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."
Funding: Funds from a Wellcome Trust Senior Fellowship awarded to Mike English (#076827) supported intervention development, provision of guidelines, and job aides and all the research components. Routine hospital care was provided by the Government of Kenya. The funders had no role in the design, conduct, analyses, or writing of this study or in the decision to submit for publication.
Competing Interests: Santau Migiro, Wycliffe Mogoa, and Annah Wamae declared that they are employed by The Kenyan Government within the Ministries of Health and have responsibilities for child and newborn health. Mike English declares: 1. I coordinated the development of the multifaceted approach prior to its being tested in the trial. 2. I help coordinate provision of ETAT+ training on a voluntary basis (one component of the intervention) as attempts are made to provide the training to non-trial hospitals and within the University of Nairobi to trainee paediatricians and medical students. 3. I am attached to KEMRI and employed by Oxford University. 4. I sit on an advisory committee (unpaid) to the government of Kenya, the Child Health Interagency Coordinating Committee and have acted as a technical advisor to WHO on several occasions in the child and newborn health arena. There is no commercial aspect to the development of the training and other aspects of the intervention. In fact all training materials are freely available on the website http://www.idoc-africa.org. All the remaining authors have declared that no competing interests exist.
Citation: Ayieko P, Ntoburi S, Wagai J, Opondo C, Opiyo N, et al. (2011) A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial. PLoS Med 8(4): e1001018. doi:10.1371/journal.pmed.1001018
Journal
PLoS Medicine