Background
Despite international efforts, newborn and child health remains a significant health challenge in low- and middle-income countries (LMICs). Reducing child mortality was one of the eight Millennium Development Goals (MDGs) adopted by the international community (MDG 4: calls for reducing the deaths of children under five years of age by two-thirds between 1990 and 2015). Remarkable progress has been recorded in saving children’s lives globally since 1990- the number of under-five deaths has declined from 12.6 million in 1990 to 6.6 million in 2012, but during the same period neonatal survival has improved more slowly, with 44% of all under-five deaths in 2012 occurring during the neonatal period [
1]. Despite progress, neonatal and child mortality remain high in LMICs. In 2013, nearly 6.3 million children under-five died worldwide [
2]. Sub-Saharan Africa accounts for nearly half (49%) of the global burden of newborn and child deaths despite being home to just 11% of the global population. Reducing these inequities and saving more children’s lives by ending preventable child deaths should therefore remain a priority on the post-MDGs 2015 agenda. The newly established Sustainable Development Goals (SDGs) seek to build on the MDGs and complete what these did not achieve [
3]. In Rwanda, approximately 24,000 children died in 2013 – of whom ~39% were neonates [
4]. The leading causes of mortality in children younger than five years in Rwanda are neonatal related complications (e.g., preterm, asphyxia, neonatal sepsis); pneumonia; dehydration/diarrhea and malaria [
4‐
6]. Previous research has also identified gaps in the quality of hospital care provided to sick newborns and children in Rwanda [
7].
A major reason for the slow progress in reaching the MDGs in many LMICs is the ‘know-do-gap’– the gap between the existing knowledge on how to reduce the burden of illness and what is implemented [
8]. While there is a wealth of evidence on the efficacy and effectiveness of numerous health care interventions in sub-Saharan Africa, there is still relatively limited evidence on how best to implement or scale up such interventions in order to achieve the desired impact [
9]. Evidence suggests that a key opportunity for narrowing the know-do gap and accelerating the attainment of the set MDG and SDG targets lies in identifying simple interventions as well as the most optimal ways to train and incentivise an implementation workforce and future scale-up leaders [
10].
Advanced pediatric life support trainings have been advocated for implementation in LMICs to contribute to the reduction of under-five mortality in these countries and thus contribute to the achievement of MDG 4 [
11]. The ETAT+ training, a locally adapted pediatric life support program, was developed in East Africa for health professionals caring for acutely ill children, and aimed to improve pediatric emergency and admission care in the initial 24–48 h of hospitalization [
12]. ETAT+ expands the original World Health Organization (WHO) emergency triage assessment and treatment (ETAT), and is an intensive five-day training covering the recognition and initial management of the commonest medical causes of pediatric hospital admission in East Africa (Table
1). Ayieko and colleagues conducted a cluster-randomized trial in Kenya that provided the state of evidence around the effectiveness of ETAT+ in improving the quality of care for children in low-resource settings [
13]. The training was designed to enable healthcare workers to provide important, evidence-based, best-practice care on admission for sick children in resource-limiting settings [
12]. Since the introduction of ETAT+ in Rwanda in 2010, in-service healthcare workers and medical students have been trained [
14‐
16].
Table 1
Topic covered in the ETAT+ training in Rwanda
Triage |
Infant and child resuscitation |
Recognition of a sick child |
Diarrhea/dehydration and shock |
Newborn care – preterm, jaundice, feeding, sepsis |
Pneumonia |
Malaria |
Asthma |
Severe malnutrition |
Meningitis |
Hypoglycaemia |
Convulsions |
Prescribing and procedures – oxygen, lumbar puncture, intra-osseous |
Hospital survey |
Morbidity and mortality audit |
Clinical practice guidelines (CPGs) such as ETAT+ are developed to help healthcare providers deliver the best care to patients by translating the best available evidence on the management of diseases into specific recommendations for care. Nevertheless, evidence-based guidelines are rarely implemented with perfect fidelity under real-world conditions [
7,
14]. Therefore, evaluations of the real-world experiences with implementing such guidelines are important in terms of identifying potential barriers to successful implementation, as well as identifying factors that contribute to their successful adoption and scale-up in various contexts.
