A multifaceted approach that addressed deficiencies in clinical knowledge, skills, motivation, resources, and the organization of care was associated with improvements in practice for high mortality conditions in young children in rural Kenya compared with less comprehensive approaches.
This finding from a novel study by Philip Ayieko from the KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya, and colleagues, published in this week's PLoS Medicine, is important as it suggests that specific efforts are needed to improve pediatric care in rural areas of poor countries such as Kenya -- where 74 in every 1000 children die before their fifth birthday.
The authors randomly assigned eight Kenyan district hospitals to the "full" or "control" intervention. The full intervention included provision of clinical practice guidelines and training in their use, 6-monthly survey-based hospital assessments followed by face-to-face feedback of survey findings, 5.5 days training for health-care workers, provision of job aids such as structured pediatric admission records, external supervision, and a local facilitator to promote guideline use and to provide on-site problem solving. The control intervention included the provision of clinical practice guidelines (without training in their use) and job aids, 6-monthly surveys with written feedback, and a 1.5 day lecture-based seminar to explain the guidelines.
The authors found that the performance of both groups of hospitals improved during the study period (18 months), despite high staff turnover, but the completion of admission assessment tasks and the uptake of guideline-recommended clinical practices were higher in the intervention hospitals than in the control hospitals. In addition, a lower proportion of children received inappropriate doses of drugs (such as quinine for malaria) in the intervention hospitals than in the control hospitals.
The authors say: "Our data… to our knowledge represent the first major report examining national adaptation and implementation of a broad set of rural hospital care recommendations. They are relevant to many of the 100 countries with [Integrated Management of Childhood Illnesses] programmes where rural hospitals have important roles supporting primary health care systems and in helping to reduce child mortality."
- Philip Ayieko, Stephen Ntoburi, John Wagai, Charles Opondo, Newton Opiyo, Santau Migiro, Annah Wamae, Wycliffe Mogoa, Fred Were, Aggrey Wasunna, Greg Fegan, Grace Irimu, Mike English. A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial. PLoS Medicine, 2011; 8 (4): e1001018 DOI: 10.1371/journal.pmed.1001018
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