International Journal for Quality in Health Care Advance Access originally published online on January 21, 2005
International Journal for Quality in Health Care 2005 17(2):147-155; doi:10.1093/intqhc/mzi017
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Theory-based identification of barriers to quality improvement: induced abortion care
1 University of Edinburgh, Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH), Edinburgh, 2 University of Aberdeen, Health Services Research Unit, Aberdeen, 3 Aberdeen Maternity Hospital, SPCERH, Aberdeen, Scotland, UK, 4 Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, Canada, 5 University of Newcastle upon Tyne, Centre for Health Services Research, Newcastle upon Tyne, UK
Background. The UK Royal College of Obstetricians and Gynaecologists published the clinical guideline, The Care of Women Requesting Induced Abortion, to address recognized variations in care. There is little empirical evidence on factors that influence compliance with the guideline. A better understanding of such factors is needed for quality improvement initiatives.
Objective. To identify factors that influence compliance with two key guideline recommendations: offer of an assessment appointment within 5 days of referral, and supply of contraceptives at discharge.
Setting. Thirteen hospital gynaecology units in Scotland.
Methods. Guideline compliance was measured by a case note review. Barriers and facilitators were identified using a combination of approaches: semi-structured interviews with local gynaecologists and a survey of clinical staff. The questionnaire, based upon constructs from the Theory of Planned Behaviour, measured behavioural intention, attitude, subjective norm (perceived social pressure), and perceived behavioural control.
Results. Of 507 cases reviewed, median unit compliance was 46% for the assessment appointment and 59% for contraceptive supplies. Questionnaires were returned by 151 (74%) of 205 staff in 12 units. The interviews and open-ended questions highlighted organizational barriers to guideline implementation. Staff generally had strong intentions and positive attitudes to follow both recommendations. For the assessment appointment, perceived behavioural control was low. The Theory of Planned Behaviour accounted for 27% of the variation in intentions, with subjective norm being the strongest predictor. Intention and perceived behavioural control best explained unit compliance, together explaining 15% of the variation. For contraceptive supplies, the theory accounted for 34% of the variation in intentions, with perceived behavioural control being the strongest predictor.
Conclusion. Clinical staff were highly motivated to implement the guideline but hindered by organizational constraints. Quality improvement initiatives need to target organizational barriers as well as individual professionals.
Keywords: behavioural theory, clinical guidelines, induced abortion
Address reprint requests to R. Foy, Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle, NE2 4AA, UK. E-mail: r.c.foy{at}ncl.ac.uk
Accepted for publication December 1, 2004.
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