Motivation – Reflective and automatic
Motivation includes behaviors corresponding to reflective motivation and those that are more automatic or habitual. We report on both reflective and automatic motivation as they include issues of emotion, professional identify, beliefs about capability and consequences. Strikingly, across all FGDs, the overwhelming majority of participants expressed motivation to use CPGs. CPG use appeared to evoke a range of positive emotional responses, particularly amongst nurses. Sentiments included ‘reassuring’, inspiring ‘confidence’ and providing a sense of autonomy or ‘independence’. The latter was particularly pronounced in more rural settings, with few doctors:
It makes [allows] us to be in line with the doctors, it makes us doctors ourself [sic], so it means you will be independent (Nurse_LPP_rural).
Additionally, CPGs were perceived as useful tools to engage the community, share information and protect healthcare providers’ professional integrity, which further motivated use:
Even if there is a complaint among the community members that we have mismanaged this client, so we say, I have managed this client … through the guidelines and we show him the guidelines (Nurse_EC_rural).
Overall, CPGs were perceived as credible sources. Nurses and allied healthcare providers in several clinics described having first-hand experience of CPGs improving patient care. One particularly significant example cited was that of HIV, where CPGs had changed rapidly as the field of HIV care changed in South Africa. Providers described having seen patients transition from dying prior to the availability of HIV CPGs, to patients living with HIV after CPGs were implemented. This underscored for them the perceived value that using CPGs bring:
It’s working, because when we want to find out our statistics, people they are now…[HIV] negative…they have got ARV’s [antiretrovirals] and they are fine… (Nurse_KZN_rural).
Compared to nursing staff, the link between CPGs, professional identity and enablement seemed lesser for doctors, as one doctor suggested:
I must confess, we doctors are not very good at seeing this is what the guidelines says. This is the way I do things and then you go on. It’s not just here but if you go to another place you’ll find the same thing. (Doctor_KZN_peri-urban).
Capability – Knowledge and skills
Capability includes knowledge, understanding, decision-making and skills as fundamental drivers of behaviour. A consistent narrative amongst participants was that knowledge of CPGs was not a barrier to usage. Participants conveyed considerable awareness of CPGs, with many naming several that were in regular, perhaps even daily use. In addition to knowledge, remembering and deciding to use CPGs was not perceived as a barrier. Some participants even voiced curiosity about why we would conduct research on something that was so obviously part of routine clinical care.
While some participants described using CPGs for ‘
each and every patient’, others suggested that they were most likely to use CPGs in particular instances. That is, they tended to use CPGs when faced with an unfamiliar clinical case or a change in the recommendations that sparked curiosity, and required learning:
…what makes me want to read some of them is because I came across such a patient, and I didn’t know what to do then I go back to read. That is what makes me wanna read, otherwise I don’t think I’ll just sit down and read the guideline (Oralhealth_LPP_peri-urban).
Despite their own knowledge, participants expressed an important gap in CPG awareness amongst patients and the public. Many felt that increasing public awareness of CPGs was important for successful CPG implementation. That is, a more health-literate and empowered public was perceived to encourage accountability of healthcare providers. Several approaches for raising public awareness were proposed, including engaging journalists, use of radio, television and social media:
Maybe when you’re listening to [the] radio and reading news, they should introduce this change everywhere, because even [the] patients should know (Oralhealth_LPP_peri-urban).
Another significant gap identified by participants was training in CPG usage. Training was perceived as an essential tool to
‘keep abreast’ or ‘get up to speed’ with CPG content. It was also considered important for enhancing clinical practice and ensuring that all disciplines
‘will be on the same level’ and thus preventing a ‘
clash of information’. While training was unanimously perceived as necessary for proficient CPG usage, participants were undecided about the setting in which training should take place. Specific feedback about the pros and cons of on-site training and off-site workshops were provided, which are detailed in Additional file
1. Though training was considered key to CPG use, many participants felt that skills building through training was inadequate. Training, regardless of whether providers were from urban or rural settings, was considered insufficient or patchy, not covering all topics and not inclusive of all clinical disciplines. This inadequacy was perceived to result in CPGs which are ‘
hard to interpret’ and thus staff having to
‘struggle’ on their own to use CPGs properly
. The management process for deciding who would attend workshops was also described as non-transparent and unfair, with ‘
no consistency’ surrounding attendance
. Thus, while participants were categorical about the need for more training, the issue of how best to do this remains complex.
Opportunity – Social and physical
Opportunity includes both physical opportunity and social opportunity. Social opportunity considers the social influences that may impact CPG use. While this domain did not generate substantial discussion amongst participants, what emerged consistently, particularly in rural facilities, was the value of supportive social and professional systems as enabling quality clinical care and CPG use. These systems, including involvement of non-governmental organisations, and associated cohesive teams and strong leadership, were perceived to enable the culture of CPG use.
