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Randomised Controlled Trials are the gold standard, but don’t forget about the others!

Posted on 10th August 2013 by

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So I’ve just clicked onto the PLOS Medicine homepage. “The Factors affecting the Delivery, Access and Use of Interventions to Prevent Malaria in Pregnancy in Sub-Saharan Africa” is the first bulletin. It is a link to a systematic review and meta-analysis.

My tired eyes see that as a lot of scientific jargon, and a very long title. Not something I would usually consider as bedtime reading. However two things in this bulletin encourage me to read on. One is the mention of global maternal health, an area I am passionate about. More importantly, is the focus on delivery, access and use of interventions.

It may seem obvious that implementation through delivery, access and use should be a focus of global health research. the fact is that widely tested and working interventions are often in existence. For example, look at the malaria article above. It states that WHO recommendations for tackling malaria in pregnancy are almost twenty years old. The interventions promoted are simple – the use of bed nets and anti-malarial drugs. Yet uptake of these interventions is low in Sub-Saharan Africa (SSA) target populations. Problems in health systems, infrastructure and education remain.

Unfortunately the predilection of the “gold-standard” Randomised Controlled Trial (RCT) over other study designs is shadowing implementation research. Randomised Controlled Trials are used to evaluate and re-evaluate interventions. Most funding is allocated to the expensive “gold standard” RCT. Paul Farmer, a leading global health professor and founder of Partners in Health, highlighted this issue in the Lancet Global Health blog this week. He argued that the global health field is wasting valuable time on evaluation of interventions known to be useful. He calls for the global health community from academics to publishers to place more value in observational studies exploring programme operation.

This is why I was intrigued to see the different types of study designs included in the PLOS Malaria systematic review and meta-analysis. It contained 48 quantitative, 20 interventional and 20 qualitative studies. Most of the evidence gathered is from alternative study designs. Perhaps this is a small indication that global health is slowly changing tack. I wonder if observational studies will become the new “gold standard” of evidence in global health?


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