Abstract
Introduction
Neonatal intensive care unit (NICU) in sub-Saharan Africa face limited resources and systemic challenges, resulting in poorer quality care, higher infant mortality, and dissatisfaction among both patients and healthcare workers. This review aims to bridge the knowledge gap by identifying and analysing the key barriers and enablers affecting quality care, informing interventions to improve patient outcomes and overall NICU effectiveness in this critical region.
Methods and analysis
This systematic review will search and gather data from a variety of databases, including JBI Database, Cochrane Database, MEDLINE/PubMed, CINAHL/EBSCO, EMBASE, PEDro, POPLINE, Proquest, OpenGrey (SIGLE), Google Scholar, Google, APA PsycINFO, Web of Science, Scopus and HINARI. The review will also include unpublished studies and grey literature from a variety of sources. This review will only include qualitative and mixed-methods studies that explore the barriers and enablers of quality care for high-acuity neonates using qualitative data collection and analysis methods. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research will be used by two independent reviewers to critically appraise the eligible studies. Any disagreements that arise will be resolved through discussion. Qualitative research findings will be pooled using the meta-aggregation approach in QARI software, where possible. Only unequivocal and credible findings will be included in the synthesis. If textual pooling is not possible, the findings will be presented in narrative form.
Ethics and dissemination
This systematic review does not require ethical clearance, and the findings will be disseminated to relevant stakeholders to ensure the widest possible outreach and impact.
PROSPERO registration number
CRD42023473134.
Keywords: Neonatal intensive & critical care, Nursing Care, Nurses, Health Services Accessibility, Quality in health care
Strengths and limitations of this study.
The review will provide a comprehensive synthesis of qualitative evidence on the barriers and enablers of quality high-acuity neonatal care in sub-Saharan Africa.
The review will use a systematic and rigorous approach to identify, select and analyse relevant studies.
The review will include a wide range of qualitative studies from different countries and settings in sub-Saharan Africa.
The review will be limited by the quality of the available qualitative studies.
The review will not be able to provide causal inferences about the barriers and enablers of quality high-acuity neonatal care.
Introduction
Quality of care is defined as the extent to which healthcare services are delivered to improve desired health outcomes. To achieve this, the services must be safe, effective, timely, efficient, equitable and person-centred.1 Quality of neonatal care includes the availability of equipment, supplies, guidelines, protocols, and trained and motivated healthcare workers, as well as supportive supervision and client satisfaction.2–4 The importance of high-quality care for newborns is increasingly recognised worldwide as essential to improving their health and well-being.3 5 6 Neonatal intensive care unit (NICU) in sub-Saharan Africa face limited resources and systemic challenges, resulting in poorer quality care, higher infant mortality, and dissatisfaction among both patients and healthcare workers.7 8 This is an alarming public health issue because it puts millions of newborns at risk of death and disability, resulting staff burnout and missed nursing care for high-acuity neonates.9–11
There are a number of potential barriers that hinder the quality of care and enablers that foster it in the NICU. Barriers related to the provider, the caregiver and the health system include inadequate knowledge and training, rigid division of roles and responsibilities, poor leadership, lack of effective communication, human resource constraints, inadequate equipment and clinical guidelines, poor documentation and infrastructure, and economic insecurity of the parents.12–22 On the other hand, barriers related to the sociocultural environment include the patterns of interaction between the staff and the parents and among the staff, and power structure of the staff and the leaders.23–25 Making the care participatory, respectful, providing emotional support to parents, positive communication and using digital technologies were some of the facilitating factors for the quality of care in the NICU.22 24 26 27
Enhancing the quality of NICU services in sub-Saharan Africa requires a multipronged approach that strengthens collaboration among various stakeholders, aligns quality of care plans with national infrastructure development strategies and ensures adequate procurement of essential medicines and commodities.28 While notable progress has been made in scaling up NICU quality in countries like Malawi, Ethiopia and Rwanda over the past few decades,29 significant gaps remain in many sub-Saharan countries, necessitating continued efforts to improve service delivery, reduce neonatal mortality and enhance parent and provider satisfaction. In this context, identifying the key barriers hindering service provision and the factors promoting positive outcomes is crucial.
This systematic review aims to bridge the existing knowledge gaps regarding the quality care for high-acuity neonates in sub-Saharan Africa. A preliminary search of relevant databases, including PROSPERO, MEDLINE, Cochrane Database of Systematic Reviews and JBI Evidence Synthesis, revealed no ongoing or recently completed systematic reviews addressing this topic.
Review objective
The primary objective of this systematic review is to comprehensively examine the evidence about barriers and enablers that influence quality high-acuity neonatal care in sub-Saharan Africa.
