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Abstract
Objective To evaluate the feasibility of implementing family-integrated newborn care (FINC) for hospitalised preterm and low birthweight infants in Ethiopia. Despite the WHO’s call for family engagement in newborn care, evidence of the feasibility of implementation remains scarce.
Design An observational feasibility study employing a mixed-methods design comprising a quantitative cross-sectional survey among 157 healthcare providers (HCPs) and a qualitative Participatory Rural Appraisal.
Setting The study was conducted in 30 neonatal care units (NCUs) of hospitals in Tigray, Northern Ethiopia.
Participants HCPs who were on duty in NCUs during the data collection period were included in the study.
Analysis Descriptive statistics were obtained for the quantitative data using STATA V.16, while qualitative data were coded and analysed using a framework analysis approach with qualitative data analysis software (Atlas.ti V.9).
Results In total, 157 HCPs were enrolled with a mean (SD) age of 32 (±6.8) years. Participants scored a higher weighted mean score for implementability (0.75) and a lower mean score for adaptability (0.50). Out of the 157 HCPs, the majority perceived that FINC was technically implementable (96%), conceptually acceptable (74%) and ethically correct (88%). Furthermore, 49% perceived that integrating FINC into the existing system was technically manageable, while 52% agreed that it was expandable to other healthcare facilities. However, HCPs reported lower confidence regarding its practicality (32%), integration (31%) and adaptability (16%). NCU space (97%), number of NCU rooms (87%) and increased risk of infection (83%) were perceived as potential challenges to the feasibility of FINC. More importantly, only 33% of HCPs felt that there was an organisational demand to consider FINC in NCUs. Furthermore, there was a statistically significant variation in the mean score for acceptability and perception of additional burden between age groups (p=0.04).
Conclusions and recommendations The current study shows that FINC is conceptually acceptable, technically implementable and expandable to other settings, with weighted mean scores of 0.75, 0.72 and 0.66, respectively. However, its practicality (0.53), integration (0.52) and adaptability (0.50) could be generally constrained mainly by the poor organisational infrastructure related to NCU space and infection prevention measures. Addressing motivational, attitudinal and competency gaps of NCU HCPs, along with organisational capacity, would be required.
- Patient-Centered Care
- NEONATOLOGY
- Health Services
- Health Literacy
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study covered hospitals with varying levels of neonatal care units (levels I–III).
The mixed-methods design enabled triangulation of findings, which maximised their external generalisability in resource-limited settings.
The interviewer-administered approach applied is prone to social-desirability bias, despite the training provided to data collectors.
The feasibility was assessed from the healthcare providers’ perspective alone and family perspectives were not included.
Cost-effectiveness and efficiency were not included as dimensions of feasibility.
Introduction
The first month of life is the most vulnerable period for a child’s survival, with 2.3 million neonates dying in 2022, and the sub-Saharan region accounting for 46% of these deaths.1 Ethiopia remains one of five countries in the world with the highest rate of neonatal mortality at 27 per 1000 live births.2
Complications from premature birth (before 37 weeks) and low birth weight (LBW <2500 g) contribute to 60%–80% of global neonatal deaths.3 Preterm and LBW infants are often in critical need of observation and treatment in neonatal care units (NCUs) immediately after birth. However, poor quality of care contributes to a large proportion of deaths.4 As a consequence, the mortality rate among infants admitted to NCUs in Ethiopia is as high as 19%.5 Moreover, postdischarge mortality among under-5 children remains high in low-resource settings, at 4.4%,6 and is even higher for LBW infants, at 6.5%.7
To prevent complications and subsequent negative outcomes, and to improve the quality of care for small and sick newborns, the WHO recommends integrating families in NCUs.3 8 Family-integrated newborn care (FINC) refers to the presence and active engagement of families in the emotional, social and cognitive development of their infant.9–11 The initiative mainly consists of orienting, training and educating parents to engage in activities such as feeding, bathing, dressing and holding skin-to-skin (kangaroo mother care (KMC), infection prevention and documentation.11–18 FINC promotes a trustworthy and respectful partnership between family members and healthcare providers (HCPs), provider–client communication, shared decision-making and readiness to continue care after discharge.13 19–21 As healthcare facilities in low-resource settings are often challenged by a shortage of qualified HCPs and poor quality of care in NCUs, FINC could potentially reduce the work burden among HCPs, and improve neonatal outcomes and parental and HCPs’ satisfaction. The need to make health services responsive to the needs of families is also underlined in the Ethiopian Health Sector Transformation Plan.22
The literature on the effectiveness and efficacy of FINC is expanding, although concentrated among high-resource settings,11 13 23 24 with a limited number of studies conducted in low-resource settings.25 26 The variation in the effect size of outcomes across studies, poor documentation of the implementation process and limited evidence regarding the acceptability and practicality of FINC in varying settings, all compel feasibility studies preceding effectiveness studies.23 27–29 As HCPs play an essential role in family-centred care, understanding their perspective on the feasibility of integrating families in NCUs is important.26 30 31 This study aims to assess the feasibility of implementing FINC for hospitalised preterm and LBW infants in hospital NCUs in the Tigray region, Northern Ethiopia.
