The development of a contextualised evidence-based clinical practice guideline for the primary health care of chronic musculoskeletal pain in the Western Cape

Thesis (PhD)--Stellenbosch University, 2017.ENGLISH SUMMARY : Background: Chronic musculoskeletal pain (CMSP) is a global healthcare concern, and is a major cause of disability and morbidity in sub-Saharan Africa. The implementation of high-quality, evidence-based clinical practice guidelines can enable quality healthcare for CMSP. Clinical guidelines for CMSP developed in developed nations may not be appropriate in developing countries with resource-constrained environments, due to differences in socio-cultural, societal and policy contexts. The contextualisation of clinical guidelines may be an option to provide guidance in resource-constrained environments. Aim: The overall aim of the research project was to develop a contextualised evidence-based, multimodal clinical practice guideline for the primary health care of chronic musculoskeletal pain in adults in the Western Cape Province of South Africa (SA). Method: The research was conducted in three parts: Part 1 comprised two qualitative descriptive studies to explore contextual factors that play a role in the health care of CMSP in three community centres. Three community health centres were strategically selected to represent a rural, a semi-urban and an urban-township setting. Study one used semi-structured interviews with patients to discover patients’ perspectives of CMSP and its healthcare management. In study two, semi-structured interviews were conducted with a diverse group of healthcare practitioners’ to explore their perspectives on the contextual barriers and facilitators regarding the healthcare of CMSP. Interviews were recorded, transcribed and analysed using inductive content analysis. Part 2 entailed study three, a systematic review conducted to identify current, high-quality clinical guidelines on the primary health care of CMSP. Guidelines that met the inclusion criteria were assessed using the Appraisal of Guidelines Research and Evaluation, Version II. Evidence-based recommendations were extracted from high-quality guidelines and synthesised for the contextualisation process. Part 3 of the project entailed the validation and contextualisation of the clinical recommendations. In study four, a multi-disciplinary panel of experts validated the clinical recommendations for the South African context using a modified Delphi approach. The panel developed context points relevant to the recommendations during a consensus meeting. In study five, potential end-users reviewed the applicability and acceptability of the contextualised clinical practice guidelines through a survey. Results: Twenty patients with CMSP and 21 practitioners participated in Part one. The findings indicated that CMSP influenced patients in multiple ways. Participants largely agreed on the context factors that influence CMSP care, namely the personal characteristics of the patient and practitioner, the social and environmental circumstances within which the patient lives, the healthcare interventions received and healthcare system factors. These contextual factors formed the foundation of the relevant facilitators and barriers to CMSP care in the context investigated. Twelve clinical guidelines on the primary healthcare management of CMSP were identified through the systematic review. Six of these clinical guidelines were of high quality, and 156 recommendations were extracted from them. The recommendations were synthesised using a structured process. The end-result was a core set of 43 multimodal evidence-based, clinical recommendations. Seventeen multi-disciplinary panel members validated the recommendations for the South African context, nominated an extra recommendation and positioned the recommendations within the context of application for primary healthcare. The contextualized guideline was reviewed by a diverse group of 18 end-users who confirmed the clinical guideline to be largely applicable and acceptable for the intended context. Conclusion: The end-product of the project was a contextualised, evidence-based and multimodal clinical guideline for the primary healthcare of CMSP in the Western Cape province of South Africa. The findings indicate that modifications in practice patterns, healthcare system organization and governance will contribute to the successful implementation of the guideline. A inter-/multi-disciplinary approach, with the outcome of the patient as self-manager within a supportive environment, is underscored. Further research avenues include the development of a multilevel implementation plan and a pragmatic trial to investigate the feasibility of the contextualised clinical guideline in the South African context.AFRIKAANSE OPSOMMING : Agtergrond: Daar is wereldwyd