Evaluating the implementation of the Pediatric Acute Care Education (PACE) program in northwestern Tanzania: a mixed-methods study guided by normalization process theory.
Acceptability
Adaptive learning
Feasibility
Implementation Science
Normalization Process Theory
Pediatrics
Tanzania
Journal
BMC health services research
ISSN: 1472-6963
Titre abrégé: BMC Health Serv Res
Pays: England
ID NLM: 101088677
Informations de publication
Date de publication:
13 Sep 2024
13 Sep 2024
Historique:
received:
16
05
2024
accepted:
06
09
2024
medline:
14
9
2024
pubmed:
14
9
2024
entrez:
13
9
2024
Statut:
epublish
Résumé
In low- and middle-income countries (LMICs), such as Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this issue, we introduced Pediatric Acute Care Education (PACE), an adaptive learning program to enhance provider competency in Tanzania's guidelines for managing seriously ill children. Adaptive learning is a promising alternative to current in-service education, yet optimal implementation strategies in LMIC settings are unknown. (1) To evaluate the initial PACE implementation in Mwanza, Tanzania, using the construct of normalization process theory (NPT); (2) To provide insights into its feasibility, acceptability, and scalability potential. Mixed-methods study involving healthcare providers at three facilities. Quantitative data was collected using the Normalization MeAsure Development (NoMAD) questionnaire, while qualitative data was gathered through in-depth interviews (IDIs) and focus groups discussions (FGDs). Eighty-two healthcare providers completed the NoMAD survey. Additionally, 24 senior providers participated in IDIs, and 79 junior providers participated in FGDs. Coherence and cognitive participation were high, demonstrating that PACE is well understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practices, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly those affecting collective action, were noted. Early indicators point toward the potential for long-term sustainability of the PACE, but assessment of reflexive monitoring was limited due to the study's focus on PACE's initial implementation. This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges as well as conducting a longer-term study to assess reflexive monitoring is crucial for its successful implementation. Furthermore, the study underscores the value of the NPT as a framework for guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.
Sections du résumé
BACKGROUND
BACKGROUND
In low- and middle-income countries (LMICs), such as Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this issue, we introduced Pediatric Acute Care Education (PACE), an adaptive learning program to enhance provider competency in Tanzania's guidelines for managing seriously ill children. Adaptive learning is a promising alternative to current in-service education, yet optimal implementation strategies in LMIC settings are unknown.
OBJECTIVES
OBJECTIVE
(1) To evaluate the initial PACE implementation in Mwanza, Tanzania, using the construct of normalization process theory (NPT); (2) To provide insights into its feasibility, acceptability, and scalability potential.
METHODS
METHODS
Mixed-methods study involving healthcare providers at three facilities. Quantitative data was collected using the Normalization MeAsure Development (NoMAD) questionnaire, while qualitative data was gathered through in-depth interviews (IDIs) and focus groups discussions (FGDs).
RESULTS
RESULTS
Eighty-two healthcare providers completed the NoMAD survey. Additionally, 24 senior providers participated in IDIs, and 79 junior providers participated in FGDs. Coherence and cognitive participation were high, demonstrating that PACE is well understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practices, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly those affecting collective action, were noted. Early indicators point toward the potential for long-term sustainability of the PACE, but assessment of reflexive monitoring was limited due to the study's focus on PACE's initial implementation.
CONCLUSION
CONCLUSIONS
This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges as well as conducting a longer-term study to assess reflexive monitoring is crucial for its successful implementation. Furthermore, the study underscores the value of the NPT as a framework for guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.
Identifiants
pubmed: 39272036
doi: 10.1186/s12913-024-11554-3
pii: 10.1186/s12913-024-11554-3
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1066Informations de copyright
© 2024. The Author(s).
Références
Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018;392(10160):2203–12.
doi: 10.1016/S0140-6736(18)31668-4
pubmed: 30195398
pmcid: 6238021
Lewis TP, Roder-DeWan S, Malata A, Ndiaye Y, Kruk ME. Clinical performance among recent graduates in nine low- and middle-income countries. Trop Med Int Health. 2019;24(5):620–35.
doi: 10.1111/tmi.13224
pubmed: 30821062
pmcid: 6850366
Perin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, et al. Global, regional, and national causes of under-5 mortality in 2000–19: an updated systematic analysis with implications for the sustainable development goals. Lancet Child Adolesc Health. 2022;6(2):106–15.
doi: 10.1016/S2352-4642(21)00311-4
pubmed: 34800370
pmcid: 8786667
Sharrow D, Hug L, Lee S, Liu Y, You D. Levels & Trends in child mortality: report 2021, estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. New York: United Nations Children’s Fund; 2021.
UNICEF Data. United Republic of Tanzania (TZA) - demographics, health & infant mortality. Available from: https://data.unicef.org/country/tza/ . Cited 2023 Jun 11.