Methods
Study setting
This study was conducted in 30 of 40 hospitals in the Tigray regional state of Northern Ethiopia. Two of the hospitals included were referral hospitals with level-3 NCUs, 9 were general hospitals with level-2 NCUs and 19 were primary hospitals with level-1 NCUs. The remaining 10 hospitals were excluded from the study for a variety of reasons (8 were inaccessible at the time of data collection, due to the conflict in Tigray; one was not providing NCU services during the study period and one was included in the pretest for the current study). All hospitals included in the study were expected to have a neonatal ward equipped with basic medical equipment, as well as trained staff to provide care for small and sick infants, with the types of care varying across NCU levels. Level-3 NCUs provide continuous life support for extremely high risk; level-2 NCUs provide care for infants born at 32 weeks or above; or 1500 g or above; or moderately sick; and level-1 NICUs provide basic care for infants born at 35–37 weeks.22 32
Study design and study period
This feasibility study was part of a larger innovation-to-scale project named Saving Little Lives, implemented by the Ministry of Health in Ethiopia. The project aimed to substantially reduce neonatal mortality by improving the quality of care for hospitalised preterm and LBW infants.33 The FINC feasibility study was performed over a 1-month period starting on 19 February 2024. It employed a mixed-methods design34 comprising a quantitative cross-sectional survey among 157 HCPs and a qualitative Participatory Rural Appraisal (PRA). The study adopted a theoretical framework by Bowen et al 35 to assess the feasibility of the study in terms of eight dimensions (conceptual acceptability, technical implementability, practicality in real settings, organisational demand, adaptability, integration, expandability and provider–family communication). The framework posits that an intervention should demonstrate feasibility through a thorough, multitiered assessment before it can be considered for efficacy testing. This comprehensive evaluation is essential to justify the intervention’s potential for further study. The theoretical framework also guides the process of feasibility assessment (figure 1).
Theoretical framework for feasibility study on family-integrated newborn care (FINC) in Ethiopian Neonatal Care Units: Adapted from Bowen et al.35
Study participants
As the number of HCPs working in hospital NCUs in Tigray is low, all HCPs who were providing service at the 30 hospital NCUs were eligible to participate. For the qualitative part of the study, participants were purposively selected based on their familiarity and experience with NCU care.
Data collection tools, procedures and outcome variables
For the quantitative part of the study, the principal investigator developed the data collection tool based on existing literature31 35–38 and experts from various disciplines reviewed the tool in a three-step process. The expert team consisted of two investigators, two residents from the Department of Paediatrics and Child Health, one senior paediatrician and four nurses familiar with the NCU setup in Tigray. The review process aimed to ensure that the experts felt confident that the items in each feasibility dimension appeared to be valid in measuring what was intended to measure (face validity), evaluating the tool for capturing the basic essence of FINC and customising it to the local context. After the tool was thoroughly reviewed, it was pretested among eight interviews (5% of the total sample) at Quiha General Hospital in Tigray. Finally, the expert team reviewed and incorporated the feedback during the pretest mainly regarding redundancy, wordings, phrasings, order of the items, and the length of the tool against time. The final version of the tool consisted of five sections: (1) sociodemographic characteristics; (2) potential care practices for family integration; (3) provider–family communication; (4) feasibility dimension and (5) individual and organisational burden. The 24 feasibility dimension items were further subgrouped into seven dimensions (eight items for acceptability of FINC, three for implementation, four for practicality, four for organisational demand, two for adaptation, one for integration and two for expansion/scalability). For each feasibility dimension, participants were asked about their level of confidence or agreement concerning each positive statement on a 5-point scale in increasing order. The responses ranged from 1 to 5, corresponding to ‘very low’ and ‘very high’, respectively (online supplemental file 1).
