Doctoral Degrees (Health Systems and Public Health)

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Browsing Doctoral Degrees (Health Systems and Public Health) by Author "Kredo, Tamara"

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    South African primary care clinical practice guidelines : exploratory study of guideline development, implementation and use
    (Stellenbosch : Stellenbosch University, 2019-12) Kredo, Tamara; Volmink, Jimmy; Atkins, Salla; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems & Public Health.
    ENGLISH SUMMARY : Strong primary health care is indicative of a functioning health system and a necessary precursor to universal health coverage (UHC). The South African government aims to strengthen primary health care and implement UHC. Within the national UHC strategy, clinical practice guidelines are named tools to support evidence-informed, cost-effective practice. However, if poorly developed, guidelines may hinder the quality of patient care; and, if not adequately implemented, they will have no impact. Against this backdrop, this dissertation aimed to explore the role-players, processes, barriers to and enablers of guideline development, implementation and use; and to suggest recommendations for improved guidelines for South African primary care. Qualitative methods were used to engage role-players contributing to primary care guidelines along the continuum from guideline development through implementation to use. In-depth interviews were conducted with national developers (n = 37) and provincial managers (n = 22); and seven focus group discussions were held with healthcare providers (n = 47) from June 2014 to August 2016. The four provinces selected represented diverse health systems and social conditions (KwaZulu Natal, Western Cape, Eastern Cape and Limpopo). All recorded data were transcribed verbatim. Thematic content analysis was used for data analysis. The initial phase engaged guideline developers who expressed the opinion that, overall, guidelines are an important means to ensure equitable and effective patient care and that the rigour of guideline development was improving. The study identified several factors which may negatively impact guideline credibility and implementability including inadequate human resources and funding for technical and methodological work; poor communication and coordination resulting in fragmentation between national, provincial, private and public sectors; lack of agreed development methods; poor management of potential conflicts of interest; and, insufficient consideration of implementation contexts. Participants felt these challenges could be mitigated by a committed guideline community working to reduce inequity. However, they thought improvements were currently being hampered by resource gaps which enable commercial or personal interests to drive development. Suggested solutions included national coordination of guideline activities which supports collaboration and transparency across sectors and disciplines. The next phase explored the experiences of guideline implementation. Provincial and district managers, clinicians and trainers are supportive of guidelines as a tool for ensuring the delivery of quality healthcare services. They report having roles in guideline adaptation, implementation and evaluation but described feeling unsupported in these tasks. Two significant themes arose in this study - health systems and socio-cultural-geographic factors. Health systems factors were financial constraints impacting access to guidelines and essential equipment/medicines; inadequate governance and audit capacity, and unclear accountability; insufficient skilled clinical staff; and, a need for interdisciplinary training and post-training mentorship. Socio-cultural-geographic factors considered to be important for improving guideline implementability were authentic consultation with end-users and implementers in the development stages to ensure feasible recommendations are made. The last phase explored perspectives of guideline use finding that healthcare providers, mostly nurses and allied healthcare providers, were knowledgeable about guidelines, generally trusted their credibility and were motivated to use them. Nurses reported that guidelines provide confidence and professional independence where doctors are scarce. Barriers to guideline use were inadequate hardcopy distribution and digital access; insufficient and substandard photocopies; linguistic challenges (e.g. complicated language, no summaries or local language versions); lack of support tools (e.g. posters); limited involvement in development impacting feasibility or acceptability of recommendations; and, patchy training and insufficient post-training supervision. Overall, the dissertation provides novel insights into the current state of primary care clinical guidelines in South Africa. The findings indicate that guidelines have the potential to strengthen primary health care in South Africa. The predominant view of guideline developers, implementers and users that guidelines add value to the health system creates a strong foundation from which to build. For further advancements the political environment needs to value and foster creativity, transparency and collaboration within and between guideline development and implementation groups to enhance guideline quality and acceptability.