Barriers and enablers of implementing bubble Continuous Positive Airway Pressure (CPAP): Perspectives of health professionals in Malawi

May combine two claims.

Caregivers sometimes feared that tubes interfered with breathing and associated oxygen therapy with death, which may have been influenced by lack of clear communication.

“Study participants reported that caregivers sometimes had fears that the many tubes interfered with breathing and that oxygen therapy was associated with death–a perception that may have been influenced by the lack of clear, effective communication between providers and caregivers.”

May combine two claims.

Monitoring was ideally supposed to be done at 15 minutes, 1 hour, then every 4-6 hours, but was not often followed due to nurse shortages.

“Study participants reported that monitoring was ideally supposed to be done in the first 15 minutes to assess the infants breathing rate, then an hour after initiation and then every four to six hours. While this is the ideal, it was not often followed because of nurse shortages especially at night and other responsibilities.”

May combine two claims.

Factors that facilitated implementation of bubble CPAP included comprehensive training, team cohesion, dedicated nurses for the nursery, and consistent availability of electricity and equipment.

“Factors that facilitated implementation of bubble CPAP were comprehensive training, team cohesion, dedicated nurses for the nursery and consistent availability of electricity and equipment.”

May combine two claims.

The process of weaning a baby off bubble CPAP was identified as a gap in knowledge secondary to inadequate training, with both nurses and clinicians confused about weaning.

“The process of weaning the baby off bubble CPAP was identified as a gap in knowledge secondary to inadequate training.”

• Also stated in: § Inadequate healthcare provider training in preparation for use · plain

  “She continued to state that not only nurses were confused but also the clinicians,”

• Also stated in: § Inadequate healthcare provider training in preparation for use · plain

  “I get confused as to how I should go about it as to whether I have to…reduce the oxygen levels or reduce the water levels together at the very same time or not or am I supposed to do it one by one…so these things always confuses me”

May combine two claims.

The practice of rotating nurses through different wards created a shortage of bubble CPAP formally trained staff because rotations disregarded trainings and trained staff did not stay in the nursery.

“The practice of rotating nurses through the different wards of the hospital created shortage of bubble CPAP formally trained staff since the rotations disregard the trainings one received and meant that those who received formal training did not stay in the nursery.”

May combine two claims.

Barriers to bubble CPAP implementation included inadequate healthcare provider training, rigid division of roles and responsibilities, lack of effective communication, human resource constraints, and inadequate equipment and infrastructure.

“Factors affecting bubble CPAP implementation were interconnected and the barriers included inadequate healthcare provider training in preparation for use, rigid division of roles and responsibilities among healthcare providers, lack of effective communication, human resource constraints, and inadequate equipment and infrastructure.”

May combine two claims.

Human resource limitations were further exacerbated by constraints around medical equipment and infrastructure, especially lack of electricity and accessories that require appropriate sizing like nasal prongs.

“Human resource limitations were further exacerbated by constraints around medical equipment and infrastructure, especially lack of electricity and accessories that require appropriate sizing like nasal prongs:”

Probably not a substantial claim: may not pass S3 (load-bearing).

Having nurses specifically dedicated or assigned to the nursery would help with regular monitoring.

“Nurses’ spoke of how having nurses that are specifically dedicated or assigned to the nursery would help with regular monitoring.”

May combine two claims. The quote only partly states this claim.

Staffing shortages, especially at night, contributed to delayed initiation and affected monitoring of patients on bubble CPAP.

“Staffing shortages, especially at night when only one nurse was on duty may also contribute to delayed initiation until they completed other tasks.”

• Also stated in: § Human resource constraints · plain

  “Staffing shortages further affected monitoring of patients on bubble CPAP, including checking over the machine, connections to the baby, as well as vital signs.”

May combine two claims.

Medical hierarchy and rigid roles complicated decision-making, with clinicians holding higher authority and some nurses reluctant to initiate CPAP for fear of being questioned.

“Medical hierarchy, including the roles and responsibilities of different cadres, sometimes complicated decision-making.”

