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Ahsan N, Malik FA, Mughis W, Jabeen R, Mehboob S, Allana R, Quratulain S, Jamal S, Paganelli CR, Goco N, Parlberg L, Omer SB, Kazi AM. Postmortem minimally invasive tissue sampling in communities: exploring perceptions of families, funeral workers, religious and community leaders and healthcare providers from Pakistan. BMC Health Serv Res 2023; 23:1402. [PMID: 38093318 PMCID: PMC10720140 DOI: 10.1186/s12913-023-10438-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Minimally invasive tissue sampling (MITS) has increasingly been used to improve the diagnosis of disease and identification of the cause of death, particularly in underserved areas. However, there are multiple barriers to accessing those who die within the community, our study aimed to explore the perceptions and insights of community members and healthcare providers regarding the feasibility of implementing MITS in community settings. METHODS A qualitative exploratory study was conducted. A total of twenty one in-depth interviews were conducted with deceased infants' parents, elders of the family, religious leaders, community leaders, and funeral workers. Focus group discussions were conducted with health care providers (n = 14) in two peri-urban slum areas of Karachi, Pakistan. The duration of this study was from August to October 2020. Data was analyzed using thematic analysis and was coded and merged into categories forming eight major themes. RESULTS In general, participants viewed minimally invasive tissue sampling (MITS) as beneficial for improving child health, though some had concerns about disrespecting the deceased during sample collection. Misinformation, fear of needles, and medical procedures were major barriers to MITS implementation. To enhance acceptance, community and religious leaders suggested using religious rulings, obtaining parental consent, ensuring confidentiality, and increasing efforts of community engagement. Community healthcare providers, along with funeral workers, recommended providing community members with grief counseling to increase study participation. Besides concerns about sampling interfering with respect for the decease, community members also raised concerns about misinformation. Further, participants provided feedback on the design and appearance of the mobile van used to collect MITS samples from children under the age of five. CONCLUSION This study is critical for understanding the challenges associated with implementation of community-based MITS sampling in Pakistan. Integrating the use of a mobile van for sample collection, grief counseling along with community engagement sessions and advocacy will help address community-based misinformation and develop community trust.
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Affiliation(s)
- Nazia Ahsan
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fauzia Aman Malik
- Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Waliyah Mughis
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rawshan Jabeen
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shaheen Mehboob
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Raheel Allana
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Syeda Quratulain
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Saima Jamal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Christina R Paganelli
- Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, Seattle Washington, NC, USA
| | - Norman Goco
- Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, Seattle Washington, NC, USA
| | - Lindsay Parlberg
- Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, Seattle Washington, NC, USA
| | - Saad B Omer
- Yale Institute for Global Health, Yale University, New Haven, Connecticut, USA
| | - Abdul Momin Kazi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
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Otieno P, Akelo V, Khagayi S, Omore R, Akoth K, Nyanjom M, Ngere S, Ochola K, Maixenchs M, Kone A, Blevins J, Zielinski-Gutierrez E, Barr BAT. Acceptability of minimally invasive autopsy by community members and healthcare workers in Siaya and Kisumu counties, western Kenya, 2017-2018. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001319. [PMID: 37747874 PMCID: PMC10519588 DOI: 10.1371/journal.pgph.0001319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/03/2023] [Indexed: 09/27/2023]
Abstract
Worldwide, nearly six million children under the age of five (<5s) die annually, a substantial proportion of which are due to preventable and treatable diseases. Efforts to reduce child mortality indicators in the most affected regions are often undermined by a lack of accurate cause of death data. To generate timely and more accurate causes of death data for <5s, the Child Health and Mortality Prevention Surveillance (CHAMPS) Network established mortality surveillance in multiple countries using Minimally Invasive Tissue Sampling (MITS) in <5 deaths. Here we present acceptability of MITS by community members and healthcare workers in Siaya and Kisumu counties, western Kenya. From April 2017 to February 2018, we conducted 40 in-depth interviews and five focus group discussions with healthcare workers and community members, before and during CHAMPS implementation. Participants were purposively selected. Field observations to understand traditional death-related practices were also performed. Interviews were transcribed into Nvivo 11.0 for data organization and management. Analysis was guided by the grounded theory approach. Facilitators of acceptability were desire to understand why death occurred, timely performance of MITS procedures, potential for MITS results in improving clinical practice and specific assistance provided to families by the CHAMPS program. However, cultural and religious beliefs highlighted important challenges to acceptability, including CHAMPS teams recruiting after a child's death, rumours and myths, unmet expectations from families, and fear by healthcare workers that some families could use MITS results to sue for negligence. Increasing MITS uptake requires sustained strategies to strengthen the identified facilitators of acceptability and simultaneously address the barriers. MITS acceptance will contribute to better characterization of causes of death and support the development of improved interventions aimed at reducing <5 mortality.
