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Using the KTA to develop a tailored program for guideline implementation in LMICs
Julia E. Moore, Caitlyn Timmings, Joshua P. Vogel, Sobia Khan, Lisa M. Puchalski Ritchie, Dina N. Khan, Jamie Park, Metin Gulmezoglu, Sharon E. Straus, and the GREAT Network
Knowledge to Action Model (KTA) by Graham ID et al., JCHEP 2006; 26:13-24
Globally there are 289,000 maternal deaths, 2.6 million stillbirths, and 2.8 million newborn deaths per year (1-3). The majority of deaths are preventable through the effective and contextualized implementation of evidence-based interventions (4). The GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge) is an international partnership whose goal is to facilitate the efforts of local stakeholders focused on enhancing maternal health in low and middle-income countries (LMIC).
Methods and Results:
Four participating countries; Myanmar, Uganda, Tanzania, Ethiopia.
2A) Identify problem and identify, review and select knowledge
- Local investigators prioritized and selected guidelines that best addressed their gaps in maternal and perinatal care (e.g., prevention and treatment of PPH in Ethiopia, Uganda and Tanzania and task-shifting in Myanmar).
2B) Adaptation of knowledge to local context
- Local stakeholders ranked guideline recommendations based on feasibility and relevance to the local context (e.g., lack of access to misoprostol).
2C) Assessing barriers and facilitators to knowledge use
- Focus groups with local stakeholders explored barriers and facilitators to the adaptation and implementation of relevant guideline recommendations.
- Barriers and facilitators were identified at 3 levels; health system, healthcare provider, community/patient.
- Common barriers included health workforce shortages and the need for improved drug procurement and distribution. Unique barriers included a lack of site-specific data of practices in Uganda and preferences regarding childbirth location in Ethiopia.
2D) Selecting and tailoring implementation strategies to local contexts
- Stakeholders linked barriers/facilitators to implementation strategies using behaviour change theory and were selected based on relevance to local context.
- For example, when provide knowledge and skill was identified as a barrier, education and training were chosen as implementation strategies.
- No two implementation plans were the same for any country due to unique barriers. For example, Myanmar was the only country that identified taskk-shifting as a priority guideline and identified that healthcare worker role confusion was a barrier. Therefore, reviewing and redefining healthcare worker role were chosen as implementation strategies to address this barrier.
3) Key findings
- We have operationalized the first few steps of a systematic process model (KTA) to inform implementation strategies designed to support behaviour change and improved patient outcomes.
- Contextualized differences in LMIC emphasize the need for tailoring which can be challenging. However, we have found an approach that is flexible and feasible which enabled countries to develop tailored guideline implementation plans. Other countries and organizations could adopt and adapt a similar methodological approach to implementation of maternal health guidelines (or other evidence-based guidelines) in their own settings.
- Identifying change champions to engage in this approach was critical as was the inclusion of a variety of different stakeholders such as policymakers, researchers, and clinicians.
- Maintaining ongoing engagement with workshop participants with implementation coaching, technical support, additional funding or other opportunities is important to ensure the actualization of the implementation plan.
1. World Health Organization. Trends in Maternal Mortality: 1990 to 2013. Geneva: World Health Organization; 2013.
2. Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, et al. National regional, and worldwide estimated of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet. 2011; 377(9774):1319-30.
3. Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet. 2015 Jan 31; 385(9966):430-40.
4. Tancalp O, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahi R, et al. Quality of care for pregnant women and newborns - the WHO vision. BJOG. 2015 May 1.