• Also stated in: § Rigid division of roles and responsibilities among healthcare providers · plain

  “While nurses were often the recipients of training as direct users of the system, clinicians held higher authority in decision-making.”

• Also stated in: § Rigid division of roles and responsibilities among healthcare providers · plain

  “Even when nurses were trained and encouraged to make the decision to initiate bubble CPAP, some nurses reported reluctance for fear that the clinician would question their decision afterwards.”

May combine two claims.

Nurses trained on the job often reported that training was inadequate and focused mainly on monitoring, and some felt not competent to initiate CPAP.

“Nurses who reported being trained on the job (or simply “orienting”) often reported that the training was inadequate and that it mainly focused on monitoring, which included ensuring that the connections to the machines remained intact and checking the baby’s vital signs at specified intervals.”

• Also stated in: § Inadequate healthcare provider training in preparation for use · plain

  “I can say it [training] wasn’t that sufficient because …it just prepared me for monitoring only… I can say hmm, I am not that comfortable or competent to insert the baby on CPAP because the training that I got was just on job from those who went for training … So I can say I am just in between. On a scale of ten, I would say I am at five.”

May combine two claims.

Effective communication and cohesion between providers and between providers and caregivers supported use of bubble CPAP.

“Effective communication and cohesion between healthcare providers as well as between providers and caregivers were reported to support use of bubble CPAP.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Delays in weaning may cause nasal complications from over-staying on bubble CPAP and lead to further delays in initiation.

“Participants shared that delays in weaning may cause nasal complications from over-staying on bubble CPAP as well as lead to further delays in initiation as CPAP system is occupied.”

May combine two claims.

There is an overall small pool of nurses assigned to the nursery, a common practice of rotating staff between wards where mentors and trained nurses may not remain in the nursery, and medical hierarchy and power dynamics around who owns the decision to initiate.

“Investment into training and mentorship for nursing staff must also be taken into context of the overall small pool of nurses assigned to the nursery, the common practice of rotating staff between wards where the mentors and trained nurses may not remain in the nursery and medical hierarchy and power dynamics around who owns the decision to initiate.”

May combine two claims.

Providers in our study highlighted how rigid divisions of roles and responsibilities and lack of training for those with decision-making authority negatively affected initiation of bubble CPAP.

“Providers in our study highlighted how rigid divisions of roles and responsibilities and lack of training for those with decision-making authority negatively affected initiation of bubble CPAP.”

May combine two claims.

Health professionals shared that they understood that using bubble CPAP required a number of items, from tubing to appropriate sized nasal prongs, an oxygen source, reliable electricity and others, and that babies on bubble CPAP needed to be monitored closely to minimize inadvertent harm.

“Health professionals shared that they understood that using bubble CPAP required a number of items, from tubing to appropriate sized nasal prongs, an oxygen source, reliable electricity and others, and that babies on bubble CPAP needed to be monitored closely to minimize inadvertent harm.”

May combine two claims.

Poor communication between the clinical team and between the clinical team and caregivers contributed to delays between the decision to initiate and initiating the baby.

“Furthermore, poor communication between the clinical team and between the clinical team and caregivers contributed to delays between the decision to initiate and initiating the baby.”

May combine two claims.

Shortages of staff and staff rotations between wards negatively affected the ability for staff to go for training and to retain trained staff in the nursery.

“In addition to compromising capacity for care, shortages of staff and staff rotations between wards negatively affected the ability for staff to go for training and to retain trained staff in the nursery.”

May combine two claims.

Delays in weaning increased the risk of complications and added to human resource and equipment needs that in turn contributed to delays in initiation for other babies.

“Delays in weaning increased the risk of complications and added to human resource and equipment needs that in turn contributed to delays in initiation for other babies.”

May combine two claims.

In addition to a lack of nurses dedicated to the nursery, there are few clinicians at the district hospitals.

“In addition to a lack of nurses dedicated to the nursery, there are few clinicians at the district hospitals.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Malawi has the highest rate of preterm births in the world, at 18% of live-births.

