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Peterson ME, Docter S, Ruiz-Betancourt DR, Alawa J, Arimino S, Weiser TG. Pulse oximetry training landscape for healthcare workers in low- and middle-income countries: A scoping review. J Glob Health 2023; 13:04074. [PMID: 37736848 PMCID: PMC10514743 DOI: 10.7189/jogh.13.04074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
Background Pulse oximetry has been used in medical care for decades. Its use quickly became standard of care in high resource settings, with delayed widespread availability and use in lower resource settings. Pulse oximetry training initiatives have been ongoing for years, but a map of the literature describing such initiatives among health care workers in low- and middle-income countries (LMICs) has not previously been conducted. Additionally, the coronavirus disease 2019 (COVID-19) pandemic further highlighted the inequitable distribution of pulse oximetry use and training. We aimed to characterise the landscape of pulse oximetry training for health care workers in LMICs prior to the COVID-19 pandemic as described in the literature. Methods We systematically searched six databases to identify studies reporting pulse oximetry training among health care workers, broadly defined, in LMICs prior to the COVID-19 pandemic. Two reviewers independently assessed titles and abstracts and relevant full texts for eligibility. Data were charted by one author and reviewed for accuracy by a second. We synthesised the results using a narrative synthesis. Results A total of 7423 studies were identified and 182 screened in full. A total of 55 training initiatives in 42 countries met inclusion criteria, as described in 66 studies since some included studies reported on different aspects of the same training initiative. Five overarching reasons for conducting pulse oximetry training were identified: 1) anaesthesia and perioperative care, 2) respiratory support programme expansion, 3) perinatal assessment and monitoring, 4) assessment and monitoring of children and 5) assessment and monitoring of adults. Educational programmes varied in their purpose with respect to the types of patients being targeted, the health care workers being instructed, and the depth of pulse oximetry specific training. Conclusions Pulse oximetry training initiatives have been ongoing for decades for a variety of purposes, utilising a multitude of approaches to equip health care workers with tools to improve patient care. It is important that these initiatives continue as pulse oximetry availability and knowledge gaps remain. Neither pulse oximetry provision nor training alone is enough to bolster patient care, but sustainable solutions for both must be considered to meet the needs of both health care workers and patients.
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Affiliation(s)
| | - Shgufta Docter
- School of Medicine, University of Limerick, Limerick, Ireland
| | | | - Jude Alawa
- Stanford University School of Medicine, Stanford, California, USA
| | - Sedera Arimino
- CHRR (Regional Hospital Centre of Reference) Vakinankaratra, Madagascar
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA
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El Arifeen S, Hossain AT, Rahman AE. Detecting hypoxaemia among children with pneumonia in low-resource settings. Lancet Respir Med 2023; 11:756-757. [PMID: 37657850 DOI: 10.1016/s2213-2600(23)00300-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/03/2023]
Affiliation(s)
- Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
| | - Aniqa Tasnim Hossain
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Ahmed Ehsanur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
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Hooli S, King C, McCollum ED, Colbourn T, Lufesi N, Mwansambo C, Gregory CJ, Thamthitiwat S, Cutland C, Madhi SA, Nunes MC, Gessner BD, Hazir T, Mathew JL, Addo-Yobo E, Chisaka N, Hassan M, Hibberd PL, Jeena P, Lozano JM, MacLeod WB, Patel A, Thea DM, Nguyen NTV, Zaman SM, Ruvinsky RO, Lucero M, Kartasasmita CB, Turner C, Asghar R, Banajeh S, Iqbal I, Maulen-Radovan I, Mino-Leon G, Saha SK, Santosham M, Singhi S, Awasthi S, Bavdekar A, Chou M, Nymadawa P, Pape JW, Paranhos-Baccala G, Picot VS, Rakoto-Andrianarivelo M, Rouzier V, Russomando G, Sylla M, Vanhems P, Wang J, Basnet S, Strand TA, Neuman MI, Arroyo LM, Echavarria M, Bhatnagar S, Wadhwa N, Lodha R, Aneja S, Gentile A, Chadha M, Hirve S, O'Grady KAF, Clara AW, Rees CA, Campbell H, Nair H, Falconer J, Williams LJ, Horne M, Qazi SA, Nisar YB. In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset. Int J Infect Dis 2023; 129:240-250. [PMID: 36805325 PMCID: PMC10017350 DOI: 10.1016/j.ijid.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. METHODS We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. RESULTS Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). CONCLUSION Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.
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Affiliation(s)
- Shubhada Hooli
- Division of Pediatric Emergency Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, United States of America
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden and Institute for Global Health, University College London, London, United Kingdom
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, United States of America and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Christopher J Gregory
- Division of Vector-Borne Diseases, US Centers for Disease Control and Prevention, Fort Collins, United States of America
| | - Somsak Thamthitiwat
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Clare Cutland
- African Leadership in Vaccinology Expertise (Alive), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir Ahmed Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Marta C Nunes
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Tabish Hazir
- The Children's Hospital, (Retired), Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Emmanuel Addo-Yobo
- Kwame Nkrumah University of Science & Technology/Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Noel Chisaka
- World Bank, Washington DC, United States of America
| | - Mumtaz Hassan
- The Children's Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Juan M Lozano
- Florida International University, Miami, United States of America
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur and Datta Meghe Institute of Medical Sciences, Sawangi, India
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Syed Ma Zaman
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Raul O Ruvinsky
- Dirección de Control de Enfermedades Inmunoprevenibles, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - Marilla Lucero
- Research Institute for Tropical Medicine, Manila, Philippines
| | - Cissy B Kartasasmita
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Rai Asghar
- Rawalpindi Medical College, Rawalpindi, Pakistan
| | | | - Imran Iqbal
- Combined Military Hospital Institute of Medical Sciences, Multan, Pakistan
| | - Irene Maulen-Radovan
- Instituto Nacional de Pediatria Division de Investigacion Insurgentes, Mexico City, Mexico
| | - Greta Mino-Leon
- Children's Hospital Dr Francisco de Ycaza Bustamante, Head of Department, Infectious diseases, Guayaquil, Ecuador
| | - Samir K Saha
- Child Health Research Foundation and Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Mathuram Santosham
- International Vaccine Access Center (IVAC), Department of International Health, Johns Hopkins University, Baltimore, United States of America
| | | | - Shally Awasthi
- King George's Medical University, Department of Pediatrics, Lucknow, India
| | | | - Monidarin Chou
- University of Health Sciences, Rodolph Mérieux Laboratory & Ministry of Environment, Phom Phen, Cambodia
| | - Pagbajabyn Nymadawa
- Mongolian Academy of Sciences, Academy of Medical Sciences, Ulaanbaatar, Mongolia
| | | | | | | | | | | | - Graciela Russomando
- Universidad Nacional de Asuncion, Departamento de Biología Molecular y Genética, Instituto de Investigaciones en Ciencias de la Salud, Asuncion, Paraguay
| | - Mariam Sylla
- Gabriel Touré Hospital, Department of Pediatrics, Bamako, Mali
| | - Philippe Vanhems
- Unité d'Hygiène, Epidémiologie, Infectiovigilance et Prévention, Hospices Civils de Lyon, Lyon, France and Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jianwei Wang
- Chinese Academy of Medical Sciences & Peking Union, Medical College Institute of Pathogen Biology, MOH Key Laboratory of Systems Biology of Pathogens and Dr Christophe Mérieux Laboratory, Beijing, China
| | - Sudha Basnet
- Center for Intervention Science in Maternal and Child Health, University of Bergen, Norway and Department of Pediatrics, Tribhuvan University Institute of Medicine, Nepal
| | - Tor A Strand
- Research Department, Innlandet Hospital Trust, Lillehammer, Norway
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, United States of America
| | | | - Marcela Echavarria
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas, Mar del Plata, Argentina
| | | | - Nitya Wadhwa
- Translational Health Science and Technology Institute, Faridabad, India
| | - Rakesh Lodha
- All India Institute of Medical Sciences, New Delhi, India
| | - Satinder Aneja
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | - Angela Gentile
- Department of Epidemiology, "R. Gutiérrez" Children's Hospital, Buenos Aires, Argentina
| | - Mandeep Chadha
- Former Scientist G, ICMR National Institute of Virology, Pune, India
| | | | - Kerry-Ann F O'Grady
- Australian Centre for Health Services Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - Alexey W Clara
- Centers for Disease Control, Central American Region, Guatemala City, Guatemala
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, United States of America
| | - Harry Campbell
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Harish Nair
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Jennifer Falconer
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Linda J Williams
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Margaret Horne
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child, and Adolescent Health (Retired), World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child, and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland.
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Sheikh M, Ahmad H, Ibrahim R, Nisar I, Jehan F. Pulse oximetry: why oxygen saturation is still not a part of standard pediatric guidelines in low-and-middle-income countries (LMICs). Pneumonia (Nathan) 2023; 15:3. [PMID: 36739442 PMCID: PMC9899156 DOI: 10.1186/s41479-023-00108-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 01/13/2023] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With the high frequency of acute respiratory infections in children worldwide, particularly so in low-resource countries, the development of effective diagnostic support is crucial. While pulse oximetry has been found to be an acceptable method of hypoxemia detection, improving clinical decision making and efficient referral, many healthcare set ups in low- and middle-income countries have not been able to implement pulse oximetry into their practice. MAIN BODY A review of past pulse oximetry implementation attempts in low- and middle-income countries proposes the barriers and potential solutions for complete integration in the healthcare systems. The addition of pulse oximetry into WHO health guidelines would prove to improve detection of respiratory distress and ensuing therapeutic measures. Incorporation is limited by the cost and unavailability of pulse oximeters, and subsequent oxygen accessibility. This restriction is compounded by the lack of trained personnel, and healthcare provider misconceptions. These hurdles can be combated by focus on low-cost devices, and cooperation at national levels for development in healthcare infrastructure, resource transport, and oxygen delivery systems. CONCLUSION The implementation of pulse oximetry shows promise to improve child morbidity and mortality from pneumonia in low- and middle-income countries. Steady measures taken to improve access to pulse oximeters and oxygen supplies, along with enhanced medical provider training are encouraging steps to thorough pulse oximetry integration.
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Affiliation(s)
- Maheen Sheikh
- grid.7147.50000 0001 0633 6224Department of Pediatrics and Child Health, Aga Khan University, Karachi, 74800 Pakistan
| | - Huzaifa Ahmad
- grid.415235.40000 0000 8585 5745Department of Medicine, MedStar Washington Hospital Center, Washington, DC 20010 USA
| | - Romesa Ibrahim
- grid.7147.50000 0001 0633 6224Department of Pediatrics and Child Health, Aga Khan University, Karachi, 74800 Pakistan
| | - Imran Nisar
- grid.7147.50000 0001 0633 6224Department of Pediatrics and Child Health, Aga Khan University, Karachi, 74800 Pakistan
| | - Fyezah Jehan
- grid.7147.50000 0001 0633 6224Department of Pediatrics and Child Health, Aga Khan University, Karachi, 74800 Pakistan
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Hedible GB, Louart S, Neboua D, Catala L, Anago G, Sawadogo AG, Kargougou GD, Meda B, Kolié JS, Hema A, Keita S, Niome M, Savadogo AS, Peters-Bokol L, Agbeci H, Zair Z, Lenaud S, Vignon M, Ouedraogo Yugbare S, Abarry H, Diakite AA, Diallo IS, Lamontagne F, Briand V, Dahourou DL, Cousien A, Ridde V, Leroy V. Evaluation of the routine implementation of pulse oximeters into integrated management of childhood illness (IMCI) guidelines at primary health care level in West Africa: the AIRE mixed-methods research protocol. BMC Health Serv Res 2022; 22:1579. [PMID: 36566173 PMCID: PMC9789366 DOI: 10.1186/s12913-022-08982-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The AIRE operational project will evaluate the implementation of the routine Pulse Oximeter (PO) use in the integrated management of childhood illness (IMCI) strategy for children under-5 in primary health care centers (PHC) in West Africa. The introduction of PO should promote the accurate identification of hypoxemia (pulse blood oxygen saturation Sp02 < 90%) among all severe IMCI cases (respiratory and non-respiratory) to prompt their effective case management (oxygen, antibiotics and other required treatments) at hospital. We seek to understand how the routine use of PO integrated in IMCI outpatients works (or not), for whom, in what contexts and with what outcomes. METHODS The AIRE project is being implemented from 03/2020 to 12/2022 in 202 PHCs in four West African countries (Burkina Faso, Guinea, Mali, Niger) including 16 research PHCs (four per country). The research protocol will assess three complementary components using mixed quantitative and qualitative methods: a) context based on repeated cross-sectional surveys: baseline and aggregated monthly data from all PHCs on infrastructure, staffing, accessibility, equipment, PO use, severe cases and care; b) the process across PHCs by assessing acceptability, fidelity, implementation challenges and realistic evaluation, and c) individual outcomes in the research PHCs: all children under-5 attending IMCI clinics, eligible for PO use will be included with parental consent in a cross-sectional study. Among them, severe IMCI cases will be followed in a prospective cohort to assess their health status at 14 days. We will analyze pathways, patterns of care, and costs of care. DISCUSSION This research will identify challenges to the systematic implementation of PO in IMCI consultations, such as health workers practices, frequent turnover, quality of care, etc. Further research will be needed to fully address key questions such as the best time to introduce PO into the IMCI process, the best SpO2 threshold for deciding on hospital referral, and assessing the cost-effectiveness of PO use. The AIRE research will provide health policy makers in West Africa with sufficient evidence on the context, process and outcomes of using PO integrated into IMCI to promote scale-up in all PHCs. TRIAL REGISTRATION Trial registration number: PACTR202206525204526 retrospectively registered on 06/15/2022.