Methods and analysis
Protocol design and registration
This systematic review protocol was developed following the Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence,30 integrated with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines31 32 (online supplemental file 1). The findings of the systematic review will be reported following the ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) guideline.33 The review title has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42023473134.
bmjopen-2023-081904supp001.pdf (88.3KB, pdf)
Inclusion criteria
The studies included in this systematic review will be selected based on the PICo mnemonic for participants, phenomena of interest and context.
Participants: The participants for this systematic review will be any individual (caregiver, parents, health professionals, etc).
Phenomena of interest: This systematic review will consider studies that explore the barriers and enablers of quality high-acuity neonatal care in the NICU.
Context: The systematic review will include studies conducted in sub-Saharan Africa.
For types of studies, this review will only include qualitative and mixed-methods studies that explore the barriers and enablers of quality high-acuity neonatal care using qualitative data collection and analysis methods.
Search strategy
This systematic review will search for both published and unpublished studies on the barriers and enablers of quality care for high-acuity neonates in sub-Saharan Africa. The search will be conducted in three steps: (1) A limited search of MEDLINE (PubMed) and CINAHL (EBSCO) will be conducted to identify relevant articles. The search terms will be based on the titles, abstracts and index terms of relevant articles, and will use the Boolean logic operators AND and OR with Medical Subject Headings (MeSH) terms, keywords and word variants for quality of care. (2) The search terms identified in the initial search will be adapted to create a full search strategy for each included database and/or information source (table 1). (3) To identify additional relevant studies, the reference lists of all included studies will be screened. This systematic review will focus exclusively on studies published in English between 1 January 2013 and 30 December 2023. This timeframe ensures the inclusion of the most recent evidence relevant to such a large geographical area. Additionally, it addresses practical considerations for conducting this review. This systematic review will search and gather data from a variety of databases, including JBI Database, Cochrane Database, MEDLINE/PubMed, CINAHL/EBSCO, EMBASE, PEDro, POPLINE, Proquest, OpenGrey (SIGLE), Google Scholar, Google, APA PsycINFO, Web of Science, Scopus and HINARI. In addition to published literature, unpublished studies and grey literature will be sought from institutional libraries and repositories, preprint websites and by contacting the authors directly. A librarian will be consulted to assist with optimising the search strategy.
Table 1.
Search strategy
| PICo components | Inclusion criteria | Search terms (keywords/MeSH terms/index terms/free text words) | Limits |
| Participants | Caregiver, nurses, parents, health professionals | nurse*[All Fields] OR caregiver*[All Fields] OR parent*[All Fields] OR health care provider*[MeSH Terms] OR health professional*[MeSH Terms] OR health care worker* [All Fields] | Language: English Publication date: 1 January 2013 to 30 December 2023 |
| Phenomena of interest | Barriers and enablers of quality high-acuity neonatal care in the NICU | barrier*[All Fields] OR enabler* [All Fields] OR facilitator*[All Fields] OR hindering factor*[All Fields] OR militating factor*[All Fields] OR challenge*[All Fields] OR neonatal intensive care unit [All Fields] OR NICU [All Fields] OR quality care [All Fields] OR high-acuity neonate*[All Fields] | |
| Context | Studies conducted in sub-Saharan Africa | sub-Saharan Africa | |
| Combine a single search strategy: (((“nurse*”[All Fields] OR “caregiver*”[All Fields] OR “parent*”[All Fields] OR ((“delivery of health care”[MeSH Terms] OR (“delivery”[All Fields] AND “health”[All Fields] AND “care”[All Fields]) OR “delivery of health care”[All Fields] OR (“health”[All Fields] AND “care”[All Fields]) OR “health care”[All Fields]) AND “provider*”[MeSH Terms]) OR ((“health”[MeSH Terms] OR “health”[All Fields] OR “health s”[All Fields] OR ”healthful”[All Fields] OR “healthfulness”[All Fields] OR “healths”[All Fields]) AND “professional*”[MeSH Terms]) OR “health care worker*”[All Fields]) AND “barrier*”[All Fields]) OR “enabler*”[All Fields] OR “facilitator*”[All Fields] OR “hindering factor*”[All Fields] OR “militating factor*”[All Fields] OR “challenge*”[All Fields] OR (“intensive care units, neonatal”[MeSH Terms] OR (“intensive”[All Fields] AND “care”[All Fields] AND “units”[All Fields] AND “neonatal”[All Fields]) OR “neonatal intensive care units”[All Fields] OR (“neonatal”[All Fields] AND “intensive”[All Fields] AND “care”[All Fields] AND “unit”[All Fields]) OR “neonatal intensive care unit”[All Fields]) OR (“intensive care units, neonatal”[MeSH Terms] OR (“intensive”[All Fields] AND “care”[All Fields] AND “units”[All Fields] AND “neonatal”[All Fields]) OR “neonatal intensive care units”[All Fields] OR “nicu”[All Fields]) OR (“quality of health care”[MeSH Terms] OR (“quality”[All Fields] AND “health”[All Fields] AND “care”[All Fields]) OR “quality of health care”[All Fields] OR (“quality”[All Fields] AND “care”[All Fields]) OR “quality care”[All Fields]) OR (“high-acuity”[All Fields] AND “neonate*”[All Fields])) AND (“africa south of the sahara”[MeSH Terms] OR (“africa”[All Fields] AND “south”[All Fields] AND “sahara”[All Fields]) OR “africa south of the sahara”[All Fields] OR (“sub”[All Fields] AND “saharan”[All Fields] AND “africa”[All Fields]) OR “sub saharan africa”[All Fields]) AND 2013/01/01:3000/12/31[Date - Publication] | |||
| Number of records retrieved by the search: 83 877 | |||
| Database used: MEDLINE (Ovid) | |||
| Date the search was conducted: 5 November 2023 Time: 10:25:48 | |||
MeSH, Medical Subject Headings; NICU, neonatal intensive care unit.
