Promoting evidence-based health care in Africa through training in research synthesis
>by Taryn Young, Jimmy Volmink (South African Cochrane Centre, South African Medical Research Council), May 06
SUMMARY: Reliable information to guide health care practice and policy is buried in a sea of studies of mixed quality. Research synthesis, a method of tracking, appraising, and summarizing primary research, has become an important tool for evidence-based practice and policy. Expertise in the process is however still very limited in Africa. The South Africa Cochrane Centre was established to change this situation through training.
What diagnostic test should be offered or used? What treatment is best? Which policy should be prioritized? These are some of the questions health care providers, policymakers, funders and consumers are faced with on a daily basis. Vital to the decision-making process is reliable information about whether an intervention being considered does more good than harm. Unfortunately, this knowledge is not readily accessible. It is frequently buried in a vast sea of studies, many of which are irrelevant, of poor quality or have conflicting findings. Research synthesis, a method of tracking, appraising, deciphering and summarizing primary research, has, in recent years, evolved as an important tool for managing health care information and facilitating evidence-based practice and policy.
Championing the routine use of research synthesis is The Cochrane Collaboration (http://www.cochrane.org), an international, non-profit organization dedicated to the task of making reliable evidence on the effects of health care interventions widely available.
Steps involved in conducting a systematic review:
1) State the objectives of the review
2) Define eligibility criteria for studies to be included in the review
3) Identify (all) potentially eligible studies
4) Apply eligibility criteria
5) Assess study quality
6) Assemble the most complete dataset feasible
7) Analyze this dataset, using statistical synthesis (meta-analysis) and sensitivity analyses, if appropriate and possible
8) Prepare a structured report of the research |
Members of the Collaboration conduct exhaustive searches for relevant studies and evaluate and summarize the evidence on the benefits and safety of interventions following a predetermined protocol. This process has been called systematic reviewing. Systematic reviews differ from traditional reviews as they involve a rigorous and transparent process aimed at reducing bias and the effects of chance in the interpretation of evidence (see Box). They are less likely than traditional reviews to result in wrong conclusions (1,2).
Expertise in preparing systematic reviews is still very limited in Africa. In 1997, the South African Cochrane Centre (SACC), the reference Cochrane Centre for individuals living in sub-Saharan Africa who wish to contribute to The Cochrane Collaboration, was established to address this need (http://www.mrc.ac.za/cochrane/). The goals of the Centre are:
1) to increase the number of high quality, up-to-date Cochrane Reviews relevant to the African region;
2) to promote access to Cochrane Reviews and derivative products in countries for which the Centre is the reference Cochrane Centre;
3) to promote evidence-based practice and policy in the African region;
4) to promote the science of research synthesis; and
5) to promote the optimal functioning and sustainable growth of The Cochrane Collaboration.
Funded predominantly by the South African Medical Research Council, the SACC focused its activities mainly on South Africa in the early years but more recently this has begun to change.
The SACC has assumed a leading role in the region in recruiting, training and mentoring authors of Cochrane Reviews. In 2000, the SACC launched the HIV/AIDS Mentoring Programme ( http://www.mrc.ac.za/cochrane/hivmentoring.htm) in collaboration with the Cochrane HIV/AIDS Review Group, based at the University of California, San Francisco. This initiative aims to increase the number of systematic reviews in the field of HIV/AIDS relevant to resource-poor settings. Novice authors are linked with more experienced authors who provide guidance and methods expertise throughout the review process. The Programme has grown considerably with 20 authors currently receiving mentorship - fifteen from South Africa, two from Kenya, one from Nigeria, one each from Cameroon and Uganda. To date four reviews have been published in The Cochrane Library; and fourteen are in progress, with ten review protocols already published.
The Reviews for Africa programme (RAP) (http://www.mrc.ac.za/cochrane/rap.htm), is a more formal training course in research synthesis for people with an interest in HIV/AIDS, tuberculosis, malaria, as well as other high priority health topics. Participants are drawn from countries in the SACC reference region (with preference given to people outside of South Africa) and equipped with knowledge and skills necessary for initiating, completing and maintaining Cochrane Reviews. RAP consists of two intensive training courses conducted at the SACC offices in Cape Town, and between course electronic support which ultimately lead to authors publishing a peer-reviewed systematic review in The Cochrane Library. The first intake of six trainees took place in September 2005 with further intakes being planned for the next three years. RAP is a collaboration between the SACC, Liverpool School of Tropical Medicine, and the Cochrane HIV/AIDS Review Group and is funded by the Nuffield Commonwealth Programme.
Staff of the SACC also participate in other research synthesis training activities in addition to those coordinated by the Centre. These include the Effective Care Research Unit course targeting practitioners working in the field of pregnancy and childbirth (http://www.gfmer.ch/International_activities_En/ECRU.htm), and Masters of Public Health courses at the Universities of Malawi and Cape Town.
We believe that these efforts to build capacity in research synthesis will lead to a substantial increase in the number of Cochrane Reviews relevant to health care in the African region. While not a sufficient condition in itself, this is a significant step towards making evidence-based health care a reality in Africa.
For further information, please contact:
Taryn Young taryn.young@mrc.ac.za
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(1) Chalmers I, Altman DG, eds. (1995) Systematic Reviews. London, BMJ Publishing Group. [This book contains the series of papers on systematic reviews published in the British Medical Journal during 1994]
(2) Volmink J, Siegfried N, Robertson K, Gulmezoglu AM (2004) Research synthesis and dissemination as a bridge to knowledge management: the Cochrane Collaboration. Bulletin of the World Health Organization, 82:778-783
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