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Affiliation(s)
- Gildas Boris Hedible
- grid.15781.3a0000 0001 0723 035XInserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | - Sarah Louart
- grid.512067.70000 0004 9338 1016ALIMA, Dakar, Senegal ,grid.500774.1IRD, CEPED, Paris, France ,grid.503422.20000 0001 2242 6780University of Lille, CLERSE - Centre Lillois d’Études et de Recherches Sociologiques et Économiques, Lille, France
| | - Désiré Neboua
- grid.512067.70000 0004 9338 1016ALIMA, Dakar, Senegal
| | - Laura Catala
- grid.15781.3a0000 0001 0723 035XInserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | - Gildas Anago
- grid.512067.70000 0004 9338 1016ALIMA, Dakar, Senegal
| | | | | | | | | | - Adama Hema
- Terre des hommes-Lausanne (Tdh), Ouagadougou, Burkina Faso
| | | | | | | | - Lucie Peters-Bokol
- grid.15781.3a0000 0001 0723 035XInserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | - Honorat Agbeci
- grid.15781.3a0000 0001 0723 035XInserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | - Zineb Zair
- grid.15781.3a0000 0001 0723 035XInserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | | | - Marine Vignon
- grid.512067.70000 0004 9338 1016ALIMA, Dakar, Senegal
| | | | - Hannatou Abarry
- Ministère de la santé, des populations et des affaires sociales, Niamey, Niger
| | | | | | | | - Valérie Briand
- grid.412041.20000 0001 2106 639XUniversity of Bordeaux, Inserm UMR 1219, IRD EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Désiré Lucien Dahourou
- grid.15781.3a0000 0001 0723 035XInserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France ,grid.433132.40000 0001 2165 6445Institut de Recherche en Sciences de la Santé/CNRST, Département Biomédical, Santé Publique, Ouagadougou, Burkina Faso
| | - Anthony Cousien
- grid.508487.60000 0004 7885 7602Université Paris Cité and Université Sorbonne Paris Nord, Inserm, IAME, F-75018 Paris, France
| | | | - Valériane Leroy
- grid.15781.3a0000 0001 0723 035XInserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France ,grid.15781.3a0000 0001 0723 035XCenter for Epidemiology and Research in Population Health (CERPOP), UMR 1295, Inserm, University Paul Sabatier Toulouse 3, Toulouse, France
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Peterson ME, Mattingly AS, Merrell SB, Asnake BM, Ahmed I, Weiser TG. Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training. BMC Health Serv Res 2022; 22:1395. [PMID: 36419106 DOI: 10.1186/s12913-022-08698-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists' perioperative care and what, if any, capacity gaps remain. METHODS We identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa > 0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care. RESULTS Ten of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial. CONCLUSION Among a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.
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Walker PJB, Wilkes C, Duke T, Graham HR. Can child pneumonia in low-resource settings be treated without antibiotics? A systematic review & meta-analysis. J Glob Health 2022; 12:10007. [DOI: 10.7189/jogh.12.10007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Patrick JB Walker
- Centre for International Child Health, Murdoch Children’s Research Institute, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Chris Wilkes
- Centre for International Child Health, Murdoch Children’s Research Institute, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Trevor Duke
- Centre for International Child Health, Murdoch Children’s Research Institute, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Hamish R Graham
- Centre for International Child Health, Murdoch Children’s Research Institute, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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Chew R, Greer RC, Tasak N, Day NPJ, Lubell Y. Modelling the cost-effectiveness of pulse oximetry in primary care management of acute respiratory infection in rural northern Thailand. Trop Med Int Health 2022; 27:881-890. [PMID: 36054516 PMCID: PMC9805201 DOI: 10.1111/tmi.13812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We aimed to determine the cost-effectiveness of supplementing standard care with pulse oximetry among children <5 years with acute respiratory infection (ARI) presenting to 32 primary care units in a rural district (total population 241,436) of Chiang Rai province, Thailand, and to assess the economic effects of extending pulse oximetry to older patients with ARI in this setting. METHODS We performed a model-based cost-effectiveness analysis from a health systems perspective. Decision trees were constructed for three patient categories (children <5 years, children 5-14 years, and adults), with a 1-year time horizon. Model parameters were based on data from 49,958 patients included in a review of acute infection management in the 32 primary care units, published studies, and procurement price lists. Parameters were varied in deterministic sensitivity analyses. Costs were expressed in 2021 US dollars with a willingness-to-pay threshold per DALY averted of $8624. RESULTS The annual direct cost of pulse oximetry, associated staff, training, and monitoring was $24,243. It reduced deaths from severe lower respiratory tract infections in children <5 years by 0.19 per 100,000 patients annually. In our population of 14,075 children <5 years, this was equivalent to 2.0 DALYs averted per year. When downstream costs such as those related to hospitalisation and inappropriate antibiotic prescription were considered, pulse oximetry dominated standard care, saving $12,757 annually. This intervention yielded smaller mortality gains in older patients but resulted in further cost savings, primarily by reducing inappropriate antibiotic prescriptions in these age groups. The dominance of the intervention was also demonstrated in all sensitivity analyses. CONCLUSIONS Pulse oximetry is a life-saving, cost-effective adjunct in ARI primary care management in rural northern Thailand. This finding is likely to be generalisable to neighbouring countries with similar disease epidemiology and health systems.
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Affiliation(s)
- Rusheng Chew
- Mahidol Oxford Tropical Medicine Research UnitBangkokThailand,Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK,Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Rachel C. Greer
- Mahidol Oxford Tropical Medicine Research UnitBangkokThailand,Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK,Chiang Rai Clinical Research UnitChiang RaiThailand
| | - Nidanuch Tasak
- Mahidol Oxford Tropical Medicine Research UnitBangkokThailand,Chiang Rai Clinical Research UnitChiang RaiThailand
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research UnitBangkokThailand,Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research UnitBangkokThailand,Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
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9
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Wilkes C, Graham H, Walker P, Duke T. Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries. J Glob Health 2022; 12:10008. [PMID: 36040992 PMCID: PMC9428503 DOI: 10.7189/jogh.12.10008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background WHO pneumonia guidelines recommend that children (aged 2-59 months) with chest indrawing pneumonia and without any “general danger sign” can be treated with oral amoxicillin without hospital admission. This recommendation was based on trial data from limited contexts whose generalisability is unclear. This review aimed to identify which children with chest-indrawing pneumonia in low- and middle-income countries can be safely treated at home, and under what conditions is it safe to do so. Methods We searched MEDLINE, EMBASE, and PubMed for observational and interventional studies of home-based management of children (aged 28 days to four years) with chest-indrawing pneumonia in low- or middle-income countries. Results We included 14 studies, including seven randomised trials, from a variety of urban and rural contexts in 11 countries. Two community-based and two hospital-based trials in Pakistan and India found that home treatment of chest-indrawing pneumonia was associated with similar or superior treatment outcomes to hospital admission. Evidence from trials (n = 3) and observational (n = 6) studies in these and other countries confirms the acceptability and feasibility of home management of chest-indrawing pneumonia in low-risk cases, so long as safeguards are in place. Risk assessment includes clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia, or HIV. Pulse oximetry is a critical risk-assessment tool that is currently not widely available and can identify severely ill patients with hypoxaemia otherwise possibly missed by clinical assessment alone. Additional safeguards include caregiver understanding and ability to return for review. Conclusions Home treatment of chest-indrawing pneumonia can be safe but should only be recommended for children confirmed to be low-risk and in contexts where appropriate care and safety measures are in place.
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10
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Graham HR, Bakare AA, Ayede AI, Eleyinmi J, Olatunde O, Bakare OR, Edunwale B, Neal EFG, Qazi S, McPake B, Peel D, Gray AZ, Duke T, Falade AG. Cost-effectiveness and sustainability of improved hospital oxygen systems in Nigeria. BMJ Glob Health 2022; 7:bmjgh-2022-009278. [PMID: 35948344 PMCID: PMC9379491 DOI: 10.1136/bmjgh-2022-009278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/19/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Improving hospital oxygen systems can improve quality of care and reduce mortality for children, but we lack data on cost-effectiveness or sustainability. This study evaluated medium-term sustainability and cost-effectiveness of the Nigeria Oxygen Implementation programme. Methods Prospective follow-up of a stepped-wedge trial involving 12 secondary-level hospitals. Cross-sectional facility assessment, clinical audit (January–March 2021), summary admission data (January 2018–December 2020), programme cost data. Intervention: pulse oximetry introduction followed by solar-powered oxygen system installation with clinical and technical training and support. Primary outcomes: (i) proportion of children screened with pulse oximetry; (ii) proportion of hypoxaemic (SpO2 <90%) children who received oxygen. Comparison across three time periods: preintervention (2014–2015), intervention (2016–2017) and follow-up (2018–2020) using mixed-effects logistic regression. Calculated cost-effectiveness of the intervention on child pneumonia mortality using programme costs, recorded deaths and estimated counterfactual deaths using effectiveness estimates from our effectiveness study. Reported cost-effectiveness over the original 2-year intervention period (2016–2017) and extrapolated over 5 years (2016–2020). Results Pulse oximetry coverage for neonates and children remained high during follow-up (83% and 81%) compared with full oxygen system period (94% and 92%) and preintervention (3.9% and 2.9%). Oxygen coverage for hypoxaemic neonates/children was similarly high (94%/88%) compared with full oxygen system period (90%/82%). Functional oxygen sources were present in 11/12 (92%) paediatric areas and all (8/8) neonatal areas; three-quarters (15/20) of wards had a functional oximeter. Of 32 concentrators deployed, 23/32 (72%) passed technical testing and usage was high (median 10 797 hours). Estimated 5-year cost-effectiveness US$86 per patient treated, $2694–4382 per life saved and $82–125 per disability-adjusted life year-averted. We identified practical issues for hospitals and Ministries of Health wishing to adapt and scale up pulse oximetry and oxygen. Conclusion Hospital-level improvements to oxygen and pulse oximetry systems in Nigerian hospitals have been sustained over the medium-term and are a highly cost-effective child pneumonia intervention.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia .,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Nigeria.,Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Adejumoke Idowu Ayede
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria.,Department of Paediatrics, School of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Joseph Eleyinmi
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Oyaniyi Olatunde
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Oluwabunmi R Bakare
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Blessing Edunwale
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Eleanor F G Neal
- Infection and Immunity, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Shamim Qazi
- Independent Consultant Paediatrician, Geneva, Switzerland
| | - Barbara McPake
- Nossal Institute for Global Health, Melbourne, Victoria, Australia
| | | | - Amy Z Gray
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria.,Department of Paediatrics, School of Medicine, University of Ibadan, Ibadan, Nigeria
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11
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Bagayana S, Subhi R, Moore G, Mugerwa J, Peake D, Nakintu E, Murokora D, Rassool R, Sklar M, Graham H, Sobott B. Technology to improve reliable access to oxygen in Western Uganda: study protocol for a phased implementation trial in neonatal and paediatric wards. BMJ Open 2022; 12:e054642. [PMID: 35768096 PMCID: PMC9240937 DOI: 10.1136/bmjopen-2021-054642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Oxygen is an essential medicine for children and adults. The current systems for its delivery can be expensive and unreliable in settings where oxygen is most needed. FREO2 Foundation Australia has developed an integrated oxygen system, driven by a mains-powered oxygen concentrator, with the ability to switch automatically between low-pressure oxygen storage device and cylinder oxygen in power interruptions. The aim of this study is to assess the clinical impact and cost-effectiveness of expanding this system to 20 community and district hospitals and level IV facilities in Western Uganda. METHODS AND ANALYSIS This will be a phased implementation with preintervention and postintervention comparison of outcomes. Standardised baseline data collection and needs assessment will be conducted, followed by implementation of the FREO2 Oxygen System in combination with pulse oximetry in 1-2 facilities per month over a 16-month period, with a total 23-month data collection period. The primary outcome will be the proportion of hypoxaemic children receiving oxygen pre and post oxygen system. Secondary outcomes will assess clinical, economic and technical aspects. Pre and post oxygen system primary and secondary outcomes will be compared using regression models and standard tests of significance. Useability will be quantitatively and qualitatively evaluated in terms of acceptability, feasibility and appropriateness, using standardised implementation outcome measure tools. ETHICS AND DISSEMINATION Ethics approval was obtained from Mbarara University of Science and Technology (MUREC 1/7) and the University of Melbourne (2021-14489-13654-2). Outcomes will be presented to the involved facilities, and to representatives of the Ministry of Health, Uganda. Broader dissemination will include publication in peer-reviewed journals and academic conference presentations. TRIAL REGISTRATION NUMBER ACTRN12621000241831.
