Protecting small and sick newborn care in the COVID-19 pandemic: multi-stakeholder qualitative data from four African countries with NEST360.

BACKGROUND: Health system shocks are increasing. The COVID-19 pandemic resulted in global disruptions to health systems, including maternal and newborn healthcare seeking and provision. Yet evidence on mitigation strategies to protect newborn service delivery is limited. We sought to understand what mitigation strategies were employed to protect small and sick newborn care (SSNC) across 65 facilities Kenya, Malawi, Nigeria and Tanzania, implementing with the NEST360 Alliance, and if any could be maintained post-pandemic. METHODS: We used qualitative methods (in-depth interviews n=132, focus group discussions n=15) with purposively sampled neonatal health systems actors in Kenya, Malawi, Nigeria and Tanzania. Data were collected from September 2021 - August 2022. Topic guides were co-developed with key stakeholders and used to gain a detailed understanding of approaches to protect SSNC during the COVID-19 pandemic. Questions explored policy development, collaboration and investments, organisation of care, human resources, and technology and device innovations. Interviews were conducted by experienced qualitative researchers and data were collected until saturation was reached. Interviews were digitally recorded and transcribed verbatim. A common coding framework was developed, and data were coded via NVivo and analysed using a thematic framework approach. FINDINGS: We identified two pathways via which SSNC was strengthened. The first pathway, COVID-19 specific responses with secondary benefit to SSNC included: rapid policy development and adaptation, new and collaborative funding partnerships, improved oxygen systems, strengthened infection prevention and control practices. The second pathway, health system mitigation strategies during the pandemic, included: enhanced information systems, human resource adaptations, service delivery innovations, e.g., telemedicine, community engagement and more emphasis on planned preventive maintenance of devices. Chronic system weaknesses were also identified that limited the sustainability and institutionalisation of actions to protect SSNC. CONCLUSION: Innovations to protect SSNC in response to the COVID-19 pandemic should be maintained to support resilience and high-quality routine SSNC delivery. In particular, allocation of resources to sustain high quality and resilient care practices and address remaining gaps for SSNC is critical.

Stakeholder perspectives for optimization of tuberculosis contact investigation in a high-burden setting.

INTRODUCTION: Optimal tuberculosis contact investigation impacts TB prevention, timely case finding and linkage to care, however data on routine implementation in high burden contexts is limited. MATERIALS AND METHODS: In a multi-method qualitative study based on individual interviews with TB patients, facility observations and focus group discussions with health workers (HWs) in 13 public health facilities, and key informant interviews with governmental and non-governmental experts, we describe TB contact investigation in the context of an urban setting in Kenya and identify opportunities for optimization. RESULTS: Invitation of TB patients to bring close contacts by HWs was key for all patient decisions that led to contact screening in addition to patients' understanding of TB transmission and desire to avoid contacts suffering from TB. Sub-optimal HW enquiry of TB patients and contacts presenting at the facility were missed opportunities which stemmed from lack of standardized operational procedures, documentation tools and HW training. Stakeholders proposed provision of fast tracked and holistic health packages for contacts seeking TB screening, and sustainable government led funding for the requisite infrastructure and workforce. CONCLUSION: TB contact invitation by HWs leading to contact screening occurs in this context. Stakeholder perspectives inform the design of an operational framework for optimized delivery.

ADAPTING A STIGMA SCALE FOR ASSESSMENT OF TUBERCULOSIS-RELATED STIGMA AMONG ENGLISH/SWAHILI-SPEAKING PATIENTS IN AN AFRICAN SETTING.

OBJECTIVE: To adapt a validated instrument that quantitatively measures stigma among English/Swahili speaking TB (tuberculosis) patients in Kenya, a high burden TB country. METHODS: Following ethical approval, we elicited feedback on the English and Swahili translated Stigma Scale for Chronic Illness (SSCI) tools through cognitive interviews. We assessed difficulties in translation, differences in meaning, TB contextual relevance, patients' acceptability to the questions, and issues in tool structure. The interviews were audio recorded, transcribed and translated. Open coding and thematic analysis of the data was conducted by two independent researchers. RESULTS: Between May and September 2015 we conducted a qualitative study among 20 adult TB patients attending 11 health facilities in Nairobi County, Kenya. Most questions were understood in both English and Swahili, deemed relevant in the context of TB and acceptable to TB patients. Key areas of adaptation of the SSCI included adding questions addressing fear of infecting others and death, HIV stigma, and intimate, family and workplace relationship contexts. Questions were revised for non-redundancy, specificity and optimized sequence. CONCLUSION: The adapted 8-item SSCI appears to be a useful tool that may be administered by health workers in English or Swahili to quantify TB stigma among TB patients in Kenya.