Caregiver perceptions of nutrition interventions in infants and children under 24 months of age: a systematic review

Abstract Objective: Efficacy studies show early nutrition interventions improving infant nutrition status, but understanding caregiver acceptability is required for implementation of such interventions. This systematic review examines caregivers’ perceptions of nutrition interventions in young children. Design: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL and PsychINFO from date of online journal inception through December 2020. Interventions included oral (powder/liquid/tablet) and/or intravenous supplementation, food fortification and nutrition counselling. Inclusion criteria included primary research, data presented on caregiver perception and studies published in English. Quality assessment was performed using the Critical Appraisal Skills Programme tool. Studies underwent narrative synthesis using inductive thematic analysis. Setting: No restriction. Participants: Caregivers of children under 24 months of age. Results: Of 11 798 records identified, thirty-seven publications were included. Interventions included oral supplementation, food fortification and nutrition counselling. Caregivers included mothers (83 %), fathers, grandparents and aunts. Perceptions were gathered through individual interviews, focus group discussions, questionnaires, surveys and ratings. Totally, 89 % of studies noted high acceptability (n 33 most notably increased appetite (n 17). In total, 57 % of studies (n 21) cited low acceptability, commonly from side effects (n 13) such as gastrointestinal issues, appetite loss and stained teeth. Conclusions: Positive perceptions and enthusiasm for interventions were frequently reported. Key to implementation was the increased appetite noted by caregivers. A substantial proportion of studies reported negative perceptions, mainly due to side effects. In future interventions, mitigation and education around common side effects are crucial for acceptability. Understanding both positive and negative caregiver perceptions is important for informing future nutrition interventions and strengthening sustainability and implementation

Pregnancy cohorts and biobanking in sub-Saharan Africa: a systematic review

Background: Technological advances and high throughput biological assays can facilitate discovery science in biobanks from population cohorts, including pregnant women. Biological pathways associated with health outcomes differ depending on geography, and high-income country data may not generalise to low-resource settings. We conducted a systematic review to identify prospective pregnancy cohorts in sub-Saharan Africa (SSA) that include biobanked samples with potential to enhance discovery science opportunity. Methods: Inclusion criteria were prospective data collection during pregnancy, with associated biobanking in SSA. Data sources included: scientific databases (with comprehensive search terms), grey literature, hand searching applicable reference lists and expert input. Results were screened in a three-stage process based on title, abstract and full text by two independent reviewers. The review is registered on PROSPERO (CRD42019147483). Results: Fourteen SSA studies met the inclusion criteria from database searches (n=8), reference list searches (n=2) and expert input (n=4). Three studies have ongoing data collection. The most represented countries were South Africa and Mozambique (Southern Africa) (n=3), Benin (Western Africa) (n=4) and Tanzania (Eastern Africa) (n=4); including an estimated 31 763 women. Samples commonly collected were blood, cord blood and placenta. Seven studies collected neonatal samples. Common clinical outcomes included maternal and perinatal mortality, malaria and preterm birth. Conclusions: Increasingly numerous pregnancy cohorts in SSA that include biobanking are generating a uniquely valuable resource for collaborative discovery science, and improved understanding of the high regional risks of maternal, fetal and neonatal morbidity and mortality. Future studies should align protocols and consider their added value and distinct contributions

Qualitative study exploring the feasibility, usability and acceptability of neonatal continuous monitoring technologies at a public tertiary hospital in Nairobi, Keny

