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Coffey PS, Israel-Ballard K, Meyer L, Mansen K, Agonafir N, Bekere M, Dube Q, Kaberuka G, Kasar J, Kharade A, Maknikar S, Namgyal KC, Nyondo-Mipando AL, Rulisa S, Worku B, Engmann C. The Journey Toward Establishing Inpatient Care for Small and Sick Newborns in Ethiopia, India, Malawi, and Rwanda. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200510. [PMID: 37640484 PMCID: PMC10461708 DOI: 10.9745/ghsp-d-22-00510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/13/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Limited information is available about the approaches used and lessons learned from low- and middle-income countries that have implemented inpatient services for small and sick newborns. We developed descriptive case studies to compare the journeys to establish inpatient newborn care across Ethiopia, India, Malawi, and Rwanda. METHODS A total of 57 interviews with stakeholders in Ethiopia (n=12), India (n=12), Malawi (n=16), and Rwanda (n=17) informed the case studies. Our heuristic data analysis followed a deductive organizing framework approach. We informed our data analysis via targeted literature searches to uncover details related to key events. We used the NEST360 Theory of Change for facility-based care, which reflects the World Health Organization (WHO) Health Systems Framework as a starting point and added, as necessary, in an edit processing format until data saturation was achieved. FINDINGS Results highlight the strategies and innovation used to establish small and sick newborn care by health system building block and by country. We conducted a gap analysis of implementation of WHO Standards for Improving Facility-Based Care. The journeys to establish inpatient newborn care across the 4 countries are similar in terms of trajectory yet unique in their implementation. Unifying themes include leadership and governance at national level to consolidate and coordinate action to improve newborn quality of care, investment to build staff skills on data collection and use, and institutionalization of regular neonatal data reviews to identify gaps and propose relevant strategies. CONCLUSION Efforts to establish and scale inpatient care for small and sick newborns in Ethiopia, India, Malawi, and Rwanda over the last decade have led to remarkable success. These country examples can inspire more nascent initiatives that other low- and middle-income countries may undertake. Documentation should give voice to lived country experience, not all of which is fully captured in existing, peer-reviewed published literature.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Bogale Worku
- Ethiopian Pediatric Society, Addis Ababa, Ethiopia
| | - Cyril Engmann
- PATH, Seattle, WA, USA
- University of Washington, Seattle, WA
- Seattle Children’s Hospital, Seattle, WA
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Wilson E, Gannon H, Chimhini G, Fitzgerald F, Khan N, Lorencatto F, Kesler E, Nkhoma D, Chiyaka T, Haghparast-Bidgoli H, Lakhanpaul M, Cortina Borja M, Stevenson AG, Crehan C, Sassoon Y, Hull-Bailey T, Curtis K, Chiume M, Chimhuya S, Heys M. Protocol for an intervention development and pilot implementation evaluation study of an e-health solution to improve newborn care quality and survival in two low-resource settings, Malawi and Zimbabwe: Neotree. BMJ Open 2022; 12:e056605. [PMID: 35790332 PMCID: PMC9258512 DOI: 10.1136/bmjopen-2021-056605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Every year 2.4 million deaths occur worldwide in babies younger than 28 days. Approximately 70% of these deaths occur in low-resource settings because of failure to implement evidence-based interventions. Digital health technologies may offer an implementation solution. Since 2014, we have worked in Bangladesh, Malawi, Zimbabwe and the UK to develop and pilot Neotree: an android app with accompanying data visualisation, linkage and export. Its low-cost hardware and state-of-the-art software are used to improve bedside postnatal care and to provide insights into population health trends, to impact wider policy and practice. METHODS AND ANALYSIS This is a mixed methods (1) intervention codevelopment and optimisation and (2) pilot implementation evaluation (including economic evaluation) study. Neotree will be implemented in two hospitals in Zimbabwe, and one in Malawi. Over the 2-year study period clinical and demographic newborn data will be collected via Neotree, in addition to behavioural science informed qualitative and quantitative implementation evaluation and measures of cost, newborn care quality and usability. Neotree clinical decision support algorithms will be optimised according to best available evidence and clinical validation studies. ETHICS AND DISSEMINATION This is a Wellcome Trust funded project (215742_Z_19_Z). Research ethics approvals have been obtained: Malawi College of Medicine Research and Ethics Committee (P.01/20/2909; P.02/19/2613); UCL (17123/001, 6681/001, 5019/004); Medical Research Council Zimbabwe (MRCZ/A/2570), BRTI and JREC institutional review boards (AP155/2020; JREC/327/19), Sally Mugabe Hospital Ethics Committee (071119/64; 250418/48). Results will be disseminated via academic publications and public and policy engagement activities. In this study, the care for an estimated 15 000 babies across three sites will be impacted. TRIAL REGISTRATION NUMBER NCT0512707; Pre-results.
