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Implementing the Emergency Triage, Assessment and Treatment plus admission care (ETAT+) clinical practice… Hategeka, Celestin; Mwai, Leah; Tuyisenge, Lisine Apr 7, 2017

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RESEARCH ARTICLE Open AccessImplementing the Emergency Triage,Assessment and Treatment plus admissioncare (ETAT+) clinical practice guidelines toimprove quality of hospital care inRwandan district hospitals: healthcareworkers’ perspectives on relevance andchallengesCelestin Hategeka1,2* , Leah Mwai3,4 and Lisine Tuyisenge1,5AbstractBackground: An emergency triage, assessment and treatment plus admission care (ETAT+) intervention wasimplemented in Rwandan district hospitals to improve hospital care for severely ill infants and children. Manyinterventions are rarely implemented with perfect fidelity under real-world conditions. Thus, evaluations of thereal-world experiences of implementing ETAT+ are important in terms of identifying potential barriers to successfulimplementation. This study explored the perspectives of Rwandan healthcare workers (HCWs) on the relevance of ETAT+and documented potential barriers to its successful implementation.Methods: HCWs enrolled in the ETAT+ training were asked, immediately after the training, their perspective regarding(i) relevance of the ETAT+ training to Rwandan district hospitals; (ii) if attending the training would bring about changein their work; and (iii) challenges that they encountered during the training, as well as those they anticipated to hampertheir ability to translate the knowledge and skills learned in the ETAT+ training into practice in order to improve care forseverely ill infants and children in their hospitals. They wrote their perspectives in French, Kinyarwanda, or English andsometimes a mixture of all these languages that are official in the post-genocide Rwanda. Their notes were translated to(if not already in) English and transcribed, and transcripts were analyzed using thematic content analysis.Results: One hundred seventy-one HCWs were included in our analysis. Nearly all these HCWs stated that the trainingwas highly relevant to the district hospitals and that it aligned with their work expectation. However, some midwivesbelieved that the “neonatal resuscitation and feeding” components of the training were more relevant to them thanother components. Many HCWs anticipated to change practice by initiating a triage system in their hospital and by usingjob aids including guidelines for prescription and feeding. Most of the challenges stemmed from the mode of the ETAT+training delivery (e.g., language barriers, intense training schedule); while others were more related to uptake of guidelinesin the district hospitals (e.g., staff turnover, reluctance to change, limited resources, conflicting protocols).(Continued on next page)* Correspondence: celestin.hategeka@alumni.ubc.ca1ETAT+ Program, Rwanda Paediatric Association, Kigali, Rwanda2School of Population and Public Health, Faculty of Medicine, University ofBritish Columbia, Vancouver, BC, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Hategeka et al. BMC Health Services Research  (2017) 17:256 DOI 10.1186/s12913-017-2193-4(Continued from previous page)Conclusion: This study highlights potential challenges to successful implementation of the ETAT+ clinical practice guidelinesin order to improve quality of hospital care in Rwandan district hospitals. Understanding these challenges, especially fromHCWs perspective, can guide efforts to improve uptake of clinical practice guidelines including ETAT+ in Rwanda.Keyword: Implementation, Clinical practical guidelines, ETAT+, Healthcare worker, District hospital, Qualitativeresearch, RwandaBackgroundDespite international efforts, newborn and child health re-mains a significant health challenge in low- and middle-income countries (LMICs). Reducing child mortality wasone of the eight Millennium Development Goals (MDGs)adopted by the international community (MDG 4: callsfor reducing the deaths of children under five years of ageby two-thirds between 1990 and 2015). Remarkable pro-gress has been recorded in saving children’s lives globallysince 1990- the number of under-five deaths has declinedfrom 12.6 million in 1990 to 6.6 million in 2012, but dur-ing the same period neonatal survival has improved moreslowly, with 44% of all under-five deaths in 2012 occurringduring the neonatal period [1]. Despite progress, neonataland child mortality remain high in LMICs. In 2013, nearly6.3 million children under-five died worldwide [2]. Sub-Saharan Africa accounts for nearly half (49%) of the globalburden of newborn and child deaths despite being hometo just 11% of the global population. Reducing these in-equities and saving more children’s lives by ending pre-ventable child deaths should therefore remain a priorityon the post-MDGs 2015 agenda. The newly establishedSustainable Development Goals (SDGs) seek to build onthe MDGs and complete what these did not achieve [3].In Rwanda, approximately 24,000 children died in 2013 –of whom ~39% were neonates [4]. The leading causes ofmortality in children younger than five years in Rwandaare neonatal related complications (e.g., preterm, asphyxia,neonatal sepsis); pneumonia; dehydration/diarrhea andmalaria [4–6]. Previous research has also identified gapsin the quality of hospital care provided to sick newbornsand children in Rwanda [7].A major reason for the slow progress in reachingthe MDGs in many LMICs is the ‘know-do-gap’– thegap between the existing knowledge on how to re-duce the burden of illness and what is implemented[8]. While there is a wealth of evidence on the effi-cacy and effectiveness of numerous health care inter-ventions in sub-Saharan Africa, there is still relativelylimited evidence on how best to implement or scaleup such interventions in order to achieve the desiredimpact [9]. Evidence suggests that a key opportunityfor narrowing the know-do gap and accelerating theattainment of the set MDG and SDG targets lies inidentifying simple interventions as well as the mostoptimal ways to train and incentivise an implementa-tion workforce and future scale-up leaders [10].Advanced pediatric life support trainings have beenadvocated for implementation in LMICs to contribute tothe reduction of under-five mortality in these countriesand thus contribute to the achievement of MDG 4 [11].The ETAT+ training, a locally adapted pediatric life sup-port program, was developed in East Africa for healthprofessionals caring for acutely ill children, and aimed toimprove pediatric emergency and admission care in theinitial 24–48 h of hospitalization [12]. ETAT+ expandsthe original World Health Organization (WHO) emer-gency triage assessment and treatment (ETAT), and isan intensive five-day training covering the recognitionand initial management of the commonest medicalcauses of pediatric hospital admission in East Africa(Table 1). Ayieko and colleagues conducted a cluster-randomized trial in Kenya that provided the state of evi-dence around the effectiveness of ETAT+ in improvingthe quality of care for children in low-resource settings[13]. The training was designed to enable healthcareworkers to provide important, evidence-based, best-practice care on admission for sick children in resource-limiting settings [12]. Since the introduction of ETAT+in Rwanda in 2010, in-service healthcare workers andmedical students have been trained [14–16].Clinical practice guidelines (CPGs) such as ETAT+ aredeveloped to help healthcare providers deliver the bestcare to patients by translating the best available evidenceon the management of diseases into specific recommen-dations for care. Nevertheless, evidence-based guidelinesare rarely implemented with perfect fidelity under real-world conditions [7, 14]. Therefore, evaluations of thereal-world experiences with implementing such guide-lines are important in terms of identifying potentialbarriers to successful implementation, as well as identi-fying factors that contribute to their successful adoptionand scale-up in various contexts.Following the demonstration of its effectiveness inKenya, it was anticipated that the ETAT+ program wouldbe easily adopted to Rwanda given the commonalities inresources as well as epidemiological profiles in the twocontexts. However, since the introduction of the programin Rwanda, its relevance and implementation challenges,especially from healthcare workers’ perspective have notHategeka et al. BMC Health Services Research  (2017) 17:256 Page 2 of 12been explored. Thus, the current study was undertaken toidentify potential challenges to successful implementationof ETAT+ guidelines in Rwandan district hospitals fromthe healthcare workers’ perspective. Furthermore, thestudy also explored healthcare workers’ perspective on therelevance of ETAT+ in the Rwanda district healthcare sys-tem, including whether they anticipated to change theirpractice, and which specific aspects of practice they mightbe willing to change.ContextRwanda – a small, low-income and landlocked country –has a population of 10,515,973 people, of which ~ 85% livesin rural areas [17]. The Rwandan healthcare system is orga-nized along the country’s administrative lay out of 30 dis-tricts, with each district having at least one district hospitalthat operates autonomously and provides healthcare ser-vices to well-defined populations in the district [5, 18, 19].During the 1994 genocide, which claimed the lives of morethan 800,000 people including healthcare workers, theRwandan healthcare system was entirely disrupted [19]. Fol-lowing this dark period, the government began to rebuildthe healthcare system; however, mortality in children youn-ger than five years did not return to pre-1990 rates until2005 [4]. Actions taken to improve access to primary healthservices included the restructuring and decentralization ofhealthcare management in district health facilities as well asdeveloping infrastructure and expanding the community-based health insurance [20]. Currently, access to healthservices is universal as nearly all Rwandans including thepoorest 25% of the population that pay no health insurancepremiums, have health insurance [21, 22]. Rwanda has oneof the youngest population worldwide, with approximately48% of its population being younger than 18 years old [17].While there are approximately 410,100 births per yearand only about 20 pediatricians were working in thecountry as of 2011, mostly in national referral hospi-tals [5, 16, 23]. Notably, the country has a combined“health – service – provider density” of 8.4 physi-cians, nurses, and midwives per 10,000 populationwhich falls far below the minimum level recom-mended by the WHO of 23 providers per 10,000population [22, 24]. The healthcare workforce in dis-trict hospitals is primarily comprised of generalistphysicians with six years of basic medical trainingand nurses with A2-level (secondary school nursingdiploma, the lowest level of nursing training available)[22]. These physicians and nurses are often requiredto handle complicated pediatric and neonatal emer-gencies in the absence of specialists. Nevertheless, itis noteworthy that efforts are underway to train spe-cialists who will be deployed in all hospitals country-wide [22].MethodsThe ETAT+ training in Rwanda consists of short lec-tures on specific topics (Table 1) followed by demonstra-tions, practical procedures and case based scenariosusing mannequins, hospital audit including a review ofselected patient medical records within the specific insti-tution where the training is occurring, and assessmentand feedback [14]. Discussions and hands on practicetake place in small groups of 5–7 participants where allhealthcare providers (nurses, midwives and physicians)learn together to promote inter-professional collabor-ation [14]. The training preparation materials are pro-vided to all participants before the ETAT+ training.These materials include an invitation letter describingthe training location and expectation, a training schedule[25], a pre-training knowledge assessment questionnaire,and the ETAT+ clinical practice guidelines disseminatedduring the training [26]. The ETAT + training for thehealthcare workers in Rwanda is run mainly in Englishlanguage and is completed in five days. Attendance ofthe training for the entire period is compulsory. Uponcompletion of the training, all participants retake theknowledge assessment. Further, the participants’ clinicalskills are assessed, using an Objective Structured ClinicalExamination (OSCE) format, on two clinical skills sce-narios (i.e., neonatal resuscitation and management of aseverely sick child with shock due to dehydration) [14].Further details about the ETAT+ training for Rwandanhealthcare providers, including effect of the training onknowledge and