SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers. Change may be more likely if implementation strategies are specifically chosen to address potential obstacles. It is logical that strategies tailored to overcome identified barriers should be more effective than non-tailored ones.
Key messages
People making decisions about quality improvement.
Baker R, Camosso-Stefinovic J, Gillies C, et al. Tailored interventions to address determinants of practice. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD005470.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Strategies to disseminate and implement change in the performance of healthcare professionals have had variable impacts. The level of effectiveness has varied not only between different strategies, but also when the same strategy has been used on different occasions.
Tailored implementation strategies require the identification of important barriers to change and the selection of implementation strategies most likely to be effective in addressing them. Tailoring strategies might help to maximise their potential impact. There are a variety of ways to identify barriers and to select ways to address them. Methods to identify barries include: making informal judgements, brainstorming, surveys, interviews, focus groups and observations. Methods to select ways to address identified barriers include theory-based approaches and experimental modeling of potential interventions.
| Review objectives: To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions |
Randomized trials of interventions tailored to address prospectively identified barriers to change. Studies had to involve a comparison group that did not receive a tailored intervention or a comparison between an intervention that was targeted at both individual and social or organisational barriers, compared with an intervention targeted at only individual barriers. |
Thirty-two randomized trials. Interventions assessed were varied and included (among others): printed materials; educational outreach; clinical guidelines; audit and feedback; interactive workshops; teaching sessions/discussions of patients; facilitation/practice meetings; and individual/group academic detailing. |
| Participants |
Healthcare professionals responsible for patient care. |
Primarily physicians (14 studies), mixed professional groups (8), nurses (4); pharmacists (2), geriatric teams (1), gynaecology teams (1), and physicians (1). |
| Settings |
Any setting |
Primary care or community settings (17 studies), hospital settings (7), nursing homes (3), and one each in child health clinics, community pharmacies, a regional health system, and a Medicaid program. The studies were conducted in the United States of America (USA) (12), the Netherlands (5), the United Kingdom (UK) (4), Belgium (2), Indonesia (2), Norway (2), South Africa (2), and Canada (1), Ireland (1), and Portugal (1). |
| Outcomes |
Objectively measured professional performance (excluding self-reporting) or patient outcomes in a healthcare setting or both. |
Change in prescribing behaviour (12 studies), management of a disease (including diagnosis, assessment and treatment) (11), preventive care (6), influenza vaccination (2), reporting adverse drug reactions (1). |
| Date of most recent search: December 2014 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Baker R, Camosso-Stefinovic J, Gillies C, et al. Tailored interventions to address determinants of practice. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD005470.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review included 32 studies. The studies used a variety of methods to identify barriers, including face-to-face interviews, focus groups with physicians or patients, surveys, workshop discussions, telephone interviews, literature reviews or brainstorming by opinion leaders.
The participants in the studies were mostly physicians and nurses. The interventions included the distribution of printed materials, educational outreach, workshop activities, small discussion groups, auditing and feedback. Most of the interventions were targeted at changing prescribing behaviour.
1) Tailored interventions compared to no intervention or guidelines alone
Mixed results were found both across and within the included studies. There was variation in the reporting of how barriers had influenced the design of the intervention. The selection of interventions often relied on the judgements of the investigators and was not informed by explicit theories of behavioural or organisational change.
Seventeen studies compared a tailored intervention to no intervention, of which it was possible to include seven in the main analysis. Fifteen studies compared a tailored intervention to a non-tailored intervention, of which it was possible to include eight in the main analysis. In all but one of the eight trials, the non-tailored intervention consisted of the dissemination of written educational materials or guidelines.
The odds ratio ranged from 1.08 to 10.59 for the 15 studies included in the main analysis. The 17 studies not included in the main analysis had findings showing variable effectiveness consistent with the studies included in the main analysis. The combined (average) odds ratio for these 15 studies was 1.56 (95% CI: 1.27 to 1.93), in favour of tailored interventions. In a situation where adherence with recommended practice was initially 60% this would correspond to an improvement to 70%. In a situation where adherence was initially 20% this would correspond to an improvement to 28%.