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Affiliation(s)
- Emma Wilson
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Hannah Gannon
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Gwendoline Chimhini
- Unit of Child and Adolescent Health, Faculty of Medicine and Health Science, University of Zimbabwe, Harare, Zimbabwe
| | - Felicity Fitzgerald
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, London, UK
| | - Nushrat Khan
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Erin Kesler
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Deliwe Nkhoma
- Parent and Child Health Initiative Trust, Lilongwe, Central Region, Malawi
| | - Tarisai Chiyaka
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Monica Lakhanpaul
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mario Cortina Borja
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Caroline Crehan
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Tim Hull-Bailey
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Msandeni Chiume
- Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Simbarashe Chimhuya
- Unit of Child and Adolescent Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Michelle Heys
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
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Carns J, Liaghati-Mobarhan S, Asibon A, Chalira A, Lufesi N, Molyneux E, Oden MZ, Richards-Kortum R, Kawaza K. National scale of neonatal CPAP to district hospitals in Malawi improves survival for neonates weighing between 1.0 and 1.3 kg. Arch Dis Child 2022; 107:553-557. [PMID: 34725045 PMCID: PMC9125365 DOI: 10.1136/archdischild-2021-322964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/19/2021] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To determine whether a national quality improvement programme implementing continuous positive airway pressure (CPAP) at government hospitals in Malawi improved outcomes for neonates prioritised by an algorithm recommending early CPAP for infants weighing 1.0-1.3 kg (the 50th percentile weight at 30 weeks' gestation). DESIGN The analysis includes neonates admitted with respiratory illness for 5.5 months before CPAP was introduced (baseline period) and for 15 months immediately after CPAP was implemented (implementation period). A follow-up data analysis was completed for neonates treated with CPAP for a further 11 months. SETTING AND PATIENTS Neonates with admission weights of 1.0-1.3 kg before (106 neonates treated with nasal oxygen) and after implementation of CPAP (153 neonates treated with nasal oxygen, 103 neonates treated with CPAP) in the newborn wards at Malawi government district hospitals. Follow-up analysis included 87 neonates treated with CPAP. INTERVENTION Neonatal CPAP. MAIN OUTCOME MEASURE We assessed survival to discharge at 23 government district hospitals with no significant differences in transfer rates before and after implementation of CPAP. RESULTS Survival improved for neonates with admission weights from 1.0 to 1.3 kg treated with CPAP (30.1%) as compared with neonates of the same weight band treated with oxygen during the baseline (17.9%) and implementation (18.3%) periods. There was no significant difference in survival for neonates treated with CPAP during the implementation and follow-up periods (30.1% vs 28.7%). CONCLUSIONS Survival for neonates weighing 1.0-1.3 kg significantly increased with a nurse-led CPAP service in a low-resource setting and improvements were sustained during follow-up.
