Improving the adaptation and implementation of public health guidelines

Background and Objectives Evidence-based guidelines could more effectively guide clinical practice and public health decisions if they are appropriately contextualised to their implementation setting. This dissertation explored three aspects of adaptation and implementation of public health guidelines: • Adaptation Frameworks: Many frameworks have been developed to describe and structure the process of guideline adaptation. I compared the advantages and disadvantages of currently available frameworks. • Experiences of Guideline Implementers: The on-the-ground experiences of WHO guideline implementers offer a different perspective on the process of guideline adaptation and implementation than those described in academia. I explored whether and how WHO guidelines are implemented in local contexts. • Active Resistance Against Guideline Implementation: Particular guidelines may be so against the common practice, values and preferences of the end user that the users stage an active resistance against their implementation. I examined this phenomenon through a case study of the resistance against the 2018 Canadian breast cancer screening guideline. Methods My methods included: 1. A systematic review of the published guideline adaptation frameworks. 2. A qualitative study utilising semi-structured interviews with WHO officers to explore their experiences with guideline adaptation and implementation. 3. A case study examining active resistance, through the lens of theories of Professionalism, Conflict of Interest, and Evidence-Based Medicine. Results I offer an overview of the academic understanding of the ideal guideline adaptation process by comparing the adaptation frameworks. Through the interviewers with WHO officers, I discovered that guidelines are utilised in a variety of ways and fulfil multiple roles in the work of WHO. Further, the interviews illuminated the diverging models of guideline adaptation that are prevalent in different settings. The case study of active resistance against guideline implementation revealed the multiple drivers of resistance. Conclusions My findings suggest ways that guideline developers, policy makers and health policy researchers can improve guideline adaptation and implementation. In particular, evaluation of the current innovations in the guideline process can be a stepping stone to future modifications to the process and products of guidelines. The value of the resources that is invested into the development and implementations guidelines depends on maximising the number and diversity of ways that they can be utilised