Evidence Uptake: Where to Begin

Attendees during the research meeting

Quite often Research uptake is misunderstood to mean research dissemination or research communication. Dissemination is the distribution of information usually one way while communication is  two way but often at the end of the process. Research uptake however is engaging at the outset and often more holistic and involves thinking about a wider group of stakeholder.

To help understand more about Research uptake, Sophie Durrans a Research Uptake Officer at the London School of Hygiene and Tropical Medicine made a presentation on “Evidence Uptake: where to begin,” at the CIDRZ weekly research meeting.

Sophie’s presentation was aimed at giving an overview on evidence uptake with specific focus on evidence application, policy making process and stakeholder analysis, reaching policymakers and policy briefs

Research uptake can be done by dedicated staff working at the intersection of research and policy, or by researchers themselves who often develop policy expertise.

In policy making, “the term evidence informed decision making/policy making is now preferred to suggest how policy decisions are not made in a vacuum but also that other factors are also important such as political climate, appetite for policy change/evidence use etc. Also the fact that sometimes research findings are considered and rejected in the formulation of a policy it’s still evidence-informed”

Sophie points out that applied evidence leads to new or amended policies, recommendations adopted by implementers, guidelines, resources, toolkits revised reflecting evidence, inclusion on technical working group agenda and other key meetings, changes in levels or focus of funding, changes made to programs or services as well as  scale up of interventions and programmes.

“In the policy making process the assumption is that policymakers  are receptive to research findings and field evidence but the reality is different. Instead of developing policies based on recommendations, policymakers may ignore them or reject them”.

Sophie the policy making process doesn’t happen by itself  but often involves many stakeholders who hold the greatest deal-breaking influence and  may not always be those who on paper look most relevant.

She recommends conducting a stakeholder analysis in evidence uptake is very important as the process brings together more ideas, enables buy-in at an early stage, saves time further down the line and helps to work effectively. Further recommendations are understanding of the power and interests of various stakeholders and knowing who keep informed, manage closely, monitor with minimum effort and keep engaged. Develop relationships with policymakers and know how to contact them and Learn about their background, interests and preferences.

“Understand the national level structures and roles relating to your area of work, eg special policy processes or timings (eg. joint sector reviews), relevant teams responsible. The entry points to achieving all this could be through routine meetings such as technical Working Groups, Cyclical events, One-off events, emails, phone calls, face to face and policy briefs”.

Time and Motion Study: Results from the CommART Baseline Assessment

“‘Cost’ is the most important component in many of evaluations used for decision making in health care”

Taniya Tembo CIDRZ Costing Research Associate said this during the CIDRZ weekly research meeting when she presented results from a study on Time and Motion Study: Results from the CommART Baseline Assessment

The study was conducted in 10 control and intervention sites selected on the basis of epidemiologic,

economic, and operational characteristics  to assess the importance of good costing during the costing of activities for the Community ART for Retention (CommART) project.

The CommART project was developed to find alternatives  to  problems in the scale-up of providing ART on an already over-stretched health care system and limited health infrastructure and decentralized ART models were found to  potentially reduce cost of HIV care due to the reduced use of providers’ time and improve patient outcomes due to increased retention.

Cost-assessment under the CommART project was based on societal perspective using micro-costing method (both bottom up and top-down), quantification of different types of resources used for the HIV, treatment and care through identification of unit costs and multiplied quantities of resource used by respective unit costs.

Further components of the cost assessment included, patient costs such as opportunity costs (including waiting time), transportation to and from clinic, provider costs( cost of ARVs, labs, personnel, equipment, supplies & administrative costs), programme costs i.e. costs to set up the monitoring and evaluation framework, technical advice, staff meetings and trainings, and facility-level costs (calculation of amounts allocated to HIV care).

Data from the study was based on ART services such as counseling, pharmacy, laboratory and clinical visits.

