Exploring Implementation Strategies to Improve Pediatric Treatment Guideline Implementation: Understanding Factors, Co-designing Strategies, and Identifying Change Mechanisms

Abstract

Background: While substantial progress has been made towards reducing child mortality, millions of preventable child deaths continue to occur every year. Clinical treatment guidelines that describe evidence-based interventions are available, however adherence to them remains suboptimal. This dissertation explores implementation strategies to support guideline adherence among health workers providing care in hospital settings in Kenya and other low- and middle-income countries (LMICs).Methods: This dissertation utilized several methods to identify factors impacting guideline implementation, co-design a strategy to improve adherence, and identify the mechanisms that generate changes in guideline adherence. In Chapter 1, a qualitative study was conducted to understand the barriers and facilitators of clinical treatment guideline adherence among health workers at two hospitals in Kenya. Interviews and focus group discussions were conducted, transcripts were coded with a codebook organized around the Theoretical Domains Framework (TDF), and analysis identified themes. In Chapter 2, we utilized a complex mixed method design to build upon the understanding gained in Chapter 1 and co-design an implementation strategy that would support health workers in applying clinical treatment guidelines at one hospital in Kenya. Through a multi-stage process of group decision making and iterative design, the Team Approach to Malnutrition Services (TeAMS) Toolkit was developed. Following a 10-week pilot of this strategy, a mixed methods evaluation of usability, feasibility, and impacts on task completion and teamwork was conducted. A survey included measurement of the System Usability Score, Feasibility of Implementation Measure as well as task analysis, and teamwork perceptions; with interviews and focus group discussions exploring these concepts in detail. In Chapter 3, a realist literature synthesis was conducted to develop and refine a program theory that explains the mechanisms through which participatory design processes and guideline implementation tools support guideline adherence in LMICs. After clarifying the scope through development of an initial program theory, we conducted a search for evidence and appraised the relevance, richness, and rigor of the identified studies. After extracting data, analysis of the evidence informed the refinement of the program theory. Results: In Chapter 1, 35 participants took part in qualitative data collection and we found that TDF domains with greatest influence on the thematic findings were environmental context and resources, social influences, beliefs about consequences, and beliefs about capabilities. Health workers reported some deviations were intentional (ex. when guidelines were deemed inadequate for a clinical scenario) and other times they were unintentional (ex. when complex patient presentations make guidelines adherence difficult). Health workers were knowledgeable about guidelines and felt strongly that adherence to them was beneficial, however they also faced barriers to implementing them. Challenges related to environmental context were pervasive, including shortages of staff, supplies, and infrastructure. While health workers described frequent interdisciplinary consultation within their teams, strict professional roles and team dynamics sometimes delayed diagnosis and treatment. In Chapter 2, we involved 34 participants in a co-design process to develop and pilot test the TeAMS Toolkit. First, health workers decided that the challenge they would address was that reliance on nutritionists to handle critical tasks sometimes delays guideline adherent care for children with severe malnutrition. They then came to consensus on a strategy that would clarify team member roles in providing care to children with malnutrition and summarize information from guidelines to support performance of those roles. The TeAMS Toolkit was developed to meet these requirements, with iterations based on feedback from health workers. After launching and piloting, we found the TeAMS Toolkit to have good usability (median 77.5, IQR 67.5-87.5). Participants described the Toolkit as easy to use and a helpful reference to look to when delivering care. While there were no significant changes identified in quantitative measures of perceived competence or frequency of task completion, qualitative findings described non-nutritionists feeling able to take on feeding tasks utilizing the Toolkit content to guide them. Participants descried improved collaboration and multidisciplinary teamwork to ensure timely care, which aligned with significant changes (p<0.05) on two out of six measures of teamwork perceptions. In Chapter 3, an initial program theory was developed that included ten context-strategy-mechanism-outcome (CSMO) configurations. Our search identified 10,883 records, and after de-duplication title and abstract screening of 8,697 records was completed. The full text of 112 articles were reviewed and data was extracted from 27 included studies. The extracted data was analyzed and synthesized to refine the initial program theory, resulting in a refined theory with eight CSMO configurations. This theory explicates how participatory processes can contribute to improved health worker engagement, acceptability of guideline implementation tools, group consensus regarding operationalization plans, and teamwork perceptions. In addition, it describes how specific types of guideline implementation tools (descriptions of roles, teamwork skills, job aids, documentation tools) may impact guideline adherence through mechanisms including improved role clarity, visible reminders, gains in competence, and improved efficiency. Conclusion: This dissertation contributes to deepening our understanding of how and why implementation strategies can support guideline adherence in LMICs. Our findings highlight how team collaboration and professional roles impact guideline adherence and describe an implementation strategy that addresses these drivers to improve guideline adherence. We plan to build on this work with further refinement and scale-up of the TeAMS Toolkit. Moreover, the refined program theory we developed can be utilized to guide the selection and design of implementation strategies, ensuring better alignment to context and the best chance of improving guideline adherence.