We present findings from the two-year implementation period by integrating implementation strategies recommended by Proctor [23] and link the strategies co-created during the formative phase and adapted continuously by PHC facilities to the implementation outcomes structured around adoption, fidelity, and sustainability. Table 2 illustrates key implementation strategies and outcomes which contributed to increased use of PSBI guidelines in PHC settings.
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Strategies to improve adoption of PSBI
We defined adoption of PSBI guidelines as the extent to which providers working within a PHC facility are using PSBI guidelines to treat SYIs. In response to the gaps and complexities of facility arrangements around management of SYIs, facilities adopted strategies to enhance uptake of PSBI guidelines. This included identifying bottlenecks and generating solutions that created opportunities for ‘doable’ steps resulting in improved efficiency of care. Four implementation strategies deployed included:
a). Designating places for newborn care
Formative findings illustrated that PHC facilities had limited space and did not have adequate mechanisms for identifying and managing SYIs promptly. During co-creation workshops, providers and managers confirmed this and designed several approaches to overcome this barrier. A common response was to designate a specific area for managing SYIs:
“One is creation of more space. Initially we used to be in a smaller room with two clinicians. So, there was congestion, and the patient flow was not smooth… So, with time they gave us a bigger room, which is very spacious now. It can even accommodate two examination couches… two clerks with tables… So at least there is privacy when you are dealing with one mother, the other one cannot hear your conversation” Provider.
Re-organizing service delivery points also supported prompt initiation of care and ability to manage SYIs in critical conditions with minimal challenges:
“You know like in our facility, we first sat and discussed, we created a room, whereby a clinician sees only under five but before they used to queue together with the adults. At least we initiated that, and we could see in case of any emergencies in under-fives they can be taken care of fast, and even the spread of infection to the infants has been reduced” Provider.
b). Triaging in support of PSBI management
During the formative phase, complex service delivery arrangements caused delays to timely receipt of care partly due to insufficient staff to support triaging. To alleviate this problem for example, 8 facilities; 4 in Bungoma and 4 in Kilifi used CHVs to assist with triaging SYI. Facility managers advocated through various county level forums for more providers, which led to increased staffing at some referral facilities and PHC facilities. Moreover, supportive facility management processes and teamwork helped prevent burnout:
“When I came to this facility, we advocated getting more clinicians and so currently we have a good number whereby we can even rotate freely without getting burnout while treating SYI. I can’t say we are badly off…but when one of us is not around… that is when we really struggle …but most of the time we are three of us… there is not much shortage of staff” Provider.
These changes eased caregiver’s access to SYI services and facilitated prompt care as envisaged in the PSBI guidelines.
“Okay, the support I got; firstly, the doctor acted fast. He left all his activities… in a quick manner… Besides that, I have been noticing the difference… because you find when the child goes to the triage and the temperatures are being checked… they also check for other stuff. If on that day the parent was last in line, they put her at the front… so they received and attended to me in a prompt manner… especially that one doctor… he is the one I mostly see handling things in a prompt manner” Case Narrative, Mother
c). Management of medicines, and commodities for SYI
We supported facilities to track stock out trends over time for recommended medicines for managing SYI. The data was used during feedback sessions to stimulate discussion on efficient ways of managing commodities within the county and sub county teams. Availability of medicines and commodities facilitated uptake of PSBI guidelines enabling providers to manage SYI effectively:
“And if you find the child has pneumonia, … when you give the Amoxicillin DT it works, because they come after maybe 48 hours and they come back… you find the child is better” Provider.
Stock-out trends illustrated as the average number of days facilities lacked essential antibiotics for management of SYI are presented in figure 2. Overall, there was reduction on the average number of days of stock-out of essential antibiotics in study facilities across all counties. Hospitals across the four counties rarely experienced stock out of gentamicin and benzylpenicillin. However, the longest duration of stock outs of amoxicillin DT were experienced in the first and second quarter of 2019 owing to indiscriminate prescription as many providers had not been trained on its use. In PHC facilities, stock-outs for gentamycin and benzyl-penicillin were reported in quarter 4 of 2019 and throughout 2020 partly due to the outbreak of the Covid-19 pandemic where the supply chain was interrupted.