“Malawi has high rates of preterm birth, with 18.1 preterm births per 100 live births.”

• cites [4] H Blencowe, 2012, National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: A systematic analysis and implications, Lancet sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

A codebook was developed inductively from the data and deductively from the study objectives.

“After familiarizing themselves with the transcripts and a review of the field notes with interviewers, two qualitative researchers (MWK, MA in Medical Anthropology, and ALNM, PhD in Health Systems and Policy) developed a codebook (see S1 Appendix) that was both inductive from the data and deductive from the study objectives.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Five Malawian researchers underwent a three-day intensive training in qualitative research methods.

“Five Malawian researchers, including two certified nurse-midwife-technicians (BC and FC, Diploma in Nursing & Midwifery), two public health specialists (LSK and SS, Masters in Public Health) and a health program manager (MB, Bachelor in Business Administration), were hired as a part of the IMCHA study and underwent a three-day intensive training in qualitative research methods led by ALNM.”

Probably not a substantial claim: may not pass S3 (load-bearing).

None of the participants knew the researchers prior to the study.

“None of the participants knew the researchers conducting the interview prior to the study.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

Lessons learned from bubble CPAP implementation may be applicable to comprehensive packages of locally appropriate neonatal care technologies.

“Lessons learned from bubble CPAP implementation may be applicable to comprehensive packages of locally appropriate neonatal care technologies, which include but are not limited to bubble CPAP.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The interview guide was developed based on a scoping literature review and preliminary stakeholder consultations.

“A semi-structured interview guide was developed based on a scoping literature review and preliminary stakeholder consultations.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Along with device installation, there is training and mentorship of nurses, clinicians and technicians, regular supply of consumables, and quarterly supportive supervisory visits led by Ministry of Health officials.

“Along with the installation of the devices, there is training and mentorship of nurses, clinicians and technicians, a regular supply of consumable items needed for its use and quarterly supportive supervisory visits led by Ministry of Health officials [13].”

• cites [13] J Carns, 2019, Neonatal CPAP for Respiratory Distress Across Malawi and Mortality, Pediatrics sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

Understanding healthcare providers' perspectives on barriers and enablers for implementing bubble CPAP can contribute towards strengthening institutional newborn care in Malawi.

“Understanding healthcare providers’ perspectives on barriers and enablers for implementing bubble CPAP can contribute towards strengthening institutional newborn care in Malawi.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The interview guide was translated into Chichewa prior to participant recruitment.

“The interview guide was translated into Chichewa, the major local language in Malawi, prior to participant recruitment.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study is reported based on the Consolidated criteria for reporting qualitative research.

“The study is reported based on the “Consolidated criteria for reporting qualitative research [20].”

• cites [20] A Tong, 2007, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, Int J Qual Heal Care sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Three researchers were involved in coding, with one completing primary coding of the entire dataset, reviewed by two researchers to verify soundness and completeness.

“Three researchers were involved in the coding with one completing the primary coding of the entire dataset (SS), which was reviewed by two researchers (MWK and ALNM) to verify for soundness and completeness, and add emerging codes.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The study conducted 46 interviews, of which 27 were females and 30 were nurses; none approached declined and one dropped out.

“We conducted interviews with 46 participants and of these, 27 were females.”

• Also stated in: § Results · plain

  “None of the healthcare providers approached declined to take part in the study and one participant dropped out during an interview due to time constraints.”

• Also stated in: § Results · plain

  “Thirty of the 46 participants were nurses.”

May combine two claims.

In Malawi, hospitals lack centrally provided medical gases, and stand-alone bubble CPAP systems cost over 6000 USD per unit, making them prohibitively expensive.

“However, even in the tertiary facilities in Malawi, hospitals do not have access to centrally provided medical gases, and stand-alone bubble CPAP systems that cost over 6000 USD per unit are prohibitively expensive [11].”

• cites [11] J Brown, 2013, A High-Value, Low-Cost Bubble Continuous Positive Airway Pressure System for Low-Resource Settings: Technical Assessment and Initial Case Reports, PLoS One sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

High-quality research on effective, safe, and sustainable implementation of bubble CPAP in LMICs is required.

