Using the behavior change wheel to identify barriers to and potential solutions for primary care clinical guideline use in four provinces in South Africa
Date
2018-12-14
Journal Title
Journal ISSN
Volume Title
Publisher
BMC (part of Springer Nature)
Abstract
Background: Clinical 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.
Methods: We 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.
Results: Participants 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.
Conclusions: South 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.
Description
CITATION: Kredo, T., et al. 2018. Using the behavior change wheel to identify barriers to and potential solutions for primary care clinical guideline use in four provinces in South Africa. BMC Health Services Research, 18:965, doi:10.1186/s12913-018-3778-2.
The original publication is available at https://bmchealthservres.biomedcentral.com
The original publication is available at https://bmchealthservres.biomedcentral.com
Keywords
Qualitative research, Clinical practice patterns, Primary care (Medicine)
Citation
Kredo, T., et al. 2018. Using the behavior change wheel to identify barriers to and potential solutions for primary care clinical guideline use in four provinces in South Africa. BMC Health Services Research, 18:965, doi:10.1186/s12913-018-3778-2