RESEARCH ARTICLE Open Access
Using he beha io change wheel o
iden i y ba ie s o and po en ial solu ions
o p ima y ca e clinical guideline use in
ou p o inces in Sou h A ica
Tama a K edo
1,2*
, Sa a Coope
1,3
, Ambe Ab ams
1
, Jocelyn Mulle
1
, Jimmy Volmink
4
and Salla A kins
5,6
Abs ac
Backg ound: Clinical p ac ice guidelines isk ha ing li le impac on heal hca e i no e ec i ely implemen ed.
Theo y in o med, a ge ed implemen a ion may maximise hei impac . Ou s udy explo ed ba ie s o and
acili a o s o guideline implemen a ion and use by Sou h A ican p ima y ca e nu ses and allied heal hca e wo ke s
in ou p o inces in Sou h A ica. We also p oposed in e en ions o add ess he issues iden i ied.
Me hods: We used quali a i e esea ch me hods, comp ising ocus g oup discussions using semi-s uc u ed opic
guides. Se en ocus g oup discussions we e conduc ed (48 p o ide s) in ou Sou h A ican p o inces (Eas e n Cape,
Wes e n Cape, Kwazulu-Na al, Limpopo). Pa icipan s included mos ly nu ses, die icians, den is s, and allied heal h
p ac i ione s, om p ima y ca e acili ies in u al and pe i-u ban se ings. The analysis p oceeded in h ee phases.
Fi s ly, wo analys s conduc ed induc i e hema ic con en analysis o de elop hemes o da a. This was ollowed by
i ing eme gen hemes o he Theo e ical Domains F amewo k and inally o he associa ed Beha iou Change
Wheel o iden i y ele an in e en ions.
Resul s: Pa icipan s a e knowledgeable abou guidelines, gene ally us hei c edibili y and a e ecep i e and
mo i a ed o use hem. Guidelines a e seen by nu ses o p o ide con idence and eassu ance, as well as
p o essional au ho i y and independence whe e doc o s a e sca ce. Ba ie s o guideline use include: inadequa e
sys ems o p in ed book dis ibu ion, insu icien and subs anda d pho ocopies, linguis ic inapp op ia eness (e.g.
complica ed language, lack o summa ies, una ailable in local languages), unsuppo i e audi ing p ocedu es, limi ed
in ol emen o end-use s in guideline de elopmen , and pa chy aining ha may no il e back o all p o ide s.
Fu u e aspi a ions iden i ied include: imp o ing he design ea u es o guidelines, accessible places o ind
guidelines, making digi ally- o ma ed e sions a ailable, mo e supplemen a y ma e ials (e.g. pos e s) o suppo
pa ien engagemen , accessible clinical suppo ollowing aining, and in- acili y aining o all p o essional cad es
o ensu e ai access, simila le els o capabili y and in e disciplina y consis ency.
Conclusions: Sou h A ican p ima y ca e nu ses and allied heal h p ac i ione s ha e high le els o mo i a ion o use
guidelines, bu ace many sys emic ba ie s. We used he Beha iou Change Wheel o sugges ele an ,
implemen able in e en ions add essing iden i ied ba ie s. This heo y-in o med app oach may imp o e clinical
guideline implemen a ion and impac heal hca e o Sou h A ica.
Keywo ds: Quali a i e esea ch, Clinical p ac ice guidelines, Implemen a ion, P ima y ca e, Focus g oups, Theo e ical
domains amewo k, Beha iou change, Quali y imp o emen
* Co espondence: [email p o ec ed]
1
Coch ane Sou h A ica, Sou h A ican Medical Resea ch Council, Cape Town,
Sou h A ica
2
Di ision o Clinical Pha macology, Facul y o Medicine and Heal h Sciences,
S ellenbosch Uni e si y, Cape Town, Sou h A ica
Full lis o au ho in o ma ion is a ailable a he end o he a icle
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K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965
h ps://doi.o g/10.1186/s12913-018-3778-2
Backg ound
In e na ionally, high-quali y, e idence-in o med clinical
p ac ice guidelines (CPGs) a e ecognised as essen ial
quali y imp o emen ools [1–3]. CPGs ha e a ange o
pu poses, in ended o s anda dise ca e, imp o e i s qual-
i y and sa e y, dec ease cos s, and imp o e pa ien ou -
comes [3,4]. They o e a ‘one-s op shop’ o end-use s,
by p o iding syn hesised in o ma ion om sys ema ic
e iews ega ding bes p ac ices [5]. Howe e , despi e
g owing a ailabili y o CPGs, i no used, hey canno
impac on he quali y o he ca e ha is deli e ed.
Sou h A ica has long been de eloping CPGs, mos
p onounced du ing he pos -apa heid pe iod when
CPGs we e conside ed impo an ools o ed ess in-
equi y, s anda dise ca e and p omo e cos -e ec i e ca e
o all. Many CPG de elopmen playe s ha e been iden-
i ied: na ional go e nmen , p o essional socie ies, hospi-
als and clinics all con ibu e acco ding o hei needs
and agendas [6,7]. Howe e , despi e de elopmen and
dis ibu ion o CPGs, heal h ou comes emain poo , and
gene ally wo se han expec ed gi en he pe capi a
heal h spend ela i e o o he simila middle-income
coun ies [8,9]. As CPGs aim o op imise ca e, and ye
ca e appea s no o be op imally deli e ed, i may be
help ul o unde s and he ba ie s o CPG implemen a-
ion and use [10,11].
We know he e a e no ‘magic bulle s’ o imp o ing
CPG implemen a ion [12,13]. Sys ema ic e iews sug-
ges many po en ial implemen a ion s a egies, such as
audi and eedback, ou each educa ion and key opinion
leade s [14]. A ailable e idence sugges s ha ailo ed,
mul i- ace ed app oaches may do be e han gene ic
and single- ocused in e en ions [13,14].
