Developing a program logic
for Neonatal Incubator use in Vietnam
Rachael Purcell1*, Joanne Durham1, Mark Griffin1
ABSTRACT
Vietnam has made progress in reducing under- five mortality rate and is on track to meet its fourth Millennium Development Goals.
However, the rate of neonatal deaths remains unacceptably high. A critical driver of neonatal mortality is premature birth. In high-income economies, neonatal incubators are a key element of premature newborn care; however, there is limited evidence supporting their use in resource-poor settings. Evaluation is a key process in maximizing the strategic allocation
of resources in such settings and one way to construct an evidence base. This research develops a program logic to guide program implementation and an evaluation of incubator use in Vietnam. Key features of program delivery include incorporating community- accepted design elements, facilitating staff training and incubator maintenance needs.
Keywords: Incubator, Millennium Development Goals, Neonatal, Premature, Public Health
1 School of Population Health, University of Queensland
* Corresponding author: Rachael Purcell, 1/9 Jones St,Thornbury, VIC 3071, Australia.
Email: [email protected]
INTRODUCTION
Globally, neonatal deaths (deaths in infants
<28 days old) account for 43% of deaths in children under 5 years of age1. Prematurity (<37 weeks gestation) is estimated to contribute to 38% of neonatal deaths in Vietnam2 and 40% of neonatal deaths world- wide3. Vietnam has made good progress in achieving its fourth Millennium Development Goal of reducing the under-five mortality rate by two-thirds by 2015, with a reduction in under-five mortality rate from 58/1000 live births in 1990 to 24.4/1000 live birth in 20094. However, the neonatal mortality rate remains unacceptably high at 12/1000 live births5, contributing 60% of the under-five mortality rate4.
Across Vietnam 88% of women have access to skilled attendants at birth.Of these skilled attendants, over 95% were doctors, nurses or midwives5. There is a referral network for unwell neonates. Typically, provincial level hospitals have neonatal units, which usually have access to continuous positive airways pressure machines, oxygen, phototherapy, essential medicines for common neonatal conditions, and warming devices such as incubators6. Incubators are a key element of neonatal care and in reducing deaths due to heat loss and dehydration7. However, design components often render them dysfunctional in low- and lower-middle-income countries6,7. An evaluation of their use in countries like Vietnam is needed. Developing an evidence base through evaluation is essential in ensuring that resources are allocated to meet the health needs of communities. Evaluations based on program theory can provide the evidence base needed for decision-makers, and insights into the intervention’s cause-and-
effect chain. Several authors propose testing the intervention’s or program’s theory before undertaking field-based evaluation in order to first check the intervention’s underlying assumptions and plausibility8.
This typically results in agraphical depiction between program inputs, outputs, assumptions, and outcomes; thus providing stakeholders a visual map of the relationship between program components and desired outcomes8. This paper illustrates the process of developing a program logic to evaluate incubator effectiveness in Vietnam. It examines key aspects of incubator design, function, and implementation; and provides a program logic guide for evaluation of these critical elements. The intent was to inform program design and implementation as well as providing a basis for subsequent evaluation.
The paper (1) provides program planners and evaluators with a guide to considerations in effective use of incubators in resource-poor countries, and (2) offers a practical example of developing a program logic, which can be adapted in other single intervention programs.
It provides a useful platform upon which to base a process evaluation of neonatal incubator use.
METHODS
A systematic literature search identified features of incubators critical to successful use in Vietnam. The intent was to gather information on the optimal conditions for incubators in resource-poor settings by looking at factors influencing incubator use and function, which would improve neonatal outcomes (e.g. design elements). The EMBASE (which includes Medline) and PubMED databases were searched for
literature published from 1992-2012.
The search term “incubator” was used, with limits set to English language; neonates;
articles, conference proceedings, conference abstracts and reviews. Inclusion criteria were (a) set in Asia, (b) incubator focused, (c) published between 1992-2012 (inclusive), and (d) addressed the question “how can incubators be used effectively in resource-poor settings such as Vietnam?” Reference lists were hand-searched to identify further studies.