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Affiliation(s)
| | - Rami Subhi
- Centre for International Child Health, MCRI, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Graham Moore
- FREO2 Foundation, Melbourne, Victoria, Australia
- School of Physics, Faculty of Science, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - David Peake
- FREO2 Foundation, Melbourne, Victoria, Australia
- School of Physics, Faculty of Science, The University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Roger Rassool
- FREO2 Foundation, Melbourne, Victoria, Australia
- School of Physics, Faculty of Science, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marc Sklar
- Brick by Brick, New York City, New York, USA
| | - Hamish Graham
- Centre for International Child Health, MCRI, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Bryn Sobott
- FREO2 Foundation, Melbourne, Victoria, Australia
- School of Physics, Faculty of Science, The University of Melbourne, Melbourne, Victoria, Australia
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12
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Graham HR, Olojede OE, Bakare AAA, McCollum ED, Iuliano A, Isah A, Osebi A, Seriki I, Ahmed T, Ahmar S, Cassar C, Valentine P, Olowookere TF, MacCalla M, Uchendu O, Burgess RA, Colbourn T, King C, Falade AG. Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation. BMJ Open 2022; 12:e058901. [PMID: 35501079 PMCID: PMC9062461 DOI: 10.1136/bmjopen-2021-058901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker (HCW) training improves the quality of care for children with pneumonia aged 0-59 months. We will explore to what extent, how, for whom and in what contexts the intervention works. METHODS AND ANALYSIS Quasi-experimental time-series impact evaluation with embedded mixed-methods process and economic evaluation. SETTING seven government primary care facilities, seven private health facilities, two government secondary care facilities. TARGET POPULATION children aged 0-59 months with clinically diagnosed pneumonia and/or suspected or confirmed COVID-19. INTERVENTION 'stabilisation rooms' within participating primary care facilities in Ikorodu local government area, designed to allow for short-term oxygen delivery for children with hypoxaemia prior to transfer to hospital, alongside HCW training on integrated management of childhood illness, pulse oximetry and oxygen therapy, immunisation and nutrition. Secondary facilities will also receive training and equipment for oxygen and pulse oximetry to ensure minimum standard of care is available for referred children. PRIMARY OUTCOME correct management of hypoxaemic pneumonia including administration of oxygen therapy, referral and presentation to hospital. SECONDARY OUTCOME 14-day pneumonia case fatality rate. Evaluation period: August 2020 to September 2022. ETHICS AND DISSEMINATION Ethical approval from University of Ibadan, Lagos State and University College London. Ongoing engagement with government and other key stakeholders during the project. Local dissemination events will be held with the State Ministry of Health at the end of the project (December 2022). We will publish the main impact results, process evaluation and economic evaluation results as open-access academic publications in international journals. TRIAL REGISTRATION NUMBER ACTRN12621001071819; Registered on the Australian and New Zealand Clinical Trials Registry.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, MCRI, University of Melbourne, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Omotayo E Olojede
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Ayobami Adebayo A Bakare
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Paediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | - Adamu Isah
- Save the Children International, Abuja, FCT, Nigeria
| | - Adams Osebi
- Save the Children International, Abuja, FCT, Nigeria
| | | | | | | | | | | | | | | | - Obioma Uchendu
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
- Department of Community Medicine, University of Ibadan, Ibadan, Oyo, Nigeria
| | | | - Timothy Colbourn
- Institute for Global Health, University College London, London, UK
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Institute for Global Health, University College London, London, UK
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Oyo, Nigeria
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13
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Oladimeji OJ, Fatusi AO. Realist Evaluation of the "Abiye" Safe Motherhood Initiative in Nigeria: Unveiling the Black-Box of Program Implementation and Health System Strengthening. Front Health Serv 2022; 2:779130. [PMID: 36925893 PMCID: PMC10012745 DOI: 10.3389/frhs.2022.779130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/24/2022] [Indexed: 11/13/2022]
Abstract
Introduction Realist evaluation studies have spanned different aspects of medicine, especially in the field of public health. However, very few of these studies explicitly detailed how program implementation triggered outcomes that could strengthen understanding of its effect on Health System Strengthening in specific settings. In low- and middle-income countries, like Nigeria, there is a paucity of realist evaluation studies, despite the implementation of multiple intervention programs and projects in these countries. This article is aimed at unveiling the black-box of program implementation and Health System Strengthening of the "Abiye" Safe Motherhood Program in Ondo State, Nigeria. Specifically, it identified the role of contextual factors in the "Abiye" program in Ondo State, determined the mechanisms that facilitated or constrained outcomes of the "Abiye" program, and developed a Context Mechanism Outcome (CMO) Configuration from which a Middle Range Theory (MRT) can be framed. Methodology This was qualitative research structured along with the realist domains (Context, Mechanism, and Outcome). The Initial Program Theory was validated by the qualitative study, after which a new MRT was developed. The study population comprised key stakeholders, secondary stakeholders, and primary stakeholders in the Abiye safe motherhood program. Data was collected through 10 key informant interviews, 28 in-depth interviews, and six focus group discussions sessions. Thematic analysis was used to analyze all the qualitative data collected, and seven themes with 19 subthemes emerged in the study. Results We identified 13 contextual factors under five principal areas, with most of the factors playing enabling roles, some playing inhibitory roles, while very few played both roles. We elicited eight mechanisms, and some of these facilitated the outcomes, while some constrained the outcomes of the program. Health system strengthening was a key feature of the outcome of the program. We developed a middle-range theory based on the 6 CMO configurations we elicited from the study. Conclusion and Policy Implications Realist evaluation is an iterative process that looks beyond the surface to generate evidence. By applying the realist approach, we generated pieces of evidence that can be adapted for policymaking in public health interventions in LMIC.
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Affiliation(s)
| | - Adesegun O Fatusi
- Academy for Health Development, Ile-Ife, Nigeria.,Office of the Vice-Chancellor, University of Medical Sciences, Ondo, Nigeria.,Department of Community Health, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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14
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Graham HR, Kamuntu Y, Miller J, Barrett A, Kunihira B, Engol S, Kabunga L, Lam F, Olaro C, Ajilong H, Kitutu FE. Hypoxaemia prevalence and management among children and adults presenting to primary care facilities in Uganda: A prospective cohort study. PLOS Glob Public Health 2022; 2:e0000352. [PMID: 36962209 PMCID: PMC10022140 DOI: 10.1371/journal.pgph.0000352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/15/2022] [Indexed: 11/19/2022]
Abstract
Hypoxaemia (low blood oxygen) is common among hospitalised patients, increasing the odds of death five-fold and requiring prompt detection and treatment. However, we know little about hypoxaemia prevalence in primary care and the role for pulse oximetry and oxygen therapy. This study assessed the prevalence and management of hypoxaemia at primary care facilities in Uganda. We conducted a cross sectional prevalence study and prospective cohort study of children with hypoxaemia in 30 primary care facilities in Uganda, Feb-Apr 2021. Clinical data collectors used handheld pulse oximeters to measure blood oxygen level (SpO2) of all acutely unwell children, adolescents, and adults. We followed up a cohort of children aged under 15 years with SpO2<93% by phone after 7 days to determine if the patient had attended another health facility, been admitted, or recovered. Primary outcome: proportion of children under 5 years of age with severe hypoxaemia (SpO2<90%). Secondary outcomes: severe (SpO2<90%) and moderate hypoxaemia (SpO2 90-93%) prevalence by age/sex/complaint; number of children with hypoxaemia referred, admitted and recovered. We included 1561 children U5, 935 children 5-14 years, and 3284 adolescents/adults 15+ years. Among children U5, the prevalence of severe hypoxaemia was 1.3% (95% CI 0.9 to 2.1); an additional 4.9% (3.9 to 6.1) had moderate hypoxaemia. Performing pulse oximetry according to World Health Organization guidelines exclusively on children with respiratory complaints would have missed 14% (3/21) of severe hypoxaemia and 11% (6/55) of moderate hypoxaemia. Hypoxaemia prevalence was low among children 5-14 years (0.3% severe, 1.1% moderate) and adolescents/adults 15+ years (0.1% severe, 0.5% moderate). A minority (12/27, 44%) of severely hypoxaemic patients were referred; 3 (12%) received oxygen. We followed 87 children aged under 15 years with SpO2<93%, with complete data for 61 (70%), finding low rates of referral (6/61, 10%), hospital attendance (10/61, 16%), and admission (6/61, 10%) with most (44/61, 72%) fully recovered at day 7. Barriers to referral included caregiver belief it was unnecessary (42/51, 82%), cost (8/51, 16%), and distance or lack of transport (3/51, 6%). Hypoxaemia is common among acutely unwell children under five years of age presenting to Ugandan primary care facilities. Routine pulse oximetry has potential to improve referral, management and clinical outcomes. Effectiveness, acceptability, and feasibility of pulse oximetry and oxygen therapy for primary care should be investigated in implementation trials, including economic analysis from health system and societal perspectives.
