Local opinion leaders effects on professional practice and health care outcomes
This commentary is now outdated and has been replaced by a new commentary. It is included in RHL for archival purposes only. It may be cited as: Sguassero Y. Local opinion leaders: effects on professional practice and health-care outcomes: RHL commentary (last revised: 8 September 2007 The WHO Reproductive Health Library; Geneva: World Health Organization.
RHL Commentary by Sguassero Y
1. EVIDENCE SUMMARY
Opinion leaders are people who are looked upon by their fellow community members as likeable, trustworthy and influential. Because of these attributes, it is thought that opinion leaders may be able to help and convince their fellow health-care providers to use the best available evidence in treating and managing patients. In this context, opinion leaders can be defined as health-care professionals nominated by their colleagues as 'educationally influential' (1). In theory, opinion leaders make use of a range of interpersonal skills to achieve the desired behaviour change. However, it remains unclear how exactly opinion leaders influence others.
This Cochrane review (2), which is an update of a previous version (3), aimed "to assess the effectiveness of the use of local opinion leaders in improving the behaviour of health care professionals and patient outcomes". In the updated review, two new objectives were added: to assess whether educational initiatives (formal or informal) used by opinion leaders are associated with successful implementation of evidence-based practice; and to determine whether the process of selection of opinion leaders affects the success of opinion leaders or of educational initiatives.
Twelve trials met the inclusion criteria of the review, the majority of which were carried out in hospitals in the USA. In 10 trials the local opinion leaders were selected by the sociometric method and in two the informant method was used. The included trials covered different clinical disciplines, such as surgery, obstetric, cardiology, and rheumatology. Most of the opinion leaders delivered educational initiatives to members of their own health-care profession. In four trials, use of local opinion leaders was compared with no intervention. In the remaining trials, work of local opinion leaders was supplemented by different types of intervention, including lectures and seminars. There were considerable differences between the included trials with regard to the outcome behaviour among those influenced by opinion leaders.
Based on the findings of this review, use of local opinion leaders can successfully promote evidence-based practice in developed countries. The adjusted risk difference (ARD) of non-compliance with the desired practice, varied from -6% (favours control) to +25% (favours treatment). Overall, the median ARD for the 12 included studies was 0.10, i.e., 10% absolute decrease in non-compliance in the intervention group. Nevertheless, when data were pooled from studies classified as having a “low to moderate” risk of bias (i.e. high-quality), the median adjusted risk difference in outcomes varied from +0.085 to +0.25 compared with -0.06 to +0.12 for the studies classified as having a “high” risk of bias.
This review suggests that interventions that use opinion leaders to promote evidence-based health care appear to reduce non-compliance with the desired clinical practice. However, due to paucity of data, most studies could not be reliably categorized according to the educational method the opinion leaders had used.
Search methods and data extraction were done with the support of the Cochrane Effective Practice and Organization of Care (EPOC) Group. The search strategy used for identifying relevant studies was comprehensive. No language restrictions were applied.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
In many developing countries, while the demand for health care is high, the health systems face acute shortages of resources. In such settings it is vital that health-care professionals practice evidence-based care, as limited health resources need to be used effectively, efficiently and equitably.
Unfortunately, access to health services is too often not equitable and is to a great extent frustrated by inefficiencies in the health systems (4). Moreover, for those who are able to access the health system, care is often substandard and expensive. Effective and inexpensive interventions, such as the use of magnesium sulfate for eclampsia and pre-eclampsia, are often not used, or are simply not available (5). On the other hand, many ineffective or expensive interventions (e.g. routine episiotomy, bronchodilators for infants, intravenous fluids rather than oral rehydration solutions for diarrhoea in children) continue to be widely used, in part because of lack of access to information regarding valid and reliable research evidence, and poor dissemination of best practice techniques.
2.2. Applicability of the results
First, 11 of the 12 trials included in the review were carried out in developed countries and mainly in hospital centres. Secondly, the sociometric method was the most common method used in the trials to identify opinion leaders. This method involves the distribution of a self-reporting questionnaire to members of a professional group and asking them to rate individuals within their group according to the extent to which they are educationally influential, knowledgeable and humanistic. Clearly, a wide variety of questions could be developed locally for this purpose. Moreover, the response rates could vary considerably from group to group. Consequently, the information gathered may not always be representative of the views of the entire professional community. Finally, the type of clinicians and the clinical conditions studied also varied considerably across the trials.
Considering the above limitations it is difficult to determine if opinion leader-led interventions would be effective in under-resourced settings where informal methods of delivering education are probably more widespread and the social and cultural differences may be different to the settings the trials in this review were conducted.
2.3. Implementation of the intervention
From the included trials it is not possible to extract a clear intervention for promoting and disseminating evidence–based practices among health-care professionals in developing countries. In under-resourced settings, more contextual factors may need to be taken into consideration in selecting, promoting and implementing evidence-based interventions, including consideration of local health system capacities.
Before this intervention can be recommended for developing-country settings, further research is needed on:
- What are the best methods for selecting opinion leaders in under-resourced settings?
- What are the best ways of delivering the opinion leader intervention at different health-care levels in under-resourced settings?
- What is the effectiveness of different formal (e.g. academic detailing, preceptorships, small-group teaching, lectures, seminars) and informal educational methods (e.g., one-on-one teaching, group discussions, informal consultations) when used as strategies for disseminating and implementing best evidence-based practices?
- How can change be effected in professional behaviour over time?
Sources of support: Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
- Hiss RG, MacDonald R, David WR. Identification of physician educational influentials in small community hospitals. Washington, DC: Proceedings of the Seventeenth Annual Conference on Research in Medical Education; 1978:283-8.
- Doumit G, Gattellari M, Grimshaw J, O'Brien MA. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007;Issue 1. Art. No.: CD000125; DOI: 10.1002/14651858.CD000125.pub3.
- O'Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1999;Issue 1. Art. No.: CD000125; DOI: 10.1002/14651858.CD000125
- Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003;362:233-41.
- Sevene E, Lewin S, Marino A, Woelk G, Oxman A, Matinhure S, et al. Can a drug be too cheap? The unavailability of magnesium sulphate for the treatment of eclampsia and preeclampsia in Mozambique and Zimbabwe: systems and market failures. BMJ 2005;331:765-9.
This document should be cited as: Sguassero Y. Local opinion leaders: effects on professional practice and health-care outcomes: RHL commentary (last revised: 8 September 2007 The WHO Reproductive Health Library; Geneva: World Health Organization.