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Affiliation(s)
- Peter Otieno
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Victor Akelo
- U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Sammy Khagayi
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Richard Omore
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Kelvin Akoth
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Maryanne Nyanjom
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Sara Ngere
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Ken Ochola
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Maria Maixenchs
- IS Global, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Ahoua Kone
- Emory University, Atlanta, Georgia, United States of America
| | - John Blevins
- Emory University, Atlanta, Georgia, United States of America
| | | | - Beth A. Tippett Barr
- U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
- Nyanja Health Research Institute, Salima, Malawi
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Lawrence S, Namusanya D, Mohamed SB, Hamuza A, Huwa C, Chasweka D, Kelley M, Molyneux S, Voskuijl W, Denno D, Desmond N. Primary motivations for and experiences with paediatric minimally invasive tissue sampling (MITS) participation in Malawi: a qualitative study. BMJ Open 2022; 12:e060061. [PMID: 35676022 PMCID: PMC9185590 DOI: 10.1136/bmjopen-2021-060061] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/20/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To understand family member consent decision-making influences and experiences in Malawi in order to inform future minimally invasive tissue sampling (MITS) studies. DESIGN Qualitative study. SETTING Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, which serves as the central referral hospital for southern Malawi and where MITS participants were recruited from. PARTICIPANTS Families of paediatric MITS participants. METHODS We conducted in-depth interviews with 16 families 6 weeks after the death of paediatric MITS participants. Data were analysed using a combination of thematic content and theoretical framework approaches to explain the findings. RESULTS Improved cause of death (CoD) ascertainment was the principal motivator for participation to protect remaining or future children. Community burial norms, religious doctrine and relationships with healthcare workers (HCWs) were not reported influencers among family members who consented to the procedure. Primary consenters varied, with single mothers more likely to consent independently or with only female family members present. Clear understanding of MITS procedures appeared limited 6 weeks postprocedure, but research was described as voluntary and preconsent information satisfactory for decision-making. Most families intended to share about MITS only with those involved in the consent process, for fear of rumours or judgement by extended family members and the wider community. CONCLUSION Among those who consented to MITS, decision-making was informed by individual and household experiences and beliefs, but not by religious affiliation or experiences with HCWs. While understanding of the MITS procedure was limited at the time of interview, families found informed consent information sufficient for decision-making. Future MITS studies should continue to explore information presentation best practices to facilitate informed consent during the immediate grieving period.
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Affiliation(s)
- Sarah Lawrence
- Pediatrics, University of Washington, Seattle, Washington, USA
| | - Dave Namusanya
- Behaviour and Health Research Group, Abertay University, Dundee, UK
- Behavior and Health Research Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Sumaya B Mohamed
- Global Health, University of Washington, Seattle, Washington, USA
| | - Andrew Hamuza
- Behaviour and Health Research Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Cornelius Huwa
- Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
| | - Dennis Chasweka
- Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
- KEMRI Wellcome Trust Research Programme, The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Maureen Kelley
- KEMRI Wellcome Trust Research Programme, The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- KEMRI Wellcome Trust Research Programme, The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Wieger Voskuijl
- KEMRI Wellcome Trust Research Programme, The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Pediatrics, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Donna Denno
- KEMRI Wellcome Trust Research Programme, The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Nicola Desmond
- Behaviour and Health Research Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Morrison LTR, Brown EG, Paganelli CR, Bhattarai S, Hailu R, Ntakirutimana G, Mbarushimana D, Subedi N, Goco N. Cost Evaluation of Minimally Invasive Tissue Sampling (MITS) Implementation in Low- and Middle-Income Countries. Clin Infect Dis 2021; 73:S401-S407. [PMID: 34910172 PMCID: PMC8672771 DOI: 10.1093/cid/ciab828] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Low- and middle-income countries (LMICs) face disproportionately high mortality rates, yet the causes of death in LMICs are not robustly understood, limiting the effectiveness of interventions to reduce mortality. Minimally invasive tissue sampling (MITS) is a standardized postmortem examination method that holds promise for use in LMICs, where other approaches for determining cause of death are too costly or unacceptable. This study documents the costs associated with implementing the MITS procedure in LMICs from the healthcare provider perspective and aims to inform resource allocation decisions by public health decisionmakers. Methods We surveyed 4 sites in LMICs across Sub-Saharan Africa and South Asia with experience conducting MITS. Using a bottom-up costing approach, we collected direct costs of resources (labor and materials) to conduct MITS and the pre-implementation costs required to initiate MITS. Results Initial investments range widely yet represent a substantial cost to implement MITS and are determined by the existing infrastructure and needs of a site. The costs to conduct a single case range between $609 and $1028 per case and are driven by labor, sample testing, and MITS supplies costs. Conclusions Variation in each site’s use of staff roles and testing protocols suggests sites conducting MITS may adapt use of resources based on available expertise, equipment, and surveillance objectives. This study is a first step toward necessary examinations of cost-effectiveness, which may provide insight into cost optimization and economic justification for the expansion of MITS.
