Documenting the experiences of health workers expected to implement guidelines during an intervention study in Kenyan hospitals
Open accessAbstract
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.
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Staff shortages, turnover, and high workloads hindered guideline implementation in Kenyan hospitals.
“Similarly, staff shortages, turnover, and high workloads hindered guideline implementation in Kenyan hospitals [75].”
From Teamwork and implementation of innovations in healthcare and human service settings: a systematic review (2024) · cites this paper as [75]
Communication beyond the team was identified as a facilitator of implementation in two qualitative studies.
“Communication beyond the team was also identified as a facilitator of implementation in two qualitative studies [47, 75].”
From Teamwork and implementation of innovations in healthcare and human service settings: a systematic review (2024) · cites this paper as [75]
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“…has recognized the need for an improved health workforce, and there have been efforts to increase both the numbers of clinical workers as well as support for leadership and management for health workers (Kenya Ministry of Health 2007; Ndavi et al. 2009; Nzinga et al. 2009; Seims et al. 2012).”
BackgroundImproving facility-based care: eliciting tacit knowledge to advance intervention design
English, M., Nzinga, J., Oliwa, J. N., Maina, M., Oluoch, D., Barasa, E., Irimu, G., Muinga, N., Vincent, C. A., & McKnight, J. (2022) · BMJ Global Health · doi:10.1136/bmjgh-2022-009410 · Cited by 15 · see citing works
Self-citationQuality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya
Clarke‐Deelder, E., Opondo, K., Achieng, E., Garg, L. F., Han, D., Henry, J., Guha, M., Lightbourne, A., Makin, J., Miller, N., et al. (2023) · PLOS Global Public Health · doi:10.1371/journal.pgph.0001670 · Cited by 14 · see citing works
Gray, A. Z., Soukaloun, D., & Soumphonphakdy, B. (2017) · American Journal of Tropical Medicine and Hygiene · doi:10.4269/ajtmh.16-1005 · Cited by 14 · see citing works
Izudi, J., Anyigu, S., & Ndungutse, D. (2017) · International Journal of Pediatrics · doi:10.1155/2017/5173416 · Cited by 13 · see citing works
Ochonma, O. G., & Nwatu, S. I. (2018) · BMC Medical Education · doi:10.1186/s12909-018-1230-2 · Cited by 12 · see citing works
“Previous work in Kenyan public hospitals has revealed leadership gaps and poor communication between senior administration and lower cadres as an impediment to achieving better practice [15, 19, 20].”
BackgroundImplementing a nationwide quality improvement approach in health services
Sahel, A., Brouwere, V. D., Dujardin, B., Kegels, G., Belkaab, N., & Alaoui, A. B. (2015) · Leadership in health services · doi:10.1108/lhs-04-2014-0042 · Cited by 12 · see citing works
The performance of health workers in decentralised services in Uganda
Lutwama, G. W. (2011) · Unisa Institutional Repository (University of South Africa) · Cited by 12 · see citing works
Musyoka, F. N. (2016) · Science Journal of Public Health · doi:10.11648/j.sjph.20160402.12 · Cited by 11 · see citing works
“Similarly, despite the fact that policies are in place to ensure the availability of HWs, less than half of HWs were present in their place of work and active at the time of survey [9,19,20].”
BackgroundMusitia, P. M., Boga, M., Oluoch, D., Haaland, A., Nzinga, J., English, M., & Molyneux, S. C. (2022) · Wellcome Open Research · doi:10.12688/wellcomeopenres.18006.1 · Cited by 11 · see citing works
Self-citationMutambo, C., Shumba, K., & Hlongwana, K. W. (2019) · AIDS Research and Treatment · doi:10.1155/2019/5139486 · Cited by 11 · see citing works
Maina, M., Molyneux, S. C., Were, F., Oluoch, D., Mutua, E., Gathara, D., English, M., Imam, A., Ngaiza, G., Rababeh, A., et al. (2025) · Global Health Action · doi:10.1080/16549716.2025.2558267 · Cited by 9 · see citing works
“Our prior work indicated this might be especially true of neonatal care units in Kenya where staff, especially nurses, face huge day-to-day pressures [4–6].”
