Improving care pathways for children with severe illness through implementation of the ASPIRE mHealth primary ETAT package in Malawi.

Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.

Paediatric oncology nursing education and training programmes: a scoping review protocol.

INTRODUCTION: The care of children with cancer is a highly specialised field which requires well-educated, trained and dedicated nurses to provide high-quality care. In low/middle-income countries, the survival rate of children with cancer is low as compared with that of high-income countries due to the limited number of specialised oncology healthcare professionals, especially nurses. To address this problem, a number of paediatric oncology education and training programmes have been developed for nurses. The objective of this scoping review is to describe the existing literature focusing on paediatric oncology nursing education and training programmes; to map the content, delivery methods, duration and mode of assessment. METHODS: The review will include articles published in English, from 2012 to 2022, that describe a paediatric oncology nursing education programme, from any setting. The review will follow Joanna Briggs Institute methodology for scoping reviews guidelines. A systematic search of literature will be performed in CINAHL, Dimensions, Embase, PubMed and Scopus. A two-stage standardised screening process will be employed to evaluate eligibility of the articles. All abstracts that will be considered relevant will be reviewed in full text form by the two reviewers independently. Conflicts will be resolved by consensus of all reviewers through a meeting. Data will be extracted by two independent reviewers using a developed data extraction tool. The results will be reported in extraction tables and diagrams with a narrative summary. ETHICS AND DISSEMINATION: This scoping review is part of the multiphase study which obtained ethical clearance from College of Medicine Research Ethics Committee in Malawi and Human Research Ethics Committee of the University of Witwatersrand, South Africa. The scoping review will be published in a peer reviewed journal. The findings will also be presented at national and international conferences. TRIAL REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/X3Q4H.

The Cry to Be Involved: Experiences of Caregivers on Participation in Decision Making and Care Provision at Mercy James PICU in Blantyre, Malawi.

A child's illness and admission in a hospital are stressful and can negatively affect the child and his/her caregivers. The stress is further exacerbated when a child is critically ill and has been admitted to an intensive care unit (ICU). The effects can be reduced when caregivers of the sick children are present and involved in decision making and actual care of their hospitalized children, a care model called family-centered care. Malawi has adopted family-centered care model in the newly instituted Mercy James Pediatric ICU. Little is known about experiences of caregivers with FCC in Malawi. This qualitative study was therefore conducted to explore experiences of caregivers on their involvement in decision making and care at Mercy James Pediatric ICU in Blantyre, Malawi. This was a descriptive qualitative study with a sample size of fifteen participants, however, data saturation was reached with ten participants. One on one in-depth interviews were conducted among a purposively selected sample of ten caregivers whose children had been discharged from the PICU. Content analysis was deductively and manually undertaken to analyze data with the aid of delve software to organize the data. Findings show that not every caregiver was involved in the decision making of their children's care, and if they did, it was not adequate. Barriers to effective involvement such as using a foreign language had a negative impact on comprehensive involvement of caregivers in decision making for their children's care. All participants were, however, involved in the physical care of their children. It is important that health care workers should continuously encourage caregivers to get involved in the decision making and care of their children.

Capacity Building for Health Care Workers and Support Staff in Pediatric Emergency Triage Assessment and Treatment (ETAT) at Primary Health Care Level in Resource Limited Settings: Experiences from Malawi.

Primary health care facilities offer an entry point to the health care system in Malawi. Challenges experienced by these facilities include limited resources (both material and human), poor or inadequate knowledge, skills and attitudes of health care workers in emergency management, and delay in referral from primary care level to other levels of care. These contribute to poor outcomes including children dying within the first 24 hours of hospital admission. Training of health care workers and support staff in Emergency Triage Assessment and Treatment (ETAT) at primary care levels can help improve care of children with acute and severe illnesses. Health care workers and support staff in the primary care settings were trained in pediatric ETAT. The training package for health care workers was adapted from the Ministry of Health ETAT training for district and tertiary health care. Content for support staff focused on non-technical responsibility for lifesaving in emergency situations. The primary health care facilities were provided with a minimum treatment package comprising emergency equipment, supplies and drugs. Supportive supervisory visits were conducted quarterly. The training manual for health care workers was adapted from the Ministry of Health package and the support staff training manual was developed from the adapted package. Eight hundred and seventy-seven participants were trained (336 health care workers and 541 support staff). Following the training, triaging of patients improved and patients were managed as emergency, priority or non-urgent. This reduced the number of referral cases and children were stabilized before referral. Capacity building of health care workers and support staff in pediatric ETAT and the provision of a basic health center package improved practice at the primary care level. The practice was sustained through institutional mentorship and pre-service and in-service training. The practice of triage and treatment including stabilization of children with dangerous signs at the primary health care facility improves emergency care of patients, reduces the burden of patients on referral hospitals and increases the number of successful referrals.