Di Giorgio L, Evans DK, Lindelow M, Nguyen SN, Svensson J, Wane W, et al. Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries. BMJ Glob Health. 2020;5(12):e003377.
doi: 10.1136/bmjgh-2020-003377
pubmed: 33355259
pmcid: 7751199
Meaney PA, Sutton RM, Tsima B, Steenhoff AP, Shilkofski N, Boulet JR, et al. Training hospital providers in basic CPR skills in Botswana: acquisition, retention and impact of novel training techniques. Resuscitation. 2012;83(12):1484–90.
doi: 10.1016/j.resuscitation.2012.04.014
pubmed: 22561463
pmcid: 3600577
Meaney PA, Topjian AA, Chandler HK, Botha M, Soar J, Berg RA, et al. Resuscitation training in developing countries: a systematic review. Resuscitation. 2010;81(11):1462–72.
doi: 10.1016/j.resuscitation.2010.06.024
pubmed: 20727656
Bloom BS. The 2 sigma problem: the search for methods of group instruction as effective as one-to-one tutoring. Educ Res. 1984;13(6):4–16.
doi: 10.3102/0013189X013006004
Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D, Rowe AK. A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: methods and descriptive results. PLoS ONE. 2019;14(5):e0217617.
doi: 10.1371/journal.pone.0217617
pubmed: 31150458
pmcid: 6544255
WHO. Recommendations on digital interventions for health system strengthening. World Health Organization: Geneva; 2019. Licence: CC BY-NC-SA 3.0 IGO.
Meaney PA, Hokororo A, Masenge T, Mwanga J, Kalabamu FS, Berg M, et al. Development of pediatric acute care education (PACE): an adaptive electronic learning (e-learning) environment for healthcare providers in Tanzania. Digit Health. 2023;1(9):20552076231180470.
doi: 10.1177/20552076231180471
Meaney P, Hokororo A, Ndosi H, Dahlen A, Jacob T, Mwanga JR, et al. Feasibility of an Adaptive E-Learning Environment to Improve Provider Proficiency in Essential and Sick Newborn Care in Mwanza, Tanzania. medRxiv; 2023. p. 2023.07.11.23292406. Available from: https://www.medrxiv.org/content/10.1101/2023.07.11.23292406v1 . Cited 2023 Aug 30.
Finch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol. 2018;18(1):135.
doi: 10.1186/s12874-018-0591-x
pubmed: 30442094
pmcid: 6238372
May C, Finch T. Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology. 2009;43(3):535–54.
doi: 10.1177/0038038509103208
May C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res. 2006;6(1):86.
doi: 10.1186/1472-6963-6-86
pubmed: 16827928
pmcid: 1534030
May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: normalization process theory. Implement Sci. 2009;4(1):29.
doi: 10.1186/1748-5908-4-29
pubmed: 19460163
pmcid: 2693517
May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, et al. Using normalization process theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci. 2018;13(1):80.
doi: 10.1186/s13012-018-0758-1
pubmed: 29879986
pmcid: 5992634
Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010;8(1):63.
doi: 10.1186/1741-7015-8-63
pubmed: 20961442
pmcid: 2978112
McEvoy R, Ballini L, Maltoni S, O’Donnell CA, Mair FS, MacFarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci. 2014;9(1):2.
doi: 10.1186/1748-5908-9-2
pubmed: 24383661
pmcid: 3905960
Finch TL, Rapley T, Girling M, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implement Sci. 2013;8(1):43.
doi: 10.1186/1748-5908-8-43
pubmed: 23578304
pmcid: 3637119
May CR, Albers B, Bracher M, Finch TL, Gilbert A, Girling M, et al. Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development. Implement Sci. 2022;17(1):19.
doi: 10.1186/s13012-022-01191-x
pubmed: 35193611
pmcid: 8861599
Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health Ment Health Serv Res. 2011;38(2):65–76.
doi: 10.1007/s10488-010-0319-7
Greenhalgh T, Taylor R. How to read a paper: papers that go beyond numbers (qualitative research). BMJ. 1997;315(7110):740–3.
doi: 10.1136/bmj.315.7110.740
pubmed: 9314762
pmcid: 2127518
von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806–8.
doi: 10.1136/bmj.39335.541782.AD
O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med J Assoc Am Med Coll. 2014;89(9):1245–51.
doi: 10.1097/ACM.0000000000000388
Bluestone J, Johnson P, Fullerton J, Carr C, Alderman J, BonTempo J. Effective in-service training design and delivery: evidence from an integrative literature review. Hum Resour Health. 2013;11(1):51.
doi: 10.1186/1478-4491-11-51
pubmed: 24083659
pmcid: 3850724
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–58.
doi: 10.1016/S0140-6736(10)61854-5
pubmed: 21112623
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet Lond Engl. 2003;362(9391):1225–30.
doi: 10.1016/S0140-6736(03)14546-1
Eccles MP, Grimshaw JM, MacLennan G, Bonetti D, Glidewell L, Pitts NB, et al. Explaining clinical behaviors using multiple theoretical models. Implement Sci. 2012;7(1):99.
doi: 10.1186/1748-5908-7-99
pubmed: 23075284
pmcid: 3500222
May C, Finch T, Mair F, Ballini L, Dowrick C, Eccles M, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res. 2007;7(1):148.
doi: 10.1186/1472-6963-7-148
pubmed: 17880693
pmcid: 2089069
Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci IS. 2011;23(6):42.
doi: 10.1186/1748-5908-6-42
Rogers EM, Singhal A, Quinlan MM. Diffusion of innovations. In: An integrated approach to communication theory and research. London: Routledge; 2014. p. 432–48.
Effectiveness of digital learning solutions to improve educational outcomes | UNICEF. Available from: https://www.unicef.org/documents/effectiveness-digital-learning-solutions-improve-educational-outcomes . Cited 2024 Aug 7.
Lawrence CE, Dunkel L, McEver M, Israel T, Taylor R, Chiriboga G, et al. A REDCap-based model for electronic consent (eConsent): oving toward a more personalized consent. J Clin Transl Sci. 2020;4(4):345–53.
doi: 10.1017/cts.2020.30
pubmed: 33244416
pmcid: 7681162