Supplemental material
For the qualitative part, a PRA approach was employed using the Feasibility Assessment Framework36 consisting of six focused group discussions (FGDs), each including 6–10 nurses. The PRA was considered as a data collection approach employing both FGDs and in-depth interviews (IDI) techniques. This approach allowed us to make the participants’ opinions shape the discussion points and to hold adequate space on the concerns most matters for them and the potential interference to feasibility of integrating families in NCU. The design was chosen to learn from people with the people to examine the feasibility of FINC in a more participatory approach. For the FGD, a semistructured guide consisting of open-ended questions regarding HCPs’ opinion towards feasibility of FINC was developed. The semistructured tool covered the potential activities in which families could be involved, provider–family communication, conceptual acceptability, implementability and practicality. The tool was improved after review and continuous modification by a team of experts during the data collection period, to capture the emerging insights (online supplemental file 2). The FGDs were conducted after the nurses completed the quantitative survey to minimise bias in their responses to the survey questions. Participants in focus groups were asked for convenient time and place to ensure that confidentiality is maintained and that recording of the discussion is possible with minimal disturbance. Code was given to each participant for anonymity and balanced contribution to the discussion was ensured. A facilitator and a note-taker conducted the FGDs and each FGD lasts a minimum of 90 minutes.
Supplemental material
In addition, IDIs were conducted with 3 NCU heads, 4 senior paediatricians and 3 general practitioners, yielding a total of 10 IDIs. IDIs were conducted after salient opinions captured from the FGDs. Participants for the interviews were purposively selected among participant who do not take part in the FGDs. The FGD guide was customised to fit IDI with the aim of deepening the nuanced opinions of the FGDs regarding the feasibility of FINC in their settings (online supplemental file 2). Participants were approached for face-to-face interview in convenient place and time, which lasts a minimum of 45 minutes.
Recruiting additional participants in both focus groups and interviews was stopped as saturation was reached. The discussion and interview guides were modified across the data collection period to capture newly emerged insights. Six Masters of Public Health (MPH) holders familiar with the NCU setting in Tigray underwent four days of training before approaching the HCPs for an interview. The data were collected using an electronic data collection tool named Open Data Kit, which is an open-source, offline tool that enables the collection and submission of data to a central server via mobile phone. The first author (male, experienced in conducting qualitative studies, MPH and a PhD student) and a resident (male, medical doctor by training and enrolled to specialise in paediatrics and child health) supervised the quantitative data collection and collected the qualitative data.
Analysis
Construct validity and reliability of the items in provider–family communication and feasibility dimensions were assessed using exploratory factor analysis after the sample adequacy was assessed and found acceptable (Kaiser-Meyer Olkin=0.8 with a significant level of Bartlett’s sphericity test=0.01). Items were subject to exploratory factor analysis with principal component, varimax rotation and an eigenvalue of 1 to determine the number of dimensions. In addition, the reliability of the items in each dimension was assessed and found to be acceptable (Cronbach’s alpha >0.6). After negative statements were reverse coded, the participant’s score for each item was added up to generate the latent variable for each dimension of feasibility.
Descriptive analyses were performed for the latent variables regarding mean score and SD. Subsequently, pairwise mean comparison using one-way analysis of variance with equal variance of the Bonferroni test was conducted to determine whether there was a significant difference in participants’ mean scores on the dimensions of feasibility by sociodemographic characteristics as well as level of the hospital. In addition, to help compare scores across dimensions, the weighted mean score of dimensions was computed for each dimension by weighing against the maximum potential score with reference to the number of items in each dimension.
Qualitative data were audio-taped, transcribed and imported into qualitative data analysis software (Atlas ti. V.9) for coding and analysis. Filed notes were added to each transcription and considered in the data analysis. The first author (ZHK) coded the transcripts, and the other authors critically assessed the list of codes for grounding in the data, soundness of the quotations in representing the participants’ opinion and fitness of the code labelling for the feasibility dimensions. The qualitative framework analysis approach was applied to identify, describe and interpret key patterns within and across the eight feasibility dimensions (conceptual acceptability, technical implementability, practicality in real settings, organisational demand, adaptability, integration, expandability and provider–family communication). Initially, transcripts were deductively coded against the eight preidentified dimensions. Similar codes were then grouped into categories, which were finally inductively thematised across the eight dimensions.39 Data from both the quantitative and qualitative methods were concurrently collected and separately analysed. Findings from each method were assessed for synchronisation, similarity, differences and complementary views of the findings. As both quantitative and qualitative methods were designed to assess the same constructs (feasibility dimensions) from their own perspectives, findings from both methods were converged/integrated and interpreted for a greater understanding of the dimensions.34 Finally, a discussion was conducted with NCU providers in Ayder referral hospital for members to check whether the emerged findings were grounded with their opinions reflected during the data collection.
