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Burhin M, Isom V, Ogaoga D, Devine S, Duke T, Bugoro H, Tamou M, Mark C, Panda N. Child health nurses in Solomon Islands, piloting the 'Bachelor of nursing: Child health'. Int Nurs Rev 2024; 71:44-53. [PMID: 37029778 DOI: 10.1111/inr.12836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 02/18/2023] [Indexed: 04/09/2023]
Abstract
AIM In 2016, the Solomon Islands National University developed and implemented the country's first nursing specialisation in child health, the Bachelor of Nursing: Child Health. This qualitative study aimed to explore the experiences of the first cohort of students (n = 14) during this course in order to evaluate the programme. BACKGROUND The Bachelor of Nursing: Child Health was implemented in 2016 to develop nurses' knowledge and skills in child health and improve child health outcomes and so on. DESIGN The qualitative evaluation study used an exploratory, descriptive design. METHODS The 14 nurses who constituted the first cohort of students were selected as study participants. Individual semi-structured interviews were conducted between August and December 2018. Thematic analysis was undertaken following the Braun and Clarke six-phase process to generate themes and sub-themes from the data. The Consolidated Criteria for Reporting Qualitative Research checklist guided the reporting of the study. RESULTS Interviews revealed important feedback about the course, including areas to strengthen and avenues to improve it in the future. Four themes emerged: learning during the Bachelor of Nursing: Child Health, support during the course, challenges experienced during the course and suggested course improvements in the future. The study found that theoretical sessions combined with practical and interactive activities were most effective in learning both theoretical concepts and their related clinical applications and skills. Although support was generally available during the course, participants emphasised their responsibility to take the lead in their learning and seek support when required. The lack of mentoring combined with logistical difficulties were perceived as barriers to learning. Participant recommendations support further development of the child health nursing specialisation, with specific strengthening in areas such as teaching and mentoring, logistics, course curriculum and human and material resources. IMPLICATIONS FOR NURSING AND HEALTH POLICY Given the potential benefits of increasing nurses' knowledge and skills in child health and paediatric care on reducing neonatal and child mortality and morbidity, ongoing support for the implementation of this course in Solomon Islands and more broadly across the Pacific region is recommended. The provision of such support is a local, regional and a global responsibility. Indeed, Sustainable Development Goal 3c calls for a substantial increase in health financing and in the recruitment, development, training and retention of the health workforce in low- and middle-income countries. CONCLUSIONS Results of the evaluation demonstrate the positive aspects of the course in relation to content and curriculum delivery strategies as well as identifying areas where further refinement and strengthening is required.
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Affiliation(s)
- Mikael Burhin
- James Cook University, Douglas Bebegu Yumba Campus, College of Public Health, Medical and Veterinary Sciences, Townsville, Queensland, Australia
- Solomon Islands National University, Faculty of Nursing, Medicine and Health Sciences, Honiara, Solomon Islands
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Verzilyn Isom
- Solomon Islands National University, Faculty of Nursing, Medicine and Health Sciences, Honiara, Solomon Islands
| | - Divinal Ogaoga
- Ministry of Health and Medical Services - Division of Reproductive, Maternal, Neonatal, Child and Adolescent Health, Honiara, Solomon Islands
| | - Sue Devine
- James Cook University, Douglas Bebegu Yumba Campus, College of Public Health, Medical and Veterinary Sciences, Townsville, Queensland, Australia
| | - Trevor Duke
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Hugo Bugoro
- Solomon Islands National University, Faculty of Nursing, Medicine and Health Sciences, Honiara, Solomon Islands
| | - Mathias Tamou
- Ministry of Health and Medical Services - Division of Reproductive, Maternal, Neonatal, Child and Adolescent Health, Honiara, Solomon Islands
| | - Caleb Mark
- Solomon Islands National University, Faculty of Nursing, Medicine and Health Sciences, Honiara, Solomon Islands
| | - Nixon Panda
- Solomon Islands National University, Faculty of Nursing, Medicine and Health Sciences, Honiara, Solomon Islands
