge 04 1377 88.0 3.4 61.3 Ethiopia-Wolaiyta 04 539 90.4 1.4 - N Sudan-W Darfur 04 1684 80.0 1.4 75.0 N Sudan-W Darfur 04 115 58.6 3.4 - N Sudan-N Darfur 05 172 65.7 7.9 - Ethiopia-Awassa 05 353 95.0 1.1 -

Niger-Maradi 05 2270 87.7 2.6 - Niger-Zinder 05 1177 - - -

TOTAL 26,308 79.5 4.1

Disseminate results widely and Disseminate results widely and effectively (1)effectively (1)Use a combination of the right

channels of dissemination– High-science journals – difficult?– Low-science journals– Practitioner publications– Meetings and teaching

Disseminate results widely and Disseminate results widely and effectively (2)effectively (2)Design message with audience in

mind:– Impact: outcomes, coverage

Comparison of coverage of severely malnourished in Comparison of coverage of severely malnourished in Dowa and Mchinji districts - Malawi (March 2003)Dowa and Mchinji districts - Malawi (March 2003)

Disseminate results widely and Disseminate results widely and effectively (2)effectively (2)Design message with audience in

mind:– Impact: outcomes, coverage– ‘Doability’: simple protocols integrated

into national PHC delivery

OTP: Appetite assessment OTP: Appetite assessment (RUTF)(RUTF)

One week ration

« Appetite test »

Disseminate results widely and Disseminate results widely and effectively (2)effectively (2)Design message with audience in

mind:– Impact: outcomes, coverage– ‘Doability’: simple protocols integrated

into national PHC deliveryFor effective communication

– Tell a story

Disseminate results widely and Disseminate results widely and effectively (3)effectively (3)Don’t be afraid to present problems

and failings > credibility

0

50

100

150

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15distribution round

num

bers

ADMISSIONS EXITS TOTAL IN PROGRAM

August 02 March 03

>70% coverage

Information and mobilisation

Positive feedback

ConclusionsConclusions

Making a good case for change supports a positive research environment

Choosing the right research tools is key to obtaining rigorous data in emergency settings

Use the right channels of dissemination to reach the target audience

Presentation of research outcomes must focus on information needs of audience