Improving capacity for evidence-based practice in South East Asia: evaluating the role of research fellowships in the SEA-ORCHID Project

Background Fellowships are a component of many professional education programs. They provide opportunities to develop skills and competencies in an environment where time is protected and resources and technical support are more readily available. The SEA-ORCHID fellowships program aimed to increase capacity for evidence-based practice and research synthesis, and to encourage fellows to become leaders in these areas. Methods Fellows included doctors, nurses, midwives and librarians working in the maternal and neonatal areas of nine hospitals in South East Asia. Fellowships were undertaken in Australia and involved specific outputs related to evidence-based practice or research synthesis. Training and support was tailored according to the type of output and the fellow's experience and expertise. We evaluated the fellowships program quantitatively and qualitatively through written evaluations, interviews and follow-up of fellowship activities. Results During 2006-07, 23 fellows from Thailand, Indonesia, Malaysia and the Philippines undertook short-term fellowships (median four weeks) in Australia. The main outputs were drafts of Cochrane systematic reviews, clinical practice guidelines and protocols for randomised trials, and training materials to support evidence-based practice. Protocols for Cochrane systematic reviews were more likely to be completed than other outcomes. The fellows identified several components that were critical to the program's overall success; these included protected time, tailored training, and access to technical expertise and resources. On returning home, fellows identified a lack of time and limited access to the internet and evidence-based resources as barriers to completing their outputs. The support of colleagues and senior staff was noted as an important enabler of progress, and research collaborators from other institutions and countries were also important sources of support. Conclusions The SEA-ORCHID fellowships program provided protected time to work on an output which would facilitate evidence-based practice. While the fellows faced substantial barriers to completing their fellowship outputs once they returned home, these fellowships resulted in a greater understanding, enthusiasm and skills for evidence-based practice. The experience of the SEA-ORCHID fellowships program may be useful for other initiatives aiming to build capacity in evidence-based practice.


Background
Healthcare organisations face considerable challenges in ensuring patient care is based on the best available evidence. Studies consistently demonstrate a failure to implement interventions that have been shown to be both effective and cost-effective [1]. Although this gap between evidence and practice is common to all health-care settings, failure to bridge this gap in developing countries can have serious consequences and hinder progress towards better health [2]. Valuable resources continue to be used for practices that are out of date, have no demonstrable benefit or are even harmful, while interventions that have been shown to be both inexpensive and effective have not been widely implemented [3]. For example, it is estimated that over 70% of neonatal deaths that occur in developing countries could be prevented by the using affordable, evidence-based interventions [4].
To support evidence-based practice (EBP) change, clinicians need skills to acquire, appraise and interpret health research. There is arguably an even greater imperative for clinicians in developing country settings to have these skills as a result of the increased health burden and limited resources [5]. Critical barriers to EBP for clinicians have been well-documented and include a lack of time, insufficient resources and limited skills in accessing and applying research [6].
Fellowships are commonly used in high-income countries as a means of providing clinicians with professional training, including development of skills in research and EBP [7][8][9][10][11][12]. Fellowships offer clinicians protected time and provide access to resources and technical support that might otherwise be difficult to obtain. The practical hands-on nature of fellowships also addresses the shortcomings of training programs that rely on the provision of knowledge alone as being sufficient for skill development or practice change [13][14][15][16].
The SEA-ORCHID project (South East Asia -Optimising Reproductive and Child Health in Developing Countries) was a five-year collaborative project between four countries in South East Asia and Australia. At nine hospitals in Thailand, Malaysia, the Philippines and Indonesia, SEA-ORCHID investigated whether the health of mothers and babies can be improved through a multifaceted intervention to strengthen capacity for research synthesis, evidence-based care and knowledge implementation. The study protocol and baseline practices in perinatal health care have been published previously [17,18].
The fellowships program was one component of the intervention that also included training of clinical educators based at the nine study sites and support for a range of activities related to EBP locally and nationally. Through the fellowships, SEA-ORCHID aimed to increase capacity for EBP at participating hospitals and provide an opportunity for fellows to take time out from clinical work to gain skills and confidence to enable them to be leaders in EBP change in their professional roles. This paper presents an evaluation of the SEA-ORCHID fellowships program, including the key results of the program in producing outputs to support EBP and clinical practice change, and the experience of the fellows involved in the program.

