title: Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers' perspectives and experiences.
abstract: 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' 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.
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC, Australia , 3004. oyun.chimeddamba@monash.edu.|Mongolian Association of Family Medicine Specialists, Street of Prime Minister Amar, Sukhbaatar District-1, Ulaanbaatar, 14210, Mongolia. oyun.chimeddamba@monash.edu.
authors.forename: Oyun
authors.initials: O
authors.lastname: Chimeddamba
authors.affiliation: Obesity and Population Health, Baker IDI Heart and Diabetes Institute, 99 Commercial Road, Melbourne, VIC, Australia , 3004. anna.peeters@bakeridi.edu.au.
authors.forename: Anna
authors.initials: A
authors.lastname: Peeters
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC, Australia , 3004. Darshini.Ayton@monash.edu.
authors.forename: Darshini
authors.initials: D
authors.lastname: Ayton
authors.affiliation: Department of Health Development, National Center of Public Health, Peace Avenue 17, Bayanzurkh District-3, Ulaanbaatar, Mongolia. enkhjargal@ncph.gov.mn.
authors.forename: Enkhjargal
authors.initials: E
authors.lastname: Tumenjargal
authors.affiliation: Mongolian Association of Family Medicine Specialists, Street of Prime Minister Amar, Sukhbaatar District-1, Ulaanbaatar, 14210, Mongolia. sonin.sodov@gmail.com.
authors.forename: Sonin
authors.initials: S
authors.lastname: Sodov
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC, Australia , 3004. catherine.joyce@monash.edu.
authors.forename: Catherine
authors.initials: C
authors.lastname: Joyce
mesh_terms: D003920:Diabetes Mellitus / Q000628:therapy*; D017144:Focus Groups; D019983:Guideline Adherence; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D007407:Interviews as Topic; D008986:Mongolia; D058007:Physicians, Primary Care / Q000523:psychology; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D016730:Program Development; D036301:Qualitative Research; D014505:Urban Population