Assessment of implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states/ Sudan

Assessment of implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states/ Sudan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states/ Sudan Hiba Salah Abdelgadir, Sahar Bajouri, Hind Salah Abdelgadir This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4316227/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jul, 2024 Read the published version in BMC Primary Care → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction: The health system in Sudan faces several challenges, including increasing numbers of patients, shortages of health supplies, and disparities in the distribution of health services. Guidelines implementation improves patients’ outcomes and ensures efficient use of the resources in such a resources limited country. The study aimed to assess the implementation of the clinical practice guidelines among family medicine doctors working in the primary health care centers in Khartoum and Gezira states to provide baseline data about the current practice in Sudan. Methods: Descriptive cross-sectional facility-based survey, conducted from April to December 2021, on 373 of the practicing family-medicine doctors. A total of 101 Primary health care centers were surveyed (77 centers in Khartoum state and 24 in Gezira state). The questionnaire was pilot tested on a small group of physicians to improve clarity and reduce response bias. Descriptive statistics were used to summarize the data and analyzed by frequency tables. Chi square and logistic regression tests were used to determine the association between categorized variables. P value < 0.05 was considered statistically significant. Results: Most of the practicing family-medicine doctors (98.4%) reported implementation of the guidelines. Moreover, (68.6%) of them received training programs which were organized and funded by the Sudan Ministry of Health. The local Sudanese guidelines were difficult to access and not regularly updated. Services unavailability and inaccessibility (87.1%), health insurance factors (83.9%), and patient factors (81.2%) were the most frequent barriers to guidelines implementation. Service cost (79.9%), lack of regular training programs (79.9%), absence of local guidelines (77.2%), lack of continuity in the comprehensive care process (63.0%), and lack of time (57.1%) were also reported as barriers to guidelines implementation. Conclusion: Guidelines implementation is limited by unavailability and inaccessibility of the health services and the health insurance limited coverage. Expansion of the health insurance coverage, organization of continuous training programs, encouragement of regular auditing and issuing regulations to ensure the use of updated guidelines, dissemination of the updated national guidelines along with establishing clinical governance in Sudan are highly recommended. Clinical Guidelines Implementation Adherence Family Medicine Primary Health Care Government Clinical Governance Sudan. Figures Figure 1 Figure 2 Introduction Clinical practice guidelines (CPG) are designed to assist health care practitioners in specific clinical conditions (1). They considered as a transformation tool in practice and policy, that covers the clinical circumstances according to evidence-based information that was summarized to assist and regulate the clinical care by providing scientific information for decision-making in order to improve patients outcome (2–4). CPG acknowledges the practicing doctors with evidence-based treatment methods and types of intervention through clearly stated recommendations. Moreover, they summarize various treatment options and plans of management tailored to suit the patient's needs according to their clinical presentation (5, 6). Implementation of the guideline’s recommendations regulate the clinical work and increase the confidence of the practicing doctors. Furthermore, CPG implementation play a role in improving patients compliance to treatment as they are informed with the evidence-based treatment methods (6, 7). CPG considered efficient tool to reduce the gap between the evidence based recommendations and the physicians clinical practice (8). To improve the quality of care, the global development and implementation of clinical practice guidelines have increased (9). Issuing regulations by the policy makers and establishment of the clinical governance ensure regular implementation of the updated guidelines recommendations (1) Despite their importance in improving the quality of medical care, and the witnessed increase of their implementation at the global level during the past several decades, there is no acknowledged standard approach to developing, adapting or implementing CPGs efficiently or effectively in Sudan (1, 10). The overall objective of the study was to investigate the implementation of clinical practice guidelines among family medicine doctors working in the referral primary health care centers in Khartoum and Gezira States in Sudan. Methods Study design and population: Descriptive cross-sectional facility-based survey was conducted in the public referral primary health care centers in Khartoum and Gezira States in Sudan during period from April to December 2021. A total of 101 primary health care centers were surveyed ( 77 centers in Khartoum state and 24 in Gezira state). The study targeted all practicing family medicine doctors in the referral primary health care centers in both Khartoum and Gezira, ( 321 in Khartoum state and 79 in Gezira State). A total of 373 doctors responded to the survey ( 301 in Khartoum state and 72 in Gezira state). The surveyed doctors were either M.Sc. holders/residents or Medical Doctorate (MD) holders/residents. Trained research assistants and enumerators were employed to collect data with use of a pre coded and pretested structured questionnaire which revised, modified, edited, and finalized after piloting. Table (1) shows the distribution of the family medicine doctors in the localities and the PHC centers in Khartoum and Gezira states. Table (1): Distribution of the practicing family medicine doctors and the PHC centers in the localities in both Khartoum and Gezira states. The locality PHC centers Family medicine doctors Interviewed doctors Number of non-responses Response rate Khartoum state: Khartoum locality 21 94 91 3 96.8% Omdurman locality 9 44 42 2 95.5% Bahry locality 12 41 39 2 95.1% Jabal Awliaa localiy 12 40 39 1 97.5% Shargalnil locality 7 44 37 7 84.1% Karrari locality 8 35 32 3 91.4% Ombada locality 8 23 21 2 91.3% Total 77 321 301 20 93.8% Gezira state: Wad-Medani locality 24 79 72 7 91.1% Total 191 400 373 27 92.8% Statistical analysis: The statistical package for social sciences (SPSS 23) was used to summarize the data numerically (mean, standard deviation, median) and graphically (frequency tables). Associations between categorical variables were determined through the Chi-squared (χ 2 ) tests. A binary logistic regression analysis was performed to determine the relationship between implementation of CPG and its associated factors. All statistical tests were considered significant when p-value < 0.05. The Cronbach Alpha test was used to measure the reliability of the respondent’s answers to the self-administrated questionnaire. The answers of the respondents tested through Cronbach's alpha were under the true of value of reliability (ranging from 0.70 to 0.95) with a value of alpha of 0.741, which reflect high consistency and reliability of the questionnaire. Results Females constituted the vast majority of the surveyed doctors (316, 84.7%). Most of the respondent doctors were registrars (298, 79.9%), while those with clinical experience ranging from 1 to 5 amounted to (317, 85.0%). Most of the PHC centers (313, 83.9%) were located in urban areas. The majority of the surveyed doctors (301, 80.7%) were stationed in Khartoum state, while the rest were in Gezira state, as displayed by Table (2). Within Khartoum state, most of the surveyed doctors were in Khartoum, Omdurman, Bahri localities, Figure (1). Table (2): Demographic characteristic of the practicing family medicine doctors, (n = 373). Variables Frequency Percent (%) Residence Khartoum state 301 80.7 Gezira State 72 19.3 Gender Male 57 15.3 Female 316 84.7 Job title Registrar 298 79.9 Consultant/Physician 75 20.1 Clinical experience 1–5 years 317 85.0 6–10 years 51 13.7 11–15 years 3 0.8 More Than 16 years 2 0.5 PHC location Rural 60 16.1 Urban 313 83.9 Investigation into CPG implementation revealed that most of the practicing family medicine doctors (367, 98.4%) were following the guidelines in their practice. Of those, (283, 77.1) were regularly following the updated editions of the guidelines. The national (Sudanese) and the international guidelines were followed by (241, 65.7%) of the respondents, Table (3). More than half of the practicing family medicine doctors (256, 68.6%) reported that they have received regular training programs, as displayed in Figure (2) . Table (3): Distribution of the respondents according to their implementation of the clinical practice guidelines. Variables Frequency Percent (%) Implementation of the existing clinical guidelines in clinical practice, (n = 373). Yes 367 98.4 No 6 1.6 Type of the Followed guidelines, (n = 367). International guidelines 67 18.3 Local Sudanese guidelines 59 16. 0 Both 241 65.7 Following the updated editions of the guidelines, (n = 367). Yes 283 77.1 No 84 22.9 Despite the high adherence and implementation rate of the guidelines, a variety of barriers were expressed by the respondents. Doctors rated guideline inaccessibility (235, 63.0%) as the most frequent barrier. Sudanese guidelines were an example to guideline inaccessibility as stated by the surveyed doctors. Regulatory changes of the guideline’s recommendation (215, 57.6%), large volume of the guideline information (186, 49.9%) and lack of outcome expectancy (150, 40.2%), lack of agreement with specific guidelines (149, 39.9%), lack of Self-Efficacy (120, 32.2%) and lack of agreement with guidelines in general (81, 21.7%) were also barriers to adherence to the guidelines, as displayed in Table (4). Table (4): Barriers to adherence to the clinical practice guidelines, (n = 373). Barriers Frequency Percent (%) Guideline inaccessibility 235 63.0 Regulatory changes of the guideline’s recommendation 215 57.6 Large volume of the guideline information 186 49.9 Lack of outcome expectancy 150 40.2 Lack of agreement with specific guidelines 149 39.9 Lack of Self-Efficacy 120 32.2 Lack of agreement with guidelines in general 81 21.7 Regarding barriers to implementation of clinical practice guidelines, services unavailability and inaccessibility, health insurance factors (services not covered by the health insurance) and patient factors were the most frequent barriers to guideline implementation, amounting to (325, 87.1%), (313, 83.9%) and (303, 81.2%) respectively, Table (5). Service cost (298, 79.9%), lack of regular training programs (298, 79.9%), lack of local PHC treatment protocol or guidelines (288, 77.2%), lack of continuity in the comprehensive care process (235, 63.0%) and lack of time (213, 57.1%) were also reported as barriers to guideline implementation, as displayed in Table (5). Table (5): Barriers to implementation of the clinical practice guidelines, (n = 373). Barriers Frequency Percent (%) Services unavailability and inaccessibility 325 87.1 Health insurance factors (services not covered by insurance) 313 83.9 Patient factors (financial issues or believes) 303 81.2 Service cost 298 79.9 Lack of regular training programs 298 79.9 Lack of local PHC treatment protocol or guidelines 288 77.2 Lack of continuity in the comprehensive care process 235 63.0 Lack of time 213 57.1 Investigation regarding respondents’ perception of clinical practice in Sudan revealed that; most of the respondents (277, 74.3%) noted that practice in Sudan doesn’t allow implementation of the guidelines. Moreover, most of the doctors consider training programs (340, 91.2%) and guidelines adherence (365, 97.9%) improve clinical practice. More than half of the practicing family medicine doctors (208, 55.8%) reported that they prefer to follow the international guidelines rather than the local Sudanese guidelines, Table (6) Table (6): Distribution of the respondents according to their perception toward the clinical practice guidelines, (n = 373). Variables Frequency Percent (%) Practice in Sudan doesn’t allow implementation of the clinical practice guidelines. Yes 277 74.3 No 96 25.7 The post-graduation training programs improve clinical practice. Yes 340 91.2 No 33 8.8 Adherence to the guidelines improves the clinical practice. Yes 365 97.9 No 8 2.1 Preferred guidelines : Local (Sudanese) guidelines 165 44.20 International guidelines 208 55.80 Residence of the respondents, job title, experience and PHC location revealed no statistically significant association when tested in cross tabulation with the CPG implementation, p value = 0.099, 0.257, 0.563 and 0.654, respectively, Table (7). Guideline implementation revealed significant association when tested in cross tabulation with following the updated editions of the guidelines and the type of the followed guideline, p value = 0. 000 and 0. 000, respectively, Table (7). Training programs revealed no significant association when tested in cross tabulation with the guideline implementation, p value = 0. 280, as displayed in Table (7). Table (7): Association between demographic characteristics of the participants and implementation of the clinical practice guidelines, (n = 373). Variables Guideline implementation P-value Yes No Residence: Khartoum state 295 6 0.099 Gezira state 72 0 Job titles : Registrar 292 6 0.257 Consultant/Physician 75 0 Clinical experience : 0–5 Years 313 4 0.563 6-10Years 49 2 11–15 Years 3 0 More Than 16 Years 2 0 PHC location : Rural 59 1 0.654 Urban 308 5 Follow the updated editions of the guidelines : Yes 283 0 0. 000 No 81 3 Type of the followed guidelines : International guidelines 67 0 0. 000 Local Sudanese guidelines 59 0 Both of them 240 1 Training programs : Yes 253 3 0. 280 No 114 3 A binary logistic regression analysis was conducted to assess the relationship between guideline implementation and the respondents’ residence, job title and training programs. The reliability of the model was 99.0%. The model perfectly predicted guideline implementation. Receiving training programs which contributed to the model by 1.130 was statistically significant with a p-value of 0.000. The training programs affect the guideline implementation positively by 3.095 times, (95% CI: 1.877–5.103). Respondents’ opinion regarding the benefit of the training programs in improving the clinical practice which was contributed to the model by 0.222 was not statistically significant with a p-value of 0.349. It is predicted to affect the guideline implementation positively by 1.249 times. Residence and job title were not statically significant with a p-value of respectively 0.436 and 0.075. Residence affects the guideline implementation by 0.963 times, (95% CI: 0.875–1.059) and job title by 0.535 times, (95% CI: 0.269–1.064), as displayed by Table (8). Table (8): Logistic regression model predicting guideline implementation based on the respondent’s residence, job title and training programs, (n = 373). Variables in the Equation B S.E Wald df p-value Odds Ratio 95% C.I. for OR Lower Upper Residence 0.038 0.049 .606 1 0.436 0.963 0.875 1.059 Job title 0.625 0.351 3.175 1 0.075 0.535 0.269 1.064 Training programs 1.130 0.255 19.603 1 0.000 3.095 1.877 5.103 Training programs improve clinical practice 0.222 0.237 0.876 1 0.349 1.249 0.784 1.988 Constant 1.380 0.225 37.682 1 0.000 0.252 A binary logistic regression analysis was conducted to assess the effect of the barriers on the guideline implementation. The reliability of the model was 76.0%. Patient factors, services unavailability, lack of local PHC treatment protocol and health insurance factors were all not significant with a p-value of 0.348, 0.997, 0.611 and 0.300. Patient factors affect guideline implementation by 2.324 times (95% CI: 0.399–13.531). Lack of local PHC treatment protocol affects guideline implementation by 1.604 times (95% CI: 0.260–9.897). Health insurance factors affect guideline implementation by 2.661times (95% CI: 0.418–16.946), as displayed by Table (9). Table (9): Logistic regression model predicting guideline implementation based on the barriers, (n = 373). Variables in the Equation B S.E Wald df p-value Odds Ratio 95% C.I. for OR Lower Upper Patient factors 0.843 0.899 0.881 1 0.348 2.324 0.399 13.531 Services unavailability -17.718- 5631.819 0.000 1 0.997 0.000 0.000 . Lack of local PHC treatment protocol 0.473 0.928 0.259 1 0.611 1.604 0.260 9.897 Health insurance factors 0.979 0.945 1.074 1 0.300 2.661 0.418 16.946 Constant -4.510- 0.601 56.295 1 0.000 0.011 Discussion Most of the surveyed family medicine doctors (79.9%) were in Khartoum state. Family medicine doctors are centralized in Khartoum state because of the availably of the family medicine training programs in many institutions. Furthermore, the presence of new and renewed PHC centers in Khartoum state facilitates the training and the clinical rotation and offers job vacancies to the family doctors. The same situation in Gezira state, presence of the family medicine training program in Al Gezira University, beside the economic factors and distribution of the PHC center resulted in centralization of family medicine doctors in Wad Medani locality. These disparities in the workforce distribution are agreed to be one of the major threats confronting Sudanese health sector today (11). Insufficient numbers and types of qualified health workers in remote and rural areas impedes access to health-care services for a significant percentage of the population, slows progress towards attaining the Millennium Development Goals and challenges the aspirations of achieving health for all (12). One of the most striking findings that most of the surveyed practicing family medicine doctors are females (84.7%). This may have implications that need to be addressed in view of the growing feminization of the Sudanese family doctors, most of them have 5 years or less experience in practicing family medicine, (317, 85.0%), followed by (51, 13.7%). Only ( 20.1%) of them are consultants and physicians, which reflect high brain drain of most of well experienced qualified family doctors, and its consistent with the evidences that migration among Sudanese doctors is traditionally been physician-led and male dominated (13). However new emerging trend of increased feminization in the migration pattern of Sudanese doctors was documented (14). This out-flux of family doctors due to poor remuneration and inadequate living and working conditions, especially in rural areas, reduces the remaining workforce’s capacity and morale Eventually, this deteriorates health service delivery effectiveness for the entire population (15, 16). Results of the study revealed that most of the doctors (98.4%) implement the guidelines in their practice and (68.6%) of them received training programs. Family medicine training in Sudan and regular training programs to the practicing family medicine doctors are thought to be the cause behind the high implementation rate of the guidelines. A previous study in Sudan reported low adherence rate of the guidelines and recommended training programs as a solution (1). Another study in Estonia reported high implementation rate of the clinical practice guidelines (79%) (17). Most of the surveyed doctors (74.3%) reported that practice in Sudan doesn’t allow implementation of the clinical practice guidelines. This result was consistent with Hwaida et al. results (8). Some setting in Sudan and the economic status impedes guideline implementation. Absence of important investigations or being so far from the health center is a reason for the practicing doctor to waive this first line investigation. Furthermore, even in presence of all the essential services, doctors are limited due to the patients’ finical issues and the health insurance. Patients tend to request the cheapest drug of investigation that they can afford or that is covered by their health insurance. Same barriers were reported in previous studies (1, 17–19). In 2019 a study in Sudan reported guideline inaccessibility, patient factors and volume of the guidelines as most frequent barriers (1). Another study reported lack of time, lack of medical resources and guideline inaccessibility were the most frequent barriers (17). The in accessibility of local Sudanese guidelines was the main driver that most of the surveyed doctors (55.8%) prefers the international guidelines. Furthermore, they reported that local guidelines is suitable for the Sudanese patients if they are available and regularly updated and adapted to the Sudanese health system (41.6%). There results were consistent with Elsadig et al. results (8). Conclusion The study reported high adherence of family physicians to CPGs (98.4%). International guidelines are preferred as they are well published and regularly updated. The political and financial constrains in Sudan jeopardize the sustainability of the training programs. Barriers-tailored interventions are needed to address the most encountered barriers such as services unavailability and inaccessibility, health insurance limited coverage and patient factors. Efforts should be directed to encourage the development of guidelines through a rigorous approach that involves a multidisciplinary team representing various stakeholders including and working with explicit harmony. These approaches must be accompanied by the development of barriers tailored interventions to implement the guidelines. A comprehensive strategy to disseminate the national guidelines is crucial. Policymakers should establish a national system to collect, disseminate, and implement guidelines, strengthen the management of conflict of interest, and provide quality assurance and control. Abbreviations AAU Alzaiem Alazhari university AICs Agency for Italian Cooperation CPG Clinical Practice Guidelines FMOH Federal Ministry of Health FMOF Federal Ministry of Finance GDP Gross Domestic Products JNC Joint National Committee PHC Primary Health Care PHI Public Health Institute MRI Magnetic Resonance Imaging MD Medical Doctorate MOH Ministry of Health NICE National Institute for Care and Health Excellence NGOs Non-Governmental Organizations SMOH State Ministry of Health SMSB Sudan Medical Specialization Board UMST University of Medical Sciences and Technology WHO World Health Organization. Declarations Ethical approval and consent to participate: Ethical clearance and approval for conducting this research was obtained from the Federal Ministry of health (FMOH) authorized ethical committee. Permission was obtained from the directors of the primary health centers. Written informed consent was taken from all participants with assurance with confidentiality and all rights. The purpose of the study was addressed briefly. Confidentiality and privacy have been maintained during data collection, analysis and reporting. Consent to publish: Not applicable. Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declared that they had no competing interests. Funding We declare that this study was fully funded by the Agency for Italian Cooperation (AICS) and was technically and operationally supervised by Sudan National Public Health Institute (PHI). Authors’ contributions: Hiba Salah: Designed and implemented the study protocol, study tool, participated in the data collection, conducted the data analysis, wrote the final research draft and drafted the manuscript. Sahar Bajouri: Reviewed and edited the study protocol, study tool, final research draft and the manuscript. S upervised the field implementation of the research. Hind Salah: Prove reading and editing of the final manuscript. All authors approved the final version of the manuscript prior to submission. Acknowledgments: Thanks and appreciations to Dr. Osama AlShafee, Dr. Muhammed ELhassein and Dr. Salwa Mudatir Ismael for their help and guidance during the study. Special thanks to Dr. Abdelkhalig Ibrahim, Dr. Sahar Faisal Mohamed Makawi, Dr. Ghedwa Awad Said Ahmed, Dr. Sumia Kabbar, Dr. Hala Satti and Dr. Mohamed Elfadil for their efforts and support. Appreciation and thanks to Dr. Salah Abdelradir for his guidance and support. References Abdelgadir HS, Elfadul MM, Hamid NH, Noma M. Adherence of doctors to hypertension clinical guidelines in academy charity teaching hospital, Khartoum, Sudan. BMC Health Services Research. 2019;19(1):309. Kredo T, Abrams A, Young T, Louw Q, Volmink J, Daniels K. Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders. BMC health services research. 2017;17(1):1-12. Oh S-W, Lee HJ, Chin HJ, Hwang J-I. Adherence to clinical practice guidelines and outcomes in diabetic patients. International Journal for Quality in Health Care. 2011;23(4):413-9. Ament SM, de Groot JJ, Maessen JM, Dirksen CD, van der Weijden T, Kleijnen J. 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Advances in medical education and practice. 2016;7:673. Qumseya B, Goddard A, Qumseya A, Estores D, Draganov PV, Forsmark C. Barriers to clinical practice guideline implementation among physicians: a physician survey. International Journal of General Medicine. 2021;14:7591. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Jul, 2024 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 26 Apr, 2024 Editor assigned by journal 25 Apr, 2024 Submission checks completed at journal 25 Apr, 2024 First submitted to journal 24 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4316227","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":295741548,"identity":"e509a6f0-d2e7-4107-856b-a8915ef8d063","order_by":0,"name":"Hiba Salah Abdelgadir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACA2YeEGUBxIkNDB+AFBs7cVokwFoYZ4C0MBPSwgDXksAA0U5Iizk778GPP2ok7Prbk9s+2/zaJs/HzMD44WMObi2WzXzJ0jzHJJJnnHnYPDu377ZhGzMDs+TMbXgcdpjHQJqBTSKZ4UZiM3Nuz21GoBY2Zl78Wox//vgnkSwP0mLZc9ueGC1mErxtEnYGIC0MP24nEqGFL82at08iwRDoF8behtvJbcyMzfj9cv7s4Zs/vtnYyx1Pf8zw489t2/ntzQc/fMSjBQaAUQ8EjG1gsoGweiCwh1B/iFI8CkbBKBgFIwwAAPuCTyRwkzR8AAAAAElFTkSuQmCC","orcid":"","institution":"Hiba Salah Abdelgadir, Alzaiem Alazhari University","correspondingAuthor":true,"prefix":"","firstName":"Hiba","middleName":"Salah","lastName":"Abdelgadir","suffix":""},{"id":295741553,"identity":"965f2fd0-12b1-40bd-918d-a6e57ac377c6","order_by":1,"name":"Sahar Bajouri","email":"","orcid":"","institution":"National Public Health Institute, Federal Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Sahar","middleName":"","lastName":"Bajouri","suffix":""},{"id":295741554,"identity":"e1ce756f-3d6e-4d9d-aeaa-0f0389c21fea","order_by":2,"name":"Hind Salah Abdelgadir","email":"","orcid":"","institution":"Hind Salah Abdelgadir, Alzaiem Alazhari University","correspondingAuthor":false,"prefix":"","firstName":"Hind","middleName":"Salah","lastName":"Abdelgadir","suffix":""}],"badges":[],"createdAt":"2024-04-24 07:27:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4316227/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4316227/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-024-02542-x","type":"published","date":"2024-07-30T15:57:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55765699,"identity":"a9fe6978-5487-40b9-b335-4a6f1268ade3","added_by":"auto","created_at":"2024-05-02 20:07:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18065,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of the respondents between Khartoum state localities, (n = 298).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4316227/v1/2e946f122a8a5fd227dba189.png"},{"id":55765698,"identity":"e210a83f-65a4-444b-9c50-e30a61504818","added_by":"auto","created_at":"2024-05-02 20:07:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":9536,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of the respondents according to their access to the training programs, (n = 373).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4316227/v1/0a40a1a9963e343d05956577.png"},{"id":61793399,"identity":"581edb71-ab10-4b91-b4eb-572738266f22","added_by":"auto","created_at":"2024-08-05 16:12:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1146146,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4316227/v1/70b453fa-fe11-4a25-ab9a-8ce005c4e865.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states/ Sudan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical practice guidelines (CPG) are designed to assist health care practitioners in specific clinical conditions (1). They considered as a transformation tool in practice and policy, that covers the clinical circumstances according to evidence-based information that was summarized to assist and regulate the clinical care by providing scientific information for decision-making in order to improve patients outcome (2\u0026ndash;4).\u003c/p\u003e \u003cp\u003eCPG acknowledges the practicing doctors with evidence-based treatment methods and types of intervention through clearly stated recommendations. Moreover, they summarize various treatment options and plans of management tailored to suit the patient's needs according to their clinical presentation (5, 6). Implementation of the guideline\u0026rsquo;s recommendations regulate the clinical work and increase the confidence of the practicing doctors. Furthermore, CPG implementation play a role in improving patients compliance to treatment as they are informed with the evidence-based treatment methods (6, 7).\u003c/p\u003e \u003cp\u003eCPG considered efficient tool to reduce the gap between the evidence based recommendations and the physicians clinical practice (8). To improve the quality of care, the global development and implementation of clinical practice guidelines have increased (9). Issuing regulations by the policy makers and establishment of the clinical governance ensure regular implementation of the updated guidelines recommendations (1)\u003c/p\u003e \u003cp\u003eDespite their importance in improving the quality of medical care, and the witnessed increase of their implementation at the global level during the past several decades, there is no acknowledged standard approach to developing, adapting or implementing CPGs efficiently or effectively in Sudan (1, 10).\u003c/p\u003e \u003cp\u003eThe overall objective of the study was to investigate the implementation of clinical practice guidelines among family medicine doctors working in the referral primary health care centers in Khartoum and Gezira States in Sudan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population:\u003c/h2\u003e \u003cp\u003eDescriptive cross-sectional facility-based survey was conducted in the public referral primary health care centers in Khartoum and Gezira States in Sudan during period from April to December 2021. A total of \u003cb\u003e101\u003c/b\u003e primary health care centers were surveyed (\u003cb\u003e77\u003c/b\u003e centers in Khartoum state and \u003cb\u003e24\u003c/b\u003e in Gezira state).\u003c/p\u003e \u003cp\u003eThe study targeted all practicing family medicine doctors in the referral primary health care centers in both Khartoum and Gezira, (\u003cb\u003e321\u003c/b\u003e in Khartoum state and \u003cb\u003e79\u003c/b\u003e in Gezira State). A total of \u003cb\u003e373\u003c/b\u003e doctors responded to the survey (\u003cb\u003e301\u003c/b\u003e in Khartoum state and \u003cb\u003e72\u003c/b\u003e in Gezira state). The surveyed doctors were either M.Sc. holders/residents or Medical Doctorate (MD) holders/residents. Trained research assistants and enumerators were employed to collect data with use of a pre coded and pretested structured questionnaire which revised, modified, edited, and finalized after piloting. Table\u0026nbsp;(1) shows the distribution of the family medicine doctors in the localities and the PHC centers in Khartoum and Gezira states.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(1): Distribution of the practicing family medicine doctors and the PHC centers in the localities in both Khartoum and Gezira states.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe locality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHC centers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily medicine doctors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterviewed doctors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber of non-responses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eResponse rate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eKhartoum state:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhartoum locality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOmdurman locality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBahry locality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJabal Awliaa localiy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e97.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShargalnil locality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKarrari locality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOmbada locality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eGezira state:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWad-Medani locality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis:\u003c/h2\u003e \u003cp\u003eThe statistical package for social sciences (SPSS 23) was used to summarize the data numerically (mean, standard deviation, median) and graphically (frequency tables). Associations between categorical variables were determined through the Chi-squared (χ\u003csup\u003e2\u003c/sup\u003e) tests. A binary logistic regression analysis was performed to determine the relationship between implementation of CPG and its associated factors. All statistical tests were considered significant when \u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The Cronbach Alpha test was used to measure the reliability of the respondent\u0026rsquo;s answers to the self-administrated questionnaire. The answers of the respondents tested through Cronbach's alpha were under the true of value of reliability (ranging from 0.70 to 0.95) with a value of alpha of 0.741, which reflect high consistency and reliability of the questionnaire.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFemales constituted the vast majority of the surveyed doctors (316, 84.7%). Most of the respondent doctors were registrars (298, 79.9%), while those with clinical experience ranging from 1 to 5 amounted to (317, 85.0%). Most of the PHC centers (313, 83.9%) were located in urban areas. The majority of the surveyed doctors (301, 80.7%) were stationed in Khartoum state, while the rest were in Gezira state, as displayed by Table\u0026nbsp;(2). Within Khartoum state, most of the surveyed doctors were in Khartoum, Omdurman, Bahri localities, Figure (1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(2): Demographic characteristic of the practicing family medicine doctors, (n\u0026thinsp;=\u0026thinsp;373).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhartoum state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGezira State\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob title\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistrar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant/Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore Than 16 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePHC location\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eInvestigation into CPG implementation revealed that most of the practicing family medicine doctors (367, 98.4%) were following the guidelines in their practice. Of those, (283, 77.1) were regularly following the updated editions of the guidelines. The national (Sudanese) and the international guidelines were followed by (241, 65.7%) of the respondents, Table\u0026nbsp;(3). More than half of the practicing family medicine doctors (256, 68.6%) reported that they have received regular training programs, as displayed in \u003cb\u003eFigure (2)\u003c/b\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eTable\u0026nbsp;(3): Distribution of the respondents according to their implementation of the clinical practice guidelines.\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eImplementation of the existing clinical guidelines in clinical practice, (n\u0026thinsp;=\u0026thinsp;373).\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of the Followed guidelines, (n\u0026thinsp;=\u0026thinsp;367).\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternational guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal Sudanese guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16. 0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollowing the updated editions of the guidelines, (n\u0026thinsp;=\u0026thinsp;367).\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDespite the high adherence and implementation rate of the guidelines, a variety of barriers were expressed by the respondents. Doctors rated guideline inaccessibility (235, 63.0%) as the most frequent barrier. Sudanese guidelines were an example to guideline inaccessibility as stated by the surveyed doctors. Regulatory changes of the guideline\u0026rsquo;s recommendation (215, 57.6%), large volume of the guideline information (186, 49.9%) and lack of outcome expectancy (150, 40.2%), lack of agreement with specific guidelines (149, 39.9%), lack of Self-Efficacy (120, 32.2%) and lack of agreement with guidelines in general (81, 21.7%) were also barriers to adherence to the guidelines, as displayed in Table\u0026nbsp;(4).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eTable\u0026nbsp;(4): Barriers to adherence to the clinical practice guidelines, (n\u0026thinsp;=\u0026thinsp;373).\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuideline inaccessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegulatory changes of the guideline\u0026rsquo;s recommendation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge volume of the guideline information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of outcome expectancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of agreement with specific guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of Self-Efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of agreement with guidelines in general\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding barriers to implementation of clinical practice guidelines, services unavailability and inaccessibility, health insurance factors (services not covered by the health insurance) and patient factors were the most frequent barriers to guideline implementation, amounting to (325, 87.1%), (313, 83.9%) and (303, 81.2%) respectively, Table\u0026nbsp;(5). Service cost (298, 79.9%), lack of regular training programs (298, 79.9%), lack of local PHC treatment protocol or guidelines (288, 77.2%), lack of continuity in the comprehensive care process (235, 63.0%) and lack of time (213, 57.1%) were also reported as barriers to guideline implementation, as displayed in Table\u0026nbsp;(5).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(5): Barriers to implementation of the clinical practice guidelines, (n\u0026thinsp;=\u0026thinsp;373).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eServices unavailability and inaccessibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e325\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth insurance factors (services not covered by insurance)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient factors (financial issues or believes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of regular training programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of local PHC treatment protocol or guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of continuity in the comprehensive care process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInvestigation regarding respondents\u0026rsquo; perception of clinical practice in Sudan revealed that; most of the respondents (277, 74.3%) noted that practice in Sudan doesn\u0026rsquo;t allow implementation of the guidelines. Moreover, most of the doctors consider training programs (340, 91.2%) and guidelines adherence (365, 97.9%) improve clinical practice. More than half of the practicing family medicine doctors (208, 55.8%) reported that they prefer to follow the international guidelines rather than the local Sudanese guidelines, Table\u0026nbsp;(6)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eTable\u0026nbsp;(6): Distribution of the respondents according to their perception toward the clinical practice guidelines, (n\u0026thinsp;=\u0026thinsp;373).\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabf\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePractice in Sudan doesn\u0026rsquo;t allow implementation of the clinical practice guidelines.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe post-graduation training programs improve clinical practice.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdherence to the guidelines improves the clinical practice.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred guidelines\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal (Sudanese) guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternational guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResidence of the respondents, job title, experience and PHC location revealed no statistically significant association when tested in cross tabulation with the CPG implementation, \u003cem\u003ep value\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.099, 0.257, 0.563 and 0.654, respectively, Table\u0026nbsp;(7).\u003c/p\u003e \u003cp\u003eGuideline implementation revealed significant association when tested in cross tabulation with following the updated editions of the guidelines and the type of the followed guideline, \u003cem\u003ep value\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0. 000 and 0. 000, respectively, Table\u0026nbsp;(7). Training programs revealed no significant association when tested in cross tabulation with the guideline implementation, \u003cem\u003ep value\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0. 280, as displayed in Table\u0026nbsp;(7).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(7): Association between demographic characteristics of the participants and implementation of the clinical practice guidelines, (n\u0026thinsp;=\u0026thinsp;373).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabg\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGuideline implementation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eResidence:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhartoum state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGezira state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eJob titles\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistrar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.257\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant/Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical experience\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;5 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-10Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;15 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore Than 16 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePHC location\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow the updated editions of the guidelines\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0. 000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of the followed guidelines\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternational guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0. 000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal Sudanese guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth of them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining programs\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0. 280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA binary logistic regression analysis was conducted to assess the relationship between guideline implementation and the respondents\u0026rsquo; residence, job title and training programs. The reliability of the model was 99.0%. The model perfectly predicted guideline implementation.\u003c/p\u003e \u003cp\u003eReceiving training programs which contributed to the model by 1.130 was statistically significant with a \u003cem\u003ep-value\u003c/em\u003e of 0.000. The training programs affect the guideline implementation positively by 3.095 times, (95% CI: 1.877\u0026ndash;5.103). Respondents\u0026rsquo; opinion regarding the benefit of the training programs in improving the clinical practice which was contributed to the model by 0.222 was not statistically significant with a \u003cem\u003ep-value\u003c/em\u003e of 0.349. It is predicted to affect the guideline implementation positively by 1.249 times. Residence and job title were not statically significant with a \u003cem\u003ep-value\u003c/em\u003e of respectively 0.436 and 0.075. Residence affects the guideline implementation by 0.963 times, (95% CI: 0.875\u0026ndash;1.059) and job title by 0.535 times, (95% CI: 0.269\u0026ndash;1.064), as displayed by Table\u0026nbsp;(8).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(8): Logistic regression model predicting guideline implementation based on the respondent\u0026rsquo;s residence, job title and training programs, (n\u0026thinsp;=\u0026thinsp;373).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabh\" border=\"1\"\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables in the Equation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e95% C.I. for OR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.963\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJob title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.603\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining programs improve clinical practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.876\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.682\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA binary logistic regression analysis was conducted to assess the effect of the barriers on the guideline implementation. The reliability of the model was 76.0%. Patient factors, services unavailability, lack of local PHC treatment protocol and health insurance factors were all not significant with a \u003cem\u003ep-value\u003c/em\u003e of 0.348, 0.997, 0.611 and 0.300. Patient factors affect guideline implementation by 2.324 times (95% CI: 0.399\u0026ndash;13.531). Lack of local PHC treatment protocol affects guideline implementation by 1.604 times (95% CI: 0.260\u0026ndash;9.897). Health insurance factors affect guideline implementation by 2.661times (95% CI: 0.418\u0026ndash;16.946), as displayed by Table\u0026nbsp;(9).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(9): Logistic regression model predicting guideline implementation based on the barriers, (n\u0026thinsp;=\u0026thinsp;373).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabi\" border=\"1\"\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables in the Equation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e95% C.I. for OR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.881\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eServices unavailability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-17.718-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5631.819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of local PHC treatment protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.928\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.611\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.897\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth insurance factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.661\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16.946\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-4.510-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMost of the surveyed family medicine doctors (79.9%) were in Khartoum state. Family medicine doctors are centralized in Khartoum state because of the availably of the family medicine training programs in many institutions. Furthermore, the presence of new and renewed PHC centers in Khartoum state facilitates the training and the clinical rotation and offers job vacancies to the family doctors. The same situation in Gezira state, presence of the family medicine training program in Al Gezira University, beside the economic factors and distribution of the PHC center resulted in centralization of family medicine doctors in Wad Medani locality.\u003c/p\u003e \u003cp\u003eThese disparities in the workforce distribution are agreed to be one of the major threats confronting Sudanese health sector today (11). Insufficient numbers and types of qualified health workers in remote and rural areas impedes access to health-care services for a significant percentage of the population, slows progress towards attaining the Millennium Development Goals and challenges the aspirations of achieving health for all (12).\u003c/p\u003e \u003cp\u003eOne of the most striking findings that most of the surveyed practicing family medicine doctors are females (84.7%). This may have implications that need to be addressed in view of the growing feminization of the Sudanese family doctors, most of them have 5 years or less experience in practicing family medicine, (317, 85.0%), followed by (51, 13.7%). Only ( 20.1%) of them are consultants and physicians, which reflect high brain drain of most of well experienced qualified family doctors, and its consistent with the evidences that migration among Sudanese doctors is traditionally been physician-led and male dominated (13). However new emerging trend of increased feminization in the migration pattern of Sudanese doctors was documented (14). This out-flux of family doctors due to poor remuneration and inadequate living and working conditions, especially in rural areas, reduces the remaining workforce\u0026rsquo;s capacity and morale Eventually, this deteriorates health service delivery effectiveness for the entire population (15, 16).\u003c/p\u003e \u003cp\u003eResults of the study revealed that most of the doctors (98.4%) implement the guidelines in their practice and (68.6%) of them received training programs. Family medicine training in Sudan and regular training programs to the practicing family medicine doctors are thought to be the cause behind the high implementation rate of the guidelines. A previous study in Sudan reported low adherence rate of the guidelines and recommended training programs as a solution (1). Another study in Estonia reported high implementation rate of the clinical practice guidelines (79%) (17).\u003c/p\u003e \u003cp\u003eMost of the surveyed doctors (74.3%) reported that practice in Sudan doesn\u0026rsquo;t allow implementation of the clinical practice guidelines. This result was consistent with Hwaida \u003cem\u003eet al.\u003c/em\u003e results (8). Some setting in Sudan and the economic status impedes guideline implementation. Absence of important investigations or being so far from the health center is a reason for the practicing doctor to waive this first line investigation. Furthermore, even in presence of all the essential services, doctors are limited due to the patients\u0026rsquo; finical issues and the health insurance. Patients tend to request the cheapest drug of investigation that they can afford or that is covered by their health insurance. Same barriers were reported in previous studies (1, 17\u0026ndash;19). In 2019 a study in Sudan reported guideline inaccessibility, patient factors and volume of the guidelines as most frequent barriers (1). Another study reported lack of time, lack of medical resources and guideline inaccessibility were the most frequent barriers (17).\u003c/p\u003e \u003cp\u003eThe in accessibility of local Sudanese guidelines was the main driver that most of the surveyed doctors (55.8%) prefers the international guidelines. Furthermore, they reported that local guidelines is suitable for the Sudanese patients if they are available and regularly updated and adapted to the Sudanese health system (41.6%). There results were consistent with Elsadig \u003cem\u003eet al.\u003c/em\u003e results (8).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study reported high adherence of family physicians to CPGs (98.4%). International guidelines are preferred as they are well published and regularly updated. The political and financial constrains in Sudan jeopardize the sustainability of the training programs. Barriers-tailored interventions are needed to address the most encountered barriers such as services unavailability and inaccessibility, health insurance limited coverage and patient factors. Efforts should be directed to encourage the development of guidelines through a rigorous approach that involves a multidisciplinary team representing various stakeholders including and working with explicit harmony. These approaches must be accompanied by the development of barriers tailored interventions to implement the guidelines. A comprehensive strategy to disseminate the national guidelines is crucial. Policymakers should establish a national system to collect, disseminate, and implement guidelines, strengthen the management of conflict of interest, and provide quality assurance and control.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAAU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlzaiem Alazhari university\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAgency for Italian Cooperation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Practice Guidelines\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFederal Ministry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMOF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFederal Ministry of Finance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGross Domestic Products\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJNC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJoint National Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic Health Institute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Doctorate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Care and Health Excellence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGOs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Governmental Organizations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eState Ministry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMSB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSudan Medical Specialization Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUMST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversity of Medical Sciences and Technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance and approval for conducting this research was obtained from the Federal Ministry of health (FMOH) authorized ethical committee. Permission was obtained from the directors of the primary health centers. Written informed consent was taken from all participants with assurance with confidentiality and all rights. The purpose of the study was addressed briefly. Confidentiality and privacy have been maintained during data collection, analysis and reporting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable\u0026nbsp;request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that they had no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare that this study was fully funded by the Agency for Italian Cooperation (AICS) and was technically and operationally supervised by Sudan National Public Health Institute (PHI).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHiba Salah: Designed and implemented the study protocol, study tool,\u0026nbsp;participated in the data collection,\u0026nbsp;conducted the data analysis,\u0026nbsp;wrote the final research draft\u0026nbsp;and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eSahar Bajouri: Reviewed and edited the study protocol, study tool, final research draft and the manuscript. \u003cstrong\u003eS\u003c/strong\u003eupervised the field implementation of the research.\u003c/p\u003e\n\u003cp\u003eHind Salah: Prove reading and editing of the final manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final version of the manuscript prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks and appreciations to Dr. Osama AlShafee, Dr. Muhammed ELhassein and Dr. Salwa Mudatir Ismael for their help and guidance during the study. Special thanks to Dr. Abdelkhalig Ibrahim, Dr. Sahar Faisal Mohamed Makawi, Dr. Ghedwa Awad Said Ahmed, Dr. Sumia Kabbar, Dr. Hala Satti and Dr. Mohamed Elfadil for their efforts and support. Appreciation and thanks to Dr. Salah Abdelradir for his guidance and support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdelgadir HS, Elfadul MM, Hamid NH, Noma M. Adherence of doctors to hypertension clinical guidelines in academy charity teaching hospital, Khartoum, Sudan. BMC Health Services Research. 