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Affiliation(s)
| | | | | | - Suraj Bhattarai
- Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | - Rahell Hailu
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Djibril Mbarushimana
- Kigali University Teaching Hospital, Kigali, Rwanda.,University Teaching Hospital of Butare, Huye, Rwanda
| | - Nuwadatta Subedi
- Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | - Norman Goco
- RTI International, Durham, North Carolina, USA
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Tikmani SS, Saleem S, Moore JL, Reza S, Gowder G, Dhaded S, Yogesh Kumar S, Goudar SS, Kulkarni V, Kumar S, Acetuino A, Parlberg L, McClure EM, Goldenberg RL. Factors Associated With Parental Acceptance of Minimally Invasive Tissue Sampling to Identify the Causes of Stillbirth and Neonatal Death. Clin Infect Dis 2021; 73:S422-S429. [PMID: 34910175 PMCID: PMC8963158 DOI: 10.1093/cid/ciab829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Minimally invasive tissue sampling (MITS) is a noninvasive technique used to determine the cause of deaths. Very little is known about the factors that affect MITS acceptance or refusal. We present findings from a prospective study conducted in Southeast Asia on the reasons for accepting or refusing MITS. Methods This substudy was conducted in India and Pakistan to determine the acceptability of MITS in women who had a stillbirth or preterm live birth who later died. A formal questionnaire was used to gather observations during the consent for MITS, such as reasons for acceptance or refusal of MITS, as well as which family members were involved in the decision process. Results In Pakistan, the MITS acceptability forms were completed for 470 of 477 women (98.5%) with an eligible stillbirth for this substudy, and 334 of 337 (99.1%) with an eligible preterm neonatal death. In India, MITS acceptability forms were completed in 219 of 305 women (71.8%) with an eligible stillbirth and 260 of 264 (98.4%) with an eligible preterm neonatal death. In India, the most common reasons for MITS refusal for both stillbirths and preterm neonatal deaths were cultural concerns, while in Pakistan, the most common reason for MITS refusal was a potential delay in the funeral. The primary reason for accepting MITS was that the parents wanted to understand the cause of death. At both sites, fathers, mothers, and relatives, often in consultation, choose whether or not to accept MITS to determine the cause of death in stillbirths and preterm neonatal deaths. Conclusions MITS was more commonly accepted in India than in Pakistan. Cultural concerns in India and funeral delays in Pakistan were common reasons for refusal. Parents from both sites were curious to know the cause of stillbirths and preterm neonatal deaths. The father, mother, and relatives were key decision makers for consenting to or declining MITS.
