Evaluating implementation of “management of Possible Serious Bacterial Infection (PSBI) when referral is not feasible” in primary health care facilities in Sindh province, Pakistan

Bhura, Maria; Ariff, Shabina; Qazi, Shamim; Qazi, Zaitoon; Ahmed, Imran; Nisar, Yasir Bin; Suhag, Zamir; Soomro, Abdul Wahab; Soofi, Sajid Bashir

doi:10.1371/journal.pone.0240688

Cited by 11 publications

(22 citation statements)

References 32 publications

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“…Over time, errors in misclassification of PSBI reduced by more than 50%, while errors in giving inappropriate dosage of antibiotics decreased from 57% to 5%. Similar errors in misclassification and dosage have been reported from PSBI management from Pakistan [30] and MaMoni project [28], Bangladesh.…”

Section: Discussionsupporting

confidence: 78%

“…The MOs therefore, seemed reluctant to give only oral antibiotics, despite trainings. This reluctance to follow guideline recommendations was also reported by sites from Bangladesh [27,29]; Lucknow [26], India; and Pakistan [30], where, in many cases pre-referral antibiotic was also not given when indicated. Stronger advocacy by the state leadership in using the agreed regimen and behaviour change of the MOs is needed.…”

Section: Discussionmentioning

confidence: 80%

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Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India

et al. 2020

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Background Government of India and the World Health Organization have guidelines for outpatient management of young infants 0–59 days with signs of Possible Serious Bacterial Infection (PSBI), when referral is not feasible. Implementation research was conducted to identify facilitators and barriers to operationalizing these guidelines. Methods Himachal Pradesh government implemented the guidelines in program settings supported by Centre for Health Research and Development, Society for Applied Studies. The strategy included community sensitization, skill enhancement of Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) to identify PSBI and treat when referral was not feasible. The research team collected information on facilitators and barriers. A technical support unit provided training and oversight. Findings Among 1997 live births from June 2017 to January 2019, we identified 160 cases of PSBI in young infants resulting in a coverage of 80%, assuming an incidence of 10%. Of these,29(18.1%) had signs of critical illness (CI), 92 (57.5%) had clinical severe infection (CSI), 5 (3.1%)had severe pneumonia (only fast breathing in young infants 0–6 days), while 34 (21%) had pneumonia (only fast breathing in young infants 7–59 days). Hospital referral was accepted by 48/160 (30%), whereas 112/160 (70%) were treated with the simplified treatment regimens at primary level facilities. Of the 29 infants with CI, 18 (62%) accepted referral; 26 (90%) recovered while 3 (10%) who had accepted referral, died. Of the 92 infants who had CSI, 86 (93%) recovered, 65 (71%) received simplified treatment and one infant who had accepted referral, died. All the five infants who had severe pneumonia, recovered; 3 (60%) had received simplified treatment. Of the 34 pneumonia cases, 33 received simplified treatment of which 5 (15%) failed treatment; two out of these 5 died. Overall, 6/160 infants died (case-fatality-rate 3.4%); 2 in the simplified treatment (case-fatality-rate 1.8%) and 4 in the hospital group (case-fatality-rate 8.3%). Delayed identification and care-seeking by families and health system weaknesses like manpower gaps and interrupted supplies were challenges in implementation. Conclusions Implementation of the guidelines in program settings is possible and acceptable. Scaling up would require creating community awareness, early identification and appropriate care-seeking, strengthening ASHA home-visitation program, building skills and confidence of MOs and ANMs, uninterrupted supplies and a dependable referral system.

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Section: Discussionsupporting

confidence: 78%

Section: Discussionmentioning

confidence: 80%

Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India

et al. 2020

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“…When implementation was well-established in study sites, they served as learning sites for district health managers and health workers from other geographical areas in the country [ 22 , 23 , 33 ]. Some specific lessons learnt from similar implementation research conducted in several districts in Bangladesh, which was not part of the WHO coordinated work, are given in Panel 4.…”

Section: Discussionmentioning

confidence: 99%

A multi-country implementation research initiative to jump-start scale-up of outpatient management of possible serious bacterial infections (PSBI) when a referral is not feasible: Summary findings and implications for programs

