Why don't clinicians adhere more consistently to guidelines for the Integrated Management of Childhood Illness (IMCI)?
Why don't clinicians adhere more consistently to guidelines for the Integrated Management of Childhood Illness (IMCI)?
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DOI：
10.1016/j.socscimed.2013.12.020
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发表时间：
2014-03-01
影响因子：
5.4
通讯作者：
Maestad, Ottar
中科院分区：
文献类型：
--
作者：
Lange, Siri;Mwisongo, Aziza;Maestad, Ottar
在卫生基础设施薄弱的国家，已开始实施儿童疾病综合管理，以降低儿童发病率和死亡率。以前的研究记录了对临床指南的依从性差，但对不依从的原因知之甚少。这项混合方法的研究措施遵守儿童疾病综合管理病例评估指南，并确定原因弱遵守。2007年，通过直接观察坦桑尼亚农村9个地区82个卫生设施的103名训练有素的临床医生进行的933次门诊咨询来衡量遵守情况，同时通过临床小插曲评估临床医生对准则的了解。通过卫生工作者和卫生设施调查以及2009年的定性后续研究评估了依从性差的其他潜在原因，其中对位于两个相同地区的30个卫生设施的40名临床医生进行了深入访谈。临床医生执行了28.4%的相关IMCI评估任务。知识水平远高于实际绩效，这表明缺乏知识并不是提高绩效的唯一限制因素。业绩不佳的其他重要原因似乎是：（1）缺乏遵守儿童疾病综合管理准则的动力，部分原因是对遵守准则的重要性缺乏信心，部分原因是内在动力不足;（2）身体和（或）认知“超负荷”，导致缺乏充分关注每一个病例的能力，只能诉诸简单的经验法则。薪酬低是其中几个因素的原因。(C)2014爱思唯尔有限公司版权所有。
The Integrated Management of Childhood Illness (IMCI) has been introduced to reduce child morbidity and mortality in countries with a poor health infrastructure. Previous studies have documented a poor adherence to clinical guidelines, but little is known about the reasons for non-adherence. This mixed-method study measures adherence to IMCI case-assessment guidelines and identifies the reasons for weak adherence. In 2007, adherence was measured through direct observation of 933 outpatient consultations performed by 103 trained clinicians in 82 health facilities in nine districts in rural Tanzania, while clinicians' knowledge of the guidelines was assessed through clinical vignettes. Other potential reasons for a weak adherence were assessed through both a health worker- and health facility survey, as well as by a qualitative follow-up study in 2009 in which in-depth interviews were conducted with 40 clinicians in 30 health facilities located in two of the same districts. Clinicians performed 28.4% of the relevant IMCI assessment tasks. The level of knowledge was considerably higher than actual performance, suggesting that lack of knowledge is not the only constraint for improved performance. Other important reasons for weak performance seem to be 1) lack of motivation to adhere to IMCI guidelines, stemming partly from a weak belief in the importance of following the guidelines and partly from weak intrinsic motivation, and 2) a physical and/or cognitive "overload", resulting in lack of capacity to concentrate fully on each and every case and a resort to simpler rules of thumb. Poor remunerations contribute to several of these factors. (C) 2014 Elsevier Ltd. All rights reserved.