Paediatrics (RCH) - Theses
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ItemImplementation of paediatric hospital guidelines in Lao PDR: the impact on quality of care and contextual factors affecting change( 2013)There is substantial evidence of deficiencies in the quality of hospital care from both developed and developing countries. Better evidence for the effectiveness of different strategies to improve care is needed, along with understanding of how the local context influences their success or failure. Lao PDR (Laos) is a resource-poor country with high rates of child mortality and a critical need to improve capacity of health staff caring for sick children. Implementation of the World Health Organisation (WHO) Pocketbook of Hospital Care for Children through the local network of paediatricians was identified as one potential strategy for improving hospital care in this setting. The principal aim of this thesis was to evaluate the impact of implementing WHO guidelines on the quality of paediatric hospital care in Laos, and to understand the contextual factors that influenced the implementation and uptake of guidelines in this setting. A before-and-after mixed methods study design was used to evaluate the implementation of a multifaceted intervention based on the WHO Pocketbook of Hospital Care for Children. Quality of hospital care was assessed in nine hospitals pre- and post-intervention using an observational assessment tool and abstraction of information from medical records. In central hospitals medical record abstraction data was used to compare case management of four sentinel conditions pre- and post-intervention, using overall case management scores and individual quality indicators. A process evaluation was performed to document the intervention that was delivered as well as the contextual factors that influenced its implementation and outcome. Focus groups were used to understand how the Pocketbook and its implementation were perceived by Lao doctors and nurses. Triangulation of quantitative and qualitative data enabled interpretation of the changes observed following Pocketbook implementation as well as identification of reasons change did, or did not, occur. The study demonstrates changes in case management of sentinel conditions in central hospitals following implementation of the WHO Pocketbook, reflecting uptake of guidelines into practice and standardisation of care. The magnitude of change observed varied according to clinical condition. The largest changes in practice were seen in pneumonia case management, followed by diarrhoea and low birth weight babies. Limited change occurred in case management of febrile encephalopathy. Improvements in monitoring, rational drug use and fluid prescribing were apparent across conditions and hospitals. Important influences on the strong intent of healthcare providers to adopt the WHO Pocketbook included local ownership, opinion leaders, the critical need met by the guidelines, the training approach, and the provision of feedback. Factors such as guideline simplicity and expectations of families, provide potential explanation for differences seen between diseases. The study supports the effectiveness of a WHO Pocketbook-based intervention in improving quality of paediatric hospital care but highlights the need for a multi-faceted intervention and an understanding of the local context in order to achieve change. In Laos, implementation efforts need to be directed towards sustainability, improving district hospital care and understanding the impact on patient outcomes. Lessons from Laos will be applicable to other countries and health care interventions.