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Affiliation(s)
- Hamish R Graham
- Melbourne Children's Global Health, MCRI, University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | | | - Jasmine Miller
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Anna Barrett
- Melbourne Children's Global Health, MCRI, University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia
- Nossal Institute of Global Health, University of Melbourne, Parkville, Australia
| | | | - Santa Engol
- Clinton Health Access Initiative Uganda, Kampala, Uganda
| | | | - Felix Lam
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Charles Olaro
- Director Health Services, Office of the Director of Curative Services, Federal Ministry of Health, Kampala, Uganda
| | | | - Freddy Eric Kitutu
- Department of Pharmacy, Makerere University School of Health Sciences, Kampala, Uganda
- Sustainable Pharmaceutical Systems (SPS) unit, Makerere University School of Health Sciences, Kampala, Uganda
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15
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Lam F, Stegmuller A, Chou VB, Graham HR. Oxygen systems strengthening as an intervention to prevent childhood deaths due to pneumonia in low-resource settings: systematic review, meta-analysis and cost-effectiveness. BMJ Glob Health 2021; 6:bmjgh-2021-007468. [PMID: 34930758 PMCID: PMC8689120 DOI: 10.1136/bmjgh-2021-007468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/24/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Increasing access to oxygen services may improve outcomes among children with pneumonia living in low-resource settings. We conducted a systematic review to estimate the impact and cost-effectiveness of strengthening oxygen services in low-income and middle-income countries with the objective of including oxygen as an intervention in the Lives Saved Tool. DESIGN We searched EMBASE and PubMed on 31 March 2021 using keywords and MeSH terms related to 'oxygen', 'pneumonia' and 'child' without restrictions on language or date. The risk of bias was assessed for all included studies using the quality assessment tool for quantitative studies, and we assessed the overall certainty of the evidence using Grading of Recommendations, Assessment, Development and Evaluations. Meta-analysis methods using random effects with inverse-variance weights was used to calculate a pooled OR and 95% CIs. Programme cost data were extracted from full study reports and correspondence with study authors, and we estimated cost-effectiveness in US dollar per disability-adjusted life-year (DALY) averted. RESULTS Our search identified 665 studies. Four studies were included in the review involving 75 hospitals and 34 485 study participants. We calculated a pooled OR of 0.52 (95% CI 0.39 to 0.70) in favour of oxygen systems reducing childhood pneumonia mortality. The median cost-effectiveness of oxygen systems strengthening was $US62 per DALY averted (range: US$44-US$225). We graded the risk of bias as moderate and the overall certainty of the evidence as low due to the non-randomised design of the studies. CONCLUSION Our findings suggest that strengthening oxygen systems is likely to reduce hospital-based pneumonia mortality and may be cost-effective in low-resource settings. Additional implementation trials using more rigorous designs are needed to strengthen the certainty in the effect estimate.
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Affiliation(s)
- Felix Lam
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Angela Stegmuller
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Victoria B Chou
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
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16
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Sanders JE, Chakare T, Mapota-Masoabi L, Ranyali M, Ramokhele MM, Rozario AM, McCollum ED. National hospital readiness for COVID-19 in Lesotho: evidence for oxygen ecosystem strengthening. Public Health Action 2021; 11:180-185. [PMID: 34956845 DOI: 10.5588/pha.21.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING Sub-Saharan African country, Lesotho, during the SARS-CoV-2 COVID-19 pandemic. OBJECTIVE To evaluate COVID-19 hospital capacity in Lesotho. DESIGN We conducted a pragmatic assessment of all public hospitals in Lesotho using a WHO COVID-19 hospital assessment tool during July 2020 (baseline), with targeted follow-up in December 2020. We adapted the WHO tool into a questionnaire with a focus on hospital services and included oxygen ecosystem elements (pulse oximeters, oxygen, and advanced respiratory care). We converted qualitative questionnaire answers into quantitative ordinal variables and used standard statistics for analysis. RESULTS At baseline, we found all 12 questionnaire domains demonstrate both hospital preparedness and weakness in infection prevention and control. Key baseline gaps were lack of a dedicated team, and insufficient personal protective equipment and space for donning and doffing. Substantial limitations were noted in hypoxemia diagnosis and treatment; information management and care coordination pathways were also suboptimal. Targeted follow-up after 5 months revealed improvement in the availability of pulse oximetry, oxygen capacity, and heated high-flow nasal cannula devices. CONCLUSION Our baseline findings may reflect uneven early pandemic care quality; targeted follow-up suggests strengthening of the oxygen ecosystem.
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Affiliation(s)
| | | | | | - M Ranyali
- Ministry of Health, Maseru, Government of Lesotho
| | | | | | - E D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Chew R, Zhang M, Chandna A, Lubell Y. The impact of pulse oximetry on diagnosis, management and outcomes of acute febrile illness in low-income and middle-income countries: a systematic review. BMJ Glob Health 2021; 6:bmjgh-2021-007282. [PMID: 34824136 PMCID: PMC8627405 DOI: 10.1136/bmjgh-2021-007282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/08/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Acute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such patients but is poorly detected by clinical examination. Therefore, including pulse oximetry in the assessment of acutely febrile patients may improve clinical outcomes in LMIC settings. METHODS We systematically reviewed studies of any design comparing one group where pulse oximetry was used and at least one group where it was not. The target population was patients of any age presenting with acute febrile illness or associated syndromes in LMICs. Studies were obtained from searching PubMed, EMBASE, CABI Global Health, Global Index Medicus, CINAHL, Cochrane CENTRAL, Web of Science and DARE. Further studies were identified through searches of non-governmental organisation websites, snowballing and input from a Technical Advisory Panel. Outcomes of interest were diagnosis, management and patient outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 tool for Cluster Randomised Trials and Risk of Bias in Non-randomized Studies of Interventions tools, as appropriate. RESULTS Ten of 4898 studies were eligible for inclusion. Their small number and heterogeneity prevented formal meta-analysis. All studies were in children, eight only recruited patients with pneumonia, and nine were conducted in Africa or Australasia. Six were at serious risk of bias. There was moderately strong evidence for the utility of pulse oximetry in diagnosing pneumonia and identifying severe disease requiring hospital referral. Pulse oximetry used as part of a quality-assured facility-wide package of interventions may reduce pneumonia mortality, but studies assessing this endpoint were at serious risk of bias. CONCLUSIONS Very few studies addressed this important question. In LMICs, pulse oximetry may assist clinicians in diagnosing and managing paediatric pneumonia, but for the greatest impact on patient outcomes should be implemented as part of a health systems approach. The evidence for these conclusions is not widely generalisable and is of poor quality.
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Affiliation(s)
- Rusheng Chew
- Economics and Implementation Research Group, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Meiwen Zhang
- Economics and Implementation Research Group, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Arjun Chandna
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
| | - Yoel Lubell
- Economics and Implementation Research Group, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Kumar H, Sarin E, Saboth P, Jaiswal A, Chaudhary N, Mohanty JS, Bisht N, Tomar SS, Gupta A, Panda R, Patel R, Kumar A, Gupta S, Alwadhi V. Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India. Clin Med Insights Pediatr 2021; 15:11795565211056649. [PMID: 34803419 PMCID: PMC8600550 DOI: 10.1177/11795565211056649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/10/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device. DESIGN The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained. SETTING Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall. PARTICIPANTS Under-5 children presenting with ARI symptoms at the OPD. RESULTS Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting. CONCLUSION Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.
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Ranjit S, Kissoon N. Challenges and Solutions in translating sepsis guidelines into practice in resource-limited settings. Transl Pediatr 2021; 10:2646-2665. [PMID: 34765491 PMCID: PMC8578780 DOI: 10.21037/tp-20-310] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large global burden of sepsis including challenges in quantifying attributable morbidity and mortality, poverty, inadequate awareness, health inequity, under-resourced public health, and low-resilient acute health care delivery systems. Context-specific approaches to this significant problem are necessary on account of important differences in populations at-risk, the nature of infecting pathogens, and the healthcare capacity to manage sepsis in LMIC. We review these challenges and propose an outline of some solutions to tackle them which include strengthening the healthcare systems, accurate and early identification of sepsis the need for inclusive research and context-specific treatment guidelines, and advocacy. Specifically, strengthening pediatric intensive care units (PICU) services can effectively treat the life-threatening complications of common diseases, such as diarrhoea, respiratory infections, severe malaria, and dengue, thereby improving the quality of pediatric care overall without the need for expensive interventions. A thoughtful approach to developing paediatric intensive care services in LMICs begins with basic fundamentals: training healthcare providers in knowledge and skills, selecting effective equipment that is resource-appropriate, and having an enabling leadership to provide location-appropriate care. These basics, if built in sustainable manner, have the potential to permit an efficient pediatric critical care service to be established that can significantly improve sepsis and other critical care outcomes.
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Affiliation(s)
- Suchitra Ranjit
- Senior Consultant and Head, Pediatric ICU, Apollo Children's Hospital, Chennai, India
| | - Niranjan Kissoon
- Children's and Women's Global Health, UBC & BC Children's Hospital Professor in Critical Care - Global Child Health, Department of Pediatrics and Emergency Medicine, UBC, Child and Family Research Institute, Vice President Global Sepsis Alliance, Vancouver, Canada
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20
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Tuti T, Aluvaala J, Akech S, Agweyu A, Irimu G, English M. Pulse oximetry adoption and oxygen orders at paediatric admission over 7 years in Kenya: a multihospital retrospective cohort study. BMJ Open 2021; 11:e050995. [PMID: 34493522 PMCID: PMC8424839 DOI: 10.1136/bmjopen-2021-050995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/13/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen. DESIGN A multihospital retrospective cohort study. SETTINGS All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020. OUTCOMES Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors. RESULTS Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO2 <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO2 <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia. CONCLUSION The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact.
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Affiliation(s)
- Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine and Department of Paediatrics, University of Oxford, Oxford, UK
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21
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Graham HR, Olojede OE, Bakare AA, Iuliano A, Olatunde O, Isah A, Osebi A, Ahmed T, Uchendu OC, Burgess R, McCollum E, Colbourn T, King C, Falade AG. Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria. BMJ Glob Health 2021; 6:bmjgh-2021-006069. [PMID: 34344666 PMCID: PMC8336153 DOI: 10.1136/bmjgh-2021-006069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/24/2021] [Indexed: 12/20/2022] Open
Abstract
The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure 'oxygen access'. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO2 documented) and negligible in private facilities (2%, 3/177) and primary health centres (<1%, 2/608). We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. However, triangulation of existing data suggested that no facilities were equipped to meet minimum oxygen demands. We highlight the importance of a multifaceted approach to measuring oxygen access that assesses access at the point-of-care and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, MCRI, University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia .,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Omotayo E Olojede
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria.,Institute for Global Health, Karolinska Institute, Stockholm, Sweden
| | - Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | - Oyaniyi Olatunde
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Adamu Isah
- Save the Children Nigeria, Abuja, FCT, Nigeria
| | - Adams Osebi
- Save the Children Nigeria, Abuja, FCT, Nigeria
| | | | - Obioma C Uchendu
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria.,Department of Community Medicine, University of Ibadan, Ibadan, Oyo, Nigeria
| | - Rochelle Burgess
- Institute for Global Health, University College London, London, UK
| | - Eric McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Carina King
- Institute for Global Health, University College London, London, UK.,Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Oyo, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Oyo, Nigeria
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22
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Baker K, Petzold M, Mucunguzi A, Wharton-Smith A, Dantzer E, Habte T, Matata L, Nanyumba D, Okwir M, Posada M, Sebsibe A, Nicholson J, Marasciulo M, Izadnegahdar R, Alfvén T, Källander K. Performance of five pulse oximeters to detect hypoxaemia as an indicator of severe illness in children under five by frontline health workers in low resource settings - A prospective, multicentre, single-blinded, trial in Cambodia, Ethiopia, South Sudan, and Uganda. EClinicalMedicine 2021; 38:101040. [PMID: 34368660 PMCID: PMC8326731 DOI: 10.1016/j.eclinm.2021.101040] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Low blood oxygen saturation (SpO2), or hypoxaemia, is an indicator of severe illness in children. Pulse oximetry is a globally accepted, non-invasive method to identify hypoxaemia, but rarely available outside higher-level facilities in resource-constrained countries. This study aims to evaluate the performance of different types of pulse oximeters amongst frontline health workers in Cambodia, Ethiopia, South Sudan, and Uganda. METHODS Five pulse oximeters (POx) which passed laboratory testing, out of an initial 32 potential pulse oximeters, were evaluated by frontline health workers for performance, defined as agreement between the SpO2 measurements of the test device and the reference standard. The study protocol is registered with the Australia New Zealand Clinical Trials Registry (Ref: ACTRrn12615000348550). FINDINGS Two finger-tip pulse oximeters (Contec and Devon), two handheld pulse oximeters (Lifebox and Utech), and one phone pulse oximeter (Masimo) passed the laboratory testing. They were evaluated for performance on 1,313 children under five years old by 207 frontline health workers between February and May 2015. Phone and handheld pulse oximeters had greater overall agreement with the reference standard (56%; 95% CI 0.52 - 0.60 to 68%; 95% CI 0.65 - 0.71) than the finger-tip POx (31%; 95% CI 0.26 to 0.36 and 47%; 95% CI 0.42 to 0.52). Fingertip POx performance was substantially lower in the 0-2 month olds; having just 17% and 25% agreement. The finger-tip devices more often underreported SpO2 readings (mean difference -7.9%; 95%CI -8.6,-7.2 and -3.9%; 95%CI -4.4,-3.4), and therefore over diagnosed hypoxaemia in the children assessed. INTERPRETATION While the Masimo phone pulse oximeter performed best, all handheld POx with age-specific probes performed well in the hands of frontline health workers, further highlighting their suitability as a screening tool of severe illness. The poor performance of the fingertip POx suggests they should not be used in children under five by frontline health workers. It is essential that POx are performance tested on children in routine settings (in vivo), not only in laboratories or controlled settings (in vitro), before being introduced at scale. FUNDING Bill & Melinda Gates Foundation [OPP1054367].
