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Table 4 Implementation factors

From: Barriers and facilitators to implementing bubble CPAP to improve neonatal health in sub-Saharan Africa: a systematic review

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.
WeaningNone 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.