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Affiliation(s)
- Jennifer Carns
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA,Department of Bioengineering, Rice University, Houston, Texas, USA
| | | | - Aba Asibon
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA
| | - Alfred Chalira
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Maria Z Oden
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA,Department of Bioengineering, Rice University, Houston, Texas, USA
| | - Rebecca Richards-Kortum
- Rice360 Institute for Global Health, Rice University, Houston, Texas, USA .,Department of Bioengineering, Rice University, Houston, Texas, USA
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
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Carns J, Liaghati-Mobarhan S, Asibon A, Ngwala S, Molyneux E, Oden M, Richards-Kortum R, Kawaza K, Chalira A, Lufesi N. A neonatal ward-strengthening program improves survival for neonates treated with CPAP at district hospitals in Malawi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000195. [PMID: 36962324 PMCID: PMC10021714 DOI: 10.1371/journal.pgph.0000195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022]
Abstract
From 2013-2015, a CPAP quality improvement program (QIP) was implemented to introduce and monitor CPAP usage and outcomes in the neonatal wards at all government district and central hospitals in Malawi. In 2016 the CPAP QIP was extended into healthcare facilities operated by the Christian Health Association of Malawi. Although clinical outcomes improved, ward assessments indicated that many rural sites lacked other essential equipment and a suitable space to adequately treat sick neonates, which likely limited the impact of improved respiratory care. The aim of this study was to determine if a ward-strengthening program improved outcomes for neonates treated with CPAP. To address the needs identified from ward assessments, a ward-strengthening program was implemented from 2017-2018 at rural hospitals in Malawi to improve the care of sick neonates. The ward-strengthening program included the distribution of a bundle of equipment, supplemental training, and, in some cases, health facility renovations. Survival to discharge was compared for neonates treated with CPAP at 12 rural hospitals for one year before and for one year immediately after implementation of the ward-strengthening program. In the year prior to ward strengthening, 189 neonates were treated with CPAP; in the year after, 232 neonates received CPAP. The overall rate of survival for those treated with CPAP improved from 46.6% to 57.3% after ward strengthening (p = 0.03). For the subset of neonates with admission weights between 1.00-2.49 kg diagnosed with respiratory distress syndrome, survival increased from 39.4% to 60.3% after ward strengthening (p = 0.001). A ward-strengthening program including the distribution of a bundle of equipment, supplemental training, and some health facility renovations, further improved survival among neonates treated with CPAP at district-level hospitals in Malawi.
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Affiliation(s)
- Jennifer Carns
- Rice360 Institute for Global Health, Houston, TX, United States of America
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | | | - Aba Asibon
- Rice360 Institute for Global Health, Houston, TX, United States of America
| | - Samuel Ngwala
- Rice360 Institute for Global Health, Houston, TX, United States of America
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Maria Oden
- Rice360 Institute for Global Health, Houston, TX, United States of America
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | - Rebecca Richards-Kortum
- Rice360 Institute for Global Health, Houston, TX, United States of America
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Alfred Chalira
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
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Dada S, Ashworth H, Sobitschka A, Raguveer V, Sharma R, Hamilton RL, Burke T. Experiences with implementation of continuous positive airway pressure for neonates and infants in low-resource settings: A scoping review. PLoS One 2021; 16:e0252718. [PMID: 34115776 PMCID: PMC8195417 DOI: 10.1371/journal.pone.0252718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background Continuous positive airway pressure (CPAP) is the gold standard of care in providing non-invasive positive pressure support to neonates in respiratory distress in high-resource settings. While safety has been demonstrated in low-resource settings, there is a lack of knowledge on the barriers and facilitators to proper implementation. Objective To identify and describe the barriers, facilitators, and priorities for future implementation of CPAP for neonates and infants in low-resource settings. Methods A systematic search (database inception to March 6, 2020) was performed on MEDLINE, Embase, Web of Science, CINAHL, Global Health, and the WHO Global Index Medicus using PRISMA-ScR guidelines. Original research articles pertaining to implementation of CPAP devices in low-resource settings, provider or parent perspectives and experiences with CPAP, cost-benefit analyses, and cost-effectiveness studies were included. Inductive content analysis was conducted. Findings 1385 article were screened and 54 studies across 19 countries met inclusion criteria. Six major themes emerged: device attributes, patient experiences, parent experiences, provider experiences, barriers, and facilitators. Nasal trauma was the most commonly reported complication. Barriers included unreliable electricity and lack of bioengineering support. Facilitators included training, mentorship and empowerment of healthcare providers. Device design, supply chain infrastructure, and training models were imperative to the adoption and sustainability of CPAP. Conclusion Sustainable implementation of CPAP in low resource settings requires easy-to-use devices, ready access to consumables, and holistic, user-driven training. Further research is necessary on standardizing metrics, interventions that support optimal provider performance, and conditions needed for successful long-term health system integration.