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Wabnitz K, Rueb M, Rehfuess EA, Strahwald B, Pfadenhauer LM. Assessing the impact of an evidence- and consensus-based guideline for controlling SARS-CoV-2 transmission in German schools on decision-making processes: a multi-component qualitative analysis. Health Res Policy Syst 2023; 21:138. [PMID: 38115061 PMCID: PMC10729453 DOI: 10.1186/s12961-023-01072-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 11/10/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION During the COVID-19 pandemic, decision-making on measures to reduce or prevent transmission of SARS-CoV-2 in schools was rendered difficult by a rapidly evolving and uncertain evidence base regarding their effectiveness and unintended consequences. To support decision-makers, an interdisciplinary panel of scientific experts, public health and school authorities as well as those directly affected by school measures, was convened in an unprecedented effort to develop an evidence- and consensus-based public health guideline for German schools. This study sought to assess whether and how this guideline impacted decision-making processes. METHODS This study comprised three components: (1) we sent inquiries according to the Freedom of Information Acts of each Federal State to ministries of education, family, and health. (2) We conducted semi-structured interviews with individuals involved in decision-making regarding school measures in two Federal States, and (3) we undertook semi-structured interviews with members of the guideline panel. The content of response letters in component 1 was analysed descriptively; data for components 2 and 3 were analysed using deductive-inductive thematic qualitative content analysis according to Kuckartz. RESULTS Responses to the Freedom of Information Act inquiries showed that the guideline was recognised as a relevant source of information by ministries of education in nine out of 16 Federal States and used as a reference to check existing directives for school measures in five Federal States. All participants (20 interviews) emphasised the value of the guideline given its evidence- and consensus-based development process but also noted limitations in its usability and usefulness, e.g., lack of context-specificity. It was consulted by participants who advised policy-makers (5 interviews) alongside other sources of evidence. Overall, perceptions regarding the guideline's impact were mixed. CONCLUSIONS Our findings suggest that the guideline was relatively well-known in Federal States' decision-making bodies and that it was considered alongside other forms of evidence in some of these. We suggest that further research to evaluate the impact of public health guidelines on (political) decision-making is warranted. Guideline development processes may need to be adapted to account for the realities of decision-making during public health emergencies and beyond.
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Affiliation(s)
- Katharina Wabnitz
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, Ludwig-Maximilians-Universität München, Elisabeth-Winterhalter-Weg 6, 81377, Munich, Germany.
- Pettenkofer School of Public Health, Munich, Germany.
| | - Mike Rueb
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, Ludwig-Maximilians-Universität München, Elisabeth-Winterhalter-Weg 6, 81377, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Eva A Rehfuess
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, Ludwig-Maximilians-Universität München, Elisabeth-Winterhalter-Weg 6, 81377, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Brigitte Strahwald
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, Ludwig-Maximilians-Universität München, Elisabeth-Winterhalter-Weg 6, 81377, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Lisa M Pfadenhauer
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, Ludwig-Maximilians-Universität München, Elisabeth-Winterhalter-Weg 6, 81377, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
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Lim R, Chaummanivong M, Taikeophithoun C, Gray A, Jenney AWJ, Sychareun V, Nguyen C, Russell F. Higher childhood pneumonia admission threshold remains in Lao PDR: an observational study. Arch Dis Child 2022; 107:872-877. [PMID: 35584907 DOI: 10.1136/archdischild-2021-323626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/22/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES WHO Integrated Management of Childhood Illness (IMCI) guidelines changed pneumonia hospitalisation criteria in 2014, which was implemented in Lao People's Democratic Republic (Lao PDR) in 2015. We determined adherence to: current (2014) IMCI guidelines for children presenting to hospitals with pneumonia, current outpatient management guidelines and identified hospitalisation predictors. DESIGN Prospective observational study (January 2017 to December 2018). SETTING Outpatient and emergency departments of four hospitals in Vientiane, Lao PDR. PATIENTS 594 children aged 2-59 months diagnosed with pneumonia. MAIN OUTCOME MEASURES Number of children diagnosed, hospitalised, managed, administered preventive measures and followed-up accordant with current guidelines. RESULTS Non-severe and severe pneumonia were correctly diagnosed in 97% and 43% of children, respectively. Non-severe pneumonia with lower chest wall indrawing (LCI) was diagnosed as severe in 15%. Hospitalisation rates were: 80% for severe pneumonia, 86% and 3% for non-severe pneumonia with and without LCI, respectively. Outpatient oral antibiotic prescribing was high (99%), but only 30% were prescribed both the recommended antibiotic and duration. Appropriate planned follow-up was 89%. Hospitalisation predictors included age 2-5 months (compared with 24-59 months; OR 3.95, 95% CI 1.90 to 8.24), public transport to hospital (compared with private vehicle; OR 2.60, 95% CI 1.09 to 6.24) and households without piped drinking water (OR 4.67, 95% CI 2.75 to 7.95). CONCLUSIONS Hospitalisation practice for childhood pneumonia in Lao PDR remains more closely aligned with the 2005 WHO IMCI guidelines than the currently implemented 2014 iteration. Compliance with current outpatient antibiotic prescribing guidelines was low.