Study selection
Following the search, all identified citations will be collated and uploaded into EndNote and duplicates removed. After pilot test, title and abstract screening process will be performed by two independent reviewers against the inclusion criteria. The inclusion criteria for the review will be used to determine if the citations are relevant. The full texts of the potentially relevant sources will then be retrieved. Two independent reviewers will assess the full texts of the retrieved studies to determine if they meet the inclusion criteria for the review. If a study is excluded, the reasons for exclusion will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion. The final systematic review will fully report search and study selection results, adhering to the ENTREQ format for transparency.33
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Research.30 The authors of the papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise will be resolved through discussion. The results of the critical appraisal will be reported in narrative form and in a table. Studies will be scored using a quality appraisal checklist, and only studies with a score of 50% or higher will be included in the systematic review and meta-synthesis. If the two assessors disagree on a score, they will review the study together to investigate the source of the disagreement. If they are still unable to agree, the average of their scores will be used. Studies that do not meet the quality threshold to merit inclusion will be excluded from the systematic review and meta-synthesis, but they will be reported narratively and in table form.
Data extraction
Data extraction from the studies included in the review will be conducted by two independent reviewers using the standardised JBI data extraction tool.30 The data extracted will encompass specific details pertaining to the populations, context, culture, geographical location, study methods and the phenomena of interest relevant to the review objective (online supplemental file 2). Findings and their corresponding illustrations will be extracted verbatim and assigned a level of credibility. Discrepancies arising between the reviewers will be resolved through discussion. The authors of the papers will be contacted to solicit missing or additional data when necessary.
bmjopen-2023-081904supp002.pdf (101.6KB, pdf)
Data synthesis
Qualitative research findings will, where possible, be pooled using QARI with the meta-aggregation approach. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorising these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. The synthesis will focus solely on unequivocal and credible findings. Unequivocal findings are considered beyond reasonable doubt, while credible findings are plausible and well supported, even if not definitive.
Assessing confidence in the findings
The synthesised findings will undergo evaluation using the ConQual approach, a method for establishing confidence in the output of qualitative research synthesis. The resulting assessment will be presented in a summary of findings table.34
Patient and public involvement
No patients involved.
Ethics and dissemination
Ethical clearance is not required for this systematic review as it does not involve any primary research or the collection of data from human participants. The review will only synthesise existing research findings which are publicly available and do not raise any ethical concerns. The findings of the systematic review will be disseminated to a wide range of stakeholders, including researchers, policymakers, healthcare professionals and patient advocates. This will be done through a variety of channels, such as publication in peer-reviewed journals, presentation at conferences and dissemination of reports and summaries.
Amendments
The authors may need to make some changes to the systematic review, but they will clearly explain what those changes are and why they are necessary in the final review.
Supplementary Material
Acknowledgments
The authors would like to express their thanks to Arba Minch University and Jimma University for their support.
Footnotes
Contributors: AM came up with the research question, wrote how the research would be done and the introduction, and created a plan for the research. AD and GN helped find information. AM, AD and GN all carefully reviewed and approved the final plan before it was sent for publication.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Ethics statements
Patient consent for publication
Not required.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
bmjopen-2023-081904supp001.pdf (88.3KB, pdf)
bmjopen-2023-081904supp002.pdf (101.6KB, pdf)