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Bakare AA, Salako J, King C, Olojede OE, Bakare D, Olasupo O, Burgess R, McCollum ED, Colbourn T, Falade AG, Molsted-Alvesson H, Graham HR. 'Let him die in peace': understanding caregiver's refusal of medical oxygen treatment for children in Nigeria. BMJ Glob Health 2024; 9:e014902. [PMID: 38760025 PMCID: PMC11103205 DOI: 10.1136/bmjgh-2023-014902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/16/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION Efforts to improve oxygen access have focused mainly on the supply side, but it is important to understand demand barriers, such as oxygen refusal among caregivers. We therefore aimed to understand caregiver, community and healthcare provider (HCP) perspectives and experiences of medical oxygen treatments and how these shape oxygen acceptance among caregivers of sick children in Lagos and Jigawa states, which are two contrasting settings in Nigeria. METHODS Between April 2022 and January 2023, we conducted an exploratory qualitative study using reflexive thematic analysis, involving semistructured interviews with caregivers (Jigawa=18 and Lagos=7), HCPs (Jigawa=7 and Lagos=6) and community group discussions (Jigawa=4 and Lagos=5). We used an inductive-deductive approach to identify codes and themes through an iterative process using the theoretical framework of acceptability and the normalisation process theory as the analytic lens. RESULTS Medical oxygen prescription was associated with tension, characterised by fear of death, hopelessness about a child's survival and financial distress. These were driven by community narratives around oxygen, past negative experiences and contextual differences between both settings. Caregiver acceptance of medical oxygen was a sense-making process from apprehension and scepticism about their child's survival chances to positioning prescribed oxygen as an 'appropriate' or 'needed' intervention. Achieving this transition occurred through various means, such as trust in HCPs, a perceived sense of urgency for care, previous positive experience of oxygen use and a symbolic perception of oxygen as a technology. Misconceptions and pervasive negative narratives were acknowledged in Jigawa, while in Lagos, the cost was a major reason for oxygen refusal. CONCLUSION Non-acceptance of medical oxygen treatment for sick children is modifiable in the Nigerian context, with the root causes of refusal being contextually specific. Therefore, a one-size-fits-all policy is unlikely to work. Financial constraints and community attitudes should be addressed in addition to improving client-provider interactions.
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Affiliation(s)
- Ayobami Adebayo Bakare
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | - Julius Salako
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Omotayo E Olojede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Damola Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Olabisi Olasupo
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Rochelle Burgess
- Institute for Global Health, University College London, London, UK
| | - Eric D McCollum
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan College of Medicine, Ibadan, Nigeria
| | | | - Hamish R Graham
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Centre for International Child Health, Murdoch Children's Research Institute, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Victoria, Australia
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Wilkes C, Subhi R, Graham HR, Duke T. Continuous Positive Airway Pressure (CPAP) for severe pneumonia in low- and middle-income countries: A systematic review of contextual factors. J Glob Health 2022; 12:10012. [PMID: 36269192 PMCID: PMC9586144 DOI: 10.7189/jogh.12.10012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Continuous positive airway pressure (CPAP) may have a role in reducing the high mortality in children less than 5 years with World Health Organization (WHO) severe pneumonia. More evidence is needed to understand important contextual factors that impact on implementation, effectiveness, and safety in low resource settings. Methods We conducted a systematic review of Medline, Embase and Pubmed (January 2000 to August 2020) with terms of "pneumonia", "CPAP" and "child". We included studies that provided original clinical or non-clinical data on the use of CPAP in children (28 days-4 years) with pneumonia in low- or middle-income countries. We used standardised tools to assess study quality, and grade levels of evidence for clinical conclusions. Results are presented as a narrative synthesis describing context, intervention, and population alongside outcome data. Results Of 902 identified unique references, 23 articles met inclusion criteria, including 6 randomised controlled trials, one cluster cross over trial, 12 observational studies, 3 case reports and 1 cost-effectiveness analysis. There was significant heterogeneity in patient population, with wide range in mortality among participants in different studies (0%-55%). Reporting of contextual factors, including staffing, costs, and details of supportive care was patchy and non-standardised. Current evidence suggests that CPAP has a role in the management of infants with bronchiolitis and as escalation therapy for children with pneumonia failing standard-flow oxygen therapy. However, CPAP must be implemented with appropriate staffing (including doctor oversight), intensive monitoring and supportive care, and technician and infrastructure capacity. We provide practical guidance and recommendations based on available evidence and published expert opinion, for the adoption of CPAP into routine care in low resource settings and for reporting of future CPAP studies. Conclusions CPAP is a safe intervention in settings that can provide intensive monitoring and supportive care, and the strongest evidence for a benefit of CPAP is in infants (aged less than 1 year) with bronchiolitis. The available published evidence and clinical experience can be used to help facilities assess appropriateness of implementing CPAP, guide health workers in refining selection of patients most likely to benefit from it, and provide a framework for components of safe and effective CPAP therapy. Protocol registration PROSPERO registration: CRD42020210597.
