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Why Educational Interventions Fail in Changing Treatment Practices in Rural Hospitals: Evidence from Sri Lanka.

Author(s) Lalith Senarathna1, Cynthia Hunter2, Andrew Dawson3, Michael Dibley 4
Affiliation(s) 1South Asian Clinical Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka, 2Sydney School of Public Health, University of Sydney, Sydney, Australia, 3National Poisons Register & Clinical Toxicology, Royal Prince Alfred Hospital, Sydney , Sydney, Australia, 4Sydney School of Public Health, University of Sydney, Sydney, Australia.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Health Systems
Summary Non-adherence to education interventions is a barrier to improving hospital treatment. This qualitative exploration reveals that education interventions are capable of improving knowledge, but success of the intervention in rural hospitals depends on social dynamics of hospital and influences from the community. In these hospitals introducing new practices was easier than changing established practices. Treatments by clinicians were easily improved than practices with non-clinical staff involvements. Interventions for specific practices will be useful in improving adherence. Similarly, parallel community awareness programs to discuss changes of hospital practices will improve this situation.
Background Lack of continuous educational programs for health care workers has created a gap between standard patient treatment guidelines and actual practice in hospitals. This gap is a significance barrier in improving patient care in rural hospitals in low and middle income countries (LMICs) like Sri Lanka where rural primary care hospitals act as initial access point to health care for majority of the population. Although different educational strategies had been in use to promote clinical guidelines aimed at closing this gap for a range of disease in rural hospitals, non-adherence to educational interventions is a major issue. Reasons for this poor adherence to educational interventions in rural hospitals in LMIC settings have not been systematically studied. This lack of evidence has created difficulties in designing educational interventions to improve hospital treatment practices.
Objectives The objective of this study was to explore reasons for non-adherence to the recommendations from education intervention in rural hospitals in Sri Lanka.
Methodology This study was a qualitative exploration related to a completed cluster randomised controlled trial (Trail Registration Number ISRCTN73983810) conducted in 46 rural primary care hospitals in North Central Province of Sri Lanka to promote poisoning treatment guidelines using an outreach education approach. This study showed that recommended treatments which were to be initiated by clinicians were well adopted while other treatments with non-clinical staff involvement did not change. Practices that were not changed following the educational intervention were used to explore the reasons for non-adherence to recommendations from education interventions.
Focus group discussions were conducted with doctors, nurses and non-clinical staff members in selected interventional hospitals. A sampling framework developed using hospital capacity and staff numbers were used to select 8 hospitals from the intervention group for the data collection. Thematic analysis was conducted using transcribed records according to the principles of grounded theory.
Results This exploration showed that outreach education intervention was capable of improving knowledge of treatment guidelines and creating a positive attitude among hospital staff members. But this attitude and knowledge alone did not change the practices as recommended during the education interventions. There were other significant internal and external influences which played a major role in treatment decisions such as social dynamics within hospital and where the influence from the communities were more prominent. In rural hospitals where there is limited staff availability, even non-clinical staff perform assisting roles in patient treatments. Hence, changing long established practices for which both clinical and non-clinical staff contribute cannot be changed using interventions designed only for clinical staff. Introducing new practises or treatments are relatively easier than changing long established inappropriate practices.
In these rural hospitals, treatment decisions are shaped to meet community expectations which are, at times, not aligned with the recommendations from clinical guidelines or interventions. Hospital staff including doctors are reluctant to neglect requests from the community in fear of becoming unpopular. During the group discussions, doctors stated that that community awareness programs parallel to hospital education interventions are essential when promoting updated treatment practices in rural hospitals.
Conclusion In rural Sri Lankan hospitals, only education interventions do not improve treatment practices. Social dynamics of the hospital and expectations of the community influence treatment decisions. Hence, these factors should be considered in designing education interventions in rural hospitals, not only in Sri Lanka, but also similar settings in other low and middle income countries. Furthermore targeted interventions aimed at selected hospital staff categories or specific treatment practices would be more appropriate than common interventions for all staff. Similarly, awareness programs to educate community about changes in village hospitals and updates of treatment practices would facilitate improvements in the hospitals.

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