skills change as well as the associatedfactors can be found in our previous study (http://jour-nals.plos.org/plosone/article?id=10.1371/journal.pone.0152882#pone.0152882.ref017).Table 1 Topic covered in the ETAT+ training in RwandaTriageInfant and child resuscitationRecognition of a sick childDiarrhea/dehydration and shockNewborn care – preterm, jaundice, feeding, sepsisPneumoniaMalariaAsthmaSevere malnutritionMeningitisHypoglycaemiaConvulsionsPrescribing and procedures – oxygen, lumbar puncture, intra-osseousHospital surveyMorbidity and mortality auditHategeka et al. BMC Health Services Research  (2017) 17:256 Page 3 of 12Using a semi-structured questionnaire (Additional file1), the healthcare workers who were working in Rwan-dan district hospitals and attended the ETAT+ train-ing between November 2012 and May 2013 wereapproached and asked, immediately after the training,their perspective regarding (i) relevance of ETAT+ toRwandan district hospitals (e.g.; “Is ETAT+ relevantto your work?” “What are the most relevant con-tents?” “Are there other materials that you thinkshould be added to the training?”); (ii) if attendingthe training would bring about change in their work;and (iii) the challenges they encountered during thetraining as well as challenges which they anticipatedmight hamper the translation of the knowledge andskills learnt in the ETAT+ training into everydaypractice in order to improve emergency care forseverely ill infants and children in their institution.Furthermore, information pertaining to healthcareworkers’ characteristics was collected including pro-fession (nurse, midwife, physician); sex; location ofdistrict hospital of affiliation (urban or rural); depart-ment of affiliation; experience; and whether they hadattended any clinical practice guideline disseminatingtraining including ETAT+ before. These healthcareworkers wrote down their perspectives / views inFrench, Kinyarwanda, or English and sometimes mix-ture of all these languages that are official in the post– genocide Rwanda [27]. Of note, these healthcareworkers were informed of the questions throughoutthe training and encouraged to think about them sothat they could provide a more comprehensive list ofchallenges that needed to be addressed in order toenhance the implementation of ETAT+, in Rwandandistrict hospitals. Moreover, they were allowed to con-sult their notes taken over the week of the training.The healthcare workers’ notes were translated to (ifnot already in) English and transcribed, and transcriptswere imported into NVivo 8 software (QSR Inter-national, Doncaster, Australia) for thematic coding andanalysis - this approach involves coding data into themesrepresenting the phenomena under investigation [28].We employed both inductive and deductive approachesto identify themes. Broad themes were developed basedon the study objectives/questions that were asked(ETAT+ relevance, anticipated change in their work,challenges encountered during the training, and chal-lenges anticipated to hamper the translation of ETAT+knowledge and skills into practice). We inductivelyidentified sub-themes within the broad themes. All tran-scripts were reviewed by two people independently line-by-line identifying anticipated and emerging themes,which were compared and discussed until consensuswas reached. The themes that emerged from the analysisare reported with the healthcare workers’ quotes, asappropriate. Further, we reviewed all the ETAT+ trainingreports, and used the data to complement and corrobor-ate the findings from the analysis of the healthcareworkers’ notes, particularly, those relevant to the train-ing delivery challenges. Several themes emerged includ-ing: language barriers, timing/delays in receiving trainingmaterials, intense training schedule.ResultsCharacteristics of the study sampleTwo hundred and eleven healthcare workers were en-rolled in the ETAT+ training between November 2012and May 2013, and were handed a questionnaire in-cluding the questions under investigation in thecurrent study. Of these, 171 (81.0%) returned theircomplete questionnaires that were analyzed in thisstudy. Table 2 shows the characteristics of the health-care workers included in the current study.Relevance of the ETAT+ guidelines to Rwandan districthospitalsNearly all healthcare workers who were trained inETAT+ stated that the training was highly relevant tothe district hospitals in which they were working, andespecially that what they learnt in the training alignedwith what they are expected or required to do as partof their work. Many healthcare providers said theywished they had been trained before starting theirwork appointment in their district hospital.“This is an important and organized training, relevantto my everyday work.”“I learned lots of materials relevant to my work indistrict hospital…. I wish I had participated in thistraining before my job.”“The [ETAT+] training uses scenarios similar to whatI encounter in my work.”Nevertheless, some midwives expressed concernsover some materials covered in the training that werenot relevant to their work, and thought that the “neo-natal resuscitation and feeding” components of thetraining were more relevant to them than other com-ponents of the training. Fourteen of the 18 healthcareworkers who were affiliated with any departmentsother than pediatrics (e.g., emergency room (ER) /outpatient department (OPD), maternity, anesthesia)thought that while the training was interesting, theymay not get the opportunity to apply what they hadlearned until or unless they shifted to relevant depart-ments (e.g., pediatrics/neonatology, ER/OPD).Hategeka et al. BMC Health Services Research  (2017) 17:256 Page 4 of 12“I enjoyed the training, however most of the contentscovered are not relevant to my work as a midwife”.“As a midwife, content related to newborn care ismost relevant to my work.”“Although I am currently not based in a unit where Iwill use what I learnt, I could be shifted anytime topaediatrics”.While the entire training seemed to be relevant to thedistrict hospitals in Rwanda, some of the contents cov-ered in the training were more highly ranked – theseinclude “triage”, “recognition and management of shock/dehydration”, “management of severe acute malnutritionincluding feeding”, and “neonatal resuscitation and feed-ing”. In particular, the mortality and morbidity audit wasfound to be an important component of the training asit helped healthcare workers to self-audit and learn fromerrors/mistakes to improve care rendered to severely illinfants and children in their hospitals. However, somehealthcare workers stated potential barriers to successfulaudit including a “culture of blame” predominant intheir institution. Overall, the healthcare providers whoattended the training showed tremendous enthusiasm tolearn in order to better help their patients in theirinstitution.