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Affiliation(s)
- Ruth Lim
- Asia-Pacific Health Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Molina Chaummanivong
- Faculty of Public Health, University of Health Sciences, Vientiane, Vientiane Capital, Lao People's Democratic Republic
| | - Chansathit Taikeophithoun
- Faculty of Public Health, University of Health Sciences, Vientiane, Vientiane Capital, Lao People's Democratic Republic
| | - Amy Gray
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Adam W J Jenney
- Department of Infectious Diseases, Monash University, Clayton, Victoria, Australia
| | - Vanphanom Sychareun
- Faculty of Public Health, University of Health Sciences, Vientiane, Vientiane Capital, Lao People's Democratic Republic
| | - Cattram Nguyen
- Asia-Pacific Health Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fiona Russell
- Asia-Pacific Health Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Saluja K, Reddy KS, Wang Q, Zhu Y, Li Y, Chu X, Li R, Hou L, Horsley T, Carden F, Bartolomeos K, Hatcher Roberts J. Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review. Health Res Policy Syst 2022; 20:98. [PMID: 36071468 PMCID: PMC9449928 DOI: 10.1186/s12961-022-00899-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship. Methods We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.
Results The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines. Conclusions The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00899-y.
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Affiliation(s)
- Kiran Saluja
- Bruyere Research Institute, Ottawa, Canada.,Science Division, World Health Organization, Geneva, Switzerland
| | - K Srikanth Reddy
- Bruyere Research Institute, Ottawa, Canada. .,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada. .,Using Evidence Inc., Ottawa, Canada. .,Science Division, World Health Organization, Geneva, Switzerland.
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Ying Zhu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Yanfei Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xiajing Chu
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Rui Li
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liangying Hou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Tanya Horsley
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | | | | | - Janet Hatcher Roberts
- WHO Collaborating Centre for Knowledge Translation and Health Impact Assessment in Health Equity, Bruyere Research Institute, University of Ottawa, Ottawa, Canada
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Safe M, Wittick P, Philaketh K, Manivong A, Gray A. Mixed‐methods evaluation of a continuing education approach to improving district hospital care for children in Lao PDR. Trop Med Int Health 2022; 27:262-270. [PMID: 35080283 PMCID: PMC9305739 DOI: 10.1111/tmi.13726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To understand the impact of a multifaceted intervention on improving acute hospital care provided to children in two district hospitals in northern Lao PDR. Methods We developed a continuing education intervention, which integrated separate program content using a common pool of facilitators and low‐fidelity simulation scenarios. Coaching was delivered over one year through two‐day hospital visits to each hospital six to eight weeks apart with visits incorporating feedback. A comparative case study was conducted between two hospital sites. Medical record abstraction from inpatient cases was performed at each visit. Focus groups and interviews with staff were conducted to understand perceived changes to case management. Results Inpatient case management scores showed incremental improvement over time, from 50% at baseline to 80% at the end of one year at Hospital A and 52% to 97% at Hospital B. The key themes that emerged from the qualitative data from both hospitals were the value of the educational method and increased belief in capability. Hospital B showed more incremental and sustained improvement. Qualitative data revealed that the directors of Hospital B demonstrated modelling and behavioural reinforcement. Conclusion Improving the quality of care in low‐resource settings is feasible. A hands‐on practical approach with repeated coaching visits reinforced by feedback can lead to behaviour change. Optimal impact requires harnessing leadership and motivation for change among health workers.