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Affiliation(s)
- Kevin Baker
- Malaria Consortium, London, United Kingdom
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Corresponding author at: Kevin Baker, Malaria Consortium, The Green House, 244-254 Cambridge Heath Road, London, E2 9DA
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | | | | | | | | | | | | | | | | | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Sachs’ Children and Youth Hospital, Stockholm, Sweden
| | - Karin Källander
- Malaria Consortium, London, United Kingdom
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Programme Division, Health Section, UNICEF, New York, United States
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23
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Graham HR, Maher J, Bakare AA, Nguyen CD, Ayede AI, Oyewole OB, Gray A, Izadnegahdar R, Duke T, Falade AG. Oxygen systems and quality of care for children with pneumonia, malaria and diarrhoea: Analysis of a stepped-wedge trial in Nigeria. PLoS One 2021; 16:e0254229. [PMID: 34237107 PMCID: PMC8266122 DOI: 10.1371/journal.pone.0254229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/22/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To evaluate the effect of improved hospital oxygen systems on quality of care (QOC) for children with severe pneumonia, severe malaria, and diarrhoea with severe dehydration. DESIGN Stepped-wedge cluster randomised trial (unblinded), randomised at hospital-level. SETTING 12 hospitals in south-west Nigeria. PARTICIPANTS 7,141 children (aged 28 days to 14 years) admitted with severe pneumonia, severe malaria or diarrhoea with severe dehydration between January 2014 and October 2017. INTERVENTIONS Phase 1 (pulse oximetry) introduced pulse oximetry for all admitted children. Phase 2 (full oxygen system) (i) standardised oxygen equipment package, (ii) clinical education and support, (iii) technical training and support, and (iv) infrastructure and systems support. OUTCOME MEASURES We used quantitative QOC scores evaluating assessment, diagnosis, treatment, and monitoring practices against World Health Organization and Nigerian standards. We evaluated mean differences in QOC scores between study periods (baseline, oximetry, full oxygen system), using mixed-effects linear regression. RESULTS 7,141 eligible participants; 6,893 (96.5%) had adequate data for analysis. Mean paediatric QOC score (maximum 6) increased from 1.64 to 3.00 (adjusted mean difference 1.39; 95% CI 1.08-1.69, p<0.001) for severe pneumonia and 2.81 to 4.04 (aMD 1.53; 95% CI 1.23-1.83, p<0.001) for severe malaria, comparing the full intervention to baseline, but did not change for diarrhoea with severe dehydration (aMD -0.12; 95% CI -0.46-0.23, p = 0.501). After excluding practices directly related to pulse oximetry and oxygen, we found aMD 0.23 for severe pneumonia (95% CI -0.02-0.48, p = 0.072) and 0.65 for severe malaria (95% CI 0.41-0.89, p<0.001) comparing full intervention to baseline. Sub-analysis showed some improvements (and no deterioration) in care processes not directly related to oxygen or pulse oximetry. CONCLUSION Improvements in hospital oxygen systems were associated with higher QOC scores, attributable to better use of pulse oximetry and oxygen as well as broader improvements in clinical care, with no negative distortions in care practices. TRIAL REGISTRATION ACTRN12617000341325.
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Affiliation(s)
- Hamish R. Graham
- Centre for International Child Health, The Royal Children’s Hospital, MCRI, University of Melbourne, Parkville, Australia
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- * E-mail:
| | - Jaclyn Maher
- Department of Paediatrics, Royal Children’s Hospital, University of Melbourne, Parkville, Australia
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Cattram D. Nguyen
- Department of Paediatrics, Royal Children’s Hospital, University of Melbourne, Parkville, Australia
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, The Royal Children’s Hospital, MCRI, University of Melbourne, Parkville, Australia
| | - Rasa Izadnegahdar
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Trevor Duke
- Centre for International Child Health, The Royal Children’s Hospital, MCRI, University of Melbourne, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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24
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Huang Y, Mian Q, Conradi N, Opoka RO, Conroy AL, Namasopo S, Hawkes MT. Estimated Cost-effectiveness of Solar-Powered Oxygen Delivery for Pneumonia in Young Children in Low-Resource Settings. JAMA Netw Open 2021; 4:e2114686. [PMID: 34165579 PMCID: PMC8226423 DOI: 10.1001/jamanetworkopen.2021.14686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE Pneumonia is the leading cause of childhood mortality worldwide. Severe pneumonia associated with hypoxemia requires oxygen therapy; however, access remains unreliable in low- and middle-income countries. Solar-powered oxygen delivery (solar-powered O2) has been shown to be a safe and effective technology for delivering medical oxygen. Examining the cost-effectiveness of this innovation is critical for guiding implementation in low-resource settings. OBJECTIVE To determine the cost-effectiveness of solar-powered O2 for treating children in low-resource settings with severe pneumonia who require oxygen therapy. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation study of solar-powered O2 was conducted from January 12, 2020, to February 27, 2021, in compliance with the World Health Organization Choosing Interventions That Are Cost-Effective (WHO-CHOICE) guidelines. Using existing literature, plausible ranges for component costs of solar-powered O2 were determined in order to calculate the expected total cost of implementation. The costs of implementing solar-powered O2 at a single health facility in low- and middle-income countries was analyzed for pediatric patients younger than 5 years who required supplemental oxygen. EXPOSURES Treatment with solar-powered O2. MAIN OUTCOMES AND MEASURES The incremental cost-effectiveness ratio (ICER) of solar-powered O2 was calculated as the additional cost per disability-adjusted life-year (DALY) saved. Sensitivity of the ICER to uncertainties of input parameters was assessed through univariate and probabilistic sensitivity analyses. RESULTS The ICER of solar-powered O2 was estimated to be $20 (US dollars) per DALY saved (95% CI, $2.83-$206) relative to the null case (no oxygen). Costs of solar-powered O2 were alternatively quantified as $26 per patient treated and $542 per life saved. Univariate sensitivity analysis found that the ICER was most sensitive to the volume of pediatric pneumonia admissions and the case fatality rate. The ICER was insensitive to component costs of solar-powered O2 systems. In secondary analyses, solar-powered O2 was cost-effective relative to grid-powered concentrators (ICER $140 per DALY saved) and cost-saving relative to fuel generator-powered concentrators (cost saving of $7120). CONCLUSIONS AND RELEVANCE The results of this economic evaluation suggest that solar-powered O2 is a cost-effective solution for treating hypoxemia in young children in low- and middle-income countries, relative to no oxygen. Future implementation should prioritize sites with high rates of pediatric pneumonia admissions and mortality. This study provides economic support for expansion of solar-powered O2 and further assessment of its efficacy and mortality benefit.
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Affiliation(s)
| | - Qaasim Mian
- University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Nicholas Conradi
- University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis
| | - Sophie Namasopo
- Department of Paediatrics, Kabale District Hospital, Kabale, Uganda
| | - Michael T. Hawkes
- University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Canada
- University of Alberta School of Public Health, Edmonton, Canada
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25
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Baker K, Ward C, Maurel A, de Cola MA, Smith H, Getachew D, Habte T, McWhorter C, LaBarre P, Karlstrom J, Ameha A, Tariku A, Black J, Bassat Q, Källander K. Usability and acceptability of a multimodal respiratory rate and pulse oximeter device in case management of children with symptoms of pneumonia: A cross-sectional study in Ethiopia. Acta Paediatr 2021; 110:1620-1632. [PMID: 33220086 PMCID: PMC8246879 DOI: 10.1111/apa.15682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/10/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022]
Abstract
Aim Pneumonia is the leading infectious cause of death among children under five globally. Many pneumonia deaths result from inappropriate treatment due to misdiagnosis of signs and symptoms. This study aims to identify whether health extension workers (HEWs) in Ethiopia, using an automated multimodal device (Masimo Rad‐G), adhere to required guidelines while assessing and classifying under five children with cough or difficulty breathing and to understand device acceptability. Methods A cross‐sectional study was conducted in three districts of Southern Nations, Nationalities, and Peoples' Region, Ethiopia. Between September and December 2018, 133 HEWs were directly observed using Rad‐G while conducting 599 sick child consultations. Usability was measured as adherence to the World Health Organization requirements to assess fast breathing and device manufacturer instructions for use. Acceptability was assessed using semi‐structured interviews with HEWs, first‐level health facility workers and caregivers. Results Adherence using the Rad‐G routinely for 2 months was 85.3% (95% CI 80.2, 89.3). Health workers and caregivers stated a preference for Rad‐G. Users highlighted a number of device design issues. Conclusion While demonstrating high levels of acceptability and usability, the device modifications to consider include better probe fit, improved user interface with exclusive age categories and simplified classification outcomes.
