Neonatal care and community-level treatment seeking for possible severe bacterial infection (PSBI) in Amhara, Ethiopia

Improving possible serious bacterial infection (PSBI) management in young infants when referral is not feasible: lessons from embedded implementation research in Ethiopia and Kenya

BACKGROUND

Sepsis is a leading cause of neonatal mortality, despite the availability of effective treatment of possible serious bacterial illness (PSBI), including when referral to a hospital is not feasible. Gaps in access and delivery worsened during COVID-19. We conducted embedded implementation research in Ethiopia and Kenya aimed at mitigating the impact of COVID-19 and addressing various implementation challenges to improve PSBI management.

METHODS

The implementation research projects were implemented at the subnational level in Ethiopia and Kenya between November 2020-June 2022 (Ethiopia) and December 2020-August 2022 (Kenya). Guided by the implementation research frameworks, both projects conducted mixed formative quantitative and exploratory research from April to May 2021, followed by summative evaluations conducted between June and July 2022. Frameworks encompassed Consolidated Framework for Implementation Research (CFIR), Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM), as well as health systems framework that incorporates cascades of care and World Health Organization Health Systems Building Blocks. Results were synthesized across the projects through document review and sharing cross-project measures and strategies through a project community of practice.

RESULTS

Despite differences in settings across the projects, cross-cutting facilitators included community health worker program and support, and existence of guidelines for PSBI management at primary care levels. Barriers included community attitudes towards seeking care for sick newborns, COVID-19 risks and fear, and lack of health care worker competence. Country-specific contextual barriers included supply chain issues, civil conflict (Ethiopia), and labor strikes (Kenya). Strategies chosen to mitigate barriers and support implementation and sustainability in both settings included leveraging community health workers to address resistance to care-seeking, health workers' training, COVID-19 infection prevention measures, stakeholder engagement, and advocacy to integrate PSBI management into existing programs, policies, and training. Other strategies addressing emerging project-specific barriers, included improving follow-up through a community health desk and PSBI mobile app (Kenya) and supply chain strengthening (Ethiopia). Both projects improved PSBI management coverage, increased adoption and uptake, and informed national policy changes supporting potential for sustainability.

CONCLUSIONS

Pragmatic embedded implementation research effectively supports the identification of barriers and mapping to strategies designed to increase effective coverage of PSBI management when referral is not feasible during the COVID-19 pandemic. Despite differences in context, cross-cutting strategies identified could inform broader scale-up in the region, including during future health system shocks.

Predictors of effective kangaroo mother care, exclusive breastfeeding, and skin-to-skin contact among low birthweight newborns in Amhara, Ethiopia

Background

Globally, 20% of all newborns are born with low birth weight (LBW). There is, therefore, an urgent need to expedite the delivery of high-impact, evidenced-based, and low-cost interventions such as kangaroo mother care (KMC (defined as continuous skin-to-skin care) and exclusive breastfeeding for this vulnerable group.

Methods

A multinational World Health Organization (WHO)-supported consortium created and tested the impact of locally-specific and globally-informed phases of KMC care on KMC uptake/scale-up across multiple sites. Here we report on the study of KMC predictors that is nested within Amhara's KMC implementation trial in Amhara, Ethiopia. We used multivariate logistic regression phases to identify diverse predictors of KMC, skin-to-skin contact, and exclusive breastfeeding at hospital discharge and day 28 of life.

Results

We analysed data from 860 LBW newborns. At day 28, implementation period (adjusted odds ratio (aOR) = 3.2-5.0), hospital facility (aOR = 3.0-4.6), and having multiple births (aOR = 0.31) were the strongest predictors of effective KMC. Meanwhile, previous death of a newborn, type of health facility where delivery occurred, and previous LBW delivery were predictors of effective KMC at both time points. No single factor predicted KMC, skin-to-skin contact, and exclusive breastfeeding at all time points and across all implementation periods. Having multiple births was a negative predictor for skin-to-skin contact, while the implementation period and having older fathers (>29 years) were strong positive predictors for exclusive breastfeeding at both discharge and day 28. Mothers with a previous history of neonatal death and current skin-to-skin-care uptake strongly predicted exclusive breastfeeding uptake at both time points. At discharge, however, having a history of preterm birth and neonatal death strongly predicted exclusive breastfeeding uptake, while multiple current births, current very LBW newborns, and the use of standard binders decreased the likelihood of exclusive breastfeeding.

