Evaluating the effects of organizational and educational interventions on adherence to clinical practice guidelines in a low-resource primary-care setting in Kenya

Health Policy Plan. 2017 Jul 1;32(6):761-768. doi: 10.1093/heapol/czx004.


Background: Mid-level care providers serve as the backbone of primary care in many parts of sub-Saharan Africa. Despite this, research suggests that the quality and consistency of this care is uneven. This study assessed the degree to which a set of four simple, low-cost interventions could improve adherence to a set of clinical quality measures (CQMs) associated with four common health conditions seen in a resource-constrained primary care setting.

Methods: A quasi-experimental, longitudinal study was carried out in three primary care clinics in Nairobi, Kenya from August 2014 to January, 2015. Mid-level clinical officers (COs) at each clinic participated in four interventions aimed at improving CQM adherence. A group of temporary COs acted as a control group. Clinical encounter data were abstracted from eligible medical charts and assessed for CQM adherence. Mixed-effects logistic regression models were then fitted to these data to determine whether adherence to CQMs improved over time, and if this adherence differed by provider type and other characteristics.

Results: Adherence to CQMs increased from 41.4% to 77.1% for COs that took part in the intervention, and dropped slightly from 26.5% to 21.8% for temporary COs over the 6-month study period. This difference was statistically different between treatment groups and suggests that environmental interventions alone cannot change behaviour. Adherence also varied significantly by health condition, but did not vary by provider gender, age or clinic site.

Conclusions: This study demonstrates the potential for low-tech, low-cost interventions to improve the quality of care delivered by mid-level care providers in resource-constrained settings. Given the widespread utilization of mid-level care providers across sub-Saharan Africa, multicomponent interventions such as this one, that consist of simple educational modules and clinic-based feedback sessions, could lead to substantial improvements in the quality of primary care in these settings.

Keywords: Adherence; behaviour change; clinical; low income; maternal and child health; quality of care.

MeSH terms

  • Adolescent
  • Adult
  • Child
  • Education, Continuing / methods
  • Education, Distance / methods
  • Female
  • Formative Feedback
  • Guideline Adherence*
  • Health Personnel / economics*
  • Health Personnel / organization & administration*
  • Humans
  • Kenya
  • Longitudinal Studies
  • Male
  • Primary Health Care / organization & administration
  • Primary Health Care / standards