Local opinion leaders: effects on professional practice and health care outcomes
Opinion leaders can successfully promote the adoption of evidence-based practices. The selection of opinion leaders to promote evidence-based care does not imply the use of sophisticated technology or processes, and it should be possible to implement the intervention even in the most under-resourced settings.
RHL commentary by Althabe FA
Effective implementation of evidence-based health-care practices remains a significant challenge in developing countries, where the public health implications of using best practices for health care of mothers and infants are considerable (1). Thus, in order to implement effectively the beneficial practices, it is crucial health health-care professionals have sound knowledge of the best evidence-based strategies. Opinion leaders are individuals who may influence the attitudes or behaviours of their peers, since opinion leaders are perceived to be credible, trustworthy, or knowledgeable, among other characteristics. Strategies that involve opinion leaders for promoting evidence-based practices hold promise of being effective and appropriate for developing countries. This Cochrane review (2) sought to assess the effectiveness of the use of local opinion leaders in terms of improving professional practice and patient outcomes.
2. METHODS OF THE REVIEW
The review authors searched rigorously and selected randomized controlled trials that had studied the effectiveness of using opinion leaders to disseminate evidence-based practices and reported objective measures of professional performance and/or health outcomes. It is important to note a few important differences between this review and other Cochrane reviews included in RHL. The participants receiving the intervention discussed in this review were health-care professionals and not patients, and the main outcome measure was the use of specific health-care practices by the health-care professionals in targeted patient populations. The review does not use meta-analysis, and the effect summary is the median of the adjusted risk difference between the intervention and control groups with regard to compliance with a desired practice. A positive risk difference (e.g. of +0.15) means an absolute improvement of 15% with the desired practice. Interventions evaluated in the review cover fields other than reproductive health.
3. RESULTS OF THE REVIEW
A total of eighteen studies were included in the review. Five of them had sought to promote reproductive health practices related to labour in women with previous caesarean section, psychosocial support for women in labour, use of antenatal steroids in women at risk of preterm delivery, use of breast-feeding, and active management of the third stage of labour and episiotomy use. Ten trials had been conducted in the USA, six in Canada, and one in China (Hong Kong) and one each in Argentina and Uruguay. Fourteen trials had been conducted in hospitals, while two interventions had been delivered in primary care clinics. In two trials the setting was unclear.
Fourteen trials had used the sociometric method to select opinion leaders. This method consists of a peer nomination process in which health-care professionals are asked to complete a self-administered questionnaire to identify 'educationally influential' colleagues. Most of the trials used a version of a questionnaire developed by Hiss and colleagues (3), in which the respondents have to judge their peers according to the extent to which their colleagues are educationally influential, knowledgeable and humanistic.
The review found that the use of opinion leaders alone or in combination with other interventions can successfully promote the adoption of evidence-based practices, increasing compliance with evidence-based practices by about 12% (absolute rate).
4.1 Applicability of the results
Although the strategy was evaluated mainly in developed countries, there is no reason to believe that similar results cannot be achieved in developing-country settings, where opinion leaders could also be highly influential in altering behaviour. In fact, two studies had been conducted in developing countries (Argentina, China and Uruguay) and showed a positive outcome. Nevertheless, the review authors emphasize that it is difficult to generalize the results of such studies. The magnitude of the effect in the included studies showed variation. The review authors suggest that these differences could be due to differences in outcomes, how they were measured, the type of clinicians and the clinical conditions studied, and whether the opinion leader strategy was used alone or in combination with other interventions.
4.2 Implementation of the intervention
It must be noted that the strategy was tested, and is mainly applicable in, health-care facilities in urban areas. To be effective, the intervention requires a “team” of health-care professionals. In rural settings, where health-care providers work in relative isolation, this intervention would not be easily applicable.
On the other hand, the selection of opinion leaders to promote evidence-based care does not require the use of sophisticated technology or processes, and it should be possible to implement the intervention even in the most under-resourced settings. However, the methods opinion leaders employ to promote evidence-based care (lectures, workshops, reminders, etc.) might differ according the resources available at each setting.
This commentary author’s experience with regard to the selection of opinion leaders is that it is best to adapt the sociometric method questionnaire developed by Hiss (3) to suit local conditions. It allows health-care professionals to describe which colleagues are educationally influential, knowledgeable, and humane. In a trial conducted by my colleagues and myself in 19 hospitals in a large urban Latin American settings, we selected opinion leaders using the sociometric method (4). The following step-by step process could be used to select opinion leaders:
- Distribute the Hiss questionnaire to all health-care professionals working in the setting where the intervention is to be implemented.
- Ask each health-care professional to complete the questionnaire anonymously and return it in an opaque envelope, preferably by placing it into a sealed box specially prepared for that purpose. Ensure that health-care professionals understand that the selection process will be managed confidentially. It will probably increase the response rate.
- Make every effort to achieve a high response rate: select a respected person to distribute the questionnaire, to periodically remind the subjects to complete it, and to collect the completed questionnaires.
- The best opinion leaders will (theoretically) be those health-care professionals who receive the most votes.
- Inform all health-care professionals (including the elected opinion leaders) of the results.
- Invite the elected professionals to work as opinion leaders.
It should be mentioned that there is no evidence that this method is better than the informant method (asking individuals to identify those individuals who act as principle sources of influence) (1).
4.3. Implications for research
The review authors conducted subgroup analysis according to the method used to select opinion leaders, as well as the method used to promote evidence-based practices. However, at the present time the results are still inconclusive and more research is needed.
There was no subgroup analysis according to setting (development status, hospital or clinic), or according to health field. It is worth mentioning that there is still no published trial in which the strategy was used in developing countries and in the reproductive health field (4).
The review authors also recommend that future studies include a detailed description of how the intervention of opinion leader was delivered (i.e. what they do, how they do it, and how frequently), in order to allow replication of the intervention in other contexts.
Sources of support: Institute for Clinical Effectiveness and Health Policy (IECS) Buenos Aires, Argentina.
- Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Child survival II. The Lancet 2003;362:65-71.
- Flodgren G, Parmelli E, Doumit G, Gattellari M, O’Brien MA, Grimshaw J, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2011;Issue 8. Art. No.: CD000125; DOI:10.1002/14651858.CD000125.pub4.
- Hiss RG, MacDonald R, Wayne K, Davis, Identification of physician educational influences in small community hospital. In: Proceedings of the 17th Annual Conference Research in Medical Education, 1978; 283–288.
- Althabe F, Buekens P, Bergel E, Belizan J, Campbell M, Moss N, Hartwell T, Wright L. A behavioral intervention to improve obstetrical care. New England Journal of Medicine 2008; 358:1929-1940.
This document should be cited as: Althabe FA. Local opinion leaders: effects on professional practice and health care outcomes: RHL commentary (last revised: 1 March 2013). The WHO Reproductive Health Library; Geneva: World Health Organization.