Conclusions

To achieve the effective KMC coverage target of ≥80% in Ethiopia, KMC scale-up phases may have to consider the key predictors of KMC, EBF, and SSC to effectively target beneficiaries.

"We want to know the cause of neonate's death to prevent similar incident in the future …": A Formative Study to Introduce Minimally Invasive Tissue Sampling Procedure at Community Level in Butajira

Background

Diagnostic autopsy has been in use for long to determine the cause of death. Since recently however 'Minimally Invasive Tissue Sampling' (MITS) is introduced to determine definitive cause of neonatal death. This study describes locally established facilitators to introduce MITS procedures to determine cause of neonatal death in Ethiopia.

Methods

Exploratory study was conducted in Butajira community where twenty-two key informants representing community opinion leaders' health care workers, five in depth interviews with parents who recently lost neonates and eight FGDs with community members were completed to generate evidences in line with the research question. Interviews and discussions were audio recorded, transcribed verbatim and analysed facilitated by open-code software. Thematic analysis was applied to identify and interpret patterns of the evidences.

Results

In Butajira, ANC and delivery in health facilities was found to have improved over the years. Yet, child death remains an outstanding problem. While different factors were identified to cause the death of a child, relatively few participants choose to accept newborn death as a natural occurrence or will of the creator. Majority of the study participants expressed interest to know definitive cause of death using MITS. Yet, awareness about MITS and how it works was unanimously desired. It was found that husbands and wives are key to authorize MITS procedure while community opinion leaders including religious leaders were identified as key to influence parental decisions for the procedure.

Conclusion

Building awareness of the community members and engagement of opinion leaders is critical to introduce MITS.

Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic

BACKGROUND

In Ethiopia, neonatal mortality is persistently high. The country has been implementing community-based treatment of possible serious bacterial infection (PSBI) in young infants when referral to a hospital is not feasible since 2012. However, access to and quality of PSBI services remained low and were worsened by COVID-19. From November 2020 to June 2022, we conducted implementation research to mitigate the impact of COVID-19 and improve PSBI management implementation uptake and delivery in two woredas in Ethiopia.

METHODS

In April-May 2021, guided by implementation research frameworks, we conducted formative research to understand the PSBI management implementation challenges, including those due to the COVID-19 pandemic. Through a participatory process engaging stakeholders, we designed adaptive implementation strategies to bridge identified gaps using mechanism mapping to achieve implementation outcomes. Strategies included training and coaching, supportive supervision and mentorship, technical support units, improved supply of essential commodities, and community awareness creation about PSBI and COVID-19. We conducted cross-sectional household surveys in the two woredas before (April 2021) and after the implementation of strategies (June 2022) to measure changes in targeted outcomes.

RESULTS

We interviewed 4,262 and 4,082 women who gave live birth 2-14 months before data collection and identified 374 and 264 PSBI cases in April 2021 and June 2022, respectively. The prevalence of PSBI significantly decreased (p-value = 0.018) from 8.7% in April 2021 to 6.4% while the mothers' care-seeking behavior from medical care for their sick newborns increased significantly from 56% to 91% (p-value <0.01). Effective coverage of severely ill young infants that took appropriate antibiotics significantly improved from 33% [95% CI: 25.5-40.7] to 62% [95% CI: 51.0-71.6]. Despite improvements in the uptake of PSBI treatment, persisting challenges at the facility and systems levels impeded optimal PSBI service delivery and uptake, including perceived low quality of service, lack of community trust, and shortage of supplies.