Following the demonstration of its effectiveness in Kenya, it was anticipated that the ETAT+ program would be easily adopted to Rwanda given the commonalities in resources as well as epidemiological profiles in the two contexts. However, since the introduction of the program in Rwanda, its relevance and implementation challenges, especially from healthcare workers’ perspective have not been explored. Thus, the current study was undertaken to identify potential challenges to successful implementation of ETAT+ guidelines in Rwandan district hospitals from the healthcare workers’ perspective. Furthermore, the study also explored healthcare workers’ perspective on the relevance of ETAT+ in the Rwanda district healthcare system, including whether they anticipated to change their practice, and which specific aspects of practice they might be willing to change.
Context
Rwanda – a small, low-income and landlocked country –has a population of 10,515,973 people, of which ~ 85% lives in rural areas [
17]. The Rwandan healthcare system is organized along the country’s administrative lay out of 30 districts, with each district having at least one district hospital that operates autonomously and provides healthcare services to well-defined populations in the district [
5,
18,
19]. During the 1994 genocide, which claimed the lives of more than 800,000 people including healthcare workers, the Rwandan healthcare system was entirely disrupted [
19]. Following this dark period, the government began to rebuild the healthcare system; however, mortality in children younger than five years did not return to pre-1990 rates until 2005 [
4]. Actions taken to improve access to primary health services included the restructuring and decentralization of healthcare management in district health facilities as well as developing infrastructure and expanding the community-based health insurance [
20]. Currently, access to health services is universal as nearly all Rwandans including the poorest 25% of the population that pay no health insurance premiums, have health insurance [
21,
22]. Rwanda has one of the youngest population worldwide, with approximately 48% of its population being younger than 18 years old [
17]. While there are approximately 410,100 births per year and only about 20 pediatricians were working in the country as of 2011, mostly in national referral hospitals [
5,
16,
23]. Notably, the country has a combined “health – service – provider density” of 8.4 physicians, nurses, and midwives per 10,000 population which falls far below the minimum level recommended by the WHO of 23 providers per 10,000 population [
22,
24]. The healthcare workforce in district hospitals is primarily comprised of generalist physicians with six years of basic medical training and nurses with A2-level (secondary school nursing diploma, the lowest level of nursing training available) [
22]. These physicians and nurses are often required to handle complicated pediatric and neonatal emergencies in the absence of specialists. Nevertheless, it is noteworthy that efforts are underway to train specialists who will be deployed in all hospitals countrywide [
22].
Methods
The ETAT+ training in Rwanda consists of short lectures on specific topics (Table
1) followed by demonstrations, practical procedures and case based scenarios using mannequins, hospital audit including a review of selected patient medical records within the specific institution where the training is occurring, and assessment and feedback [
14]. Discussions and hands on practice take place in small groups of 5–7 participants where all healthcare providers (nurses, midwives and physicians) learn together to promote inter-professional collaboration [
14]. The training preparation materials are provided to all participants before the ETAT+ training. These materials include an invitation letter describing the training location and expectation, a training schedule [
25], a pre-training knowledge assessment questionnaire, and the ETAT+ clinical practice guidelines disseminated during the training [
26]. The ETAT + training for the healthcare workers in Rwanda is run mainly in English language and is completed in five days. Attendance of the training for the entire period is compulsory. Upon completion of the training, all participants retake the knowledge assessment. Further, the participants’ clinical skills are assessed, using an Objective Structured Clinical Examination (OSCE) format, on two clinical skills scenarios (i.e., neonatal resuscitation and management of a severely sick child with shock due to dehydration) [
14]. Further details about the ETAT+ training for Rwandan healthcare providers, including effect of the training on knowledge and skills change as well as the associated factors can be found in our previous study (http://journals.plos.org/plosone/article?id=
10.1371/journal.pone.0152882#pone.0152882.ref017).
