Exploring barriers to guideline implementation for prescription of surgical antibiotic prophylaxis in Nigeria.

Background: In Nigeria, the prescription of surgical antibiotic prophylaxis for prevention of surgical site infection tends to be driven by local policy rather than by published guidelines (e.g. WHO and Sanford). Objectives: To triangulate three datasets and understand key barriers to implementation using a behavioural science framework. Methods: Surgeons (N = 94) from three teaching hospitals in Nigeria participated in an online survey and in focus group discussions about barriers to implementation. The theoretical domains framework (TDF) was used to structure question items and interview schedules. A subgroup (N = 20) piloted a gamified decision support app over the course of 6 months and reported barriers at the point of care. Results: Knowledge of guidelines and intention to implement them in practice was high. Key barriers to implementation were related to environmental context and resources and concern over potential consequences of implementing recommendations within the Nigerian context applicable for similar settings in low-to-middle-income countries. Conclusions: The environmental context and limited resource setting of Nigerian hospitals currently presents a significant barrier to implementation of WHO and Sanford guidelines. Research and data collected from the local context must directly inform the writing of future international guidelines to increase rates of implementation.

MANTRA: Improving Knowledge of Maternal Health, Neonatal Health, and Geohazards in Women in Rural Nepal Using a Mobile Serious Game.

Serious games, conveying educational knowledge rather than merely entertainment, are a rapidly expanding research domain for cutting-edge educational technology. Digital interventions like serious games are great opportunities to overcome challenges in low-and-middle-income countries that limit access to health information, such as social barriers like low-literacy and gender. MANTRA: Increasing maternal and child health resilience before, during and after disasters using mobile technology in Nepal takes on these challenges with a novel digital health intervention; a serious mobile game aimed at vulnerable low-literacy female audiences in rural Nepal. The serious game teaches 28 learning objectives of danger signs in geohazards, maternal, and neonatal health to improve knowledge and self-assessment of common conditions and risks to inform healthcare-seeking behavior. Evaluations consisted of recruiting 35 end users to participate in a pre-test assessment, playing the game, post-test assessment, and focus groups to elicit qualitative feedback. Assessments analyzed knowledge gain in two ways; by learning objective with McNemar tests for each learning objective, and by participant scores with paired t-tests of overall scores and by module. Results of assessments of knowledge gain by learning objective (McNemar tests) indicate participants had sufficient prior knowledge to correctly interpret and respond to 26% of pictograms (coded AA), which is a desirable result although without the possibility of improvement through the intervention. The geohazard module had greatest impact as 16% of responses showed knowledge gain (coded BA). The two most successful learning objectives showing statistically significant positive change were evidence of rockfalls and small cracks in the ground (p = < 0.05). Assessment of knowledge gain by participant scores (paired t-tests) showed the 35 participants averaged a 7.7 point improvement (p < 0.001) in the assessment (28 learning objectives). Average change in knowledge of subdivided module scores (each module normalized to 100 points for comparison) was greatest in the geohazard module (9.5 points, p < 0.001), then maternal health (7.4 points, p = 0.0067), and neonatal health (6.0 points, p = 0.013). This evaluation demonstrated that carefully designed digital health interventions with pictograms co-authored by experts and users can teach complex health and geohazard situations. Significant knowledge gain was demonstrated for several learning objectives while those with non-significant or negative change will be re-designed to effectively convey information.

MANTRA: development and localization of a mobile educational health game targeting low literacy players in low and middle income countries.

BACKGROUND: Mobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal. METHODS: The serious game was developed through a co-creation process between London and Kathmandu based researchers by email and video-calling, and face-to-face with local stakeholders in Nepal. The process identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot serious game to the local cultural context. Evaluations and feedback from end users took place in rural villages and suburban Kathmandu in Province Three. Field evaluation sessions used mixed methods. Researchers observed game play and held focus group discussions to elicit qualitative feedback and understand engagement, motivation, and usability, and conducted a paired pre- and post-game knowledge assessment. RESULTS: The MANTRA serious game is contextualized to rural Nepal. The game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geohazards, through picture matching with immediate audio and visual feedback. User feedback from focus groups demonstrated high engagement, motivation, and usability of the game. CONCLUSIONS: This MANTRA study is a unique mHealth intervention of a serious game to teach core health and geohazards messages to low-literacy audiences in rural Nepal. Although the mobile game is tailored for this specific context, the developmental process and insights could be transferable to the development of other games-based interventions and contextualized for any part of the world. Successfully targeting this low-literacy and illiterate audience makes the MANTRA development process the first of its kind and a novel research endeavor with potential for widespread impact and adoption following further game development. TRIAL REGISTRATION: This project was approved by the University College London Ethics Committee in London, United Kingdom [10547/001], and the Nepal Health Research Council in Kathmandu, Nepal [Reg. No. 105/2017]. All participants provided informed written consent.