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Affiliation(s)
- Marianne Safe
- Department of Paediatrics University of Melbourne Melbourne Australia
| | - Penelope Wittick
- Department of Paediatrics University of Melbourne Melbourne Australia
| | - Khammanh Philaketh
- Primary Health Care Program Office Save the Children, Luang Prabang, Lao PDR
| | | | - Amy Gray
- Department of Paediatrics University of Melbourne Melbourne Australia
- The Royal Children’s Hospital Melbourne Australia
- Murdoch Children’s Research Institute Melbourne Australia
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Foxlee ND, Townell N, Heney C, McIver L, Lau CL. Strategies Used for Implementing and Promoting Adherence to Antibiotic Guidelines in Low- and Lower-Middle-Income Countries: A Systematic Review. Trop Med Infect Dis 2021; 6:tropicalmed6030166. [PMID: 34564550 PMCID: PMC8482147 DOI: 10.3390/tropicalmed6030166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/09/2023] Open
Abstract
Containing antimicrobial resistance and reducing high levels of antibiotic consumption in low- and lower middle-income countries are a major challenge. Clinical guidelines targeting antibiotic prescribing can reduce consumption, however, the degrees to which clinical guidelines are adopted and adhered to are challenging for developers, policy makers and users. The aim of this study was to review the strategies used for implementing and promoting antibiotic guideline adherence in low- and lower middle-income countries. A review of published literature was conducted using PubMed, Cochrane Library, SCOPUS and the information systems of the World Health Organization and the Australian National University according to PRISMA guidelines and our PROSPERO protocol. The strategies were grouped into five broad categories based on the Cochrane Effective Practice and Organization of Care taxonomy. The 33 selected studies, representing 16 countries varied widely in design, setting, disease focus, methods, intervention components, outcomes and effects. The majority of interventions were multifaceted and resulted in a positive direction of effect. The nature of the interventions and study variability made it impossible to tease out which strategies had the greatest impact on improving CG compliance. Audit and feedback coupled with either workshops and/or focus group discussions were the most frequently used intervention components. All the reported strategies are established practices used in antimicrobial stewardship programs in high-income countries. We recommend interrupted time series studies be used as an alternative design to pre- and post-intervention studies, information about the clinical guidelines be made more transparent, and prescriber confidence be investigated.
