EARLY IMPLEMENTATION OF GUIDELINES FOR MANAGING YOUNG INFANTS WITH INFECTION IN RURAL BANGLADESH: AN IMPLEMENTATION RESEARCH STUDY
Applegate, Jennifer Anne
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Background: Neonatal infections remain a leading cause of newborn deaths globally. In 2015, the World Health Organization (WHO) issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO’s guidelines for implementation. This implementation research study assessed fidelity and acceptability of the guidelines in three rural sub-districts of Bangladesh during August 2015-August 2016. Methods: This study was conducted in 19 primary health centers and their catchment areas. Facility readiness was assessed using checklists completed by study staff at three time points and case management data were extracted from registers weekly. Questionnaires were administered to caregivers of cases to assess treatment adherence. To measure fidelity, we assessed 1) trends in provider adherence to guidelines; and 2) conducted a multinomial logistic regression to assess patterns and determinants of caregiver adherence to the oral amoxicillin regimen. Caregiver acceptability was measured for key guideline components including acceptance of referral and simplified antibiotic treatment. Focus group discussions and in-depth interviews with providers and caregivers were conducted to identify barriers and facilitators for implementation fidelity and acceptability. Results: Provider errors in classification and antibiotic treatment were highest at the beginning of the study period, but performance improved over time. Qualitative data suggest errors in early implementation may be due to providers learning new methods for assessment and treatment, and some providers’ concerns about the efficacy of simplified antibiotic regimens. Few caregivers accepted referral to the hospital, which was attributed to previous negative experiences at these facilities. Caregivers that received follow-up from the provider during the illness episode were less likely to provide fewer than the recommended doses of oral amoxicillin. Acceptability of simplified antibiotic treatment was high, especially when caregivers had trust and good communication with the provider. Conclusions: Clinical supervision and mentoring are important drivers of implementation when introducing complex guidelines. Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity. Counseling on continued treatment and follow-up by the provider improved caregiver acceptability and adherence to the simplified antibiotic regimen.