Context revisited: situations beyond our kin

During a recent training event of the Queen's Collaboration for Health Care Quality: a Joanna Briggs Institute Centre of Excellence (QcHcQ), at Queen's University in Kingston, Canada, attendees were discussing topics for a systematic review. These attendees were all library scientists, six of whom were from Sub Saharan African countries. One attendee posed an important question about strategies used to keep patients safe in a hospital setting. Even though our team at QcHcQ has extensive expertise in health care quality and patient safety in both developed and developing countries, our thoughts went to risks such as hospital acquired infections, falls and adverse drug events. However, one attendee went on to explain that patients were often assaulted in their hospital beds and was determined to investigate strategies to prevent these violations and keep patients safe. This alarming and unexpected extension of the bounds of the concept of patient safety highlights the importance of being aware of the context in which people live and work. Remaining mindful and open to listening to the experiences of health professionals is a key part of bringing evidence into practice globally and is consistent with the tailoring, problem solving and mutual learning activities that are part of the knowledge translation process.1-3 These activities address the “gap” between what is known and what is done that exists despite evidence synthesis and the development of important clinical guidelines that are accessible in low- and middle-income countries (LMICs).4 Examination of the context of care in diverse settings, such as those in LMICs, must go beyond cursory description and surface assessment of current practice and processes. Collaborators who seek to work together to achieve contextualized evidence for care in LMICs must focus on engagement with local colleagues: to dig deep in environments to uncover the features of society and culture, structure, relationships and resources encountered in these settings. For example, in a recent study of clinician and environmental factors affecting pain care in one LMIC, Nyirigira et al.5 found that factors in organizational culture and clinical resource allocation were cited by clinicians as barriers to the sustainable implementation of evidence-informed care. Bayou6 also described the difficulties clinicians face in breaking free of established practices to innovate and “lead change” in evidence informed practice, particularly when the evidence is not produced locally. Okwen confirmed this challenge and added a call to develop innovations to challenge the status quo while recognizing the financial barriers to evidence use in LMICs.7 There is a fundamental need to bring together clinicians, policy-makers and researchers in LMICs to define concepts like quality of care at a cultural level to avoid inappropriate comparisons that can add increase barriers to evidence use in LMIC. Jayasekara and Shultz provide an example from curriculum development with their recommendation for assessment of cultural relevance of concepts that are appropriate to developed countries prior to implementation.8 Meaningful and mutual engagement in the contextualization of evidence for practice takes time. Collaborators from developed countries need to be prepared to provide consistent support and to give as well as receive guidance from local colleagues in the knowledge translation process. Ultimately, the sustainability of evidence informed implementation projects depends on its appropriateness and feasibility in the environment and the commitment of the setting to a local definition of quality.

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