Table 4.

Implementation factors

Topic	Facilitators	Barriers
Device	• Simple to use, affordable and low maintenance for low-resource settings. • A temperature-controlled gas circuit may reduce the risk of hypothermia especially in extremely low-birthweight babies.	• Efficacy may be limited to mild to moderate respiratory distress and less effective with severe cases.
Training and staffing	• Regular and interactive training with intermittent refresher trainings. • Clinical mentorship with training on how to train others to use bubble CPAP. • Investing in nurses dedicated to the nursery. • Clinicians that stay longer term in the nursery. • Combination of external consultant with local clinicians as trainers. • Health facility management that prioritized neonatal care.	• Understaffed neonatal units limit the capacity for care. • Staffing shortages exacerbated by healthcare provider strikes in some locations. • High turnover of nurses and doctors necessitated repeated training of new staff. • Lack of motivation and accountability. • Gaps in training as many nurses and doctors are untrained in bubble CPAP. • Communication barriers between doctors and nurses.
Initiation	• Decision-making aided by clinical algorithm that is clearly posted by the machine.	• Gaps in correct identification of early and mild signs of distress. • Reluctance of nurses to initiate while short-staffed at night and without consulting a clinician. • Overtightening the chin strap can lead to facial swelling.
Monitoring	• Appropriate and regular monitoring. • Monitoring with pulse oximetry. • Monitoring respiratory distress with respiratory severity score.	• Complications such as CPAP belly syndrome and mucosal drying require regular monitoring and actions to prevent.
Weaning	None discussed.	• Knowing when to wean, especially when resources are limited. • A need to monitor closely after weaning to ensure the infant is not desaturating.
Caregivers	• Peer support from caregivers with positive experiences with bubble CPAP use on their own newborns.	• Local beliefs that the oxygen led to poor outcomes. • Poorly providing information to caregivers and gaps in consenting parents before starting bubble CPAP. • Bubble CPAP may complicate mother-infant interaction as mothers were afraid to hold babies, unable to see their infant’s faces and interrupted skin-to-skin contact.
Supplies and equipment	• Appropriate snug-fitting nasal prongs. • Soft nasal prongs. • Use of locally available materials.	• Cost of disposable nasal prongs. • Oxygen concentrators not always available. • CPAP machines not always available. • Different machines cause challenges in training, set up and maintenance. • Poor equipment maintenance once donors withdraw support.