At the district hospital in Batibo, Cameroon, a clinician is having a tough time dealing with an increased patient load when a baby is rushed in with a three-day fever and persistent vomiting. The doctor on call is ready for the task but is unsure how best to go about with the child's management. He is well equipped with an evidence-based WHO guideline for management of a febrile child,1 however, he is unsure about what to do about feeding and the mode of administration of medication, or how to manage the uninsured client who cannot afford the test for malaria, or why his clients prefer to use their insecticide treated bed nets for farming rather than for protection against mosquito bites. The guidelines recommend the 3Ts – test, treat and track.1 Simply put, however, the clinician must consider cultural practices that lead mothers to “auto medicate” with both orthodox medicines and traditional remedies before they bring their children to hospital. They must also consider aspects of nutrition and feeding using locally available food and technology.
This story tells a typical situation clinicians face in lower- and middle-income country (LMIC) clinical practice settings. The story uses a condition (malaria) which probably boasts some of the best evidence directly relevant in LMICs. Other conditions suffer from a paucity of evidence relevant to LMICs. In most cases, therefore, a clinician may have available evidence on a topic but not in its entirety, or evidence which is not relevant to the LMIC context. The challenge is now to use the best available evidence in their practice – an art that many clinicians have struggled to develop.
This editorial highlights the challenges of implementing guidelines in settings where local factors such as financial ability and culture could influence the effectiveness of an intervention. It also highlights the importance of “feasibility”, “appropriateness” and “meaningfulness” in addition to “effectiveness” when implementing evidence in LMICs.
The Centre for Evidence Based Healthcare Africa (CEBHA) outlines five simple steps for implementing evidence:2
- Step 1: Formulate your question
- Step 2: Search for the evidence
- Step 3: Appraise the evidence
- Step 4: Put the evidence into practice
- Step 5: Monitor what has been done.
As simple as these steps may seem, they are not free of challenges in LMICs. It may be easy to formulate a PICO question, but it may not be easy to conduct a search when there are no up-to-date libraries or when individuals do not have the skills to appraise existing evidence or find evidence which is appropriate to LMIC settings.
As leaders in evidence synthesis, dissemination and implementation, it bears upon us to challenge this status quo and develop innovative approaches to address gaps in the face of incomplete resources for implementing evidence. There currently exists a number of strategies to address this:
- Evidence-based clinical audit3
- Contextualization approach4
- WikiRecs and the evidence ecosystem5
- Guidelines adolopment.6
In Africa, it is said that “beta soup na money killam o”, meaning money makes the soup good. This is true for evidence as well. Evidence synthesis, translation and implementation is an expensive process and the final product requires large budgets usually lacking in LMICs.
The majority of systematic reviews used in LMICs has focused on effectiveness, however, in LMICs culture is often central to how people perceive, demand for and utilize healthcare. This affects health system policies, financial resources, available healthcare services, attitudes and practices of healthcare providers, and development agency agendas, all within the complex symphony of an evidence ecosystem that requires innovative approaches from evidence generation through evidence implementation. This is the challenge that evidence implementation stakeholders must face daily.
As a further example – nutrition is a bedrock for good health – both anecdotes and evidence suggest that what goes in plays a key role in how healthy you will be. In LMICs, children under five suffer from nutrition related anemia; this in turn affects how their systems react to infections or disease; they also may be unable to feed well with severe illness and require special diets and/or approaches to feeding. Evidence will be available, but is this evidence appropriate for a healthcare system that lacks facilities for assisted feeding or is unaware of the nutritional value of local foods? Therein lies the challenge for the clinician: the child suffering from severe malaria is lying in the ward requiring intravenous management and he is unsure what to introduce into the naso-gastric tube. Implementing evidence in LMICs encompasses challenges of this nature on a daily basis, and the community of science, although already doing a great deal, will need to do more to address existing gaps in evidence implementation in LMICs. This process can be facilitated in a number of ways:
- Evidence implementation capacity building in LMICs.
- Incorporating evidence into health system policies and strategies at ministries of health and health development agencies.
- Evaluating evidence needs in LMICs.
- Understanding of local cultures, practices and beliefs within both communities and healthcare practice settings (demand and supply).
- Engaging local stakeholders in LMICs in evidence generation, synthesis, translation and implementation.
- Measuring the impact of these processes in LMICs.
3. Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare. Int J Evid Based Healthc
2005; 3 8:207–215.
4. Grimmer K, Machingaidze S, Dizon J, Kredo T, Louw Q, Young T. South African clinical practice guidelines quality measured with complex and rapid appraisal instruments. BMC Res Notes
2016; 9 1:244.
5. Otto CM, Spencer FA, Vandvik PO. Evidence, experts, trustworthy guidelines and WikiRecs. Heart
2017; 103 1:3–5.
6. Schünemann HJ, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa RA, Manja V, et al. GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol