Barriers and facilitators to implementation of outcome measures among physiotherapists in Nepal: A mixed-methods study

Background: Standardised outcome measures are essential to evidence-based practice but their implementation remains a significant challenge in low-and middle-income countries. The barriers and enablers for implementation of outcome measures are likely different in these settings.Objectives: We sought to understand barriers and facilitators to use of standardised outcome measures (e.g. patient-reported, performance-based, clinician-reported) in clinical practice among physiotherapists in Nepal.Design: Exploratory sequential mixed-method study.Methods: We conducted focus groups with physiotherapists in Nepal to understand factors contributing to standardised outcome measure use/non-use in depth and thematically analysed the data using Consolidated Framework for Implementation Research (CFIR). To triangulate the findings, we used an online survey which was distributed to practicing physiotherapists in Nepal using social media. Results: We interviewed 26 physiotherapists for the qualitative phase and 125 physiotherapists responded to our online survey. The most endorsed facilitator was mandating outcome measure use through regulations at organisational or national level, for example, submission of patient-level outcome measures to an insurance system. Major barriers were lack of time, lack of outcome measures in local languages, inability to follow-up with patients and perceived inability of patients to understand outcome measures. Challenges that had not yet been identified in previous studies were inability to follow-up with patients and organisational culture (e.g., cultural hierarchy within an institution).Conclusion: The findings of our study provide an understanding of the contextual needs, and potential way forward for implementation of outcome measures in developing countries like Nepal. Future studies should focus on establishing consensus on which measures to use, the cross-cultural adaptation of these measures, and developing pathways for regulation.