The key cost parameters were analysed from two dimensions: Patients and healthy systems Parameters:

From a patient’s perspective, it included issues to do with lost productivity, lost wages due to illness and seeking care, out of pocket costs for each clinic visit, including repeat visits (drugs, tests, hospitalization among others). From a health system perspective, the study looked at costs of providing clinical services per patient visit and cost of evaluation, diagnosis, treatment and hospitalization.

The results revealed that on average patient waiting time to receive all the above services were 254 minutes in urban and 215 minutes in rural clinics per day respectively. The study also found that in terms of direct patient activities, Counselors spent 978 minutes, Pharmacy Technicians 298 minutes, Clinical Officers 302 minutes and Nurses 593 minutes on average per day.

The study concluded that good costing was important in standard treatment and introduction of new health interventions.

For details, TAM-Baseline-Assessment_PP_TT.pdf (34 downloads)

Researchers Offer New Model for Uncovering True HIV Mortality Rates in Zambia: Accurate information needed to improve treatment outcomes

LUSAKA/WASHINGTON 12 Jan. 2018 A new study that seeks to better ascertain HIV mortality rates in Zambia could provide a model for improved national and regional surveillance approaches, and ultimately, more effective HIV treatment strategies.

Survival represents the most important indicator of successful HIV treatment, according to the researchers. According to UNAIDS, mortality from HIV has fallen by 50 percent since 2004—largely due to the successes of national HIV programs, PEPFAR, and the Global Fund. Yet, because routine monitoring and evaluation fails to systematically capture most deaths, it can be challenging to accurately assess the impact of HIV services and to identify where improvement is most needed, the researchers say.

The Better Information for Health in Zambia (“BetterInfo”) study begins to examine survival rates in Zambia. Published January 12 in PLOS Medicine, the work was conducted by a team of researchers co-led by Charles Holmes, MD, MPH, faculty co-director of Georgetown University Medical Center’s Center for Global Health and Quality, and visiting associate professor at Georgetown’s School of Medicine. Holmes led the work along with Izukanji Sikazwe, MBChB, MPH, Chief Executive Officer of the Centre for Infectious Research in Zambia (CIDRZ) and Elvin Geng, MD, MPH, of the University of California, San Francisco. Holmes, who previously led CIDRZ, also serves as associate professor of international health at Johns Hopkins Bloomberg School of Public Health and associate professor of medicine at Johns Hopkins School of Medicine.

The research was conducted in Zambia through a partnership with CIDRZ and the Zambian Ministry of Health, in close collaboration with numerous local and global academic centers and researchers.

The research group set out to provide a more accurate representation of site- and regional-level mortality among people on HIV therapy in Zambia by characterizing the extent of under-reporting of mortality and the variability in data collection and use, and to assess the broader impact this might have on treatment programs and outcomes.

The group applied a multistage sampling-based approach—which they say is a novel methodology in this context—to obtain regionally representative mortality estimates in four Zambian provinces (Lusaka, Southern, Eastern, and Western). The estimates were also sufficiently precise to quantify variation in death rates among clinic sites.

They looked at a sample population of more than 160,000 patients who had visited government-operated HIV treatment sites in these provinces to determine: the magnitude of deaths of those who were taking antiretroviral therapy (ART); when deaths occurred; which groups are at highest risk of death; and whether these factors differ by region, facility, or other variables.

They also traced patients who were lost to follow-up to ascertain their status, and then used this information to create a corrected regional survival estimate as well as corrected site-specific mortality estimates.

The BetterInfo study concluded that mortality is substantially underreported in routine provincial program data—by as much as three- to nine-fold—among HIV-infected individuals starting ART, leading to a change in the ranking of provinces by mortality rates.

At the site-level, “corrected” mortality rates were found to be up to 23-fold higher among those on ART. The study also found unexpectedly high variability from site to site in reported mortality rates, ranging from less than 1 death per 100 person-years to up to 13.4 deaths per 100 person-years over a two-year period.

“Even as we strive to reduce new HIV infections and end the HIV pandemic as a public health threat, we must not lose sight of premature deaths occurring amongst people living with HIV who are on treatment,” Holmes says. “HIV treatment is not a ‘set it and forget it’ proposition—deaths often occur outside of the health system and are therefore ‘silent’ events that are unknown to those providing or managing care.

