Moving knowledge into practice: evaluating cross cultural applicability of the promoting action on research implementation in health service (PARIHS) framework

Clinical practice guidelines are developed worldwide, at an ever increasing rate (Sandström et al., 2015) and accessed internationally without a full understanding as to whether they are applicable in cross cultural settings. Informed by a review of the literature which identified a range of theories, frameworks and models to guide knowledge translation, the Promoting Action on Research Implementation in Health Services (PARIHS) framework (Kitson et al., 1998b), was selected as a suitable framework to explore evidence based clinical guideline development work in a cross cultural context. This research study was an exploration of the appropriateness and utility of the PARIHS framework, in the cultural translation and adaptation of an evidence based clinical practice guideline into clinical practice in the healthcare system in Malta. It also aimed to identify challenges and barriers to successful cultural translation and implementation to inform future cross cultural knowledge translation programs. A case study using an embedded single case was used. Data collection consisted of two focus groups with multidisciplinary healthcare professionals (n=11 and n=5), eighteen semi structured interviews (n=9 pre and n=9 post) and non-participant observation of two guideline development groups. Data was analysed both inductively and deductively using Framework Analysis. Findings of the study indicate that the components of the PARIHS framework of evidence, context and facilitation are useful to guide the cultural translation and adaptation of an evidence based clinical practice guideline. In addition, a number of challenges and barriers to successful translation and potential implementation were identified; the influence of politics, culture and context, stakeholder involvement including patient involvement, and resources, both human and financial. Overall the PARIHS framework is a useful tool to guide the cultural translation and adaptation of an evidence based clinical practice guideline. The study identified important additions to the PARIHS framework to improve its utility: expanding the use of culture in the PARIHS framework to include macro, meso and micro dimensions; the need for a definition of what context means within the PARIHS framework; the inclusion of politics as a sub element of context; the importance of resources, and acknowledging the role of the patient within the framework