Se e al p agma ic ials o CPG implemen a ion o
lung heal h, Human Immunode iciency Vi us (HIV)
and b oade p ima y ca e ha e been conduc ed in
Sou h A ica, inding some imp o emen s when educa-
ional ou each is used [15–17]. I is he e o e possible
ha , when used, CPGs may imp o e heal h ou comes. I
we be e unde s ood when and how CPGs a e used by
Sou h A ican p ima y ca e p o ide s, hen CPG de el-
ope s may design e idence-in o med s a egies o enhance
enable s and o e come ba ie s.
The Theo e ical Domains F amewo k (TDF) is a use ul
app oach o iden i ying acili a o s o and ba ie s o be-
ha iou change, and o de eloping ailo ed in e en ions
when implemen ing CPGs [18]. Unde s anding how bes
o enhance heal hca e p o ide s’use o CPGs equi es
conside a ion o he complex in e play o clinician and pa-
ien beha iou s, en i onmen al con ex and social in lu-
ences. The TDF in ends o in eg a e heo ies o beha iou
change, and b idge heal h psychology, o ganisa ional he-
o y and heal h se ices, p o iding a heo e ical basis o
implemen a ion esea ch [19]. Se e al s udies ha e used
he TDF o e alua e heal hca e implemen a ion challenges
o o design heo y-in o med implemen a ion s a egies.
Examples include hand hygiene, child en’s heal h checks,
human papilloma i us accina ion, den al in ec ions, and
lowe back pain [10,11,20–22]. Some o hese explo a-
ions u he in o med he design o complex in e en-
ions o esea ch o public heal h p og ammes [20].
U ilising he TDF, his s udy aimed o explo e p ima y
ca e heal hca e p o ide s’pe spec i es ega ding he
con ex , po en ial ba ie s o and enable s o CPG use in
ou p o inces in Sou h A ica. Based on he indings,
and d awing on concep s om he Beha iou Change
Wheel (BCW), his s udy also sough o p o ide ecom-
menda ions o po en ial in e en ions o imp o e CPG
usage and implemen a ion.
Me hods
Theo e ical amewo k
We used a quali a i e s udy design, including semi-s uc-
u ed ocus g oup discussions (FGDs). The o e a ching con-
cep ual amewo k used o his a icle was he Theo e ical
DomainsF amewo k(TDF) ha also o medpa o ou
analysis p ocess desc ibed below. The TDF p o ides a basis
o unde s and beha iou s heo e ically and he e o e a ge
p ocesses mos likely o implemen desi ed change [19,23].
The 14 domains o TDF ha e been u he mapped on o he
Capabili y, Oppo uni y, Mo i a ion –Beha iou al model
(COM-B model), a ‘beha iou sys em’model which seeks o
encapsula e he condi ions in e nal o indi iduals and hose
wi hin hei social and physical en i onmen necessa y o
achie ing speci ied beha iou al a ge s [18]. Th ee essen ial
condi ions: Capabili y, Oppo uni y, and Mo i a ion
(COM-B) a e a he co e o his sys em, which posi s ha
hese componen s in e ac o gene a e beha iou , which in
u n in luences hem in a back-and- o h cycle. These com-
ponen s o m he hub o wha is e med a ‘Beha iou Change
Wheel’(BCW), a ound which a e a numbe o in e en ions
which may be implemen ed a he indi idual (e.g. educa ion
and aining), o policy le el (e.g. legisla ion o iscal mea-
su es) o enable he COM-B elemen s [18]. The BCW is a
p ac ical ool ha can be applied in implemen a ion esea ch
o mo e om iden i ying ba ie s and enable s o aligning
hese wi h ailo ed in e en ions [24]. De ini ions o he
COM-B domains, how hey map o he TDF and o he
BCW in e en ion unc ions a e shown (Table 1).
S udy se ings
Sou h A ica has a popula ion app oaching 57 million and
a heal h sys em in es ed in p ima y heal hca e [25–29].
The coun y is cu en ly s i ing o uni e sal heal h
co e age, publishing a Whi e pape (2015) desc ibing as-
pec s o he Na ional Heal h Insu ance sys em [30]. Finan-
cial ede alism is in place in which na ional go e nmen
de elops s a egies, policies and clinical CPGs; and
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 2 o 12
p o incial go e nmen s implemen CPGs, some imes a e
adap a ion, o heal hca e acili ies ( om egional, o dis-
ic , o communi y heal hca e acili ies) [8].
Sampling and ec ui men
Sou h A ica is a la ge and di e se coun y. We he e o e
selec ed ou o he nine p o inces o ep esen a
spec um o p ima y heal hca e se ings: Wes e n Cape,
Kwazulu-Na al, Eas e n Cape and Limpopo p o inces.
Each p o ince is di e en in e ms o popula ion size
and densi y, economic de elopmen , heal hca e spending
and esou ces, and heal h ou comes (Table 2). While he
Wes e n Cape, Eas e n Cape and Limpopo ha e simila
popula ion sizes, he Wes e n Cape is be e unded, and
Table 1 Links be ween COM-B, Theo e ical Domains F amewo k and Beha iou Change Wheel in e en ion unc ions
COM-B model Theo e ical Domains
F amewo k
Beha iou Change Wheel In e en ion
unc ions
Mo i a ion
De ini ion: all hose cogni i e p ocesses ha
di ec beha iou , including habi ual p ocesses,
emo ional esponding, as well
as analy ical decision-making.
Re lec i e mo i a ion P o essional/ social ole and
iden i y
Educa ion, pe suasion, modelling
Belie s abou capabili ies Educa ion, pe suasion, enablemen
Op imism Educa ion, pe suasion, modelling,
enablemen
Belie s abou consequences Educa ion, pe suasion, modelling
In en ions Educa ion, pe suasion, incen i isa ion,
coe cion, modelling, enablemen
Au oma ic mo i a ion Rein o cemen T aining, Incen i isa ion, coe cion,
En i onmen al es uc u ing
Emo ion Pe suasion, incen i isa ion, coe cion,
modelling, enablemen
Capabili y
De ini ion: he indi idual’s psychological and
physical capaci y o engage in he ac i i y
conce ned, and includes ha ing he
necessa y knowledge and skills.