“I found hospital audit helpful and engaging, as Icould see what was done wrong, and discussed withothers what could have been done based on [ETAT+clinical practice guidelines] recommendations.”“Using the while booklet [Rwanda basic pediatricsprotocols] as we were auditing medical record helpedintegrating [ETAT+] materials.”“The audit here [in ETAT+ training] seems friendly.We are learning not blaming.”Ironically, while many of the healthcare workers com-plained about the intensity of the training (as describedbelow), some of them suggested additional topics in theETAT+ training. Specifically, these healthcare workersexpressed a need to include topics such as “child abuse”(62/171), “pediatric tuberculosis and HIV” (89/171), aswell as “interpretation of chest radiography” (42/171).Fifty-two of the 171 also suggested including the ETAT+training in the formal professional medical and nursingeducation in Rwanda, or at a minimum, making theETAT+ training a requirement before working in thepediatrics department (48/171).Anticipated change to practiceWithin the 171 questionnaires returned, the followingareas of anticipated change in practice after attendingthe ETAT+ training emerged: (1) Triage, (2) Confidence/reference job aids, (3) resuscitation, (4) prescribing, and(5) feeding.○ TriageTriage emerged as one of the most favorite topics forall healthcare workers who attended the ETAT+ training.It was consistently ranked as the most important andrelevant topic for the district hospitals in Rwanda. Giventhe shortage of staff and crowded hospitals, the need toTable 2 Characteristics of the study sampleOverall Study Samplen = 171 %ProfessionNurse 110 64.4Midwife 24 14.0Physician 37 21.6Language proficiencyFrench 92 53.8English 20 11.7Bilingual 59 34.5SexFemale 114 66.6Male 57 33.3Country regionEastern 23 13.4Kigali City 24 14.0Northern 47 27.5Southern 55 32.2Western 22 12.9Hospital locationRural 64 37.4Urban 107 62.6Department of affiliationEmergency Room 47 27.5Maternity 83 48.5Pediatrics 70 41.0Other 18 10.5ExperienceLess than or equal to one year 22 12.9More than one year 149 87.1Ever attended CPGa including ETAT+ training beforeYes 150 87.7No 21 11.3aCPG, clinical practice guidelines (including ETAT+)Hategeka et al. BMC Health Services Research  (2017) 17:256 Page 5 of 12identify, based on evidence, those children and infantsthat need the most attention was recognized. Concur-rently, many healthcare workers mentioned that therewas no functional triage in their hospitals, and thus wereeager to initiate triage system in their institution.“I now understand what I should be looking for whenI have several children queuing at the OPD“I will always be walking with my white booklet[Rwanda basic pediatrics protocols] to checkemergency, priority, and non-emergency/prioritysigns…even before calling MDs. I will know whatto say when I call MDs or transfer [a patient]”.○ Handing unstable patientsMost of healthcare workers, particularly nurses who con-stitute the majority of the workforce in the district hospi-tals, stated that ‘participating in the ETAT+ trainingincreased their confidence with respect to handling un-stable children’. They also expressed how they appreciatethe clear and concise instruction and case based scenariosthat mimic what they encountered in their practice.“Now I will be confident when I call for help. I knowwhat to say… I can do preliminary assessment of aseverely ill child while waiting for an attendingphysician to show up”.“When I started my appointment in the districthospital, I noted that all unstable patients were givenoxygen and IV fluids, I did so too…now I believe Iwill have ideas, for example, how to treat shock,especially how much fluids to give and how tomonitor [the patients]”.“I used to say it’s emergency usually MDs don’t askwhy, but in case they ask…I don’t have much to say.Now I know what to document and how tosubstantiate my decision”.○ Prescribing and feedingIn the ETAT+ training, healthcare workers are providedcurrently recommended protocols including drug prescrip-tion guidelines. The training also promotes using referenceguidelines, especially when it comes to prescribing to pre-vent errors. While most healthcare workers acknowledgedthat they used to prescribe without referring to guidelines,they commended how the ETAT+ training promoted theuse of job aids and stated that they would start using thesejob aids when prescribing any treatment to their patients.Some therapies including oxygen, feeds and gentamicinwere consistently listed as not being prescribed based oncurrent recommendations in their hospitals. Most of thetrained healthcare workers said gentamicin is prescribedtwice or thrice daily while current recommendation is oncedaily. Some healthcare workers, especially, nurses men-tioned that having the white booklet [Rwanda BasicPediatric Protocols] in their pocket will help not only facili-tate discussion with MDs who may be prescribing wrongdosages and or dosing schedules (e.g., gentamicin and oxy-gen), but also to provide treatment consistent with theRwandan clinical practice guidelines.“It’s unbelievable how we have been prescribinggentamicin BID, while current protocol recommendOD as discussed here [in the ETAT+ training]”.“I had attended another training when we were toldhow to appropriately prescribe gentamicin, but whendiscuss with MDs they refuse to abide…now I am happythat I have a reference adopted by our own MOHto use to argue with them. And honestly I think Iwont administer it or write in the nurse cardex if Ibelieve it’s a wrong dose”.“I used to think that one consults protocols becausethey are mediocre…but now I understand that betterquality of care relies on team work, and consultingreference”.