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The GREAT Network: A global implementation collaborative supporting WHO guideline implementation in low- and middle-income countries Julia E. Moore, Caitlyn Timmings, Joshua Vogel, Sobia Khan, Sami Uka, A. Metin Gülmezoglu, & Sharon E. Straus
Acknowledgements
2
• Introduce GREAT Network
• Models, Theories, & Frameworks
• World Health Organization Guidelines
• GREAT Network Activities: – In-country workshops
– Seed grants
– Capacity Building
Road Map
3
Implementation in low- and middle-income countries
How many people have worked to support implementation in
low- and middle-income countries?
4
The GREAT Network facilitates the
efforts of local stakeholders to
address challenges in maternal and
perinatal health guideline
implementation in low- and middle-
income countries (LMICs).
5
Guideline-driven
Research Priorities
Evidence Synthesis
Application of Evidence
Transfer of Knowledge
The GREAT Network
Diversity of funding sources
CIHR dissemination
Kosovo workshop
CIHR Network grant
GREAT Network
IRP
Myanmar workshop
UNC1
Uganda, Tanzania, Ethiopia
workshops
UNC2
Uganda, Tanzania, Ethiopia
implementation
CIHR: Canadian Institutes of Health Research
IRP: Implementation Research Platform of WHO
UNC1: Round 1 of funding from the UN Commission on Life-Saving Commodities
UNC2: Round 2 of funding from the UN Commission on Life-Saving Commodities
6
The GREAT Network
World Health Organization
St. Michael’s
Hospital/University of Toronto
GREAT
Network
Executive
Committee
Country
Partners
7
Network objectives
Establish a network of partners and stakeholders who are interested in improving maternal and infant health in LMICs through effective knowledge translation (KT) and implementation approaches;
Build capacity in the science and practice of KT and implementation across relevant stakeholder groups in LMICs; and
Develop a framework for guideline implementation relevant to the needs of partners in LMICs, and advance the science and practice of KT and implementation.
8
Timeline of activities
GN= GREAT Network
9
10
Models, Theories & Frameworks
Evidence-informed, Theory-driven Program (ETP)
11
Evidence-informed
theory-driven program (ETP)
Evidence-based Clinical
Guideline
Implementation Strategies
An evidence-informed, theory-driven program (ETP) is a comprehensive set of
activities designed to impact behaviour change related to practice (e.g., clinical
guideline).
The guideline recommendations must have been demonstrated to significantly affect
desired outcomes through rigorous scientific research, and implementation strategies
selected to change practice must be rooted in behaviour change theory
and supported by implementation research evidence.
