Implementation research on management of sick young infants with possible serious bacterial infection when referral is not possible in Jimma Zone, Ethiopia: Challenges and solutions

Introduction Of 2.5 million newborn deaths each year, serious neonatal infections are a leading cause of neonatal death for which inpatient treatment is recommended. However, manysick newborns in sub-Saharan Africa and south Asia do not have access to inpatientcare. A World Health Organization (WHO) guideline recommends simplified antibiotic treatment atan outpatient level for young infants up to two months of age with possible serious bacterial infection (PSBI), when referral is not feasible.We implemented this guidelinein Ethiopia to increase coverage of treatment and to learn about potential facilitating factors and barriers for implementation. Methods We conducted implementation research in two districts (Tiro Afata and Gera) in Jimma Zone, Ethiopia, to learn about the feasibility of implementing the WHO PSBI guideline within a programme setting using the existing health care structure. We conducted orientation meetings and policy dialogue with key stakeholders and trained health extension workers and health centre staff to identify and manage sick young infants with PSBI signs at a primary health care unit. We established a Technical Support Unit (TSU) to facilitate programme learning, built health workers’ capacity and provided support for quality control, monitoring and data collection.We sensitized the community to appropriate care-seeking and supported the health care system in implementation. The research team collected data using structured case recording forms. Results From September 2016 to August 2017, 6185 live births and 601 sick young infants 0–59 days of age with signs of PSBI were identified. Assuming that 25% of births were missed (total births 7731) and 10% of births had an episode of PSBI in the first two months of life, the coverage of appropriate treatment for PSBI was 77.7% (601/773). Of 601 infants with PSBI, fast breathing only (pneumonia) was recorded in 432 (71.9%) infants 7–59 days of age; signs of clinical severe infection (CSI) in 155 (25.8%) and critical illnessin 14 (2.3%). Of the 432 pneumonia cases who received oral amoxicillin treatment without referral, 419 (97.0%) were successfully treated without any deaths. Of 169 sick young infants with either CSI or critical illness, only 110 were referred to a hospital; 83 did not accept referral advice and received outpatient injectable gentamicin plus oral amoxicillin treatment either at a health post or health centre. Additionally, 59 infants who should have been referred, but were not received injectable gentamicin plus oral amoxicillin outpatient treatment. Of infants with CSI, 129 (82.2%) were successfully treated as outpatients, while two died (1.3%). Of 14 infants with critical illness, the caregivers of five accepted referral to a hospital, and nine were treated with simplified antibiotics on an outpatient basis. Two of 14 (14.3%) infants with critical illness died within 14 days of initial presentation. Conclusion In settings where referral to a hospital is not feasible, young infants with PSBI can be treated on an outpatient basis at either a health post or health centre, which can contribute to saving many lives. Scaling-up will require health system strengthening including community mobilization. Registration Trial is registered on Australian New Zealand Clinical Trials registry (ANZCTR) ACTRN12617001373369.

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Innovative approach for potential scale-up to jump-start simplified management of sick young infants with possible serious bacterial infection when a referral is not feasible: Findings from implementation research

PLoS ONE ◽

10.1371/journal.pone.0244192 ◽

2021 ◽

Vol 16 (2) ◽

pp. e0244192

Author(s):

Abadi Leul ◽

Tadele Hailu ◽

Loko Abraham ◽

Alemayehu Bayray ◽

Wondwossen Terefe ◽

...

Keyword(s):