One reviewer (RP) identified studies meeting the inclusion criteria through assessing abstracts and titles of retrieved references.
Through hand searching key references, 26 articles and grey literature were found relevant and included.
RESULTS
The electronic database search yielded 86 results with 34 relevant titles. Articles not meeting inclusion criteria were excluded (n=26). The full articles of the remaining eight titles were assessed.
Analysis identified that incubator design should incorporate atransparently-walled, rigid, box-like structure containing a fan circulating warmed air, AC-powered heater, temperature-regulating servo control, humidifier, oxygen supply, and access ports for nursing care. Temperature should be maintained between 34-37°C and humidity at 80-90%. Air purification and filtration systems should ensure sterile air supply. There should be unobstructed infant access and the container should be robust, portable and easily dismantable. A sustainable source of energy is essential, particularly in regions with variable access to electricity. One design used paraffin lamps for heating, however this was not widely accepted by the community due to bulky design, daily paraffin requirement, and concern of infant suffocation due to paraffin exposure7. This suggests the importance of community acceptance of incubator design7. Motorcycle batteries have been used as a power reservoir due to their cost, ready accessibility, and availability of local mechanics familiar with their design9. There is no evaluation of this strategy’s effectiveness.
It has been found that ninety-six percent of donated equipment from developed countries was non-functional at five years. This was often due to a lack of availability of parts for maintenance, user manuals, and staff training.
This was seen as a disincentive for timely referral9. Staff training in incubator use is essential. Analysis demonstrated that staff preferred formal training to reading document guidelines, and valued the opportunity to learn from experienced colleagues10.
The program logic demonstrates a synthesis of the findings (Table 2), illustrating the process from literature recommendations to program implementation and subsequent evaluation.
Table 1. Framework for staff training
Key findings from the review were used as inputs for the development of the program logic. These included recognition of the importance of staff training and technical support, use of a sustainable energy source, and appropriate incubator design. Community acceptance of incubator use and the accessibility of incubators were also key findings. Through recognizing these key findings, the program logic identifies
appropriate outputs, for example family awareness of the role of incubators in newborn care. These outputs then lead to important intermediate results, such as placement of the neonate into an appropriately designed and powered incubator, with the result being an improvement in neonatal health. The inputs, assumptions, outputs, intermediate and final results of the program logic (Table 2) provide a valuable guide to the implementation of neonatal incubator use.
DISCUSSION
This study provides a basis for strong evaluation efforts in the appropriate use and design of neonatal incubators in Vietnam.
Improving neonatal mortality in Vietnam through using incubators is yet to be evaluated.
There are several elements influencing their appropriate use in this region. Factors in staff training were identified (Table 1) including recognition of training preferences, barriers of training, and necessary inputs and outputs for training success (Table 2).
Lacking locally available equipment was a barrier to effective maintenance of incubator equipment. Methods using such equipment are currently being piloted. If successful, incorporating these technologies into incubator design may decrease this barrier.
Consideration of equipment transportation, financial costs, and staff training in equipment use is also required9.
Community acceptance of design is a key aspect of incubator implementation7. Stakeholder consultation on design elements outlined in the program logic (Table 2) using focus groups or a survey tool is recommended.
The synthesis of recommendations into a program logic model (Table 2) provides strong Table 2.Program logic
foundations for developing an evaluation of incubator use in Vietnam. Collaboration with local partner organizations such as health services would add a valuable local perspective. Approaching relevant stakeholders for logic model feedback is the next recommended stage of the evaluation design. Involving local stakeholders such as health services, health workers, policy advisors and local community membersshould be prioritized.
CONCLUSION
Program evaluation is a key strategy in ensuring appropriate resource allocation in resource-poor settings. The effectiveness of incubators in decreasing neonatal mortality in low- and middle-income countries is yet to be evaluated. This study provides a program logic to guide a process evaluation of effective incubator use in Vietnam. Future outcome evaluation may provide an insight to the impact of such a program on neonatal mortality and health outcomes.
CONFLICTS OF INTEREST
The authors declare that they have no competing interests.
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