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Affiliation(s)
- Kevin Baker
- Malaria Consortium London UK
- Department of Global Public Health Karolinska Institutet Solna Sweden
| | | | | | | | | | | | | | | | | | | | | | | | - Jim Black
- Nossal Institute for Global Health Melbourne School of Population and Global Health The University of Melbourne Parkville Vic. Australia
| | - Quique Bassat
- ISGlobal Hospital Clínic ‐ Universitat de Barcelona Barcelona Spain
- Centro de Investigação em Saúde de Manhiça (CISM) Maputo Mozambique
- ICREA Barcelona Spain
- Paediatric Infectious Diseases Unit Paediatrics Department Hospital Sant Joan de Déu (University of Barcelona) Barcelona Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP) Madrid Spain
| | - Karin Källander
- Malaria Consortium London UK
- Department of Global Public Health Karolinska Institutet Solna Sweden
- Programme Division UNICEF New York NY USA
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26
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Graham HR, Bagayana SM, Bakare AA, Olayo BO, Peterson SS, Duke T, Falade AG. Improving Hospital Oxygen Systems for COVID-19 in Low-Resource Settings: Lessons From the Field. Glob Health Sci Pract 2020; 8:858-862. [PMID: 33361248 PMCID: PMC7784072 DOI: 10.9745/ghsp-d-20-00224] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/21/2020] [Indexed: 01/10/2023]
Abstract
Oxygen therapy is an essential medicine and core component of effective hospital systems. However, many hospitals in low- and middle-income countries lack reliable oxygen access-a deficiency highlighted and exacerbated by the coronavirus disease (COVID-19) pandemic. Oxygen access can be challenged by equipment that is low quality and poorly maintained, lack of clinical and technical training and protocols, and deficiencies in local infrastructure and policy environment. We share learnings from 2 decades of oxygen systems work with hospitals in Africa and the Asia-Pacific regions, highlighting practical actions that hospitals can take to immediately expand oxygen access. These include strategies to: (1) improve pulse oximetry and oxygen use, (2) support biomedical engineers to optimize existing oxygen supplies, and (3) expand on existing oxygen systems with robust equipment and smart design. We make all our resources freely available for use and local adaptation.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Melbourne, Australia. .,Department of Paediatrics, University College Hospital, Ibadan, Oyo, Nigeria
| | - Sheillah M Bagayana
- FREO2 Uganda, FREO2 Foundation, Kampala, Uganda.,Biomedical consultant, Uganda Ministry of Health, Kampala, Uganda
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Oyo, Nigeria.,Oxygen for Life Initiative, Oyo, Nigeria
| | | | - Stefan S Peterson
- Chief of Health, United Nations Children's Fund, New York, NY, USA.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,School of Public Health, Makerere University, Kampala, Uganda
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Melbourne, Australia.,School of Medicine and Health Sciences, University of Papua New Guinea, National Capital District, Papua New Guinea
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Oyo, Nigeria.,Oxygen for Life Initiative, Oyo, Nigeria
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Graham HR, Bagayana SM, Bakare AA, Olayo BO, Peterson SS, Duke T, Falade AG. Improving Hospital Oxygen Systems for COVID-19 in Low-Resource Settings: Lessons From the Field. Glob Health Sci Pract 2020. [PMID: 33361248 DOI: 10.9745/ghsp-d-20-00224.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Oxygen therapy is an essential medicine and core component of effective hospital systems. However, many hospitals in low- and middle-income countries lack reliable oxygen access-a deficiency highlighted and exacerbated by the coronavirus disease (COVID-19) pandemic. Oxygen access can be challenged by equipment that is low quality and poorly maintained, lack of clinical and technical training and protocols, and deficiencies in local infrastructure and policy environment. We share learnings from 2 decades of oxygen systems work with hospitals in Africa and the Asia-Pacific regions, highlighting practical actions that hospitals can take to immediately expand oxygen access. These include strategies to: (1) improve pulse oximetry and oxygen use, (2) support biomedical engineers to optimize existing oxygen supplies, and (3) expand on existing oxygen systems with robust equipment and smart design. We make all our resources freely available for use and local adaptation.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Melbourne, Australia. .,Department of Paediatrics, University College Hospital, Ibadan, Oyo, Nigeria
| | - Sheillah M Bagayana
- FREO2 Uganda, FREO2 Foundation, Kampala, Uganda.,Biomedical consultant, Uganda Ministry of Health, Kampala, Uganda
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Oyo, Nigeria.,Oxygen for Life Initiative, Oyo, Nigeria
| | | | - Stefan S Peterson
- Chief of Health, United Nations Children's Fund, New York, NY, USA.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,School of Public Health, Makerere University, Kampala, Uganda
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Melbourne, Australia.,School of Medicine and Health Sciences, University of Papua New Guinea, National Capital District, Papua New Guinea
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Oyo, Nigeria.,Oxygen for Life Initiative, Oyo, Nigeria
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Graham H, Bakare AA, Ayede AI, Oyewole OB, Gray A, Neal E, Qazi SA, Duke T, Falade AG. Diagnosis of pneumonia and malaria in Nigerian hospitals: A prospective cohort study. Pediatr Pulmonol 2020; 55 Suppl 1:S37-S50. [PMID: 32074408 PMCID: PMC7318580 DOI: 10.1002/ppul.24691] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pneumonia and malaria are the leading causes of global childhood mortality. We describe the clinical presentation of children diagnosed with pneumonia and/or malaria, and identify possible missed cases and diagnostic predictors. METHODS Prospective cohort study involving children (aged 28 days to 15 years) admitted to 12 secondary-level hospitals in south-west Nigeria, from November 2015 to October 2017. We described children diagnosed with malaria and/or pneumonia on admission and identified potential missed cases using WHO criteria. We used logistic regression models to identify associations between clinical features and severe pneumonia and malaria diagnoses. RESULTS Of 16 432 admitted children, 16 184 (98.5%) had adequate data for analysis. Two-thirds (10 561, 65.4%) of children were diagnosed with malaria and/or pneumonia by the admitting doctor; 31.5% (567/1799) of those with pneumonia were also diagnosed with malaria. Of 1345 (8.3%) children who met WHO severe pneumonia criteria, 557 (41.4%) lacked a pneumonia diagnosis. Compared with "potential missed" diagnoses of severe pneumonia, children with "detected" severe pneumonia were more likely to receive antibiotics (odds ratio [OR], 4.03; 2.63-6.16, P < .001), and less likely to die (OR, 0.72; 0.51-1.02, P = .067). Of 2299 (14.2%) children who met WHO severe malaria criteria, 365 (15.9%) lacked a malaria diagnosis. Compared with "potential missed" diagnoses of severe malaria, children with "detected" severe malaria were less likely to die (OR, 0.59; 0.38-0.91, P = 0.017), with no observed difference in antimalarial administration (OR, 0.29; 0.87-1.93, P = .374). We identified predictors of severe pneumonia and malaria diagnosis. CONCLUSION Pneumonia should be considered in all severely unwell children with respiratory signs, regardless of treatment for malaria or other conditions.
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Affiliation(s)
- Hamish Graham
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Oladapo B Oyewole
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Amy Gray
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Eleanor Neal
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.,Infection & Immunity, MCRI, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Trevor Duke
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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Fashanu C, Mekonnen T, Amedu J, Onwundiwe N, Adebiyi A, Omokere O, Olaleye T, Gartley M, Gansallo S, Lewu F, Okita A, Musa M, Abubakar A, Ojo T, Ja'afar A, Ekundayo AA, Abubakar ML, Schroder K, Battu A, Wiwa O, Houdek J, Lam F. Improved oxygen systems at hospitals in three Nigerian states: An implementation research study. Pediatr Pulmonol 2020; 55 Suppl 1:S65-S77. [PMID: 32130796 DOI: 10.1002/ppul.24694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Hypoxemia is a life-threatening condition and is commonly seen in children with severe pneumonia. A government-led, NGO-supported, multifaceted oxygen improvement program was implemented to increase access to oxygen therapy in 29 hospitals in Kaduna, Kano, and Niger states. The program installed pulse oximeters and oxygen concentrators, trained health care workers, and biomedical engineers (BMEs), and provided regular feedback to health care staff through quality improvement teams. OBJECTIVE The aim of this study is to evaluate whether the program increased screening for hypoxemia with pulse oximetry and prescription of oxygen for patients with hypoxemia. METHODOLOGY The study is an uncontrolled before-after interventional study implemented at the hospital level. Medical charts of patients under 5 admitted for pneumonia between January 2017 and August 2018 were reviewed and information on patient care was extracted using a standardized form. The preintervention period of this study was defined as 1 January to 31 October 2017 and the postintervention period as 1 February to 31 August 2018. The primary outcomes of the study were whether blood-oxygen saturation measurements (SpO2 ) were documented and whether children with hypoxemia were prescribed oxygen. RESULTS A total of 3418 patient charts were reviewed (1601 during the preintervention period and 1817 during the postintervention period). There was a significant increase in the proportion of patients with SpO2 measurements after the interventions were conducted (adjusted odds ratio [aOR] 5.0; 4.3-5.7, P < .001). Before the interventions, only 13.7% (95% confidence interval [CI]: 12.2-15.3) of patients had SpO2 measurements and after the interventions, 82.4% (95% CI: 80.7-84.1) had SpO2 measurements. Oxygen administration for patients with clinical signs of hypoxemia also increased significantly (aOR 5.0; 4.2-5.9, P < .001)-from 22.8% (95% CI: 18.8-27.2) to 77.9% (95% CI: 73.9-81.5). CONCLUSION Increasing pulse oximetry and oxygen therapy access and utilization in a low-resourced environment is achievable through a multifaceted program focused on strengthening government-owned systems.
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Affiliation(s)
| | | | - Joseph Amedu
- Department of Hospital Services, Federal Ministry of Health, Abuja, Nigeria.,Department of Family Health, Federal Ministry of Health, Abuja, Nigeria
| | - Ngozi Onwundiwe
- Department of Hospital Services, Federal Ministry of Health, Abuja, Nigeria.,Department of Family Health, Federal Ministry of Health, Abuja, Nigeria
| | - Adebimpe Adebiyi
- Department of Hospital Services, Federal Ministry of Health, Abuja, Nigeria.,Department of Family Health, Federal Ministry of Health, Abuja, Nigeria
| | - Oluseyi Omokere
- Department of Hospital Services, Federal Ministry of Health, Abuja, Nigeria.,Department of Family Health, Federal Ministry of Health, Abuja, Nigeria
| | - Tayo Olaleye
- Clinton Health Access Initiative, Abuja, Nigeria
| | | | | | - Funsho Lewu
- Clinton Health Access Initiative, Abuja, Nigeria
| | | | - Mahmud Musa
- Clinton Health Access Initiative, Abuja, Nigeria
| | | | - Tolulope Ojo
- Clinton Health Access Initiative, Abuja, Nigeria
| | | | | | | | - Kate Schroder
- Clinton Health Access Initiative, Boston, Massachusetts
| | - Audrey Battu
- Clinton Health Access Initiative, Boston, Massachusetts
| | - Owens Wiwa
- Clinton Health Access Initiative, Abuja, Nigeria
| | - Jason Houdek
- Clinton Health Access Initiative, Boston, Massachusetts
| | - Felix Lam
- Clinton Health Access Initiative, Boston, Massachusetts
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King C, Iuliano A, Burgess RA, Agwai I, Ahmar S, Aranda Z, Bahiru S, Bakare AA, Colbourn T, Shittu F, Graham H, Isah A, McCollum ED, Falade AG. A mixed-methods evaluation of stakeholder perspectives on pediatric pneumonia in Nigeria-priorities, challenges, and champions. Pediatr Pulmonol 2020; 55 Suppl 1:S25-S33. [PMID: 31985139 DOI: 10.1002/ppul.24607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/28/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Interventions to reduce pneumonia mortality exist; however, stakeholder engagement is needed to prioritize these. We explored diverse stakeholder opinions on current policy challenges and priorities for pediatric pneumonia in Nigeria. METHODS We conducted a mixed-methods study, with a web-survey and semi-structured interviews, to explore stakeholder roles, policy barriers, opportunities, and priorities. Web-survey participants were identified through stakeholder mapping, including researchers' networks, academic and grey literature, and "Every Breath Counts" coalition membership. Stakeholders included actors involved in pediatric pneumonia in Nigeria from non-governmental, government, academic, civil society, private, and professional organizations. Stakeholder interviews were conducted with local government, healthcare managers, professional associations, and local leaders in Lagos and Jigawa states. Quantitative data were analyzed descriptively; qualitative data were analyzed using a thematic framework. RESULTS Of 111 stakeholders, 38 (34%) participated in the web-survey and 18 stakeholder interviews were conducted. Four thematic areas emerged: current policy, systems barriers, intervention priorities, and champions. Interviewees reported a lack of pneumonia-specific policies, despite acknowledging guidelines had been adopted in their settings. Barriers to effective pneumonia management were seen at all levels of the system, from the community to healthcare to policy, with key issues of resourcing and infrastructure. Intervention priorities were the strengthening of community knowledge and improving case management, focused on primary care. While stakeholders identified several key actors for pediatric pneumonia, they also highlighted a lack of champions. CONCLUSION Consistent messages emerged to prioritize community and primary care initiatives, alongside improved access to oxygen, and pulse oximetry. There is a need for clear pneumonia policies, and support for adoption at a state level.
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Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
| | - Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | | | - Imaria Agwai
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Zeus Aranda
- Institute for Global Health, University College London, London, UK
| | | | - Ayobami A Bakare
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Funmilayo Shittu
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Hamish Graham
- International Child Health, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adamu Isah
- Save the Children International, Abuja, Nigeria
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adegoke G Falade
- Department of Paediatrics, University of Ibadan and University College Hospital, Ibadan, Nigeria
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Iuliano A, Aranda Z, Colbourn T, Agwai IC, Bahiru S, Bakare AA, Burgess RA, Cassar C, Shittu F, Graham H, Isah A, McCollum ED, Falade AG, King C, On Behalf Of The Inspiring Project Consortium. The burden and risks of pediatric pneumonia in Nigeria: A desk-based review of existing literature and data. Pediatr Pulmonol 2020; 55 Suppl 1:S10-S21. [PMID: 31985170 DOI: 10.1002/ppul.24626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/22/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pneumonia is a leading killer of children under-5 years, with a high burden in Nigeria. We aimed to quantify the regional burden and risks of pediatric pneumonia in Nigeria, and specifically the states of Lagos and Jigawa. METHODS We conducted a scoping literature search for studies of pneumonia morbidity and mortality in under-5 children in Nigeria from 10th December 2018 to 26th April 2019, searching: Cochrane, PubMed, and Web of Science. We included grey literature from stakeholders' websites and information shared by organizations working in Nigeria. We conducted multivariable logistic regression using the 2016 to 2017 Multiple Cluster Indicators Survey data set to explore factors associated with pneumonia. Descriptive analyses of datasets from 2010 to 2019 was done to estimate trends in mortality, morbidity, and vaccination coverage. RESULTS We identified 25 relevant papers (10 from Jigawa, 8 from Lagos, and 14 national data). None included data on pneumonia or acute respiratory tract infection burden in the health system, inpatient case-fatality rates, severity, or age-specific pneumonia mortality rates at state level. Secondary data analysis found that no household or caregiver socioeconomic indicators were consistently associated with self-reported symptoms of cough and/or difficulty breathing, and seasonality was inconsistently associated, dependant on region. CONCLUSION There is a clear evidence gap around the burden of pediatric pneumonia in Nigeria, and challenges with the interpretation of existing household survey data. Improved survey approaches are needed to understand the risks of pediatric pneumonia in Nigeria, alongside the need for investment in reliable routine data systems to provide data on the clinical pneumonia burden in Nigeria.
