Developing practice points for healthcare workers to optimise lymphoedema care in low and middle-income countries: a nominal group technique

Abstract Background: Lymphoedema is a common, distressing, and debilitating condition affecting over 200 million people globally. While the World Health Organization has developed a Wound and Lymphoedema Management guidance document to support lymphoedema care in low- and middle-income countries (LMIC), it mainly focuses on lymphoedema caused by wounds and infectious filariasis and has limited content on lymphoedema diagnosis and assessment. Several lymphoedema clinical practice guidelines have been developed for high-income countries (HIC), but some recommendations are unlikely to be feasible in low-resource settings. Aim: To develop practice points for healthcare workers that optimise lymphoedema care in LMIC. Methods: A nominal group technique (NGT) was undertaken to gain consensus on which content from HIC guidelines are important and feasible to include in practice points for LMIC, plus other important advice or recommendations. Participants included experts, clinicians, and volunteers involved in lymphoedema care in LMIC. The NGT followed five key stages: silent ‘ideas’ generation, round-robin rationale, clarification, refinement and verification. The first, fourth and fifth stages were completed via email, and the second and third during a video meeting. Practice points were divided into prevention, assessment, diagnosis, and management of lymphoedema in LMIC. Results: Of 16 participants invited, 10 members completed stage 1 of the NGT (ideas generation), of whom six contributed to stages 2 (round-robin) and 3 (clarification). All those who completed stage 1 also completed stages 4 (refinement) and 5 (verification). Practice points unanimously agreed on included Complex Decongestive Therapy (CDT) and good skin care, with management to be determined by lymphoedema stage. For podoconiosis-endemic areas, the use of socks and shoes was identified as very important in the prevention of non-filarial lymphoedema and other lymphoedema-causing conditions. Participants indicated that diagnosing lymphoedema using the lymphoscintigraphy and Indocyanine green (ICG) fluorescent lymphography was not possible due to unavailability and cost in LMIC. Surgical procedures for lymphoedema management were unanimously eliminated due to the unavailability of technology, limited workforce, and expensive cost in LMIC. Conclusion: The consensus-based practice points generated by this project provide healthcare workers with guidance on caring for people with lymphoedema in LMIC. Further development of workforce capacity is needed.