CONCLUSION

The participatory design and implementation of adaptive COVID-19 strategies effectively improved the uptake and delivery of PSBI treatment. Support systems were critical for frontline health workers to deliver PSBI services and create a resilient community health system to provide quality PSBI care during the pandemic. Additional strategies are needed to address persistent gaps, including improvement in client-provider interactions, supply of essential drugs, and increased social mobilization strategies targeting families and communities to further increase uptake.

Care-seeking behaviours of mothers and associated factors for possible serious bacterial infection in young infants during COVID-19 pandemic in Ethiopia: mixed-methods formative research

OBJECTIVES

Implementation research was employed to examine rates and contextual factors associated with mothers' care-seeking for their sick neonates and identify challenges for community-based possible serious bacterial infection (PSBI) services access and implementation during the COVID-19 pandemic.

DESIGN

We conducted formative research involving household survey and programmatic qualitative study.

SETTING

This formative study was conducted in Dembecha and Lume woredas of Amhara and Oromia regions.

PARTICIPANTS

Data were captured from 4262 mothers aged 15-49 years who gave live birth 2-14 months before data collection, and interviews with 18 programme managers and 16 service providers in April to May 2021.

ANALYSIS

A multilevel regression model was employed to identify predictors of maternal care-seeking for PSBI and thematic qualitative analysis to inform strategy development to strengthen PSBI implementation.

RESULTS

Overall, 12% (95% CI 11.0% to 12.9%) and 8% (95% CI 7.9% to 9.6%) of mothers reported any newborn illness and severe neonatal infection (PSBI), respectively. More than half of mothers sought formal medical care, 56% (95% CI 50.7% to 60.8%) for PSBI. Women who received postnatal care within 6 weeks (adjusted OR (AOR) 2.08; 95% CI 1.12 to 3.87) and complete antenatal care (ie, weight measured, blood pressure taken, urine and blood tested) (AOR 2.04; 95% CI 1.12 to 3.75) had higher odds of care-seeking for PSBI. Conversely, fear of COVID-19 (AOR 0.27; 95% CI 0.15 to 0.47) and residing more than 2 hours of walking distance from the health centre (AOR 0.39; 95% CI 0.16 to 0.93) were negatively associated with care-seeking for severe newborn infection. Multiple pre-existing health system bottlenecks were identified from interviews as barriers to PSBI service delivery and exacerbated by the COVID-19 pandemic.

CONCLUSION

We found gaps in and factors associated with care-seeking behaviour of mothers for their sick young infants including fear of COVID-19 and pre-existing health system-level barriers. The findings of the study were used to design and implement strategies to mitigate COVID-19 impacts on management of PSBI.

Measuring implementation outcomes in the context of scaling up possible serious bacterial infection guidelines: Implications for measurement and programs

BACKGROUND

Reducing the burden of neonatal sepsis requires timely identification and initiation of suitable antibiotic treatment in primary health care (PHC) settings. Countries are encouraged to adopt simplified antibiotic regimens at the PHC level for treating sick young infants (SYI) with signs of possible serious bacterial infection (PSBI). As countries implement PSBI guidelines, more lessons on effective implementation strategies and outcome measurements are needed. We document pragmatic approaches used to design, measure and report implementation strategies and outcomes while adopting PSBI guidelines in Kenya.

METHODS

We designed implementation research using longitudinal mixed methods embedded in a continuous regular systematic learning and adoption of evidence in the PHC context. We synthesized formative data to co-create with stakeholders, implementation strategies to incorporate PSBI guidelines into routine service delivery for SYIs. This was followed by quarterly monitoring for learning and feedback on the effect of implementation strategies, documented lessons learned and tracked implementation outcomes. We collected endline data to measure the overall effect on service level outcomes.

