Adapting guidelines to local settings

Using the best evidence is essential to support quality healthcare and develop valid guidelines for clinical practice to inform evidence-based practice. Clinical practice guidelines are generally developed from synthesized evidence that has been translated into specific practice-oriented recommendations.1 Practice guidelines are used in many settings to reduce variations across clinical practice and to ensure the use of the best available evidence for patient care. Many organizations across the world are adapting existing high-quality guidelines in their own settings to avoid work duplication and enhance applicability. However, little research is done into the best way of adapting clinical practice guidelines into local settings. The challenge in this area is compromising the integrity of the evidence base and the resources required for the implementation of the guidelines.1,2 A few systematic reviews addressed the effectiveness of adaptation models of clinical guidelines into local settings.3–5 Gagliardi et al. developed a framework of guidelines implementation into local settings. The framework consisted of 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation and evaluation. Another review identified the importance of opinion leaders, reminders and feedback to be essential in translating evidence into practice.3 A third review of the literature identifying factors that are important in guidelines implementation in low-income countries found several challenges to translate evidence into practice.4 Some of these barriers included the degree of support from facility management and higher organizations such as the Ministry of Health or similar organizations, credibility and acceptability of clinical guidelines from the viewpoint of healthcare providers and willingness to adapt clinical guidelines to local circumstances.5 Wang et al. identified two main ways to adapt existent guidelines in local settings. These were divided into formal and informal processes. The informal process may include identifying international guidelines on a particular area in the literature, compare them according to the Appraisal of Guidelines Research and Evaluation instrument and then develop a best practice guideline for the local setting. Another example of an informal adaptation is at either a local provider or a patient level, when doctors use international guidelines and apply them in an ad-hoc manner for their local patients. Such an adaptation may not be suitable as it poses the risk of working outside the scope of practice of the practitioners in their countries.7 Another approach of guidelines adaptation is a formal process. This process involves several steps of implementation. Examples of these steps include forming a committee of experts in the field on a particular topic, identifying resources and skills required for the process, devising an adaptation plan, searching for relevant guidelines, formal screening and evaluating the existing guidelines, external reviewing of the adapted guidelines by experts in the field and relevant endorsement bodies and finally scheduling reviews for guidelines updates.7 Several implementation frameworks are described in the literature such as the ADAPTE, the Alberta Ambassador Program adaptation process, CAN-IMPLEMENT, SNAP IT by GRADE MAGIC and Adapted ADAPTE.7,8 They all have four main stages and these are defining the health questions, searching and screening the guidelines, evaluating the guidelines and selecting a single or a set of guideline/s to adapt.7,8 Some of the limitations of the above-mentioned frameworks are the lack of information about the resources, time and cost needed for the implementation of the guidelines. Other limitations are the need for specialized experts in methodologies to be able to evaluate the evidence generated, and a lack of data on their uptake by organizations and patient-related outcomes.6–8 Having a checklist of and procedures on how to implement guidelines into local settings might be one way of enhancing their uptake. Furthermore, dedicating a section in each newly developed guideline on adaptation methods might facilitate their uptake into various and differing settings. Finally, clinical decisions about guideline use and implementation are influenced by the availability and mobilization of organizational or system level resources, which are governed by managers and policy makers who need to meet the competing interests of multiple stakeholders. Guidelines adaptation has been a recent priority of the WHO, and further research is needed into effective ways to adapt high-quality guidelines developed in high-income countries into different settings, especially in low-income countries. Acknowledgements Conflicts of interest The author reports no conflicts of interest.

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