Next generation clinical guidance for primary care in South Africa – credible, consistent and pragmatic

Abstract

BackgroundAgreed international development standards underpin high quality de novo clinical practice guidelines (CPGs). There is however, no international consensus on how high quality CPGs should ‘look’; or on whether high quality CPGs from one country can be viably implemented elsewhere. Writing de novo CPGs is generally resource-intensive and expensive, making this challenging in resource-poor environments. This paper proposes an alternative, efficient method of producing high quality CPGs in such circumstances, using existing CPGs layered by local knowledge, contexts and products.MethodsWe undertook a mixed methods case study in South African (SA) primary healthcare (PHC), building on findings from four independent studies. These comprised an overview of international CPG activities; a rapid literature review on international CPG development practices; critical appraisal of 16 purposively-sampled SA PHC CPGs; and additional interrogation of these CPGs regarding how, why and for whom, they had been produced, and how they ‘looked’.ResultsDespite a common aim to improve SA PHC healthcare practices, the included CPGs had different, unclear and inconsistent production processes, terminology and evidence presentation styles. None aligned with international quality standards. However many included innovative succinct guidance for end-users (which we classified as evidence-based summary recommendations, patient management tools or protocols). We developed a three-tiered model, a checklist and a glossary of common terms, for more efficient future production of better quality, contextually-relevant, locally-implementable SA PHC CPGs. Tier 1 involves transparent synthesis of existing high quality CPG recommendations; Tier 2 reflects local expertise to layer Tier 1 evidence with local contexts; and Tier 3 comprises tailored locally-relevant end-user guidance.ConclusionOur model could be relevant for any resource-poor environment. It should reduce effort and costs in finding and synthesising available research evidence, whilst efficiently focusing scant resources on contextually-relevant evidence-based guidance, and implementation.

Building capacity in primary care rehabilitation clinical practice guidelines: a South African initiative

“…The design, practicality and local relevance of rehabilitation CPGs were highlighted as essential elements to improve CPG uptake in primary care. This concurs with published reports that state that barriers to CPG use are the length of guidelines, the lack of relevant strategies and facilitation for implementation and environment, and organisational constraints [ 25 ]. These findings suggest that a pragmatic approach to CPG capacity-building is needed.…”

“…Contextualisation of CPGs requires methodological knowledge and skills that are not as well understood as de novo CPG development skills [ 25 – 27 ]. However, as contextualisation is critical to CPG implementation within the South African context, a cohort of methodologists who are trained and experienced in these approaches is needed.…”

“…Understanding, accessing and implementing rehabilitation CPGs in South Africa will continue to be a challenge for all health professionals, unless the suggested principles and strategies can be actioned [ 4 , 24 , 25 ]. The participants in our study demonstrated how much guidance was required on what constituted a good CPG, how to disseminate and implement them, or evaluate their impact.…”

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“…Health workers are expected to comply with a plethora of these, even though they may be out of date or inconsistent with one another. 4 …”

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