Physical capabili y Physical skills T aining
Psychological capabili y Knowledge Educa ion
Cogni i e and in e pe sonal
skills
T aining
Memo y, a en ion and decision
p ocesses
T aining, en i onmen al es uc u ing,
Enablemen
Beha io al egula ion Educa ion, aining, modelling,
enablemen
Oppo uni y
De ini ion: all he ac o s ha lie ou side he
indi idual ha make he beha iou possible
o p omp i .
Physical oppo uni y En i onmen al con ex and
esou ces
T aining, es ic ion, en i onmen al,
es uc u ing, enablemen
Social oppo uni y Social in luences Res ic ion, en i onmen al, es uc u ing,
modelling, enablemen
Table 2 Key heal h and demog aphic indica o s by Sou h A ican p o ince
a
Indica o Yea P o ince
WC KZN EC LPP
A ea as a % o o al a ea o Sou h A ica 2011 10.6 7.7 13.8 10.3
Popula ion 2016 6,279,730 11,065,240 6,996,976 5,799,090
Popula ion % by p o ince 2016 11.3 19.8 12.6 10.4
GDP pe capi a (USA) 2010 8.69 4.77 3.65 4259
Educa ion le el (% popula ion wi h no schooling) 2015 1.5 6.7 6.1 9.8
Po e y p e alence ( ood po e y line) 2011 23.2 37.4 40.5 41.5
Popula ion % dependen on public sec o 2016 75.96 88.22 90.13 91.58
Heal h as % o o al expendi u e 2000 30.0 26.7 20.9 17.8
Pe capi a public sec o heal h expendi u e 2015 4242.5 3623.1 3304.4 2957.7
Li e expec ancy a bi h 2010 68.0 52.9 53.8 63.6
Adul mo ali y a e (p obabili y o dying be ween 15 and 60 yea s) 2010 26.6 52.8 52.2 37.7
Unde 5 mo ali y a e 2015 23.1 57.8 59.6 36.6
a
Adap ed om Sou h A ican Heal h Re iew 2017 [27]
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 3 o 12
has highe educa ional le els, lowe le els o po e y and
a highe li e expec ancy han he o he s. Kwazulu-Na al
has he la ges popula ion size, a high po e y p e alence
and poo li e expec ancy, despi e heal h expendi u e ap-
p oaching ha o he Wes e n Cape. O he ac o s be-
sides a ailable unds, a e likely o play a ole in his
ega d, including high p e alence o in ec ious diseases,
such as HIV [25]. Wi hin each p o ince, we a ge ed wo
public sec o p ima y ca e clinics, one u al and one
u ban o pe i-u ban. While we in ended o conduc
eigh FGDs, we comple ed se en due o delayed access
in he Wes e n Cape. To iden i y clinics, we con ac ed
he p o incial esea ch di ec o a es and colleagues wo k-
ing in he p o inces o guidance. All heal hca e p o-
ide s wo king a clinics, ega dless o cad e, we e
in i ed o pa icipa e (Table 3).
Da a collec ion and managemen
The FGDs enabled us o explo e collec i e expe iences
o CPG use a he on line o heal hca e deli e y. This
me hod is sui ed o explo ing complexi y su ounding
CPG use wi hin he con ex o li ed expe iences, in ways
ha encou age pa icipan s o engage ac i ely wi h he
esea ch opic [31,32].
Se en FGDs we e held om No embe 2015 o Augus
2016. G oup sizes anged om h ee o ele en pa icipan s
and las ed om 60 o 90 min. A o al o o y-eigh p o-
ide s pa icipa ed. P ima y ca e p o ide s who ook pa
included nu ses, occupa ional he apis s, physio he apis s,
die icians, den is s, o al hygienis s and medical doc o s.
The FGDs we e guided by a semi-s uc u ed opic
guide which explo ed he ollowing opics: he con ex
o CPG awa eness and use; speci ic CPGs used (and e-
quency o usage); access o CPGs; gene al iews and ex-
pe iences o using speci ic CPGs; pe cep ions o ba ie s
o and enable s o CPG use; and ecommenda ions o
s a egies ha migh add ess cu en ba ie s o use. The
guide was lexible o ensu e ha pa icipan s could ex-
p ess wha was impo an o hem, and so lea nings
om p e ious FGDs could be cla i ied and p obed
u he in subsequen FGDs. The FGD guide was no
based on he TDF, bu a he sough o unde s and
nu ses’pe cep ions abou and expe iences wi h using
CPGs on hei own e ms and hei own meaning
ames. The TDF was used du ing he analysis s age
o help analyse and o ganise he da a as desc ibed
below. FGD acili a o s ecei ed aining in acili a ion
echniques. All FGDs we e conduc ed in pai s; mem-
be s o he esea ch eam (all emales) ook u ns o
acili a e.
FGDs we e eco ded digi ally. Re lec ions and sum-
ma ies we e w i en a e FGDs o cap u e insigh s. Ini-
ial coding and hema ic analysis we e conduc ed a e
each FGD o guide he sampling p ocess and o ensu e
da a sa u a ion.
FGDs we e ansc ibed e ba im, and ansc ip ions
we e e iewed o accu acy by he esea ch eam (TK,
TM). A ew pa icipan s including a lay counsello and
en y le el nu se chose o sha e hei iews using hei
mo he ongue which was no English. A esea ch eam
membe assis ed o ansla e hese sho sec ions o us
o include in he analysis. Da a we e s o ed elec onically
on passwo d-p o ec ed compu e s; a mas e lis and
consen o ms we e s o ed in a locked cabine o which
only he p ojec lead had access.