Critical Illness ◽

Bacterial Infection ◽

Implementation Research ◽

Severe Infection ◽

World Health ◽

Policy Dialogue ◽

Health Post ◽

Live Births ◽

Young Infants ◽

Oral Amoxicillin

Background Neonatal bacterial infections are a common cause of death, which can be managed well with inpatient treatment. Unfortunately, many families in low resource settings do not accept referral to a hospital. The World Health Organization (WHO) developed a guideline for management of young infants up to 2 months of age with possible serious bacterial infection (PSBI) when referral is not feasible. Government of Ethiopia with WHO evaluated the feasibility of implementing this guideline to increase coverage of treatment. Objective The objective of this study was to implement a simplified antibiotic regimen (2 days gentamicin injection and 7 days oral amoxicillin) for management of sick young infants with PSBI in a programme setting when referral was not feasible to identify at least 80% of PSBI cases, achieve an overall adequate treatment coverage of at least 80% and document the challenges and opportunities for implementation at the community level in two districts in Tigray, Ethiopia. Methods Using implementation research, we applied the PSBI guideline in a programme setting from January 2016 to August 2017 in Raya Alamata and Raya Azebo Woredas (districts) in Southern Tigray, Ethiopia with a population of 260884. Policy dialogue was held with decision-makers, programme implementers and stakeholders at federal, regional and district levels, and a Technical Support Unit (TSU) was established. Health Extension Workers (HEWs) working at the health posts and supervisors working at the health centres were trained in WHO guideline to manage sick young infants when referral was not feasible. Communities were sensitized towards appropriate home care. Results We identified 854 young infants with any sign of PSBI in the study population of 7857 live births. The expected live births during the study period were 9821. Assuming 10% of neonates will have any sign of PSBI within the first 2 months of life (n = 982), the coverage of appropriate treatment of PSBI cases in our study area was 87% (854/982). Of the 854 sick young infants, 333 (39%) were taken directly to a hospital and 521 (61%) were identified by HEW at health posts. Of the 521 young infants, 27 (5.2%) had signs of critical illness, 181 (34.7%) had signs of clinical severe infection, whereas 313 (60.1%) young infants 7–59 days of age had only fast breathing pneumonia. All young infants with critical illness accepted referral to a hospital, while 117/181 (64.6%) infants with clinical severe infection accepted referral. Families of 64 (35.3%) infants with clinical severe infection refused referral and were treated at the health post with injectable gentamicin for 2 days plus oral amoxicillin for 7 days. All 64 completed recommended gentamicin doses and 63/64 (98%) completed recommended amoxicillin doses. Of 313 young infants, 7–59 days with pneumonia who were treated by the HEWs without referral with oral amoxicillin for 7 days, 310 (99%) received all 14 doses. No deaths were reported among those treated on an outpatient basis at health posts. But 35/477 (7%) deaths occurred among young infants treated at hospital. Conclusions When referral is not feasible, young infants with PSBI can be managed appropriately at health posts by HEWs in the existing health system in Ethiopia with high coverage, low treatment failure and a low case fatality rate. Moreover, fast breathing pneumonia in infants 7–59 days of age can be successfully treated at the health post without referral. Relatively higher mortality in sick young infants at the referral level health facilities warrants further investigation.

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Management of possible serious bacterial infection in young infants where referral is not possible in the context of existing health system structure in Ibadan, South-west Nigeria

PLoS ONE ◽

10.1371/journal.pone.0248720 ◽

2021 ◽

Vol 16 (3) ◽

pp. e0248720

Author(s):

Adejumoke Idowu Ayede ◽

Oluwakemi Oluwafunmi Ashubu ◽

Kayode Raphael Fowobaje ◽

Samira Aboubaker ◽

Yasir Bin Nisar ◽

...

Keyword(s):