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Affiliation(s)
- Nicola D. Foxlee
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, ACT 2600, Australia;
- Correspondence: ; Tel.: +61-7-435-549-071
| | - Nicola Townell
- Infectious Disease Department, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia;
| | - Claire Heney
- Pathology Queensland, Central Microbiology, Brisbane, QLD 4006, Australia;
| | - Lachlan McIver
- Rocketship Pacific Ltd., Port Melbourne, Melbourne, VIC 3207, Australia;
| | - Colleen L. Lau
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, ACT 2600, Australia;
- School of Public Health, University of Queensland, Herston, QLD 4006, Australia
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Graham HR, Maher J, Bakare AA, Nguyen CD, Ayede AI, Oyewole OB, Gray A, Izadnegahdar R, Duke T, Falade AG. Oxygen systems and quality of care for children with pneumonia, malaria and diarrhoea: Analysis of a stepped-wedge trial in Nigeria. PLoS One 2021; 16:e0254229. [PMID: 34237107 PMCID: PMC8266122 DOI: 10.1371/journal.pone.0254229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/22/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To evaluate the effect of improved hospital oxygen systems on quality of care (QOC) for children with severe pneumonia, severe malaria, and diarrhoea with severe dehydration. DESIGN Stepped-wedge cluster randomised trial (unblinded), randomised at hospital-level. SETTING 12 hospitals in south-west Nigeria. PARTICIPANTS 7,141 children (aged 28 days to 14 years) admitted with severe pneumonia, severe malaria or diarrhoea with severe dehydration between January 2014 and October 2017. INTERVENTIONS Phase 1 (pulse oximetry) introduced pulse oximetry for all admitted children. Phase 2 (full oxygen system) (i) standardised oxygen equipment package, (ii) clinical education and support, (iii) technical training and support, and (iv) infrastructure and systems support. OUTCOME MEASURES We used quantitative QOC scores evaluating assessment, diagnosis, treatment, and monitoring practices against World Health Organization and Nigerian standards. We evaluated mean differences in QOC scores between study periods (baseline, oximetry, full oxygen system), using mixed-effects linear regression. RESULTS 7,141 eligible participants; 6,893 (96.5%) had adequate data for analysis. Mean paediatric QOC score (maximum 6) increased from 1.64 to 3.00 (adjusted mean difference 1.39; 95% CI 1.08-1.69, p<0.001) for severe pneumonia and 2.81 to 4.04 (aMD 1.53; 95% CI 1.23-1.83, p<0.001) for severe malaria, comparing the full intervention to baseline, but did not change for diarrhoea with severe dehydration (aMD -0.12; 95% CI -0.46-0.23, p = 0.501). After excluding practices directly related to pulse oximetry and oxygen, we found aMD 0.23 for severe pneumonia (95% CI -0.02-0.48, p = 0.072) and 0.65 for severe malaria (95% CI 0.41-0.89, p<0.001) comparing full intervention to baseline. Sub-analysis showed some improvements (and no deterioration) in care processes not directly related to oxygen or pulse oximetry. CONCLUSION Improvements in hospital oxygen systems were associated with higher QOC scores, attributable to better use of pulse oximetry and oxygen as well as broader improvements in clinical care, with no negative distortions in care practices. TRIAL REGISTRATION ACTRN12617000341325.
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Affiliation(s)
- Hamish R. Graham
- Centre for International Child Health, The Royal Children’s Hospital, MCRI, University of Melbourne, Parkville, Australia
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- * E-mail:
| | - Jaclyn Maher
- Department of Paediatrics, Royal Children’s Hospital, University of Melbourne, Parkville, Australia
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Cattram D. Nguyen
- Department of Paediatrics, Royal Children’s Hospital, University of Melbourne, Parkville, Australia
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, The Royal Children’s Hospital, MCRI, University of Melbourne, Parkville, Australia
| | - Rasa Izadnegahdar
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Trevor Duke
- Centre for International Child Health, The Royal Children’s Hospital, MCRI, University of Melbourne, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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Wang Z, Grundy Q, Parker L, Bero L. Variations in processes for guideline adaptation: a qualitative study of World Health Organization staff experiences in implementing guidelines. BMC Public Health 2020; 20:1758. [PMID: 33228608 PMCID: PMC7686668 DOI: 10.1186/s12889-020-09812-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The World Health Organisation (WHO) publishes a large number of clinical practice and public health guidelines to promote evidence-based practice across the world. Due to the variety of health system capacities and contextual issues in different regions and countries, adapting the recommendations in the guidelines to the local situation is vital for the success of their implementation. We aim to understand the range of experiences with guideline adaptation from the perspectives of those working in WHO regional and country offices. Our