Strengthening prehospital clinical practice guideline implementation in South Africa: a qualitative case study

Abstract

Background: Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, research into alternative methods of CPG development using existing CPG documents (CPG adaptation)a specific issue for guideline development groups in low-and middle-income countriesis sparse. There are only a few examples showcasing the pragmatic application of such alternative approaches in settings with time and budget constraints, especially in the prehospital setting. This paper aims to describe and strengthen the methods of developing prehospital CPGs using alternative guideline development methods through a case study design. Methods: We qualitatively explored a CPG development project conducted in 2016 for prehospital providers in South Africa as a case study. Key stakeholders, involved in various processes of the guideline project, were purposefully sampled. Data were collected from one focus group and six in-depth interviews and analysed using thematic analysis. Overarching themes and sub-themes were inductively developed and categorised as challenges and recommendations and further transformed into action points. Results: Key challenges revolved around guideline implementation as opposed to development. These included the unavoidable effect of interest and beliefs on implementing recommendations, the local evidence void, a shifting implementation context, and opposing end-user needs. Guideline development and implementation strengthening priority actions included: i) developing a national end-user document; ii) aligning recommendations with local practice; iii) communicating a clear and consistent message; iv) addressing controversial recommendations; v) managing the impact of interests, beliefs and intellectual conflicts; and vi) transparently reporting implementation decisions. Conclusion: The cornerstone of a successful guideline development process is the translation and implementation of CPG recommendations into clinical practice. We highlight key priority actions for prehospital guideline development teams with limited resources to strengthen guideline development, dissemination, and implementation by drawing from lessons learnt from a prehospital guideline project conducted in South Africa.

Guidance we can trust? The status and quality of prehospital clinical guidance in sub-Saharan Africa: A scoping review

“…The majority used literature reviews, expert input or informal guideline adaptation methods, as opposed to formal adaptation methods such as adolopment [ 32 ], ADAPT [ 33 ], or others [ 19 , [34] , [35] , [36] ]. Considering the international standards in guidance development and the continuous movement toward evidence-based decision-making [ 4 ], we argue that if any guidance in prehospital care is to be developed, the methods of development should be transparently and clearly reported [ 37 ]. This would be recommended irrespective of whether guidance takes the form of formal CPGs, protocols, or algorithms.…”

“…This undermines trust in guidance, and ultimately affects patient outcomes. As a consequence, when evidence is open to misinterpretation [ 38 ], recommendations are open to conflicts of interest [ 39 ] and undue influence, especially, in situations where decisions are being made by various stakeholders on how recommendations should be implemented [ 18 , 37 ]. Considering how important locally appropriate guidance is to clinicians in day to day practice, it is essential that African guidance developers are aware of international standards when developing and reporting clinical guidance.…”

How evidence, implementation, policy, and politics come together within evidence systems: Lessons from South Africa

“…What we have not explored in this case study, and should perhaps be a subject for another analysis, is the extent to which evidence-informed policy is implemented in South Africa. This is something that has been considered elsewhere, including in Cameroon (Okwen, 2017), and in the UK (Breckon & Gough, 2019), and there is a growing body of relevant literature within South Africa from specific sectors, including health care (McCaul et al, 2020) and policing (Newham & Rappert, 2018), as well as in government performance (Tirivanhu et al, 2017).…”

Adopting a ‘System of Caring' as a leadership strategy toward professionalisation within South African emergency medical services: A grounded theory

“…Within the South African setting there have been a number of focused research initiatives aimed at improving pre-hospital care systems, however these initiatives have highlighted the need for further research into, and development of SA EMS systems and processes [6 , 7] . Mianda et al suggest there is an ongoing systemic lag in the development of clinical leadership competency among frontline healthcare providers, leading to slow professionalization of ‘non-physician’ based healthcare units [8] .…”