Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa.
BMJ Open. 2020 May 30;10(5):e031468. doi: 10.1136/bmjopen-2019-031468.
Clinical guidelines support evidence-informed quality patient care. Our study explored perspectives of South African subnational health managers regarding barriers to and enablers for implementation for all available primary care guidelines.
We used qualitative research methods, including semistructured, individual interviews and an interpretative perspective. Thematic content analysis was used to develop data categories and themes.
We conducted research in four of nine South African provinces with diverse geographic, economic and health system arrangements (Eastern Cape, Western Cape, KwaZulu-Natal, Limpopo). South Africa is a middle-income country with high levels of inequality. The settings represented public sector rural and peri-urban health facilities.
Twenty-two participants with provincial and district health management roles, that comprised implementation and/or training on primary care guidelines, were included.
Participants recommended urgent consideration of health system challenges, particularly financial constraints, impacting on access to the guidelines themselves and to medical equipment and supplies necessary to adhere to guidelines. They suggested that overcoming service delivery gaps requires strengthening of leadership, clarification of roles and enhanced accountability. Participants suggested that inadequate numbers of skilled clinical staff hampered guideline use and, ultimately, patient care. Quality assurance of training programmes for clinicians-particularly nurses-interdisciplinary training, and strengthening post-training mentorship were recommended. Furthermore, fit-for-purpose guideline implementation necessitates considering the unique settings of facilities, including local culture and geography. This requires guideline development to include guideline end users.
Guidelines are one of the policy tools to achieve evidence-informed, cost-effective and universal healthcare. But, if not effectively implemented, they have no impact. Subnational health managers in poorly resourced settings suggested that shortcomings in the health system, along with poor consultation with end users, affect implementation. Short-term improvements are possible through increasing access to and training on guidelines. However, health system strengthening and recognition of socio-cultural-geographic diversity are prerequisites for context-appropriate evidence-informed practice.
临床指南支持循证的高质量患者护理。我们的研究探讨了南非次国家卫生管理人员对实施所有可用初级保健指南的障碍和促进因素的看法。
我们使用了定性研究方法，包括半结构化的个人访谈和解释性观点。使用主题内容分析来开发数据类别和主题。
我们在南非九个省份中的四个省份进行了研究，这些省份具有不同的地理、经济和卫生系统安排（东开普省、西开普省、夸祖鲁-纳塔尔省、林波波省）。南非是一个中等收入国家，不平等程度很高。研究地点代表了公共部门农村和城市周边地区的卫生设施。
22 名参与者具有省级和地区卫生管理角色，包括实施和/或培训初级保健指南，他们被包括在内。
参与者建议紧急考虑卫生系统挑战，特别是影响获得指南本身以及遵守指南所需的医疗设备和用品的财政限制。他们认为，克服服务提供差距需要加强领导、明确角色和增强问责制。参与者认为，熟练临床工作人员人数不足阻碍了指南的使用，最终影响了患者护理。建议对临床医生（特别是护士）的培训计划进行质量保证——包括跨学科培训和加强培训后的指导。此外，适合设施独特环境的指南实施需要考虑包括当地文化和地理在内的因素。这需要指南制定者包括指南的最终用户。
指南是实现循证、具有成本效益和普及医疗保健的政策工具之一。但是，如果不能有效地实施，它们就没有影响。资源匮乏环境中的次国家卫生管理人员表示，卫生系统的缺陷以及与最终用户缺乏协商，会影响实施。通过增加对指南的获取和培训，可以实现短期的改进。然而，卫生系统的加强和对社会文化地理多样性的认识是实现循证实践的必要前提。