Analysis
We used an i e a i e, hema ic con en analysis ap-
p oach [31,33]. Speci ically, wo esea che s ead he
ansc ip s (TK, SA) and ag eed on he gene al mean-
ing and cen al issues p esen ed. One esea che (TK)
hen e- ead ansc ip s, pe o ming open coding e-
la ed o gene al ques ions posed, including con ex ,
use, ba ie s o and enable s o CPG use, ex ac ing
he ela ed quo es [34]. Quo es we e hen u he ex-
amined (TK, SA) o mani es and la en meanings
[35]. A his poin , we sea ched o concep ual ame-
wo ks ha migh help us be e unde s and and
o ganize he da a. The TDF was conside ed o p o-
ide a use ul model in his ega d, enabling us o en-
capsula e he indi idual and con ex ac o s ha
acili a e and /o hinde CPG use ha we saw eme -
ging om he da a. The model was also deemed alu-
able o acili a e he subsequen ansla ion o ou
indings in o ac ionable ecommenda ions o in e -
en ions which a ge speci ic ba ie s. This model
has been used success ully by o he s o e alua e
heal hca e implemen a ion challenges and o design
heo y-in o med implemen a ion s a egies [20,21].
Ha ing examined indi idual quo es o mani es and
la en meanings, wo esea che s (TK, SC) hen used
he TDF o u he ca ego ise he da a. In pa icula ,
speci ic quo a ions and hei meanings we e ma ched
o he 14 domains wi hin he TDF. The wo e-
sea che s pe o med he ma ching independen ly, and
Table 3 Schedule o Focus G oups
Loca ion Discipline Numbe o
ocus g oups
(pa icipan s)
Wes e n Cape Nu ses, den is s, heal h p omo ions
o ice
1(n=6)
Eas e n Cape Nu ses 2 (n= 12)
Limpopo Den is s, o al hygienis , occupa ional
he apy, physio he apy, die ician,
counsello s, da abase adminis a o
2(n= 17)
Kwa-Zulu Na al Doc o s, nu ses, quali y assu ance
o ice , den is , physio he apis ,
counsello s
2 (n = 12)
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 4 o 12
subsequen ly discussed hese wi h each o he and he
hi d esea che (SA) o each ag eemen and esol e
unce ain ies. Each quo a ion was coded o a leas
one TDF domain, bu some we el could be coded
in o wo o h ee domains. In he case o he la e ,
judgmen s we e made abou which speci ic domain
he quo es should be ca ego ized, in a manne ha
cap u ed he meaning o indi idual quo es and i ed
wi h he b oade hemes ha we e eme ging. Once
ou indings we e aligned wi h he TDF domains and
associa ed COM-B sys em, hen p oceeded o map
he indings on o he espec i e in e en ion unc ions
o gene a e ecommenda ions based on he BCW
[24]. The p ocess o de eloping ecommenda ions was
in o med by he me hods used by Michie and col-
leagues o link hei analysis o he a ge ed beha -
iou s o app op ia e in e en ions o con olling
obacco and educing obesi y [18].
Rigou
C edibili y was ensu ed h ough de ailed cap u ing and
desc ip ion o ou app oach o sampling, da a collec ion,
da a managemen , analysis and in e p e a ion [35]. Con-
side a ion o issues ega ding e lexi i y and ans e abil-
i y we e conside ed h oughou he p ocess. Quo a ions
we e chosen o p o ide eade s he oppo uni y o in e -
p e da a, es ablish con i mabili y and o show he ich-
ness o he da a. Complemen a y esea ch compe encies
and expe iences among all esea che s in luenced da a
in e p e a ion and s eng hened s udy igou .
Resul s
Mos pa icipan s we e nu ses; wo we e doc o s a one
FGD in Kwa-Zulu Na al (Table 3). Al hough we col-
lec ed limi ed demog aphic da a, we obse ed ha hose
in u al acili ies had wo ked o a longe ime and li ed
in he a ea, whe eas a he mo e u ban acili ies, pa ici-
pan s we e gene ally younge , mo e ecen ly appoin ed
and po en ially mo e mobile.
In his sec ion we epo he po en ial enable s o and
ba ie s o CPG use in e ms o he COM-B domains o
‘Mo i a ion’( e lec i e, au oma ic), ‘Capabili y’(psycho-
logical, social) and ‘Oppo uni y’(social, physical)
(Table 1)[23], and e lec on and unpack he TDF ca -
ego ies wi hin hem.
Mo i a ion –Re lec i e and au oma ic
Mo i a ion includes beha io s co esponding o e lec i e
mo i a ion and hose ha a e mo e au oma ic o habi ual.
We epo on bo h e lec i e and au oma ic mo i a ion as
hey include issues o emo ion, p o essional iden i y, be-
lie s abou capabili y and consequences. S ikingly, ac oss
all FGDs, he o e whelming majo i y o pa icipan s
exp essed mo i a ion o use CPGs. CPG use appea ed o
e oke a ange o posi i e emo ional esponses, pa icula ly
amongs nu ses. Sen imen s included ‘ eassu ing’,inspi ing
‘con idence’and p o iding a sense o au onomy o ‘inde-
pendence’. The la e was pa icula ly p onounced in mo e
u al se ings, wi h ew doc o s:
I makes [allows] us o be in line wi h he doc o s, i
makes us doc o s ou sel [sic], so i means you will be in-
dependen (Nu se_LPP_ u al).
Addi ionally, CPGs we e pe cei ed as use ul ools o
engage he communi y, sha e in o ma ion and p o ec
heal hca e p o ide s’p o essional in eg i y, which u -
he mo i a ed use:
E en i he e is a complain among he communi y
membe s ha we ha e mismanaged his clien , so we say,
I ha e managed his clien … h ough he guidelines and
we show him he guidelines (Nu se_EC_ u al).