“We believe our scalable approach, which builds on and extends earlier sampling methods, provides actionable data to clinic, provincial and national decision-makers to ensure the HIV program in Zambia is able to become more patient-centered and impactful,” he says.

Based on the findings, certain prevailing assumptions that underlie HIV programs may need to be reexamined. For example, the researchers say it has been assumed that most patients on treatment for longer periods of time will be more stable than those just starting treatment. However, the study data suggest that time on therapy alone may not be a reliable marker of stability, a finding that will have implications for delivery strategies recommending less health system interaction for patients considered clinically stable.

In addition, approximately 50% of deaths among those newly starting ART occurred relatively shortly after a recent clinic visit, suggesting even greater need for attention to diagnostic services and clinical vigilance for potential co-existing illnesses.

Overall, the authors seek to encourage national- and global-level policy makers to investigate and address the root causes of underestimated and highly variable mortality rates so they can refocus their quality improvement efforts and strengthen HIV programs.

“These data from the BetterInfo study have provided new targets for quality improvement efforts, and we look forward to further evidence as it emerges that will enable us to support the strongest possible national HIV program in Zambia,” says CIDRZ’s Sikazwe. “We recommend that others consider the application of similar large-scale surveillance methodologies in order to better understand their program outcomes, and we are excited to facilitate broader adoption through the forthcoming release of a “BetterInfo” toolkit and other materials.”

Holmes adds, “We believe our study also highlights the critical need for investments in vital status registries and data systems to enable better visibility into patient outcomes. These investments are critical not just for the HIV response, but for broader efforts to combat chronic conditions such non-communicable diseases and achieve universal health coverage.”

Additional co-authors of the study include Kombatende Sikombe, MPH, Njekwa Mukamba, Sandra Simbeza, MSc, and Cardinal Hantuba from CIDRZ; Ingrid Eshun-Wilson, MBChB, MSc, from Stellenbosch University in Cape Town, South Africa; Nancy Czaicki, PhD, MPH, from CIDRZ and University of California, Berkeley; Laura K. Beres, MPH, from Johns Hopkins University; Carolyn Bolton Moore, MBBCh, MSc, from CIDRZ and University of Alabama at Birmingham; Peter Mwaba, MBChB, PhD, from Lusaka Apex Medical University in Lusaka, Zambia; Caroline Phiri, MD, MPH, from the Ministry of Health, Government of the Republic of Zambia; Nancy Padian, PhD, MPH, from the University of California, Berkeley; and David V. Glidden, PhD, from the University of California, San Francisco.

The study was funded by the Bill & Melinda Gates Foundation (OPP1105071). The authors report having no personal interests related to the study.

“Estimated mortality on HIV treatment among active patients and patients lost to follow-up in 4 provinces of Zambia: Findings from a multistage sampling-based survey.” https://doi.org/10.1371/journal.pmed.1002489

About Georgetown University Medical Center
Georgetown University Medical Center (GUMC) is an internationally recognized academic medical center with a three-part mission of research, teaching and patient care (through MedStar Health). GUMC’s mission is carried out with a strong emphasis on public service and a dedication to the Catholic, Jesuit principle of cura personalis — or “care of the whole person.” The Medical Center includes the School of Medicine and the School of Nursing & Health Studies, both nationally ranked; Georgetown Lombardi Comprehensive Cancer Center, designated as a comprehensive cancer center by the National Cancer Institute; and the Biomedical Graduate Research Organization, which accounts for the majority of externally funded research at GUMC including a Clinical and Translational Science Award from the National Institutes of Health. Connect with GUMC on Facebook (Facebook.com/GUMCUpdate), Twitter (@gumedcenter). Connect with Georgetown University School of Medicine on Facebook (Facebook.com/somgeorgetown), Twitter (gumedicine) and Instagram (@GeorgetownMedicine).