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Affiliation(s)
- Agnese Iuliano
- Institute for Global Health, University College London, London, UK
| | - Zeus Aranda
- Institute for Global Health, University College London, London, UK
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Imaria C Agwai
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | - Funmilayo Shittu
- Department of Health Promotion and Education, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
| | - Hamish Graham
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adamu Isah
- Save the Children International, Abuja, Nigeria
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adegoke G Falade
- Department of Paediatrics, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Carina King
- Institute for Global Health, University College London, London, UK.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Walker PJB, Bakare AA, Ayede AI, Oluwafemi RO, Olubosede OA, Olafimihan IV, Tan K, Duke T, Falade AG, Graham H. Using intermittent pulse oximetry to guide neonatal oxygen therapy in a low-resource context. Arch Dis Child Fetal Neonatal Ed 2020; 105:316-321. [PMID: 31462405 PMCID: PMC7363784 DOI: 10.1136/archdischild-2019-317630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/31/2019] [Accepted: 08/08/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of intermittent pulse oximetry in guiding oxygen therapy in neonates in a low-resource setting. DESIGN AND SETTING Prospective validation study at three hospitals in southwest Nigeria. We performed concealed continuous pulse oximetry on participants to evaluate intermittent SpO2 monitoring. PATIENTS We recruited all preterm or low birthweight neonates, and all term neonates who required oxygen therapy, who were admitted to the neonatal ward(s) of the study hospitals during the study period. MAIN OUTCOME MEASURES Proportion of time preterm/low birthweight neonates on oxygen spent within, above and below the target SpO2 range of 90%-95%; and the proportion of time term neonates and neonates not on oxygen spent within and below the target range of 90%-100%. RESULTS Preterm/low birthweight neonates receiving oxygen therapy (group A) spent 15.7% (95% CI 13.3 to 18.9) of time in the target SpO2 range of 90%-95%. They spent 75.0% (63.6-81.1) of time above 95%, and 2.7% (1.7-5.6) of time below 85%. Term neonates and all neonates not receiving oxygen (group B) spent 97.3% (95% CI 96.4 to 98.6) of time within the target range of 90%-100%, and 0.9% (0.3-1.4) of time below 85%. Guidelines recommended SpO2 monitoring 3 times per day for all patients, however neonates in groups A and B were monitored an average of 4.7 and 5.3 times per day, respectively. CONCLUSIONS To better maintain SpO2 within the target range, preterm/low birthweight neonates on oxygen should have their SpO2 monitored more frequently than the current 4.7 times per day. In all other neonates, however, monitoring SpO2 5.3 times per day appears suitable.
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Affiliation(s)
- Patrick James Berkeley Walker
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia .,Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Ayobami Adebayo Bakare
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria,University College Hospital Ibadan, Ibadan, Nigeria
| | | | | | | | | | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Trevor Duke
- Intensive Care Unit and University of Melbourne Department of Paediatrics, Royal Children's Hospital, Parkville, Victoria, Australia,Department of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Adegoke Gbadegesin Falade
- College of Medicine, University of Ibadan, Ibadan, Nigeria,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Hamish Graham
- Centre for International Child Health, University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia
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Abstract
PURPOSE OF REVIEW This review focuses on the emerging body of literature regarding the management of acute respiratory failure in low- and middle-income countries (LMICs). The aim is to abstract management principles that are of relevance across a variety of settings where resources are severely limited. RECENT FINDINGS Mechanical ventilation is an expensive intervention associated with considerable mortality and a high rate of iatrogenic complications in many LMICs. Recent case series report crude mortality rates for ventilated patients of between 36 and 72%. Measures to avert the need for invasive mechanical ventilation in LMICs are showing promise: bubble continuous positive airway pressure has been demonstrated to decrease mortality in children with acute respiratory failure and trials suggest that noninvasive ventilation can be conducted safely in settings where resources are low. SUMMARY The management of patients with acute respiratory failure in LMICs should focus on avoiding intubation where possible, improving the safety of mechanical ventilation and expediting weaning. Future directions should involve the development and trialing of robust and context-appropriate respiratory support technology.
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Orchard J, Li J, Gallagher R, Freedman B, Lowres N, Neubeck L. Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice. BMC Fam Pract 2019; 20:170. [PMID: 31810441 DOI: 10.1186/s12875-019-1058-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/22/2019] [Indexed: 11/17/2022]
Abstract
Background Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016–June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice. Methods A realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory. Results GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP ‘screening champion’ had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated. Conclusions Introducing an AF screening program is likely to be successful in contexts where there is a senior GP ‘screening champion’, a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke. Trial registrations AF SMART (metropolitan): ACTRN12616000850471 (Australia New Zealand Clinical Trials Registry). AF SMART II (rural): ACTRN12618000004268 (Australia New Zealand Clinical Trials Registry).
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35
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Conradi N, Mian Q, Namasopo S, Conroy AL, Hermann LL, Olaro C, Amone J, Opoka RO, Hawkes MT. Solar-powered oxygen delivery for the treatment of children with hypoxemia: protocol for a cluster-randomized stepped-wedge controlled trial in Uganda. Trials 2019; 20:679. [PMID: 31805985 PMCID: PMC6896330 DOI: 10.1186/s13063-019-3752-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 09/24/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Child mortality due to pneumonia is a major global health problem and is associated with hypoxemia. Access to safe and continuous oxygen therapy can reduce mortality; however, low-income countries may lack the necessary resources for oxygen delivery. We have previously demonstrated proof-of-concept that solar-powered oxygen (SPO2) delivery can reliably provide medical oxygen remote settings with minimal access to electricity. This study aims to demonstrate the efficacy of SPO2 in children hospitalized with acute hypoxemic respiratory illness across Uganda. METHODS Objectives: Demonstrate efficacy of SPO2 in children hospitalized with acute hypoxemic respiratory illness. STUDY DESIGN Multi-center, stepped-wedge cluster-randomized trial. SETTING Twenty health facilities across Uganda, a low-income, high-burden country for pediatric pneumonia. Site selection: Facilities with pediatric inpatient services lacking consistent O2 supply on pediatric wards. PARTICIPANTS Children aged < 5 years hospitalized with hypoxemia (saturation < 92%) warranting hospital admission based on clinical judgement. Randomization methods: Random installation order generated a priori with allocation concealment. Study procedure: Patients receive standard of care within pediatric wards with or without SPO2 system installed. OUTCOME MEASURES Primary: 48-h mortality. Secondary: safety, efficacy, SPO2 system functionality, operating costs, nursing knowledge, skills, and retention for oxygen administration. Statistical analysis of primary outcome: Linear mixed effects logistic regression model with 48-h mortality (dependent variable) as a function of SPO2 treatment (before versus after installation), while adjusting for confounding effects of calendar time (fixed effect) and site (random effect). SAMPLE SIZE 2400 patients across 20 health facilities, predicted to provide 80% power to detect a 35% reduction in mortality after introduction of SPO2, based on a computer simulation of > 5000 trials. DISCUSSION Overall, our study aims to demonstrate mortality benefit of SPO2 relative to standard (unreliable) oxygen delivery. The innovative trial design (stepped-wedge, cluster-randomized) is supported by a computer simulation. Capacity building for nursing care and oxygen therapy is a non-scientific objective of the study. If successful, SPO2 could be scaled across a variety of resource-constrained remote or rural settings in sub-Saharan Africa and beyond. TRIAL REGISTRATION Clinicaltrials.gov, NCT03851783. Registered on 22 February 2019.
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Affiliation(s)
- Nicholas Conradi
- Department of Pediatrics, University of Alberta, 3-588D Edmonton Clinic Health Academy, 11405 87 Ave NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Qaasim Mian
- Department of Pediatrics, University of Alberta, 3-588D Edmonton Clinic Health Academy, 11405 87 Ave NW, Edmonton, Alberta, T6G 1C9, Canada
| | | | | | | | | | | | - Robert O Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda
| | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, 3-588D Edmonton Clinic Health Academy, 11405 87 Ave NW, Edmonton, Alberta, T6G 1C9, Canada.
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Canada.
- School of Public Health, University of Alberta, Edmonton, Canada.
- Stollery Science Lab, Edmonton, Canada.
- Women and Children's Health Research Institute, Edmonton, Canada.
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Enoch AJ, English M, McGivern G, Shepperd S. Variability in the use of pulse oximeters with children in Kenyan hospitals: A mixed-methods analysis. PLoS Med 2019; 16:e1002987. [PMID: 31891572 PMCID: PMC6938307 DOI: 10.1371/journal.pmed.1002987] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/21/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use. METHODS AND FINDINGS We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups. CONCLUSIONS There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized.
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Affiliation(s)
- Abigail J Enoch
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom (former DPhil student)
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Gerald McGivern
- Warwick Business School, University of Warwick, Coventry, United Kingdom
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Graham HR, Bakare AA, Ayede AI, Gray AZ, McPake B, Peel D, Olatinwo O, Oyewole OB, Neal EFG, Nguyen CD, Qazi SA, Izadnegahdar R, Carlin JB, Falade AG, Duke T. Oxygen systems to improve clinical care and outcomes for children and neonates: A stepped-wedge cluster-randomised trial in Nigeria. PLoS Med 2019; 16:e1002951. [PMID: 31710601 PMCID: PMC6844455 DOI: 10.1371/journal.pmed.1002951] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/11/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Improving oxygen systems may improve clinical outcomes for hospitalised children with acute lower respiratory infection (ALRI). This paper reports the effects of an improved oxygen system on mortality and clinical practices in 12 general, paediatric, and maternity hospitals in southwest Nigeria. METHODS AND FINDINGS We conducted an unblinded stepped-wedge cluster-randomised trial comparing three study periods: baseline (usual care), pulse oximetry introduction, and stepped introduction of a multifaceted oxygen system. We collected data from clinical records of all admitted neonates (<28 days old) and children (28 days to 14 years old). Primary analysis compared the full oxygen system period to the pulse oximetry period and evaluated odds of death for children, children with ALRI, neonates, and preterm neonates using mixed-effects logistic regression. Secondary analyses included the baseline period (enabling evaluation of pulse oximetry introduction) and evaluated mortality and practice outcomes on additional subgroups. Three hospitals received the oxygen system intervention at 4-month intervals. Primary analysis included 7,716 neonates and 17,143 children admitted during the 2-year stepped crossover period (November 2015 to October 2017). Compared to the pulse oximetry period, the full oxygen system had no association with death for children (adjusted odds ratio [aOR] 1.06; 95% confidence interval [CI] 0.77-1.46; p = 0.721) or children with ALRI (aOR 1.09; 95% CI 0.50-2.41; p = 0.824) and was associated with an increased risk of death for neonates overall (aOR 1.45; 95% CI 1.04-2.00; p = 0.026) but not preterm/low-birth-weight neonates (aOR 1.30; 95% CI 0.76-2.23; p = 0.366). Secondary analyses suggested that the introduction of pulse oximetry improved oxygen practices prior to implementation of the full oxygen system and was associated with lower odds of death for children with ALRI (aOR 0.33; 95% CI 0.12-0.92; p = 0.035) but not for children, preterm neonates, or neonates overall (aOR 0.97, 95% CI 0.60-1.58, p = 0.913; aOR 1.12, 95% CI 0.56-2.26, p = 0.762; aOR 0.90, 95% CI 0.57-1.43, p = 0.651). Limitations of our study are a lower-than-anticipated power to detect change in mortality outcomes (low event rates, low participant numbers, high intracluster correlation) and major contextual changes related to the 2016-2017 Nigerian economic recession that influenced care-seeking and hospital function during the study period, potentially confounding mortality outcomes. CONCLUSIONS We observed no mortality benefit for children and a possible higher risk of neonatal death following the introduction of a multifaceted oxygen system compared to introducing pulse oximetry alone. Where some oxygen is available, pulse oximetry may improve oxygen usage and clinical outcomes for children with ALRI. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12617000341325.
