Family and provider perceptions of quality of care in the management of sick young infants in primary healthcare settings in four counties of Kenya

Background Understanding the perceptions of quality of care given to sick young infants in primary healthcare settings is key for developing strategies for effective uptake and utilisation of possible severe bacterial infection guidelines. The purpose of this study is to assess families and providers’ perceptions of care given to sick young infants at primary healthcare facilities in four diverse counties in Kenya. Methods A cross-sectional qualitative design involving 37 in-depth interviews and 39 focus group discussions with very young (15-18 years), young (19-24 years) and older (25-45 years) caregivers of young infants aged 0-59 days; and key informant interviews with community-based and facility-based front-line health providers (14) in primary healthcare facilities. Qualitative data were captured using audio tapes and field notes, transcribed, translated and exported into QSR NVivo V.12 for analysis. A thematic framework approach was adopted to classify and analyse data. Results Perceived care given to sick young infants was described around six domains of the WHO framework for the quality of maternal and newborn healthcare: evidence-based practices for routine and emergency care; functional referral systems; effective communication; respect and preservation of dignity; availability of competent, motivated human resources; and availability of physical resources. Views of caregivers and providers regarding sick young infant care in primary healthcare settings were similar across the four sites. Main hindrance to sick young infant care includes stockout of essential drugs, limited infrastructure, lack of functional referral system, inadequate providers which led to delays in receiving treatment, inadequate provider skills and poor provider attitudes. Despite these challenges, motivation and teamwork of health providers were key tenets in care provision. Conclusion The findings underscore the need to prioritise improving quality of sick young infant services at primary healthcare settings by building capacity of providers through training, ensuring continuous supply of essential medicines and equipment and improving infrastructure including referral.

We used a cross-sectional qualitative study design with 37 in-depth interviews and 39 focus group discussions in four counties. The study draws on data from a formative assessment that is part of implementation research (IR) aimed at guiding the operationalisation of PSBI guidelines in Kenya. The formative assessment refers to the initial baseline survey conducted in the development and institution of public health interventions to inform learning in research and practice. Data were collected in four purposively sampled counties. These sites are representative of a mix of varying contexts characterised by rural and urban slum disadvantage, nomadic pastoralist and agrarian settings that impact access to healthcare. The four settings have higher NMRs ranging from 26 to 60 deaths per 1000 live births in each of the counties compared with the national mean of 22 deaths per 1000 live births with many other deaths in the community going unreported.24 Two subcounties in each county were selected in consultation with respective County Health Management Teams. Six facilities in each subcounty were subsequently purposively selected as implementation sites. For purposes of presenting the results, we anonymised the sites using symbols as County A, B, C and D. Caregivers were selected based on age; residency in the project site and with newborns or young infants aged 0–59 days. They were recruited with the help of village elders or community health volunteers (CHVs). The interviews were conducted in Kiswahili or local languages by research assistants with training in qualitative data collection using an interview guide. Health providers were interviewed to examine the facility-level perceptions of quality of care for SYIs and challenges faced during service delivery among other aspects. Table 1 outlines the type and number of qualitative interviews conducted. Distribution of qualitative data collection by site CHV, community health volunteer; FGD, focus group discussion; IDI, in-depth interview. In-depth interviews were held with very young mothers (15–18 years) and young mothers (19–24 years) to provide deeper context of the quality of care provided to SYIs in each study site. The in-depth interviews with providers and facility managers in turn provided health system-related reflections of the quality of care. The focus groups were critical in illuminating community perceptions on the quality of care and the different factors affecting the care of young infants. The qualitative interviews in each county and participant category outlined in table 1 were arrived at in consideration of the number of community units attached to each health facility which in turn informed the population coverage of the facility to ensure qualitative data saturation. To address the contextual convergent relationship between the research team and the participants, the researchers employed a combination of three mechanisms in each study site: (1) a detailed research log with details on date, time, place, participants and type of qualitative data method used, (2) field notes providing an account of all aspects discussed and observed during the interaction, and (3) a research journal with the researcher’s questions, thoughts and notes to self well outlined. The data from these notes helped enrich the correspondent thematic area in the Results and Discussion sections. Qualitative data were captured via audio tapes and field notes, translated, transcribed and exported into QSR NVivo V.12 for analysis. Ten members of the research team used an iterative analysis process to develop a coding framework and later a thematic framework to classify and organise data into emergent themes. A team of research assistants conducted a second iteration of analysis using the frameworks developed by the research team. Analysis charts were developed for each theme and categorised across participants and sites in accordance with WHO’s standard for improving quality of maternal and newborn care in health facilities.25 Community and public engagement activities included community advisory forums and community education days in which sensitisation, understanding and dialogue around research priorities were fostered. Community advisory forums entailed public meetings with the communities organised in collaboration with local leaders and the CHVs. Health providers in the facility serving the community played the crucial role of child health champions to ensure community ownership and leadership in implementation. Through these forums, the findings were shared and discussed, in form of posters, provider and caregiver pamphlets translated to local languages, continuously to ensure community and public participation.

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• Dima Health