How we define key terms
Dissemination
Implementation
Dissemination Science
Implementation Science
KT
Practice
KT
Science
Knowledge Translation
12
The Knowledge to Action Cycle
Knowledge Inquiry
Knowledge
Synthesis
Knowledge
Tools/
Products
Select, Tailor,
Implement
Interventions
Monitor
Knowledge
Use
Evaluate
Outcomes
Sustain
Knowledge
Use
Assess
Barriers/
Facilitators to
Knowledge
Use
Adapt
Knowledge
to Local
Context
Identify Problem
Determine the
Know/Do Gap
Identify, Review,
Select Knowledge
13 Source: Graham ID et al. JCHEP 2006;26:13-24.
Knowledge Inquiry
Knowledge
Synthesis
Knowledge
Tools/
Products
Knowledge Creation
14 Source: Graham ID et al. JCHEP 2006;26:13-24.
Select, Tailor,
Implement
Interventions
Monitor
Knowledge
Use
Evaluate
Outcomes
Sustain
Knowledge
Use
Assess
Barriers/
Facilitators to
Knowledge
Use
Adapt
Knowledge
to Local
Context
Identify Problem
Determine the
Know/Do Gap
Identify, Review,
Select Knowledge
The Action Cycle
15 Source: Graham ID et al. JCHEP 2006;26:13-24.
Developing an ETP
16
1. Identify barriers and facilitators
2. Map to a framework: Theoretical
Domains Framework
3. Map to a theory: Capability,
Opportunity, Motivation -Behaviour
4. Select implementation
strategies
6. Create an ETP logic model
Frameworks & Theories
17
Theoretical Domains Framework
Stages of Change
Capability, Opportunity, Motivation - Behaviour
Evidence-informed, Theory-driven Program (ETP)
18
Evidence-informed
theory-driven program (ETP)
Evidence-based Clinical
Guideline
Implementation Strategies
Select, Tailor,
Implement
Interventions
Monitor
Knowledge
Use
Evaluate
Outcomes
Sustain
Knowledge
Use
Assess
Barriers/
Facilitators to
Knowledge
Use
Adapt
Knowledge
to Local
Context
Identify Problem
Determine the
Know/Do Gap
Identify, Review,
Select Knowledge
The Action Cycle
19 Source: Graham ID et al. JCHEP 2006;26:13-24.
• Any questions regarding theories, frameworks and models?
Questions & Clarifications
20
21
World Health Organization Guidelines
Department of Reproductive Health and Research,
WHO
• Global leadership on sexual and
reproductive health
• Setting norms and standards
• Research capacity strengthening in
reproductive health research in
lower-income countries
Maternal and Perinatal Health
• Quantitative and qualitative research
on priority issues in low and middle-
income countries, to inform practice
and policy
• Knowledge synthesis activities
• Development of clinical and health
system guidelines
• Plenty of guidelines…. not enough implementation!
• How can we best facilitate evidence-based implementation of
WHO recommendations in resource-constrained settings?
Filename
The guideline implementation challenge
25
GREAT Network Activities
• Develop a network of partners and stakeholders interested in
improving maternal and infant health in LMIC through
effective KT
• Build capacity in the science and practice of KT across
relevant stakeholder groups in LMIC
• Develop a research agenda to advance the science and
practice of KT in LMICs
• Conduct primary research
Following the Knowledge-to-Action Cycle
Aiming to improve implementation of maternal and perinatal health guidelines by:
• Identifying local priorities for implementation of recommendations
• Identifying barriers and facilitators at provider and health system levels
• Develop, initiate and sustain a pilot implementation strategy to improve guideline use based on local context
• Evaluate outcomes
GREAT Research activities
The GREAT Network Activity 1: In-country activities
Seed Grants In-country
Activities
28
Developed a protocol, applied & adapted in 5 countries
Mixed methods design
• Phase 1: – Assessing priorities for guideline implementation
– barriers and facilitators to behaviour change
– potential implementation strategies
– Methods:
• quantitative surveys
• in-person workshops with focus group discussions and prioritization activities
• Phase 2: – Develop, implement and evaluate ETP
– Led by small, in-country working group
GREAT Research activities
29
30
Workshop host countries
Kosovo
Myanmar
Uganda
Tanzania
Ethiopia
• Early engagement/buy-in of stakeholders at beginning of
process
• Engage multiple disciplines and stakeholders • Policymakers, healthcare providers, researchers, NGOs, professional
associations, UN agencies, etc.
• Consensus on priority recommendations, barriers,
facilitators, feasibility and strategies
Why do in-country workshops?