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Affiliation(s)
- Hamish R. Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Amy Z. Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Parkville, Australia
| | | | - Olatayo Olatinwo
- Biomedical Services, University College Hospital, Ibadan, Nigeria
| | | | - Eleanor F. G. Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
- Asia-Pacific Health, New Vaccines, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Cattram D. Nguyen
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Australia
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Rasa Izadnegahdar
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - John B. Carlin
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
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Graham H, Bakare AA, Ayede AI, Oyewole OB, Gray A, Peel D, McPake B, Neal E, Qazi SA, Izadnegahdar R, Duke T, Falade AG. Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals. EClinicalMedicine 2019; 16:51-63. [PMID: 31832620 PMCID: PMC6890969 DOI: 10.1016/j.eclinm.2019.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria. METHODS We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not). FINDINGS Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming ∼3500 L of oxygen per admission. INTERPRETATION Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children.
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Affiliation(s)
- Hamish Graham
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Corresponding author at: Centre for International Child Health, Department of Paediatrics, Level 2 East, 50 Flemington Road, Parkville, VIC 3052, Australia.
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | | | - Barbara McPake
- Nossal Institute of Global Health, University of Melbourne, Parkville, Australia
| | - Eleanor Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Pneumococcal Research, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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39
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Gilmore B. Realist evaluations in low- and middle-income countries: reflections and recommendations from the experiences of a foreign researcher. BMJ Glob Health 2019; 4:e001638. [PMID: 31749993 PMCID: PMC6830045 DOI: 10.1136/bmjgh-2019-001638] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 09/06/2019] [Accepted: 09/11/2019] [Indexed: 11/04/2022] Open
Abstract
Realist evaluation, a methodology for exploring generative causation within complex health interventions to understand 'how, why and for whom' programmes work, is experiencing a surge of interest. Trends indicate that the proliferation in the use of this methodology also applies to research in low- and middle-income countries (LMICs). The value of using realist evaluation for project evaluation is also being noticed by non-governmental organisations (NGOs) and other programme implementers within such contexts. Yet, there is limited exploration of the use of realist evaluations in LMICs, especially their use by foreign researchers. This paper draws on the author's experience of conducting two realist evaluations across three different sub-Saharan African settings: Mundemu, Tanzania; Kabale, Uganda and Marsabit, Kenya. The realist evaluations were used as an operations research methodology to study two NGO community health programmes. This paper highlights four main challenges experienced by the author throughout the methodological process: (1) power imbalances prevalent during realist interviews, (2) working through translation and what this means for identfying Context-Mechanism-Outcome Configurations, (3) limited contextual familiarity and being an 'engaged researcher' and (4) the use or dependence on 'WEIRD' theories (i.e. theories based on the study of Western, Educated, Industrialized, Rich, Democratic people) within testing and refinement. Realist evaluation's enticing and straightforward slogan of finding 'what works, for whom and why' is in contrast to the complexity of the methodology used to generate these results (and often to the results themselves). Striking a balance between theory and pragmatism, while adhering to realist ontological underpinnings of generative causation and retroduction, is no easy task. This paper concludes by providing concrete recommendations for those who want to undertake a realist evaluation, with particular attention to cross-cultural settings, in light of the aforementioned challenges. In doing so, it aims to foster improved methodological rigour and help those engaging in this research methodology to work towards more appropriate and contextually relevant findings.
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Affiliation(s)
- Brynne Gilmore
- Centre for Global Health, Trinity College Dublin, University of Dublin, Dublin, Ireland
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40
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King C, Mvalo T, Sessions K, Wilson I, Walker I, Zadutsa B, Makwenda C, Phiri T, Boyd N, Bernstein M, McCollum ED. Performance of a novel reusable pediatric pulse oximeter probe. Pediatr Pulmonol 2019; 54:1052-1059. [PMID: 30912314 PMCID: PMC6591029 DOI: 10.1002/ppul.24295] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/23/2019] [Accepted: 02/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the performance of reusable pulse oximeter probe and microprocessor box combinations, of varying price-points, in the context of a low-income pediatric setting. METHODS A prospective, randomized cross-over study comparing time to biologically plausible oxygen saturation (SpO2 ) between: (1) Lifebox LB-01 probe with Masimo Rad-87 box (L + M) and (2) a weight-appropriate reusable Masimo probe with Masimo Rad-87 box (M + M). A post hoc secondary analysis comparison with historical usability testing data with the Lifebox LB-01 probe and Lifebox V1.5 box (L + L) was also conducted. Participants, children aged 0 to 35 months, were recruited from pediatric wards and outpatient clinics in the central region of Malawi. The primary outcome was time taken to achieve a biologically plausible SpO 2 measurement, compared using t tests for equivalence. RESULTS We recruited 572 children. Plausible SpO2 measurements were obtained in less than 1 minute, 71%, 70%, and 63% for the M + M, L + M, and L + L combinations, respectively. A similar pattern was seen for less than 2 minutes, however, this effect disappeared at less than 5 minutes with 96%, 96%, and 95% plausible measurements. Using a ±10 second threshold for equivalence, we found L + M and M + M to be equivalent, but were under-powered to assess equivalence for L + L. CONCLUSIONS The novel reusable pediatric Lifebox probe can achieve a quality SpO2 measurement within a pragmatic time range of weight-appropriate Masimo equivalent probes. Further research, which considers the cost of the devices, is needed to assess the added value of sophisticated motion tolerance software.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, UK.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi.,Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | | | | | - Isabeau Walker
- Lifebox Foundation, London, UK.,Great Ormond Street Hospital, London, UK.,Institute for Child Health, University College London, London, UK
| | | | | | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Nicholas Boyd
- King's Sierra Leona Partnership, Freetown, Sierra Leone
| | | | - Eric D McCollum
- Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Tolla HS, Letebo M, Asemere YA, Belete AB, Tumbule TC, Fekadu ZF, Woyessa DB, Ameha S, Feyisa YM, Lam F. Use of pulse oximetry during initial assessments of children under five with pneumonia: a retrospective cross-sectional study from 14 hospitals in Ethiopia. J Glob Health Rep 2019; 3:JOGHR-03-2019016. [PMID: 33409377 PMCID: PMC7771585 DOI: 10.29392/joghr.3.e2019016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Hypoxemia, a fatal condition characterized by low concentration of oxygen in
the blood, is strongly associated with death among children with pneumonia.
Ethiopia’s Federal Ministry of Health launched its first National
Oxygen and Pulse Oximetry Scale-up road map to improve access and
utilization of pulse oximetry and oxygen. This study aimed to describe the
use of pulse oximetry during the initial patient assessment among children
under five diagnosed with pneumonia and serves as a benchmark to measure
progress of the road map. Methods The study design was an observational study using retrospective review of
patient medical records at 14 hospitals. Medical records of 443 children age
0-59 months with a primary diagnosis of pneumonia were randomly selected for
review. The primary outcome was whether an arterial blood oxygen saturation
(SpO2) measurement was recorded in the patient’s
medical record at the initial assessment. Results Overall, 10% (95% confidence interval CI = 4%-22%) of patient medical records
had a SpO2 measurement. Admitted patients were more likely to
have a SpO2 measurement recorded in their medical records than
patients treated in the outpatient department
(P<0.01). Among admitted patients, 19% (95% CI =
8%-38%) had a SpO2 measurement compared to 3% (95% CI = 1%-11%)
of patients treated in the outpatient department. Conclusion In Ethiopia, patients under five with a primary diagnosis of pneumonia are
rarely screened for hypoxemia with a pulse oximeter, and hypoxemia may be
severely underdiagnosed. Much needs to be done to improve the routine use of
pulse oximetry.
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Affiliation(s)
| | | | | | | | | | | | | | - Simret Ameha
- Ethiopia Federal Ministry of Health, Addis Ababa, Ethiopia
| | | | - Felix Lam
- Clinton Health Access Initiative, Boston, Massachusetts, USA
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42
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Zhang J, Tüshaus L, Nuño Martínez N, Moreo M, Verastegui H, Hartinger SM, Mäusezahl D, Karlen W. Data Integrity-Based Methodology and Checklist for Identifying Implementation Risks of Physiological Sensing in Mobile Health Projects: Quantitative and Qualitative Analysis. JMIR Mhealth Uhealth 2018; 6:e11896. [PMID: 30552079 PMCID: PMC6315242 DOI: 10.2196/11896] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/14/2018] [Accepted: 11/22/2018] [Indexed: 01/21/2023] Open
Abstract
Background Mobile health (mHealth) technologies have the potential to bring health care closer to people with otherwise limited access to adequate health care. However, physiological monitoring using mobile medical sensors is not yet widely used as adding biomedical sensors to mHealth projects inherently introduces new challenges. Thus far, no methodology exists to systematically evaluate these implementation challenges and identify the related risks. Objective This study aimed to facilitate the implementation of mHealth initiatives with mobile physiological sensing in constrained health systems by developing a methodology to systematically evaluate potential challenges and implementation risks. Methods We performed a quantitative analysis of physiological data obtained from a randomized household intervention trial that implemented sensor-based mHealth tools (pulse oximetry combined with a respiratory rate assessment app) to monitor health outcomes of 317 children (aged 6-36 months) that were visited weekly by 1 of 9 field workers in a rural Peruvian setting. The analysis focused on data integrity such as data completeness and signal quality. In addition, we performed a qualitative analysis of pretrial usability and semistructured posttrial interviews with a subset of app users (7 field workers and 7 health care center staff members) focusing on data integrity and reasons for loss thereof. Common themes were identified using a content analysis approach. Risk factors of each theme were detailed and then generalized and expanded into a checklist by reviewing 8 mHealth projects from the literature. An expert panel evaluated the checklist during 2 iterations until agreement between the 5 experts was achieved. Results Pulse oximetry signals were recorded in 78.36% (12,098/15,439) of subject visits where tablets were used. Signal quality decreased for 1 and increased for 7 field workers over time (1 excluded). Usability issues were addressed and the workflow was improved. Users considered the app easy and logical to use. In the qualitative analysis, we constructed a thematic map with the causes of low data integrity. We sorted them into 5 main challenge categories: environment, technology, user skills, user motivation, and subject engagement. The obtained categories were translated into detailed risk factors and presented in the form of an actionable checklist to evaluate possible implementation risks. By visually inspecting the checklist, open issues and sources for potential risks can be easily identified. Conclusions We developed a data integrity–based methodology to assess the potential challenges and risks of sensor-based mHealth projects. Aiming at improving data integrity, implementers can focus on the evaluation of environment, technology, user skills, user motivation, and subject engagement challenges. We provide a checklist to assist mHealth implementers with a structured evaluation protocol when planning and preparing projects.
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Affiliation(s)
- Jia Zhang
- Mobile Health Systems Lab, Institute of Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Laura Tüshaus
- Mobile Health Systems Lab, Institute of Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Néstor Nuño Martínez
- Department of Epidemiology & Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Monica Moreo
- Mobile Health Systems Lab, Institute of Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | | | - Stella M Hartinger
- Department of Epidemiology & Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Daniel Mäusezahl
- Department of Epidemiology & Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Walter Karlen
- Mobile Health Systems Lab, Institute of Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
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