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Affiliation(s)
- Chris Wilkes
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Rami Subhi
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Hamish R Graham
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Trevor Duke
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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Need for routine pulse oximetry and oxygen delivery systems in low-income and middle-income countries. Lancet Glob Health 2022; 10:e301-e302. [DOI: 10.1016/s2214-109x(22)00025-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 01/27/2023]
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King C, Banda M, Bar-Zeev N, Beard J, French N, Makwenda C, McCollum ED, Mdala M, Bin Nisar Y, Phiri T, Ahmad Qazi S, Colbourn T. Care-seeking patterns amongst suspected paediatric pneumonia deaths in rural Malawi. Gates Open Res 2021; 4:178. [PMID: 33537557 PMCID: PMC7835598 DOI: 10.12688/gatesopenres.13208.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 02/03/2023] Open
Abstract
Background: Pneumonia remains a leading cause of paediatric deaths. To understand contextual challenges in care pathways, we explored patterns in care-seeking amongst children who died of pneumonia in Malawi. Methods: We conducted a mixed-methods analysis of verbal autopsies (VA) amongst deaths in children aged 1-59 months from 10/2011 to 06/2016 in Mchinji district, Malawi. Suspected pneumonia deaths were defined as: 1. caregiver reported cough and fast breathing in the 2-weeks prior to death; or, 2. the caregiver specifically stated the child died of pneumonia; or 3. cause of death assigned as ‘acute respiratory infection’ using InterVA-4. Data were extracted from free-text narratives based on domains in the ‘Pathways to Survival’ framework, and described using proportions. Qualitative analysis used a framework approach, with pre-specified themes. Results: We analysed 171 suspected pneumonia deaths. In total, 86% of children were taken to a healthcare facility during their final illness episode, and 44% sought care more than once. Of children who went to hospital (n=119), 70% were admitted, and 25% received oxygen. Half of the children died within a healthcare setting (43% hospital, 5% health centre and 2% private clinics), 64 (37%) at home, and 22 (13%) in transit. Challenges in delayed care, transport and quality of care (including oxygen), were reported. Conclusions: Healthcare was frequently sought for children who died of suspected pneumonia, however several missed opportunities for care were seen. Sustained investment in timely appropriate care seeking, quick transportation to hospital and improved case management at all levels of the system is needed.
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Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
| | - Masford Banda
- Parent and Child Health Initiative, Lilongwe, Malawi.,Centres for Disease Control and Prevention, Lilongwe, Malawi
| | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - James Beard
- Institute for Global Health, University College London, London, UK
| | - Neil French
- Institute of Infection, University of Liverpool, Liverpool, UK
| | | | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Department of Pediatrics, Johns Hopkins Medicine, Baltimore, USA
| | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
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King C, Banda M, Bar-Zeev N, Beard J, French N, Makwenda C, McCollum ED, Mdala M, Bin Nisar Y, Phiri T, Ahmad Qazi S, Colbourn T. Care-seeking patterns amongst suspected paediatric pneumonia deaths in rural Malawi. Gates Open Res 2021; 4:178. [PMID: 33537557 DOI: 10.12688/gatesopenres.13208.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 02/03/2023] Open
Abstract
Background: Pneumonia remains a leading cause of paediatric deaths. To understand contextual challenges in care pathways, we explored patterns in care-seeking amongst children who died of pneumonia in Malawi. Methods: We conducted a mixed-methods analysis of verbal autopsies (VA) amongst deaths in children aged 1-59 months from 10/2011 to 06/2016 in Mchinji district, Malawi. Suspected pneumonia deaths were defined as: 1. caregiver reported cough and fast breathing in the 2-weeks prior to death; or, 2. the caregiver specifically stated the child died of pneumonia; or 3. cause of death assigned as 'acute respiratory infection' using InterVA-4. Data were extracted from free-text narratives based on domains in the 'Pathways to Survival' framework, and described using proportions. Qualitative analysis used a framework approach, with pre-specified themes. Results: We analysed 171 suspected pneumonia deaths. In total, 86% of children were taken to a healthcare facility during their final illness episode, and 44% sought care more than once. Of children who went to hospital (n=119), 70% were admitted, and 25% received oxygen. Half of the children died within a healthcare setting (43% hospital, 5% health centre and 2% private clinics), 64 (37%) at home, and 22 (13%) in transit. Challenges in delayed care, transport and quality of care (including oxygen), were reported. Conclusions: Healthcare was frequently sought for children who died of suspected pneumonia, however several missed opportunities for care were seen. Sustained investment in timely appropriate care seeking, quick transportation to hospital and improved case management at all levels of the system is needed.
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Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
| | - Masford Banda
- Parent and Child Health Initiative, Lilongwe, Malawi.,Centres for Disease Control and Prevention, Lilongwe, Malawi
| | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - James Beard
- Institute for Global Health, University College London, London, UK
| | - Neil French
- Institute of Infection, University of Liverpool, Liverpool, UK
| | | | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Department of Pediatrics, Johns Hopkins Medicine, Baltimore, USA
| | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
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