“High-quality research studies on effective, safe, and sustainable implementation of bubble CPAP in LMICs are required [6,12].”

• cites [6] OA Ekhaguere, 2019, Risk and benefits of Bubble Continuous Positive Airway Pressure for neonatal and childhood respiratory diseases in Low- and Middle-Income countries, Paediatric Respiratory Reviews sourceNot checked yet

  Not checked in the free run.

• cites [12] S Martin, 2014, Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review, Arch Dis Child Fetal Neonatal Ed sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The interview guide was piloted with nurses and physicians at QECH, and pilot data were used to refine phrasing and not included in analysis.

“The interview guide was piloted with several nurses and physicians at QECH who had experience with bubble CPAP. Pilot data obtained was used to refine phrasing of questions and was not included in analysis.”

May combine two claims.

Pumani was initially trialed at QECH in Malawi in 2012 and scaled from 2012 to 2017 to all 28 central and district hospitals and eight mission hospitals.

“The Pumani was initially trialed at Queen Elizabeth Central Hospital (QECH) in Malawi in 2012 [5] and from 2012 to 2017, scaled to all 28 central and district hospitals across the country, followed by eight mission hospitals.”

• cites [5] K Kawaza, 2014, Efficacy of a low-cost bubble CPAP system in treatment of respiratory distress in a neonatal ward in Malawi, PLoS One Jan Malawi Med J sourceNot checked yet

  Not checked in the free run.

• cites [13] J Carns, 2019, Neonatal CPAP for Respiratory Distress Across Malawi and Mortality, Pediatrics sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Many preterm neonates develop respiratory distress and subsequent respiratory failure, contributing to high neonatal mortality.

“Many preterm neonates develop respiratory distress and subsequent respiratory failure, contributing to high neonatal mortality [5,6].”

• cites [5] K Kawaza, 2014, Efficacy of a low-cost bubble CPAP system in treatment of respiratory distress in a neonatal ward in Malawi, PLoS One Jan Malawi Med J sourceNot checked yet

  Not checked in the free run.

• cites [6] OA Ekhaguere, 2019, Risk and benefits of Bubble Continuous Positive Airway Pressure for neonatal and childhood respiratory diseases in Low- and Middle-Income countries, Paediatric Respiratory Reviews sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

Written informed consent was obtained from participants.

“A written informed consent form was provided to participants in advance to allow them to fully consider questions about the study and their participation.”

May combine two claims.

Bubble CPAP is a simple and relatively inexpensive form of CPAP that may be safe and cost-effective for delivering CPAP and reducing neonatal mortality in LMICs.

“Bubble CPAP is a simple and relatively inexpensive form of CPAP [8,11].”

• Also stated in: § Introduction · hedged

  “It may represent a safe and cost-effective method for delivering CPAP and reducing neonatal mortality rates in low- and middle-income countries (LMICs) [6,12,13].”

• Also stated in: § Background · hedged

  “Bubble CPAP may represent a safe and cost-effective method for delivering CPAP in low-income settings.”

• cites [8] JE Dewez, 2017, Continuous positive airway pressure (CPAP) to treat respiratory distress in newborns in low- and middle-income countries, Trop Doct sourceNot checked yet

  Not checked in the free run.

• cites [11] J Brown, 2013, A High-Value, Low-Cost Bubble Continuous Positive Airway Pressure System for Low-Resource Settings: Technical Assessment and Initial Case Reports, PLoS One sourceNot checked yet

  Not checked in the free run.

• cites [6] OA Ekhaguere, 2019, Risk and benefits of Bubble Continuous Positive Airway Pressure for neonatal and childhood respiratory diseases in Low- and Middle-Income countries, Paediatric Respiratory Reviews sourceNot checked yet

  Not checked in the free run.

• cites [12] S Martin, 2014, Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review, Arch Dis Child Fetal Neonatal Ed sourceNot checked yet

  Not checked in the free run.

