The GREAT Network: A global implementation collaborative supporting WHO guideline implementation in low- and middle-income countries Julia E. Moore, Caitlyn Timmings, Joshua Vogel, Sobia Khan, Sami Uka, A. Metin Gülmezoglu, & Sharon E. Straus

Acknowledgements

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• Introduce GREAT Network

• Models, Theories, & Frameworks

• World Health Organization Guidelines

• GREAT Network Activities: – In-country workshops

– Seed grants

– Capacity Building

Road Map

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Implementation in low- and middle-income countries

How many people have worked to support implementation in

low- and middle-income countries?

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The GREAT Network facilitates the

efforts of local stakeholders to

address challenges in maternal and

perinatal health guideline

implementation in low- and middle-

income countries (LMICs).

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Guideline-driven

Research Priorities

Evidence Synthesis

Application of Evidence

Transfer of Knowledge

The GREAT Network

Diversity of funding sources

CIHR dissemination

Kosovo workshop

CIHR Network grant

GREAT Network

IRP

Myanmar workshop

UNC1

Uganda, Tanzania, Ethiopia

workshops

UNC2

Uganda, Tanzania, Ethiopia

implementation

CIHR: Canadian Institutes of Health Research

IRP: Implementation Research Platform of WHO

UNC1: Round 1 of funding from the UN Commission on Life-Saving Commodities

UNC2: Round 2 of funding from the UN Commission on Life-Saving Commodities

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The GREAT Network

World Health Organization

St. Michael’s

Hospital/University of Toronto

GREAT

Network

Executive

Committee

Country

Partners

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Network objectives

Establish a network of partners and stakeholders who are interested in improving maternal and infant health in LMICs through effective knowledge translation (KT) and implementation approaches;

Build capacity in the science and practice of KT and implementation across relevant stakeholder groups in LMICs; and

Develop a framework for guideline implementation relevant to the needs of partners in LMICs, and advance the science and practice of KT and implementation.

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Timeline of activities

GN= GREAT Network

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Models, Theories & Frameworks

Evidence-informed, Theory-driven Program (ETP)

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Evidence-informed

theory-driven program (ETP)

Evidence-based Clinical

Guideline

Implementation Strategies

An evidence-informed, theory-driven program (ETP) is a comprehensive set of

activities designed to impact behaviour change related to practice (e.g., clinical

guideline).

The guideline recommendations must have been demonstrated to significantly affect

desired outcomes through rigorous scientific research, and implementation strategies

selected to change practice must be rooted in behaviour change theory

and supported by implementation research evidence.

How we define key terms

Dissemination

Implementation

Dissemination Science

Implementation Science

KT

Practice

KT

Science

Knowledge Translation

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The Knowledge to Action Cycle

Knowledge Inquiry

Knowledge

Synthesis

Knowledge

Tools/

Products

Select, Tailor,

Implement

Interventions

Monitor

Knowledge

Use

Evaluate

Outcomes

Sustain

Knowledge

Use

Assess

Barriers/

Facilitators to

Knowledge

Use

Adapt

Knowledge

to Local

Context

Identify Problem

Determine the

Know/Do Gap

Identify, Review,

Select Knowledge

13 Source: Graham ID et al. JCHEP 2006;26:13-24.

Knowledge Inquiry

Knowledge

Synthesis

Knowledge

Tools/

Products

Knowledge Creation

14 Source: Graham ID et al. JCHEP 2006;26:13-24.

Select, Tailor,

Implement

Interventions

Monitor

Knowledge

Use

Evaluate

Outcomes

Sustain

Knowledge

Use

Assess

Barriers/

Facilitators to

Knowledge

Use

Adapt

Knowledge

to Local

Context

Identify Problem

Determine the

Know/Do Gap

Identify, Review,

Select Knowledge

The Action Cycle

15 Source: Graham ID et al. JCHEP 2006;26:13-24.

Developing an ETP

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1. Identify barriers and facilitators

2. Map to a framework: Theoretical

Domains Framework

3. Map to a theory: Capability,

Opportunity, Motivation -Behaviour

4. Select implementation

strategies

6. Create an ETP logic model

Frameworks & Theories

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Theoretical Domains Framework

Stages of Change

Capability, Opportunity, Motivation - Behaviour

Evidence-informed, Theory-driven Program (ETP)

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Evidence-informed

theory-driven program (ETP)

Evidence-based Clinical

Guideline

Implementation Strategies

Select, Tailor,

Implement

Interventions

Monitor

Knowledge

Use

Evaluate

Outcomes

Sustain

Knowledge

Use

Assess

Barriers/

Facilitators to

Knowledge

Use

Adapt

Knowledge

to Local

Context

Identify Problem

Determine the

Know/Do Gap

Identify, Review,

Select Knowledge

The Action Cycle

19 Source: Graham ID et al. JCHEP 2006;26:13-24.

• Any questions regarding theories, frameworks and models?