Self-citationIlesanmi, O. S., Ayodeji, O. O., Bakare, A. A., Adedosu, N., Adeagbo, A., Odutayo, A., Ayun, F. O., & Bello, A. E. (2020) · Journal of Ideas in Health · doi:10.47108/jidhealth.vol3.iss3.66 · Cited by 9 · see citing works
“These have previously been reported in another study on guidelines implementation in Kenya [11].”
ResultInfant malnutrition treatment in Kenya: Health worker and breastfeeding peer supporter experiences
Chabeda, S. V., Oluoch, D., Mwangome, M., & Jones, C. O. H. (2021) · Maternal and Child Nutrition · doi:10.1111/mcn.13148 · Cited by 9 · see citing works
Krüger, C., Niemi, M., Espeland, H., Naman, N., & Malleyeck, I. (2011) · International Health · doi:10.1016/j.inhe.2011.10.002 · Cited by 8 · see citing works
Access to and value of information to support good practice for staff in Kenyan hospitals
Muinga, N., Sen, B. A., Ayieko, P., Todd, J., & English, M. (2015) · Global Health Action · doi:10.3402/gha.v8.26559 · Cited by 8 · see citing works
“(14) reveals that one of the Global Health Action”
BackgroundSelf-citationMorseth, M. S., Nguyen, T. T., Skui, M., Terragni, L., Ngo, Q. V., Vu, H. T. T., Mathisen, R., & Henjum, S. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-05449-2 · Cited by 8 · see citing works
“In a study from Kenya, one main barrier to guideline implementation was that not all health staff members were trained, resulting in a lack of knowledge and skills to apply the guidelines in general [38].”
BackgroundINFLUENCE OF DEVOLVED GOVERNANCE AND PERFORMACE OF THE HEALTH SECTOR IN KENYA
MUCHOMBA, F. G. (2015) · Strategic Journal of Business & Change Management · doi:10.61426/sjbcm.v2i2.123 · Cited by 7 · see citing works
Quality management: where is the evidence? Developing an indicator-based approach in Kenya
Prytherch, H., Nafula, M., Kandie, C., Brodowski, M., Marx, I., Kubaj, S., Omogi, I., Zurkuhlen, A., Herrler, C., Goetz, K., et al. (2016) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzw147 · Cited by 7 · see citing works
“Important guidelines are either not available at facility level, or are not used [9].”
BackgroundHow to do no harm: empowering local leaders to make care safer in low-resource settings
Vincent, C. A., Mboga, M., Gathara, D., Were, F., Amalberti, R., & English, M. (2021) · Archives of Disease in Childhood · doi:10.1136/archdischild-2020-320631 · Cited by 6 · see citing works
Self-citationSchuele, E., & MacDougall, C. (2022) · PLoS ONE · doi:10.1371/journal.pone.0266931 · Cited by 5 · see citing works
“These constraining factors are common in other low-and middle- income countries compared to high-income settings [49].”
BackgroundLumadi, T. G. (2017) · Curationis · doi:10.4102/curationis.v40i1.1770 · Cited by 4 · see citing works
Musitia, P. M., Boga, M., Oluoch, D., Haaland, A., Nzinga, J., English, M., & Molyneux, S. C. (2025) · Wellcome Open Research · doi:10.12688/wellcomeopenres.18006.2 · Cited by 4 · see citing works
“Stress and burn-out negatively affect relationships with colleagues, patients and family members, which undermines motivation, team work, and ultimately quality of care 11 .”
Self-citationMcGivern, G., Nzinga, J., Boussebaa, M., & English, M. (2020) · Organizational behaviour in health care · doi:10.1007/978-3-030-40889-3_11 · Cited by 4 · see citing works
“…pastoral constellation), involving eight years of sustained ‘whole systems’ working with political, social and political complexity (for more detail see English et al., 2014, 2017b, 2011, Nzinga et al., 2009b, 2009a), provided the foundation for CIN’s establishment, which we discuss next.”