Health Care ◽

Critical Illness ◽

Health System ◽

Severe Pneumonia ◽

Severe Infection ◽

Technical Support ◽

High Coverage ◽

Young Infants ◽

Oral Amoxicillin ◽

Primary Health

Introduction Neonatal infections contribute substantially to infant mortality in Nigeria and globally. Management requires hospitalization, which is not accessible to many in low resource settings. World Health Organization developed a guideline to manage possible serious bacterial infection (PSBI) in young infants up to two months of age when a referral is not feasible. We evaluated the feasibility of implementing this guideline to achieve high coverage of treatment. Methods This implementation research was conducted in out-patient settings of eight primary health care centres (PHC) in Lagelu Local Government Area (LGA) of Ibadan, Oyo State, Nigeria. We conducted policy dialogue with the Federal and State officials to adopt the WHO guideline within the existing programme setting and held orientation and sensitization meetings with communities. We established a Technical Support Unit (TSU), built the capacity of health care providers, supervised and mentored them, monitored the quality of services and collected data for management and outcomes of sick young infants with PSBI signs. The Primary Health Care Directorate of the state ministry and the local government led the implementation and provided technical support. The enablers and barriers to implementation were documented. Results From 1 April 2016 to 31 July 2017 we identified 5278 live births and of these, 1214 had a sign of PSBI. Assuming 30% of births were missed due to temporary migration to maternal homes for delivery care and approximately 45% cases came from outside the catchment area due to free availability of medicines, the treatment coverage was 97.3% (668 cases/6861 expected births) with an expected 10% PSBI prevalence within the first 2 months of life. Of 1214 infants with PSBI, 392 (32%) infants 7–59 days had only fast breathing (pneumonia), 338 (27.8%) infants 0–6 days had only fast breathing (severe pneumonia), 462 (38%) presented with signs of clinical severe infection (CSI) and 22 (1.8%) with signs of critical illness. All but two, 7–59 days old infants with pneumonia were treated with oral amoxicillin without a referral; 80% (312/390) adhered to full treatment; 97.7% (381/390) were cured, and no deaths were reported. Referral to the hospital was not accepted by 87.7% (721/822) families of infants presenting with signs of PSBI needing hospitalization (critical illness 5/22; clinical severe infection; 399/462 and severe pneumonia 317/338). They were treated on an outpatient basis with two days of injectable gentamicin and seven days of oral amoxicillin. Among these 81% (584/721) completed treatment; 97% (700/721) were cured, and three deaths were reported (two with critical illness and one with clinical severe infection). We identified health system gaps including lack of staff motivation and work strikes, medicines stockouts, sub-optimal home visits that affected implementation. Conclusions When a referral is not feasible, outpatient treatment for young infants with signs of PSBI is possible within existing programme structures in Nigeria with high coverage and low case fatality. To scale up this intervention successfully, government commitment is needed to strengthen the health system, motivate and train health workers, provide necessary commodities, establish technical support for implementation and strengthen linkages with communities. Registration Trial is registered on Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001373369.

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Lessons from implementation research on community management of Possible Serious Bacterial Infection (PSBI) in young infants (0-59 days), when the referral is not feasible in Palwal district of Haryana, India

PLoS ONE ◽

10.1371/journal.pone.0252700 ◽

2021 ◽

Vol 16 (7) ◽

pp. e0252700

Author(s):

Rupak Mukhopadhyay ◽

Narendra Kumar Arora ◽

Pradeep Kumar Sharma ◽

Suresh Dalpath ◽

Priya Limbu ◽

...

Keyword(s):

Bacterial Infection ◽

Implementation Research ◽

Implementation Strategies ◽

Technical Support ◽

Health Centers ◽

World Health ◽

Policy Dialogue ◽

Live Births ◽

Young Infants ◽

Oral Amoxicillin

Background Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality. Methodology The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0–59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs). Findings A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0–6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7–59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI. Conclusion The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7–59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7–59 days old fast breathers and recommend a review of the current national policy.

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Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study

BMJ Open ◽

10.1136/bmjopen-2020-047640 ◽

2021 ◽

Vol 11 (6) ◽

pp. e047640

Author(s):

Habtamu Beyene ◽

Dejene Hailu Kassa ◽

Henok Dangiso Tadele ◽

Lars Persson ◽

Atkure Defar ◽

...

Keyword(s):

Primary Care ◽

Severe Disease ◽

Health Centre ◽

Severe Illness ◽

Health Post ◽

Health Extension Workers ◽

Cross Sectional ◽

Factors Associated ◽

Young Infants ◽

Sick Children

Context and objectiveEthiopia’s primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0–59 months of age and evaluate the healthcare providers’ adherence to referral guidelines.DesignA cross-sectional facility-based survey.SettingThis study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child’s characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions.Outcome measureReferral to the nearest health centre of sick young infants aged 0–59 days and sick children 2–59 months.ResultsThe health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2–59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group.ConclusionFew children with severe illness were referred from health posts to health centres. Improving the health posts’ medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.