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Affiliation(s)
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | | | - Sayyeda Reza
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | | | - Sangappa Dhaded
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, India
| | - S Yogesh Kumar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, India
| | | | | | | | | | | | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University School of Medicine, New York, New York, USA
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Rugwizangoga B, Niyibizi JB, Ndayisaba MC, Musoni E, Manirakiza F, Uwineza A, Tuyisenge L, Nyundo M, Hategekimana T, Ntakirutimana G. Exploring Perceptions and Acceptance of Minimally Invasive Tissue Sampling among Bereaved Relatives and Health-Care Professionals in Rwanda. J Multidiscip Healthc 2021; 14:3421-3427. [PMID: 34938081 PMCID: PMC8685444 DOI: 10.2147/jmdh.s340428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose In most low- and lower middle-income countries (LMICs), minimally invasive tissue sampling (MITS) is a relatively new procedure for identifying the cause of death (CoD). This study aimed to explore perceptions and acceptance of bereaved families and health-care professionals regarding MITS in the context of MITS initiation in Rwanda as an alternative to clinical autopsy. Methods This was a qualitative phenomenological study with thematic analysis. Participants were bereaved relatives (individual interviews) and health-care professionals (focus-group discussions) involved in MITS implementation. It was conducted in the largest referral and teaching hospital in Rwanda. Results Motivators of MITS acceptance included eagerness to know the CoD, noninvasiveness of MITS, trust in medics, and the fact that it was free. Barriers to consent to MITS included inadequate explanations from health-care professionals, high socioeconomic status, lack of power to make decisions, and lack of trust in medics. Health-care professionals perceived both conventional autopsy and MITS as gold-standard procedures in CoD determination. They recommended including MITS among hospital services and commended the post-MITS multidisciplinary discussion panel in CoD determination. They pointed out that there might be reticence in approaching bereaved relatives to obtain consent for MITS. Both groups of participants highlighted the issue of delay in releasing MITS results. Conclusion Both health-care professionals and bereaved relatives appreciate that MITS is an acceptable procedure to include in routine hospital services. Dealing with barriers met by either group is to be considered in the eventual next phases of MITS implementation in Rwanda and similar sociocultural contexts.
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Affiliation(s)
- Belson Rugwizangoga
- Department of Clinical Biology, University of Rwanda, Kigali, Rwanda
- Department of Pathology, University Teaching Hospital of Kigali, Kigali, Rwanda
- Correspondence: Belson Rugwizangoga PO Box 655, Kigali, Rwanda, Tel +250-78-854-6597 Email ;
| | | | | | - Emile Musoni
- Department of Clinical Biology, University of Rwanda, Kigali, Rwanda
- Department of Pathology, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Felix Manirakiza
- Department of Clinical Biology, University of Rwanda, Kigali, Rwanda
- Department of Pathology, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Annette Uwineza
- Department of Clinical Biology, University of Rwanda, Kigali, Rwanda
- Department of Pathology, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Lisine Tuyisenge
- Department of Pediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Martin Nyundo
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
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Tanko NM, Bakytkaly I, Issanov A, Poddighe D, Terzic M. Validating a Minimally Invasive Tissue Sampling (MITS) Method in Determining Cause of Death in Stillbirths and Neonates. CHILDREN 2021; 8:children8121095. [PMID: 34943291 PMCID: PMC8700338 DOI: 10.3390/children8121095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022]
Abstract
Complete diagnostic autopsy (CDA) remains the gold standard and a valuable technique for determining cause of death. It is a source of health statistics that can be used to measure health care services’ quality, unraveling important information on disease processes, particularly in emerging and unknown diseases. It can also be a vital tool for medical education and biomedical research. However, autopsy rates have been declining globally. There is an urgent need to develop and validate alternative methods in different settings to provide reliable information on cause of death. In this study, we aimed to determine cause of death (KazCoDe) in neonates and infants using minimally invasive tissue sampling (MITS), and to compare these results with those of CDA. We conducted MITS and CDA sequentially on 24 deceased children at the Pathological Bureau of the Akimat of the city of Nur-Sultan. Clinical data of the study subjects were extracted from their clinical records. During both procedures, brain, liver and lung tissues were collected for pathological diagnosis. Fifteen (62.5%) and nine (37.5%) were stillbirths and neonates, respectively. Eight (33.3%) were females and 16 (66.7%) were males. MITS diagnosis of cause of death was concordant with CDA diagnosis in 83.3% out of the 24 cases when considering the immediate and underlying causes of death and reviewing all the clinical and laboratory test results as part of the diagnostic evaluation to arrive at a cause of death (ICD-PM). We concluded that MITS is a valuable and reliable method for cause of death diagnosis in stillbirths and neonates, which can contribute vital mortality statistics in children in the absence of CDA.
