The effect of an automated integrated management of childhood illness guideline on the training of professional nurses in the Western Cape, South Africa

Using technology-based educational interventions to improve knowledge about clinical practice guidelines

OBJECTIVE

To describe the best evidence on the effectiveness of technology-based learning tools designed to improve knowledge of health care providers about clinical practice guidelines (CPGs).

METHODS

We conducted a systematic review, searching MEDLINE, Embase, and CINAHL from inception to July 2018. Included studies investigated the effectiveness of any technology-based learning tools developed to improve knowledge of health care providers about CPGs. We used a 2-phase screening process to determine eligibility. Pairs of reviewers critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network checklist for randomized controlled trials or the National Institutes of Health checklist for pre- and postintervention trials. Evidence from internally valid studies was described using a best-evidence summary. We conducted a sensitivity analysis to determine whether results varied according to methodological quality.

RESULTS

Twenty-five of 8321 articles met our selection criteria. Six studies had a low risk of bias and were included in this review. Spaced education was associated with improvement in knowledge; however, its effectiveness relative to other interventions is unknown. Module-based online educational interventions were associated with improvement in knowledge of CPGs; however, they may not be more effective than paper-based self-learning or in-person workshops. The sensitivity analysis determined that the evidence was similar between the high and low risk of bias studies.

CONCLUSION

Module-based- and spaced-education interventions may be beneficial for improving health care providers' knowledge of CPGs; however, much of the evidence toward their use is preliminary.

Acceptability and uptake of an electronic decision-making tool to support the implementation of IMCI in primary healthcare facilities in KwaZulu-Natal, South Africa

Background: Despite progress in reducing child mortality, preventable child deaths remain a challenge in South Africa. Poor implementation of Integrated Management of Childhood Illness (IMCI) guidelines has been well described, and the reported barriers to implementation include a lack of user-friendly implementation tools. Aim: To investigate whether an electronic decision support tool to strengthen IMCI implementation is acceptable to nurses, clinic managers and caregivers at primary care facilities in KwaZulu-Natal, South Africa. Methods: The electronic IMCI (eIMCI) software was tested in 15 health facilities in uMgungundlovu district from May to July 2018. System use was tracked and qualitative data obtained from three user groups. IMCI practitioners participated in questionnaires and focus groups, operational managers in in-depth interviews and caregivers in exit interviews. Results: Thirty-two IMCI practitioners, six operational managers and 30 caregivers were included. Acceptance was high among caregivers and operational managers, albeit less conclusive among IMCI practitioners whose eIMCI uptake indicated higher variability in acceptance than the qualitative reports. Despite suboptimal staff deployment after training and low baseline computer literacy levels, 3626 eIMCI records were captured across 12 sites over 14 weeks, with a median of 19 records per facility per week. Practitioners' indicators of self-efficacy improved significantly (p < 0.05) post-implementation compared to baseline. Seventy-six percent of caregivers reported a marked difference in experience compared to previous consultations, emphasising the comprehensiveness and efficiency of care. Conclusion: Uptake was promising and acceptance was good, with themes converging across participant groups to highlight improved comprehensiveness and efficiency of service. Limited computer literacy was the principal barrier to uptake. The next steps include incremental scale-up with stronger mentoring and supervision components and evaluations to assess the feasibility, effectiveness and cost-effectiveness of eIMCI implementation. Abbreviations: CDSS: clinical decision support system; CHCs: community health centres; DoH: Department of Health; eIMCI: electronic IMCI; eHealth: electronic health; EHR: electronic health records; ICT: information and communication technology; IMCI: Integrated Management of Childhood Illness; OM: operational managers; PHCs: primary healthcare clinics; SA: South Africa; SSA: sub-Saharan Africa.

Family physicians' experience and understanding of evidence-based practice and guideline implementation in primary care practice, Cape Town, South Africa

BACKGROUND

In primary care, patients present with multimorbidity and a wide spectrum of undifferentiated illnesses, which makes the application of evidence-based practice (EBP) principles more challenging than in other practice contexts.

AIM

The goal of this study was to explore the experiences and understanding of family physicians (FP) in primary care with regard to EBP and the implementation of evidence-based guidelines.

SETTING

The study was conducted in Cape Town primary care facilities and South African university departments of Family Medicine.

METHODS

For this phenomenological, qualitative study, 27 purposefully selected FPs from three groups were interviewed: senior academic FPs; local FPs in public-sector practice; and local FPs in private-sector practice. Data were analysed using the framework method with the assistance of ATLAS.ti, version 6.1.

RESULTS

Guideline development should be a more inclusive process that incorporates more evidence from primary care. Contextualisation should happen at an organisational level and may include adaptation as well as the development of practical or integrated tools. Organisations should ensure synergy between corporate and clinical governance activities. Dissemination should ensure that all practitioners are aware of and know how to access guidelines. Implementation should include training that is interactive and recognises individual practitioners' readiness to change, as well as local barriers. Quality improvement cycles may reinforce implementation and provide feedback on the process.

CONCLUSION

Evidence-based practice is currently limited in its capacity to inform primary care. The conceptual framework provided illustrates the key steps in guideline development, contextualisation, dissemination, implementation and evaluation, as well as the interconnections between steps and barriers or enablers to progress. The framework may be useful for policymakers, health care managers and practitioners in similar settings.