The SEA-ORCHID fellowships program
The fellowships program ran during the intervention phase of the project (2006 to 2007) and was designed to support clinicians and other professionals working at the nine SEA-ORCHID sites in South East Asia to undertake short-term EBP projects in Australia. The original research protocol specified a limited number of sixmonth fellowships. However, when it became clear that hospitals were reluctant to approve extended leave because of the difficulty of replacing staff and fellows themselves were often unable to be away from their families for this length of time, we decided to offer more fellowships of shorter duration.
Fellowships were tailored according to the fellows' professional background and chosen projects, the needs of their hospital, and the duration, location and timing of the fellowship. Fellows were assigned to one of the three Australian SEA-ORCHID sites (Adelaide, Melbourne, Sydney) depending on the type of support required for the fellowship and staff availability. In some cases, fellows divided their time between two Australian sites.

Selection of fellows
The SEA-ORCHID investigators in Thailand, Malaysia, the Philippines and Indonesia selected fellows and fellowship projects on the basis of local needs for strengthening capacity in EBP. This process was pragmatic and based on subjective criteria and the availability of fellows, as well as recognising the importance of selecting fellows who were, or had the potential to be, leaders and champions for practice change [19].
Fellows were chosen from the doctors, nurses and midwives working in the maternal and neonatal areas of the nine participating hospitals. Non-clinical professionals, such as medical librarians, were not considered for fellowships in the original project proposal but their critical role in facilitating knowledge transfer to clinicians led us to reassess this and include them.

Fellowship activities and outputs
At a broad level, fellowships were designed to equip fellows with basic knowledge and skills to support and facilitate EBP and research synthesis. This involved learning about the components of EBP (question formulation, literature searching, critical appraisal, etc.) and having the opportunity to put this knowledge into practice during the fellowship.
There was a specific structured output for each fellowship. In the fellowship proposals, fellows nominated one or more outputs to focus on during their fellowship and to continue with on their return home. The outputs were determined by each site based on local needs and perceived barriers to evidence-based care [20], and agreed to by the Australian SEA-ORCHID team. Fellowships centred on developing skills in research synthesis and supporting EBP. Planned project outputs included: • Cochrane systematic reviews • clinical practice guidelines • research protocols for randomised trials • teaching materials based on effective methods for teaching/supporting EBP and facilitating behaviour change.
Fellowships were based on adult learning principles [21] of active, self-directed, problem-based learning [22][23][24], critical thinking [25][26][27] and the provision of appropriate professional support as required. This problembased learning approach where skills are mastered through supported practice has been a successful model of education and EBP change [28]. Formal training activities were designed in the form of interactive workshops rather than lectures as they have been found to be more likely to result in practice change [16].
Structured EBP education programs were provided which covered the concept of and need for EBP, and the skills required for EBP including asking answerable questions, database searching and critical appraisal. Training was also provided on methods of development of research protocols, systematic reviews and clinical practice guidelines as appropriate the fellowship output.
The amount of tailored training and support each fellow received depended on the type of project, the fellow's previous experience and expertise, and the time available. We also encouraged fellows to join in the routine activities of the department hosting them, including ward rounds, journal clubs, staff meetings and seminars. Wherever possible we took advantage of pre-scheduled training opportunities and enrolled fellows in Cochrane review training and research protocol-writing workshops. We also organised periods of clinical observation for the clinical fellows as we wanted them to see how clinicians incorporated EBP principles in routine clinical care.

Evaluating the impact of the fellowships program
The evaluation of the fellowships program included: • documenting the number and type of fellowships • assessing the outputs of the fellowships (i.e. reviews, training materials, etc.) • investigating the experience of fellows and barriers to and enablers of the completion of fellowship outputs.

Data collection
The Australian SEA-ORCHID educators and project coordinator were responsible for collecting data from several sources for each fellow. These included written evaluations, face-to-face interviews and follow-up of fellowship activities.

1) Written evaluations
Fellows completed written evaluations of the fellowship program using a structured evaluation form at the end of their fellowship and again six months later.

2) Learning portfolios
Fellows were encouraged to keep a learning portfolio during their fellowship to capture thoughts and reflections about significant experiences and future plans. Although the portfolios were personal documents, fellows provided reflective summaries of these portfolios for inclusion in the evaluation of the program.

