Strengthening pre-hospital clinical practice guideline development for South Africa

Thesis (PhD)--Stellenbosch University, 2020.ENGLISH SUMMARY : In 2016, the first evidence-based prehospital clinical practice guideline was developed for South African paramedics, replacing outdated and eminence-based practice protocols. Rather than de novo development, alternative methods were used to develop these guidelines. These methods, however, require further strengthening and there is a modest gap in the literature regarding such methods. This strengthening would make it possible to address issues in current and future guideline development and implementation practices in South Africa and beyond, especially in resourcelimited settings. Issues include poor guideline quality and lack of appropriate methods, especially in prehospital care. In this thesis, I explore how to strengthen prehospital clinical practice guideline (CPG) development and implementation in low-resource settings. Using the African Federation for Emergency Medicine (AFEM) prehospital CPG as a case study, I used various research methods to i) identify, map and appraise global and regional prehospital guidelines (via a descriptive study and a scoping review); ii) describe and strengthen guideline development methods (via a qualitative case study, an expert review and a critical reflection/report); and iii) identify guideline implementation challenges and solutions (via a qualitative implementation research study). I show that overall, both global and regional (African) prehospital guidance quality is poor; however, an existing pool of high-quality CPGs can be adapted to fit national and local settings. I identify guideline development and implementation challenges within the AFEM guideline project and provide solutions and linked priority actions for guideline stakeholders. Considering these results, I have produced an alternative guideline development roadmap for prehospital guideline development in South Africa and beyond. This PhD argues that in order to strengthen existing and future prehospital CPG and end-user products, I suggest developers use existing high-quality guidelines, together with national policy and evidence to support context-specific recommendations. I argue that when developing and implementing guidelines, careful consideration of conflicts of interest during implementation decisions must be considered, together with ensuring wide and open consultation with stakeholders. To support robust development, I provide a critical report and roadmap for guideline development producers in resource-limited settings. This PhD highlights implications for future research, including the need to determine the cost-effectiveness of alternative versus de novo methods, identify prehospital topics with the greatest impact where CPGs are lacking, exploring the roles, need and objectives of policy-makers in prehospital guideline development, and testing and evaluating methods of dealing with consolidating multiple conflicting CPG recommendations and levels of evidence.AFRIKAANSE OPSOMMING : In 2016 is die eerste bewysgebaseerde voorhospitaalse kliniese praktykriglyn vir Suid-Afrikaanse paramedici ontwikkel, wat verouderde en vooropgestel-gebaseerde praktykprotokolle vervang. Alternatiewe bewysgebaseerde metodes is gebruik om hierdie riglyne te ontwikkel. Hierdie metodes wys 'n beskeie leemte in die literatuur en vereis verdere versterking. Dit is nodig om huidige en toekomstige riglyne vir die ontwikkeling en implementering van riglyne aan te spreek - wat swak riglynkwaliteit en 'n gebrek aan toepaslike metodes in voorhospitaalse sorg insluit - in Suid-Afrika en verder, veral in omgewings met beperkte hulpbronne. In hierdie tesis ondersoek ek hoe om die ontwikkeling en implementering van voorhospitaalse kliniese riglyne (VKR) vir die kliniese praktyk in lae-hulpbronomgewing te versterk. Met behulp van die “African Federation for Emergency Medicine (AFEM)” voorhospitaalse kliniese riglyne as 'n gevallestudie, het ek verskillende navorsingsmetodes gebruik om i) globale en streeks voorhospitaalse riglyne te identifiseer, te karteer en te beoordeel (via beskrywende studie en bestekopname); ii) riglyne-ontwikkelingsmetodes te beskryf en te versterk (via kwalitatiewe gevallestudie, kundige oorsig en kritiese besinning / verslagdoening); en iii) riglyne vir implementerings uitdagings en -oplossings (via kwalitatiewe implementeringsnavorsing) te identifiseer. Ek toon aan dat die globale sowel as streeks- (Afrika-) voorhospitaalse voorligtingkwaliteit oor die algemeen swak is; 'n bestaande poel hoë-gehalte-kliniese riglyne kan egter aangepas word om by die plaaslike instellings te pas. Ek identifiseer riglyne-ontwikkeling en implementeringsuitdagings binne die AFEM-riglynprojek en bied oplossings en gekoppelde prioriteitsaksies vir belanghebbendes. As ek hierdie resultate in ag neem, het ek 'n alternatiewe riglyn vir die ontwikkeling van riglyne vir prehospitaalse riglyne in Suid-Afrika en verder opgestel. Hierdie PhD argumenteer dat, ten einde die bestaande en toekomstige VKR en eindgebruikersprodukte te bevorder, voorstel ek dat ontwikkelaars bestaande riglyne van hoë gehalte gebruik, saam met die plaaslike beleid en bewyse om kontekspesifieke aanbevelings te ondersteun. Ek argumenteer dat by die opstel en implementering van riglyne, noukeurige oorweging van belangebotsings tydens implementeringsbesluite oorweeg moet word, tesame met die versekering van 'n wye en oop konsultasie met belanghebbendes. Om robuuste ontwikkeling te ondersteun, bied ek 'n kritiese verslag en 'n padkaart vir produsente wat riglyne ontwikkel in hulpbronbeperkte omgewings. Hierdie PhD beklemtoon implikasies vir toekomstige navorsing, met inbegrip van die noodsaaklikheid om die koste-effektiwiteit van alternatiewe teenoor de novometodes te bepaal, voorhospitaalse onderwerpe te identifiseer wat die grootste impak het waar riglyne ontbreek, die rol, behoefte en doelstellings van beleidmakers in die ontwikkeling van voorhospitaalse ondersoek, en metodes om die konsolidering van verskeie teenstrydige riglyne - aanbevelings en bewyse te toets en te evalueer.Doctora