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Affiliation(s)
- Sara Dada
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- * E-mail:
| | - Henry Ashworth
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alina Sobitschka
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of Göttingen, Göttingen, Germany
| | - Vanitha Raguveer
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of Illinois College of Medicine, Chicago, Illinois, United States of America
| | - Rupam Sharma
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of California Los Angeles Kern Medical Center, Bakersfield, California, United States of America
| | - Rebecca L. Hamilton
- Massachusetts General Hospital, Department of Anesthesiology, Boston, Massachusetts, United States of America
- Karolinska Institute, Department of Cell and Molecular Biology, Solna, Sweden
| | - Thomas Burke
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Global Health Innovation Lab, Department of Emergency Medicine, Boston, Massachusetts, United States of America
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Kinshella MLW, Salimu S, Hiwa T, Banda M, Vidler M, Newberry L, Dube Q, Molyneux EM, Goldfarb DM, Kawaza K, Nyondo-Mipando AL. Scaling up newborn care technologies from tertiary- to secondary-level hospitals in Malawi: an implementation case study of health professional perspectives on bubble CPAP. Implement Sci Commun 2020; 1:100. [PMID: 33292844 PMCID: PMC7640662 DOI: 10.1186/s43058-020-00092-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/25/2020] [Indexed: 11/10/2022] Open
Abstract
Background While Malawi has achieved success in reducing overall under-five mortality, reduction of neonatal mortality remains a persistent challenge. There has, therefore, been a push to strengthen the capacity for quality newborn care at district hospitals through the implementation of innovative neonatal technologies such as bubble continuous positive airway pressure (CPAP). This study investigates tertiary- versus secondary-level hospital differences in capacities for bubble CPAP use and implications for implementation policies. Methods A secondary analysis of interviews was conducted with 46 health workers at one tertiary hospital and three secondary hospitals in rural Southern Malawi. Grounded theory was utilized to explore the emerging themes according to health worker cadres (nurse, clinician, district health management) and facility level (tertiary- and secondary-level facilities), which were managed using NVivo 12 (QSR International, Melbourne, Australia). Results We identified frequent CPAP use and the availability of neonatal nurses, physicians, and reliable electricity as facilitators for CPAP use at the tertiary hospital. Barriers at the tertiary hospital included initiation eligibility disagreements between clinicians and nurses and insufficient availability of the CPAP machines. At secondary-level hospitals, the use was supported by decision-making and initiation by nurses, involving caretakers to assist in monitoring and reliable availability of CPAP machines. Bubble CPAP was hindered by unreliable electricity, staffing shortages and rotation policies, and poor systems of accountability. Conclusion While this study looked at the implementation of bubble CPAP in Malawi, the findings may be applicable for scaling up other novel neonatal technologies in low-resource settings. Implementation policies must consider staffing and management structures at different health services levels for effective scale-up.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Sangwani Salimu
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mwai Banda
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Laura Newberry
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth M Molyneux
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- School of Public Health and Family Medicine, Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi.