“This booklet [Rwanda basic pediatrics protocols] willbe an important guide me to correctly prescribe drugsand feeds to newborns and children with SAM [severeacute malnutrition].”Moreover, the healthcare workers mentioned inconsist-ency in prescribing feeding in their health facilities, andsome said that there are no clear protocols as things keepon changing depending of the head of departments amongother things. Nevertheless, it is noteworthy that thesehealthcare workers appreciated referring to locally rele-vant guidelines such as ETAT+ clinical practice guidelines,which they perceived to be more relevant than guidelinesfrom elsewhere which have not been adapted locally.Further, they highlighted that the provision of case basedscenarios mimicking what they encountered in theirhospitals would facilitate their ability to apply what theyhad learned in the ETAT+ training.Barriers to implementation of the ETAT+ clinical practiceguidelinesThe analysis of the healthcare providers’ perspectives re-vealed the following themes and sub-themes related tochallenges hindering successful implementation of theCPGs in the district hospitals in Rwanda:Hategeka et al. BMC Health Services Research  (2017) 17:256 Page 6 of 12 Challenges during the ETAT+ training: (i)Language barriers, (ii) intensity of the training, (iii)onsite training, (iv) shortage of staff & traininghealthcare workers who are unlikely to use skills/knowledge gained in the ETAT+. Challenges anticipated to hamper successfulimplementation in the district hospitals: (i) staffshifting/turnover, (ii) reluctance to change, (iii)limited resources, (iv) knowledge and skills decay, (v)hospital leadership, and (vi) conflicting protocols.Challenges encountered during the ETAT+ training○ Language barriersLanguage issues were highlighted as one of the majorchallenges many healthcare workers faced during theETAT+ training. Because most of the training materialswere in English, those who were not fluent in Englishconsistently reported language as a major barrier to keepup with the training.“Training, and booklet [training materials] are inEnglish that I barely understand”“I had trouble understanding the pre-training mate-rials because was in English. But at least the trainingwas a mixture of English, French and Kinyarwandaand I could follow”“The booklet [Rwanda basic pediatric protocols] areinteresting but is in English so I write translated term,during the training, that I will be referring to”.Review of the training reports also revealed lan-guage as significant challenges particularly whentraining healthcare workers who did not identifythemselves as fluent in English. While during thetraining participants could ask questions and requirefurther explanations in Kinyarwanda (mother tonguein Rwanda), there were some participants who didnot speak Kinyarwanda, especially some healthcareworkers from foreign countries such as DR Congo,who constitute the majority of the foreign medicalgraduates in Rwanda. Notwithstanding the challenges,some participants shared their enthusiasm stating thatthe ETAT+ training was one of the best trainings theyhad ever attended, and indicated that they had feltlike they had got an opportunity to return to schooland learn, and were eager to go back to theirhospitals to help patients.○ High drop out rates associated with onsite trainingOnsite held ETAT+ trainings were associated withhigh dropouts, and staffs being required to do some hos-pital work (e.g., night call) during the intense five-dayETAT+ training. Additionally, for those whose ETAT+training was held in or close to their facility, hospitalstended to release more staff than they could handle,contributing to dropouts.“I attended the training held in my hospital, and hadbeen on night call every other day because of limitedstaff in my department”“I had to cover night calls in order to attend thetraining during the day. I was exhausted during thetraining and could not concentrate enough, and thetraining itself is so demanding”○ Challenges associated with the duration and intensityof the trainingA review of the notes of healthcare workers whoattended the training as well as the training reports re-vealed issues related to intensity of the training. The par-ticipants suggested revisiting the schedule to extend thetraining over at least a two-week period. Many partici-pants also suggested minimizing lecturing in the after-noon as they were usually tired and preferred practicalsessions. In addition, some healthcare workers statedthat they got tired and did not get the chance to revisethe material before the following day.“Too much [material to cover] in just a week”“There are too much information to learn and a weekis really short”.○ Staff shortage and not sending healthcare workerswho would use skills post training.While the ETAT+ training is for healthcare pro-viders working in the pediatrics/neonatology, ER, OD,labour and delivery room, some participants frompharmacy, ARV (HIV treatment unit), social workersand other departments also attended the training.These participants mentioned that they were willingto be shifted to departments where they could usethe skills/knowledge acquired. Likewise, a review ofthe training reports revealed similar issues – someparticipants were less likely to use acquired skills andknowledge in patient care.“None from ER came because shortage of staff there…so they send me, and I am not likely to use what Ilearnt here”.Hategeka et al. BMC Health Services Research  (2017) 17:256 Page 7 of 12“Sometimes if a workshop is incentivized those inleadership position, decide to attend although theydon’t practice”○ Format and timing of delivery of the trainingmaterials.Sometimes because of limited budget, trainingmaterials were not printed and participants were sente-copies. Some of these participants mentioned lack ofinternet and computer to access these materials beforethe training, and they believed that they could havelearned more had they prepared for the trainingbeforehand.“I don’t have access to internet or computer fromhome. I can access a computer from the hospital;[however, I am] not there for that purpose”Challenges anticipated to hinder the implementation ofETAT+ in Rwandan district hospitalsHealthcare workers highlighted the following chal-lenges they thought would hamper translating intopractice what they learnt to improve patient out-comes: (i) staff shifting/turnover; (ii) reluctance tochange; (iii) limited resources; (iv) knowledge andskills decay; (v) hospital leadership; and (vi) conflict-ing protocols.