The authors investigated the following possible causes of variability in the effect of tailored interventions across the 15 studies: the type of control group (no intervention versus dissemination of written educational materials or guidelines), the risk of bias, explicit utilisation of a theory to select the interventions, adjustment to local factors, and the number of domains addressed by the determinants identified.
None of these were found to be associated with the reported effectiveness of the tailored interventions.
Tailored interventions compared to no intervention or guidelines alone |
||||||
| People: Healthcare professionals responsible for patient care Settings: High income countries Intervention: Tailored interventions to implement practice guidelines Comparison: No intervention or dissemination of guidelines alone |
||||||
|
Outcomes |
Absolute effect |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
|||
|
Without tailored intervention |
With tailored intervention |
|||||
|
Difference (Margin of error) |
||||||
|
Desired professional practice (adherence to guideline recommendations) |
Moderate adherence* 60 per 100 patients |
70 per 100 patients |
OR 1.56 (1.27 to 1.93) |
Moderate |
||
|
Difference: 10 more patients receiving recommended practice per 100 patient encounters (Margin of error: 6 to 14 more patients) |
||||||
|
Low adherence* 20 per 100 patients |
||||||
|
Difference: 8 more patients receiving recommended practice per 100 patient encounters (Margin of error: 4 to 13 more patients) |
||||||
|
Margin of error = Confidence Interval (95% CI) OR: Odds Ratio GRADE: GRADE Working Group grades of evidence (see above and last page) * The assumed adherence WITHOUT the tailored intervention was selected to aid interpretation of the overall odds ratios in situations in which there was low adherence (20% desired practice) and moderate adherence (60% desired practice). The corresponding adherence WITH the intervention (and the 95% confidence interval for the difference) is based on the overall odds ratio (and its 95% confidence interval). † The OR and confidence intervals shown are taken from a meta-regression. The results of 14 studies not included in the meta-regression indicated that, on average, tailored interventions improve professional practice. However, the effects were mixed. |
||||||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
|
Interventions tailored to barriers identified prospectively are more likely to improve professional practice than no intervention or the dissemination of guidelines or educational materials alone. |
|
| EQUITY | |
|
The systematic review did not address equity issues. |
|
| ECONOMIC CONSIDERATIONS | |
|
The review did not find evidence of the cost-effectiveness of tailored interventions or of the effectiveness of alternative methods of tailoring interventions. |
|
| MONITORING & EVALUATION | |
|
At present, there is no single, standard method for tailoring strategies to address identified barriers. Based on the available evidence, it is not possible to decide which approach is most effective. The relative costs of different approaches are also unclear. |
|
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
|
Related literature
Fretheim A, Munabi-Babigumira S, Oxman AD, et al. SUPPORT Tools for Evidence-informed policymaking in health 6: Using research evidence to address how an option will be implemented. Health Res Policy Syst 2009; 7 Suppl 1:S6.
Flottorp SA, Oxman AD, Krause J, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation science 2013; 8:35.
Krause J, Van Lieshout J, Klomp R, et al. Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods. Implementation science 2014; 9:102.
Huntink E, Lieshout J van, Aakhus E, et al. Stakeholders' contributions to tailored implementation programs: an observational study of group interview methods. Implementation Science 2014; 9:185.
Wensing M, Huntink E, van Lieshout J, et al. Tailored implementation of evidence-based practice for patients with chronic diseases. PloS One 2014; 9(7):e101981.
This summary was prepared by
Sebastián García Martí and Agustín Ciapponi, Argentine Cochrane Centre IECS -Institute for Clinical Effectiveness and Health Policy- Iberoamerican Cochrane Network, Argentina.
Conflict of interest
None declared. For details, see: www.supportsummaries.org/coi
Acknowledgements
This summary has been peer reviewed by: Tomas Pantoja and Richard Baker.
This review should be cited as
Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki-Cwirko M, van Lieshout J, Jäger C.
Tailored interventions to address determinants of practice.
Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD005470.
The summary should be cited as
García Martí S, Ciapponi A. Are tailored strategies effective for changing healthcare professional practice? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org
Keywords
All Summaries: evidence-informed health policy, evidence-based, systematic re-view, health systems research, healthcare, low- and middle-income countries, developing countries, primary healthcare
tailored interventions, implementation strategies, professional practice