Using a semi-structured questionnaire (Additional file
1), the healthcare workers who were working in Rwandan district hospitals and attended the ETAT+ training between November 2012 and May 2013 were approached and asked, immediately after the training, their perspective regarding (i) relevance of ETAT+ to Rwandan district hospitals (e.g.; “Is ETAT+ relevant to your work?” “What are the most relevant contents?” “Are there other materials that you think should be added to the training?”); (ii) if attending the training would bring about change in their work; and (iii) the challenges they encountered during the training as well as challenges which they anticipated might hamper the translation of the knowledge and skills learnt in the ETAT+ training into everyday practice in order to improve emergency care for severely ill infants and children in their institution. Furthermore, information pertaining to healthcare workers’ characteristics was collected including profession (nurse, midwife, physician); sex; location of district hospital of affiliation (urban or rural); department of affiliation; experience; and whether they had attended any clinical practice guideline disseminating training including ETAT+ before. These healthcare workers wrote down their perspectives / views in French, Kinyarwanda, or English and sometimes mixture of all these languages that are official in the post – genocide Rwanda [
27]. Of note, these healthcare workers were informed of the questions throughout the training and encouraged to think about them so that they could provide a more comprehensive list of challenges that needed to be addressed in order to enhance the implementation of ETAT+, in Rwandan district hospitals. Moreover, they were allowed to consult their notes taken over the week of the training.
The healthcare workers’ notes were translated to (if not already in) English and transcribed, and transcripts were imported into NVivo 8 software (QSR International, Doncaster, Australia) for thematic coding and analysis - this approach involves coding data into themes representing the phenomena under investigation [
28]. We employed both inductive and deductive approaches to identify themes. Broad themes were developed based on the study objectives/questions that were asked (ETAT+ relevance, anticipated change in their work, challenges encountered during the training, and challenges anticipated to hamper the translation of ETAT+ knowledge and skills into practice). We inductively identified sub-themes within the broad themes. All transcripts were reviewed by two people independently line-by-line identifying anticipated and emerging themes, which were compared and discussed until consensus was reached. The themes that emerged from the analysis are reported with the healthcare workers’ quotes, as appropriate. Further, we reviewed all the ETAT+ training reports, and used the data to complement and corroborate the findings from the analysis of the healthcare workers’ notes, particularly, those relevant to the training delivery challenges. Several themes emerged including:
language barriers, timing/delays in receiving training materials, intense training schedule.
Discussion
Proven effective newborn and child health interventions need to be successfully implemented to contribute to sustainable reduction of mortality in children under-five years in low- and middle- income countries. The primary purpose of this study was to identify challenges that healthcare workers anticipated as likely to hinder successful implementation of the ETAT+ clinical practice guidelines in Rwandan district hospitals. In addition, we explored healthcare workers’ perspectives with regards to the relevance to ETAT+ in Rwandan district hospitals, whether these healthcare workers anticipated to change practice, and which specific aspects of practice they might be willing to change following the ETAT+ training. Nearly all participating healthcare workers stated that the training was highly relevant to the district hospitals and that it aligned with their work expectations. However, some midwives believed that the “neonatal resuscitation and feeding” components of the training were more relevant to them than other components. Many healthcare workers anticipated to change practice by initiating a triage system in their hospital and to use job aids including guidelines for prescription and feeding. Most of the anticipated challenges stemmed from perceived ETAT+ dissemination issues (e.g., language barriers, format of training materials, intense training schedule) and health facility related challenges (e.g., staff shifting/turnover, limited resources, reluctance to change, conflicting clinical practice guidelines).