○ Staff shifting/turnoverOne of the major issues that healthcare workershighlighted was the high rate of staff shifting/turnoverboth externally and internally. With respect to withinfacility (internal) shifting/turnover some healthcareworkers noted that although they benefited fromtrainings they were scheduled to ‘shift’ to new depart-ments where they could not use the skills/knowledgelearnt in ETAT+. Likewise, these healthcare workerssaid they would easily forget what they learnt if theydid not get a chance to apply it. In addition, somehealthcare workers mentioned their intention to leavetheir position in the district hospitals for better jobsor studies in the future.“I was trained in essential neonatal care now I amworking in the internal medicine department”.“[I] trained in ALSO …now working in pharmacy andadministration”.“Although I am attending this training I work in HIVdrug unit so I may not use what I am learning here[in the ETAT+ training]”.○ Conflicting protocolsThe healthcare workers shared their concerns aboutseveral conflicting protocols in their hospitals (e.g., neo-natal feeding and resuscitation), stating that it was diffi-cult for them to know which one to use. Districthospital administration, the MOH and Rwandan health-care professional associations should ensure consistentand harmonize protocols where necessary.“There are a lot of guidelines out there, don’t knowwhich one to use or not, particularly in neonatology”○ Limited resourcesSome of the resources needed to implement ETAT+were not readily available in their hospitals (e.g., intra-osseous (IO) equipment, metered dose inhaler (MDI)and nebulizers, equipment needed to conduct some in-vestigations) and limited healthcare workforce. For in-stance, while the healthcare workers found the ETAT+training component on the “IO access” helpful, most ofthem mentioned that they had never had a chance ofputting an intra-osseous (IO) access/line and were notlikely to get a chance to perform the procedure in theirinstitution.“We practiced how to give an IO infusion, but wedon’t have the [IO] equipment in the hospital.”“I have never seen the IO before this training. I don’tthink we have it in my hospital.”“No nebuliser in my hospital.”“The [ETAT+] program should provide us somenecessary equipment to implement what we learnt.”Lack of supervision/mentorship, knowledge/skills decay,and reluctance to change were also highlighted as im-portant challenges that hindered successful translationof knowledge to practice. Resistance to change washighlighted as a significant challenge to implementingnew clinical practice guidelines in Rwandan district hos-pitals. Healthcare professionals with more experience,especially MDs, along with heads of departments aremore reluctant to change if they are not trained or in-volved in the implementation process.“Old people, senior staff…particularly MDs if nottrained don’t comply with new guidelines comparedto nurses”.“While I learnt a lot of stuff in the training, I willforget them if no follow up/ refresher course”Hategeka et al. BMC Health Services Research  (2017) 17:256 Page 8 of 12“We learnt a lot of stuff in trainings but like othertrainings I attended it can be difficult to translatewhat learnt in these trainings to practice withoutsupervision, we would like to have trainers come inour setting to help us”DiscussionProven effective newborn and child health interventionsneed to be successfully implemented to contribute tosustainable reduction of mortality in children under-fiveyears in low- and middle- income countries. The pri-mary purpose of this study was to identify challengesthat healthcare workers anticipated as likely to hindersuccessful implementation of the ETAT+ clinical prac-tice guidelines in Rwandan district hospitals. In addition,we explored healthcare workers’ perspectives withregards to the relevance to ETAT+ in Rwandan districthospitals, whether these healthcare workers anticipatedto change practice, and which specific aspects of practicethey might be willing to change following the ETAT+training. Nearly all participating healthcare workersstated that the training was highly relevant to the districthospitals and that it aligned with their work expecta-tions. However, some midwives believed that the “neo-natal resuscitation and feeding” components of thetraining were more relevant to them than other compo-nents. Many healthcare workers anticipated to changepractice by initiating a triage system in their hospitaland to use job aids including guidelines for prescriptionand feeding. Most of the anticipated challenges stemmedfrom perceived ETAT+ dissemination issues (e.g., lan-guage barriers, format of training materials, intensetraining schedule) and health facility related challenges(e.g., staff shifting/turnover, limited resources, reluctanceto change, conflicting clinical practice guidelines).While uptake of clinical practice guidelines is a complexprocess, key factors including relevance of these guidelinesto the system and routine work of healthcare workers canenhance their uptake. For example, Irimu et al.’s ethno-graphic study conducted in a Kenyan hospital suggestedthat ETAT+ relevance to routine clinical practice was ofthe of the factors that facilitated its uptake by healthcareworkers in Kenya [29]. Our findings suggest that health-care workers trained in ETAT+ believe that the training ishighly relevant to the Rwandan healthcare system, espe-cially in district hospitals (which constitute the backboneof the Rwandan healthcare system) where healthcare pro-viders who do not have specialty training generally takecare of severely sick infants and children withoutsupervision. The ETAT+ training highlights the mostcommon illnesses – leading causes of under-five mor-tality in Rwanda and in the region – that healthcareworkers involved in providing healthcare to sick in-fants and children would encounter in everydaypractice in Rwandan district hospitals [12, 14]. Assuch, the high relevance of ETAT+, as expressed byRwandan healthcare workers, could contribute to itssuccessful implementation in Rwandan district hospi-tals. Rwandan healthcare workers even expressed will-ingness to make the training a requirement (e.g.,recertification) to work in paediatrics and neonat-ology. Moreover, while recognizing challenges totranslate what they learned into practice, trainedhealthcare workers anticipated to make changes intheir practice after the training, including establishinga functional triage system in their facilities and regu-lar use of job aids especially when prescribing drugtherapies, which could help bridge gaps