In addition, the structure of the manuscript was assessed against applicable checklists, specifically the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (online Research checklist 1) for observational quantitative part and the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (online Research checklist 2) for the qualitative part.
Supplemental material
Supplemental material
Results
All HCPs on duty during the study period were included, yielding 157 participants in total, with a response rate of 94%. Nine employed HCPs did not participate in the study as they were off duty due to maternity leave, sick leave or training. The mean (SD) age of the participants was 32 (±6.8) years. Almost all (98%) were nurses by training, and 41% of the participants had served at least 5 years in NCU (n=157). In addition, 44% worked at level 2 NCU (table 1).
Sociodemographic characteristics and work experience of HCPs working at hospital NCUs in Tigray, Northern Ethiopia (n=157)
Potential activities for family integration in the NCU
Of the 157 HCPs, almost all (97%) reported that involving families in the NCU would be helpful, out of which 149 (98%) specified the mother as a potential family member to be involved, followed by fathers (85%), grandmothers (23%) and parents’ siblings (21%) (figure 2).
Healthcare providers’ response on the potential care practices family of preterm and low birthweight infants could be involved in hospital neonatal care units (n=152). KMC, kangaroo mother care.
Regarding potential activities for families to be involved in, 124 (81%) mentioned KMC, 119 (78%) feeding support, 83 (55%) changing diapers and 46 (30%) infection prevention (n=157) (figure 2). Monitoring oxygen delivery, and provision and continuation of oral medications were also raised as potential activities. Participants in both focus groups and interviews considered fathers and grandmothers appropriate for KMC under the following conditions: (a) if the mother had to stay at the postnatal unit due to her medical condition, (b) twins and (c) when the mother had to go to the toilet or shower. Furthermore, HCPs specified the benefits of integrating families into the NCU:
She could have alerted us if the oxygen supply had stopped. The lack of oxygen caused the deaths of some newborns. Because of the large number of newborns, it might occasionally be challenging for us [HCPs) to supervise every infant. On the other hand, the mother is devoted to just one newborn (nurse, general hospital).
[…] […] Consider phenobarbital, the medication most frequently given to newborns. It must be gradually stopped after discharge and is typically taken for months. Consequently, it helps the family practice giving the medication until they are able to do it on their own if we involve them in the process (medical doctor, referral hospital).
Among the 152 HCPs who responded that integrating families in the NCU would be helpful, 118 (78%) reported that it could potentially improve neonatal outcomes, while 84 (55%) reported that it could potentially reduce HCPs’ work burden. In addition, 66 (43%) specified that it could improve family bonding (online supplemental figure 1). The participants in the qualitative part also uncovered that it could contribute to faster recovery through improved temperature control and breathing, earlier initiation of breastfeeding, improved weight gain and bonding. A nurse explained this:
Supplemental material
Longer stays in the NCU are common for preterm newborns with minimal progress. They begin to get better the day they begin to breastfeed as opposed to using a nasogastric tube. The heater/radiant warmer is likewise prone to imbalances occasionally. While we might make an effort to rectify and manage residuals, it’s not always the case. Reuniting the newborn with the mother in these circumstances produces an instantaneous response [improvement]. A newborn spent twenty days staying here. Connecting the newborn with the mother between days 21 and 23 reveals impressive development (nurse, general hospital).
In addition, participants in the qualitative part revealed that families were always keen to enter the NCU to visit the infant, and they would prefer to stay longer in the NCU if allowed. Hence, HCPs and families were frequently in conflict regarding family presence in the NCU, which sometimes escalated into fights in cases of negative neonatal outcomes, including death. Two HCPs explained this as follows:
[…] They feel that we [HCP] did less for the baby because we will not let the family into the NCU. If they had been involved, the efforts made would have satisfied them. If not, they will not trust you [HCP], and they might even ask to be discharged home or referred to another institution in the event that the newborn’s condition worsens. Consequently, I think that even in cases when the outcome is unfavorable, involving and collaborating closely with the family promotes pleasure (medical doctor, primary hospital).
