Admissions to a low resource neonatal unit in Malawi using The NeoTree application: A digital perinatal outcome audit

Background: Mobile-health has increasing potential to address health outcomes in under-resourced settings as smart-phone coverage increases. The NeoTree is a mobile-health application co-developed in Malawi to improve the quality of newborn care at the point of admission to neonatal units. While collecting vital demographic and clinical data this interactive platform provides clinical decision-support, and training for the end-users (health care workers (HCW)), according to evidence based national and international guidelines. Objective: Our aims were to examine one month of data collected using the NeoTree in an outcome audit of babies admitted to a district-level neonatal nursery in Malawi and to demonstrate proof of concept of digital audit data in this setting. Methods: Using a phased approach over one month (21 Nov – 19 Dec, 2016), frontline HCWs were trained and supported to use the NeoTree to admit newborns. Discharge data were collected by the research team using a discharge form within the NeoTree ‘NeoDischarge’. Descriptive analysis was conducted on the exported pseudonomysed data and presented to the newborn care department as a digital audit. Results: Of 191 total admissions, 134 (70%) admissions were completed using the NeoTree and 129 (67%) were exported and analysed. Of these 129, 102 (79%) were discharged alive. Overall case fatality rate was 93 per 1000 admitted babies. Prematurity with respiratory distress syndrome, Birth Asphyxia, and Neonatal sepsis contributed to 41.6%, 58.3% and 16.6% of deaths respectively. Deaths may have been under-reported due to phased implementation and some families of babies with imminent deaths self-discharging home. Detailed characterisation of the data enabled departmental discussion of modifiable factors for quality improvement, for example improved thermoregulation of infants. Conclusions: This digital outcome audit demonstrates that data can be captured digitally at the bedside by HCWs in under-resourced newborn facilities and these data can contribute to meaningful review of quality of care/outcomes and potential modifiable factors. Coverage may be improved during future implementation by streamlining the admission process to be solely via digital format. Our results present a new methodology for newborn audit in low-resource settings and are a proof of concept for a novel newborn data system in these settings

Semiclassical transmission across transition states

It is shown that the probability of quantum-mechanical transmission across a phase space bottleneck can be compactly approximated using an operator derived from a complex Poincar\'e return map. This result uniformly incorporates tunnelling effects with classically-allowed transmission and generalises a result previously derived for a classically small region of phase space.Comment: To appear in Nonlinearit

The NeoTree application: developing an integrated mHealth solution to improve quality of newborn care and survival in a district hospital in Malawi

More than two-thirds of newborn lives could be saved worldwide if evidence-based interventions were successfully implemented. We developed the NeoTree application to improve quality of newborn care in resource-poor countries. The NeoTree is a fully integrated digital health intervention that combines immediate data capture, entered by healthcare workers (HCW) on admission, while simultaneously providing them with evidence-based clinical decision support and newborn care education. We conducted a mixed-methods intervention development study, codeveloping and testing the NeoTree prototype with HCWs in a district hospital in Malawi. Focus groups explored the acceptability and feasibility of digital health solutions before and after implementation of the NeoTree in the clinical setting. One-to-one theoretical usability workshops and a 1-month clinical usability study informed iterative changes, gathered process and clinical data, System Usability Scale (SUS) and perceived improvements in quality of care. HCWs perceived the NeoTree to be acceptable and feasible. Mean SUS before and after the clinical usability study were high at 80.4 and 86.1, respectively (above average is >68). HCWs reported high-perceived improvements in quality of newborn care after using the NeoTree on the ward. They described improved confidence in clinical decision-making, clinical skills, critical thinking and standardisation of care. Identified factors for successful implementation included a technical support worker. Coproduction, mixed-methods approaches and user-focused iterative development were key to the development of the NeoTree prototype, which was shown to be an agile, acceptable, feasible and highly usable tool with the potential to improve the quality of newborn care in resource-poor settings

Protocol for an intervention development and pilot implementation evaluation study of an e-health solution to improve newborn care quality and survival in two low-resource settings, Malawi and Zimbabwe: Neotree.