Questions & Clarifications

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World Health Organization Guidelines

Department of Reproductive Health and Research,

WHO

• Global leadership on sexual and

reproductive health

• Setting norms and standards

• Research capacity strengthening in

reproductive health research in

lower-income countries

Maternal and Perinatal Health

• Quantitative and qualitative research

on priority issues in low and middle-

income countries, to inform practice

and policy

• Knowledge synthesis activities

• Development of clinical and health

system guidelines

• Plenty of guidelines…. not enough implementation!

• How can we best facilitate evidence-based implementation of

WHO recommendations in resource-constrained settings?

Filename

The guideline implementation challenge

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GREAT Network Activities

• Develop a network of partners and stakeholders interested in

improving maternal and infant health in LMIC through

effective KT

• Build capacity in the science and practice of KT across

relevant stakeholder groups in LMIC

• Develop a research agenda to advance the science and

practice of KT in LMICs

• Conduct primary research

Following the Knowledge-to-Action Cycle

Aiming to improve implementation of maternal and perinatal health guidelines by:

• Identifying local priorities for implementation of recommendations

• Identifying barriers and facilitators at provider and health system levels

• Develop, initiate and sustain a pilot implementation strategy to improve guideline use based on local context

• Evaluate outcomes

GREAT Research activities

The GREAT Network Activity 1: In-country activities

Seed Grants In-country

Activities

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Developed a protocol, applied & adapted in 5 countries

Mixed methods design

• Phase 1: – Assessing priorities for guideline implementation

– barriers and facilitators to behaviour change

– potential implementation strategies

– Methods:

• quantitative surveys

• in-person workshops with focus group discussions and prioritization activities

• Phase 2: – Develop, implement and evaluate ETP

– Led by small, in-country working group

GREAT Research activities

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Workshop host countries

Kosovo

Myanmar

Uganda

Tanzania

Ethiopia

• Early engagement/buy-in of stakeholders at beginning of

process

• Engage multiple disciplines and stakeholders • Policymakers, healthcare providers, researchers, NGOs, professional

associations, UN agencies, etc.

• Consensus on priority recommendations, barriers,

facilitators, feasibility and strategies

Why do in-country workshops?

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• Improve access to and use of three maternal health

commodities (oxytocin, misoprostol and magnesium sulfate)

in health facilities

• Objective: – Identify priority recommendations from WHO guidelines

– Identify barriers/facilitators to their implementation

– Develop and pilot a contextualised implementation strategy

Case study: Uganda

• Informal consultations with key stakeholders (Ministry of

Health, WHO, professional associations)

• Pre-workshop survey

• Two-day in person workshop – 40+ stakeholders (midwives, auxiliary midwives, clinicians, Ministry of

Health, professional associations, international organizations,

researchers)

– Focus group discussions (FGDs) on barriers and facilitators

– Ranking exercises on priority and feasibility for implementation

– FGDs on potential strategies

Case study: Uganda

• Four WHO guidelines (92 recommendations)

• 16 recommendations were “high priority” and feasible for implementation

• Barriers & facilitators at women, provider, facility system level mapped

• Multiple potential strategies identified

Case study: Uganda

Priority Recommendations

Barriers Facilitators Implementation

Oral misoprostol (25umgs) for induction

Knowledge gap on safe use of misoprostol Available formulation is 200 micrograms only; 25umgs misoprostol formulation not available Many facilities not using misoprostol dilution of 25mcg Recent maternal death related to IoL in woman with history of CS

Misoprostol is widely available Misoprostol dilution in regular use in private

facilities

NDA needs to register misoprostol

as a drug for IOL, so there is need

to lobby whoever is responsible for

this purpose Improved pregnancy dating strategies, particularly in rural/remote settings Explore and Encourage use of misoprostol dilution techniques General implementation activities: Improved dissemination of recommendations, particularly: Through Ministry of Health, AOGU,

UMA, Midwives and Nursing

Associations, Teaching Institutions

Need to have legal essential

guidelines updates tied towards

practitioners practicing license periodical renewal and accreditation

IOL is recommended in women with pre-labor rupture of membranes at term

Misoprostol is not recommended for IOL in previous C/S

Induction of labour

• In-country working group developed a proposal for pilot

implementation project in 3 districts:

1. Mentor and support health facility teams to identify gaps in

implementation, and develop, implement and evaluate ‘local

homegrown’ or in-house solutions to addressing these gaps

2. To establish platform to share progress and good practices

through a “quality improvement collaborative” and a KT

newsletter

3. To strengthen community expectation of and demand for key

aspects evidence based practices supported by the

guidelines

Next steps

• Implementation in participating countries to be led by local

teams, with technical support where needed from GREAT

Network

• Evaluate (process outcomes)

• Journal article on assessing priorities, barriers & facilitators

Ongoing research activities

• Straus SE, Moore JE, Uka S, Marquez C, Gülmezoglu AM.