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Crehan C, Kesler E, Chikomoni IA, Sun K, Dube Q, Lakhanpaul M, Heys M. Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App: Digital Perinatal Outcome Audit. JMIR Mhealth Uhealth 2020; 8:e16485. [PMID: 33084581 PMCID: PMC7641784 DOI: 10.2196/16485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 11/28/2022] Open
Abstract
Background Mobile health (mHealth) is showing increasing potential to address health outcomes in underresourced settings as smartphone coverage increases. The NeoTree is an mHealth app codeveloped in Malawi to improve the quality of newborn care at the point of admission to neonatal units. When collecting vital demographic and clinical data, this interactive platform provides clinical decision support and training for the end users (health care professionals [HCPs]), according to evidence-based national and international guidelines. Objective This study aims to examine 1 month’s data collected using NeoTree in an outcome audit of babies admitted to a district-level neonatal nursery in Malawi and to demonstrate proof of concept of digital outcome audit data in this setting. Methods Using a phased approach over 1 month (November 21-December 19, 2016), frontline HCPs were trained and supported to use NeoTree to admit newborns. Discharge data were collected by the research team using a discharge form within NeoTree, called NeoDischarge. We conducted a descriptive analysis of the exported pseudoanonymized data and presented it to the newborn care department as a digital outcome audit. Results Of 191 total admissions, 134 (70.2%) admissions were completed using NeoTree, and 129 (67.5%) were exported and analyzed. Of 121 patients for whom outcome data were available, 102 (84.3%) were discharged alive. The overall case fatality rate was 93 per 1000 admitted babies. Prematurity with respiratory distress syndrome, birth asphyxia, and neonatal sepsis contributed to 25% (3/12), 58% (7/12), and 8% (1/12) of deaths, respectively. Data were more than 90% complete for all fields. Deaths may have been underreported because of phased implementation and some families of babies with imminent deaths self-discharging home. Detailed characterization of the data enabled departmental discussion of modifiable factors for quality improvement, for example, improved thermoregulation of infants. Conclusions This digital outcome audit demonstrates that data can be captured digitally at the bedside by HCPs in underresourced newborn facilities, and these data can contribute to a meaningful review of the quality of care, outcomes, and potential modifiable factors. Coverage may be improved during future implementation by streamlining the admission process to be solely via digital format. Our results present a new methodology for newborn audits in low-resource settings and are a proof of concept for a novel newborn data system in these settings.
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Affiliation(s)
- Caroline Crehan
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom
| | - Erin Kesler
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom
| | | | - Kristi Sun
- Whittington Hospital, London, United Kingdom
| | - Queen Dube
- Paediatric Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Monica Lakhanpaul
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom.,Whittington Hospital, London, United Kingdom
| | - Michelle Heys
- UCL-Great Ormond Street Hospital Institute of Child Health, University College London, London, United Kingdom.,East London NHS Foundation Trust, London, United Kingdom
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Kiyasseh D, Zhu T, Clifton D. The Promise of Clinical Decision Support Systems Targetting Low-Resource Settings. IEEE Rev Biomed Eng 2020; 15:354-371. [PMID: 32813662 DOI: 10.1109/rbme.2020.3017868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Low-resource clinical settings are plagued by low physician-to-patient ratios and a shortage of high-quality medical expertise and infrastructure. Together, these phenomena lead to over-burdened healthcare systems that under-serve the needs of the community. Alleviating this burden can be undertaken by the introduction of clinical decision support systems (CDSSs); systems that support stakeholders (ranging from physicians to patients) within the clinical setting in their day-to-day activities. Such systems, which have proven to be effective in the developed world, remain to be under-explored in low-resource settings. This review attempts to summarize the research focused on clinical decision support systems that either target stakeholders within low-resource clinical settings or diseases commonly found in such environments. When categorizing our findings according to disease applications, we find that CDSSs are predominantly focused on dealing with bacterial infections and maternal care, do not leverage deep learning, and have not been evaluated prospectively. Together, these highlight the need for increased research in this domain in order to impact a diverse set of medical conditions and ultimately improve patient outcomes.