in the processof neonatal and pediatric care identified in Rwandandistrict hospitals [7]. Going forward, complementingthe ETAT+ training with regular supervision andmentorship could help not only to ensure that know-ledge translation takes place, but also identify furtheropportunities to enhance the impact of the ETAT+program.While it is well known that participating in a trainingprogram improves knowledge and skills [14–16, 30],there are barriers that might hamper the use of newlyacquired skills, especially in a context where peoplecould be resistant to changing things. For example, a re-cent study that evaluated the performance of health careproviders in the management of seriously sick childrenin Kenya suggests that educational interventions alonemay not be sufficient to deliver high quality care, and ef-fectively adapting interventions to the local context isequally as important [29]. Similarly, Baradaran-Seyedet al.’s study found that one of the major barriers toimplementation of clinical practice guidelines in Iran was ahealthcare system not designed to easily integrate evidence-based clinical practice guidelines [31]. Arguably, an under-standing of local healthcare system organizational factorsthat can affect healthcare providers’ behavior should guideand inform the implementation of clinical practice guide-lines such as ETAT+.In Rwanda, involving district hospital leadership aswell as training large numbers of healthcare workers anduse of standards might help bring about change. For ex-ample, a district hospital could ensure that all healthcareworkers are ‘certified’ in pediatric resuscitation and regu-lar ongoing professional training could be introduced tomake sure people retained their skills. An outreach typeof program that supports healthcare workers in theirown environment and ensures that the necessary equip-ment is available in good condition, would be timely.This would involve working at the ministry level to de-velop effective policies and standards for continuingmedical education (CME) and health care assessments.Further, engaging all stakeholders involved in clinicalHategeka et al. BMC Health Services Research  (2017) 17:256 Page 9 of 12practice guidelines development and implementationcould help to avoid disseminating conflicting clinicalpractice guidelines – an important challenge highlightedin our study.Lack of resources was identified as a significantchallenge to successful implementation of the ETAT+program in our study. This is consistent with previ-ous research in similar settings [11, 32–34]. Forexample, a survey of Rwandan district hospitals iden-tified limited availability of resources necessary toprovide neonatal and pediatric emergency care (e.g.,all hospitals surveyed lacked intra-osseous needles forthe management of shock and half of the hospitalsevaluated lacked BVM for newborns) [34]. In Kenya,English and colleagues found that many essentialitems for the care of severely ill children were lackingin many district hospitals [33]. Likewise, shortages ofdrugs, equipment, disposable materials as well asfacilities made it difficult to implement sepsis man-agement guidelines in Mongolia [32]. While in theETAT+ training healthcare workers are taught how tocorrectly assess children with dehydration/shock andhow to resuscitate them with fluid, including puttingan intra-osseous (IO) line when necessary, our find-ings and prior research suggest that some of the re-quired equipment are not available in the hospitalsand this may therefore hamper successful implemen-tation of the ETAT+ program in Rwanda [34]. Giventhat dehydration/shock usually due to diarrhealdiseases is one of the leading causes of under-fivemortality and morbidity in Rwanda [4–6] and the evi-dence from prior research recommending IO access ifIV cannot be promptly established, and suggestingthat IO access may be ‘easily established’ by healthcareworkers with little training and is ‘more rapidly achieved’than IV access, IO access equipment should be madereadily available in the district hospitals [35, 36].The ETAT+ clinical practice guideline disseminationrelated challenges (e.g., format of course materials,location of the training) and healthcare workers’ lan-guage proficiency have been suggested as correlates ofhealthcare providers’ performance in the ETAT+training in Rwanda [14]. Rwanda shifted its officiallanguage from French to English in 2008 [37], andsecondary and post-secondary education and CMEprograms are run primarily in English. The currentstudy findings, using qualitative methods, are in linewith findings from our previous quantitative studythat used within the ETAT+ training metrics to ex-plore potential factors associated with performance ofRwandan healthcare providers in ETAT+ [14]. It wasfound that relative to healthcare workers who identi-fied as proficient in French, those who identified asproficient in both English and French had on averagea higher improvement in knowledge and were morethan twice likely to pass the practical skills assess-ment. This discrepancy might be explained by chal-lenges expressed by healthcare providers who werenot proficient in English (e.g., unable to adequatelyprepare or understand course content, if it was taughtmainly in English). In addition, low computer ownershipand internet penetration in rural areas [38] might explainchallenges experienced by healthcare workers from ruralareas in the preparation for the training when they werenot provided printed training materials. While ETAT+training held within health facilities was cost saving (e.g.,costs associated with accommodation of participants andtraining venue were saved), it was found as in a previousstudy, to be associated with a poorer performance, whichmay be due to the fact that healthcare workers may havebeen required to continue to be involved in some of thework-related activities (e.g., direct patient care, night call)during training time and could have missed importantmaterial when away [14, 15]. Going forward, we believethat printed training materials should be provided toETAT+ training participants and these materials shouldbe available in a language that participants understand.Moreover, efforts should be made to organize trainings inFrench or English separately to accommodate partici-pants’ language proficiencies. Further, for each training,participants could be recruited from across many districthospitals so as not to put excessive personnel