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The need for research in primary care to solve global health problems View review Introduction This position paper is the result of collaboration and review between 28 individuals in 17 different countries. They are listed at the end. To develop this position paper, The Network: TUFH’s list server was used to solicit interest. The immediate response from such a large number of people from many different settings in both developed and developing countries with widely divergent medical and social cultures demonstrates the global importance of establishing a primary care research enterprise to improve health. Why bother with research in primary care? The writers agreed that improving the evidence base for primary care practice, policy and education has the potential to improve care and reduce costs. This question could well be phrased as “What are the costs to each country of failing to do research in primary care?” A strong primary health care research system, with sufficient capacity to address local and national needs and the capacity to link evidence to practice and policy making is needed in each country. Such a system would be congruent with the Mexico Statement on Health Research developed by the WHO Ministerial Health Summit with representatives of 58 countries. (Ministerial Summit on Health Research, 2004) First, it is well documented that an effective primary health care system is critical for any country, developed or developing, to maximize outcomes and minimize costs. (Starfield, 1991; Perry et al., 1999; Sant’Ana, Rosser, & Talbot, 2002; Macinko, Starfield, & Shi, 2003; Baicker & Chandra, 2004) The Alma-Ata conference recommended that health care systems have a sound foundation in primary care (World Health Organization, 1978) and acknowledged that research is a basic requirement for primary care development. Second, accurate and relevant data gathering and information processing are necessary for any field of endeavor whether in health care or any other field. Third, every discipline needs to develop its own internal scholarly tradition and ability so as to enable it to undertake self-examination and to develop means to be more effective and efficient. Finally, it has long been recognized that clinical issues in primary care are different from those in other types of care. For example, the predictive values of symptoms may be quite different in different settings (McWhinney, 1989) and clinical evidence derived from other settings may have limited applicability. This is due not only to differences in the prevalence of specific diseases (Mansson, Marklun, & Hultborn, 2001) but also to the fact that patients in primary care have many problems and the clinician must prioritize the diagnosis and management of all of these together over time, often in a setting where continuity of care plays a crucial role. (Hjortdahl & Borchgrevink, 1991; Hjortdahl & Lærum, 1992; Beasley et al., 2004) Beyond simply understanding clinical issues in primary care, research is needed to develop means to facilitate the translation of research into practice (TRIP) and to inform the organization of health services, including the appropriate use of primary, secondary and tertiary services effectively. Research activities within (not just “about”) primary care are needed to narrow the gap between the clinicians providing the care and the consultants and academics. This issue is especially critical in many countries where there is not only a huge gap between primary care clinicians and academic researchers but also severe variations between day-to-day care in affluent parts of urban centers and poorer parts of those urban centers and even more between urban and poor rural areas. In the rural areas, primary care clinicians are often the only clinicians providing care and even they may not be available. The expected outcomes of a strong primary care research enterprise in each country will include: Improve the quality and cost-effectiveness of care by informing practice, policy and education Enhance the primary care professions and work towards equity in primary care Develop primary care practices as learning systems Improve the social equity of health care In 2004 Wonca convened a conference on the need for and nature of research in Family Medicine. While not addressing the larger world of primary care, this Kingston Conference did develop recommendations which have broad applicability to primary care in general. (van Weel & Rosser, 2004) Other authors have also outlined the need for research in primary care. (De Maeseneer, van Driel, Green, & van Weel, 2003) The lack of research in primary care is one of the reasons there is a mismatch between the global burden of disease and the research being done. (Rochon et al., 2004) There is a lack of evidence and technology to guide and support practice, (Jha & Lavery, 2004), including primary care practice. Yet research in primary care continues to lag, even in developed Western countries. (Askew, Glasziou, & Del Mar, 2001) What is research in primary care? Put most succinctly, primary care research is “any research done in any primary care setting”. (Starfield, 1996). A useful taxonomy of primary care research has been developed which breaks down this research into five broad categories. (Mold & Green, 2000; Starfield, 1996). These are: Methods: Research into the methods being used to create new knowledge and link it to practice. This would include, for example, research into the ways to develop and use primary care research networks, how to survey patients and collect data, how