Building capacity for evidence generation, synthesis and implementation to improve the care of mothers and babies in South East Asia: methods and design of the SEA-ORCHID Project using a logical framework approach.

BACKGROUND: Rates of maternal and perinatal mortality remain high in developing countries despite the existence of effective interventions. Efforts to strengthen evidence-based approaches to improve health in these settings are partly hindered by restricted access to the best available evidence, limited training in evidence-based practice and concerns about the relevance of existing evidence. South East Asia--Optimising Reproductive and Child Health in Developing Countries (SEA-ORCHID) was a five-year project that aimed to determine whether a multifaceted intervention designed to strengthen the capacity for research synthesis, evidence-based care and knowledge implementation improved clinical practice and led to better health outcomes for mothers and babies. This paper describes the development and design of the SEA-ORCHID intervention plan using a logical framework approach. METHODS: SEA-ORCHID used a before-and-after design to evaluate the impact of a multifaceted tailored intervention at nine sites across Thailand, Malaysia, Philippines and Indonesia, supported by three centres in Australia. We used a logical framework approach to systematically prepare and summarise the project plan in a clear and logical way. The development and design of the SEA-ORCHID project was based around the three components of a logical framework (problem analysis, project plan and evaluation strategy). RESULTS: The SEA-ORCHID logical framework defined the project's goal and purpose (To improve the health of mothers and babies in South East Asia and To improve clinical practice in reproductive health in South East Asia), and outlined a series of project objectives and activities designed to achieve these. The logical framework also established outcome and process measures appropriate to each level of the project plan, and guided project work in each of the participating countries and hospitals. CONCLUSIONS: Development of a logical framework in the SEA-ORCHID project enabled a reasoned, logical approach to the project design that ensured the project activities would achieve the desired outcomes and that the evaluation plan would assess both the process and outcome of the project. The logical framework was also valuable over the course of the project to facilitate communication, assess progress and build a shared understanding of the project activities, purpose and goal.

Improving capacity for evidence-based practice in South East Asia: evaluating the role of research fellowships in the SEA-ORCHID Project.

BACKGROUND: Fellowships are a component of many professional education programs. They provide opportunities to develop skills and competencies in an environment where time is protected and resources and technical support are more readily available. The SEA-ORCHID fellowships program aimed to increase capacity for evidence-based practice and research synthesis, and to encourage fellows to become leaders in these areas. METHODS: Fellows included doctors, nurses, midwives and librarians working in the maternal and neonatal areas of nine hospitals in South East Asia. Fellowships were undertaken in Australia and involved specific outputs related to evidence-based practice or research synthesis. Training and support was tailored according to the type of output and the fellow's experience and expertise. We evaluated the fellowships program quantitatively and qualitatively through written evaluations, interviews and follow-up of fellowship activities. RESULTS: During 2006-07, 23 fellows from Thailand, Indonesia, Malaysia and the Philippines undertook short-term fellowships (median four weeks) in Australia. The main outputs were drafts of Cochrane systematic reviews, clinical practice guidelines and protocols for randomised trials, and training materials to support evidence-based practice. Protocols for Cochrane systematic reviews were more likely to be completed than other outcomes. The fellows identified several components that were critical to the program's overall success; these included protected time, tailored training, and access to technical expertise and resources. On returning home, fellows identified a lack of time and limited access to the internet and evidence-based resources as barriers to completing their outputs. The support of colleagues and senior staff was noted as an important enabler of progress, and research collaborators from other institutions and countries were also important sources of support. CONCLUSIONS: The SEA-ORCHID fellowships program provided protected time to work on an output which would facilitate evidence-based practice. While the fellows faced substantial barriers to completing their fellowship outputs once they returned home, these fellowships resulted in a greater understanding, enthusiasm and skills for evidence-based practice. The experience of the SEA-ORCHID fellowships program may be useful for other initiatives aiming to build capacity in evidence-based practice.

Maternal and perinatal guideline development in hospitals in South East Asia: the experience of the SEA-ORCHID project.