absence orstrain on any single hospital to require those attending in-tensive training such as ETAT+ to cover night calls.Equally important, ETAT+ organizers should commu-nicate to the hospitals early about the training so thatstaff rotation can be modified to accommodateabsences for training.Prior research suggested a number of factors (e.g., staffturner-over, knowledge/skills decay) to be significantbarriers to the translation of knowledge and skills topractice [16, 39–42]. For example, a recent study byTuyisenge found that 62.5% of healthcare workers fromthe district hospitals in the Eastern Province of Rwandathat were trained in Advanced Life Support in Obstetrics(ALSO®) between October 2012 and October 2013 hadleft their work in the district hospitals by August 2014for various reasons including taking better job/position(26.6%) and furthering their studies (42.2%) [39]. Clearly,it is possible that some of the healthcare workers trainedin ETAT+ may stop working in the district hospitals forvarious reasons as well. Thus, given the need for a bettertrained health workforce along with significant resources(both international and local) invested in training health-care providers, there is an urgent need to evaluate strat-egies to retain healthcare providers in district hospitalsin Rwanda, especially in remote areas. Moreover, effortsshould be deployed to prevent internal staff shifting (i.e.Hategeka et al. BMC Health Services Research  (2017) 17:256 Page 10 of 12staff shifting from one department to another) as thiswould potentially affect the fidelity of the ETAT+ imple-mentation in Rwandan district hospitals as trainedhealthcare workers may not be working in departmentswhere their skills and knowledge are most valuable.Further, it is critical that participants who attend theETAT+ training are selected from the healthcareworkers working in the departments (e.g., paediatrics,neonatology, delivery room, emergency room) whereETAT+ knowledge and skills gained could be put intopractice to benefit patients. Clearly, training healthcareworkers who do not work in relevant departments mayhamper the successful implementation of ETAT+ even ifphysical resources (e.g., IO) were available in the districthospitals, as these resources would not be appropriatelyused to benefit patients. As such, ETAT+ trainingorganizers should work with district hospital administrationto establish a system to ensure that healthcare workersattending the training work in relevant departments.ConclusionsThe study findings provide evidence on factors thatcan hamper successful implementation and scale upof the ETAT+ clinical practice guidelines in Rwandandistrict hospitals. These factors need to be taken inaccount when implementing ETAT+ and other con-tinuing medical education interventions within theRwandan context. However, our findings should beinterpreted in light of a number of limitations. Theresearcher's presence during data gathering, may haveaffected the participants’ responses. Moreover, typingand translating healthcare workers’ notes may haveintroduced bias. Further, the current study findingsare drawn from data collected about three years agoand, therefore, it is possible that some of our findingsmay not reflect exactly the current reality on ground.For example, the ETAT+ training materials have beentranslated to French to accommodate participants’language proficiencies, and therefore language maynot currently be a significant barrier to ETAT+ guide-lines dissemination. Despite the age of the data, ourfindings from a representative sample of healthcareproviders working in Rwandan district hospitals, arestill relevant – especially as the ETAT+ program iscurrently been scaled up nationally – and may begeneralized countrywide and to other settings withsimilar context. In particular, the findings of ourstudy suggest that the durability of continued ETAT+training efforts will be dependent on ensuring thattraining content is better targeted to selected partici-pants, and in ensuring that those who receive thetraining are facilitated to apply the knowledge andskills they acquire.Additional fileAdditional file 1: ETAT+ evaluation questionnaire completed byparticipants immediately following the ETAT+ training. (DOCX 68 kb)AcknowledgementsWe thank the RPA for granting permission and access to the data analyzedsecondarily in the current study.FundingNone.Availability of data and materialsAll relevant data are included in the paper. Access to raw data would requirefurther approval; CH and LT could be contacted to facilitate the process.Authors' contributionsCH and LT made substantial contributions to conception, design, analysis andacquisition of data. CH and LT organized the ETAT+ trainings and evaluation.CH synthetized the findings and drafted the manuscript. LM and LT revised themanuscript for important intellectual content. All authors read and approvedthe final manuscript.Competing interestsCH received consultation fee from the Rwanda Paediatric Association (RPA) –an organisation that oversees the implementation of the ETAT+ program inRwanda –, and facilitation fee as an ETAT+ instructor in Rwanda. LM and LTdeclare no conflict of interest.Consent for publicationCH, LM and LT have given final approval of the version to be published,and agreed to be accountable for all aspects of the work in ensuring thatquestions related to the accuracy or integrity of any part of the work areappropriately investigated and resolved.Ethics approval and consent to participateWith the RPA approval, we conducted a secondary analysis on anonymousdata, routinely collected by RPA as part of the ETAT+ training evaluation inRwanda.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1ETAT+ Program, Rwanda Paediatric Association, Kigali, Rwanda. 2School ofPopulation and Public Health, Faculty of Medicine, University of BritishColumbia, Vancouver, BC, Canada. 3Maternal and Child Health Program,International Development Research Centre, Ottawa, ON, Canada. 4AfyaResearch Africa, Nairobi, Kenya. 5Department of Paediatrics, UniversityTeaching Hospital of Kigali, Kigali, Rwanda.Received: 15 December 2015 Accepted: 28 March 2017References1. 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Drug Alcohol Rev. 2009;28(4):353–9.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Hategeka et al. BMC Health Services Research  (2017) 17:256 Page 12 of 12

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