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Identification and management of young infants with possible serious bacterial infection where referral was not feasible in rural Lucknow district of Uttar Pradesh, India: An implementation research

PLoS ONE ◽

10.1371/journal.pone.0234212 ◽

2020 ◽

Vol 15 (6) ◽

pp. e0234212

Author(s):

Shally Awasthi ◽

Naveen Kesarwani ◽

Raj Kumar Verma ◽

Girdhar Gopal Agarwal ◽

Luxmi Shanker Tewari ◽

...

Keyword(s):

Bacterial Infection ◽

Implementation Research ◽

Uttar Pradesh ◽

Young Infants

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Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India

PLoS ONE ◽

10.1371/journal.pone.0243724 ◽

2020 ◽

Vol 15 (12) ◽

pp. e0243724

Author(s):

Nidhi Goyal ◽

Temsunaro Rongsen-Chandola ◽

Mangla Sood ◽

Bireshwar Sinha ◽

Amit Kumar ◽

...

Keyword(s):

Bacterial Infection ◽

Implementation Research ◽

Case Fatality Rate ◽

Case Fatality ◽

Severe Pneumonia ◽

Himachal Pradesh ◽

Care Seeking ◽

Fatality Rate ◽

Young Infants ◽

Facilitators And Barriers

Background Government of India and the World Health Organization have guidelines for outpatient management of young infants 0–59 days with signs of Possible Serious Bacterial Infection (PSBI), when referral is not feasible. Implementation research was conducted to identify facilitators and barriers to operationalizing these guidelines. Methods Himachal Pradesh government implemented the guidelines in program settings supported by Centre for Health Research and Development, Society for Applied Studies. The strategy included community sensitization, skill enhancement of Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) to identify PSBI and treat when referral was not feasible. The research team collected information on facilitators and barriers. A technical support unit provided training and oversight. Findings Among 1997 live births from June 2017 to January 2019, we identified 160 cases of PSBI in young infants resulting in a coverage of 80%, assuming an incidence of 10%. Of these,29(18.1%) had signs of critical illness (CI), 92 (57.5%) had clinical severe infection (CSI), 5 (3.1%)had severe pneumonia (only fast breathing in young infants 0–6 days), while 34 (21%) had pneumonia (only fast breathing in young infants 7–59 days). Hospital referral was accepted by 48/160 (30%), whereas 112/160 (70%) were treated with the simplified treatment regimens at primary level facilities. Of the 29 infants with CI, 18 (62%) accepted referral; 26 (90%) recovered while 3 (10%) who had accepted referral, died. Of the 92 infants who had CSI, 86 (93%) recovered, 65 (71%) received simplified treatment and one infant who had accepted referral, died. All the five infants who had severe pneumonia, recovered; 3 (60%) had received simplified treatment. Of the 34 pneumonia cases, 33 received simplified treatment of which 5 (15%) failed treatment; two out of these 5 died. Overall, 6/160 infants died (case-fatality-rate 3.4%); 2 in the simplified treatment (case-fatality-rate 1.8%) and 4 in the hospital group (case-fatality-rate 8.3%). Delayed identification and care-seeking by families and health system weaknesses like manpower gaps and interrupted supplies were challenges in implementation. Conclusions Implementation of the guidelines in program settings is possible and acceptable. Scaling up would require creating community awareness, early identification and appropriate care-seeking, strengthening ASHA home-visitation program, building skills and confidence of MOs and ANMs, uninterrupted supplies and a dependable referral system.

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Measurement Issues in Dissemination and Implementation Research

10.1093/oso/9780190683214.003.0014 ◽

2017 ◽

Cited By ~ 5

Author(s):

Cara C. Lewis ◽

Enola K. Proctor ◽

Ross C. Brownson

Keyword(s):

Health Care ◽

Implementation Research ◽

Health Care Access ◽

Healthcare Research ◽

Dissemination And Implementation ◽

Measurement Issues ◽

Care Access ◽

Dissemination And Implementation Science ◽

Dissemination And Implementation Research ◽

Access And Quality

The National Institutes of Health, the Agency for Healthcare Research and Quality, the CDC, and a number of private foundations have expressed the need for advancing the science of dissemination and implementation. Interest in dissemination and implementation research is present in many countries. Improving health care requires not only effective programs and interventions, but also effective strategies to move them into community based settings of care. But before discrete strategies can be tested for effectiveness, comparative effectiveness, or cost effectiveness, context and outcome constructs must be identified and defined in such a way that enables their manipulation and measurement. Measurement is underdeveloped, with few psychometrically strong measures and very little attention paid to their pragmatic nature. A variety of tools are needed to capture health care access and quality, and no measurement issues are more pressing than those for dissemination and implementation science.