Determinants of implementation of maternal health guidelines

in Kosovo: mixed methods study. Implement Sci. 2013 Sep

9;8:108.

• Implementation of WHO postpartum haemorrhage guidelines

• Workshop in October 2012 – developed 9 specific

recommendations for action

Kosovo (Pilot Study)

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Kosovo process evaluation – 2 years post-workshop

Phase 1 Recommendation Progress to date (based on Phase 2 Process Evaluation)

Centralized system for data

collection

o Efforts to consolidate all institutions in improving data collection

processes have been piloted

o A health information system using intranet has been established and is

used for data reporting at local hospitals/family medicine centres.

o Until full implementation of the directives outlined in the Strategy of

Information 2010-2019, local level data is being collected through

different sources e.g.; working records, registers, reports to the national

institute of public health.

Incorporate standards into

clinical practice

o WHO guidelines are used and monitored on a case by case basis at

institutional and regional levels, but there is no central monitoring

system

o Steps have been taken to encourage the incorporation of standards

into practice

Motivational strategies to

encourage guideline

adherence

o Local level incentives are being used to motivate trained to encourage

guideline implementation as part of CME, but these receive modest

support.

o A national level performance based incentive program is currently in

the development stages.

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• Keep it simple and focused: – prioritize one or a few key recommendations/gaps, and focus on a sustained

solution to improving these

• High turnover of key individuals

• Work to support local ownership – Engage local partners in every step of the process, including leadership during

in-country activities

– Training and support

– Need for “the right champion” to make it work

A few lessons learned

• Any questions regarding methods and in-country activities?

Questions or clarifications?

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The GREAT Network Activity 2: Seed grants

Seed Grants In-country

Activities

Seed

Grants

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Funded Projects

Implementation Seed Grant Recipients

• Sri Lanka – maternal complications in hospital

• Uganda - use of partograph at the point of care

Knowledge Synthesis Seed Grant Recipients

• China - Intervention for emergency contraception

• Italy - Impact of the facility-based individual case near-miss reviews

• Ethiopia – clearinghouse of maternal health guidelines

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Call for Proposals for Round 3 will be released in the Fall of

2015

For implementation projects in maternal and perinatal health

projects in low- and middle-income countries

Future directions for seed grants

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The GREAT Network Activity 3: Capacity building

In-country

workshops

Seed Grants

Capacity

Building

In-country

Activities

Capacity

Building

Seed

Grants

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To facilitate applied learning of KT/guideline implementation

using real-world project examples

To increase the number of people in-country who can teach

and share this content with others

To support the sustainability and spread after funding ends

Why support capacity building?

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Future directions for capacity building

Provide coaching and technical assistance to reach implementation goals.

Facilitate applied learning and problem-solving in the specific context of implementation.

Offer assistance in brainstorming key next steps for evidence-based implementation.

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The GREAT Network is launching a quarterly newsletter to showcase some

of the excellent work that is being done globally in the area of knowledge

translation and guideline implementation in maternal health; share relevant

resources, funding and training opportunities; and more!

If you would like to receive the GREAT Network Newsletter, please

subscribe to our mailing list and visit the GREAT Network Website for more

information:

http://greatnetworkglobal.org/

The GREAT Network Newsletter

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We will use a mixed methods approach to evaluate processes and

impacts of the various initiatives completed by the Network over time.

Evaluating GREAT Network activities and impact

Process evaluation of Network inputs

• Number of trainees • Numbers of publications, research presentations,

grants, programs developed and implemented by trainees and members of the Network

• Number and type of KT tools developed • Number of KT implementation projects initiated and

completed

Outcome evaluation of Network impacts

• Changes in maternal mortality rates • Changes in guideline use

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Discussion Questions

What strategies have you used successfully to develop and strengthen implementation networks?

What strategies are you using to build capacity?

What models, frameworks, and theories are you using?

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Questions?

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Additional Information

Network objectives

Establish a network of partners and stakeholders who are interested in improving maternal and infant health in LMICs through effective knowledge translation (KT) and implementation approaches;

Build capacity in the science and practice of KT and implementation across relevant stakeholder groups in LMICs; and

Develop a framework for guideline implementation relevant to the needs of partners in LMICs, and advance the science and practice of KT and implementation.