to run randomized controlled trials in primary care settings and how to best translate research into practice. Clinical: Research to guide clinical practice. This would include, for example, research into the epidemiology and natural history of common diseases, the utility of continuity of care, the methods to improve the interactions between patients and clinicians, how to best treat common infections or psychosocial problems, and the integration of social and environmental factors into care. Health Services: Research that provides information about the methods to provide care for patients. This would include, for example, research into how best to use non-physician clinicians, the impact of continuity of care, how to develop systems to address mental health issues or how to manage information flow in practice. Health Systems (also called Operational Research in some settings): Research that guides policy at national or regional levels. This would include, for example, research to guide the development of payment systems, how to integrate primary care with other health care services, how to strengthen community strengthen community participation for health, or how to develop socially equitable systems. (Starfield, 2001) Health systems research can help countries to set targets, assess progress and develop better ways to link research to teaching and clinical care. Educational: Research to guide education both for trainees and for clinicians in community practices. This would include, for example, research that leads to understanding about how to develop optimal pre- and post-graduate programs are best for assuring the number and quality of primary care clinicians; and how to conduct research to better define educational needs. What is special about research in primary care? There are a number of attributes of primary care research which, although they do not define it, do impart a somewhat unique character to this research. Research in primary care poses a number of challenges which are less problematic in traditional academic settings. For example, it is difficult to conduct classic, double-blind placebo controlled trials in the primary care setting. Furthermore, primary care is often more interested in the effects of disparate interventions all working at once than the effect of one or another specific intervention. In addition, primary care research, because it is often conducted in practice settings, is frequently dependent not only on positive interactions with those who finance and support the research but also on those who are the subjects of the research, including the clinicians themselves. Taken together, these challenges are make research in primary care a difficult task. The primary care research is generally characterized (to a greater extent than traditional biomedical research by: Attempting to link practice, research and education so that research may inform education and practice, and education may work to improve both research and practice as well. Involving community practitioners as active colleagues and participants. Community practices are often the laboratories for primary care research. In some cases, primary care research involves communities as part of the “practice” as well. Involving research networks which link community practices to academic resources. Encompassing a broad view of “health” including social issues such as violence, economic health, and education for populations. Interdependence with other disciplines (e.g. anthropology, medical sociology, nutrition, engineering, as well as other medical specialties). Academic-community practice linkages are particularly important. Acknowledging a greater social accountability than many other fields of research with emphasis on selecting questions that matter to clinicians and on applying the answers to practice. Gathering evidence which often derives from and applies to a broader context than evidence derived from limited specialty and biomedical disciplines. Using multiple methods with the method selected depending on the question being asked. These methods may include randomized controlled trials, surveys, qualitative research, data-mining and epidemiologic research, and other methods designed to address the question being asked. Integrating with related activities such as quality assurance to a greater extent than many other types of research. Primary care research attempts to take the issue of the translation of research results into practice seriously. There is a greater concern about the applicability of results – and their social utility – than in most other fields of research. Achieving benefits (as noted above) that extend well beyond the specific knowledge produced by the studies. These include enhancing the scholarship of the discipline so as to attract the best students and facilitating further funding and support by academics and government. What progress has been made? Looking worldwide, there is great variability in the development of the primary care research enterprise. The status of one aspect of primary care research activity, the role of Family Doctors, has been recently summarized.