Objective: To assess the feasibility, usability and acceptability of two non-invasive, multiparameter, continuous physiological monitoring (MCPM) technologies for use in neonates within a resource-constrained healthcare setting in sub-Saharan Africa. Design: A qualitative study using in-depth interviews and direct observations to describe healthcare professional and caregiver perspectives and experiences with investigational MCPM technologies from EarlySense and Sibel compared with selected reference technologies. Setting: Pumwani Maternity Hospital is a public, high-volume, tertiary hospital in Nairobi, Kenya. Participants: In-depth interviews were conducted with five healthcare administrators, 12 healthcare providers and 10 caregivers. Direct observations were made of healthcare providers using the technologies on 12 neonates overall. Results: Design factors like non-invasiveness, portability, ease-of-use and ability to measure multiple vital signs concurrently emerged as key themes supporting the usability and acceptability of the investigational technologies. However, respondents also reported feasibility challenges to implementation, including overcrowding in the neonatal unit, lack of reliable access to electricity and computers, and concerns about cost and maintenance needs. To improve acceptability, respondents highlighted the need for adequate staffing to appropriately engage caregivers and dispel misconceptions about the technologies. Conclusion: Study participants were positive about the usefulness of the investigational technologies to strengthen clinical care quality and identification of at-risk neonates for better access to timely interventions. These technologies have the potential to improve equity of access to appropriate healthcare services and neonatal outcomes in sub-Saharan African healthcare facilities. However, health system strengthening is also critical to support sustainable uptake of technologies into routine care

Acceptability and Feasibility of a Low-Cost Device for Gestational Age Assessment in a Low-Resource Setting: Qualitative Study

Background: Ultrasound for gestational age (GA) assessment is not routinely available in resource-constrained settings, particularly in rural and remote locations. The TraCer device combines a handheld wireless ultrasound probe and a tablet with artificial intelligence (AI)-enabled software that obtains GA from videos of the fetal head by automated measurements of the fetal transcerebellar diameter and head circumference. Objective: The aim of this study was to assess the perceptions of pregnant women, their families, and health care workers regarding the feasibility and acceptability of the TraCer device in an appropriate setting. Methods: A descriptive study using qualitative methods was conducted in two public health facilities in Kilifi county in coastal Kenya prior to introduction of the new technology. Study participants were shown a video role-play of the use of TraCer at a typical antenatal clinic visit. Data were collected through 6 focus group discussions (N=52) and 18 in-depth interviews. Results: Overall, TraCer was found to be highly acceptable to women, their families, and health care workers, and its implementation at health care facilities was considered to be feasible. Its introduction was predicted to reduce anxiety regarding fetal well-being, increase antenatal care attendance, increase confidence by women in their care providers, as well as save time and cost by reducing unnecessary referrals. TraCer was felt to increase the self-image of health care workers and reduce time spent providing antenatal care. Some participants expressed hesitancy toward the new technology, indicating the need to test its performance over time before full acceptance by some users. The preferred cadre of health care professionals to use the device were antenatal clinic nurses. Important implementation considerations included adequate staff training and the need to ensure sustainability and consistency of the service. Misconceptions were common, with a tendency to overestimate the diagnostic capability, and expectations that it would provide complete reassurance of fetal and maternal well-being and not primarily the GA. Conclusions: This study shows a positive attitude toward TraCer and highlights the potential role of this innovation that uses AI-enabled automation to assess GA. Clarity of messaging about the tool and its role in pregnancy is essential to address misconceptions and prevent misuse. Further research on clinical validation and related usability and safety evaluations are recommended

“Like works of our hands are giving testimony!” A qualitative study on kangaroo mother care and health worker empowerment in southern Malawi