3) Follow-up of outputs
Each fellow gave an update on the status of their output six months after the completion of their fellowship. For some outputs, such as Cochrane reviews, the status of the output was verified through independent sources (such as Archie, the Cochrane Collaboration's central server for managing documents). Data collection on the progress of fellowship outputs continued until July 2008.

4) Interviews
Semi-structured, face-to-face interviews with the fellows were undertaken at the end of each fellowship and again after six months. The interviews were conducted by two of the Australian SEA-ORCHID educators (JS and TT) who had been closely involved in supporting the fellows. The interviews covered a range of topics, including experiences of the fellowship, how fellows had applied the knowledge and skills learned, progress with fellowship outputs, implementation plans and activities, and perceived barriers to and enablers of EBP.

Data analysis
Data on the fellowship outputs were analysed quantitatively. Qualitative analysis included the six-month postfellowship interviews, which were audio-recorded and transcribed by a transcription service. JS and TT reviewed and corrected the transcripts and JS analysed the data in emerging themes. NVivo software was used to store and manage the data. The written evaluations, notes from exit interviews and portfolio summaries were included in the qualitative thematic analysis.

Fellows
SEA-ORCHID supported 23 fellowships between August 2006 and September 2007 (Table 1). There were seven fellows from Thailand, six from Malaysia and five each from the Philippines and Indonesia. The median fellowship duration was four weeks (range 2 to 13). Fellows included eight obstetricians, six neonatologists/paediatricians, five medical librarians, two labour room nurse-midwives, a neonatal nurse and a biostatistician. Three-quarters of the fellows were female.

Fellowship Outputs
The main outputs of the fellowships were drafts of Cochrane systematic reviews, clinical practice guidelines (CPGs) and protocols for randomised controlled trials (RCTs), and the development of training materials to support EBP (see Tables 2, 3, 4, 5 below). At the end of follow-up in July 2008, five fellows had published and six had submitted protocols for Cochrane systematic reviews, with one still in the draft stage. Five fellows had Six months after completion of each fellow's program there had been some development in the drafting and submission process for Cochrane systematic reviews but little progress on development of RCTs or CPGs.
Twelve of the fellows undertook a Cochrane systematic review and registered their topic with either the Cochrane Pregnancy and Childbirth Group or Cochrane Neonatal Group. By the end of the fellowship most fellows had a protocol for their review that was either an advanced draft or had been submitted to the respective review group. By July 2008 all but one protocol had been submitted, two had been published in The Cochrane Library and the remainder were in various stages of editorial review. Fewer fellows attempted to tackle clinical practice guidelines or RCT protocols, and their progress was slower.
Fellows also reported that there was considerable activity in delivery and dissemination of EBP training (especially arising from the fellowships for medical librarians), and an increase in evidence-based clinical practice change, journal clubs and Cochrane Library use.
Most of the fellows were clinicians who, in addition to the research and education components of their fellowships, reflected on the implications of EBP for their clinical work. As a result, many of the fellows were keen to implement specific clinical practice changes which they had often observed in Australia. In this way the fellowships will directly contribute to the impact of the SEA-ORCHID project on healthcare processes and outcomes.

Benefits of the fellowships
Overall the fellows reported that they enjoyed the fellowships program and gained skills and experience in EBP and research use that were beneficial for them as well as their hospitals.

Barriers to completing outputs
Fellows identified several barriers to successfully completing their fellowship outputs once they returned home. These included lack of time, lack of equipment and lack of access to the internet and evidence-based resources such as The Cochrane Library. Because

Enablers of completing outputs
Fellows identified a range of enablers of the completion of fellowship outputs. Access to computers and evidencebased internet sources to overcome the barriers identified above was regarded as an important enabler. Support from senior staff, colleagues and junior staff at their home institution was also noted as an important enabler of progress on the fellowship output. External research collaborators from other institutions and other countries were recognised as another important source of support.
The support we get [from SEA-ORCHID] helps us get our researches finished and published.
[SEA-ORCHID Investigator] has started research groups with membership from different institutions. The members may function as support groups to each other in conducting research and implementing evidence-based practice.
Fellows recognised the importance of protected time in enabling completion of their fellowship outputs, but were not able to identify how this could be secured once they returned home.