(J.W. Beasley et al., 2004) In brief, there are three general levels of the development of primary care research. First, in many economically developed Western countries (though certainly not all) research in primary care is becoming well established. The primary care disciplines and research have been part of academic institutions for many years, clinicians are actively involved (often through primary care research networks), and governmental support (although limited) has been available. This has resulted in an outpouring of relevant literature. The situation in Europe has been reviewed recently (Lionis et al., 2004). In Turkey, for example, a European General Practice Research Network course on Research Methods in Primary Care is scheduled, thus laying the foundation for a PCRN and a MSc Program in Family Health. In another group of countries, also including some Western developed countries, it is only recently that primary care disciplines have gained a even a marginal position in the academic institutions and support for research is only minimally available. In a third group of countries, there is virtually no organized training or research in the primary care disciplines or it is just beginning in a few locations. Tragically, in some of these countries, war and political instability have made the pursuit of any scholarly agenda nearly impossible in the face of critical issues of physical and economic survival. The increasing emphasis on primary care research is evident in many countries, including Nigeria (Ransome-Kuti, Sorunggbe, Oyegbite, & Bamisaiye, 1990) In Egypt, a recent Health Sector Reform Program includes research training for Family Physicians as an integral part of the design of primary health care centers. Similar efforts are underway in Columbia where the need to contextualize care has been recognized and where many challenges for research have been recognized. More educational resources for training primary care researchers are becoming available. In the more economically developed countries progressively more training and funding for that training is available to primary care clinicians. International collaborative efforts through Wonca’s Brisbane Initiative (details available: www.globalfamilydoctor.com) are underway to facilitate international collaboration in education for research and it is intended that this collaboration will involve countries with less developed primary care research structures. Many countries now have degree-awarding programs in public health, primary care or family medicine. Advances in technology may be useful. For example, in Uganda, the use of personal digital assistants (PDAs) linked though the cellular telephone system is being explored as a way to support primary care and public health professionals. (SatelLife Inc.) Primary care research networks (PCRNs) are becoming a global resource for research. (Nutting, Beasley, & Werner, 1999; Beasley et al., 2004; Lionis et al., 2004) Data from the International Federation of Primary Care Research Networks (IFPCRN) indicate that PRCNs, which link clinicians in community practices as partners with academic researchers, now exist in at least 39 different countries with interest evident in many more. The IFPCRN, which is organized under Wonca, has been developed to facilitate communication between these networks to aid in their development and the dissemination of success stories (Details available: www.globalfamilydoctor.com) National federations of networks exist in the US, the UK, and Canada. Finally, there is an increasing recognition in all areas of the world that research in, not just about, primary care is of importance if we are to gain needed evidence, develop ways to apply this evidence and transform primary care practice into a learning discipline. What challenges remain? Despite the optimism expressed above, huge challenges remain in the task of developing the research needed to improve the world’s health care at its most fundamental level. The task of getting large organizations, such as the World Health Organization to recognize the importance of primary care research, remains unfinished. For example, their 2003 report on strategic directions makes no significant mention of the need for research in primary care. (World Health Organization, 2003) Similar work remains to be done to educate granting agencies and national and regional governments. In all cases the lack of sufficient funding for primary care research remains a critical issue, even in the developed countries, and is especially problematic given the need to build the infrastructure for research in primary care and the lack of trained primary care clinicians with researcher skills. Moreover, due to historical factors in many countries where the “GPs” were physicians receiving no additional education beyond basic medical school education, there is a lack of effective primary care clinician leadership in academic institutions. Ironically, in some of the countries where the primary care infrastructure is most lacking and research is just getting underway, there is also the greatest potential to build a new model of research and scholarship – a model where, in distinction to the traditional academic model, the desired immediate and direct goal of research can be the improvement in health care and education rather than the publication of papers and the garnering of grant funds. (van Weel, Gouma, & Lamberts, 2003; van Weel & Rosser, 2004) Not that these latter two goals are unimportant, but rather that these goals would be secondary after the goals of improving health and education. Thus, while one challenge is to build the research enterprise from the ground up, there is an opportunity to unite research with practice from the beginning. Finally, there is the problem of the culture of primary care, as research has not been part of the culture. This means that not only is it necessary to build academic infrastructure but also to work to achieve cultural change among practitioners as well as academics. This is a major issue in both developing and developed countries. What