While uptake of clinical practice guidelines is a complex process, key factors including relevance of these guidelines to the system and routine work of healthcare workers can enhance their uptake. For example, Irimu et al.’s ethnographic study conducted in a Kenyan hospital suggested that ETAT+ relevance to routine clinical practice was of the of the factors that facilitated its uptake by healthcare workers in Kenya [
29]. Our findings suggest that healthcare workers trained in ETAT+ believe that the training is highly relevant to the Rwandan healthcare system, especially in district hospitals (which constitute the backbone of the Rwandan healthcare system) where healthcare providers who do not have specialty training generally take care of severely sick infants and children without supervision. The ETAT+ training highlights the most common illnesses – leading causes of under-five mortality in Rwanda and in the region – that healthcare workers involved in providing healthcare to sick infants and children would encounter in everyday practice in Rwandan district hospitals [
12,
14]. As such, the high relevance of ETAT+, as expressed by Rwandan healthcare workers, could contribute to its successful implementation in Rwandan district hospitals. Rwandan healthcare workers even expressed willingness to make the training a requirement (e.g., recertification) to work in paediatrics and neonatology. Moreover, while recognizing challenges to translate what they learned into practice, trained healthcare workers anticipated to make changes in their practice after the training, including establishing a functional triage system in their facilities and regular use of job aids especially when prescribing drug therapies, which could help bridge gaps in the process of neonatal and pediatric care identified in Rwandan district hospitals [
7]. Going forward, complementing the ETAT+ training with regular supervision and mentorship could help not only to ensure that knowledge translation takes place, but also identify further opportunities to enhance the impact of the ETAT+ program.
While it is well known that participating in a training program improves knowledge and skills [
14‐
16,
30], there are barriers that might hamper the use of newly acquired skills, especially in a context where people could be resistant to changing things. For example, a recent study that evaluated the performance of health care providers in the management of seriously sick children in Kenya suggests that educational interventions alone may not be sufficient to deliver high quality care, and effectively adapting interventions to the local context is equally as important [
29]. Similarly, Baradaran-Seyed et al.’s study found that one of the major barriers to implementation of clinical practice guidelines in Iran was a healthcare system not designed to easily integrate evidence-based clinical practice guidelines [
31]. Arguably, an understanding of local healthcare system organizational factors that can affect healthcare providers’ behavior should guide and inform the implementation of clinical practice guidelines such as ETAT+.
In Rwanda, involving district hospital leadership as well as training large numbers of healthcare workers and use of standards might help bring about change. For example, a district hospital could ensure that all healthcare workers are ‘certified’ in pediatric resuscitation and regular ongoing professional training could be introduced to make sure people retained their skills. An outreach type of program that supports healthcare workers in their own environment and ensures that the necessary equipment is available in good condition, would be timely. This would involve working at the ministry level to develop effective policies and standards for continuing medical education (CME) and health care assessments. Further, engaging all stakeholders involved in clinical practice guidelines development and implementation could help to avoid disseminating conflicting clinical practice guidelines – an important challenge highlighted in our study.
Lack of resources was identified as a significant challenge to successful implementation of the ETAT+ program in our study. This is consistent with previous research in similar settings [
11,
32‐
34]. For example, a survey of Rwandan district hospitals identified limited availability of resources necessary to provide neonatal and pediatric emergency care (e.g., all hospitals surveyed lacked intra-osseous needles for the management of shock and half of the hospitals evaluated lacked BVM for newborns) [
34]. In Kenya, English and colleagues found that many essential items for the care of severely ill children were lacking in many district hospitals [
33]. Likewise, shortages of drugs, equipment, disposable materials as well as facilities made it difficult to implement sepsis management guidelines in Mongolia [
32]. While in the ETAT+ training healthcare workers are taught how to correctly assess children with dehydration/shock and how to resuscitate them with fluid, including putting an intra-osseous (IO) line when necessary, our findings and prior research suggest that some of the required equipment are not available in the hospitals and this may therefore hamper successful implementation of the ETAT+ program in Rwanda [
34]. Given that dehydration/shock usually due to diarrheal diseases is one of the leading causes of under-five mortality and morbidity in Rwanda [
4‐
6] and the evidence from prior research recommending IO access if IV cannot be promptly established, and suggesting that IO access may be ‘easily established’ by healthcare workers with little training and is ‘more rapidly achieved’ than IV access, IO access equipment should be made readily available in the district hospitals [
35,
36].
