"Though there are some challenges, we try our best to follow the guidelines": a qualitative study exploring determinants of providing guideline-adherent care to hospitalized children in Kenya.

BACKGROUND: Clinical treatment guidelines are designed to improve quality of care by offering clear recommendations for health workers; however, across many settings, implementing guidelines is a challenge. For over 20 years, comprehensive World Health Organization guidelines for care of hospitalized children have provided guidance for treating the primary causes of childhood death. These recommendations were adapted in Kenya and codified in the Basic Paediatric Protocol; however, adherence to these evidence-based interventions remains suboptimal. METHODS: This qualitative study identified the barriers and facilitators of providing guideline-adherent care to children admitted to two hospitals in Kenya. The semi-structured question guide was informed by the Theoretical Domains Framework (TDF). Three focus group discussions and 16 in-depth interviews were conducted with 35 health workers. Participants were nurses, doctors, clinical officers, or nutritionists (including in-charges and clinical supervisors). Interviews were audio recorded and transcribed. Transcripts were coded using a TDF-based codebook, validated, and analyzed for themes. RESULTS: TDF domains with the greatest influence on the thematic findings were environmental context and resources, social influences, beliefs about consequences, and beliefs about capabilities. Health workers were knowledgeable about guidelines and felt strongly that adherence to them was beneficial; however, they also faced barriers implementing them. Challenges related to the environmental context were pervasive, including shortages of staff and supplies. Participants praised the simplicity of guidelines but also noted that simplified diagnostic criteria don't align with complex patient presentations. While guidelines empowered some nurses to make clinical decisions, respondents reported that strict professional roles sometimes delayed diagnosis and treatment. Further, health workers reported some deviations were intentional (ex. when guidelines were not aligned to their beliefs) and other times they were unintentional (ex. when complex patient presentations make guideline adherence difficult). CONCLUSIONS: Knowledge of guidelines and motivation to use them were not major determinants in this analysis. Rather, human and material resource shortages presented the greatest barrier to guideline adherence in this setting. Improving guidelines by involving health workers in participatory development of guidelines would improve both clarity and feasibility. Health workers are well-versed in guideline recommendations, so educational strategies should focus on knowledge gaps or changes in the latest version of guidelines.