RESULTS

Our findings show that characterizing implementation strategies and linking them with implementation outcomes, helps illustrate the pathway between the implementation process and outcomes. Although we have demonstrated that it is feasible to implement PSBI in PHC, effective investment in continuous capacity strengthening of providers through blended approaches, efficient use of available human resources, and improving the efficiency of service areas for managing SYIs optimizes timely identification and management of SYI. Sustained provision of commodities for management of SYI facilitates increased uptake of services. Strengthening facility-community linkages supports adherence to scheduled visits. Enhancing the caregiver's preparedness during postnatal contacts in the community or facility will facilitate the effective completion of treatment.

CONCLUSION

Careful design, and definition of terms related to the measurement of implementation outcomes and strategies enable ease of interpretation of findings. Using the taxonomy of implementation outcomes help frame the measurement process and provides empirical evidence in a structured way to demonstrate causal relationships between implementation strategies and outcomes. Using this approach, we have illustrated that the implementation of simplified antibiotic regimens for treating SYIs with PSBI in PHC settings is feasible in Kenya.

Using the Implementation Research Logic Model to design and implement community-based management of possible serious bacterial infection during COVID-19 pandemic in Ethiopia

BACKGROUND

Community-based treatment of possible serious bacterial infection (PSBI) in young infants, when referral to a hospital is not possible, can result in high treatment coverage and low case fatality. However, in Ethiopia, the coverage of PSBI treatment remains low, worsened by COVID-19. To understand the challenges of delivery of PSBI treatment and design and test adaptative strategies to mitigate the impact of COVID-19 on neonatal mortality, we did implementation research (IR) employing Implementation Research Logic Model (IRLM). In this paper, we describe IRLM application experiences in designing, implementing, and evaluating strategies to improve community-based treatment of PSBI during the COVID-19 pandemic in Ethiopia.

METHODS

This IR was conducted between November 2020-April 2022 at Dembecha and Lume woredas of Amhara and Oromia regions, respectively. We employed narrative reviews, formative assessment and facilitated stakeholder engagement to develop the PSBI treatment IRLM to identify barriers, understand the conceptual linkages among determinants, choose implementation strategies, elicit mechanisms, and link to implementation outcomes. In addition, we used the IRLM to structure the capture of emerging implementation challenges and resulting strategy adaptations throughout implementation.

RESULTS

This IR identified COVID-19 and multiple pre-existing contextual factors. We designed and implemented implementation strategies to address these challenges. These adaptive strategies were implemented with sufficient strength to maintain the delivery of PSBI services and improve mothers' care-seeking behavior for their sick young infants. The IRLM offers us a clear process and path to prioritize implementation challenges, choose strategies informed by mechanisms of action, and where the adaptive implementation of community-based management of PSBI would lead to high-implementation fidelity and change in mother behavior to seek care for their sick young infants. The IRLM was also an effective tool for stakeholder engagement, easily explained and used to structure discussion and decision-making during co-design meetings.

CONCLUSIONS

The use of the IRLM helps us to specify the conceptual links between the implementation challenges, strategies, mechanisms of action, and outcomes to explore the complex community-based management of PSBI during complex contexts to improve high-fidelity implementation and integration of PSBI treatment in the primary healthcare delivery systems through active engagement of stakeholders.

Management of bacterial infections in young infants in Ethiopia: Facility preparedness, health workers' knowledge and quality of care

AIM

We assessed primary care facility preparedness, health workers' knowledge and their classification and treatment of possible serious bacterial infection and local bacterial infection in young infants aged 0-59 days.

METHOD

A cross-sectional survey was conducted in four regions of Ethiopia, including 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Registers of 1058 sick young infants were reviewed.

RESULT

Antibiotics to treat possible serious bacterial infection were available in 71% of the health centres and 38% of the health posts. Nine of ten health extension workers and eight of ten health centre staff mentioned at least one sign of possible serious bacterial infection and local bacterial infection. Among the registered cases with signs of bacterial infections, the health extension workers classified 49% as having a possible serious bacterial infection and 88% as local bacterial infection. The health centre staff classified 25% as possible serious bacterial infections and 86% as local bacterial infections. One-fourth (26%) of possible serious bacterial infection received the recommended treatment at health posts and 35% at health centres.

