CAN EVIDENCE FROM HIGH-INCOME COUNTRIES BE USED IN LOW-INCOME COUNTRIES?
H. Devan1, S. Dorsch2, A. Inman3,4, C. Brandt5
All authors, affiliations and abstracts have been published as submitted.
1University of Otago, Wellington, New Zealand, 2Australian Catholic University, Sydney, Australia, 3University of Plymouth, Devon, United Kingdom, 4ADAPT, Physiotherapists for Global Health, Devon, United Kingdom, 5University of the Witwatersrand, Johannesburg, South Africa
Learning objective 1: Understand the background and principles of evidence-based practice.
Learning objective 2: Identify challenges to implementing evidence-based practice in local context and strategies to overcome these.
Learning objective 3: Apply evidence-based practice principles in one’s own settings and clinical conditions.
Description: Evidence-based practice is the process of utilising high-quality research to inform clinical practice (Herbert, 2011). This research evidence is combined with clinical reasoning and the practice knowledge of the clinician and the preferences and values of the patient. One challenge for physiotherapists trying to implement research into practice in low- and middle-income countries is that research is produced predominantly in high-income countries (86% of physiotherapy research indexed in Physiotherapy Evidence Database; PEDro). This Symposium will highlight the principles of evidence-based practice and strategies for using evidence generated in high-income countries to guide practice in low- and middle-income countries. These will be illustrated by examples from three leading causes of disability as well as prominent areas of physiotherapy practice: musculoskeletal, neurology and women’s health.
From 1990 to 2019, Disability-Adjusted Life Years due to stroke increased by 32% with the highest age-standardised rates being in the World Bank low-income group (Global Burden of Disease Stroke Collaborators, 2021). To improve outcomes after stroke, intensive rehabilitation is critical as there is a dose-response relationship between the amount of active exercise and treatment outcomes. It is also evident that active task practice is more effective than approaches requiring therapist facilitation of movement (Scrivener, 2020). However, in high-income countries, most stroke rehabilitation is delivered one to one by a therapist with high amounts of therapist assistance, resulting in insufficient amounts of active exercise. Solutions include the use of exercise classes and exercises done independently or with assistance from the family (Dorsch, 2019). Strategies for high-intensity active exercise can be used to guide the provision of effective stroke rehabilitation in low- and middle-income countries.
Years lived with disability due to low back pain has increased by over 50% since 1990. This burden is disproportionate and more evident in low- and middle-income countries (Buchbinder, 2018; Sharma, 2022), but current evidence for the management of low back pain comes almost exclusively from high-income countries (Buchbinder, 2018). There are key learnings to consider, such as advice and activity being first-line options in the treatment of non-specific low back pain and avoiding inappropriate and excessive imaging (Sharma, 2019). Physiotherapists in low- and middle-income countries should also consider external research evidence in the light of patient sociodemographic characteristics, cultural considerations, and local epidemiology among others.
Pelvic floor disorders such as incontinence, pelvic organ prolapse, pain and sexual dysfunction are prevalent and more common in low- and middle-income countries compared to high-income countries. They can be managed effectively at a primary care level using physiotherapy treatments such as pelvic floor muscle training (Dufour, 2019). The high prevalence of pelvic floor disorders is however closely related to contextual factors such as age, gender, not being able to attend visits to health practitioners, poor adherence to management programmes and lack of motivation (Berghmans, 2020). Although the patient’s needs and expectations should be the centre of care, healthcare providers commonly ignore the communities’ preferences (Girma, 2020). Barriers to implementing high-quality women’s health care in low- and middle-income countries include the lack of training and education in addition to the lack of access to care, communication, transport, effective use of resources and referral systems.
As can be seen from the case examples, evidence generated in low- and middle-income countries for the most burgeoning health conditions is scarce while the disease burden is high. Physiotherapists need specialised evidence-based practice skills of appraising the existing research evidence from high-income countries and adapting it to the context of low- and middle-income settings so that they provide timely, effective, culturally appropriate, affordable and high-quality care (Buchbinder, 2018; Sharma, 2022).
Summary and implications: Knowledge and skills of evidence-based practice are critical to physiotherapy practice. This symposium will provide participants with strategies to use research evidence generated in high-income countries to guide practice in low- and middle-income countries. Real case examples from three areas of physiotherapy practice will enable attendees to reflect on their current practice and also assist in translating external evidence into their own clinical practice by considering cultural and health system differences in where the evidence is generated and where it is applied.
From 1990 to 2019, Disability-Adjusted Life Years due to stroke increased by 32% with the highest age-standardised rates being in the World Bank low-income group (Global Burden of Disease Stroke Collaborators, 2021). To improve outcomes after stroke, intensive rehabilitation is critical as there is a dose-response relationship between the amount of active exercise and treatment outcomes. It is also evident that active task practice is more effective than approaches requiring therapist facilitation of movement (Scrivener, 2020). However, in high-income countries, most stroke rehabilitation is delivered one to one by a therapist with high amounts of therapist assistance, resulting in insufficient amounts of active exercise. Solutions include the use of exercise classes and exercises done independently or with assistance from the family (Dorsch, 2019). Strategies for high-intensity active exercise can be used to guide the provision of effective stroke rehabilitation in low- and middle-income countries.
