Table 1 Definition of predisposing, enabling and reinforcing factors and the strategies employed to influence them

Predisposing factors

Factors that improve care providers’ knowledge, existing skills, values, attitudes, beliefs, personal preferences and self-efficacy towards desired change in practice.

Creating awareness of the gap between current practices and expected practices, enhancing staff’s knowledge and skills, and promoting ownership of the quality initiatives.

Enabling factors

Psychological, emotional or physical factors in the local context that would facilitate motivation to change behaviour.

i) Skill enhancement e.g. using CPGs to aid in clinical decision-making, ii) engaging staff in identifying problems and feasible solutions at all levels, iii) provision of basic resources, iv) better organization of service delivery and, v) encouraging the front-line service providers to do things differently to improve service efficiency.

Reinforcing factors

Factors that strengthen the motivation to perform the desired action [10].

Making the staff aware of the progress of implementation of the quality initiatives, making their progress visible, having them identify with the initiatives by involving them in problem-solving and action planning sessions.