O e all, CPGs we e pe cei ed as c edible sou ces. Nu ses
and allied heal hca e p o ide s in se e al clinics desc ibed
ha ing i s -hand expe ience o CPGs imp o ing pa ien ca e.
One pa icula ly signi ican example ci ed was ha o HIV,
whe e CPGs had changed apidly as he ield o HIV ca e
changed in Sou h A ica. P o ide s desc ibed ha ing seen pa-
ien s ansi ion om dying p io o he a ailabili y o HIV
CPGs, o pa ien s li ing wi h HIV a e CPGs we e imple-
men ed. This unde sco ed o hem he pe cei ed alue ha
using CPGs b ing:
I ’s wo king, because when we wan o ind ou ou
s a is ics, people hey a e now…[HIV] nega i e… hey
ha e go ARV’s [an i e o i als] and hey a e ine…
(Nu se_KZN_ u al).
Compa ed o nu sing s a , he link be ween CPGs,
p o essional iden i y and enablemen seemed lesse o
doc o s, as one doc o sugges ed:
I mus con ess, we doc o s a e no e y good a seeing
his is wha he guidelines says. This is he way I do
hings and hen you go on. I ’s no jus he e bu i you
go o ano he place you’ll ind he same hing.
(Doc o _KZN_pe i-u ban).
Capabili y –Knowledge and skills
Capabili y includes knowledge, unde s anding, decision-making
and skills as undamen al d i e s o beha iou . A con-
sis en na a i e amongs pa icipan s was ha know-
ledge o CPGs was no a ba ie o usage. Pa icipan s
con eyed conside able awa eness o CPGs, wi h many
naming se e al ha we e in egula , pe haps e en
daily use. In addi ion o knowledge, emembe ing and
deciding o use CPGs was no pe cei ed as a ba ie .
Some pa icipan s e en oiced cu iosi y abou why we
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 5 o 12

would conduc esea ch on some hing ha was so ob-
iously pa o ou ine clinical ca e.
While some pa icipan s desc ibed using CPGs o
‘each and e e y pa ien ’, o he s sugges ed ha hey we e
mos likely o use CPGs in pa icula ins ances. Tha is,
hey ended o use CPGs when aced wi h an un amilia
clinical case o a change in he ecommenda ions ha
spa ked cu iosi y, and equi ed lea ning:
…wha makes me wan o ead some o hem is
because I came ac oss such a pa ien , and I didn’
know wha o do hen I go back o ead. Tha is wha
makes me wanna ead, o he wise I don’ hink I’ll jus
si down and ead he guideline
(O alheal h_LPP_pe i-u ban).
Despi e hei own knowledge, pa icipan s exp essed an
impo an gap in CPG awa eness amongs pa ien s and
he public. Many el ha inc easing public awa eness o
CPGs was impo an o success ul CPG implemen a ion.
Tha is, a mo e heal h-li e a e and empowe ed public was
pe cei ed o encou age accoun abili y o heal hca e p o-
ide s. Se e al app oaches o aising public awa eness
we e p oposed, including engaging jou nalis s, use o
adio, ele ision and social media:
Maybe when you’ e lis ening o [ he] adio and eading
news, hey should in oduce his change e e ywhe e, be-
cause e en [ he] pa ien s should know (O alheal h_LPP_
pe i-u ban).
Ano he signi ican gap iden i ied by pa icipan s
was aining in CPG usage. T aining was pe cei ed as
an essen ial ool o ‘keep ab eas ’o ‘ge up o speed’
wi h CPG con en . I was also conside ed impo an
o enhancing clinical p ac ice and ensu ing ha all
disciplines ‘will be on he same le el’and hus p e en -
ing a ‘clash o in o ma ion’.While aining was unani-
mously pe cei ed as necessa y o p o icien CPG
usage, pa icipan s we e undecided abou he se ing
in which aining should ake place. Speci ic eedback
abou he p os and cons o on-si e aining and
o -si e wo kshops we e p o ided, which a e de ailed
in Addi ional ile 1. Though aining was conside ed
key o CPG use, many pa icipan s el ha skills
building h ough aining was inadequa e. T aining,
ega dless o whe he p o ide s we e om u ban o
u al se ings, was conside ed insu icien o pa chy,
no co e ing all opics and no inclusi e o all clinical
disciplines. This inadequacy was pe cei ed o esul in
CPGs which a e ‘ha d o in e p e ’and hus s a ha -
ing o ‘s uggle’on hei own o use CPGs p ope ly.
The managemen p ocess o deciding who would a -
end wo kshops was also desc ibed as non- anspa en
and un ai , wi h ‘no consis ency’su ounding a end-
ance.Thus, while pa icipan s we e ca ego ical abou
heneed o mo e aining, heissueo howbes odo
his emains complex.
Oppo uni y –Social and physical
Oppo uni y includes bo h physical oppo uni y and social
oppo uni y. Social oppo uni y conside s he social in lu-
ences ha may impac CPG use. While his domain did no
gene a e subs an ial discussion amongs pa icipan s, wha
eme ged consis en ly, pa icula ly in u al acili ies, was he
alue o suppo i e social and p o essional sys ems as enab-
ling quali y clinical ca e and CPG use. These sys ems, in-
cluding in ol emen o non-go e nmen al o ganisa ions,
and associa ed cohesi e eams and s ong leade ship, we e
pe cei ed o enable he cul u e o CPG use.
So i ’s eam wo k ha ma e s, i you a e wo king as a
eam you do (Nu se_EC_pe i-u ban).
