Practice based research networks are research
laboratories as essential to advancing the scientific understanding
of medical care as bench laboratories are to advancing knowledge in
the basic sciences.
For much of the past century the prevailing view
was that the problems faced in family practice could be resolved by
research carried out by others in other settings. The failure to
implement research findings in daily practice raised some
researchable questions about knowledge transfer, but it did not
engender interest in the research needs and opportunities in family
practice.
Countries rich enough to afford medical research
have devoted many of their resources to establishing the
laboratories, scientists, and methods necessary to advance genetic
and molecular knowledge – as if this would prove sufficient to
relieve most human suffering and provide an adequate scientific
basis for practice and policy making.
This approach is exemplified dramatically in the
United States where annual investment in the National Institutes of
Health, of more than $20bn (£13bn), contrasts with expenditure of
$0.27bn by the only federal agency charged with primary care
research, the Agency for Healthcare Research and Quality.
The recent ranking by the World Health
Organisation of the US health system at 72nd in the world
in terms of disability adjusted life expectancy shows that there are
other factors at play that determine the performance of a healthcare
system and the health of a nation.
There is reason to believe that among these is a
solid foundation of primary care. There is also reason to believe
that primary care is amenable to discovery and improvement through
the methods of science.
Early surveillance systems in the United Kingdom
and the Netherlands inspired family physicians in other countries to
create during the past 40 years research networks that explored
frontline clinical practice.
Networks in the United Kingdom, Israel and France
consistent with experience from New Zealand to South Africa to
Canada. What these laboratories need now is broader recognition of
their viability, importance, and impact, and acceptance that they
merit sustained funding as a continuing infrastructure. Over time a
new understanding of how people get sick, how they get well, and how
they stay healthy will be discovered using the practice based
research network.
Practice based research networks are one of the
critical medical laboratories, now available for everyday use. It is
time to secure these networks as a place of learning, where doctors
and patients in the community are united with science to search for
answers that can provide a better basis for daily practice. When
this happens in countries around the world, the world will be a
better place for all who become patients.
The impact of insecticide treated materials on
mortality was determined by intervention studies carried out in four
African countries. All reported an impact on all cause childhood
mortality, although this was not uniform (ranging from 15% to 63%)
and fell with increasing intensity of malaria transmission. However,
when the risk difference was used the insecticide treated materials
seem to work at least as well in areas of high endemicity as in
areas of lower endemicity.
In many cases, however, the introduction of
insecticide treated materials requires behavioural changes,
particularly where the use of bed nets is low, so it is not always
clear how these benefits can be obtained. Moreover, some form of
cost recovery might have to be built into the programme – simply in
order to sustain it – but this might have an important adverse
influence on coverage. In particular, a policy of cost recovery will
reduce access for poorer groups in the population. An apparently
simple intervention thus becomes difficult to implement when the
issues of coverage, accessibility, equity, and sustainability are
considered. We need new approaches to tackle these issues.
Social marketing uses the methods of commercial
marketing and applies them to a product with a social benefit. It
has already been successfully used to promote the use of condoms,
contraceptives, and oral rehydration solutions, and in this week’s
issue Abdulla et al describe its use for promoting insecticide
treated bed nets in the Kilombero valley in Tanzania (p 000). The
results are impressive, not only because of the rapid increase of
net ownership and the resulting high percentage of treated bed nets
in just three years but also because of the dramatic impact on
anaemia, parasitaemia, and splenomegaly in children aged under 2
years. This indicates that the social marketing programme succeeded
in convincing the population of the usefulness of using insecticide
treated material, even though a payment had to be made.
The campaign described by Abdulla et al was
carefully planned and used a pragmatic approach involving the public
and private sectors. Several points are worth emphasising. Firstly,
the campaign was based on the results of market research that helped
to identify the most suitable brand and logo for the products to be
promoted and also the most effective message for the promotional
campaign. Secondly, the prices for the bed nets and the insecticide
were adjusted according to the willingness to pay of the local
people and thus their cost was only partially recovered. This
implies that programmes to promote the use of insecticide treated
material will still need external financial support. Thirdly,
distribution of the bed nets was done through a network of agents
(shopkeepers and community leaders as well as health workers)
trained for this purpose and involved the public as well as the
private sector. Fourthly, the issue of accessibility of vulnerable
groups was tackled by setting up a voucher system for mothers of
young children and pregnant women so that they could buy insecticide
treated bed nets at a lower price.
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