Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers\u27 perspectives and experiences

BACKGROUND: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting. METHODS: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework. RESULTS: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants\u27 commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy. CONCLUSIONS: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere

Increases in waist circumference independent of weight in Mongolia over the last decade: the Mongolian STEPS surveys

Abstract Background In Mongolia, mean waist circumference (WC) has increased dramatically over the last decade, however, it is unknown whether these increases have been greater than corresponding increases in weight. In this study we aimed to assess whether recent increases in WC were greater than expected from changes in weight in Mongolian adults. Methods We used data on 13260 Mongolian adults, aged between 18 and 64 years, who participated in one of three (2005, 2009, 2013) nationally representative cross-sectional surveys. Linear regression was used to estimate changes in mean WC over time, adjusted for age, sex, height and weight. We also estimated the age-standardised prevalence for four obesity classification categories (not obese; obese by WC only; obese by body mass index (BMI) only; obese by both BMI and WC) at each survey year. Results The estimated mean WC in 2009 and 2013, respectively, was 1.26 cm (95% CI: 0.35 to 2.17) and 1.88 cm (95% CI: 1.09 to 2.67) greater compared to 2005, after adjusting for age, sex, height and weight. Between 2005 and 2013, the age-standardised prevalence of those obese according to both BMI and WC increased from 8.0 to 13.6% for men and from 16.5 to 25.5% for women. During the same period, the percentage who were obese by WC only increased from 1.8 to 4.8% for men and from 16.5 to 26.8% for women. In contrast, the percentage who were obese by BMI only remained relatively stable (women: 2.4% in 2005 to 1.0% in 2013; men: 2.7% in 2005 to 4.0% in 2013). Conclusion Over the last decade, among Mongolian adults, there has been substantially greater increase in WC and the prevalence of abdominal obesity than would be expected from increases in weight. Women are at greater risk than men of being misclassified as not obese if obesity is defined using BMI only. Obesity should be monitored using WC in addition to BMI to ensure the prevalence of obesity is not underestimated