A neonate’s family frequently assumes the infant is in excellent hands and anticipates recovery when the child is admitted to the NCU. They aren’t even observing what we [HCP] are doing. Thus, in the unfortunate event that the results are poor, the family finds it difficult to accept it, presuming that the infant was doing well at the time of admittance. I so encourage family participation in the NCU as long as everyone takes the appropriate safety measures and wears personal protective equipment (nurse, referral hospital).
Provider–family communication in the NCUs
Out of the 157 participants, 100 (64%) HCPs reported that they always informed families about the clinical status of the infant, and 71 (45%) stated that they always encouraged families to ask questions about their infant. A higher proportion of HCPs counselled families at discharge (84%) and at referral (75%). However, only 29% and 35% of HCPs applied mechanisms to check whether families had understood the information provided to them during their stay in the NCU and at discharge, respectively (table 2).
HCPs’ communication with the family of preterm and LBW infants at hospital NCUs (n=157)
Furthermore, participants in the qualitative part underlined that HCPs often overlooked the role of communicating with families about the condition of their neonate. Meanwhile, it was frequently mentioned that HCPs’ limited communication skills, medical jargon in communication, inadequate time and unbalanced provider-to-neonate ratio, left the families with limited quality information about the medical condition of their neonate. A nurse explained the gap as:
The primary communication obstacle is that information is only given in the form of commands or instructions. For instance, I should thoroughly explain to her why practicing skin-to-skin care is beneficial for the newborn if I advise her to do so. If she understood the intent, they might think about using it (nurse, general hospital).
A general practitioner also stated the HCPs’ limited skills as:
We do not communicate well at all, to be honest! Even when we are asked to communicate with the family, we don’t. Typically, what happens is that we say things like ‘I'm not sure, we're handling it,’ and similar things. On the other hand, I believe that giving the family comprehensive knowledge is far more crucial. For example, if a patient was treated here and his medical record is missing, you may contact the relatives to find out about the condition and give treatment (medical doctor, referral hospital).
A paediatrician from Aksum referral hospital added:
There is a gap in the ability to reliably deliver comprehensive counseling because the majority of the care professionals here are not adequately trained in NCU care. Counseling would be challenging for someone who has never been in the NCU because of the staff rotation. If you ask most NCU staff members, they might not know what an attachment is in breastfeeding. These [skills] are typically overlooked in academic instruction (pediatrician, referral hospital).
Another paediatrician highlighted the difficulty HCPs faced in making the information understandable to families:
[…] When I consider giving families information, this is what frustrates me. I was attempting to inform the mother of a newborn who has a congenital malformation recently about the problem. I was unable to explain the situation to her. The mother questioned me again after we had been talking for about an hour, saying that she still didn’t understand what I was saying. Few HCPs are skilled in counseling, and the majority of us suffer from it (pediatrician, referral hospital).
Although information was provided to families in NCU, only half (48%) of the 157 HCPs felt that the information provided was easily understood by families (figure 3).
Organisational support to make information regarding medical condition of a neonate accessible, understandable and applicable to families (n=157).
Feasibility of the FINC initiative
HCPs’ perceived acceptability of FINC
Out of 157 HCPs, 74% considered FINC as acceptable, 86% agreed on its effectiveness in improving neonatal outcomes and 88% felt that it was ethically correct (table 3). Likewise, a participant in the qualitative part strongly underlined the acceptability of integrating families of preterm and LBW infants in the NCU, explaining the potential benefits in terms of improving neonatal outcomes, family satisfaction and ethicality. A paediatrician stated the acceptability of FINC concerning the neonate’s clinical outcomes and ethical aspects:
Infections are a concern when it comes to integrating families in the NCU. I agree that mothers have to practice good personal hygiene. However, when you take the babies away from the mothers, there are a lot of issues. For instance, immediate KMC is required for preterm newborns. Stimulation is another important element. Breastfeeding is also very important since it interferes with bonding between the mother and her newborn, which has an impact on milk production (pediatrician, referral hospital).
Assume that the family has the right to see the infant. Just as we would like to do for our children, NCU families have the right to see and hug their newborn for as much time as they wish (nurse, referral hospital).