• cites [13] J Carns, 2019, Neonatal CPAP for Respiratory Distress Across Malawi and Mortality, Pediatrics sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Interviews were audio recorded with permission, and transcripts were reviewed against audio to ensure quality and translate Chichewa terms.

“The interviews were audio recorded with permission of the participants.”

• Also stated in: § Analysis · plain

  “The completed transcripts were sent to the transcription coordinator (SS), who then reviewed the transcript with the audio to ensure quality and translated any Chichewa terms in the interviews into English where necessary.”

May combine two claims.

Pumani is a bubble CPAP system designed for low-resource settings, durable, easy to use and repair, and costs 800 USD per unit, making it more affordable than conventional commercial systems.

“In 2011, researchers from Rice University developed Pumani, a bubble CPAP system designed for low-resource settings with similar delivery of air pressure and flow to bubble CPAP systems used in high-resource settings.”

• Also stated in: § Introduction · plain

  “Pumani is durable, easy to use and repair, is durable [11].”

• Also stated in: § Introduction · plain

  “At 800 USD a unit, it is also more affordable than conventional commercial bubble CPAP systems as well.”

• cites [11] J Brown, 2013, A High-Value, Low-Cost Bubble Continuous Positive Airway Pressure System for Low-Resource Settings: Technical Assessment and Initial Case Reports, PLoS One sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The median length of service as a healthcare provider was eight years and median experience with bubble CPAP was three years.

“The median length of service as a healthcare provider was eight years [IQR 3,15] while the median number of years of experience in using the bubble CPAP was three [IQR 1.2,4] (see Table 1).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Ethics approvals were obtained from University of Malawi College of Medicine and University of British Columbia.

“Ethics approvals were obtained from the University of Malawi College of Medicine (P.08/15/1783) and the University of British Columbia (H15-01463-A003).”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Our study suggests that efforts must go deeper to understand the health system issues around staffing of nursery wards, empowerment of nurses and developing medical team cohesion.

“While our research findings agree with previous recommendations for regular training, mentorship and investment in nursing staff [22,24,25], our study suggests that efforts must go deeper to understand the health system issues around staffing of nursery wards, empowerment of nurses and developing medical team cohesion.”

May combine two claims.

The Pumani bubble CPAP system does not have a built in humidifier, which required regular nasal saline drops.

“The Pumani bubble CPAP system does not have a built in humidifier, which required regular nasal saline drops [5].”

• cites [5] K Kawaza, 2014, Efficacy of a low-cost bubble CPAP system in treatment of respiratory distress in a neonatal ward in Malawi, PLoS One Jan Malawi Med J sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Researchers' background and motivations inevitably influence the researcher-study participant dynamics and therefore participants' responses.

“Researchers’ background and motivations inevitably influence the researcher-study participant dynamics and therefore participants’ responses.”

May combine two claims.

A Kenyan study reported training-of-trainers concept with both nurses and clinicians together was effective and demonstrated that nursing staff were able to initiate bubble CPAP.

“A Kenyan study reported training-of-trainers concept with both nurses and clinicians together was effective and demonstrated that nursing staff were able to initiate bubble CPAP [29].”

• cites [29] B Olayo, 2019, Effective training-of-trainers model for the introduction of continuous positive airway pressure for neonatal and paediatric patients in Kenya, Paediatr Int Child HealthNot checked yet

  Not checked in the free run.

May combine two claims.

Currently, Malawian government hospitals have 29% vacancies for medical officers, 63% for clinical officers, 66% for registered nurse-midwives and 60% for nurse-midwife-technicians, which affects the provisioning of neonatal services.

“Currently, Malawian government hospitals have 29% vacancies for medical officers, 63% for clinical officers, 66% for registered nurse-midwives and 60% for nurse-midwife-technicians, which affects the provisioning of neonatal services [35].”

• cites [35] Ministry of Health and Population. Health Sector Strategic Plan II 2017–2022 Towards Universal Health Coverag. Lilongwe, Malawi; 2017.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Training reinforced with standardized tools that illustrate and engage the learner is more effective.