besorgdheid oor gesondheidsorg vir kroniese muskuloskeletale pyn (KMSP). Muskuloskeletale toestande is ‘n groot oorsaak van beperkte funksie en morbiditeit in sub-Sahara Afrika. Hoe-kwaliteit, bewysgesteunde kliniese praktyk riglyne is een manier om kwaliteit-gesondheidsorg aan individue met KMSP te lewer. Kliniese riglyne vir KMSP wat in ontwikkelde lande ontwikkel is, is waarskynlik nie toepaslik vir omgewings met beperkte hulpbronne nie, vanwee verskille in die sosio-kulturele, samelewings- en politieke konteks. Die kontekstualisering van bestaande riglyne is dus ‘n opsie. Doel: Die oorhoofse doelwit van hierdie navorsingsprojek was om ‘n gekontekstualiseerde, bewysgesteunde, multimodaliteit kliniese praktyk riglyn vir die primere gesondheidsorg van KMSP in volwassenes in die Wes-Kaap, ‘n provinsie van Suid Afrika, te ontwikkel. Metode: Die navorsing het uit drie dele bestaan: Deel 1 het twee kwalitatiewe beskrywende studies behels om die konteks faktore wat 'n rol speel in die behandeling van KMSP te ondersoek, in ‘n steekproef van drie gesondheidsorgsentrums. Die drie gesondheidsentrums is strategies gekies om landelike, semi-stedelike en 'n stedelike-township te verteenwoordig. Studie een het semi-gestruktureerde onderhoude met pasiente gebruik om hul perspektiewe rakende KMSP, en die behandeling daarvan te ondersoek. In studie twee is semi-gestruktureerde onderhoude met 'n diverse groep gesondheidsorg praktisyns gevoer om hul perspektiewe rakende potensiele kontekstuele struikelblokke en fasiliteerders vir die behandeling van KMSP in primere gesondheidsorg te bepaal. Die onderhoude is opgeneem, getranskribeer en ge-analiseer deur middel van induktiewe inhoud analise. Deel 2 het studie drie van die navorsing behels. 'n Sistematiese oorsig is gedoen om huidige, hoe-kwaliteit kliniese praktyk riglyne ten opsigte van die primere gesondheidsorg van KMSP te identifiseer. Die kliniese riglyne wat voldoen het aan die insluitingskriteria is geevalueer met behulp van die Beoordeling van Kliniese Riglyne Navorsing en Evaluering, weergawe II. Bewysgebaseerde kliniese aanbevelings is vanuit die hoe-kwaliteit riglyne ontgin en verwerk vir die kontekstualiseringsproses. eel 3 van die projek het die bekragtiging en kontekstualisering van die kliniese aanbevelings behels. ‘n Multi-dissiplinere groep kundiges het die kliniese aanbevelings vir die Suid-Afrikaanse primere gesondheidsorg konteks bekragtig deur ‘n aangepaste Delphi-metode (studie vier). Die paneel het kontekspunte relevant tot die kliniese aanbevelings ontwikkel tydens ‘n konsensus vergadering. In studie vyf, het potensiele eindgebruikers die toepaslikheid en aanvaarbaarheid van die gekontekstualiseerde kliniese praktyk riglyn geevalueer deur middel van ‘n vraelys. Resultate: Twintig pasiente met KMSP en 21 praktisyns het deelgeneem aan Deel een van die projek. Die bevindinge dui daarop dat KMSP pasiente op verskeie maniere beinvloed. Deelnemers het grootliks saamgestem oor die konteks faktore wat die behandeling van KMSP beinvloed, naamlik die persoonlike eienskappe van pasiente en praktisyns, die sosiale en die omgewings omstandighede waarbinne die pasient leef, die behandeling ontvang en faktore wat betrekking het op die gesondheidsorg stelsel. Twaalf kliniese praktyk riglyne rakende die primere gesondheidsorg van KMSP is met die sistematiese oorsig geidentifiseer. Ses kliniese riglyne was van 'n hoe gehalte, en 156 aanbevelings is uit die riglyne versamel. Die aanbevelings is met behulp van 'n gestruktureerde proses gesintetiseer. Die eindresultaat was 'n kern stel van 43 multimodale, bewysgesteunde kliniese aanbevelings. 'n Multidissiplinere groep van tot 17 kundiges het die lys van aanbevelings vir die behandeling van KMSP in die Suid-Afrikaanse konteks goedgekeur, ‘n ekstra aanbeveling genomineer en het die aanbevelings binne die konteks van implementering in die Suid-Afrikaanse konteks geposisioneer. Die gekontekstualiseerde riglyn is geevalueer deur 'n diverse groep van 18 eind-verbruikers, wat bevestig het dat die riglyn grootliks toepaslik en uitvoerbaar is vir die bedoelde konteks. Gevolgtrekking: Die eind-produk van die projek was 'n gekontekstualiseerde, bewysgesteunde en multimodale kliniese riglyn vir die primere gesondheidsorg van KMSP in die Wes-Kaap provinsie van Suid-Afrika. Die bevindinge dui daarop dat veranderinge in die praktykpatrone, organisasie en bestuur van die gesondheidsorg stelsel sal bydra tot die suksesvolle implementering van die kliniese riglyn. 'n Inter-/multi-dissiplinere benadering, met die uitkoms 'n pasient as self-bestuurder binne 'n ondersteunende omgewing, word beklemtoon. Verdere navorsing behels die ontwikkeling van 'n multivlak implementeringsplan, asook 'n pragmatiese proefneming om die haalbaarheid van die gekontekstualiseerde kliniese riglyn in die Suid-Afrikaanse konteks te evalueer