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Affiliation(s)
- Naanlep Matthew Tanko
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Nur Sultan 010000, Kazakhstan;
- Clinical Academic Department of Laboratory Medicine, Pathology and Genetics, University Medical Center, Nur Sultan 010000, Kazakhstan;
- Correspondence: ; Tel.: +7-775-658-6325
| | - Ibrayimov Bakytkaly
- Clinical Academic Department of Laboratory Medicine, Pathology and Genetics, University Medical Center, Nur Sultan 010000, Kazakhstan;
| | - Alpamys Issanov
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Nur Sultan 010000, Kazakhstan;
| | - Dimitri Poddighe
- Department of Medicine, School of Medicine, Nazarbayev University, Nur Sultan 010000, Kazakhstan; (D.P.); (M.T.)
- Clinical Academic Department of Pediatrics, University Medical Center, Nur Sultan 010000, Kazakhstan
| | - Milan Terzic
- Department of Medicine, School of Medicine, Nazarbayev University, Nur Sultan 010000, Kazakhstan; (D.P.); (M.T.)
- Clinical Academic Department of Women’s Health, University Medical Center, Nur Sultan 010000, Kazakhstan
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Das MK, Arora NK, Debata P, Chellani H, Rasaily R, Gaikwad H, Meena KR, Kaur G, Malik P, Joshi S, Kumari M. Why parents agree or disagree for minimally invasive tissue sampling (MITS) to identify causes of death in under-five children and stillbirth in North India: a qualitative study. BMC Pediatr 2021; 21:513. [PMID: 34784903 PMCID: PMC8597286 DOI: 10.1186/s12887-021-02993-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/04/2021] [Indexed: 12/01/2022] Open
Abstract
Background Information on exact causes of death and stillbirth are limited in low and middle income countries. Minimally invasive tissue sampling (MITS) is increasingly practiced in place of autopsy across several settings. A formative research documented the experiences of counselling and consenting for MITS in north India. Methods This exploratory qualitative study was conducted at a tertiary care hospital in Delhi. During the early implementation of MITS, observations of the counselling and consenting process (n = 13) for under-five child death and stillbirths were conducted. In-depth interviews with MITS team members (n = 3) were also conducted. Observation and interview data were transcribed and inductively analysed using thematic content analysis to identify emerging themes and codes. Results The MITS team participated in daily ward rounds for familiarisation with parents/families. Following death declaration the counselling was done in counselling corner of the ward or adjacent corridor. Mostly the counselling was targeted at the father and family members present, using verbal explanation and the consent document in local language. The key concerns raised by parents/family were possible disfigurement, time needed and possible benefits. Most of the parents consulted family members before consent. Among those who consented, desire for next pregnancy, previous pregnancy or neonatal loss and participation of treating senior doctor were the key factors. The negative experience of hospital care, poor comprehension and distance from residence were the factors for consent refusal. Lesser number of parents of deceased children consented for MITS compared to the neonates and stillbirths. Conclusions The initial experiences of obtaining consent for MITS were encouraging. Consent for MITS may be improved with active involvement of the treating doctors and nurses, better bereavement support, private counselling area along with improvement in quality of care and communication during hospitalisation. Special efforts and refinement in counselling are needed to improve consent for MITS in older children. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02993-6. Information about exact cause of death and stillbirth are essential for appropriate care of children and pregnant women. Autopsy assists in establishing exact cause of death, but not preferred by the parents/families. Minimally invasive tissue sampling (MITS) is a suitable alternate to autopsy for establishing causes of death and stillbirth. A pilot project on MITS was initiated at a tertiary care hospital in north India (New Delhi). An exploratory formative research was conducted to document the experiences of counselling and consenting for MITS. Under this study, observation of the counselling and consenting process for conduct of MITS in under-five children (including neonates) and stillbirths were done. Additionally, in-depth interviews with MITS team members were also conducted. Counselling for MITS was done in one corner of the ward or adjacent corridor and mostly targeted at the father and family members present. Counselling was primarily verbal explanation in local language. The key concerns from parents/family were disfigurement, time needed and possible benefits. Most of the parents consulted family members before decision. Benefit during next pregnancy, past previous pregnancy or neonatal loss and senior treating doctor’s involvement were key factors for consent. Poor quality of care and comprehension were the reasons for refusal.