BackgroundSelf-citationImplementation Science for Evidence-Based Policy
Fixsen, D. L., Dyke, M. K. V., & Blasé, K. A. (2024) · Oxford University Press eBooks · doi:10.1093/oxfordhb/9780197618110.013.4 · Cited by 4 · see citing works
Nitschke, C., Nafula, M., Brodowski, M., Marx, I., Kandie, C., Omogi, I., Paul-Fariborz, F., Szécsényi, J., Brugnara, L., & Marx, M. (2020) · BMJ Open Quality · doi:10.1136/bmjoq-2020-001139 · Cited by 4 · see citing works
Ogola, M., Wainaina, J., Muinga, N., Kimani, W., Murithi, M. K., Aluvaala, J., English, M., & Irimu, G. (2023) · PLOS Global Public Health · doi:10.1371/journal.pgph.0001577 · Cited by 4 · see citing works
Self-citationSafe, M., Wittick, P., Philaketh, K., Manivong, A., & Gray, A. Z. (2022) · Tropical Medicine & International Health · doi:10.1111/tmi.13726 · Cited by 4 · see citing works
Blacklock, C., Wanyama, C., Jepkosgei, J., Hinton, L., McKnight, J., Jepkosgei, J., Oluoch, D., Molyneux, S., Hogan, B., English, M., et al. (2025) · BMC Health Services Research · doi:10.1186/s12913-025-13686-6 · Cited by 2 · see citing works
“To complement and optimise such efforts, the complexity of social and relational processes within the diverse workforce must also be considered [4, 18].”
Self-citationOdafe, S. F., Stafford, K. A., Gambo, A., Onotu, D., Swaminathan, M., Dalhatu, I., Ene, U., Oladipo, A., Ahmed, M., Ibrahim, R., et al. (2019) · Journal of AIDS and HIV Treatment · doi:10.33696/aids.1.007 · Cited by 2 · see citing works
“The study used an interview guide specially developed for the study, guided by a previous study evaluating guidelines among health workers in Kenya [19].”
BackgroundMethodKamanga, G. (2018) · Malawi Medical Journal · doi:10.4314/mmj.v30i2.1 · Cited by 2 · see citing works
Yarow, A. A., Jirma, S., & Siringi, E. (2019) · International Journal of Business and Management · doi:10.5539/ijbm.v14n11p1 · Cited by 2 · see citing works
Hussein, S., & Farhood, H. (2019) · Medical Journal of Babylon · doi:10.4103/mjbl.mjbl_50_19 · Cited by 2 · see citing works
“Our result agreed with several studies conducted in Sudan[9] and Kenya[10] Table 1: Distribution of study sample according to sociodemographic data”
ResultRazzaq, A., Stephenson, N., Raynes‐Greenow, C. H., Travaglia, J., & Alam, A. (2023) · Midwifery · doi:10.1016/j.midw.2023.103634 · Cited by 1 · see citing works
Muinga, N., Ayieko, P., Opondo, C., Ntoburi, S., Todd, J., Allen, E., & English, M. (2014) · BMC Health Services Research · doi:10.1186/1472-6963-14-282 · Cited by 1 · see citing works
“While the contribution of different effects across sites cannot be determined reliably parallel, qualitative work would suggest some effect of the intervention is plausible [18,26].”
BackgroundSelf-citationYarow, A. A., Jirma, S., & Siringi, E. (2019) · International Journal of Business and Management · doi:10.5539/ijbm.v14n10p21 · Cited by 1 · see citing works
“…governments to have successful health care system the leaders must understand the nature and implications of change, have the ability to develop effective strategies that account for change, and the will as well as the ability to actively manage the momentum of the devolution (Nzinga et al., 2013).”