The ETAT+ clinical practice guideline dissemination related challenges (e.g., format of course materials, location of the training) and healthcare workers’ language proficiency have been suggested as correlates of healthcare providers’ performance in the ETAT+ training in Rwanda [
14]. Rwanda shifted its official language from French to English in 2008 [
37], and secondary and post-secondary education and CME programs are run primarily in English. The current study findings, using qualitative methods, are in line with findings from our previous quantitative study that used within the ETAT+ training metrics to explore potential factors associated with performance of Rwandan healthcare providers in ETAT+ [
14]. It was found that relative to healthcare workers who identified as proficient in French, those who identified as proficient in both English and French had on average a higher improvement in knowledge and were more than twice likely to pass the practical skills assessment. This discrepancy might be explained by challenges expressed by healthcare providers who were not proficient in English (e.g., unable to adequately prepare or understand course content, if it was taught mainly in English). In addition, low computer ownership and internet penetration in rural areas [
38] might explain challenges experienced by healthcare workers from rural areas in the preparation for the training when they were not provided printed training materials. While ETAT+ training held within health facilities was cost saving (e.g., costs associated with accommodation of participants and training venue were saved), it was found as in a previous study, to be associated with a poorer performance, which may be due to the fact that healthcare workers may have been required to continue to be involved in some of the work-related activities (e.g., direct patient care, night call) during training time and could have missed important material when away [
14,
15]. Going forward, we believe that printed training materials should be provided to ETAT+ training participants and these materials should be available in a language that participants understand. Moreover, efforts should be made to organize trainings in French or English
separately to accommodate participants’ language proficiencies. Further, for each training, participants could be recruited from across many district hospitals so as not to put excessive personnel absence or strain on any single hospital to require those attending intensive training such as ETAT+ to cover night calls. Equally important, ETAT+ organizers should communicate to the hospitals early about the training so that staff rotation can be modified to accommodate absences for training.
Prior research suggested a number of factors (e.g., staff turner-over, knowledge/skills decay) to be significant barriers to the translation of knowledge and skills to practice [
16,
39‐
42]. For example, a recent study by Tuyisenge found that 62.5% of healthcare workers from the district hospitals in the Eastern Province of Rwanda that were trained in Advanced Life Support in Obstetrics (ALSO®) between October 2012 and October 2013 had left their work in the district hospitals by August 2014 for various reasons including taking better job/position (26.6%) and furthering their studies (42.2%) [
39]. Clearly, it is possible that some of the healthcare workers trained in ETAT+ may stop working in the district hospitals for various reasons as well. Thus, given the need for a better trained health workforce along with significant resources (both international and local) invested in training healthcare providers, there is an urgent need to evaluate strategies to retain healthcare providers in district hospitals in Rwanda, especially in remote areas. Moreover, efforts should be deployed to prevent internal staff shifting (i.e. staff shifting from one department to another) as this would potentially affect the fidelity of the ETAT+ implementation in Rwandan district hospitals as trained healthcare workers may not be working in departments where their skills and knowledge are most valuable.
Further, it is critical that participants who attend the ETAT+ training are selected from the healthcare workers working in the departments (e.g., paediatrics, neonatology, delivery room, emergency room) where ETAT+ knowledge and skills gained could be put into practice to benefit patients. Clearly, training healthcare workers who do not work in relevant departments may hamper the successful implementation of ETAT+ even if physical resources (e.g., IO) were available in the district hospitals, as these resources would not be appropriately used to benefit patients. As such, ETAT+ training organizers should work with district hospital administration to establish a system to ensure that healthcare workers attending the training work in relevant departments.