Evidence-based Diabetes Care in Indonesia - Knowledge translation and transfer of best practice

Abstract

Indonesia is continuously among the top ten countries worldwide in the number of people living with diabetes. Evidence-based practice (EBP) has the potential to improve the effectiveness and efficiency of diabetes care. However, the strategy to efficiently translate the best evidence into practice isof particular concern in developing countries. The overall aim of this thesis is to explore the status of knowledge translation on diabetes care in Indonesia. To answer that, we conducted various assessment on each of the stages on the knowledge translation process. Initially we conducted a survey to assess the degree of awareness, agreement, adoption and adherence of general practitioners (GPs) in Indonesia to type 2 diabetes mellitus guidelines, and their association with characteristics of the responders. The survey found that high awareness of the Indonesian type 2 diabetes guideline does not necessary lead to adoption or adherence to recommendations important for outcomes and quality of care. However, the awareness-to-adherence model helps in identifying barriers for the use of guidelines. We then evaluated the quality of an Indonesian type 2 diabetes guideline (Perkeni’s guideline 2011) adapted from four international guidelines. We found that the process underlying the Indonesian type 2 diabetes guideline development is curtailed due to being under-resourced and the use of the cited suboptimal source guidelines might risk the validity of the recommendations it contains. Implementation of evidence-based practice principles such as those proposed by ADAPTE collaboration should be adhered to when guideline are derived from other guidelines to be used in other than its original context or circumstances. We also conducted an evaluation of the quality of reporting of the risk of bias of the Indonesian medical research. As we found only a small proportion of Indonesian studies which have high quality reporting or methods, we recommend to endorse and follow international reporting guidelines to improve the quality of future studies. In the end we learned that although EBP is a concept which originated from developed countries, its implementation in developing countries like Indonesia is highly relevant. The development of the knowledge and skills on EBP in Indonesia is progressing as there are efforts in integrating evidence-based practice in the medical curriculum along with continuing professional development activities. However, to achieve health benefits, the evidence must be moved into action. This thesis helps identified some gaps in the knowledge creation and application especially on diabetes care. The gaps on the knowledge creation include limited number and low quality of evidence on diabetes care, very little production of systematic reviews on the problems related to diabetes care which are relevant to Indonesian situation and low rigor of development as well as low applicability of the existing diabetes guidelines. The remaining gaps should be assessed thoroughly using rigorous methods which involve relevant stakeholders. The effort should be followed by the continuous action cycle of the knowledge translation process. Promoting the knowledge translation process should be done simultaneously with the evidence-based practice capacity building to achieve improvement in health care in a developing country like Indonesia.