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

[摘要] 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.

[发布机构] Stellenbosch University