Global review on access to
health information in developing countries
From HIF-net at WHO
Discussion Paper 1. The role of systematic reviews
by Paul Chinnock, Cochrane Collaboration
Systematic reviews are a cornerstone of evidence-based medicine. If the
argument for systematic reviews works in the industrialised world, then it
is even more true for the developing countries. Where resources are scarce,
it is vital that these are invested primarily in safe, effective
The Cochrane Collaboration has published more than 2000 systematic reviews
and over 1500 protocols. It has taken steps to make access to the Cochrane
Library online free of charge in many parts of the developing world and its
policy is to encourage people in such countries to participate in the
writing of reviews. But are Cochrane reviews useful to practitioners in 'the
majority world'? Are reviewers' conclusions 'globally relevant'?
It will be several years before the majority of medical conditions and
interventions have been addressed in systematic reviews. However, there is a
mismatch between the global burden of diseases and the amount of research
devoted to these conditions. Conditions of particular interest to
resource-rich settings are more frequently addressed by reviewers. This is
reflected even in the background discussions, which usually focus on the
impact of conditions in the USA and/or Western Europe
Many major concerns in developing nations have yet to be the subject of a
review. To take surgical conditions as an example, African surgeons would
list amongst their priorities sigmoid volvulus, umbilical hernia, gunshot
wounds and gangrene. Many such areas remain unaddressed, despite important
improvements, illustrated for example by the list of reviews delivered by
the Cochrane Infectious Diseases Group.
Healthcare professionals in resource-poor settings may wonder whether
reliance on older, cheaper, lower-tech approaches, has made their practice
quite distinct from that of their colleagues in the West. For example,
ketamine, which is widely used for anaesthesia in Africa has not been the
subject of a Cochrane review.
The usefulness of existing reviews is limited because they rely largely on
research in resource-rich settings. Research from developing countries is
seldom indexed or published in retrievable media. Cochrane reviewers aim to
identify all studies published or unpublished, and in whichever language.
Yet it is still possible that important data are missed.
Identified studies are appraised by reviewers and when the inclusion
criteria are met (in most cases this requires a trial to be properly
randomised) these are included in the analysis. However, RCTs may not be the
sole or appropriate source of evidence in resource-poor situations, and
these criteria may result in the exclusion of valuable valid evidence.
There are concerns about the 'transferability' of evidence between settings
with different resourcing. To give just a few examples, patients in poorly
resourced areas typically consult when disease is more advanced, compared
with highly resourced settings. , they are more likely to have been
self-medicating on 'prescription-only' drugs or on traditional treatments;
even when they have presented to a health facility, diagnosis and referral
(when needed) will take much longer. Limited resources will affect the
delivery of treatment itself and follow-up. Levels of compliance with
treatment are also much lower. Similarly, legislation is a healthcare
intervention that is important, for example, in the prevention of road
traffic injury but enforcing the legislation is usually harder in developing
Potentially, these differences may result in a mismatch in the effectiveness
of treatments evaluated in RCTs between highly resourced and poorly
resourced settings. Some treatments will be sufficiently robust to retain
much of their effectiveness in a resource-poor context; others will not.
Rather than claiming that their conclusions are globally applicable,
reviewers could conclude with statements such as, ''There is evidence for
the effectiveness of this intervention in the settings where the included
studies were conducted and in other settings with similar levels of
- What should we do to make a good product (the systematic review)
better? The following questions are offered for consideration.
- Titles. How can we get more reviews written on a) priority health
problems in the majority world, b) affordable interventions?
- Context. Should there be some reviews that specify the context in
which the condition is occurring and in which the intervention is
- Background sections. How can we persuade reviewers to look at
conditions/ interventions globally and not just as they affect the US and
- Search for studies. How can we improve our success rate in finding
work done in developing countries?
- Inclusion criteria. Are high thresholds in the quality assessment of
studies excluding valid useful research conducted in developing nations?
- Analysis. How can we persuade reviewers to consider whether
heterogeneity can be explained by differences in resourcing and to conduct
the appropriate analysis?
- Discussion/conclusions/implications must address the issue of where
the recommendations apply — everywhere, or just in settings similar to
where the research has been done?
- Dissemination of the findings of reviews. Is this best done by
circulating the reviews themselves, or are reviews a stage in the
production of more accessible evidence-based health information materials?
WHO's Reproductive Health Library (RHL) presents Cochrane reviews on
CD-Rom with summaries, commentaries etc. from a developing world
perspective. Clinical Evidence produces synopses of the evidence,
integrating Cochrane Reviews into clinical questions, delivered in
user-friendly formats and languages. Are more initiatives like these
- Research is needed into the impact of systematic reviews on practice
in the developing world so far. Specific questions include: What
percentage of reviews are relevant to healthcare in low-resource
settings?, Is policy being set in different countries, using
evidence-based sources?, How many healthcare workers use the Cochrane
Library? Has this influenced their practice?, What do they think would
make reviews more useful?
- How can we involve more people from developing countries in the
writing and peer reviewing of systematic reviews?
My thanks to Dr Fred Bukachi (Norrlands University Hospital, Sweden) and
Dr Luis Cuervo (Clinical Evidence/BMJ Knowledge) for valuable input into the
This is the first in a series of discussion
papers that will be posted on HIF-net at WHO and other email lists as part
of the Global Review on Access to Health Information in Developing Countries
— see below*. We look forward to hearing your reactions and ideas — please
send your responses to email@example.com
Your views will be collated
and presented at a special session of the Cochrane Colloquium in Ottawa,
Canada, on Monday 4 October 2004:
[HIF-net at WHO profile: Paul Chinnock taught in Kenya, then edited
schoolbooks for developing countries. He retrained as a nutritionist and
worked in The Gambia. He was Editor of Africa Health for most of the 1990s,
and was also responsible for Medicine Digest, International Diabetes Digest
and Caribbean Health. He became Managing Editor of the Injuries Group of the
Cochrane Collaboration in September 2002. Paul would like there to be more
information for evidence based medicine that reflects the realities of
working in resource-poor environments. Paul has also worked as a freelance
editor and writer for WHO, DFID, Panos Institute, Healthlink and the
International Hospitals Federation.
[*The Global Review on Access to Health Information in Developing
Countries was launched on 12 July 2004 with the technical and in-kind
support of 20 organizations working in health information and
knowledge exchange. The Review aims to review what works and what doesn't,
lessons learned, and ways forward for the future. ***Further progress on the
Review is dependent on funding to cover the costs of coordination,
consultation, and networking activities in developing countries***. For
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