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Nabwera HM, Wright JL, Patil M, Dickinson F, Godia P, Maua J, Sammy MK, Naimoi BC, Warfa OH, Dewez JE, Murila F, Manu A, Smith H, Mathai M. 'Sometimes you are forced to play God…': a qualitative study of healthcare worker experiences of using continuous positive airway pressure in newborn care in Kenya. BMJ Open 2020; 10:e034668. [PMID: 32792424 PMCID: PMC7430418 DOI: 10.1136/bmjopen-2019-034668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE: To explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up. DESIGN AND SETTING: A qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya. PARTICIPANTS: Healthcare workers in the newborn units providing CPAP. PRIMARY AND SECONDARY OUTCOME MEASURE: Facilitators and barriers of CPAP use in newborn care in Kenya. RESULTS: 16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available. CONCLUSION: CPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use. ETHICS: This study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.
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Affiliation(s)
- Helen M Nabwera
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jemma L Wright
- Paediatrics Department, Betsi Cadwaladr CHC, Wrexham, UK
| | - Manasi Patil
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Fiona Dickinson
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pamela Godia
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Judith Maua
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Mercy K Sammy
- General Paediatrics, Gertrude's Garden Children's Hospital, Nairobi, Kenya
| | | | - Osman H Warfa
- Neonatal, Child and Adolescent Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Juan Emmanuel Dewez
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Florence Murila
- Paediatrics and Child Health, University of Nairobi School of Medicine, Nairobi, Kenya
| | - Alexander Manu
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Smith
- Maternal and Newborn Health, International Health Consulting Services Ltd, Liverpool, UK
| | - Matthews Mathai
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Kinshella MLW, Walker CR, Hiwa T, Vidler M, Nyondo-Mipando AL, Dube Q, Goldfarb DM, Kawaza K. Barriers and facilitators to implementing bubble CPAP to improve neonatal health in sub-Saharan Africa: a systematic review. Public Health Rev 2020; 41:6. [PMID: 32368359 PMCID: PMC7189679 DOI: 10.1186/s40985-020-00124-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 04/07/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Bubble continuous positive airway pressure (CPAP) has been shown to be effective in supporting breathing in newborns with respiratory distress. The factors that influence implementation in resource-constrained settings remain unclear. The objective of this review is to evaluate the barriers and facilitators of CPAP implementation for newborn care at sub-Saharan African health facilities and how different facility levels and types of bubble CPAP systems may impact utilization. METHODS A systematic search (database inception to July 2019) was performed on MEDLINE Ovid, EMBASE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), the WHO Regional Database for Africa, African Index Medicus (AIM), African Journals Online, grey literature and the references of relevant articles. Studies that met the inclusion criteria (primary research, bubble CPAP implementation with neonates ≤ 28 days old at a health facility in sub-Saharan Africa) were included in the review and assessed with National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) quality assessment tools. The review protocol was published to PROSPERO (CRD42018116082). RESULTS Seventeen studies were included in the review. Reliable availability of equipment, effectively informing and engaging caregivers and staffing shortages were frequently mentioned barriers to the implementation of bubble CPAP. Understaffed neonatal units and high turnover of nurses and doctors compromised effective training. Provider-to-provider clinical mentorship models as well as affordability and cost-effectiveness of innovative bubble CPAP systems were identified as frequently mentioned facilitators of implementation. CONCLUSIONS With a strong recommendation by the World Health Organization for its use with premature infants with respiratory distress, it is important to understand the barriers and facilitators that can inform the implementation of bubble CPAP. More research is needed into health system factors that can support or impede the use of this potentially promising intervention.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Celia R. Walker
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Alinane Linda Nyondo-Mipando
- School of Public Health and Family Medicine, Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - David M. Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
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11