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Two key approaches were used to ensure continuous supply of essential SYI medicines and commodities, including redistribution of medicines to facilities with need and inclusion of key antibiotics for PSBI in the counties’ forecasting, and procurement system. These efforts led to improved availability of antibiotics coinciding with a significant increase in the PSBI cases reported at PHC level.
d). Strengthening Quality improvement teams
Initially Ponya Mtoto recognized that some facilities did not have QITs partly due to sub-optimal functionality of the teams or some facilities having only one provider. During co-creation sessions, some facility managers suggested strengthening the functionality of the QITs, subsequently increasing number of facilities with functional QITs-Table 3. Facilities with active QITs reviewed data and identified gaps in management of SYIs and recorded notable changes in adopting PSBI guidelines. Suggestions included checking medicine expiry dates through proactive forecasting and monitoring the completeness of patient records. Ponya Mtoto discovered that there were challenges for providers in documenting management of SYIs, due to limitations in newborn and child registers that did not include the age of the SYI. The study team subsequently worked with National Child Health Technical Working Group to advocate for and introduce registers for the newborns and young infants up to 2 months old. In addition, simplified clinical forms were introduced by the study team for providers to document management of SYI.
Strategies to improve fidelity of PSBI
Fidelity was defined as the degree to which the treatment regimen was implemented as per PSBI guidelines. We assessed the extent in which providers adhere to the assessment, classification, as well as treatment schedule and use. From the user perspective we explored reasons for non-adherence among caregivers in return for the scheduled visit on day 4.
a). Emphasis on use of protocol, guidelines, and job aids
Provider knowledge gaps on assessment, classification, and treatment of SYI with PSBI identified during the formative phase indicated the need to develop materials to aid providers in service provision. The study team distributed materials in all facilities included IMNCI flow charts, client and provider job aid and pediatric clinical protocols. Job-aids for caregivers and families helped demystify the cause of illness and reinforce caregivers understanding on treatment of SYI. Initial monitoring visits to facilities showed that some providers were not using the guidelines effectively, prompting the study team to emphasize its use during subsequent quarterly monitoring visits and included reported use of guidelines in the monitoring tool, partly contributing to improvement on use of guidelines. Protocols, guidelines, and materials placed prominently, and easily accessible in-service delivery points also improved their use.
“We have the charts placed in the consultation rooms, so every clinician when they are orientating new clinicians will use those charts to explain to them”, Provider.
b). Continuous capacity strengthening activities
One key assumption identified during the development of the TOC (Figure 1) was that county teams would train health providers on IMNCI and integrate PSBI guidelines onto the existing platforms, but the formative data suggested that very few providers had been inducted. Our initial approach advocated for counties to implement updates and trainings from their budgeted annual plans or through implementing partners. However, it was evident toward the end of the first year that this was unlikely to happen due to several reasons. 1), counties had not prioritized funds for IMNCI that year, 2) partner mapping conducted during the formative phase indicated that many partners had not prioritized child health issues, 3) the period coincided with IMNCI assessments by partners to then develop IMNCI training plans.
In view of these challenges, and following discussions with county health representatives, we modified our implementation strategy and introduced other approaches to inducting providers in PSBI management during monitoring visits. We advocated use of trained county level IMNCI and senior clinical staff to support providers in continuous professional development (CPD) during structured monitoring visits. This helped providers clarify approaches to classification, and treatment and use of job aids. The monitoring teams also encouraged facilities to adopt various CPD approaches including on the-job-training or mentoring on IMNCI as need arose. This was in addition to encouraging them to use a digital IMNCI application platform developed by the ministry of health that enables self-learning on managing children using IMNCI guidelines and enrolling providers willing to be part of local community of practice (CoP) designed to reinforce learning on better management of SYIs. Continuous emphasis on the need for counties to budget for trainings was conducted during quarterly feedback sessions. Overall, providing opportunities for county teams to review challenges faced and generate solutions on capacity strengthening enabled them to incorporate changes easily. This facilitated regular CPD sessions which empowered providers to use PSBI guidelines when managing SYI and increased their confidence in symptom identification, classification, and treatment.
“Some were trained on PSBI while some have done the on-the-job training on PSBI and IMNCI, also, on availability of drugs and provision of services. Then we have guidelines in place on prescription and how to educate mothers on the administration of drugs. We have service provider and caregiver pamphlets. We have booklets for review that help healthcare workers” Provider.
