Barriers and facilitators to implementing a national guideline on foot assessment in people with diabetes in primary care: a qualitative study with insights to advance guideline practice, Singapore

Diabetes-related foot ulcers precede 85% of lower extremity amputations, with Singapore among countries with the highest rates. To improve early detection and management, Singapore’s Agency for Care Effectiveness (ACE), Ministry of Health, introduced a national ACE clinical guideline (ACG) on diabetes-related foot assessment in 2019, with an updated edition released in 2024. This ACG is intended to guide routine diabetes-related foot screening (DFS), risk stratification and referral decisions across public and private primary care settings, and serves as a national reference for evidence-based practice. However, little is known about its implementation. This study aimed to explore barriers and facilitators to the implementation of the ACG on Foot Assessment in primary care, and to generate practice-relevant insights to improve implementation. Semi-structured interviews were conducted with 28 healthcare professionals (14 nurses, 9 podiatrists, 5 primary care doctors) from public and private primary care clinics. Interviews explored barriers and facilitators to ACG adoption and were analysed thematically using the Tailored Implementation for Chronic Diseases (TICD) checklist and the Theoretical Domains Framework (TDF). Seven overarching themes mapped to TICD domains were identified: (1) sensemaking the guideline at the frontline; (2) the clinician behind the care; (3) navigating patient realities in practice; (4) the fabric of professional collaboration; (5) equipping places and people for care; (6) organisational readiness for change; and (7) governing the boundaries of practice. The ACG was valued for its clarity, risk stratification framework and professional credibility, but implementation was constrained by ambiguous terminology, uneven training, fragmented referral pathways and limited patient-facing resources. Patient literacy, motivation and cultural practices were central to success, while interprofessional collaboration, infrastructure and financing shaped adoption across settings. Using TDF, we derived practice-relevant insights spanning guideline content (terminology, scope, patient resources) and implementation supports (training, workflows, professional roles, system integration, policy levers). The ACG on Foot Assessment is a useful foundation for DFS in Singapore, but effective implementation requires alignment across behavioural, organisational and system-level determinants. Our study highlights three key challenges surrounding guideline development and implementation: (1) limited integration of patient and caregiver perspectives, (2) limited visibility of guideline implementation evaluation and fidelity and (3) a need to better account for heterogeneity in care delivery contexts. These insights, while grounded in Singapore, may be transferable to other health systems grappling with similar challenges in hybrid public-private primary care delivery and the translation of guidelines into routine practice. Not applicable.