The purpose of this paper is to explore health worker perspectives of empowerment associated with kangaroo mother care in southern Malawi. We conducted a secondary analysis of 27 in-depth interviews collected between May-Aug 2019 at a large Malawian tertiary hospital and three rural referral hospitals. Data was analyzed using a thematic approach with NVivo 12 software (QSR International, Melbourne, Australia). Health workers reported positive perceptions of kangaroo mother care because it helped save the lives of preterm and low birthweight infants who previously did not frequently survive. This gave them hope due to increased capacity to care for low birthweight infants and subsequently increased job satisfaction. Experiences of success supported workplace morale and strengthened commitment to their clinical roles. This study suggests that kangaroo mother care may support health worker empowerment and resilience in their work.   Cet article-ci se prend pour son objectif d'explorer les perspectives de l'autonomie associée avec les soins maternels kangourous implémentés aux cliniques médicales dans le sud du Malawi. Les perspectives de l'autonomie dont on parle ici appartiennent aux travailleurs de la santé. Nous avons effectué une analyse secondaire de vingt-sept entrevues collectionnées entre les mois mai et août en 2019 au Malawi à une hôpital de soins tertiaires et aux trois hôpitaux d'aiguillage ruraux. Les données ont été analysées en utilisant l'approche thématique avec le logiciel NVivo 12 (QSR International, Melbourne, Australia). Les travailleurs de la santé ont communiqué les perceptions positives des soins maternels kangourous parce que ceux-ci les ont aidé à sauver les vies des nourrissons prématurés et de faible poids de naissance qui autrefois souvent n'avaient pas survécu. Ceci leur a donné de l'espoir parce que leur capacité de prendre soin des nourrissons de faible poids de naissance est accrue et ensuite leur satisfaction au travail a augmenté aussi. Ces expériences de succès ont soutenu leur morale au travail et ont renforcé leur engagement envers leur rôles cliniques. Cette étude-ci suggère que les soins maternels kangourou peuvent promouvoir l'autonomie des travailleurs de la santé et leur résilience dans leur travail. &nbsp

Methodological Insights, Advantages and Innovations Manuscript Title: Lessons Learned in Conducting Qualitative Healthcare Research Interviews in Malawi: A Qualitative Evaluation

With the growth of qualitative health research in low- and middle-income countries, local health professionals are increasingly involved in facilitating interviews with their fellow health workers. Understanding the methodological implications of such situations is required to ensure high-quality study findings and to build capacity and skills for interviewers with clinical backgrounds working with limited resources. This article reports a qualitative process evaluation of a study that assessed barriers and enablers of implementing bubble continuous positive airway pressure in Malawi. Findings were summarized through an iterative process of reflection on what worked, what did not work, areas for improvement, structural challenges, negotiating dual roles as nurses and researchers and the professional hierarchy within the health care system. Comprehensive practical training was critical to conducting qualitative research in a health setting. Interviewers were health workers themselves and required skills in reflexivity to effectively probe and navigate interviewing other health professionals, including senior staff. The main challenge in conducting interviews in a resource-limited healthcare setting was time constraints, which were compounded by staffing shortages. Lessons from this qualitative evaluation highlight the importance of training in reflexivity, engaging interviewers as collaborators and reserving adequate time to accommodate healthcare workers’ multiple roles and responsibilities

Calcium for pre-eclampsia prevention: A systematic review and network meta-analysis to guide personalised antenatal care

Background: Calcium supplementation reduces the risk of pre-eclampsia, but questions remain about the dosage to prescribe and who would benefit most. Objectives: To evaluate the effectiveness of high (≥1 g/day) and low (<1 g/day) calcium dosing for pre-eclampsia prevention, according to baseline dietary calcium, pre-eclampsia risk and co-interventions, and intervention timing. Search strategy: CENTRAL, PubMed, Global Index Medicus and CINAHL, from inception to 2 February 2021, clinical trial registries, reference lists and expert input (CRD42018111239). Selection criteria: Randomised controlled trials of calcium supplementation for pre-eclampsia prevention, for women before or during pregnancy. Network meta-analysis (NMA) also included trials of different calcium doses. Data collection and analysis: Two independent reviewers extracted published data. The meta-analysis employed random-effects models and the NMA, a Bayesian random-effects model, to obtain direct and indirect effect estimates. Main results: The meta-analysis included 30 trials (N = 20 445 women), and the NMA to evaluate calcium dosage included 25 trials (N = 15 038). Calcium supplementation prevented pre-eclampsia similarly with a high dose (RR 0.49, 95% CI 0.36–0.66) or a low dose (RR 0.49, 95% CI 0.36–0.65). By NMA, high-dose (vs low-dose) calcium did not differ in effect (RR 0.79, 95% CI 0.43–1.40). Calcium was similarly effective regardless of baseline pre-eclampsia risk, vitamin D co-administration or timing of calcium initiation, but calcium was ineffective among women with adequate average baseline calcium intake. Conclusions: Low- and high-dose calcium supplementation are effective for pre-eclampsia prevention in women with low calcium intake. This has implications for population-level implementation where dietary calcium is low, and targeted implementation where average intake is adequate. Tweetable abstract: A network meta-analysis of 25 trials found that low-dose calcium supplementation (<1 g/day) is as effective as high-dose calcium supplementation (≥1 g/day) in halving the risk of pre-eclampsia when baseline calcium intake is low.Fil: Woo Kinshella, Mai-Lei. University of British Columbia; CanadáFil: Sarr, Catherine. Kings College London (kcl);Fil: Sandhu, Akshdeep. University of British Columbia; CanadáFil: Bone, Jeffrey N.. University of British Columbia; CanadáFil: Vidler, Marianne. University of British Columbia; CanadáFil: Moore, Sophie E.. Kings College London (kcl);Fil: Elango, Rajavel. University of British Columbia; CanadáFil: Cormick, Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Hofmeyr, G. Justus. University of the Witwatersrand; Sudáfrica. University of Walter Sisulu; Sudáfrica. University of Fort Hare; Sudáfrica. University of Botswana; BotsuanaFil: Magee, Laura A.. University of British Columbia; Canadá. Kings College London (kcl);Fil: von Dadelszen, Peter. University of British Columbia; Canadá. Kings College London (kcl)