Years lived with disability due to low back pain has increased by over 50% since 1990. This burden is disproportionate and more evident in low- and middle-income countries (Buchbinder, 2018; Sharma, 2022), but current evidence for the management of low back pain comes almost exclusively from high-income countries (Buchbinder, 2018). There are key learnings to consider, such as advice and activity being first-line options in the treatment of non-specific low back pain and avoiding inappropriate and excessive imaging (Sharma, 2019). Physiotherapists in low- and middle-income countries should also consider external research evidence in the light of patient sociodemographic characteristics, cultural considerations, and local epidemiology among others.
Pelvic floor disorders such as incontinence, pelvic organ prolapse, pain and sexual dysfunction are prevalent and more common in low- and middle-income countries compared to high-income countries. They can be managed effectively at a primary care level using physiotherapy treatments such as pelvic floor muscle training (Dufour, 2019). The high prevalence of pelvic floor disorders is however closely related to contextual factors such as age, gender, not being able to attend visits to health practitioners, poor adherence to management programmes and lack of motivation (Berghmans, 2020). Although the patient’s needs and expectations should be the centre of care, healthcare providers commonly ignore the communities’ preferences (Girma, 2020). Barriers to implementing high-quality women’s health care in low- and middle-income countries include the lack of training and education in addition to the lack of access to care, communication, transport, effective use of resources and referral systems.
As can be seen from the case examples, evidence generated in low- and middle-income countries for the most burgeoning health conditions is scarce while the disease burden is high. Physiotherapists need specialised evidence-based practice skills of appraising the existing research evidence from high-income countries and adapting it to the context of low- and middle-income settings so that they provide timely, effective, culturally appropriate, affordable and high-quality care (Buchbinder, 2018; Sharma, 2022).
Summary and implications: Knowledge and skills of evidence-based practice are critical to physiotherapy practice. This symposium will provide participants with strategies to use research evidence generated in high-income countries to guide practice in low- and middle-income countries. Real case examples from three areas of physiotherapy practice will enable attendees to reflect on their current practice and also assist in translating external evidence into their own clinical practice by considering cultural and health system differences in where the evidence is generated and where it is applied.
References: Berghmans, B., et al. (2020). Physiotherapy assessment for female urinary incontinence. Int Urogynecol J,31(5), 917-931. https://doi.org/10.1007/s00192-020-04251-2
Buchbinder, R., et al (2018). Low back pain: a call for action. The Lancet,391(10137), 2384-2388.
Dorsch, S.,et al. (2019). In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study. Journal of physiotherapy,65(1), 23-27.
Dufour, S., et al. (2019). Enhancing Pelvic Health: Optimizing the Services Provided by Primary Health Care Teams in Ontario by Integrating Physiotherapists. Physiother Can,71(2), 168-175. https://doi.org/10.3138/ptc.2017-81.pc
GBD Stroke Collaborators. (2021). Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol,20(10), 795-820. https://doi.org/10.1016/S1474-4422(21)00252-0
Girma, M., et al. (2020). Community perception regarding maternity service provision in public health institutions in 2018 and 2019: A qualitative study. International Journal of Women's Health,12, 773.
Herbert, R., et al. (2011). Practical evidence-based physiotherapy. Elsevier Health Sciences; E-Book. 2nd Edition.
Scrivener, K., Dorsch, S., et al. (2020). Bobath therapy is inferior to task-specific training and not superior to other interventions in improving lower limb activities after stroke: a systematic review. J Physiother,66(4), 225-235. https://doi.org/10.1016/j.jphys.2020.09.008
Sharma, S., …, Sharma, S., & Maher, C. G. Delivering the right care to people with low back pain in low-and middle-income countries: the case of Nepal. J Glob Health. 2019; 9 (1).
Sharma, S., & McAuley, J. H. (2022). Low back pain in low and middle-income countries. Part 1: The Problem. J Orthop Sports Phys Ther,52(5), 1-3.
Buchbinder, R., et al (2018). Low back pain: a call for action. The Lancet,391(10137), 2384-2388.
Dorsch, S.,et al. (2019). In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study. Journal of physiotherapy,65(1), 23-27.
Dufour, S., et al. (2019). Enhancing Pelvic Health: Optimizing the Services Provided by Primary Health Care Teams in Ontario by Integrating Physiotherapists. Physiother Can,71(2), 168-175. https://doi.org/10.3138/ptc.2017-81.pc
GBD Stroke Collaborators. (2021). Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol,20(10), 795-820. https://doi.org/10.1016/S1474-4422(21)00252-0
Girma, M., et al. (2020). Community perception regarding maternity service provision in public health institutions in 2018 and 2019: A qualitative study. International Journal of Women's Health,12, 773.
Herbert, R., et al. (2011). Practical evidence-based physiotherapy. Elsevier Health Sciences; E-Book. 2nd Edition.
Scrivener, K., Dorsch, S., et al. (2020). Bobath therapy is inferior to task-specific training and not superior to other interventions in improving lower limb activities after stroke: a systematic review. J Physiother,66(4), 225-235. https://doi.org/10.1016/j.jphys.2020.09.008
Sharma, S., …, Sharma, S., & Maher, C. G. Delivering the right care to people with low back pain in low-and middle-income countries: the case of Nepal. J Glob Health. 2019; 9 (1).
Sharma, S., & McAuley, J. H. (2022). Low back pain in low and middle-income countries. Part 1: The Problem. J Orthop Sports Phys Ther,52(5), 1-3.
Funding acknowledgements:
- Simone Dorsch, Alice Inman, Corlia Brandt - none to disclose
All authors, affiliations and abstracts have been published as submitted.