Healthcare providers’ perception of the conceptual acceptability of integrating families in care for preterm and LBW infants at hospital NCUs (n=157)
However, negative emotional reactions were also reflected towards integrating families in the NCU with regard to the existing norms and culture in NCUs. The perceived increased risk of infection was the main argument against FINC. A participant reflected:
The fact that families are allowed to move around NCU anytime they want concerns me. They cannot spend the entire time sitting here [in the NCU], and they would leave the NCU and perhaps meet someone outside. Thus, I would say that allowing them to return to the NCU is not an excellent practice with reference to the risk of infection (nurse, general hospital).
Perceived confidence in implementability, practicality and organisational demand for FINC
HCPs reported that FINC was technically implementable, explaining that almost all HCPs (96%) were confident they had the individual skills required to fully implement it. However, the majority of the participants reported low confidence in its practicality, mainly due to limitations in the existing number of rooms (87%), financial resources (75%), manpower (64%), time constraints (53%) and low organisational demand based on the current status (33%) (table 4). The participants in the qualitative part also explained their concern about space as a major challenge to integrating families in the NCU:
Although it is confined and uncomfortable, I would prefer if the mother could be allowed to engage fully in the [NCU]. It would have been extremely pleasant if there had been sufficient space in the NCU. There is no doubt about the advantages, yet the setting poses a challenge (nurse, general hospital).
Due to our current space constraints, it is challenging to think of integrating families. Due to a lack of space, KMC has been discontinued. Some babies were supposed to have been in KMC, however, as you can see, there isn’t a space or a chair for them, and some of the mothers are even sleeping on the floor (nurse, general hospital).
HCPs’ perceived confidence in implementability, practicality and organisational demand to integrate families of preterm and LBW infants into hospital NCUs (n=157)
More specifically, the potential burden related to space was raised by almost all participants (97%), while concern related to increased risk of infection was perceived by 83%. Contrasting views were reflected regarding the role of integrating families into the workload among HCPs. Of the 157 participants, 71% agreed that it would represent an additional cognitive burden for the HCPs (figure 4). Likewise, participants also reflected on the additional emotional burden for the HCPs to communicate, train and educate families. Participants argued as follows:
A mother entering the NCU and lending a helping hand? It would be terrible, particularly for her initial exposure. It can occasionally be shocking for the mother, let alone for an abnormal newborn [Preterm and LBW], and even for a normal newborn. It is terrifying for a mother to be around all the oxygen cylinders, CPAP (Continuous Positive Airway Pressure) machines, nasogastric tube attachments, and other things. The mother probably wouldn’t even want to look at it (nurse, referral hospital).
Healthcare providers’ perceived burden of integrating families of preterm and low birthweight neonates at hospital neonatal care units (n=157). FINC, family-integrated newborn care.
On the other hand, participants in both focus groups and interviews in the qualitative part repeatedly mentioned that integrating families would reduce the workload by undertaking to perform some key activities for the neonate. A paediatrician stated:
The quantity of patients exceeds the number of healthcare providers when you look at the ratio. […] Consequently, the mother can reduce the care provider’s burden when she engages (pediatrician, general hospital).
Adaptability, integration and expansion of FINC to various situations
HCPs also reported concerns regarding the adaptability and integration of FINC into existing newborn care. Only 16% of the HCPs perceived that adapting FINC would be easy, and 37% perceived that it was adaptable to the varying needs and preferences of families. On the other hand, half (49%) of the participants perceived that the level of systemic change needed to integrate FINC was technically manageable (table 4). Likewise, participants in both focus groups and interviews in the qualitative part also mentioned their concerns about integrating families into NCU. Some participants perceived that allowing families to spend much time with their sick neonate could be emotionally challenging for the families.
Allowing families to look at the neonate, even for a little moment, would undoubtedly frighten them. The newborn feels afraid when they see all the medical equipment in their mouth, nose, and bloodstream, and when they hear the sounds in the NCU (nurse, referral hospital).
Furthermore, HCPs underlined their concern regarding the adaptability of the FINC to the existing work culture in the NCU by using the following terms: ‘as we should focus on our main task [clinical care] primarily’; ‘You know! While we focus on ‘our’ task, we often miss to involve the families…’; ‘let alone to encourage them to get involved, we do not tell them about what is going on’. Pattern analysis of the opinions of participants in interview shows that they mentioned such terms at least once, indicating that involving families in NCU was overlooked.