2019;19(1):309.\u003c/li\u003e\n\u003cli\u003eKredo T, Abrams A, Young T, Louw Q, Volmink J, Daniels K. Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders. BMC health services research. 2017;17(1):1-12.\u003c/li\u003e\n\u003cli\u003eOh S-W, Lee HJ, Chin HJ, Hwang J-I. Adherence to clinical practice guidelines and outcomes in diabetic patients. International Journal for Quality in Health Care. 2011;23(4):413-9.\u003c/li\u003e\n\u003cli\u003eAment SM, de Groot JJ, Maessen JM, Dirksen CD, van der Weijden T, Kleijnen J. Sustainability of professionals\u0026rsquo; adherence to clinical practice guidelines in medical care: a systematic review. BMJ open. 2015;5(12).\u003c/li\u003e\n\u003cli\u003eCorrea VC, Lugo-Agudelo LH, Aguirre-Acevedo DC, Contreras JAP, Borrero AMP, Pati\u0026ntilde;o-Lugo DF, et al. Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview. Health research policy and systems. 2020;18(1):1-11.\u003c/li\u003e\n\u003cli\u003eKredo T, Cooper S, Abrams A, Daniels K, Volmink J, Atkins S. National stakeholders\u0026rsquo; perceptions of the processes that inform the development of national clinical practice guidelines for primary healthcare in South Africa. Health research policy and systems. 2018;16(1):68.\u003c/li\u003e\n\u003cli\u003eDizon J, Grimmer K, Machingaidze S, Louw Q, Parker H. South African primary health care allied health clinical practice guidelines: the big picture. BMC health services research. 2018;18(1):1-13.\u003c/li\u003e\n\u003cli\u003eElsadig H, Weiss M, Scott J, Laaksonen R. Use of clinical guidelines in cardiology practice in S udan. Journal of Evaluation in Clinical Practice. 2018;24(1):127-34.\u003c/li\u003e\n\u003cli\u003eDeng Q, Liu W. Utilization of clinical practice guideline on antimicrobial in China: an exploratory survey on multilevel determinants. BMC health services research. 2020;20:1-9.\u003c/li\u003e\n\u003cli\u003eSudan GDP. 2021.\u003c/li\u003e\n\u003cli\u003eNurelhuda N, Bashir A, ElKogali S, Mustafa M, Kruk M, Aziz MA. Encouraging junior doctors to work in rural Sudan: a discrete choice experiment. Special issue on scaling up health workforce in the Eastern Mediterranean Region. 2018;24(9-2018).\u003c/li\u003e\n\u003cli\u003eOrganization WH. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations: World Health Organization; 2010.\u003c/li\u003e\n\u003cli\u003eAbuagla A, Badr E. Challenges to implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel: the case of Sudan. Human resources for health. 2016;14(1):5-10.\u003c/li\u003e\n\u003cli\u003eAbuagla A. Magnitude, trends and implications of health professional out migration in Sudan 2012. MD thesis Khartoum: Sudan Medical Specialization Board. 2013.\u003c/li\u003e\n\u003cli\u003eTankwanchi ABS, \u0026Ouml;zden \u0026Ccedil;, Vermund SH. Physician emigration from sub-Saharan Africa to the United States: analysis of the 2011 AMA physician masterfile. PLoS medicine. 2013;10(9):e1001513.\u003c/li\u003e\n\u003cli\u003eAbdalla FM, Omar MA, Badr EE. Contribution of Sudanese medical diaspora to the healthcare delivery system in Sudan: exploring options and barriers. Human resources for health. 2016;14(1):65-77.\u003c/li\u003e\n\u003cli\u003eTaba P, Rosenthal M, Habicht J, Tarien H, Mathiesen M, Hill S, et al. Barriers and facilitators to the implementation of clinical practice guidelines: a cross-sectional survey among physicians in Estonia. BMC health services research. 2012;12(1):1-7.\u003c/li\u003e\n\u003cli\u003eBirrenbach T, Kraehenmann S, Perrig M, Berendonk C, Huwendiek S. Physicians\u0026rsquo; attitudes toward, use of, and perceived barriers to clinical guidelines: a survey among Swiss physicians. Advances in medical education and practice. 2016;7:673.\u003c/li\u003e\n\u003cli\u003eQumseya B, Goddard A, Qumseya A, Estores D, Draganov PV, Forsmark C. Barriers to clinical practice guideline implementation among physicians: a physician survey. International Journal of General Medicine. 2021;14:7591.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical, Guidelines, Implementation, Adherence, Family Medicine, Primary Health Care, Government, Clinical Governance, Sudan.","lastPublishedDoi":"10.21203/rs.3.rs-4316227/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4316227/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThe health system in Sudan faces several challenges, including increasing numbers of patients, shortages of health supplies, and disparities in the distribution of health services. Guidelines implementation improves patients\u0026rsquo; outcomes and ensures efficient use of the resources in such a resources limited country. The study aimed to assess the implementation of the clinical practice guidelines among family medicine doctors working in the primary health care centers in Khartoum and Gezira states to provide baseline data about the current practice in Sudan.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eDescriptive cross-sectional facility-based survey, conducted from April to December 2021, on 373 of the practicing family-medicine doctors. A total of 101 Primary health care centers were surveyed (77 centers in Khartoum state and 24 in Gezira state). The questionnaire was pilot tested on a small group of physicians to improve clarity and reduce response bias. Descriptive statistics were used to summarize the data and analyzed by frequency tables. Chi square and logistic regression tests were used to determine the association between categorized variables. \u003cem\u003eP value\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eMost of the practicing family-medicine doctors (98.4%) reported implementation of the guidelines. Moreover, (68.6%) of them received training programs which were organized and funded by the Sudan Ministry of Health. The local Sudanese guidelines were difficult to access and not regularly updated. Services unavailability and inaccessibility (87.1%), health insurance factors (83.9%), and patient factors (81.2%) were the most frequent barriers to guidelines implementation. Service cost (79.9%), lack of regular training programs (79.9%), absence of local guidelines (77.2%), lack of continuity in the comprehensive care process (63.0%), and lack of time (57.1%) were also reported as barriers to guidelines implementation.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eGuidelines implementation is limited by unavailability and inaccessibility of the health services and the health insurance limited coverage. Expansion of the health insurance coverage, organization of continuous training programs, encouragement of regular auditing and issuing regulations to ensure the use of updated guidelines, dissemination of the updated national guidelines along with establishing clinical governance in Sudan are highly recommended.\u003c/p\u003e","manuscriptTitle":"Assessment of implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states/ Sudan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-02 20:07:49","doi":"10.21203/rs.3.rs-4316227/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-26T08:41:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-26T01:12:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-26T01:12:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-04-24T07:24:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"43199b9c-5c05-43fc-8903-1e86be71432f","owner":[],"postedDate":"May 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T16:00:33+00:00","versionOfRecord":{"articleIdentity":"rs-4316227","link":"https://doi.org/10.1186/s12875-024-02542-x","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2024-07-30 15:57:08","publishedOnDateReadable":"July 30th, 2024"},"versionCreatedAt":"2024-05-02 20:07:49","video":"","vorDoi":"10.1186/s12875-024-02542-x","vorDoiUrl":"https://doi.org/10.1186/s12875-024-02542-x","workflowStages":[]},"version":"v1","identity":"rs-4316227","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4316227","identity":"rs-4316227","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}