Characteristics of children readmitted with severe pneumonia in Kenyan hospitals.

BACKGROUND: Pneumonia is a leading cause of childhood morbidity and mortality. Hospital re-admission may signify missed opportunities for care or undiagnosed comorbidities. METHODS: We conducted a retrospective cohort study including children aged ≥ 2 months-14 years hospitalised with severe pneumonia between 2013 and 2021 in a network of 20 primary referral hospitals in Kenya. Severe pneumonia was defined using the 2013 World Health Organization criteria, and re-admission was based on clinical documentation from individual patient case notes. We estimated the prevalence of re-admission, described clinical management practices, and modelled risk factors for re-admission and inpatient mortality. RESULTS: Among 20,603 children diagnosed with severe pneumonia, 2,274 (11.0%, 95% CI 10.6-11.5) were readmitted. Re-admission was independently associated with age (12-59 months vs. 2-11 months: adjusted odds ratio (aOR) 1.70, 1.54-1.87; >5 years vs. 2-11 months: aOR 1.85, 1.55-2.22), malnutrition (weight-for-age-z-score (WAZ) <-3SD vs. WAZ> -2SD: aOR 2.05, 1.84-2.29); WAZ - 2 to -3 SD vs. WAZ> -2SD: aOR 1.37, 1.20-1.57), wheeze (aOR 1.17, 1.03-1.33) and presence of a concurrent neurological disorder (aOR 4.42, 1.70-11.48). Chest radiography was ordered more frequently among those readmitted (540/2,274 [23.7%] vs. 3,102/18,329 [16.9%], p < 0.001). Readmitted patients more frequently received second-line antibiotics (808/2,256 [35.8%] vs. 5,538/18,173 [30.5%], p < 0.001), TB medication (69/2,256 [3.1%] vs. 298/18,173 [1.6%], p < 0.001), salbutamol (530/2,256 [23.5%] vs. 3,707/18,173 [20.4%], p = 0.003), and prednisolone (157/2,256 [7.0%] vs. 764/18,173 [4.2%], p < 0.001). Inpatient mortality was 2,354/18,329 (12.8%) among children admitted with a first episode of severe pneumonia and 269/2,274 (11.8%) among those who were readmitted (adjusted hazard ratio (aHR) 0.93, 95% CI 0.82-1.07). Age (12-59 months vs. 2-11 months: aHR 0.62, 0.57-0.67), male sex (aHR 0.81, 0.75-0.88), malnutrition (WAZ <-3SD vs. WAZ >-2SD: aHR 1.87, 1.71-2.05); WAZ - 2 to -3 SD vs. WAZ >-2SD: aHR 1.46, 1.31-1.63), complete vaccination (aHR 0.74, 0.60-0.91), wheeze (aHR 0.87, 0.78-0.98) and anaemia (aHR 2.14, 1.89-2.43) were independently associated with mortality. CONCLUSIONS: Children readmitted with severe pneumonia account for a substantial proportion of pneumonia hospitalisations and deaths. Further research is required to develop evidence-based approaches to screening, case management, and follow-up of children with severe pneumonia, prioritising those with underlying risk factors for readmission and mortality.

Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers' Learning Gain: Randomized Controlled Trial.

BACKGROUND: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. OBJECTIVE: The primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. METHODS: The experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants' personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. RESULTS: The effect of adaptive feedback on care providers' learning gain was found to be g=0.09 (95% CI -0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled for, this effect increased significantly to 0.644 (95% CI 0.35 to 0.94; P<.001) with immediate repetition, which is a moderate learning effect, but reduced significantly by 0.28 after a week. The overall learning change from the app use in both arms was large and may have obscured a direct effect of feedback. CONCLUSIONS: There is a considerable learning gain between the first two rounds of learning with both forms of feedback and a small added benefit of adaptive feedback after controlling for learner differences. We suggest that linking the adaptive feedback provided to care providers to how they space their repeat learning session(s) may yield higher learning gains. Future work might explore in more depth the feedback content, in particular whether or not explanatory feedback (why answers were wrong) enhances learning more than reflective feedback (information about what the right answers are). TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR) 201901783811130; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/13034.

Protocol for the Pathways Study: a realist evaluation of staff social ties and communication in the delivery of neonatal care in Kenya.