Whe eas we ound gene ally suppo i e social and
p o essional en i onmen s, he physical en i onmen
eme ged as a conside able obs acle o CPG use. This do-
main gene a ed ex ensi e discussion, wi h se e al
sub- hemes eme ging, namely: he need o adap o local
con ex ; heal h sys em challenges; access o CPGs; CPG
design needs; and digi al CPGs. In addi ion o desc ibing
hese ba ie s in g ea dep h, pa icipan s om all disci-
plines also p o ided p ac ical ecommenda ions o how
hese con ex ual ba ie s migh be add essed.
CPGs being insu icien ly adap ed o local con ex s
eme ged as a key issue. Gi en he di e si y in a la ge
coun y like Sou h A ica, he con ex in which CPGs
a e used may di e by p o ince. Some CPG ecommen-
da ions we e expe ienced as ‘no p ac ical’and no ap-
p op ia e o local heal hca e con ex s. Many ag eed ha
o CPGs o become ‘some hing ha can eally apply o
us’and ha ‘ac ually wo ks o sui he PHC [p ima y
heal h ca e]’,heal hca e p o ide s should be pa o CPG
de elopmen p ocesses.
Heal h sys em challenges eme ged as ano he majo
ba ie o CPG implemen a ion. The abili y o ope a ion-
alise CPG ecommenda ions was desc ibed as signi i-
can ly hinde ed by ‘no budge ’,‘slow p ocu emen ’, o he
lack o equipmen whe e s a simply ‘don’ ha e he ma-
chine’. S ock ou s o medicines was highligh ed as an
issue:
when he e is a ecommenda ion and he medica ion
is no he e…we a e s uck (Nu se_LPP_ u al).
Rela edly, p ima y ca e clinic p essu es we e pe cei ed
o limi p o ide s’abili y o p ope ly ead CPGs. All
cad es desc ibed ha he ‘long queues ou side’and he
ime needed o ‘page and page’ h ough a CPG was no
easible du ing a consul a ion.
Pa icipan s also iden i ied ba ie s ela ed o he
design, layou and language o CPGs, and made
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 6 o 12
sugges ions o how hese migh be imp o ed o en-
hanceCPGuse(Addi ional ile2). Many spoke abou
he leng hy na u e o CPGs and he ‘big ja gon Eng-
lish’,which limi ed unde s anding and use. They
exp essed a wish o ‘much mo e use iendly’CPGs,
including using ‘sho di ec i e’and mo e simple lan-
guage, and inco po a ing ‘summa ised’ e sions, mo e
de ini ions, local e nacula and supplemen a y ools
(e.g. pos e s) o aid unde s anding and suppo pa-
ien engagemen . A doc o sugges ed ha , as people
maybe ‘ isual lea ne s’,use o mo e a ac i e and ap-
pealing o ma s, such as g aphics, cha s, and colou ,
would enhance CPG use. Colou -coding in one o he
p ima y ca e CPGs (PC101) was desc ibed as e ec -
i e, as one nu se said, i ‘keeps you on he oes’
(EC_pe i-u ban).
Poo access o good quali y and up- o-da e CPGs
ma e ialised as an especially pe inen physical ba ie
o CPG usage. Many pa icipan s, pa icula ly hose in
u al se ings, p o ided de ailed na a i es abou how
‘ha d o each’CPGs we e. Many desc ibed how hey
equen ly ‘ge hem la e’o ha e access o ‘only one
copy’in hei clinics. O he s spoke abou he way in
which CPGs a e o en s o ed inaccessibly ou side o
consul ing ooms, while o he s highligh ed he poo
sys ems ha exis o CPG e sion con ol, ul ima ely
esul ing in ‘con usion’and ou da ed in o ma ion. Fu -
he mo e, i eme ged ha e en when CPGs a e a ail-
able, hey a e equen ly o sub-s anda d quali y:
They make copies and pages a e missing, he
a angemen o he pages, [i ] becomes bulkie
and all hese hings. So ha ’s a p oblem, I mean
people don’ eally ge he eal hing, a ep in o
make a copy and make you own.
(Doc o _KZN_pe i-u ban).
Nume ous pa icipan s, bo h u al and u ban,
highligh ed ha many o hese ba ie s a ound access
would be add essed i CPGs we e a ailable digi ally.
They explained ha access o digi al CPGs would en-
able hem o ead hem in hei own ime, no only
du ing consul a ions, which would in u n make keep-
ing up- o-da e easie . They also sugges ed ha i
would imp o e knowledge ans e a e wo kshops,
educing issues ela ed o in o ma ion sha ing.
Addi ionally, many belie ed ha digi al CPGs would
esul in all heal hca e p o ide s ecei ing CPGs in a
imely manne and u he suppo in- acili y capaci y
building when new CPGs we e dissemina ed.
Despi e gene al ag eemen ha digi al CPGs may a-
cili a e usage, a numbe o complexi ies associa ed wi h
his medium eme ged. Some pa icipan wonde ed
whe he use o digi al CPGs in on o pa ien s would
gene a e nega i e pa ien pe cep ions, who migh belie e
ha heal hca e p o ide s a e ‘busy on Wha sapp’,acces-
sing o he nonwo k- ela ed con en , o ha hey lack
knowledge. A he same ime, while some pa icipan s
had CPGs on hei phones, including he CPG app o
elec onic books, his was a mino i y, and mos ly seen in
pe i-u ban acili ies. Mos clinics did no ha e in e ne
access ei he ia compu e s a ions o wi eless in e ne ,
and heal hca e p o ide s did no consis en ly ha e sma
phones, da a and in e ne access h ough o he means.
This was pa icula ly e iden in he mo e u al clinics
whe e in a FGD o 11 s a , one nu se epo ed ha ing
opened a pe sonal email accoun , and e en ha was a
ecen de elopmen . Al hough pa icipan s in he Wes -
e n Cape FGD desc ibed ha ing pe sonal in e ne access,
hey sugges ed ha limi ed phone memo y, high da a
cos s and he need o download CPGs a hei own ex-
pense was a ba ie . Thus, use o digi al CPGs was de-
sc ibed o come wi h i s own se o access issues, and
while e iden ly desi able, emains aspi a ional om p o-
ide s pe spec i es.
