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      Barriers and enablers of implementing bubble Continuous Positive Airway Pressure (CPAP): Perspectives of health professionals in Malawi

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          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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          Most cited references29

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          Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework

          Background The effectiveness of complex interventions, as well as their success in reaching relevant populations, is critically influenced by their implementation in a given context. Current conceptual frameworks often fail to address context and implementation in an integrated way and, where addressed, they tend to focus on organisational context and are mostly concerned with specific health fields. Our objective was to develop a framework to facilitate the structured and comprehensive conceptualisation and assessment of context and implementation of complex interventions. Methods The Context and Implementation of Complex Interventions (CICI) framework was developed in an iterative manner and underwent extensive application. An initial framework based on a scoping review was tested in rapid assessments, revealing inconsistencies with respect to the underlying concepts. Thus, pragmatic utility concept analysis was undertaken to advance the concepts of context and implementation. Based on these findings, the framework was revised and applied in several systematic reviews, one health technology assessment (HTA) and one applicability assessment of very different complex interventions. Lessons learnt from these applications and from peer review were incorporated, resulting in the CICI framework. Results The CICI framework comprises three dimensions—context, implementation and setting—which interact with one another and with the intervention dimension. Context comprises seven domains (i.e., geographical, epidemiological, socio-cultural, socio-economic, ethical, legal, political); implementation consists of five domains (i.e., implementation theory, process, strategies, agents and outcomes); setting refers to the specific physical location, in which the intervention is put into practise. The intervention and the way it is implemented in a given setting and context can occur on a micro, meso and macro level. Tools to operationalise the framework comprise a checklist, data extraction tools for qualitative and quantitative reviews and a consultation guide for applicability assessments. Conclusions The CICI framework addresses and graphically presents context, implementation and setting in an integrated way. It aims at simplifying and structuring complexity in order to advance our understanding of whether and how interventions work. The framework can be applied in systematic reviews and HTA as well as primary research and facilitate communication among teams of researchers and with various stakeholders. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0552-5) contains supplementary material, which is available to authorized users.
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            Respiratory distress of the term newborn infant.

            Respiratory distress is recognised as any signs of breathing difficulties in neonates. In the early neonatal period respiratory distress is common, occurring in up to 7% of newborn infants, resulting in significant numbers of term-born infants being admitted to neonatal units. Many risk factors are involved; the increasing number of term infants delivered by elective caesarean section has also increased the incidence. Additionally the risk decreases with each advancing week of gestation. At 37 weeks, the chances are three times greater than at 39-40 weeks gestation. Multiple conditions can present with features of respiratory distress. Common causes in term newborn infants include transient tachypnoea of the newborn, respiratory distress syndrome, pneumonia, meconium aspiration syndrome, persistent pulmonary hypertension of the neonate and pneumothorax. Early recognition of respiratory distress and initiation of appropriate treatment is important to ensure optimal outcomes. This review will discuss these common causes of respiratory distress in term-born infants.
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              Collaboration between hospital physicians and nurses: an integrated literature review.

              Ineffective physician-nurse collaboration has been shown to cause work dissatisfaction among physicians and nurses and compromised the quality of patient care.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: InvestigationRole: Writing – original draftRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: Funding acquisitionRole: SupervisionRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: SupervisionRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                13 February 2020
                2020
                : 15
                : 2
                : e0228915
                Affiliations
                [1 ] Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
                [2 ] College of Medicine, IMCHA Project, Blantyre, Malawi
                [3 ] Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
                [4 ] Institute for Global Health, NEST 360°, Rice University, Houston, Texas, United States of America
                [5 ] Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
                [6 ] Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
                [7 ] Center of Bioethics for Eastern & Southern Africa (CEBESA), Blantyre, Malawi
                [8 ] Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
                [9 ] Department of Pediatrics, BC Children’s Hospital and University of British Columbia, Vancouver, Canada
                Liverpool School of Tropical Medicine, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-3572-3810
                http://orcid.org/0000-0001-5846-3014
                http://orcid.org/0000-0001-8541-1324
                http://orcid.org/0000-0002-7633-8812
                http://orcid.org/0000-0002-6324-0779
                Article
                PONE-D-19-22572
                10.1371/journal.pone.0228915
                7018070
                32053649
                f3ff594c-7033-4472-9d01-ae1669932ff2
                © 2020 Nyondo-Mipando et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 9 August 2019
                : 27 January 2020
                Page count
                Figures: 0, Tables: 1, Pages: 16
                Funding
                Funded by: Canadian International Development Research Centre (IDRC), Global Affairs Canada (GAC) and the Canadian Institutes for Health Research (CIHR)
                Award ID: 108030
                Award Recipient :
                ALNM, KK, QD and DG were funded by the Canadian International Development Research Centre (IDRC), Global Affairs Canada (GAC) and the Canadian Institutes for Health Research (CIHR). Project ID is 108030. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                People and Places
                Population Groupings
                Professions
                Medical Personnel
                Nurses
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Nurses
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Allied Health Care Professionals
                Biology and Life Sciences
                Developmental Biology
                Neonates
                Medicine and Health Sciences
                Pediatrics
                Neonatology
                Neonatal Care
                Medicine and Health Sciences
                Health Care
                Neonatal Care
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                People and Places
                Geographical Locations
                Africa
                Malawi
                Medicine and Health Sciences
                Pediatrics
                Engineering and Technology
                Equipment
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                All relevant data are within the manuscript and its Supporting Information files.

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