So it’s team work that matters, if you are working as a team you do (Nurse_EC_peri-urban).
Whereas we found generally supportive social and professional environments, the physical environment emerged as a considerable obstacle to CPG use. This domain generated extensive discussion, with several sub-themes emerging, namely: the need to adapt to local context; health system challenges; access to CPGs; CPG design needs; and digital CPGs. In addition to describing these barriers in great depth, participants from all disciplines also provided practical recommendations for how these contextual barriers might be addressed.
CPGs being insufficiently adapted to local contexts emerged as a key issue. Given the diversity in a large country like South Africa, the context in which CPGs are used may differ by province. Some CPG recommendations were experienced as ‘not practical’ and not appropriate to local healthcare contexts. Many agreed that for CPGs to become ‘something that can really apply to us’ and that ‘actually works to suit the PHC [primary health care]’, healthcare providers should be part of CPG development processes.
Health system challenges emerged as another major barrier to CPG implementation. The ability to operationalise CPG recommendations was described as significantly hindered by
‘no budget’,
‘slow procurement’, or the lack of equipment where staff simply
‘don’t have the machine’. Stock outs of medicines was highlighted as an issue:
when there is a recommendation and the medication is not there… we are stuck (Nurse_LPP_rural).
Relatedly, primary care clinic pressures were perceived to limit providers’ ability to properly read CPGs. All cadres described that the ‘long queues outside’ and the time needed to ‘page and page’ through a CPG was not feasible during a consultation.
Participants also identified barriers related to the design, layout and language of CPGs, and made suggestions for how these might be improved to enhance CPG use (Additional file
2). Many spoke about the lengthy nature of CPGs and the
‘big jargon English’, which limited understanding and use. They expressed a wish for
‘much more user friendly’ CPGs, including using
‘short directive’ and more simple language, and incorporating ‘
summarised’ versions, more definitions, local vernacular and supplementary tools (e.g. posters) to aid understanding and support patient engagement. A doctor suggested that, as people maybe ‘
visual learners’, use of more attractive and appealing formats, such as graphics, charts, and colour, would enhance CPG use. Colour-coding in one of the primary care CPGs (PC101) was described as effective, as one nurse said, it ‘
keeps you on the toes’ (EC_peri-urban).
Poor access to good quality and up-to-date CPGs materialised as an especially pertinent physical barrier to CPG usage. Many participants, particularly those in rural settings, provided detailed narratives about how
‘hard to reach’ CPGs were. Many described how they frequently
‘get them late’ or have access to ‘
only one copy’ in their clinics. Others spoke about the way in which CPGs are often stored inaccessibly outside of consulting rooms, while others highlighted the poor systems that exist for CPG version control, ultimately resulting in ‘
confusion’ and outdated information. Furthermore, it emerged that even when CPGs are available, they are frequently of sub-standard quality:
They make copies and pages are missing, the arrangement of the pages, [it] becomes bulkier and all these things. So that’s a problem, I mean people don’t really get the real thing, a reprint or make a copy and make your own. (Doctor_KZN_peri-urban).
Numerous participants, both rural and urban, highlighted that many of these barriers around access would be addressed if CPGs were available digitally. They explained that access to digital CPGs would enable them to read them in their own time, not only during consultations, which would in turn make keeping up-to-date easier. They also suggested that it would improve knowledge transfer after workshops, reducing issues related to information sharing. Additionally, many believed that digital CPGs would result in all healthcare providers receiving CPGs in a timely manner and further support in-facility capacity building when new CPGs were disseminated.
Despite general agreement that digital CPGs may facilitate usage, a number of complexities associated with this medium emerged. Some participant wondered whether use of digital CPGs in front of patients would generate negative patient perceptions, who might believe that healthcare providers are ‘busy on Whatsapp’, accessing other nonwork-related content, or that they lack knowledge. At the same time, while some participants had CPGs on their phones, including the CPG app or electronic books, this was a minority, and mostly seen in peri-urban facilities. Most clinics did not have internet access either via computer stations or wireless internet, and healthcare providers did not consistently have smart phones, data and internet access through other means. This was particularly evident in the more rural clinics where in a FGD of 11 staff, one nurse reported having opened a personal email account, and even that was a recent development. Although participants in the Western Cape FGD described having personal internet access, they suggested that limited phone memory, high data costs and the need to download CPGs at their own expense was a barrier. Thus, use of digital CPGs was described to come with its own set of access issues, and while evidently desirable, remains aspirational from providers perspectives.