Implica ions o policy and p ac ice: Theo y in o med
in e en ions
The ba ie s mos o en exp essed by pa icipan s
we e ela ed o he en i onmen al con ex , esou ces
and aining needs. We hus used he BCW app oach
o map he mos ele an in e en ion unc ions o
add ess hese speci ic ba ie s, as shown in Fig. 1
[18]. In his ma ix we p o ide speci ic sugges ions
o possible in e en ions o inc ease use o Sou h A -
ican p ima y ca e CPGs.
The e o e, om ou indings, ‘physical and psycho-
logical capaci y’, in pa icula poo ly suppo ed aining
was a ba ie o CPG use; and mos s ikingly, he ‘phys-
ical oppo uni y’, in ha he en i onmen al con ex and
a ailable esou ces we e subs an ial challenges o CPG
use. Based on ou esul s, he ollowing in e en ion
unc ions a e sugges ed ha align he COM-B domain,
beha iou al ba ie s and possible in e en ions:
–T aining - impa ing skills ( o example wo kshops,
on si e men o ing and supe ision, pos - aining
suppo )
–Educa ion –inc easing knowledge o unde s anding
abou speci ic CPG ecommenda ions (e.g.
wo kshops, pos wo kshop suppo and clinical
suppo )
–En i onmen al es uc u ing –changing he physical
en i onmen (e.g. making he CPGs mo e accessible
h ough di e en o ma s, g ea e design
conside a ion, summa ized simple language, mo e
appealing ools ha suppo implemen a ion ha
help engage pa ien s such as pos e s and algo i hms;
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 7 o 12
ensu ing supply chain unc ioning and access o
medicines and equipmen ; building ICT
in as uc u e and c ea ing digi al access)
–Enablemen –inc easing means and educing
ba ie s o inc ease capabili y o oppo uni y ( o
example, his may include audi and eedback,
clinical suppo and eam building).
Discussion
This s udy explo ed he pe spec i es o p ima y ca e
heal hca e p o ide s, wo king in public sec o clinics, e-
ga ding he con ex , po en ial ba ie s o and enable s o
CPG use in ou di e se p o inces in Sou h A ica. We
in es iga ed hese issues h ough he lens o he TDF, in
o de o ca ego ise he ba ie s and enable s in e ms o
COM-B: Capabili y, Oppo uni y, and Mo i a ion.
Enable s –mo i a ion, knowledge and social oppo uni y.
Ou indings e ealed ha p ima y heal hca e nu ses
and allied heal h p ac i ione s gene ally us he c ed-
ibili y o CPGs and a e highly mo i a ed o use hem.
CPG usage was pe cei ed o be associa ed wi h a ange
o posi i e emo ional and p o essional consequences, ex-
pe iences ha ha e been desc ibed elsewhe e as po en-
ial bene i s o CPGs [3]. In addi ion, knowledge o
CPGs, along wi h egula use, we e epo ed by mos
heal hca e p o ide s, a inding o impo ance, gi en ha
bo h knowledge abou and posi i e a i ude owa ds a
CPG a e ac o s ha ha e been iden i ied as po en ially
enhancing CPG implemen a ion [36].
Pa icipan s in ou s udy, pa icula ly nu sing s a ,
emphasised he impo ance o cohesi e eams, clinical
supe ision and s ong leade ship o enable CPG use.
This co obo a es epo s om highe income se ings,
which desc ibe he impo ance o socio-beha iou al ac-
o s, such as pee suppo , o enhance CPG use [36–38].
S udies in Sou h A ica ha e e ealed ha suppo and
supe ision o heal hca e p o ide s a e cu en ly inad-
equa e. Fo example, a quali a i e s udy in which allied
heal h p ac i ione s and heal h manage s we e in e -
iewed, ound a lack o suppo o allied heal h p ac i-
ione s in hei p ac ice [39,40]. Simila ly, a ecen
su ey among p ima y heal hca e nu ses sugges s ha
many el unsuppo ed by supe iso s o p o ide bes
quali y clinical ca e [37,41]. Agains his backd op, and
in ligh o he indings om ou s udy, enhancing CPG
use in Sou h A ica necessi a es de eloping cohesi e
p o essional eams and building clinical suppo o
p ac i ione s.
Ba ie s –Physical capabili y (skills and aining)
Despi e appa en knowledge o CPGs and mo i a ion o
use hem, pa chy and non-inclusi e aining in CPGs
eme ged as an impo an ba ie o hei usage. Lack o
equisi e skills and sel -e icacy a e epo ed ba ie s o
CPG implemen a ion [36]. The pa icipan s in ou s udy
conside ed skills building in CPGs essen ial o enhan-
cing p o iciency o use CPGs p ope ly, ensu ing simila
le els o capabili y and knowledge amongs heal hca e
p o ide s, and o acili a ing s anda dised use ac oss
disciplines.
Howe e , exac ly how his aining should be deli e ed
eme ged as a complex issue, wi h pa icipan s sugges ing
ad an ages and disad an ages o bo h on- o o -si e ain-
ing. Ou pa icipan s alked abou o -si e educa ional
mee ings, on-si e educa ional ou each and suppo i e
Fig. 1 Ma ix o COM-B Model ba ie s and sugges ed in e en ion unc ions. This igu e ep esen s a Ma ix o ba ie s ha we e iden i ied om
pa icipan s and he po en ial in e en ions o o e come hem, as guided by he BCW. The ma ix is colou coded and all blue colou ed a eas
ep esen whe e he COM-B domain aligns wi h he in e en ion unc ions. The da ke he shade o blue, he mo e pe inen he need o an
in e en ion, in ligh o ou indings
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 8 o 12
clinical audi s as desi able. In an o e iew o sys ema ic
e iews, se e al skills building s a egies o implemen ing
heal h sys ems in low- and middle-income se ings we e
epo ed wi h a ying le els o e ec i eness, including
p ac ice acili a ion, educa ional ou each, audi and eed-
back, educa ional mee ings, and local opinion leade s [14].
