Paediatrics (RCH) - Theses

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    Improving oxygen therapy for children and newborns in Nigerian hospitals
    Graham, Hamish Robert ( 2018)
    Oxygen is a long-established medical therapy that can be life-saving for severely ill children admitted to hospital. Effective provision of oxygen to patients requires a multifaceted system that involves technical, clinical, supply chain, financing, and other managerial and policy elements. However, this system is currently difficult to achieve in many low-resource settings resulting in poor access to, and use of, oxygen and subsequent excess mortality. Previous work has shown that improved hospital oxygen systems can improve patient access to oxygen therapy and reduce inpatient case fatality rates from childhood pneumonia. However, studies have shown variable impact in different settings due to contextual factors that are not well understood. In addition, the burden of hypoxaemia and impact of oxygen on conditions other than pneumonia is unclear – particularly in the large neonatal population. This study aimed to understand how to improve oxygen systems in particular contexts, and generate evidence to support the scale-up of effective oxygen systems in Nigeria and globally. My realist review of past oxygen projects developed a theoretical framework describing how improved oxygen systems could improve clinical outcomes in particular contexts – highlighting the interaction between efforts to improve oxygen access and the clinical use of oxygen. My oxygen needs assessment in 12 secondary-level Nigerian hospitals provided detailed data on existing oxygen systems – highlighting the impact of poor power supplies, weak maintenance systems, and lack of pulse oximetry. My prospective cohort study provided new data on the epidemiology of hypoxaemia in the Nigerian context. This study showed high prevalence of hypoxaemia among admitted children and neonates with a range of conditions, highlighted the strong association between hypoxaemia and death, and demonstrated poor accuracy of clinical signs to predict hypoxaemia (particularly for children with non-respiratory conditions). My mixed-methods realist evaluation identified how pulse oximetry could be most effectively adopted into routine paediatric and neonatal care – highlighting the role of key influencers to model behaviour, practical training and ongoing encouragement, personal experience of benefit, and the reasons why nurses valued pulse oximetry. My stepped wedge trial evaluated the effect of our intervention (improved oxygen system) on clinical outcomes and care practices. This study demonstrated mortality benefit for children admitted with pneumonia, and suggested that the introduction of pulse oximetry generated most of this benefit by stimulating better use of existing oxygen supplies. We found no mortality benefit for children with other conditions or neonates, and detected an unexpected trend towards higher mortality in the “full oxygen system” period compared to the “pulse oximetry period” for neonates. Post-hoc analysis tested some potential explanatory theories for these findings – highlighting the effects of pre-existing oxygen access and external factors. In conclusion, improving oxygen systems is complex. The studies contained in this thesis have helped fill evidence gaps that are hindering oxygen policy and planning decision-making in Nigeria and globally. They have directly informed national and global policies and program planning.
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    Implementation of paediatric hospital guidelines in Lao PDR: the impact on quality of care and contextual factors affecting change
    Gray, Amy Zigrida ( 2013)
    There is substantial evidence of deficiencies in the quality of hospital care from both developed and developing countries. Better evidence for the effectiveness of different strategies to improve care is needed, along with understanding of how the local context influences their success or failure. Lao PDR (Laos) is a resource-poor country with high rates of child mortality and a critical need to improve capacity of health staff caring for sick children. Implementation of the World Health Organisation (WHO) Pocketbook of Hospital Care for Children through the local network of paediatricians was identified as one potential strategy for improving hospital care in this setting. The principal aim of this thesis was to evaluate the impact of implementing WHO guidelines on the quality of paediatric hospital care in Laos, and to understand the contextual factors that influenced the implementation and uptake of guidelines in this setting. A before-and-after mixed methods study design was used to evaluate the implementation of a multifaceted intervention based on the WHO Pocketbook of Hospital Care for Children. Quality of hospital care was assessed in nine hospitals pre- and post-intervention using an observational assessment tool and abstraction of information from medical records. In central hospitals medical record abstraction data was used to compare case management of four sentinel conditions pre- and post-intervention, using overall case management scores and individual quality indicators. A process evaluation was performed to document the intervention that was delivered as well as the contextual factors that influenced its implementation and outcome. Focus groups were used to understand how the Pocketbook and its implementation were perceived by Lao doctors and nurses. Triangulation of quantitative and qualitative data enabled interpretation of the changes observed following Pocketbook implementation as well as identification of reasons change did, or did not, occur. The study demonstrates changes in case management of sentinel conditions in central hospitals following implementation of the WHO Pocketbook, reflecting uptake of guidelines into practice and standardisation of care. The magnitude of change observed varied according to clinical condition. The largest changes in practice were seen in pneumonia case management, followed by diarrhoea and low birth weight babies. Limited change occurred in case management of febrile encephalopathy. Improvements in monitoring, rational drug use and fluid prescribing were apparent across conditions and hospitals. Important influences on the strong intent of healthcare providers to adopt the WHO Pocketbook included local ownership, opinion leaders, the critical need met by the guidelines, the training approach, and the provision of feedback. Factors such as guideline simplicity and expectations of families, provide potential explanation for differences seen between diseases. The study supports the effectiveness of a WHO Pocketbook-based intervention in improving quality of paediatric hospital care but highlights the need for a multi-faceted intervention and an understanding of the local context in order to achieve change. In Laos, implementation efforts need to be directed towards sustainability, improving district hospital care and understanding the impact on patient outcomes. Lessons from Laos will be applicable to other countries and health care interventions.