31
• Improve access to and use of three maternal health
commodities (oxytocin, misoprostol and magnesium sulfate)
in health facilities
• Objective: – Identify priority recommendations from WHO guidelines
– Identify barriers/facilitators to their implementation
– Develop and pilot a contextualised implementation strategy
Case study: Uganda
• Informal consultations with key stakeholders (Ministry of
Health, WHO, professional associations)
• Pre-workshop survey
• Two-day in person workshop – 40+ stakeholders (midwives, auxiliary midwives, clinicians, Ministry of
Health, professional associations, international organizations,
researchers)
– Focus group discussions (FGDs) on barriers and facilitators
– Ranking exercises on priority and feasibility for implementation
– FGDs on potential strategies
Case study: Uganda
• Four WHO guidelines (92 recommendations)
• 16 recommendations were “high priority” and feasible for implementation
• Barriers & facilitators at women, provider, facility system level mapped
• Multiple potential strategies identified
Case study: Uganda
Priority Recommendations
Barriers Facilitators Implementation
Oral misoprostol (25umgs) for induction
Knowledge gap on safe use of misoprostol Available formulation is 200 micrograms only; 25umgs misoprostol formulation not available Many facilities not using misoprostol dilution of 25mcg Recent maternal death related to IoL in woman with history of CS
Misoprostol is widely available Misoprostol dilution in regular use in private
facilities
NDA needs to register misoprostol
as a drug for IOL, so there is need
to lobby whoever is responsible for
this purpose Improved pregnancy dating strategies, particularly in rural/remote settings Explore and Encourage use of misoprostol dilution techniques General implementation activities: Improved dissemination of recommendations, particularly: Through Ministry of Health, AOGU,
UMA, Midwives and Nursing
Associations, Teaching Institutions
Need to have legal essential
guidelines updates tied towards
practitioners practicing license periodical renewal and accreditation
IOL is recommended in women with pre-labor rupture of membranes at term
Misoprostol is not recommended for IOL in previous C/S
Induction of labour
• In-country working group developed a proposal for pilot
implementation project in 3 districts:
1. Mentor and support health facility teams to identify gaps in
implementation, and develop, implement and evaluate ‘local
homegrown’ or in-house solutions to addressing these gaps
2. To establish platform to share progress and good practices
through a “quality improvement collaborative” and a KT
newsletter
3. To strengthen community expectation of and demand for key
aspects evidence based practices supported by the
guidelines
Next steps
• Implementation in participating countries to be led by local
teams, with technical support where needed from GREAT
Network
• Evaluate (process outcomes)
• Journal article on assessing priorities, barriers & facilitators
Ongoing research activities
• Straus SE, Moore JE, Uka S, Marquez C, Gülmezoglu AM.
Determinants of implementation of maternal health guidelines
in Kosovo: mixed methods study. Implement Sci. 2013 Sep
9;8:108.
• Implementation of WHO postpartum haemorrhage guidelines
• Workshop in October 2012 – developed 9 specific
recommendations for action
Kosovo (Pilot Study)
38
Kosovo process evaluation – 2 years post-workshop
Phase 1 Recommendation Progress to date (based on Phase 2 Process Evaluation)
Centralized system for data
collection
o Efforts to consolidate all institutions in improving data collection
processes have been piloted
o A health information system using intranet has been established and is
used for data reporting at local hospitals/family medicine centres.
o Until full implementation of the directives outlined in the Strategy of
Information 2010-2019, local level data is being collected through
different sources e.g.; working records, registers, reports to the national
institute of public health.
Incorporate standards into
clinical practice
o WHO guidelines are used and monitored on a case by case basis at
institutional and regional levels, but there is no central monitoring
system
o Steps have been taken to encourage the incorporation of standards
into practice
Motivational strategies to
encourage guideline
adherence
o Local level incentives are being used to motivate trained to encourage
guideline implementation as part of CME, but these receive modest
support.
o A national level performance based incentive program is currently in
the development stages.
39
• Keep it simple and focused: – prioritize one or a few key recommendations/gaps, and focus on a sustained
solution to improving these
• High turnover of key individuals
• Work to support local ownership – Engage local partners in every step of the process, including leadership during
in-country activities
– Training and support
– Need for “the right champion” to make it work
A few lessons learned
• Any questions regarding methods and in-country activities?
Questions or clarifications?