INTRODUCTION: The informal social ties that health workers form with their colleagues influence knowledge, skills and individual and group behaviours and norms in the workplace. However, improved understanding of these 'software' aspects of the workforce (eg, relationships, norms, power) have been neglected in health systems research. In Kenya, neonatal mortality has lagged despite reductions in other age groups under 5 years. A rich understanding of workforce social ties is likely to be valuable to inform behavioural change initiatives seeking to improve quality of neonatal healthcare.This study aims to better understand the relational components among health workers in Kenyan neonatal care areas, and how such understanding might inform the design and implementation of quality improvement interventions targeting health workers' behaviours. METHODS AND ANALYSIS: We will collect data in two phases. In phase 1, we will conduct non-participant observation of hospital staff during patient care and hospital meetings, a social network questionnaire with staff, in-depth interviews, key informant interviews and focus group discussions at two large public hospitals in Kenya. Data will be collected purposively and analysed using realist evaluation, interim analyses including thematic analysis of qualitative data and quantitative analysis of social network metrics. In phase 2, a stakeholder workshop will be held to discuss and refine phase one findings.Study findings will help refine an evolving programme theory with recommendations used to develop theory-informed interventions targeted at enhancing quality improvement efforts in Kenyan hospitals. ETHICS AND DISSEMINATION: The study has been approved by Kenya Medical Research Institute (KEMRI/SERU/CGMR-C/241/4374) and Oxford Tropical Research Ethics Committee (OxTREC 519-22). Research findings will be shared with the sites, and disseminated in seminars, conferences and published in open-access scientific journals.

Lessons from the design, development and implementation of a three-dimensional (3D) neonatal resuscitation training smartphone application: Life-saving Instruction for Emergencies (LIFE app).

Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health workers using innovative technological approaches. This practice paper describes the key steps involved in the design, development and implementation of an innovative smartphone-based training application using an agile, human-centred design approach. The Life-saving Instruction for Emergencies (LIFE) app is a three-dimension (3D) scenario-based mobile app for smartphones and is free to download. Two clinical modules are currently included with further scenarios planned. Whilst the focus of the practice paper is on the lessons learned during the design and development process, we also share key learning related to project management and sustainability plans, which we hope will help researchers working on similar projects.

Evaluation of Adaptive Feedback in a Smartphone-Based Serious Game on Health Care Providers' Knowledge Gain in Neonatal Emergency Care: Protocol for a Randomized Controlled Trial.

BACKGROUND: Although smartphone-based clinical training to support emergency care training is more affordable than traditional avenues of training, it is still in its infancy and remains poorly implemented. In addition, its current implementations tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with serious-gaming approaches remain largely unexplored and underdeveloped, even though they offer promise in terms of addressing the health workforce skill imbalance and lack of training opportunities associated with the high neonatal mortality rates in these settings. OBJECTIVE: This randomized controlled study aims to assess the effectiveness of offering adaptive versus standard feedback through a smartphone-based serious game on health care providers' knowledge gain on the management of a neonatal medical emergency. METHODS: The study is aimed at health care workers (physicians, nurses, and clinical officers) who provide bedside neonatal care in low-income settings. We will use data captured through an Android smartphone-based serious-game app that will be downloaded to personal phones belonging to the study participants. The intervention will be adaptive feedback provided within the app. The data captured will include the level of feedback provided to participants as they learn to use the mobile app, and performance data from attempts made during the assessment questions on interactive tasks participants perform as they progress through the app on emergency neonatal care delivery. The primary endpoint will be the first two complete rounds of learning within the app, from which the individuals' "learning gains" and Morris G intervention effect size will be computed. To minimize bias, participants will be assigned to an experimental or a control group by a within-app random generator, and this process will be concealed to both the study participants and the investigators until the primary endpoint is reached. RESULTS: This project was funded in November 2016. It has been approved by the Central University Research Ethics Committee of the University of Oxford and the Scientific and Ethics Review Unit of the Kenya Medical Research Institute. Recruitment and data collection began from February 2019 and will continue up to July 31, 2019. As of July 18, 2019, we enrolled 541 participants, of whom 238 reached the primary endpoint, with a further 19 qualitative interviews conducted to support evaluation. Full analysis will be conducted once we reach the end of the study recruitment period. CONCLUSIONS: This study will be used to explore the effectiveness of adaptive feedback in a smartphone-based serious game on health care providers in a low-income setting. This aspect of medical education is a largely unexplored topic in this context. In this randomized experiment, the risk of performance bias across arms is moderate, given that the active ingredient of the intervention (ie, knowledge) is a latent trait that is difficult to comprehensively control for in a real-world setting. However, the influence of any resulting bias that has the ability to alter the results will be assessed using alternative methods such as qualitative interviews. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201901783811130; https://pactr.samrc.ac.za/TrialDisplay. aspx?TrialID=5836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/13034.