Resulting outcomes of these strategies were tracked using monitoring data which showed gradual improvement of identification and classification of SYIs with PSBI (Figure 3).
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Drivers of fidelity to PSBI guidelines
Formative findings indicated gaps in coordination, adequate linkages between community and PHC as well as poor documentation of SYI. We tested the assumption of the role of proper coordination between community and facilities on improving adherence to PSBI guidelines. Our findings illustrated the value of supervisory support, and improved documentation on SYI as a facilitating feature of adherence to PSBI guidelines. For example, supportive facility management processes ensured providers were given on-site technical input and their challenges were responded to during facility visits. During the quarter preceding the endline survey, nearly 80% of PHC facilities reported having been supervised and given feedback on issues observed, which provided opportunities to strengthen their capacity (table 3)
Continuity of care through CHVs follow up was instrumental in improving linkages and follow up of SYIs. The ability of CHVs to visit SYIs at home and sensitize community members on the need for referral facilitated adherence to treatment.
“Previously…we didn’t have CHVs… of which we have them now and they are really moving and visiting the homes, so in case of any SYI …they refer to the facility, at times they accompany … so at least there is a big change because previously those children visiting the facility… you could not even know from the nearest village that they were sick” Provider.
Following the introduction of the PSBI guidelines, we saw an increase in number families seeking care for their SYIs- especially at PHC level see Figures 3 and 4. Moreover, at the caregiver level, the cost of the new PSBI regimen was considered cheaper in terms of out-of-pocket costs and allows mothers time to attend to social demands when using outpatient treatment. Although caregivers did incur costs associated with transport and medicines (if not available at facility), this was still considered favorable as opposed to referral or inpatient treatment.
“The extent is that the percentage of mothers who have been coming for treatment as advised is big, because using the outpatient is cheaper compared to inpatient care, they have accepted because you see them coming back until the last review, and I think it allows them to take care of other responsibilities at home” Provider
Although we observed positive changes in adherence from both the provider and client perspectives, there were several reasons for non-adherence to the treatment regimen specifically the scheduled return visit on day 4. The first set of factors related to non-adherence was logistical challenges including long distances to the facility, transport cost and/or lack of transport to the facility. In remote settings such as in Turkana, the direct transport can be as high as $80 which makes it difficult for families to bring their SYI back to complete their PSBI treatment:
“Yes, long distance to a health facility, lack of money to pay for transport and health services in some facilities, scarcity on means of transport (few motor bikes, poor infrastructure). We use KES 2000 to and fro to the facility if using motorbike totaling to KES 8000 in all visits”, caregiver, completed visit.
Other direct financial costs are linked to stockouts meaning caregivers are expected to buy medicines elsewhere. This together with other requirements such as buying ‘consultation materials’ such as notebooks whose price range between $3-5 cents, delay timely treatment since not everyone can afford them.
“I remember telling you that some are unable to pay for services because whenever we have shortages with some drugs, they cannot buy another thing they come from remote areas where it requires a vehicle to reach the facility. They are pastoralists… so, it takes them days to reach here because they come on foot.” Provider.
In other instances, families lose income on days when they seek care for their infants especially women who earn from casual labor. This in addition to other social costs that limit completion of PSBI treatment where caregivers expressed challenges of having to leave other children under someone’s care, increasing costs associated with seeking care for SYI. In situations where caregivers lack people to support other children, this delayed scheduled visits. Finally, caregivers may not complete the PSBI regimen because they see improvement in their infant’s health and don’t think it is necessary
“….… you can come back and find she has cooked for them… so you buy her sugar, you buy her milk, and you thank her. Of course, you have no money to offer her, but you have bought her something small as a gesture of appreciation on her staying with your kids”, Caregiver.
“Sometimes when you ask them, they try to explain, “I was just looking for someone to come look after my children as I come to the hospital." That’s their challenge always” provider.
“So, the two injections calmed him and when I returned for the checkup on the fourth day, he was doing better. So, on the 8th day I had been told to go back, but I found the baby had gotten well within the six days, he had no fever” Caregiver.
