Implementing global knowledge in local practice: a WHO lung health initiative in Nepal

Abstract

Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the 'implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.

Practical Approach to Lung Health in Nepal: better prescribing and reduction of cost

“…2005). In Nepal, the Ministry of Health (MoH) introduced the generic PAL guidelines in one district, adapting them to national circumstances (Asbroek et al. 2005), and training primary healthcare workers from selected pilot health facilities in them.…”

Making the AGREE tool more user‐friendly: the feasibility of a user guide based on Boolean operators

“…The simplicity of the Boolean operator framework means that elements can be rewritten to reflect the perspectives of appraisers, and their particular stakeholder groups, and to allow for the characteristics peculiar to the set of guidelines being analysed. For example, guidelines written for less developed countries may have extensive generic background material that would not normally score well on AGREE, but which is necessary for less skilled health workers [35]. The Boolean‐based User Guide can be rewritten so that scorers can accommodate this.…”

Practical approach to lung health: lung health for everyone?

“…The assessment of PAL feasibility in rural Nepalese areas showed that to improve implementation, the national guidelines should be better and the implementation strategy upgraded [44]. It is vital to keep health centre staff engaged and aware of the value of the study.…”

“…The integration of guidelines requires intensive collaboration, bringing together key personnel from multiple Ministry of Health Units and vertical disease programmes [45]. It is necessary to develop additional interventions that tackle culture-specific and health system-specific barriers [44].…”