BACKGROUND: Clinical practice guidelines (CPGs) are commonly used to support practitioners to improve practice. However many studies have raised concerns about guideline quality. The reasons why guidelines are not developed following the established development methods are not clear.The SEA-ORCHID project aims to increase the generation and use of locally relevant research and improve clinical practice in maternal and perinatal care in four countries in South East Asia. Baseline data highlighted that development of evidence-based CPGs according to recommended processes was very rare in the SEA-ORCHID hospitals. The project investigators suggested that there were aspects of the recommended development process that made it very difficult in the participating hospitals.We therefore aimed to explore the experience of guideline development and particularly the enablers of and barriers to developing evidence-based guidelines in the nine hospitals in South East Asia participating in the SEA-ORCHID project, so as to better understand how evidence-based guideline development could be facilitated in these settings. METHODS: Semi-structured, face-to-face interviews were undertaken with senior and junior healthcare providers (nurses, midwives, doctors) from the maternal and neonatal services at each of the nine participating hospitals. Interviews were audio-recorded, transcribed and a thematic analysis undertaken. RESULTS: Seventy-five individual, 25 pair and eleven group interviews were conducted. Participants clearly valued evidence-based guidelines. However they also identified several major barriers to guideline development including time, lack of awareness of process, difficulties searching for evidence and arranging guideline development group meetings, issues with achieving multi-disciplinarity and consumer involvement. They also highlighted the central importance of keeping guidelines up-to-date. CONCLUSION: Healthcare providers in the SEA-ORCHID hospitals face a series of barriers to developing evidence-based guidelines. At present, in many hospitals, several of these barriers are insurmountable, and as a result, rigorous, evidence-based guidelines are not being developed. Given the acknowledged benefits of evidence-based guidelines, perhaps a new approach to supporting their development in these contexts is needed.

A psychologist-led educational intervention results in a sustained reduction in neonatal intensive care unit infections.

UNLABELLED: Even though in the corporate world psychological science has been widely used, the formal use of evidence-based psychology in important areas of clinical medicine has been scanty at best. It was the aim of this study to determine the efficacy of a psychologist-led 2-week nurse educator training on the infection rate in the neonatal intensive care unit (NICU). MATERIALS AND METHODS: In 2007, six senior neonatal nurses underwent a training course focusing on the retrieval of evidence and knowledge of psychological principles that would allow them to share the evidence in such a way that evidence is effectively brought into practice. The course was led by a psychologist. The nurses created and delivered their own teaching modules, all focused on infection control. The rates of bacteremia, 2 years prior to intervention were analyzed and compared with the rate following the intervention for 3 years. RESULTS: The immediate output of the course included three teaching modules: hand washing, sterile procedures, and general measures to control infection. These modules were subsequently administered to the NICU nurses in regular structured continuous nursing education sessions. The psychological techniques taught in the course were applied. Bacteremia in the NICU significantly decreased in the year of the course and the subsequent years when compared to previous years (from more than 17 in 2005 and 2006 to less than 10 per 100 admissions to the NICU in 2008 and 2009). CONCLUSION: This study suggests that a psychologist-led course, followed by a structured CNE can lead to a sustainable reduction in infection rates in a NICU.

Barriers to and enablers of evidence-based practice in perinatal care in the SEA-ORCHID project.

RATIONALE, AIMS AND OBJECTIVES: The South-East Asia Optimising Reproductive and Child Health in Developing Countries (SEA-ORCHID) project aimed to improve health outcomes for mothers and babies in nine hospitals in South-East Asia by supporting evidence-based perinatal health care. In this research, we aimed to identify and explore the factors that may have acted as barriers to or enablers of evidence-based practice change at each of the hospitals. METHODS: During the final 6 months of the intervention phase of the project, semi-structured, face-to-face interviews were undertaken with 179 nurses, midwives and doctors from the maternal and neonatal departments at each of the nine participating South-East Asian hospitals. RESULTS: The interviews identified several factors that participants believed had a substantial impact on the effectiveness of the SEA-ORCHID intervention. These included knowledge, skills, hierarchy, multidisciplinarity and leadership, beliefs about consequences, resources, and the nature of the behaviours. The success of the SEA-ORCHID intervention in improving practice may reflect the extent to which tailored strategies were effective in overcoming these barriers. CONCLUSION: Effective interventions to align practice with evidence rely on identifying and addressing barriers to practice change. The barriers identified in this study may be useful for those designing similar clinical practice improvement projects, as well as for continued efforts to improve practice in the SEA-ORCHID hospitals.