Strategies to improve sustainability
Sustainability in this context is defined as the extent to which PSBI guidelines are maintained over time or institutionalized within a service delivery setting. To explore sustainability, we examined changes made over the implementation period to improve identification and management of SYIs and ways in which PSBI management has been institutionalized as part of routine young infant care. This was one of our impact outcome ( see figure 1).
a). Identifying challenges, generating, and tracking local solutions
Over the course of implementation period, we observed that providers and sub county/facility managers increasingly identified challenges and addressed them with local solutions to streamline quality improvement and care for SYI. We documented changes related to structural improvement of services ranging from provision of medicines (antibiotics) commodities (oxygen, pediatric ambu bag, nebulizer machine) and equipment, (incubators, and weighing scale) to infrastructural changes such as rearranging spaces for triaging and managing SYIs. Other changes on service delivery included strengthened SYI referral system.
Consistent documentation of SYIs seen in facilities, treated and /or referred was poor initially and continued to be challenging for some health providers. There was poor use of clinical PSBI clinical form (developed with ministry of health-MoH) where forms were lacking important information such as date the client was seen; dosage given, while others had incorrect entries. Elsewhere, providers completed the registers but did not fill the clinical forms and vice versa. The study team encouraged proper use of clinical forms and worked with facility managers to ensure the laminated colored dosage charts were mounted strategically in the consultation areas to improve use.
CHVs client referrals were also not documented due to shortages of referral booklets, and incomplete feedback loops. In many facilities, there was no one dedicated to handle referral forms and filing them to designated files as mothers come through different service points and in the process, the referral slips got lost. The study team focused on streamlining documentation using clinical forms as means to improve the follow-up loop. Even when the clinical forms were used, there were still follow-up gaps due to caregiver failure to return with their young infant on Day 4.
b). Increasing visibility and integration of PSBI in existing guidelines
At the system level there were efforts to ensure PSBI guidelines were integrated into IMNCI. This started at national level in February 2018 when the MoH embarked on the revision of the national IMNCI guidelines. MoH attendance at the global WHO meeting on PSBI in Ethiopia in January 2018 accelerated the decision to adopt the PSBI strategy and incorporate into national documents. Subsequently a series of advocacy meetings within the four counties took place during which they updated their annual work plans to integrate IMNCI/PSBI within routine activities. The WHO meeting outputs galvanized local efforts and facilitated national teamwork to continue providing guidance in revising training and service delivery materials on the use of simplified antibiotic treatment regimens of SYI at PHC level. This together with packaging evidence generated from previous research trials and the Ponya Mtoto formative phase in form of technical briefs, provided an avenue for sustained efforts to institutionalize PSBI guidelines.
To increase visibility of PSBI at community level, existing community dialogues sessions enabled CHVs provide information on management of SYI to increase awareness of PSBI while others utilized existing mentor mothers (peer mothers who support in HIV activities) in identification and management of SYI. Some CHVs integrated tracing caregivers of SYI with other specific programs like HIV who conduct defaulter tracing. The endline assessment shows that most CHVs continued to provide services such as health education on care for children at home for both well and sick children, follow up visits, pre-referral treatments, referrals, supporting providers in convincing those with severely SYI to accept admission, and assisting caregivers in the identification of danger signs:
“For the small children… we always tell them that small children should not be treated at home, and if she displays any signs whatsoever… the child should be rushed to the hospital at once… so that she can get treatment … and a government hospital is the best …” CHV
CHVs efforts resulted in a better understanding and improved awareness of SYI services including the referral process from the community. Figure 4 presents trends in the number of SYI identified and referred to facilities by CHVs. Overall, the number of SYIs referred from the community to a facility gradually increased throughout 2019 before declining in quarter 2 in 2020 then rose again in quarter 3 of 2020 partly due to the COVID-19 pandemic. Similar patterns were observed in both health centers and dispensaries, however, the number of SYI referred to hospitals by CHVs gradually increased in 2019 then plateaued in 2020 perhaps due to reduced referalls. Proper understanding and cooperation amongst caregivers, especially those who take in advice from the CHVs, created trust for effective referrals
“In accordance with the knowledge we have spread in our community, the mothers have accepted the importance of services provided to their children once they come to the hospital…one of them is the drugs and instructions they are given after getting services. When you go to the mother’s home, she will explain… if you ask her what kind of drugs, she has been given… she will bring it to you… and if you ask her how she was told to administer it… she will explain it to you” CHV.
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