Table 4.

Environmental factors influencing uptake and use of pediatric hospital guidelines in Lao PDR

Theme	Subtheme	Exemplar quotation
Social influences	Consensus/group norms	“There is agreement across the whole country already. You can say it comes from WHO it is easy to say.” (Pediatric resident 10)
		“Because the [workshop] attendees came from everywhere, so they have to agree after the workshop, they have to make a decision how to do [to use the guidelines] and follow.” (Pediatrician 11, central hospital 2)
	Local opinion leaders	“...if it is a good book but they [senior doctors] do not agree, we cannot use it.” (Pediatric resident 6)
		So you know, here in our country, when teachers in central hospitals say something, they doctors or medical staff from rural areas, from provincial or district hospitals, they would believe us. So when we use it they would use it too... (Pediatrician 3, central hospital 2)
	Modeling	“I could see the residents too, they encourage each other [to use the book], they ask each other. And I could see residents teaching medical students to use the book too, so medical students can use the book and residents explain to medical students from the book.” (Pediatrician 9, central hospital 1)
Reinforcement		“Yes the book is in their pocket. If the resident does not have it I will…(indicates cutting motion)…their score.” (Pediatrician 5, central hospital 1)
Environmental context and resources	Culture	“You have to respond to the family, to make them happy. Even if the child will die [if you do what the family wants]...you have to ask their opinion.”(Provincial hospital doctor 3)
	Equipment and supplies	Yes some problems, for example, for very severe pneumonia with cyanosis, we should have oxygen prongs but we don’t have them. It says to give the oxygen by nose but we only have the nasal prongs for adults so we give by mask. We have a problem.” (District hospital nurse 3)