Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers’ perspectives and experiences

Abstract

BackgroundHypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting.MethodsA phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework.ResultsThe majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants’ commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy.ConclusionsThis study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.

Diabetic Guidelines;

“…15 Similarly a study done in China noted that increased workload made it difficult for health care professionals to adhere to the guidelines. 16 successful diabetic guidelines implementation. 16,17 Factor 2 category (Lack of information related factors) included items related to lack of diabetic guideline information in doctors and patients.…”

“…16 successful diabetic guidelines implementation. 16,17 Factor 2 category (Lack of information related factors) included items related to lack of diabetic guideline information in doctors and patients. Other studies have also identified lack of knowledge and culturally sensitive diabetic education as a barrier to diabetes guideline implementation.…”

“…18 It has been noted that patients who lack health information have difficulty in adopting healthy life style for adequate diabetes managment. 16 Lack of knowledge about the guidelines among physicians also effects the implement ability of the guidelines. 19 Other studies have identified poor awareness among physicians (22.7%), lack of applicability of western guidelines (22.7%) as barriers for guidelines usage.…”

Factors hindering the adherence to clinical practice guideline for diabetes mellitus in the Palestinian primary healthcare clinics: a qualitative study

“…Similar result revealed the majority of the key informants reported that the main barriers that prevented them from adhering to guideline recommendations of diabetes and hypertension were the time constraints and increased workload. 34 Higher provider workloads have potentially negative impact on patients’ quality of care, 35 patient satisfaction 36 and job satisfaction. 37 Time constraints largely increase with higher workloads.…”

Implementación y aplicación de la “Guía de práctica clínica para el diagnóstico, tratamiento y control de la diabetes mellitus tipo 2 en el primer nivel de atención” en una red de establecimientos de salud públicos de Lima

“…Los esfuerzos por lograr su implementación surgen desde su planificación y elaboración, priorizando las recomendaciones a implementar, identificando barreras y facilitadores de manera que el proceso logre ajustarse al contexto y al personal de salud objetivo [12] . Un estudio previo realizado en Mongolia mostró que el tener capacitaciones que permitan un mejor conocimiento y entendimiento de una guía, genera en el receptor una mayor preparación y habilidades para poder brindar una adecuada atención primaria [13] . La falta de capacitación limita no sólo el entendimiento de la guía sino también su aplicación en la práctica diaria, obteniéndose mejores resultados y preparación cuando existe un entrenamiento teórico-práctico [12,14] .…”