41
The GREAT Network Activity 2: Seed grants
Seed Grants In-country
Activities
Seed
Grants
42
Funded Projects
Implementation Seed Grant Recipients
• Sri Lanka – maternal complications in hospital
• Uganda - use of partograph at the point of care
Knowledge Synthesis Seed Grant Recipients
• China - Intervention for emergency contraception
• Italy - Impact of the facility-based individual case near-miss reviews
• Ethiopia – clearinghouse of maternal health guidelines
43
Call for Proposals for Round 3 will be released in the Fall of
2015
For implementation projects in maternal and perinatal health
projects in low- and middle-income countries
Future directions for seed grants
44
The GREAT Network Activity 3: Capacity building
In-country
workshops
Seed Grants
Capacity
Building
In-country
Activities
Capacity
Building
Seed
Grants
45
To facilitate applied learning of KT/guideline implementation
using real-world project examples
To increase the number of people in-country who can teach
and share this content with others
To support the sustainability and spread after funding ends
Why support capacity building?
46
Future directions for capacity building
Provide coaching and technical assistance to reach implementation goals.
Facilitate applied learning and problem-solving in the specific context of implementation.
Offer assistance in brainstorming key next steps for evidence-based implementation.
47
The GREAT Network is launching a quarterly newsletter to showcase some
of the excellent work that is being done globally in the area of knowledge
translation and guideline implementation in maternal health; share relevant
resources, funding and training opportunities; and more!
If you would like to receive the GREAT Network Newsletter, please
subscribe to our mailing list and visit the GREAT Network Website for more
information:
http://greatnetworkglobal.org/
The GREAT Network Newsletter
48
We will use a mixed methods approach to evaluate processes and
impacts of the various initiatives completed by the Network over time.
Evaluating GREAT Network activities and impact
Process evaluation of Network inputs
• Number of trainees • Numbers of publications, research presentations,
grants, programs developed and implemented by trainees and members of the Network
• Number and type of KT tools developed • Number of KT implementation projects initiated and
completed
Outcome evaluation of Network impacts
• Changes in maternal mortality rates • Changes in guideline use
49
Discussion Questions
What strategies have you used successfully to develop and strengthen implementation networks?
What strategies are you using to build capacity?
What models, frameworks, and theories are you using?
50
Questions?
51
52
Additional Information
Network objectives
Establish a network of partners and stakeholders who are interested in improving maternal and infant health in LMICs through effective knowledge translation (KT) and implementation approaches;
Build capacity in the science and practice of KT and implementation across relevant stakeholder groups in LMICs; and
Develop a framework for guideline implementation relevant to the needs of partners in LMICs, and advance the science and practice of KT and implementation.
53
Barriers to implementing guidelines
Health system/Policy level
Lack of Physical Resources
Funding, medications/ supplies, monitoring and evaluation data
Lack of Human Resources
Staff shortages/unequal distribution, supervision/mentorship
Lack of Communication/ Information Sharing
Communication between clinicians/ policy makers
Policy Issues
Lack of policy, meds not approved for use
Health care provider level
Training/Knowledge/Skills
Lack of training, time to attend training, baseline education
Access/Awareness
access/awareness, understanding process/trust in guideline
Attitudes/Beliefs
Role confusion, fear of misuse, poor inter-professional
communication/confidence
Patient/Community level
Knowledge/Beliefs
Values/Preferences
Patient Resources
Health seeking behavior
Patient-Provider relationship
54
Pre-workshop survey example: Ethiopia pre-workshop survey
Prioritization of Clinical Areas in the
Prevention and Treatment of PPH Guideline Priority
N
(n=53)
Recommendations related to the clinical
area of Use of Uterotonics
1 (highest priority) 35
2 17
3 1
4 (lowest priority) 0
Recommendations related to the clinical
area of Cord Clamping
1 (highest priority) 2
2 20
3 20
4 (lowest priority) 11
55
Workshop activity example: Tanzania workshop feasibility ranking exercise
56
Findings
The process of selecting priority maternal and perinatal
health recommendations and exploring barriers and
facilitators to implementation of the four priority WHO
guidelines yielded rich information to inform implementation
planning in Uganda. Participants across all FGs described
issues at the level of the healthcare system, which
included various factors related to policies and wider
systemic conditions in Uganda that can affect the
implementation of the WHO guideline recommendations.
