Page 345 Guide to Pain Management in Low-Resource Settings

Setting up Guidelines for Local Requirements 333

regarding the motives for encouraging their use or as list accordingly. To give an example, the introduction
to their credibility. Th is has been recognized as a defi - of basic palliative care in East African Uganda was only
cit, since certain motives could cause practitioners and possible when the essential drug list was amended by
their patients to resist PGs. adding morphine.
Some studies indicate that the physician’s ad- Another fact to be respected when introducing
herence to guidelines may be hindered by a variety of PGs in low-resource settings is the disparity regarding
barriers. Identifi ed were: (i) awareness, (ii) familiarity, access to medical services depending on geographic
(iii) agreement, (iv) self-effi cacy, (v) outcome expec- factors, such as the diff erence between the capital and
tancy, (vi) ability to overcome the inertia of previous rural regions or the diff erence between underfunded
practice, and (vii) absence of external barriers to per- national health system institutions and high-standard
form recommendations. private ones.
Another factor that may slow down adherence On the one hand, PGs have to be adapted in a
by physicians to PGs may be the dogmatic educational stepwise structure to be used depending on the resourc-
background. For example, Canadian family physicians es available, and on the other hand, PGs may be used as
show little resistance to guidelines and appear to need an instrument to optimize resources and the quality of
less threat of external control to incorporate them into delivery of health care.
their practice. On the other hand, American internists Also, certain national diff erences exist, due to
are less supportive of PGs. It is possible that informa- cultural, ethnic/genetic, and traditional reasons, regard-
tion acquired from medical training may play a role in ing the use of certain drugs and procedures. In Mexico,
PG support from practitioners. Th erefore, the develop- for example, 80% of the population use herbal medi-
ment of PGs must include lecturers and opinion lead- cine, and 3,500 registered medical plants with medicinal
ers at medical schools and respected organizations to properties are available. For that reason, phytotherapy
foster dissemination. or other complementary medicine could be considered
Th e clarity and readability and the clinical ap- for inclusion in locally adapted PGs.
plicability of a guideline are other elements that con- Finally, potentially eff ective dissemination and
tribute to the acceptance of guidelines by clinicians. education techniques developed in high-resource set-
In conclusion, PGs must be written in a user-friendly tings may also have to undergo some changes to be fea-
way, adapted to the practical needs of the clinician’s sible in a specifi c low-resource setting. It is understood
daily practice, and advocated thoroughly by medical that such an initiative will mean a considerable eff ort,
boards, opinion leaders, and medical societies. If the although the work of local PGs could at least be based
implementation of a PG is successful, the results for on international accepted PGs. It will be necessary to
patient safety are encouraging. get all stakeholders at one table: rural and academic
practitioners, other health providers, patients and their
Why must practice guidelines families, local organizations, and academic institutions.
consider regional resources? Th is sounds like a lot of work, but the gain in safety and
economy following the publication and implementation
Developing countries have limited access to expensive of (adapted) PGs will justify the eff ort.
drugs or procedures. Th erefore, PGs must consider
regional resources for their feasibility and routine ap-
Pearls of wisdom
plication, often making it impossible to simply copy
international PGs. It may be inevitable to make certain • Practice guidelines (PGs) are “a systematically de-
evidence-based approaches to diagnosis and treatment veloped statement to assist the practitioner’s and
optional, e.g., by including phrases like “if available.” Ex- patient’s decisions about appropriate health care
isting PGs have to be adapted if possible according to for specifi c clinical circumstances.” Guidelines are
the national “essential drug list.” If no reasonable alter- not rules or standards, but they are a helpful, fl ex-
native drug choice is available, no further compromise ible synthesis of all the available, relevant, high-
for a national PG is recommended. Instead, the essen- quality information applicable to a particular
tial drug list should be targeted. Th e eff ort should be clinical situation, so that the clinician and patient
made to encourage all stakeholders to change the drug may make a good decision.