findings will inform development of guidance on how to improve adaptability of WHO guidelines. METHODS A grounded theory-informed, qualitative study was carried out between March 2018 and December 2018. Seventeen semi-structured interviews were conducted with participants who included WHO guideline developers and staff in the headquarters, regional and country offices recruited from a sample of published WHO guidelines. Participants were eligible for recruitment if they had recent experience in clinical practice or public health guideline implementation. Deidentified transcripts of these interview were analysed through three cycles of coding. RESULTS We categorised the adaptation processes described by the participants into two dominant models along a spectrum of guideline adaptation processes. First, the Copy or Customise Model is a pragmatic approach of either copying or customising WHO guidelines to suit local needs. This is done by local health authorities and/or clinicians directly through consultations with WHO staff. Selections and adjustments of guideline recommendations are made according to what the implementers deemed important, feasible and applicable through the consensus discussions. Second, the Capacity Building Model focuses on WHO building local capacity in evidence synthesis methods and adaptation frameworks to support local development of a national guideline informed by international guidelines. CONCLUSIONS In comparing and contrasting these two models of guideline adaptation, we outline the different kinds of support from WHO that may be necessary to improve the effectiveness and efficiency of the respective models. We also suggest clarifications in the descriptions of the process of guideline adaptation in WHO and academic literature, to help guideline adaptors and implementers decide on the appropriate course of action according to their specific circumstances. ETHICS This project was conducted with ethics approval from The University of Sydney (Project number: 2017/723) and WHO (Protocol ID: 00001).
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Affiliation(s)
- Zhicheng Wang
- Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney School of Pharmacy, Sydney, Australia
| | - Quinn Grundy
- Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney School of Pharmacy, Sydney, Australia
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Lisa Parker
- Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney School of Pharmacy, Sydney, Australia
| | - Lisa Bero
- Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney School of Pharmacy, Sydney, Australia
- Colorado School of Public Health and Center for Bioethics and Humanities, University of Colorado School of Medicine, Aurora, USA
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Wang Z, Grundy Q, Parker L, Bero L. Health promoter, advocate, legitimiser - the many roles of WHO guidelines: a qualitative study. Health Res Policy Syst 2019; 17:96. [PMID: 31805956 PMCID: PMC6896683 DOI: 10.1186/s12961-019-0489-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/20/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Properly implemented evidence-based clinical and public health guidelines can improve patient outcomes. WHO has been a major contributor to guideline development, publishing more than 250 guidelines on various topics since 2008. However, well-developed guidelines can only be effective if they are adequately and appropriately implemented. Herein, we aimed to explore whether and how WHO guidelines are implemented in local contexts to inform the success of future guideline implementation. METHODS Seventeen interviews were carried out between March 2018 and December 2018 with WHO guideline developers, headquarter staff, and regional and country office staff. Participants were purposely sampled from a variety of WHO guidelines and snowball sampling was used to identify regional and country office staff. The deidentified transcripts were analysed through three phases of coding, using grounded theory as the analytic approach. RESULTS WHO guidelines played a variety of roles in the work of WHO at all levels. WHO officers and local government officials used WHO guidelines to influence health policy. We categorised the uses of guidelines as (1) directly changing policy, (2) justifying policy change, (3) engaging stakeholders, (4) being guarantors of legitimacy, (5) being advocacy tools, and (6) intertwining with WHO's various roles. Participants refuted the perception of the guidelines as mere lists of technical recommendations that needed to be implemented in different contexts. We found that the existence, quality and credibility, rather than the content of the guidelines, are the keys to health policy change initiatives in different local contexts. CONCLUSIONS Used as a guarantor of legitimacy by policy-makers, WHO guidelines can be better positioned to influence health policy and practice change. Understanding the various roles of guidelines can help WHO developers package guidelines to optimise their effective implementation. ETHICS This project was conducted with ethics approval from The University of Sydney (Project number: 2017/723) and WHO (Protocol ID: 00001).