Beyond early initiation: A qualitative study on the challenges of hospital-based postpartum breastfeeding support.

Improving breastfeeding practices is key to reducing child mortality globally. Sub-optimal exclusive breastfeeding rates may be associated with inadequate hospital-based postpartum breastfeeding support, particularly in resource-limited health settings such as Malawi. While almost all children in Malawi are breastfed, it is a concern that exclusive breastfeeding rates in Malawi are declining. The objective of this study is to understand postpartum breastfeeding support after delivery at Malawian hospitals from the perspectives of health workers and caregivers. We conducted a secondary analysis of a descriptive qualitative study on health worker and caregiver experiences of breastfeeding support at health facilities in southern Malawi as part of the Innovating for Maternal and Child Health in Africa Initiative. In-depth interviews following a semi-structured topic guide were conducted at three secondary-level district hospitals and one tertiary-level central hospital. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia). We interviewed a total of 61 participants, including 30 caregivers and 31 health care workers. Participants shared the following themes: 1) a focus on early initiation of breastfeeding, 2) inadequate follow-up on breastfeeding practice, and 3) feasibility challenges and local solutions. There was an emphasis on early initiation of breastfeeding, which was challenged by maternal exhaustion after delivery. Study participants reported poor follow-up on breastfeeding practice after initial counselling and reacting to adverse outcomes in lieu of adequate monitoring, with a reliance on caregivers to follow-up on challenges. There was poor support for facility-based breastfeeding after initial counselling post-delivery, which revealed an overall neglect in hospital postpartum care for those considered to be in good health after initial assessment. We recommend the development of indicators to track continued facility-based breastfeeding, identify vulnerable infants at-risk of feeding problems, and strengthening care in postnatal wards, which is currently as neglected component of maternity care

Role of community engagement in maternal health in rural Pakistan: Findings from the CLIP randomized trial

Background: Community-based strategies to promote maternal health can help raise awareness of pregnancy danger signs and preparations for emergencies. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women\u27s knowledge about pre-eclampsia as part of community engagement (CE) activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) Trial.Methods: The CLIP Trial was a cluster randomized controlled trial that aimed to reduce maternal and perinatal morbidity and mortality using CE strategies alongside mobile health-supported care by community health care providers. CE activities engaged pregnant women at their homes and male stakeholders through village meetings in Hyderabad and Matiari in Sindh, Pakistan. These sessions covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR and details of the CLIP intervention package. BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarized as odds ratios and 95% confidence intervals.Results: There were 15 137 home-based CE sessions with pregnant women and families (n = 46 614) and 695 village meetings with male stakeholders (n = 7784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (odds ratio (OR) = 2.17, 95% confidence interval (CI) = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters.Conclusions: The findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study.Trial registration: Clinical Trials.gov - INCT01911494