Abstract

BackgroundImplementation of World Health Organization case management guidelines for serious childhood illnesses remains a challenge in hospitals in low-income countries. Facilitators of and barriers to implementation of locally adapted clinical practice guidelines (CPGs) have not been explored.MethodsThis ethnographic study based on the theory of participatory action research (PAR) was conducted in Kenyatta National Hospital, Kenya’s largest teaching hospital. The primary intervention consisted of dissemination of locally adapted CPGs. The PRECEDE-PROCEED health education model was used as the conceptual framework to guide and examine further reinforcement activities to improve the uptake of the CPGs. Activities focussed on introduction of routine clinical audits and tailored educational sessions. Data were collected by a participant observer who also facilitated the PAR over an eighteen-month period. Naturalistic inquiry was utilized to obtain information from all hospital staff encountered while theoretical sampling allowed in-depth exploration of emerging issues. Data were analysed using interpretive description.ResultsRelevance of the CPGs to routine work and emergence of a champion of change facilitated uptake of best-practices. Mobilization of basic resources was relatively easily undertaken while activities that required real intellectual and professional engagement of the senior staff were a challenge. Accomplishments of the PAR were largely with the passive rather than active involvement of the hospital management. Barriers to implementation of best-practices included i) mismatch between the hospital’s vision and reality, ii) poor communication, iii) lack of objective mechanisms for monitoring and evaluating quality of clinical care, iv) limited capacity for planning strategic change, v) limited management skills to introduce and manage change, vi) hierarchical relationships, and vii) inadequate adaptation of the interventions to the local context.ConclusionsEducational interventions, often regarded as ‘quick-fixes’ to improve care in low-income countries, may be necessary but are unlikely to be sufficient to deliver improved services. We propose that an understanding of organizational issues that influence the behaviour of individual health professionals should guide and inform the implementation of best-practices.

Highlights

  • Implementation of World Health Organization case management guidelines for serious childhood illnesses remains a challenge in hospitals in low-income countries

  • From 2006 they started to become available to junior clinicians in the university and Kenyatta National Hospital (KNH) with availability increasing in parallel with increased provision of ‘Emergency Triage Assessment and Treatment Plus admission care’ (ETAT+) training so that by 2008 most junior and senior clinicians had copies of the clinical practice guidelines (CPGs)

  • We describe how strategies to promote uptake of the CPGs and ETAT+ evolved with a focus on audit and feedback and continuing medical education sessions (CMEs)

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Summary

Introduction

Implementation of World Health Organization case management guidelines for serious childhood illnesses remains a challenge in hospitals in low-income countries. The need for improving health workers’ practice in low-income countries (LICs) has been frequently demonstrated in international and local surveys assessing the quality of care for the sick child. These studies identified poor compliance with evidence-based standards for care as some of the problems facing paediatric service delivery [1,2,3]. The protocols comprised of clinical practice guidelines (CPGs) adapted from World Health Organization and local disease specific guidelines [4] and originating from consultation with senior paediatricians from the University of Nairobi, Kenyatta National Hospital (KNH) and the Ministry of Health in 2005 [4,5]. Course design draw on educational theory and, for content, on the WHO’s Emergency Triage Assessment and Treatment (ETAT) course as well as the evidence-based CPGs [5,6]

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