In Sou h A ica, he e ha e been se e al ials o educa-
ional ou each o nu se-d i en p ima y ca e e alua ing
CPG implemen a ion [15,17]. As such, we ha e suppo -
ing e idence ega ding easibili y o his app oach o
managing co-mo bidi y, and in some s udies, e idence o
e ec i eness o ube culosis and HIV CPG implemen a-
ion [15,17,42,43]. Thus, while his s udy e ealed a clea
s a ed need o inc eased skills building, he bes means o
p o iding his in Sou h A ican p ima y ca e migh con-
side using a combina ion o me hods o enable CPG up-
ake and use.
Ba ie s - physical oppo uni y (en i onmen al con ex
and esou ces)
While o he COM-B cons uc s eme ged as enable s o
CPG usage, ‘physical oppo uni y’ma e ialised as he
mos subs an ial ba ie , wi h pa icipan s highligh ing
nume ous con ex ual issues ha hinde e ec i e CPG
use. These may be u he unde s ood as pe aining o
wo aspec s, he CPG i sel o he en i onmen al con ex
in which CPGs a e implemen ed.
Rega ding he CPG i sel , pa icipan s pe cei ed ha
usage o CPGs is hinde ed signi ican ly when hei con en
is imp ac ical o implemen and linguis ically inapp op i-
a e; when CPG design ea u es a e no use - iendly; and i
he e a e inadequa e CPG supplemen a y ools (e.g. pic-
u es) o no summa ised e sions. This esona es wi h a
e iew o di e en ea u es o ensu ing CPG ‘implemen -
abili y’, oge he wi h a suppo ing checklis o CPG de-
elope s o conside [44]. These esou ces sugges ha
speci ic ea u es o CPGs a e likely o enhance hei usage,
including s uc u ed ecommenda ions; p o iding con-
ex ual in o ma ion ega ding clinical cases; explici e-
sou ce implica ions; and suppo ing algo i hms and
clinical ools [44,45].
In e ms o he physical en i onmen , se e al ac o s
we e iden i ied as c i ical obs acles o CPG implemen a-
ion. In pa icula , a lack o necessa y equipmen and e-
po ed budge a y and supply cons ain s, including s ock
ou s o medicines, we e a conce n and pe cei ed o be
ela ed o poo dis ic o p o incial managemen sys-
ems. These heal h sys em challenges a e well desc ibed
in he coun y, including a ecen quali a i e s udy in
which access o equipmen o medicines posed se ious
challenges o deli e y o heal h se ices o bo h use s
and p o ide s o ca e [6,9,26,46,47]. In ou s udy, in-
adequa e sys ems o dis ibu ion o p in ed CPGs and
CPG- ela ed ci cula s, as well as poo CPG e sion and
quali y con ol, appea ed o impac upon CPG use.
Taken oge he , his collec ion o en i onmen al issues
was seen by pa icipan s o esul in CPGs ha a e e-
quen ly una ailable, inaccessible, o a subop imal quali y
and/o di icul o implemen . While hese ba ie s
eme ged ac oss he di e en s udy se ings, hey ap-
pea ed o be pa icula ly pe inen and heigh ened in
u al a eas.
Aspi a ional enable - digi al access o CPGs
Pa icipan s consis en ly sugges ed ha making digi ally-
o ma ed CPGs and associa ed echnologies (e.g. in e -
ne , compu e s, lap ops) a ailable was a key s a egy o
inc ease CPG access and use. Digi al CPGs we e sug-
ges ed o ed ess many o he con ex ual challenges hey
cu en ly ace, such as lack o su icien CPG ha d copies
o poo e sion con ol. The e is g owing e idence
ega ding he ole o handheld de ices o suppo CPG
use. A sys ema ic e iew epo ed ha doc o s and
nu ses using a CPG on a handheld de ice may inc ease
access o in o ma ion, adhe ence o a CPG and suppo
o diagnosing condi ions, in compa ison o pee s using
pape -based esou ces [48]. Howe e , despi e his
p omising e idence, esul s emana e p edominan ly om
high-income se ings whe e access and a ailabili y o
echnologies a e di e en o hose in low- and
middle-income se ings. The e o e, despi e in e es in
his a ea and as -g owing oppo uni ies in echnology,
cu en da a cos s, lack o in as uc u e, in e ne o
de ices, pa icula ly in u al se ings, p esen majo
challenges o his becoming a eali y, as e ealed in ou
s udy.
Implica ions o policy and p ac ice: S a egic heo y
in o med in e en ions o o e come ba ie s
Gi en he limi ed esou ces o in es in CPG implemen-
a ion in many se ings, ensu ing ha he in e en ions
bes ma ch he issues and ba ie s ha eme ge is a a-
ional app oach. We iden i ied ha in es men o
implemen ing p ima y ca e CPGs should conside en i -
onmen al es uc u ing, enablemen , and aining and
educa ion (Fig. 1).
T aining and educa ion is al eady a majo means o
deli e ing in o ma ion o p ima y ca e ia egional ain-
ing cen es and esponsible dis ic aining pe sonnel.
Howe e , he esul s o his and o he s udies, sugges
speci ic adap a ions and enhancemen s need o be con-
side ed and implemen ed [39,40] such as enhanced
in- acili y aining and pos - aining clinical suppo . An-
o he in e en ion unc ion is enablemen . Gi en he
mo i a ion o heal hca e p o ide s o use CPG, u he
enablemen using e idence-based s a egies, such as
cons uc i e clinical audi and eedback, clinical suppo
K edo e al. BMC Heal h Se ices Resea ch (2018) 18:965 Page 9 o 12