BackgroundMbindyo, P. (2012) · University of the Witwatersrand, Johannesburg Institutional Repository on DSpace (University of the Witwatersrand, Johannesburg) · Cited by 1 · see citing works
Self-citationOguta, J. O., Wambiya, E. O. A., Breeze, P. R., Akparibo, R., Akoth, C., Okemwa, S., Mbuthia, G. W., Kisaka, Y., Ombiro, O. N., Onyango, E., et al. (2025) · Research Square · doi:10.21203/rs.3.rs-7623904/v1 · Cited by 1 · see citing works
Care of The Newborn in Uganda : Studies of the use of simple affordable effective interventions
Byaruhanga, R. (2009) · Figshare
Barreiras à implementação da Terapia Compressiva
Pereira, A., & Gaspar, P. J. S. (2012) · Revista de Enfermagem Referência · doi:10.12707/riii1173
Can (imported) Knowledge Change Systems? Understanding the Dynamics of Behaviour Change
Ackers, H. L., & Ackers-Johnson, J. (2016) · Palgrave Macmillan US eBooks · doi:10.1057/978-1-137-55833-6_4
“…reviews the following papers: Buchan (2000: 2004); Chen et al. (2004); Chopra et al. (2008); Dieleman et al. (2006); Franco et al. 2002); Mangham and Hanson (2008); Mathauer and Imhoff (2006); Mbindyo et al. (2009); Nzinga et al. (2009); Stringhini et al. (2009); Willis-Shattuck et al. (2008).”
BackgroundLumadi, T. G. (2017) · Africa Journal of Nursing and Midwifery · doi:10.25159/2520-5293/1271
Nzinga, J. (2026) · Warwick Research Archive Portal (University of Warwick) · doi:10.82444/warw.33743572
Self-citationOdafe, S. F., Stafford, K. A., Gambo, A., Onotu, D., Swaminathan, M., Dalhatu, I., Ene, U., Oladipo, A., Ahmed, M., Ibrahim, R., et al. (2019) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/523548
Physician Burnout and Patient Care Practices in Sierra LeonePreprint
Naveed, A., Jalloh, M. B., Johnson, S. A. A., Bah, A. K., Barrie, F. B., Jegede, A. G., Sengeh, J. V., & Sillah, A. (2024) · Research Square · doi:10.21203/rs.3.rs-4708983/v1
Muriithi, F. G., Makabong’o, P., Osoti, A. O., Qureshi, Z. P., Devall, A., Coomarasamy, A., & Ladur, A. N. (2025) · Research Square · doi:10.21203/rs.3.rs-6615286/v1
Razzaq, A., Worth, H., & Alam, N. A. (2025) · Nursing & Midwifery Research Journal · doi:10.1177/0974150x251339013
McGuier, E. A., Kolko, D. J., Aarons, G. A., Schachter, A., Klem, M. L., Diabes, M. A., Weingart, L. R., Salas, E., & Wolk, C. B. (2024) · Figshare · doi:10.6084/m9.figshare.26749418
Morseth, M. S., Nguyen, T. T., Skui, M., Terragni, L., Ngo, Q. V., Vu, H. T. T., Mathisen, R., & Henjum, S. (2020) · Figshare · doi:10.6084/m9.figshare.12577574
McGuier, E. A., Kolko, D. J., Aarons, G. A., Schachter, A., Klem, M. L., Diabes, M. A., Weingart, L. R., Salas, E., & Wolk, C. B. (2024) · Figshare · doi:10.6084/m9.figshare.26749415
- Authors
- Nzinga, J., Mbindyo, P., Mbaabu, L., Warira, A., & English, M.
- Affiliations
- Kenya Medical Research Institute (KE)
- John Radcliffe Hospital (GB)
- Corresponding author
- Nzinga, Jacinta
- Venue
- Implementation Science
- Published
- 2009-07-23
- Volume
- 4
- Issue
- 1
- Pages
- 44-44
- ISSN
- 1748-5908 (ISSN-L)
- PMC
- PMC2726115
- OpenAlex
- W2147364604
- Cited by
- 81
- References
- 41
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 5 · 2023: 4 · 2022: 4 · 2021: 2 · 2020: 6 · 2019: 9 · 2018: 5 · 2017: 7 · 2016: 6 · 2015: 4 · 2014: 3 · 2013: 4 · 2012: 6
- FWCI
- 5.04
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Implementation Science (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Wellcome Trust (076827, 097170)
- Ministry of Public Health and Sanitation
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
- Keywords
- guideline implementation, healthcare workers, paediatric care, neonatal care, in-service training, organizational constraints, teamwork, leadership, low-income settings, district hospitals, Kenya
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