Furthermore, weighted mean score of participants on the feasibility dimensions (weighted by the maximum possible score) was relatively higher for acceptability (0.75), implementability (0.72) and expansion (0.66). In contrast, the score was lower for demand (0.60), practicality (0.53), integration (0.52) and adaptability (0.50%) (online supplemental figure 2).
Supplemental material
Sociodemographic characteristics were assessed for association with feasibility dimensions. However, only HCPs’ work experience was significantly associated with perceived acceptability and burden. Participants with work experience of ≤5 years had significantly lower mean scores for acceptability (mean 28.9, p=0.04) and higher mean scores for added burden (mean 26.2, p=0.04) in comparison to those who had work experience of 6–9 years (p=0.04) and ≥10 years.
Discussion
The current mixed-methods study convergently showed that integrating families in the NCUs is conceptually acceptable (from effectiveness and ethical perspectives), technically implementable and expandable/scalable, implying its feasibility. However, HCPs felt less confident about its practicality, adaptability and integration of FINC into the existing system. Organisational temporal factors included narrow NCU space, poor infection prevention practices and low organisational demand to modify the work culture in the NCUs. HCPs’ limited communication skills and readiness to spend adequate time with families were perceived as potential challenges. Equivocal views were reported regarding the implications of implementing FINC for the time and work burden it would pose for HCPs.
Findings from the current study showed that families with hospitalised infants strongly wanted to stay closer to their neonates, if allowed. Specifically, families could engage in KMC, feeding support, infection prevention, monitoring vital signs and identifying neonatal danger signs during the NCU stay, if oriented and trained. HCPs scored higher for the perceived acceptability of FINC (weighted mean score=0.75), which also impacts their assessment of the feasibility of the initiative. Likewise, the literature also shows that perceived acceptability is a critical dimension in evaluating the feasibility of an initiative.31 38 In addition, previous studies show that building the family’s knowledge and skills enhances their engagement in NCU care.9 26 40 A pre–post study from Uganda revealed that trained families achieved a 60% increase in days with documented danger signs and a 50% increase in documented daily weights during NCU hospitalisation, in comparison to the baseline. In addition, the mothers documented infants’ feeds for 83% of the hospitalised days.26 Likewise, an observational cohort study from India showed that infants admitted to a ‘mother–baby unit’ achieved 95% exclusive breastfeeding on day four and 85% skin-to-skin practice on day 5.9 This implies the untapped potential of FINC in NCUs for premature and LBW infants, which in turn depicts the perception of its feasibility.
The current study underlined that the perception of HCPs regarding the risk of infection made them feel less confident regarding the practicality, adaptability and integration of FINC. This in turn could negatively affect their evaluation of the feasibility of FINC, as well as their motivation to change the existing restrictive policy and work culture in NCUs. It has been previously reported that implementing FINC requires motivation, commitment and readiness of HCPs to change the work culture, as well as to recognise and embrace parents as collaborative partners in NCUs.11 In addition to the technical knowledge and skills required to implement FINC, its feasibility is also affected by organisational factors, including the architecture and space of NCU rooms, restrictive policies for visiting a neonate and limited commitment.41 More importantly, the low provider-to-neonate ratio in low-resource settings and stressful work in the NCU often create an emotional burden and even post-traumatic distress.42 Although integrating families in NCUs may close the gap in work burden and improve outcomes, strategies to introduce system-level shifts in thinking are required. In line with studies from other low-resource settings,40 43 the current study also showed that space is a potential challenge to the practicality of FINC. A study from Nigeria also reported limited space as a challenge for mothers to practice KMC in the NCU.40
Equally contrasting views were reflected in the current study regarding the implications of implementing FINC and the work burden for HCPs. More than half of the HCPs perceived that the FINC initiative would reduce the workload for HCPs. However, 33% strongly agreed with the potential additional cognitive burden with current NCU staffing. Limited human resources have persisted as a key barrier to quality of care in NCUs in low-resource settings, explained by the low staff-to-neonate ratio.43 In Ethiopia, the mean (SD) number of staff in level-I NCUs is 2.6 (±4) for nurses, 0.28 for general practitioners (±2) and 2.9 for support staff (±4).44 A report from all hospitals with level-2 NCUs in Tigray shows that the nurse-to-neonate ratio is 13:1, ranging from 5:1 in Quiha Hospital to 32:1 in Sihul Shire Hospital (report from the registration book over a 6-month period). Therefore, concerns regarding the possible additional work burden associated with implementing FINC would be minimal, if not protective, if the NCUs were staffed according to the national standard. As lower nurse-to-patient ratios are often associated with higher mortality, introducing motivation and retention strategies for trained NCU staff enhances the feasibility of the FINC initiative.45 46
The current study also revealed that HCPs fail to inform and counsel families during their stay in the NCU, which may create a missed opportunity to build a family’s knowledge and skill regarding newborn care. The hospital stay can be used as an opportunity to provide educational and training sessions for the families.47 A previously reported finding from a qualitative synthesis of existing evidence also showed that families often expect to be actively involved in care, and to get support from HCPs on how to cope at home after discharge, as well as emotional support, a positive response to their need for information, and positive relationships with staff.48 Furthermore, findings from systematic review studies also uncovered that family presence in even more invasive procedures, like neonatal resuscitation, provides opportunities for family involvement and communication.49 Likewise, a pre–post study from Uganda showed that FINC enhanced families’ preparedness for discharge and built their confidence,26 boosted their satisfaction and reduced parental stress.11 50 Therefore, building the family’s knowledge and skills could be better achieved if interventions were in place before discharge.