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Nyondo-Mipando AL, Woo Kinshella ML, Bohne C, Suwedi-Kapesa LC, Salimu S, Banda M, Newberry L, Njirammadzi J, Hiwa T, Chiwaya B, Chikoti F, Vidler M, Dube Q, Molyneux E, Mfutso-Bengo J, Goldfarb DM, Kawaza K, Mijovic H. Barriers and enablers of implementing bubble Continuous Positive Airway Pressure (CPAP): Perspectives of health professionals in Malawi. PLoS One 2020; 15:e0228915. [PMID: 32053649 PMCID: PMC7018070 DOI: 10.1371/journal.pone.0228915] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/27/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Preterm birth complications are the leading cause of neonatal deaths. Malawi has high rates of preterm birth, with 18.1 preterm births per 100 live births. More than 50% of preterm neonates develop respiratory distress which if left untreated, can lead to respiratory failure and death. Term and preterm neonates with respiratory distress can often be effectively managed with Continuous Positive Airway Pressure (CPAP) and this is considered an essential intervention for the management of preterm neonates by the World Health Organization. Bubble CPAP may represent a safe and cost-effective method for delivering CPAP in low-income settings. OBJECTIVE The study explored the factors that influence the implementation of bubble CPAP among health care professionals in secondary and tertiary hospitals in Malawi. METHODS This was a qualitative study conducted in three district hospitals and a tertiary hospital in southern Malawi. We conducted 46 in-depth interviews with nurses, clinicians and clinical supervisors, from June to August 2018. All data were digitally recorded, transcribed verbatim and thematically analyzed. RESULTS Factors that influenced implementation of bubble CPAP occurred in an interconnected manner and included: inadequate healthcare provider training in preparation for use, rigid division of roles and responsibilities among providers, lack of effective communication among providers and between providers and newborn's caregivers, human resource constraints, and inadequate equipment and infrastructure. CONCLUSION There are provider, caregiver and health system level factors that influence the implementation of bubble CPAP among neonates in Malawian health facilities. Ensuring adequate staffing in the nurseries, combined with ongoing training for providers, team cohesion, improved communication with caregivers, and improved hospital infrastructure would ensure optimal utilization of bubble CPAP and avoid inadvertent harm from inappropriate use.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Christine Bohne
- Institute for Global Health, NEST 360°, Rice University, Houston, Texas, United States of America
| | | | | | - Mwai Banda
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Laura Newberry
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jenala Njirammadzi
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Tamanda Hiwa
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Felix Chikoti
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Queen Dube
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth Molyneux
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Joseph Mfutso-Bengo
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Center of Bioethics for Eastern & Southern Africa (CEBESA), Blantyre, Malawi
| | - David M. Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Hana Mijovic
- Department of Pediatrics, BC Children’s Hospital and University of British Columbia, Vancouver, Canada
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Carns J, Kawaza K, Liaghati-Mobarhan S, Asibon A, Quinn MK, Chalira A, Lufesi N, Molyneux E, Oden M, Richards-Kortum R. Neonatal CPAP for Respiratory Distress Across Malawi and Mortality. Pediatrics 2019; 144:peds.2019-0668. [PMID: 31540968 DOI: 10.1542/peds.2019-0668] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our aim in this observational study was to monitor continuous positive airway pressure (CPAP) usage and outcomes in newborn wards at 26 government hospitals in Malawi after the introduction of CPAP as part of a quality-improvement initiative. CPAP was implemented in 3 phases from 2013 through 2015. METHODS Survival to discharge was analyzed for neonates treated with nasal oxygen and/or CPAP with admission weights of 1 to 2.49 kg at 24 government hospitals with transfer rates <15%. This analysis includes neonates admitted with respiratory illness for 5.5 months before (621 neonates) and 15 months immediately after CPAP implementation (1836 neonates). A follow-up data analysis was completed for neonates treated with CPAP at all hospitals during an additional 11 months (194 neonates). RESULTS On implementation of CPAP, survival to discharge improved for all neonates admitted with respiratory distress (48.6% vs 54.5%; P = .012) and for those diagnosed with respiratory distress syndrome (39.8% vs 48.3%; P = .042). There were no significant differences in outcomes for neonates treated with CPAP during the implementation and follow-up periods. Hypothermia on admission was pervasive and associated with poor outcomes. Neonates with normal mean temperatures during CPAP treatment experienced the highest survival rates (65.7% for all neonates treated with CPAP and 60.0% for those diagnosed with respiratory distress syndrome). CONCLUSIONS A nurse-led CPAP service can improve outcomes for neonates in respiratory distress in low-resource settings. However, the results show that real-world improvements in survival may be limited without access to comprehensive newborn care, especially for small and sick infants.