These factors include: access to resources; drug
procurement, distribution, and management; human
resources; access to site-specific data; accountability and
monitoring; and policies/political context. Issues at the level
of the healthcare provider were prevalent, where factors
related directly to frontline implementers (e.g., physicians,
midwives) were described. Specific factors discussed
include: beliefs, attitudes, and buy-in; knowledge and skills;
training, mentorship, and professional development; and
scope of roles. Finally, issues at the level of the
patient/community were described and include: traditional
beliefs; knowledge and awareness; and socioeconomic
status.
Post-workshop report example: Understanding Barriers and Facilitators to Implementation of Maternal Health Guidelines in Uganda:
A GREAT Network Research Activity
57
Recommendations
The most salient points that emerged from the pre-workshop and
workshop activities were as follows:
There is a need and an opportunity to improve implementation of the
priority recommendations across the four selected WHO guidelines
(Prevention and treatment of PPH; Prevention and treatment of pre-
eclampsia and eclampsia; Induction of Labour; and Augmentation of
Labour).
Drug procurement, management, and distribution practices are not
operating at an optimal level. There are cases where drugs are
expiring on the shelves and other examples where drugs are
unavailable. This suggests a need for current drug ordering and
monitoring policies and practices to be reviewed at both the level of
healthcare facilities and nationally.
There is a concern around the misuse of misoprostol to increase the
speed of labour (either inappropriately administered by healthcare
workers or self-administered by the patient by securing the drug over
the counter). Further research is required to better understand the
misuse of misoprostol and the resultant harms. Results of this research
could be used to provide evidence to support a change to the
regulation of misoprostol in the market.
Recruitment of more healthcare workers is needed across the
healthcare system, but particularly in rural/remote areas; infrastructure
(e.g., housing for healthcare workers, schools for the children of
healthcare workers, etc.) and incentives (i.e., a competitive salary
comparable to urban centres) are needed as a preliminary step. Lifting
the current recruitment ban in Uganda may also be considered.
The role of village health teams is expanding to include maternal and
perinatal care. There is a need to create more formal linkages between
healthcare facilities and village health teams to better coordinate and
standardize maternal healthcare for the community.
Future directions for in-country workshop activities
A paper on the Guideline Implementation methods used in GREAT Projects is currently under development.
Potential tools/toolkits to help others recreate the process in LMICs are currently being explored. These will be developed based on consideration of contextual factors, resource limitation and feasibility in LMICs.
Conducting an evaluation of post in-country workshop activities.
58
Encourage local ownership of work
Build capacity in researchers/academics, frontline clinicians
involved with KT and implementation work
Provide resources to support work as financial resources are
often a barrier to implementation, particularly in LMICs
Why provide funding to LMICs for guideline implementation?
59
Future directions for capacity building
Country Implementation Objective
Implementation support provided by the GREAT Network
Form Implementation Working Group (WG) [in
country]
Identify a multi-disciplinary implementation team
Develop an Evidence-informed Theory-driven
Program (ETP)
Provide an overview of and resources on mapping barriers and
identifying implementation strategies; provide input on/review
Terms of Reference document for Implementation WG; support
the initiation of ETP development.
Develop an Evidence-informed Theory-driven
Program (ETP) cont’d
Revisit the mapping process using a hands on interactive
approach to develop an ETP
Provide input on/review ETP
Develop and submit proposal on Phase 2 activities:
Developing, implementing, evaluating, and
sustaining a tailored implementation strategy
Provide input on/review Phase 2 proposal
Develop an implementation plan for your ETP Develop an implementation plan and evaluation strategy
60