Provider performance and facility readiness for managing infections in young infants in primary care facilities in rural Bangladesh

BackgroundNeonatal infections remain a leading cause of newborn deaths globally. In 2015, 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. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016.MethodsThis study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers’ diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance.ResultsAt baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7–57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers’ assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers’ concerns about the efficacy of simplified antibiotic regimens.ConclusionsStrategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers’ assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.研究背景 新生儿感染仍是全球新生儿死亡的首要诱因。2015年，世界卫生组织（World Health Organization, WHO）发布了针对0~59日龄婴儿的疑似重症细菌感染（possible serious bacterial infection, PSBI）管理指南，当无法落实医院转诊时，可采用简化抗生素治疗方案。孟加拉国是首批采纳并落地WHO该指南的国家之一。本研究针对2015年8月至2016年8月期间孟加拉国3个农村乡级行政区的机构筹备情况与医护人员诊疗执行情况展开实施性研究，现将研究结果报告如下。 研究方法 本研究在19家基层医疗卫生机构开展。研究人员在三个时间点使用核查清单评估各机构的筹备情况。为评估医护人员的诊疗执行情况，研究人员从机构就诊登记册中提取所有感染病例的数据，并将医护人员的诊断与治疗方案与指南要求进行比对。本研究绘制了整个研究周期内分类错误与给药剂量错误的分布曲线，并叠加局部加权平滑（LOWESS）曲线以分析执行情况随时间的变化趋势。此外，研究人员与医护人员开展了2场焦点小组讨论与28次深入访谈，以识别影响机构筹备情况与医护人员诊疗执行情况的障碍与促进因素。 研究结果 基线阶段，所有受访机构均未储备充足的抗生素。在为期10个月的研究周期内，共有606名出现感染征象的患病婴儿在本研究的医疗卫生机构就诊。在全部606份就诊记录中，14.9%（N=90/606）存在分类错误。在接受首剂及以上抗生素治疗的551名婴儿中，22.9%（N=126/551）的给药剂量存在错误。错误分布因机构而异（整体占比35.7%，四分位距[Interquartile Range, IQR]：24.7%~57.4%），且与感染严重程度相关。错误发生率在研究初期最高，随后随时间推移逐渐降低。定性数据分析显示，实施初期的错误主要源于医护人员的评估与诊疗操作规范发生改变，包括对存在多种感染征象的婴儿进行分类时存在困惑，以及部分医护人员对简化抗生素治疗方案的有效性存在疑虑。 研究结论 在新的医疗环境中推行复杂诊疗指南时，监测早期执行情况并提供针对性支持的策略，对于提升实施保真度至关重要。未来的研究应评估医护人员对简化治疗方案有效性的认知，并纠正本研究场景下关于广谱抗生素治疗社区获得性新生儿感染更具优势的认知误区。