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Affiliation(s)
- Zhicheng Wang
- Charles Perkins Centre, The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, Australia.
| | - Quinn Grundy
- Charles Perkins Centre, The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, Australia.,Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Lisa Parker
- Charles Perkins Centre, The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, Australia
| | - Lisa Bero
- Charles Perkins Centre, The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Sydney, Australia
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Wang Z, Norris SL, Bero L. The advantages and limitations of guideline adaptation frameworks. Implement Sci 2018; 13:72. [PMID: 29843737 PMCID: PMC5975671 DOI: 10.1186/s13012-018-0763-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The implementation of evidence-based guidelines can improve clinical and public health outcomes by helping health professionals practice in the most effective manner, as well as assisting policy-makers in designing optimal programs. Adaptation of a guideline to suit the context in which it is intended to be applied can be a key step in the implementation process. Without taking the local context into account, certain interventions recommended in evidence-based guidelines may be infeasible under local conditions. Guideline adaptation frameworks provide a systematic way of approaching adaptation, and their use may increase transparency, methodological rigor, and the quality of the adapted guideline. This paper presents a number of adaptation frameworks that are currently available. We aim to compare the advantages and limitations of their processes, methods, and resource implications. These insights into adaptation frameworks can inform the future development of guidelines and systematic methods to optimize their adaptation. ANALYSIS Recent adaptation frameworks show an evolution from adapting entire existing guidelines, to adapting specific recommendations extracted from an existing guideline, to constructing evidence tables for each recommendation that needs to be adapted. This is a move towards more recommendation-focused, context-specific processes and considerations. There are still many gaps in knowledge about guideline adaptation. Most of the frameworks reviewed lack any evaluation of the adaptation process and outcomes, including user satisfaction and resources expended. The validity, usability, and health impact of guidelines developed via an adaptation process have not been studied. Lastly, adaptation frameworks have not been evaluated for use in low-income countries. CONCLUSION Despite the limitations in frameworks, a more systematic approach to adaptation based on a framework is valuable, as it helps to ensure that the recommendations stay true to the evidence while taking local needs into account. The utilization of frameworks in the guideline implementation process can be optimized by increasing the understanding and upfront estimation of resource and time needed, capacity building in adaptation methods, and increasing the adaptability of the source recommendation document.
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Affiliation(s)
- Zhicheng Wang
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales Australia
- Charles Perkins Centre, The University of Sydney, D17, The Hub, 6th floor, Sydney, New South Wales Australia
| | | | - Lisa Bero
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales Australia
- Charles Perkins Centre, The University of Sydney, D17, The Hub, 6th floor, Sydney, New South Wales Australia
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Gray A, Chhor L, Sanyalack S, Lim R, Lai J, Vilivong K, Morpeth M, Soukaloun D, Russell F. Some sustained improvements in pneumonia case management four and five years following implementation of paediatric hospital guidelines in Lao PDR. Sci Rep 2017; 7:10679. [PMID: 28878405 PMCID: PMC5587579 DOI: 10.1038/s41598-017-10880-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 08/15/2017] [Indexed: 11/23/2022] Open
Abstract
In 2010, WHO paediatric hospital guidelines were implemented in Lao PDR, along with training workshops and feedback audits, achieving significant improvements in pneumonia case management when assessed one-year post-intervention. The sustainability of these improvements is hereby assessed, four and five years post-intervention. Medical records of children aged 1-59 months, diagnosed with pneumonia in 2010, 2011, 2014 and 2015 from a central Lao hospital were reviewed. Information relating to clinical steps in pneumonia case management was extracted and a scoring system applied based on the documentation of each clinical step, producing a pneumonia assessment score for each case. Comparisons of clinical steps and mean assessment score across study years were performed using Pearson's chi-squared and t-tests, respectively. Of 231 pneumonia cases, the mean assessment scores in 2010, 2011, 2014 and 2015 were 57%, 96%, 69% and 69% respectively, showing a significant reduction from the immediate post-intervention period (2011) to 2015 (p < 0.01). Mean assessment score in 2014/2015 was significantly higher than in 2010 (p < 0.01). The high standards of pneumonia case management in 2011 were not observed in 2014/2015 in the absence of ongoing intervention but overall quality of care remained higher than pre-intervention levels, suggesting some degree of sustainability in the long-term.
