Article type
Year
Abstract
Objectives: We hypothesized that equipping health care workers with the skills and knowledge to use systematic reviews and how to implement change will improve their practices.
Methods: The methods were published in detail recently [1]. Briefly, the study has a stratified cluster randomized trial design. Stratification was by country (Mexico-Thailand), hospital type (state-social security) and hospital size (small-large based on annual delivery rates). The core intervention consisted of meetings with hospital directors, three interactive workshops delivered over a period of six months, provision of RHL, identification of a hospital RHL coordinator, RHL information materials and provision of computers and printers located in an accessible part of the labour ward. The control group continued to receive their standard performance improvement methods.
Seven practices with clear conclusions from the Cochrane reviews included in RHL were selected as primary outcomes. Clinical practice data were collected from 1000 consecutive women per hospital before and 10-12 months after the first workshop.
Results: The intervention was successfully implemented in the 22 hospitals randomly allocated to the intervention group. All hospitals except one accepted referrals from peripheral clinics or hospitals. In Mexico, the hospitals were urban, doctors provided care and most hospitals had guidelines (17/22) and continued education programmes (18/22) available. In Thailand, hospitals were in smaller towns, routine care was provided mainly by midwives and there were no guidelines or continued education programmes in place.
Practice rates for many outcomes varied between and within countries. There was a ceiling effect (> 70% using the recommended practice at baseline) for two of the seven practices (active management of the third stage of labour and breastfeeding on demand) and we were unable to measure one predefined practice satisfactorily (external cephalic version). There was scope for improvement in social support during labour, selective episiotomy, magnesium sulfate for eclampsia and corticosteroids for preterm birth based on baseline practice rates.
Conclusions: The preparatory phase of complex intervention trials is time consuming and several iterations are necessary to tailor the intervention for the local settings. This should be taken into account when planning and fundraising for such trials. Complete results of the intervention effect and the implications of the trial results for practice will be discussed at the Colloquium.
Reference: 1. Gülmezoglu AM, Villar J, Grimshaw J, Piaggio G, Lumbiganon P, Langer A. Cluster randomized trial of an active, multifaceted information dissemination intervention based on The WHO Reproductive Health Library to change obstetric practices: methods and design issues [ISRCTN14055385]. BMC Med Res Methodol. 2004 Jan 15;4(1):2.
Methods: The methods were published in detail recently [1]. Briefly, the study has a stratified cluster randomized trial design. Stratification was by country (Mexico-Thailand), hospital type (state-social security) and hospital size (small-large based on annual delivery rates). The core intervention consisted of meetings with hospital directors, three interactive workshops delivered over a period of six months, provision of RHL, identification of a hospital RHL coordinator, RHL information materials and provision of computers and printers located in an accessible part of the labour ward. The control group continued to receive their standard performance improvement methods.
Seven practices with clear conclusions from the Cochrane reviews included in RHL were selected as primary outcomes. Clinical practice data were collected from 1000 consecutive women per hospital before and 10-12 months after the first workshop.
Results: The intervention was successfully implemented in the 22 hospitals randomly allocated to the intervention group. All hospitals except one accepted referrals from peripheral clinics or hospitals. In Mexico, the hospitals were urban, doctors provided care and most hospitals had guidelines (17/22) and continued education programmes (18/22) available. In Thailand, hospitals were in smaller towns, routine care was provided mainly by midwives and there were no guidelines or continued education programmes in place.
Practice rates for many outcomes varied between and within countries. There was a ceiling effect (> 70% using the recommended practice at baseline) for two of the seven practices (active management of the third stage of labour and breastfeeding on demand) and we were unable to measure one predefined practice satisfactorily (external cephalic version). There was scope for improvement in social support during labour, selective episiotomy, magnesium sulfate for eclampsia and corticosteroids for preterm birth based on baseline practice rates.
Conclusions: The preparatory phase of complex intervention trials is time consuming and several iterations are necessary to tailor the intervention for the local settings. This should be taken into account when planning and fundraising for such trials. Complete results of the intervention effect and the implications of the trial results for practice will be discussed at the Colloquium.
Reference: 1. Gülmezoglu AM, Villar J, Grimshaw J, Piaggio G, Lumbiganon P, Langer A. Cluster randomized trial of an active, multifaceted information dissemination intervention based on The WHO Reproductive Health Library to change obstetric practices: methods and design issues [ISRCTN14055385]. BMC Med Res Methodol. 2004 Jan 15;4(1):2.