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Affiliation(s)
| | | | - Pradeep Debata
- Department of Pediatrics, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - Harish Chellani
- Department of Pediatrics, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - Reeta Rasaily
- Division of Division of Reproductive Biology Maternal and Child Health, Indian Council of Medical Research, New Delhi, 110029, India
| | - Harsha Gaikwad
- Department of Obstetrics and Gynaecology, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - K R Meena
- Department of Pediatrics, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - Gurkirat Kaur
- The INCLEN Trust International, New Delhi, 110020, India
| | | | - Shipra Joshi
- The INCLEN Trust International, New Delhi, 110020, India
| | - Mahisha Kumari
- The INCLEN Trust International, New Delhi, 110020, India
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9
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Lawrence S, Namusanya D, Hamuza A, Huwa C, Chasweka D, Kelley M, Molyneux S, Voskuijl W, Denno DM, Desmond N. Hypothetical acceptability of hospital-based post-mortem pediatric minimally invasive tissue sampling in Malawi: The role of complex social relationships. PLoS One 2021; 16:e0246369. [PMID: 33539411 PMCID: PMC7861399 DOI: 10.1371/journal.pone.0246369] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Child mortality rates remain unacceptably high in low-resource settings. Cause of death (CoD) is often unknown. Minimally invasive tissue sampling (MITS)-using biopsy needles to obtain post-mortem samples-for histopathological and microbiologic investigation is increasingly being promoted to improve child and adult CoD attribution. "MITS in Malawi" is a sub-study of the Childhood Acute Illness & Nutrition (CHAIN) Network, which aims to identify biological and socioeconomic mortality risk factors among young children hospitalized for acute illness or undernutrition. MITS in Malawi employs standard MITS and a novel post-mortem endoscopic intestinal sampling approach to better understand CoD among children with acute illness and/or malnutrition who die during hospitalization. AIM To understand factors that may impact MITS acceptability and inform introduction of the procedure to ascertain CoD among children with acute illness or malnutrition who die during hospitalization in Malawi. METHODS We conducted eight focus group discussions with key hospital staff and community members (religious leaders and parents of children under 5) to explore attitudes towards MITS and inform consent processes prior to commencing the MITS in Malawi study. We used thematic content analysis drawing on a conceptual framework developed from emergent themes and MITS acceptability literature. RESULTS Feelings of power over decision-making within the hospital and household, trust in health systems, and open and respectful health worker communication with parents were important dimensions of MITS acceptability. Other facilitating factors included the potential for MITS to add CoD information to aid sense-making of death and contribute to medical knowledge and new interventions. Potential barriers to acceptability included fears of organ and blood harvesting, disfigurement to the body, and disruption to transportation and burial plans. CONCLUSION Social relationships and power dynamics within healthcare systems and households are a critical component of MITS acceptability, especially given the sensitivity of death and autopsy.
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Affiliation(s)
- Sarah Lawrence
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Dave Namusanya
- Behaviour and Health Research Group, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
| | - Andrew Hamuza
- Behaviour and Health Research Group, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
| | - Cornelius Huwa
- Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi
- The Childhood Acute Illness & Nutrition (CHAIN) Network, C/o KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dennis Chasweka
- Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi
- The Childhood Acute Illness & Nutrition (CHAIN) Network, C/o KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Maureen Kelley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, C/o KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Wellcome Centre for Ethics & Humanities and Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Sassy Molyneux
- The Childhood Acute Illness & Nutrition (CHAIN) Network, C/o KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Wellcome Centre for Ethics & Humanities and Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Wieger Voskuijl
- Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi
- The Childhood Acute Illness & Nutrition (CHAIN) Network, C/o KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Amsterdam Centre for Global Child Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Donna M. Denno
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, C/o KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Nicola Desmond
- Behaviour and Health Research Group, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Das MK, Arora NK, Rasaily R, Kaur G, Malik P, Kumari M, Joshi S, Chellani H, Gaekwad H, Debata P, Meena KR. Perceptions of the healthcare providers regarding acceptability and conduct of minimal invasive tissue sampling (MITS) to identify the cause of death in under-five deaths and stillbirths in North India: a qualitative study. BMC Health Serv Res 2020; 20:833. [PMID: 32887603 PMCID: PMC7472696 DOI: 10.1186/s12913-020-05693-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 08/31/2020] [Indexed: 11/12/2022] Open
