Enhancing capacity for clinical practice guidelines in South Africa

Introduction Use of good quality, evidence-informed and up-to-date clinical practice guidelines (CPGs) has the potential to impact health outcomes. This paper describes the development, implementation and evaluation of a dedicated CPG training course to address the training needs of CPG stakeholders in South Africa. Methods We first reviewed the content and teaching strategies of existing CPG courses. This review consisted of a systematic review of teaching and learning strategies for guideline teams and a document review of existing courses offered by international guideline groups, universities and professional groups. We then strengthened an existing CPG course and evaluated it. Results We found no studies on teaching and learning strategies for guideline teams. We identified six CPG courses being offered as full courses (part of a postgraduate degree program) by universities or as independent training for continuing professional education by professional groups. Contents focused on new guideline development. One course included alternative methods of guideline approaches such as contextualization and adaptation. The format varied from face-to-face sessions, to online sessions, group exercises and discussions, seminar format and project based activities. The revised CPG four-month long course that we implemented was designed to be pragmatic, reflective and contextually relevant. It used local guideline examples, authentic tasks, and an online forum for discussions and resources. It covered de novo CPG development, alternative methods of development (adopting, contextualising, adapting), and implementing CPGs. Course evaluation identified strengths and areas for improvement. Conclusion Dedicated capacity development has potential to positively influence CPG development and implementation.


Introduction
High quality, evidence-informed clinical practice guidelines (CPGs) offer a way of bridging the gap between policy, best-practice, local contexts and patient choice [1]. Good quality CPGs offer a 'one stop shop' for end-users [2]. They present current best evidence (primary, secondary or opinion-based) to answer questions pertaining to care for a health condition [3]. The development of CPGs has traditionally been motivated by the need to improve efficiency and cost-effectiveness of health system utilization, and to decrease costly and preventable mistakes and adverse events [4]. CPGs are intended to provide transparent synthesis of the evidence on which sound, 'on balance' judgments can be made by clinicians, administrators, policy-makers and patients. Evidence-informed decisions should minimise over-, under-or mis-use of services [5]. Constructing a good quality CPG and presenting recommendations in a user-friendly format is a more complex process, compared to constructing other forms of secondary evidence (such as systematic literature reviews) [6]. CPG construction usually involves multiple stakeholders including content experts, methodologists, systematic reviewers and guideline users.
CPG methodologists have knowledge and experience to conduct evidence syntheses of multiple clinical questions for a single guideline, and guide the transparent and justified approach to assess the level of evidence to inform the final recommendation. Furthermore, the ability to formulate real-world recommendations is not only based on the evidence but also considers other factors such as applicability and acceptability to a local context. Consequently, specific training is required to understand the nuances of CPG writing, and to assist in efficient task completion.
South Africa has a long history of developing various CPGs. Key role players include the National Department of Health, professional societies, private sector and non-governmental organisations producing guidance for their respective constituents. Our team came together in 2014 to conduct the South African Guidelines Excellence (SAGE) Project [7]. We undertook a range of projects to understand the context, processes, and the need for, South African CPGs. Project SAGE explored perspectives of over 100 CPG stakeholders, regarding CPG development and use, how they assessed CPG believability and impact, how they implemented CPGs and what implementation barriers they faced [8][9][10]. Stakeholder interviews, particularly those involved with CPG development activities, consistently expressed a need for greater technical capacity to develop and implement CPGs.
This was perceived to be important to ensure efficient and competent CPG construction, interpretation, updating and implementation. This finding was supported by the quantitative evaluation of 16 South African primary care clinical CPGs which were critically appraised for methodological quality. This activity found these CPGs to be substantially lacking in their reporting on methodological rigour, applicability and editorial independence [11,12]. Project SAGE findings led to an innovative model of CPG transferability and implementation (adopt, contextualise, adapt) [8,13]. In response to the gaps we identified in CPG reporting, and the expressed need for capacity building in evidence-informed CPG development and implementation, this paper describes the development, implementation and evaluation of a dedicated CPG training course to address the training needs of CPG stakeholders in South Africa.

Methods
We first reviewed the content and teaching strategies of existing CPG courses using a systematic review of teaching and learning strategies for guideline teams and a document review of existing courses offered by international guideline groups, universities and professional groups. We then developed, implemented and evaluated a CPG course targeted to the needs of end-users in resource constrained environments.

Results
Systematic review: our search for teaching and learning strategies yielded 6224 hits. Upon screening the titles and abstracts, we found nine potentially-eligible studies and excluded all upon reading the full texts, three articles were primary guidelines [15][16][17], two focused on guideline methodology [18,19], two were on guideline implementation [20,21] and two were surveys on methodological process [22,23] (Figure 1). Thus, we found no eligible studies from our systematic literature review.
Document review of existing CPG courses: we found six (6)

Discussion
With the growth in evidence-informed practices in the African region [24,25] and the recognised role of evidence-informed CPGs in shaping healthcare practices, there is an increasing need, and demand for, building capacity for evidence-informed CPG development and implementation [9,10]. This paper described the development, implementation and evaluation of a dedicated CPG training course designed to meet specific development needs in South Africa and other similar resource constrained settings. The paucity of courses may be that CPG activities are traditionally learned on the job with panels often consisting of practicing clinical experts. However, this approach has long been recognised as insufficient [26]. Evidence of poor CPG quality, globally and in our region, provide a sound case for the need for additional training [12,[27][28][29]. In response to these needs, we used an already available CPG course offered as part of the awareness and discussion of these approaches [13,31]. We are already seeing the benefits of skills development as students exposed to CPG training have lead CPG processes using rigorous reportable methods [32,33].

Conclusion
We used an evidence-informed multifaceted approach to enhance a master's level CPG course for the needs of CPG developers and implementers in resource constrained settings. Dedicated, evidence-informed capacity development for CPG activities may empower current and future CPG developers and end-users and has the potential to positively influence CPG development and implementation.
What is known about this topic • High quality, evidence-informed CPGs offer a way of bridging the gap between policy, best-practice, local contexts and patient choice; • There is an increasing need, and demand for, building capacity for evidence-informed CPG development and implementation.

What this study adds
• There are limited robust evaluations of CPG capacity-development initiatives; • This paper described the development, implementation and evaluation of a dedicated CPG training course designed to meet specific development needs in South Africa; • The course fills a specific gap for decision-makers from resource constrained settings.

Competing interests
The authors declare no competing interests.  Table 1: CPG module characteristics