INTRODUCTION: Every year 2.4 million deaths occur worldwide in babies younger than 28 days. Approximately 70% of these deaths occur in low-resource settings because of failure to implement evidence-based interventions. Digital health technologies may offer an implementation solution. Since 2014, we have worked in Bangladesh, Malawi, Zimbabwe and the UK to develop and pilot Neotree: an android app with accompanying data visualisation, linkage and export. Its low-cost hardware and state-of-the-art software are used to improve bedside postnatal care and to provide insights into population health trends, to impact wider policy and practice. METHODS AND ANALYSIS: This is a mixed methods (1) intervention codevelopment and optimisation and (2) pilot implementation evaluation (including economic evaluation) study. Neotree will be implemented in two hospitals in Zimbabwe, and one in Malawi. Over the 2-year study period clinical and demographic newborn data will be collected via Neotree, in addition to behavioural science informed qualitative and quantitative implementation evaluation and measures of cost, newborn care quality and usability. Neotree clinical decision support algorithms will be optimised according to best available evidence and clinical validation studies. ETHICS AND DISSEMINATION: This is a Wellcome Trust funded project (215742_Z_19_Z). Research ethics approvals have been obtained: Malawi College of Medicine Research and Ethics Committee (P.01/20/2909; P.02/19/2613); UCL (17123/001, 6681/001, 5019/004); Medical Research Council Zimbabwe (MRCZ/A/2570), BRTI and JREC institutional review boards (AP155/2020; JREC/327/19), Sally Mugabe Hospital Ethics Committee (071119/64; 250418/48). Results will be disseminated via academic publications and public and policy engagement activities. In this study, the care for an estimated 15 000 babies across three sites will be impacted. TRIAL REGISTRATION NUMBER: NCT0512707; Pre-results

Wigner's Dynamical Transition State Theory in Phase Space: Classical and Quantum

A quantum version of transition state theory based on a quantum normal form (QNF) expansion about a saddle-centre-...-centre equilibrium point is presented. A general algorithm is provided which allows one to explictly compute QNF to any desired order. This leads to an efficient procedure to compute quantum reaction rates and the associated Gamov-Siegert resonances. In the classical limit the QNF reduces to the classical normal form which leads to the recently developed phase space realisation of Wigner's transition state theory. It is shown that the phase space structures that govern the classical reaction d ynamicsform a skeleton for the quantum scattering and resonance wavefunctions which can also be computed from the QNF. Several examples are worked out explicitly to illustrate the efficiency of the procedure presented.Comment: 132 pages, 31 figures, corrected version, Nonlinearity, 21 (2008) R1-R11

Talking South African fathers: a critical examination of men’s constructions and experiences of fatherhood and fatherlessness

The absence of biological fathers in South Africa has been constructed as a problem for children of both sexes but more so for boy-children. Arguably the dominant discourse in this respect has demonized non-nuclear, female-headed households. Fathers are constructed as either absent or ‘bad’. Thus it has become important to explore more closely how male care-givers have been experienced by groups of men in South Africa. This article examines discourses of fatherhood and fatherlessness by drawing on qualitative interviews with a group of 29 men who speak about their reported experiences and understandings of being fathered or growing up without biological fathers. Two major and intertwined subjugated discourses about adult men’s experiences of being fathered that counter- balance the prevailing discourses about meaning of fatherhood and fatherlessness became evident, namely, ‘being always there’ and ‘talking fatherhood’. The importance of the experience of fatherhood as ‘being there’, which relates to a quality of time and relationship between child and father rather than physical time together, is illustrated. It is not only biological fathers who can ‘be there’ for their sons but also social fathers, other significant male role models and father figures who step in at different times in participants’ lives when biological fathers are unavailable for whatever reason. Second, many positive experiences of fathers or father figures that resist a traditional role of authority and control and subscribe to more nurturant and non-violent forms of care, represented as ‘talking’ fathers, are underlined. If we are to better understand the impact of colonial and apartheid history and its legacy on family life in contemporary society, there is a need for more historically and contextually informed studies on the meaning of fatherhood and fatherlessness.Web of Scienc

'Family comes in all forms, blood or not': disrupting dominant narratives around the patriarchal nuclear family

After nearly 25 years of democracy, lives of young South Africans are still profoundly shaped by the legacies of apartheid. This paper considers how these differences are produced, maintained and disrupted through an exploration of changing narratives developed by a small group of South African pre-service teachers, with a particular focus on the narratives developed around discourses of fatherhood generally and absent fathers in particular. We draw on interviews conducted with three students in which we discussed their digital stories and literature reviews. In this paper, we draw attention to the limitations of digital storytelling and the risks such autobiographical storytelling presents of perpetuating dominant narratives that maintain and reproduce historical inequalities. At the same time, in highlighting ways in which this risk might be confronted, the paper also aims to show the possibilities in which these dominant narratives may be challenged.IBS

Dominance through Coercion: Strategic Rhetorical Balancing and the Tactics of Justification in Afghanistan and Libya

This article analyses British and American justifications for military intervention in the decade following 9/11. Taking Afghanistan in 2001 and Libya in 2011 as the main case studies, the article explores the ways in which political elites attempt to achieve policy dominance through rhetorical coercion, whereby potential opponents are left unable to formulate a socially sustainable rebuttal. Specifically, in these case studies, the article explores the use of strategic rhetorical balancing, whereby secondary rationales for intervention are emphasized as part of a tactic of justification designed to secure doubters' acquiescence by narrowing the discursive space in which an alternative counter-narrative could be successfully and sustainably formulated