“Training may occur on-the job through observation and mentorship as described by many of the health professionals in our study, which has been found to be more effective when reinforced with use of standardized tools that illustrate and engage the learner [23].”

• cites [23] S O’Regan, 2016, Observer roles that optimise learning in healthcare simulation education: a systematic review, Adv Simul sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Respondent's desirability bias could not be avoided.

“While the researchers made it clear that the objective of this research study was not to evaluate healthcare providers’ performance or to provide additional hospital resources, we acknowledge that respondent’s desirability bias could not be avoided.”

May combine two claims.

Our research on implementation factors for the use of bubble CPAP for neonates in Malawian hospitals from the perspective of healthcare professionals revealed an interconnection of provider, caregiver and health system level factors that contribute to delays in its use but also highlights potential areas where the implementation of bubble CPAP can be strengthened for more effective use.

“Our research on implementation factors for the use of bubble CPAP for neonates in Malawian hospitals from the perspective of healthcare professionals revealed an interconnection of provider, caregiver and health system level factors that contribute to delays in its use but also highlights potential areas where the implementation of bubble CPAP can be strengthened for more effective use.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The qualitative approach may limit generalisations of the results.

“Although our study followed a qualitative approach, which may limit generalisations of the results, our findings offer concepts that can be taken onboard when implementing bubble CPAP in other hospitals.”

Probably not a substantial claim: may not pass S4 (based).

An intervention implemented in a tertiary hospital will not involve the same process as in a secondary level facility.

“While this paper considered implementation factors for bubble CPAP utilization in resource-constrained settings found in Malawian hospitals more generally, an intervention implemented in a tertiary hospital will not involve the same process as in a secondary level facility.”

May combine two claims.

Training that enabled effective use was comprehensive, included hands-on practice, troubleshooting problems and weaning, as well as training both clinicians and nurses so there is a common understanding and better team cohesion.

“Training that enabled effective use was comprehensive, included hands-on practice, troubleshooting problems and weaning, as well as training both clinicians and nurses so there is a common understanding and better team cohesion.”

May combine two claims.

Both human and infrastructural resources were fundamental to effective bubble CPAP use, including dedicated neonatal nurses and consistent availability of electricity and equipment.

“Lastly, both human and infrastructural resources were fundamental to effective bubble CPAP use including dedicated neonatal nurses and consistent availability of electricity and equipment.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Our findings on constraints resulting from inadequate human resources resonate with a previous qualitative study on health care worker perspectives on bubble CPAP in India where although CPAP was accepted by health care workers, its use was impeded by shortages of staff, along with equipment.

“Our findings on constraints resulting from inadequate human resources resonates with a previous qualitative study on health care worker perspectives on bubble CPAP in India where although CPAP was accepted by health care workers, its use was impeded by shortages of staff, along with equipment [36].”

• cites [36] JE Dewez, 2018, Healthcare workers’ views on the use of continuous positive airway pressure (CPAP) in neonates: A qualitative study in Andhra Pradesh, India, BMC Pediatr sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Two innovative studies in Nigeria and South Africa have highlighted the potential for using a WhatsApp platform for teaching, supervising and supporting students in their integration of theory with clinical practice.

“Two innovative studies in Nigeria [39] and South Africa [40] has highlighted the potential for using a WhatsApp platform for teaching, supervising and supporting students in their integration of theory with clinical practice.”

• cites [39] A Ajuwon, 2018, Mobile Instant Messaging (MIM) to support teaching practice: Insights from a nurse tutor program in Nigeria, Malawi Med J sourceNot checked yet

  Not checked in the free run.

• cites [40] JJ Willemse, 2015, Undergraduate nurses reflections on Whatsapp use in improving primary health care education, Curationis sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

Our study was conducted in hospitals with varying authority structures, ownership, and across different cadres of healthcare providers, therefore offering a holistic view of the implementation of bubble CPAP.

“Our study was conducted in hospitals with varying authority structures, ownership, and across different cadres of healthcare providers, therefore offering a holistic view of the implementation of bubble CPAP.”