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Background: Severe respiratory distress is a leading cause of mortality among neonates in Malawi. Despite evidence on the safety, cost effectiveness and efficacy of bubble continuous positive airway pressure (CPAP) in managing the condition, its use in Malawian health facilities is limited and little is known about caregivers’ engagement with perspectives of bubble CPAP. The purpose of this study was to explore caregiver perspectives for bubble CPAP at both central and district hospitals and key factors that enable effective caregiver engagement in Malawi. Methods: This was a descriptive qualitative study employing secondary analysis of 46 health care worker in-depth interviews. We interviewed the health workers about their thoughts on caregiver perspectives regarding use of bubble CPAP. We implemented the study at a tertiary facility and three district hospitals in southern Malawi. This was a part of a larger study to understand barriers and facilitators to implementing neonatal innovations in resource-constrained hospitals. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia). Health workers were purposively selected to include nurses, clinicians and district health management involved in the use of bubble CPAP. Results: Emerging issues included caregiver fears around bubble CPAP equipment as potentially harmful to their new-borns and how inadequate information provided to caregivers exacerbated knowledge gaps and was associated with refusal of care. However, good communication between health care providers and caregivers was associated with acceptance of care. Caregivers’ decision-making was influenced by relatives and peer advocates were helpful in supporting caregivers and alleviating fears or misconceptions about bubble CPAP. Conclusions: Since caregivers turn to relatives and peers for support, there is need to ensure that both relatives and peers are counselled on bubble CPAP for improved understanding and uptake. Health workers need to provide simplified, accurate, up-to-date information on the intervention as per caregivers’ level of understanding. Notably, contextualised comprehensible information will help alleviate caregivers’ fear and anxieties about bubble CPAP.
This is a secondary analysis of 46 semi-structured, in-depth interviews with health workers in southern Malawi on their experiences of using bubble CPAP as part of a larger project, “Integrating a neonatal healthcare package for Malawi” which seeks to inform the scale-up of low-cost and locally appropriate innovations to improve newborn care at low-resource health facilities. The project is a part of the Innovating for Maternal and Child Health in Africa (IMCHA) initiative funded by the Canadian International Development Research Centre (IDRC), Global Affairs Canada (GAC) and the Canadian Institutes for Health Research (CIHR). Through health worker interviews, we sought to understand caregivers’ perspectives on their experiences on using bubble CPAP. The study was conducted at a tertiary hospital and three secondary level hospitals (hereafter referred to as district 1, district 2 and district 3) in the southern region of Malawi. The tertiary and districts 1 and 3 are public government facilities and provide services for free while district 2 is a private mission hospital. While the mission hospital charges a fee for its services, it serves as a referral centre for the district and clients referred from public facilities access care for free. The tertiary facility administers bubble CPAP in the nursery unit and paediatric nursery ward. The district facilities all provide bubble CPAP in smaller rooms within the nursery units. In total, there are two tertiary and 11 district facilities in southern Malawi. The facilities were chosen in consultation with Ministry of Health. More information is provided a facility assessment paper (see Kawaza et al., 2020 [14] and a primary paper on bubble CPAP (see Nyondo- Mipando et al., 2020 [15]. The sample was purposively drawn to include health workers involved in delivery and/or decision-making for newborn care at the four health facilities. At the tertiary facility, we recruited nurses and clinicians working in neonatal units, nurses in charge of the ward, registrars and pediatric consultants while at district facility, we recruited nurses and clinicians engaged in neonatal units plus district health officers (DHOs), district medical officers (DMOs), district nursing officers (DNOs), nurses in charge of the pediatric ward. We approached health workers in person and or by phone and asked for an interview after briefing them on the study. Based on the number of health workers that interfaced with bubble CPAP and the limited number of staff available for neonatal care especially at district hospitals, a sample size of 10–15 participants was estimated at each site as being needed to achieve data saturation with a variety of perspectives. We used in semi-structured interview guide for its ability to allow participants to detail their personal experiences. A team of five trained data collectors conducted 46 interviews with health care workers on perspectives of caregivers towards bubble CPAP. Data collection took place between June and August 2018 (for more information, see Nyondo- Mipando et al., 2020 [15]). We piloted the interview guide and made corrections to the tools before data collection commenced. Data from the pilot phase was not included in the final analysis. Face-to-face interviews were conducted in a secluded place within the facilities and lasted 30–60 min each. Participants provided written informed consent and filled out a demographics form. Interview questions focussed on training, initiation, monitoring, differences in opinions, perception and personal experiences and perception on caregiver understanding of bubble CPAP. Data was analyzed using an iterative thematic approach where the research team first familiarized themselves with the interviews to develop a coding framework to be analyzed using NVivo 12 software (QSR International, Melbourne, Australia). The iteration process was applied as developed by Srivastava, 2009 [16] while the thematic analysis was applied as developed by Braun and Clark, 2006 [17]. Analysis commenced during data collection period and involved a constant loop process with researchers reflectively referring back to raw data. SS and ALNM listened to the audios in both languages (Chichewa and English) while MLWK reviewed the transcripts after translation to English. All three read the transcripts several times to familiarize with the data and then generated initial codes together. Where differences arose, all three researchers discussed the suggested codes, constantly referring bact to the raw data until a consensus was reached. The initial transcript was coded by SS and MLWK and codes were compared and areas that differed were discussed between the two researchers until a consensus was reached regarding the most plausible code for that aspect. Thereafter, ALNM checked the transcipt and if any differences arose, all three researchers constantly referred back to the raw data. After completion of each transcript coding, all three researchers referred the coded transcript back to the raw data, objectively reflecting if the codes sppoke to the data. We searched for themes from the codes by organising all similar and recurrent. We examined each code for further subcategories [17]. We reviewed the themes and this resulted in maintaining, combining, separating or discarding themes as necessary [17] and the decision to change was dependent on the richness and breadth of the proposed theme to accommodate other sub themes. For instance, we combined findings on support received from significant others into one theme. We did this to ensure that all themes presented had rich data that substantiated the theme, which resulted into discarding of themes without supporting data. Before discarding, SS and MWLK also reflectively referred back to the raw data to verify if we were making the right decision. We refined the themes and verified our results against the digital recordings. The refined themes were checked for quality by ALNM.
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