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HUBUNGAN PENGETAHUAN DAN KINERJA KADER TERHADAP KUNJUNGAN BAYI BALITA KE POSYANDU DI PUSKESMAS LUBUK BAJA KOTA BATAM

Zona Kedokteran: Program Studi Pendidikan Dokter Universitas Batam ◽

10.37776/zked.v7i3.3 ◽

2019 ◽

Vol 7 (3) ◽

pp. 14-21

Author(s):

Siti Alfiah ◽

Rini Susanti

Keyword(s):

Health Care ◽

Health Care Workers ◽

Health Centre ◽

General Knowledge ◽

Knowledge Level ◽

Well Performance ◽

Chi Square ◽

Significance Level ◽

Care Workers ◽

And Performance

The success development in the health fields is concentrated at the attempts to reduce the mortality rate of infants and toddlers at the same time. The purpose of this research is to analyze whether there is a correlation between knowledge and performance of the health care workers to the number of the babies, specifically the ones under five years old, to visit the posyandu as an integral part of the Lubuk Baja Health Centre in Batam.This study is a descriptive analytic research with 56 respondentsthat covers all health care workers in the service area ofLubuk Baja Health Care. The data is analyzed using Chi Square statistical test at significance level of 95%. The result reveals that based on the respondentsâ€™ characteristic, it was obtained 56 respondents have good knowledge level and able to apply their knowledge to posyanduactivities. Besides, it is also noted that 44 respondents have well performance. On the other hand, the researchersdiscover 28 toddlers getgood treatment meanwhile 28 of them are not treated very well. Therefore, it can be concluded that there is no significant correlation between knowledge levels and performance of the health care workers to the number of theunder-five years children to visits the posyanduwhich indicated byÂ each of p> 0.05 for knowledge and performance. In general, knowledge and good performance of posyandu cadres and society surroundingsaretwo very important aspects to improvethe number of the children to attend the posyandu. As the suggestion, it is expected that theposyandu cadres and society to be more concerned about the presence of posyandufor benefit of the newborns as well as the enhancement of the health sciences for life.

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Water, Sanitation, and Hygiene Service Availability at Rural Health Care Facilities in Southwestern Uganda

Journal of Environmental and Public Health ◽

10.1155/2018/5403795 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Edgar Mugema Mulogo ◽

Micheal Matte ◽

Andrew Wesuta ◽

Fred Bagenda ◽

Richard Apecu ◽

...

Keyword(s):

Health Care ◽

Health Centre ◽

High Volume ◽

Health Care Facilities ◽

Hand Washing ◽

Service Availability ◽

Sanitation And Hygiene ◽

Care Facilities ◽

Improved Sanitation ◽

Southwestern Uganda

There is a paucity of information on the state of water, sanitation, and hygiene (WASH) at health care facilities in Uganda. A survey on WASH service availability was conducted at 50 health care facilities across 4 districts of rural southwestern Uganda between September and November 2015. The main water points at the majority (94%) of the health care facilities were improved sources, while improved toilets were available at 96% of the health care facilities visited. Hospitals had the poorest toilet to patient ratio (1 : 63). Only 38% of the health care facilities had hand washing facilities at the toilets. The lack of hand washing facilities was most prominent at the level IV health centre toilets (71%). Hand washing facilities were available at other points within most (76%) of the health care facilities. However, both water and soap were present at only 24% of these health care facilities. The poor toilet to patient/caregiver ratios particularly in the high volume health care facilities calls for the provision of cheaper options for improved sanitation in these settings. Priority should also be given to the sustainable provision of hygiene amenities such as soap for hand washing particularly the high patient volume health care facilities, in this case the level IV health centres and hospitals.

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