Discussion
The SEA-ORCHID fellowships program resulted in 23 fellows, from a range of backgrounds and with diverse skills and experience, producing evidence-based training materials, drafts of Cochrane systematic reviews, clinical practice guidelines and trial protocols, plans for clinical practice change and a commentary for the WHO Reproductive Health Library. Six months after completing their fellowships there was some development in the drafting and submission process for Cochrane systematic reviews but little development of RCTs or CPGs. There was considerable activity in the delivery and dissemination of EBP training and materials, reported clinical practice changes, journal clubs and Cochrane Library use.
The benefits of the SEA-ORCHID fellowships program to both fellows and the hospitals from which they were selected are similar to those reported from clinical fellowship programs in high-income countries like Australia and the United States [10,11]. Most fellows made substantial progress towards their chosen output and all gained substantial skills and experience in the elements of EBP. Several fellows reported that they were able to make practice changes in their hospitals and some also identified personal accomplishments resulting from the fellowship.
One of the main outputs of the fellowships program was the production of Cochrane systematic reviews, designed to be a practical way of introducing clinicians to the links between clinical practice and research. Systematic reviews and guidelines can take years to complete, so not surprisingly, busy clinicians returning home struggled to complete protocols for their reviews. Within six months of returning to busy clinical practices, and without protected time, it was not feasible for some fellows to complete even the protocol for their reviews.
While we did not expect these outputs to be completed within the fellowship period or the six month follow-up, we hoped that the fellowships would enable greater understanding of, skill in and access to resources necessary for EBP, and this appears to have happened.
The importance of selecting fellows who were practicing clinicians and librarians (and able to directly translate knowledge into practice change) cannot be overstated, and this has also been identified by other studies [10]. While knowledge champions can drive practice change, the perception and/or reality of limited power in a workplace can impede this [29]. In this project, fellows' roles as senior clinicians, librarians and educators in their hospi-  tal departments and universities meant they could strongly influence the teaching and practice of junior staff and students. Both the number of evidence-based training modules and materials developed during the fellowships and the amount of dissemination activity postfellowship, suggest that this area of output of the fellowships was very successful. The program also highlighted the critical role medical librarians play in knowledge translation and their participation was particularly valuable. This study has some limitations. There were some difficulties with data collection which make definitive conclusions difficult to draw. It was not always possible to measure progress with fellowship outputs. For instance, in the case of some training workshops, it was not always clear what was being taught and how, with whom, for how many, how often and what the outcomes were (i.e. changes in knowledge, skills and practice). Sometimes it was unclear if the fellowship output was an entirely new activity or how it extended or enhanced existing EBP activities. It was also not always clear at what stage drafts of SRs, RCTs, and CPGs were up to or whether fellows still plan to complete them. Fellowship evaluation interviews were conducted by fellowship hosts which may have compromised impartiality, however data collection, analysis and interpretation were undertaken in awareness of this.
Protected time, access to academic/technical expertise and resources, training, opportunities for clinically relevant research and opportunities for presentation of and feedback on work were all identified as critical components to the success of the fellowships program. Some suggestions for improving the program included: stronger support for links between fellows after their return from the fellowships; continuing to build and foster relationships with external collaborators; provision of access to well maintained computers, the internet and EBP resources in the fellows' work environments.
The capacity of the fellows selected for the program is also a critical success factor. The motivation and commitment of fellows to spend time in another country (in some cases for the first time) and work on a project (often in a second language) took remarkable courage and perseverance. Acknowledging the achievements of the 23 fellows, in often very difficult circumstances, is vital to ensure the gains from these fellowships continue. During the six-month follow-up data collection, some fellows were embarrassed and apologetic about not having been able to complete outputs as they might have hoped. Despite significant environmental challenges, the personal and professional commitment of fellows to bring about change in their hospitals and universities is a tribute to the fellows.
The results of this study highlight the potential value of fellowship programs as a method of increasing capacity in EBP. They also highlight key barriers that need to be addressed for fellowships to be ultimately successful and enablers that can be used to achieve this aim. These factors should, therefore, be considered when designing fellowship programs and selecting fellows for future capacity building initiatives.

Conclusions
The SEA-ORCHID fellowships program provided protected time for fellows to work on individually selected, clinically relevant, projects which would produce specific outputs and lead to greater implementation of EBP. While the fellows faced substantial barriers to completing their project outputs once they returned to their clinical environments, these fellowships resulted in a greater understanding of, skill in, and enthusiasm for EBP. The experience of the SEA-ORCHID fellowships program may be useful for other initiatives aiming to build capacity in evidence-based practice.