are the needs for education for research? First, there is a need to develop future leaders and scholars in the field. These will be persons with advanced degrees (Masters and Ph.D.) and persons who are in positions of influence within academia and government. The trend for this is underway in many countries, but just starting in many others. Wonca, through its Brisbane Initiative, mentioned above, is working to address this issue on a global scale. The second area of need is for education for the clinicians who are an integral part of the process of primary care research. They need to be educated as to the importance (and rewards) of research. Furthermore, they need education in the basic techniques for identifying areas where new knowledge is needed and the techniques for collecting data related to those areas. There needs to be, of course, education in the ethical aspects of research and of sociomedical concerns related to primary care. Much of the need for mentoring and education will be met through collaboration with topic and methods experts in other fields which may be as diverse as epidemiology, engineering, data management and analysis, other medical specialties, sociology, anthropology and community development. What can The Network: TUFH do? The Network: TUFH should actively seek out ways to advocate for and support the development of primary care research, including the development of PCRNs. First and foremost, it can work with Wonca and other concerned organizations to approach funding agencies (including philanthropic groups and governments) to advocate support for primary care research. This support can be administrative as well as financial and requires support not only for specific research projects but also for the development of infrastructure and education for future researchers, both academic leaders and community clinicians. In addition, The Network: TUFH can: Highlight primary care research issues at its meetings and in its publications Help to identify important questions that are needed to provide the evidence for practice and policy Help to link research needs with experts and authorities in systems such as philanthropic groups, governments and academic institutions Collaborate with Wonca to support initiatives such as the Brisbane Initiative and the IFPCRN In sum, The Network: TUFH should actively seek out ways to become involved in the promotion of research about, as Paul Nutting said, “the problems most of the people have most of the time”. (P.A. Nutting & Green, 1994) Corresponding Author on Behalf of the Writing Group: John W. Beasley, MD. Professor Emeritus, Department of Family Medicine, University of Wisconsin, USA Email: John.beasley@fammed.wisc.edu References Askew, D. A., Glasziou, P. P., & Del Mar, C. B. (2001). 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Primary Health Care: A Framework for Future Strategic Directions. Geneva, Switzerland: World Health Organization. Writing Group: contributors and reviewers: Ilene Abramson, Ph.D., Adjunct Professor, Lawrence Technological University, USA Palitha Abeykoon, Consultant, World Health Organization, Colombo, Sri Lanka Mohamed Farouk Allam, MPH, PhD. Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt Amador Flores Arechiga, MD. University of Nevo Leon, Monterrey, Mexico M.C. Asuzu, MB, BS, MSc. Professor of Public Health and Community Medicine, Department of Community Medicine, University of Ihadan, Ihadan, Nigeria Nazan Bilgel, MD. Professor of Public Health, Bursa Turkey Cecilia Björkelund, Professor, Department of Primary Health Care, Göteborg University, Göteborg, Sweden Ioan Stelian Bocsan, MD, Ph.D. Professor and Chair, Department of Epidemiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania Ivan Chopey, MD. Professor of Family Medicine and Dean, Department of Postgraduate Education, University of Uzhgorod, Ukraine Stefan Grzybowski, MD, MClSc. Associate Professor and Director of Research, Department of Family Practice, University of British Columbia, Vancouver, Canada Sylvia de Haan, MSc, Deputy-Director, Council on Health Research for Development Per Hjortdahl MD, PhD. Professor, Department of General Practice / Family Medicine, University of Oslo, Norway Jan De Maeseneer, MD, PhD. Professor of Family Medicine and Primary Health Care, Ghent University, Belgium Tayyeb Imran Masud, MBBS, MPH., Johns Hopkins School of Public Health, USA Sheila Torres Nunes, MHPE, Nutritionist and Professor, Nutrition Institute, Rio de Janeiro State University, Brazil Peter M. Nyarang'o, MBChB, MMED, MPH. Eritrea Carlo Irwin A. Panelo, MD, MA, Associate Professor, Department of Clinical Epidemiology, University of the Philippines, Manila, Phillipines Henry B. Perry, MD, PhD, Professor for Equity and Empowerment, USA Ashia Qureshi, Lecturer, College of Nursing, All India Institute of Medical Sciences, New Delhi, India Leonardo Cancado Monteiro Savassi, MD, Informatics and Telemedicine Director, Brazillian Society of Family and Community Medicine. Brazil Babar Tasneem Shaikh, MD, MPH. Senior Instructor, Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan Richard E. Steele, MD, MPH. Silkeborg, Denmark Firdouza Waggie, Foundational Learning and Teaching Specialist, Faculty of Community and Health Sciences, University of the Western Cape, South Africa Chris van Weel, MD, Ph.D. Department of Family Medicine, University Medical Center, Nijmegen, Nijmegen, The Netherlands. Hakan Yaman, MD, MS, Associate Professor of Family Medicine, University of Akdeniz, Antalya, Turkey Thamer Kadum Yousif, M.B.ch., FICMS, Assistant Professor Community Medicine, Tikreet University, Iraq