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A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial

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      Abstract

      Philip Ayieko and colleagues report the outcomes of a cluster-randomized trial carried out in eight Kenyan district hospitals evaluating the effects of a complex intervention involving improved training and supervision for clinicians. They found a higher performance of hospitals assigned to the complex intervention on a variety of process of care measures, as compared to those receiving the control intervention.

      Abstract

      Background

      In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated.

      Methods and Findings

      This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n = 4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n = 4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline.

      In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean = 0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05–0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%; 17.1% [8.04%–26.1%]); loading dose quinine (91.9% versus 66.7%, 26.3% [−3.66% to 56.3%]); and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%; 29.9% [10.9%–48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose >40 mg/kg/day; 1.0% versus 7.5%; −6.5% [−12.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%; −6.8% [−11.9% to −1.6%]).

      Conclusions

      Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings.

      Trial registration

      Current Controlled Trials ISRCTN42996612

      Please see later in the article for the Editors' Summary

      Editors' Summary

      Background

      In 2008, nearly 10 million children died in early childhood. Nearly all these deaths were in low- and middle-income countries—half were in Africa. In Kenya, for example, 74 out every 1,000 children born died before they reached their fifth birthday. About half of all childhood (pediatric) deaths in developing countries are caused by pneumonia, diarrhea, and malaria. Deaths from these common diseases could be prevented if all sick children had access to quality health care in the community (“primary” health care provided by health centers, pharmacists, family doctors, and traditional healers) and in district hospitals (“secondary” health care). Unfortunately, primary health care facilities in developing countries often lack essential diagnostic capabilities and drugs, and pediatric hospital care is frequently inadequate with many deaths occurring soon after admission. Consequently, in 1996, as part of global efforts to reduce childhood illnesses and deaths, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) introduced the Integrated Management of Childhood Illnesses (IMCI) strategy. This approach to child health focuses on the well-being of the whole child and aims to improve the case management skills of health care staff at all levels, health systems, and family and community health practices.

      Why Was This Study Done?

      The implementation of IMCI has been evaluated at the primary health care level, but its implementation in district hospitals has not been evaluated. So, for example, interventions designed to encourage the routine use of WHO disease-specific guidelines in rural pediatric hospitals have not been tested. In this cluster randomized trial, the researchers develop and test a multifaceted intervention designed to improve the implementation of treatment guidelines and admission pediatric care in district hospitals in Kenya. In a cluster randomized trial, groups of patients rather than individual patients are randomly assigned to receive alternative interventions and the outcomes in different “clusters” of patients are compared. In this trial, each cluster is a district hospital.

      What Did the Researchers Do and Find?

      The researchers randomly assigned eight Kenyan district hospitals to the “full” or “control” intervention, interventions that differed in intensity but that both included more strategies to promote implementation of best practice than are usually applied in Kenyan rural hospitals. The full intervention included provision of clinical practice guidelines and training in their use, six-monthly survey-based hospital assessments followed by face-to-face feedback of survey findings, 5.5 days training for health care workers, provision of job aids such as structured pediatric admission records, external supervision, and the identification of a local facilitator to promote guideline use and to provide on-site problem solving. The control intervention included the provision of clinical practice guidelines (without training in their use) and job aids, six-monthly surveys with written feedback, and a 1.5-day lecture-based seminar to explain the guidelines. The researchers compared the implementation of various processes of care (activities of patients and doctors undertaken to ensure delivery of care) in the intervention and control hospitals at baseline and 18 months later. The performance of both groups of hospitals improved during the trial but more markedly in the intervention hospitals than in the control hospitals. At 18 months, the completion of admission assessment tasks and the uptake of guideline-recommended clinical practices were both higher in the intervention hospitals than in the control hospitals. Moreover, a lower proportion of children received inappropriate doses of drugs such as quinine for malaria in the intervention hospitals than in the control hospitals.

      What Do These Findings Mean?

      These findings show that specific efforts are needed to improve pediatric care in rural Kenya and suggest that interventions that include more approaches to changing clinical practice may be more effective than interventions that include fewer approaches. These findings are limited by certain aspects of the trial design, such as the small number of participating hospitals, and may not be generalizable to other hospitals in Kenya or to hospitals in other developing countries. Thus, although these findings seem to suggest that efforts to implement and scale up improved secondary pediatric health care will need to include more than the production and dissemination of printed materials, further research including trials or evaluation of test programs are necessary before widespread adoption of any multifaceted approach (which will need to be tailored to local conditions and available resources) can be contemplated.

      Additional Information

      Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001018.

      • WHO provides information on efforts to reduce global child mortality and on Integrated Management of Childhood Illness (IMCI); the WHO pocket book “Hospital care for children contains guidelines for the management of common illnesses with limited resources (available in several languages)

      • UNICEF also provides information on efforts to reduce child mortality and detailed statistics on child mortality

      • The iDOC Africa Web site, which is dedicated to improving the delivery of hospital care for children and newborns in Africa, provides links to the clinical guidelines and other resources used in this study

      Related collections

      Most cited references 57

      • Record: found
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      • Article: not found

      Making psychological theory useful for implementing evidence based practice: a consensus approach.

