Implementation of hypertension and guidelines in urban Mongolia: A Qualitative study of primary care providers

Introduction: Hypertension and diabetes are an emerging problem within Mongolia. The prevalence of high blood pressure was 28.1% and diabetes 8.2% in 2009. Cardiovascular disease (CVD) has been one of the leading causes of mortality since 2000. NCD Risk Factors Survey in Mongolia conducted in 2009 found that a large proportion of the population has never had their blood pressure (42.6%) or blood glucose (85.2%) measured. This suggests that early detection of risk factors for diabetes and CVDs is limited in Mongolia. Short description of practice change implemented: In 2011, the working group of the Ministry of Health, Mongolia in co-operation with Millennium Challenge Account-Mongolia Health Project developed and published clinical guidelines on arterial hypertension and diabetes. Primary prevention is the main focus of the guidelines. Family physicians, nurses, dieticians and podiatrists comprising the health care team are responsible for most primary diabetes and hypertension care. However, there is international evidence that guidelines are not always implemented well in practice. Aim and theory of change used if any: There has been no attempt to examine how the guidelines have been implemented and applied at the primary care level in Mongolia. This paper aims to explore the experiences, barriers, and enablers to implementation of these guidelines in primary care settings. Targeted population and stakeholders: A qualitative study with semi-structured interviews was conducted to explore the process of implementing the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the guidelines and their implementation. Twenty individual interviews and ten focus group discussions were conducted with primary care providers in urban Mongolia. Data was analysed using a thematic inductive approach. Timeline: The research was conducted from November 2013 to February 2014 in Ulaanbaatar city, Mongolia. Highlights: (innovation, Impact and outcomes) All study participants were aware of the guidelines, and were using them in daily practice. A number of study participants attended guideline training sessions to enhance their knowledge and skills associated with guideline recommendations. A 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117081– http://www.ijic.org/ wide range of resources, including screening devices, blood tests, medications and educational materials, had been supplied by the Mongolian Government. This study found that primary care providers experienced a number of challenges in implementing the guidelines including frustration caused by increased workload, and low patient health literacy. Conclusions: (comprising key findings) The supply of medical appliances and numerous training sessions contributed to the positive experiences of primary care providers in implementing the diabetes and hypertension guidelines in urban Mongolia. In this sample of practitioners there appears to have been good uptake of the guidelines, which were integrated effectively into daily practice. Primary practitioners gained new knowledge and skills in implementing the guidelines and were able to incorporate them into their primary care practices. Discussions: This study provides strong evidence that comprehensive and rigorous dissemination and implementation strategies might be a prerequisite for the successful implementation of guidelines. The study critically underlines a significance of legal background embedded in strong professional culture, employment relationship between providers and funders, funding mechanism tied with a state budget and hierarchically-built health system design. These aspects led to a widespread acceptance and broad adoption of the guidelines. Lessons learned: This study provides a key message/lesson to be carefully considered when other evidence based clinical guidelines are released into effect in Mongolia and elsewhere. There are a variety of systemic or organisational barriers to the implementing the guidelines, which include lack of time due to competing tasks, lack of necessary built environment to exercise the lifestyle interventions, increased workload due to a number of new services and clinical procedures introduced along with the guidelines and complexity of some aspects in the guidelines that must be carefully reviewed prior to launch any clinical guidelines. By not considering the variety of barriers, interventions to improve adherence are less likely to be successful. We strongly urge that the issuing of guidelines should be preceded by workload studies as well as situational analyses so that resources can be put in place before their implementation to enable evidence-based changes in medical practice that should result in reducing the long term cardiovascular consequences of hypertension and diabetes.


Short description of practice change implemented:
In 2011, the working group of the Ministry of Health, Mongolia in co-operation with Millennium Challenge Account-Mongolia Health Project developed and published clinical guidelines on arterial hypertension and diabetes.Primary prevention is the main focus of the guidelines.Family physicians, nurses, dieticians and podiatrists comprising the health care team are responsible for most primary diabetes and hypertension care.However, there is international evidence that guidelines are not always implemented well in practice.

Aim and theory of change used if any:
There has been no attempt to examine how the guidelines have been implemented and applied at the primary care level in Mongolia.This paper aims to explore the experiences, barriers, and enablers to implementation of these guidelines in primary care settings.

Targeted population and stakeholders:
A qualitative study with semi-structured interviews was conducted to explore the process of implementing the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the guidelines and their implementation.Twenty individual interviews and ten focus group discussions were conducted with primary care providers in urban Mongolia.Data was analysed using a thematic inductive approach.wide range of resources, including screening devices, blood tests, medications and educational materials, had been supplied by the Mongolian Government.This study found that primary care providers experienced a number of challenges in implementing the guidelines including frustration caused by increased workload, and low patient health literacy.
Conclusions: (comprising key findings) The supply of medical appliances and numerous training sessions contributed to the positive experiences of primary care providers in implementing the diabetes and hypertension guidelines in urban Mongolia.In this sample of practitioners there appears to have been good uptake of the guidelines, which were integrated effectively into daily practice.Primary practitioners gained new knowledge and skills in implementing the guidelines and were able to incorporate them into their primary care practices.

Discussions:
This study provides strong evidence that comprehensive and rigorous dissemination and implementation strategies might be a prerequisite for the successful implementation of guidelines.The study critically underlines a significance of legal background embedded in strong professional culture, employment relationship between providers and funders, funding mechanism tied with a state budget and hierarchically-built health system design.These aspects led to a widespread acceptance and broad adoption of the guidelines.

Lessons learned:
This study provides a key message/lesson to be carefully considered when other evidence based clinical guidelines are released into effect in Mongolia and elsewhere.There are a variety of systemic or organisational barriers to the implementing the guidelines, which include lack of time due to competing tasks, lack of necessary built environment to exercise the lifestyle interventions, increased workload due to a number of new services and clinical procedures introduced along with the guidelines and complexity of some aspects in the guidelines that must be carefully reviewed prior to launch any clinical guidelines.By not considering the variety of barriers, interventions to improve adherence are less likely to be successful.We strongly urge that the issuing of guidelines should be preceded by workload studies as well as situational analyses so that resources can be put in place before their implementation to enable evidence-based changes in medical practice that should result in reducing the long term cardiovascular consequences of hypertension and diabetes.

Timeline:
The research was conducted from November 2013 to February 2014 in Ulaanbaatar city, Mongolia.Highlights: (innovation, Impact and outcomes) All study participants were aware of the guidelines, and were using them in daily practice.A number of study participants attended guideline training sessions to enhance their knowledge and skills associated with guideline recommendations.A 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 International Journal of Integrated Care -Volume 15, 27 May -URN:NBN:NL:UI:10-1-117081-http://www.ijic.org/