Abstract:
Background: Although considerable efforts are directed at developing international guidelines to
improve clinical management in low-income settings they appear to influence practice rarely. This
study aimed to explore barriers to guideline implementation in the early phase of an intervention
study in four district hospitals in Kenya.
Methods: We developed a simple interview guide based on a simple characterisation of the
intervention informed by review of major theories on barriers to uptake of guidelines. In-depth
interviews, non-participatory observation, and informal discussions were then used to explore
perceived barriers to guideline introduction and general improvements in paediatric and newborn
care. Data were collected four to five months after in-service training in the hospitals. Data were
transcribed, themes explored, and revised in two rounds of coding and analysis using NVivo 7
software, subjected to a layered analysis, reviewed, and revised after discussion with four hospital
staff who acted as within-hospital facilitators.
Results: A total of 29 health workers were interviewed. Ten major themes preventing guideline
uptake were identified: incomplete training coverage; inadequacies in local standard setting and
leadership; lack of recognition and appreciation of good work; poor communication and teamwork;
organizational constraints and limited resources; counterproductive health worker norms; absence
of perceived benefits linked to adoption of new practices; difficulties accepting change; lack of
motivation; and conflicting attitudes and beliefs.
Conclusion: While the barriers identified are broadly similar in theme to those reported from
high-income settings, their specific nature often differs. For example, at an institutional level there
is an almost complete lack of systems to introduce or reinforce guidelines, poor teamwork across
different cadres of health worker, and failure to confront poor practice. At an individual level, lack
of interest in the evidence supporting guidelines, feelings that they erode professionalism, and
expectations that people should be paid to change practice threaten successful implementation
