Using the behavior change wheel to identify barriers to and potential solutions for primary care clinical guideline use in four provinces in South Africa

Abstract

BackgroundClinical practice guidelines risk having little impact on healthcare if not effectively implemented. Theory informed, targeted implementation may maximise their impact. Our study explored barriers to and facilitators of guideline implementation and use by South African primary care nurses and allied healthcare workers in four provinces in South Africa. We also proposed interventions to address the issues identified.MethodsWe used qualitative research methods, comprising focus group discussions using semi-structured topic guides. Seven focus group discussions were conducted (48 providers) in four South African provinces (Eastern Cape, Western Cape, Kwazulu-Natal, Limpopo). Participants included mostly nurses, dieticians, dentists, and allied health practitioners, from primary care facilities in rural and peri-urban settings. The analysis proceeded in three phases. Firstly, two analysts conducted inductive thematic content analysis to develop themes of data. This was followed by fitting emergent themes to the Theoretical Domains Framework and finally to the associated Behaviour Change Wheel to identify relevant interventions.ResultsParticipants are knowledgeable about guidelines, generally trust their credibility and are receptive and motivated to use them. Guidelines are seen by nurses to provide confidence and reassurance, as well as professional authority and independence where doctors are scarce. Barriers to guideline use include: inadequate systems for printed book distribution, insufficient and substandard photocopies, linguistic inappropriateness (e.g. complicated language, lack of summaries, unavailable in local languages), unsupportive auditing procedures, limited involvement of end-users in guideline development, and patchy training that may not filter back to all providers. Future aspirations identified include: improving the design features of guidelines, accessible places to find guidelines, making digitally-formatted versions available, more supplementary materials (e.g. posters) to support patient engagement, accessible clinical support following training, and in-facility training for all professional cadres to ensure fair access, similar levels of capability and interdisciplinary consistency.ConclusionsSouth African primary care nurses and allied health practitioners have high levels of motivation to use guidelines, but face many systemic barriers. We used the Behaviour Change Wheel to suggest relevant, implementable interventions addressing identified barriers. This theory-informed approach may improve clinical guideline implementation and impact healthcare for South Africa.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3778-2) contains supplementary material, which is available to authorized users.

‘Building on shaky ground’—challenges to and solutions for primary care guideline implementation in four provinces in South Africa: a qualitative study

“…These views mirrored those of PHC providers in the same districts that we spoke to who described that they would be more likely to use CPGs if digital access was possible. 32 However, like the managers, they perceived lack of internet in facilities, and exorbitant costs of data required for downloading CPGs, asbarriers to digital access. 32 Human resource constraints, such as clinical workload and understaffing, was another health system issue hindering CPG implementation, a finding that echoes a substudy of PHC clinical staff in these districts.…”

“…We used qualitative methods from an interpretative paradigm to understand the experiences and perspectives of provincial and district managers responsible for primary care guideline implementation. The methods and study context have been described in detail elsewhere, 32 and thus only a summary is provided here, together with a detailed description of the participants and analysis methods used.…”

“…In the EC, we were invited to present at a provincial research day, where we received buy-in for our planned research. 32 In the WC, we contacted known provincial managers involved with PHC CPGs. In the other provinces, we invited individuals recommended by the Provincial Research Units.…”

“…For the qualitative component of SAGE, we interviewed diverse role players involved in primary care CPG development, implementation and/or use. We have reported the findings from national CPG developers 30 31 ; frontline healthcare workers who use CPGs 32 ; as well as allied healthcare providers regarding CPG development and implementation. [33][34][35][36] In this paper, we build on this work but delve further into the area of health system and service governance to explore the perspectives of provincial and district health managers who have responsibility for CPG implementation.…”

Improving case detection of tuberculosis in hospitalised Kenyan children– employing the Behaviour Change Wheel to aid intervention design and implementation

“…Behaviour Change Techniques are the active, observable and replicable components that make up an intervention. COM-B/BCW have been used successfully for behavioural analysis and to design interventions in both health and non-health-related elds [26,[36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55], but to our knowledge, has been used in only one study of TB on contact tracing in a low-resource setting, to identify barriers and facilitators and to tailor interventions to improve contact investigation in Kampala [26]. In the qualitative arm, to understand the challenges in recognising and testing for TB in admitted children we analysed data from: i) semi-structured interviews, small-group discussions and key informant interviews with front line health workers and mid-level managers; ii) observations of TB trainings, sensitisation meetings, policy meetings, and hospital practices, and iii) desk review of guidelines, job aides and policy documents, which have been reported elsewhere [31].…”