CONCLUSION

Many health posts lacked antibiotics. The classification and treatment of possible serious bacterial infection did not follow guidelines. The lack of medicines and poor adherence compromise the quality of care.

Prelacteal feeding practice and its determinant factors among mothers having children less than 6 months of age in Bure district, Northwest Ethiopia: a community-based cross-sectional study

OBJECTIVE

The main aim of this study was to assess prelacteal feeding practice and its determinant factors among mothers having children less than 6 months of age in Bure district, Northwest Ethiopia.

DESIGN

Community-based cross-sectional study design.

SETTING

Northern Ethiopia.

PARTICIPANTS

The present study was conducted among 621 mothers who had children less than 6 months of age in Bure district, Northwest Ethiopia, from 1 March 2019 to 30 March 2019.

PRIMARY OUTCOME

Mothers prelacteal feeding practice, modelled using multivariable logistic regression.

SECONDARY OUTCOME

Determinant factors of prelacteal feeding practice.

RESULTS

This study found that the prevalence of prelacteal feeding practice was 11.6% ((95% CI 9.0% to 14.2%)). Delayed initiation of breast feeding (adjusted OR, AOR=5.4, 95% CI 2.2 to 13.5), mothers who did not get counselling of breast feeding (AOR=2.9, 95% CI 1.2 to 7.2), home delivery (AOR=6.9, 95% CI 2.2 to 21.5), primiparous mothers (AOR=4.1, 95% CI 1.4 to 12.2), a newborn with history of neonatal illness (AOR=3.3, 95% CI 1.3 to 8.5) and lack of postnatal care visits (AOR=3.9, 95% CI 1.3 to 11.8) were determinant factors of prelacteal feeding practice.

CONCLUSIONS

Delayed initiation of breast feeding, mothers who did not get counselling of breast feeding, home delivery, primiparous mothers, newborns with a history of neonatal illness and lack of postnatal care visits were determinant factors of prelacteal feeding practice. Therefore, healthcare workers should provide a home to home health education for mothers on the merits of early initiation of breast feeding, promote institutional delivery, enhance maternal health-seeking behaviour and encourage mothers to have postnatal care visits is recommended.

Exploring communities' perceptions of the etiology of illnesses in newborns and young infants 0-59 days old in 4 counties in Kenya

BACKGROUND

Understanding communities' beliefs about the causes of illnesses in sick young infants (SYIs) is key to strengthening interventions and improving newborn health outcomes. This study explored communities' perception of the etiology of illnesses in SYIs 0-59 days old in four counties in Kenya.

METHODS

We used an exploratory qualitative study design. Data were collected between August and September 2018 and involved 23 in-depth interviews with female caregivers aged 15-24years; 25 focus group discussions with female caregivers aged 15-18 years, 19-24 years and 25-45 years; and 7 focus group discussions with fathers aged 18-34 years and 35 or more years. Participants were purposely sampled, only those with SYIs 0-59 days old were eligible to participate. Data were analyzed using inductive thematic analysis framework approach.

RESULTS

Female caregivers and fathers attributed illnesses in SYIs 0-59 days old to natural (biomedical) and supernatural causes which sometimes co-existed. There were commonalities in perceived natural causes of illness in SYIs across sites, age groups and gender. Perceived natural causes of illness in SYIs include unfavorable environmental and hygiene conditions, poor maternal and child nutrition, and healthcare practices. Perceived supernatural causes of illness in SYIs such as 'evil eyes' were common across the four counties while others were geographically unique such as the belief that owls cause illnesses.

CONCLUSION

Communities' understanding of the etiology of illnesses in SYIs in the study settings overlapped between natural and supernatural causes. There is need for child health programmes to take into consideration communities' beliefs and practices regarding disease and health to improve newborn health outcomes.