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Affiliation(s)
- Amy Gray
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia.
- The Royal Children's Hospital, Parkville, Victoria, Australia.
| | - Louis Chhor
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
| | | | - Ruth Lim
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
- The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jana Lai
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
| | | | - Melinda Morpeth
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Douangdao Soukaloun
- Mahosot Hospital, Vientiane, Lao PDR
- University of Health Sciences, Vientiane, Lao PDR
| | - Fiona Russell
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
- Pneumococcal Group, Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
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Gray AZ, Soukaloun D, Soumphonphakdy B. A Qualitative Study of Provider Perceptions of Influences on Uptake of Pediatric Hospital Guidelines in Lao PDR. Am J Trop Med Hyg 2017; 97:602-610. [PMID: 28722590 DOI: 10.4269/ajtmh.16-1005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Strategies to improve the quality of hospital care are needed if ongoing gains in child health and survival are to be made. We previously reported on improvements in the quality of case management in hospitals following a guideline-based intervention in Lao PDR, with variation in the degree of change achieved between clinical conditions. This study aims to understand the factors that influenced the uptake of the guideline-based intervention, and its impact on care. This qualitative study was embedded in a mixed-methods evaluation of guideline implementation in nine hospitals in Lao PDR. Focus groups and individual interviews were conducted with 70 health staff from central, provincial, and district hospitals. The interview guide was based on the Theoretical Domains Framework. Inductive content analysis was performed on interview transcripts to identify themes, supported by field notes from the intervention. Findings were triangulated against previously reported quantitative outcomes using driver diagrams. Key influences on guidelines uptake related to the guideline and intervention (filling a void, physical accessibility, comprehensibility, training in guideline use), health staff (behavior regulation, trust in guidelines, and beliefs about consequences), and the environment (social influences particularly consensus and incorporation into clinical norms). The major barrier was family preference for treatments in conflict with guideline recommendations. This study identifies contextual factors that explain, as well as validate previously identified improvements in care following guideline implementation in Lao PDR. It provides novel understanding of why the same intervention may have a differential impact on different clinical conditions.
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Affiliation(s)
- Amy Z Gray
- Royal Children's Hospital, Melbourne, Australia.,Centre for International Child Health, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
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Implementation plans included in World Health Organisation guidelines. Implement Sci 2016; 11:76. [PMID: 27207104 PMCID: PMC4875699 DOI: 10.1186/s13012-016-0440-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/12/2016] [Indexed: 11/21/2022] Open
Abstract
Background The implementation of high-quality guidelines is essential to improve clinical practice and public health. The World Health Organisation (WHO) develops evidence-based public health and other guidelines that are used or adapted by countries around the world. Detailed implementation plans are often necessary for local policymakers to properly use the guidelines developed by WHO. This paper describes the plans for guideline implementation reported in WHO guidelines and indicates which of these plans are evidence-based. Methods We conducted a content analysis of the implementation sections of WHO guidelines approved by the WHO guideline review committee between December 2007 and May 2015. The implementation techniques reported in each guideline were coded according to the Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) taxonomy and classified as passive, active or policy strategies. The frequencies of implementation techniques are reported. Results The WHO guidelines (n = 123) analysed mentioned implementation techniques 800 times, although most mentioned implementation techniques very briefly, if at all. Passive strategies (21 %, 167/800) and general policy strategies (62 %, 496/800) occurred most often. Evidence-based active implementation methods were generally neglected with no guideline mentioning reminders (computerised or paper) and only one mentioning a multifaceted approach. Many guidelines contained implementation sections that were identical to those used in older guidelines produced by the same WHO technical unit. Conclusions The prevalence of passive and policy-based implementation techniques as opposed to evidence-based active techniques suggests that WHO guidelines should contain stronger guidance for implementation. This could include structured and increased detail on implementation considerations, accompanying or linked documents that provide information on what is needed to contextualise or adapt a guideline and specific options from among evidence-based implementation strategies.
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