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Barriers to implementing guidelines

Health system/Policy level

Lack of Physical Resources

Funding, medications/ supplies, monitoring and evaluation data

Lack of Human Resources

Staff shortages/unequal distribution, supervision/mentorship

Lack of Communication/ Information Sharing

Communication between clinicians/ policy makers

Policy Issues

Lack of policy, meds not approved for use

Health care provider level

Training/Knowledge/Skills

Lack of training, time to attend training, baseline education

Access/Awareness

access/awareness, understanding process/trust in guideline

Attitudes/Beliefs

Role confusion, fear of misuse, poor inter-professional

communication/confidence

Patient/Community level

Knowledge/Beliefs

Values/Preferences

Patient Resources

Health seeking behavior

Patient-Provider relationship

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Pre-workshop survey example: Ethiopia pre-workshop survey

Prioritization of Clinical Areas in the

Prevention and Treatment of PPH Guideline Priority

N

(n=53)

Recommendations related to the clinical

area of Use of Uterotonics

1 (highest priority) 35

2 17

3 1

4 (lowest priority) 0

Recommendations related to the clinical

area of Cord Clamping

1 (highest priority) 2

2 20

3 20

4 (lowest priority) 11

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Workshop activity example: Tanzania workshop feasibility ranking exercise

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Findings

The process of selecting priority maternal and perinatal

health recommendations and exploring barriers and

facilitators to implementation of the four priority WHO

guidelines yielded rich information to inform implementation

planning in Uganda. Participants across all FGs described

issues at the level of the healthcare system, which

included various factors related to policies and wider

systemic conditions in Uganda that can affect the

implementation of the WHO guideline recommendations.

These factors include: access to resources; drug

procurement, distribution, and management; human

resources; access to site-specific data; accountability and

monitoring; and policies/political context. Issues at the level

of the healthcare provider were prevalent, where factors

related directly to frontline implementers (e.g., physicians,

midwives) were described. Specific factors discussed

include: beliefs, attitudes, and buy-in; knowledge and skills;

training, mentorship, and professional development; and

scope of roles. Finally, issues at the level of the

patient/community were described and include: traditional

beliefs; knowledge and awareness; and socioeconomic

status.

Post-workshop report example: Understanding Barriers and Facilitators to Implementation of Maternal Health Guidelines in Uganda:

A GREAT Network Research Activity

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Recommendations

The most salient points that emerged from the pre-workshop and

workshop activities were as follows:

There is a need and an opportunity to improve implementation of the

priority recommendations across the four selected WHO guidelines

(Prevention and treatment of PPH; Prevention and treatment of pre-

eclampsia and eclampsia; Induction of Labour; and Augmentation of

Labour).

Drug procurement, management, and distribution practices are not

operating at an optimal level. There are cases where drugs are

expiring on the shelves and other examples where drugs are

unavailable. This suggests a need for current drug ordering and

monitoring policies and practices to be reviewed at both the level of

healthcare facilities and nationally.

There is a concern around the misuse of misoprostol to increase the

speed of labour (either inappropriately administered by healthcare

workers or self-administered by the patient by securing the drug over

the counter). Further research is required to better understand the

misuse of misoprostol and the resultant harms. Results of this research

could be used to provide evidence to support a change to the

regulation of misoprostol in the market.

Recruitment of more healthcare workers is needed across the

healthcare system, but particularly in rural/remote areas; infrastructure

(e.g., housing for healthcare workers, schools for the children of

healthcare workers, etc.) and incentives (i.e., a competitive salary

comparable to urban centres) are needed as a preliminary step. Lifting

the current recruitment ban in Uganda may also be considered.

The role of village health teams is expanding to include maternal and

perinatal care. There is a need to create more formal linkages between

healthcare facilities and village health teams to better coordinate and

standardize maternal healthcare for the community.

Future directions for in-country workshop activities

A paper on the Guideline Implementation methods used in GREAT Projects is currently under development.

Potential tools/toolkits to help others recreate the process in LMICs are currently being explored. These will be developed based on consideration of contextual factors, resource limitation and feasibility in LMICs.

Conducting an evaluation of post in-country workshop activities.

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Encourage local ownership of work

Build capacity in researchers/academics, frontline clinicians

involved with KT and implementation work

Provide resources to support work as financial resources are

often a barrier to implementation, particularly in LMICs

Why provide funding to LMICs for guideline implementation?

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Future directions for capacity building

Country Implementation Objective

Implementation support provided by the GREAT Network

Form Implementation Working Group (WG) [in

country]

Identify a multi-disciplinary implementation team

Develop an Evidence-informed Theory-driven

Program (ETP)

Provide an overview of and resources on mapping barriers and

identifying implementation strategies; provide input on/review

Terms of Reference document for Implementation WG; support

the initiation of ETP development.

Develop an Evidence-informed Theory-driven

Program (ETP) cont’d

Revisit the mapping process using a hands on interactive

approach to develop an ETP

Provide input on/review ETP

Develop and submit proposal on Phase 2 activities:

Developing, implementing, evaluating, and

sustaining a tailored implementation strategy

Provide input on/review Phase 2 proposal

Develop an implementation plan for your ETP Develop an implementation plan and evaluation strategy

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