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Affiliation(s)
- Jennifer Carns
- Rice 360 Institute for Global Health Technology, Houston, Texas.,Department of Bioengineering, Rice University, Houston, Texas
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi; and
| | | | - Aba Asibon
- Rice 360 Institute for Global Health Technology, Houston, Texas
| | - Mary K Quinn
- Rice 360 Institute for Global Health Technology, Houston, Texas
| | - Alfred Chalira
- Department of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Elizabeth Molyneux
- Department of Pediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi; and
| | - Maria Oden
- Rice 360 Institute for Global Health Technology, Houston, Texas.,Department of Bioengineering, Rice University, Houston, Texas
| | - Rebecca Richards-Kortum
- Rice 360 Institute for Global Health Technology, Houston, Texas; .,Department of Bioengineering, Rice University, Houston, Texas
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13
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Crehan C, Kesler E, Nambiar B, Dube Q, Lufesi N, Giaccone M, Normand C, Azad K, Heys M. The NeoTree application: developing an integrated mHealth solution to improve quality of newborn care and survival in a district hospital in Malawi. BMJ Glob Health 2019; 4:e000860. [PMID: 30713745 PMCID: PMC6340059 DOI: 10.1136/bmjgh-2018-000860] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 12/03/2022] Open
Abstract
More than two-thirds of newborn lives could be saved worldwide if evidence-based interventions were successfully implemented. We developed the NeoTree application to improve quality of newborn care in resource-poor countries. The NeoTree is a fully integrated digital health intervention that combines immediate data capture, entered by healthcare workers (HCW) on admission, while simultaneously providing them with evidence-based clinical decision support and newborn care education. We conducted a mixed-methods intervention development study, codeveloping and testing the NeoTree prototype with HCWs in a district hospital in Malawi. Focus groups explored the acceptability and feasibility of digital health solutions before and after implementation of the NeoTree in the clinical setting. One-to-one theoretical usability workshops and a 1-month clinical usability study informed iterative changes, gathered process and clinical data, System Usability Scale (SUS) and perceived improvements in quality of care. HCWs perceived the NeoTree to be acceptable and feasible. Mean SUS before and after the clinical usability study were high at 80.4 and 86.1, respectively (above average is >68). HCWs reported high-perceived improvements in quality of newborn care after using the NeoTree on the ward. They described improved confidence in clinical decision-making, clinical skills, critical thinking and standardisation of care. Identified factors for successful implementation included a technical support worker. Coproduction, mixed-methods approaches and user-focused iterative development were key to the development of the NeoTree prototype, which was shown to be an agile, acceptable, feasible and highly usable tool with the potential to improve the quality of newborn care in resource-poor settings.
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Affiliation(s)
- Caroline Crehan
- Great Ormond Street Hospital Institute of Child Health, University College London, London, UK
| | - Erin Kesler
- Great Ormond Street Hospital Institute of Child Health, University College London, London, UK
| | - Bejoy Nambiar
- Institute for Global Child Health, University College London, London, UK
| | - Queen Dube
- Paediatric Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Norman Lufesi
- Ministry of Health Acute Respiratory Illness Unit, Government of Malawi, Lilongwe, Malawi.,Paediatrics and Child Health Association (PACHA), Blantyre, Malawi
| | | | | | - Kishwar Azad
- Ibrahim Medical College, Dhaka, Bangladesh.,Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders at Shahbag, Dhaka, Bangladesh
| | - Michelle Heys
- Great Ormond Street Hospital Institute of Child Health, University College London, London, UK
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