Nisar

Aboubaker²,

Arifeen

et al. 2022

PLoS ONE

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Introduction Research on simplified antibiotic regimens for outpatient treatment of ‘Possible Serious Bacterial Infection’ (PSBI) and the subsequent World Health Organization (WHO) guidelines provide an opportunity to increase treatment coverage. This multi-country implementation research initiative aimed to learn how to implement the WHO guideline in diverse contexts. These experiences have been individually published; this overview paper provides a summary of results and lessons learned across sites. Methods summary A common mixed qualitative and quantitative methods protocol for implementation research was used in eleven sites in the Democratic Republic of Congo (Equateur province), Ethiopia (Tigray and Oromia regions), India (Haryana, Himachal Pradesh, Maharashtra, and Uttar Pradesh states), Malawi (Central Region), Nigeria (Kaduna and Oyo states), and Pakistan (Sindh province). Key steps in implementation research were: i) policy dialogue with the national government and key stakeholders, ii) the establishment of a ‘Technical Support Unit’ with the research team and district level managers, and iii) development of an implementation strategy and its refinement using an iterative process of implementation, programme learning and evaluation. Results summary All sites successfully developed and evaluated an implementation strategy to increase coverage of PSBI treatment. During the study period, a total of 6677 young infants from the study catchment area were identified and treated at health facilities in the study area as inpatients or outpatients among 88179 live births identified. The estimated coverage of PSBI treatment was 75.7% (95% CI 74.8% to 78.6%), assuming a 10% incidence of PSBI among all live births. The treatment coverage was variable, ranging from 53.3% in Lucknow, India to 97.3% in Ibadan, Nigeria. The coverage of inpatient treatment ranged from 1.9% in Zaria, Nigeria, to 33.9% in Tigray, Ethiopia. The outpatient treatment coverage ranged from 30.6% in Pune, India, to 93.6% in Zaria, Nigeria. Overall, the case fatality rate (CFR) was 14.6% (95% CI 11.5% to 18.2%) for 0-59-day old infants with critical illness, 1.9% (95% CI 1.5% to 2.4%) for 0-59-day old infants with clinical severe infection and 0.1% for fast breathing in 7–59 days old. Among infants treated as outpatients, CFR was 13.7% (95% CI 8.7% to 20.2%) for 0-59-day old infants with critical illness, 0.9% (95% CI 0.6% to 1.2%) for 0-59-day old infants with clinical severe infection, and 0.1% for infants 7–59 days old with fast breathing. Conclusion Important lessons on how to conduct each step of implementation research, and the challenges and facilitators for implementation of PSBI management guideline in routine health systems are summarised and discussed. These lessons will be used to introduce and scale-up implementation in relevant Low- and middle-income countries.

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“…Systematic screening for danger signs by frontline health workers is an essential step to overcome the last mile gap and ensure that poor and rural communities also have access to the care cascade, i.e., screening, diagnosis, treatment and treatment completion and control [23]. However, frontline health workers do not possess the time, focus and experience to reliably count the RR or to simply count the RR at all [3,[6][7][8][9]. As a result, screening of febrile illness in children is incomplete, fast breathing is overlooked and children with severe febrile illness requiring urgent referral or treatment are missed [3,23].…”

Section: Discussionmentioning

confidence: 99%

“…Despite its importance as a clinical danger sign, RR counting is frequently neglected or incorrectly performed by frontline health workers [3,[6][7][8][9]. Manual RR counting can be difficult and time consuming, particularly in agitated children.…”

Section: Introductionmentioning

confidence: 99%

Performance of Automated Point-of-Care Respiratory Rate Counting versus Manual Counting in Children under Five Admitted with Severe Febrile Illness to Kisantu Hospital, DR Congo

Tack

Vita²,

Mbaki³

et al. 2021

Diagnostics

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To improve the early recognition of danger signs in children with severe febrile illness in low resource settings, WHO promotes automated respiratory rate (RR) counting, but its performance is unknown in this population. Therefore, we prospectively evaluated the field performance of automated point-of-care plethysmography-based RR counting in hospitalized children with severe febrile illness (<5 years) in DR Congo. A trained research nurse simultaneously counted the RR manually (comparative method) and automatically with the Masimo Rad G pulse oximeter. Valid paired RR measurements were obtained in 202 (83.1%) children, among whom 43.1% (87/202) had fast breathing according to WHO criteria based on manual counting. Automated counting frequently underestimated the RR (median difference of −1 breath/minute; p2.5–p97.5 limits of agreement: −34–6), particularly at higher RR. This resulted in a failure to detect fast breathing in 24.1% (21/87) of fast breathing children (positive percent agreement: 75.9%), which was not explained by clinical characteristics (p > 0.05). Children without fast breathing were mostly correctly classified (negative percent agreement: 98.3%). In conclusion, in the present setting the automated RR counter performed insufficiently to facilitate the early recognition of danger signs in children with severe febrile illness, given wide limits of agreement and a too low positive percent agreement.

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Evaluating implementation of “management of Possible Serious Bacterial Infection (PSBI) when referral is not feasible” in primary health care facilities in Sindh province, Pakistan

Cited by 11 publications

References 32 publications

Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India

Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India

A multi-country implementation research initiative to jump-start scale-up of outpatient management of possible serious bacterial infections (PSBI) when a referral is not feasible: Summary findings and implications for programs

Performance of Automated Point-of-Care Respiratory Rate Counting versus Manual Counting in Children under Five Admitted with Severe Febrile Illness to Kisantu Hospital, DR Congo

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