Health Systems and Public Health

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Browsing Health Systems and Public Health by browse.metadata.advisor "Bruijns, Stevan"

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    Strengthening pre-hospital clinical practice guideline development for South Africa
    (Stellenbosch : Stellenbosch University, 2020-12) McCaul, Michael Gilbert; Clarke, Mike; Young, Taryn; Bruijns, Stevan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    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the first evidence-based prehospital clinical practice guideline was developed for South African paramedics, replacing outdated and eminence-based practice protocols.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.