The current study showed that the information provided to families is not always understood. Preparing families for the FINC requires educational sessions ranging from the one-way provision of information (orientation) to two-way communication (counselling and demonstration). A FINC feasibility study from India showed that three-quarters of enrolled families completed all of 4 sessions covering 10 essential care activities in total, and the compliance with practice as trained ranged from 53% for handwashing up to 95% for breastfeeding positioning.37 Moreover, identifying coverage and process indicators for family engagement in the NCU is crucial for effectiveness studies.
HCPs’ work experience was statistically associated with acceptance and perceived burden regarding FINC. Similarly, previous studies also reveal the positive association of work experience with a more supportive attitude towards FINC 51 52. In contrast, a study from Brazilian university hospitals shows that HCPs with work experience greater than 10 years are less supportive of FINC.53 Systematic review studies also capture the inconsistency in the direction of the association (favourable or unfavourable).41 51 53 54 The inconsistency in the direction of the association may imply the interaction of other factors such as access to capacity-building opportunities, the curriculum in preservice training and the motivation to change the existing work culture in the NCU. However, further meta-analysis studies may be needed to examine the linearity of the association. Although not statistically significant, participants in the survey and qualitative part of the current study from hospitals with level-3 NCUs, working in extremely narrow NCUs, at a lower professional career level and older HCPs, tend to be hesitant about the feasibility of FINC.
Despite the strengths of the current study in uncovering the perception of HCPs across varying NICU levels using mixed-methods design, the study was not without limitations. Applying the findings should take into account that the interviewer administering interviews might pose a response bias, making HCPs respond in a way they believe to be an acceptable norm rather than their actual opinion. In addition, the study could have been strengthened by incorporating the cost-effectiveness component into the feasibility analysis and documenting how families would evaluate the feasibility of the FINC initiative.
Conclusions and recommendations
HCPs found the FINC initiative for hospitalised preterm and LBW infants conceptually acceptable, technically implementable and expandable, with weighted mean scores of 0.75, 0.72 and 0.66, respectively. However, putting the initiative into practice could generally be constrained by poor organisational infrastructure related to NCU space and infection prevention measures. In addition, the existing work culture and perceptions of HCPs could affect the adaptability and integration of FINC, as it generally demands the motivation and commitment of HCPs. Addressing motivational, attitudinal and competency gaps in NCU HCPs, supplemented by the organisational capacity to overcome structural challenges, would be required to implement FINC. Furthermore, improving the communication skills of HCPs should be considered an integral component, as this would bridge the implementation process and intermediate outcomes of the FINC intervention.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and the Norwegian Ethical Committee (reference number 804184) and the Ethical Review Board of the College of Health Science in Mekelle University granted ethical approval (MU-IRB 2162/2024). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank the Laerdal Foundation for financial support, study participants for their participation in the study and Mr. Abiy Seifu for his expertise guidance in the conception phase.
References
Footnotes
Contributors All authors participated in conceiving and designing the study. ZHK and AAM led the data collection process. ZHK drafted the first draft of the manuscript. SR, AAM, HLE and DHM were involved in the methodology, design of the study, and data analysis. All authors critically reviewed the first draft and approved the final draft. ZHK is the guarantor.
Funding The study was funded by the Laerdal Foundation through the Embedding Doctoral Training Program in Saving Little Lives Scale-up project in Ethiopia (SPH/126/15).
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.