       ,  S Michie,  Mark Parker (2005)
      Evidence-based guidelines are often not implemented effectively with the result that best health outcomes are not achieved. This may be due to a lack of theoretical understanding of the processes involved in changing the behaviour of healthcare professionals. This paper reports the development of a consensus on a theoretical framework that could be used in implementation research. The objectives were to identify an agreed set of key theoretical constructs for use in (1) studying the implementation of evidence based practice and (2) developing strategies for effective implementation, and to communicate these constructs to an interdisciplinary audience. Six phases of work were conducted to develop a consensus: (1) identifying theoretical constructs; (2) simplifying into construct domains; (3) evaluating the importance of the construct domains; (4) interdisciplinary evaluation; (5) validating the domain list; and (6) piloting interview questions. The contributors were a "psychological theory" group (n = 18), a "health services research" group (n = 13), and a "health psychology" group (n = 30). Twelve domains were identified to explain behaviour change: (1) knowledge, (2) skills, (3) social/professional role and identity, (4) beliefs about capabilities, (5) beliefs about consequences, (6) motivation and goals, (7) memory, attention and decision processes, (8) environmental context and resources, (9) social influences, (10) emotion regulation, (11) behavioural regulation, and (12) nature of the behaviour. A set of behaviour change domains agreed by a consensus of experts is available for use in implementation research. Applications of this domain list will enhance understanding of the behaviour change processes inherent in implementation of evidence-based practice and will also test the validity of these proposed domains.
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        • Record: found
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        The quality of care. How can it be assessed?

         A Donabedian (2015)
        Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.
          Bookmark
          • Record: found
          • Abstract: found
          • Article: not found

          How many child deaths can we prevent this year?

          This is the second of five papers in the child survival series. The first focused on continuing high rates of child mortality (over 10 million each year) from preventable causes: diarrhoea, pneumonia, measles, malaria, HIV/AIDS, the underlying cause of undernutrition, and a small group of causes leading to neonatal deaths. We review child survival interventions feasible for delivery at high coverage in low-income settings, and classify these as level 1 (sufficient evidence of effect), level 2 (limited evidence), or level 3 (inadequate evidence). Our results show that at least one level-1 intervention is available for preventing or treating each main cause of death among children younger than 5 years, apart from birth asphyxia, for which a level-2 intervention is available. There is also limited evidence for several other interventions. However, global coverage for most interventions is below 50%. If level 1 or 2 interventions were universally available, 63% of child deaths could be prevented. These findings show that the interventions needed to achieve the millennium development goal of reducing child mortality by two-thirds by 2015 are available, but that they are not being delivered to the mothers and children who need them.
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            Author and article information

            Affiliations
            [1 ]KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
            [2 ]Division of Child Health, Ministry of Public Health and Sanitation, Nairobi, Kenya
            [3 ]Ministry of Medical Services, Nairobi, Kenya
            [4 ]Department of Paediatrics and Child Health, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
            [5 ]Infectious Disease Epidemiology Unit, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
            [6 ]Department of Paediatrics, University of Oxford and John Radcliffe Hospital, Headington, Oxford, United Kingdom
            University of Edinburgh and Andrija Stampar School of Public Health, Scotland
            Author notes

            ICMJE criteria for authorship read and met: P Ayieko, S Ntoburi, J Wagai, C Opondo, N Opiyo, S Migiro, A Wamae, W Mogoa, F Were, A Wasunna, G Fegan, G Irimu, M English. Agree with the results and conclusions: P Ayieko, S Ntoburi, J Wagai, C Opondo, N Opiyo, S Migiro, A Wamae, W Mogoa, F Were, A Wasunna, G Fegan, G Irimu, M English. Conceived and designed the experiments: A Wamae, F Were, A Wassuna, M English. Analyzed the data: P Ayieko, C Opondo, G Fegan, M English. Wrote the first draft: P Ayieko, M English. Wrote the paper: P Ayieko, M English. Obtained the funding for this project: M English. Provided and coordinated training and supervision: S Ntoburi, J Wagai, G Irimu, M English. Responsible for surveys, and analyses conducted to inform feedback: P Aiyeko, S Ntoburi, C Opundo, N Opiyo, J Wagai, G Irimu, M English.

            Contributors
            Role: Academic Editor
            Journal
            PLoS Med
            PLoS
            plosmed
            PLoS Medicine
            Public Library of Science (San Francisco, USA )
            1549-1277
            1549-1676
            April 2011
            April 2011
            5 April 2011
            : 8
            : 4
            3071366
            21483712
            PMEDICINE-D-10-00227
            10.1371/journal.pmed.1001018
            (Academic Editor)
            Ayieko et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
            Counts
            Pages: 14
            Categories
            Research Article
            Medicine
            Pediatrics

            Medicine

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