Abstract
Background India contributes the highest share of under-five and neonatal deaths and stillbirths globally. Diagnostic autopsy, although useful for cause of death identification, have limited acceptance. Minimally invasive tissue sampling (MITS) is an alternative to autopsy for identification of the cause of death (CoD). A formative research linked to pilot MITS implementation was conducted to document the perceptions and attitudes of the healthcare professionals and the barriers for implementation. Methods This exploratory qualitative study conducted at a tertiary care hospital in New Delhi, India included the hospital staffs. In-depth interviews were conducted with the doctors, nurses and support staffs from pediatrics, neonatology, obstetrics and forensic medicine departments. Inductive data analysis was done to identify the emerging themes and codes. Results A total of 26 interviews (doctors, n = 10; nurses, n = 9 and support staffs, n = 7) were conducted. Almost all professional and support staffs were positive about the MITS and its advantage for CoD identification including co-existing and underlying illnesses. Some opined conduct of MITS for the cases without clear diagnosis. All participants perceived that MITS would be acceptable for parents due to the non-disfigurement and preferred by those who had unexplained child deaths or stillbirths in past. The key factors for MITS acceptance were appropriate communication, trust building, involvement of senior doctors, and engagement of the counselor prior to deaths and training of the personnel. For implementation and sustenance of MITS, involvement of the institute authority and government stakeholders would be essential. Conclusions MITS was acceptable for the doctors, nurses and support staffs and critical for better identification of the causes of death and stillbirths. The key facilitating factors and challenges for implementing MITS at the hospital in Indian context were identified. It emphasized on appropriate skill building, counseling, system organization and buy-in from institution and health authorities for sustenance of MITS.
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Affiliation(s)
| | | | - Reeta Rasaily
- Division of Reproductive Biology Maternal and Child Health, Indian Council of Medical Research, New Delhi, 110029, India
| | - Gurkirat Kaur
- The INCLEN Trust International, New Delhi, 110020, India
| | | | - Mahisha Kumari
- The INCLEN Trust International, New Delhi, 110020, India
| | - Shipra Joshi
- The INCLEN Trust International, New Delhi, 110020, India
| | - Harish Chellani
- Department of Pediatrics, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - Harsha Gaekwad
- Department of Obstetrics and Gynaecology, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - Pradeep Debata
- Department of Pediatrics, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - K R Meena
- Department of Pediatrics, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
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A comparison of MITS counseling and informed consent processes in Pakistan, India, Bangladesh, Kenya, and Ethiopia. Reprod Health 2020; 17:120. [PMID: 32787868 PMCID: PMC7425595 DOI: 10.1186/s12978-020-00969-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/30/2020] [Indexed: 11/13/2022] Open
Abstract
Globally, more than 5 million stillbirths and neonatal deaths occur annually. For many, the cause of death (CoD) is unknown. Minimally invasive tissue sampling (MITS) has been increasingly used in postmortem examinations for ascertaining the CoD in stillbirths and neonates. Our study compared the counseling and consent methods used in MITS projects in five countries in Africa and south Asia. Key informant interviews were conducted with researchers to describe the characteristics and backgrounds of counselors, the environment and timing of consent and perceived facilitators and barriers encountered during the consent process. Counselors at all sites had backgrounds in social science, psychology and counseling or clinical expertise in obstetrics/gynecology or pediatrics. All counsellors received training about techniques for building rapport and offering emotional support to families; training duration and methods differed across sites. Counselling environments varied significantly; some sites allocated a separate room, others counselled families at the bedside or nursing stations. All counsellors had a central role in explaining the MITS procedure to families in their local languages. Most sites did not use visual aids during the process, relying solely on verbal descriptions. In most sites, parents were approached within one hour of death. The time needed for decision making by families varied from a few minutes to 24 h. In most sites, extended family took part in the decision making. Because many parents wanted burial as soon as possible, counsellors ensured that MITS would be conducted promptly after receiving consent. Barriers to consent included decreased comprehension of information due to the emotional and psychological impact of grief. Moreover, having more family members engaged in decision-making increased the complexity of counselling and achieving consensus to consent for the procedure. While each site adapted their approach to fit the context, consistencies and similarities across sites were observed.
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