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Oxygen systems and quality of care for children with pneumonia, malaria and diarrhoea: Analysis of a stepped-wedge trial in Nigeria
Open accessAbstract
Objectives: To evaluate the effect of improved hospital oxygen systems on quality of care (QOC) for children with severe pneumonia, severe malaria, and diarrhoea with severe dehydration. Design: Stepped-wedge cluster randomised trial (unblinded), randomised at hospital-level. Setting: 12 hospitals in south-west Nigeria. Participants: 7,141 children (aged 28 days to 14 years) admitted with severe pneumonia, severe malaria or diarrhoea with severe dehydration between January 2014 and October 2017. Interventions: Phase 1 (pulse oximetry) introduced pulse oximetry for all admitted children. Phase 2 (full oxygen system) (i) standardised oxygen equipment package, (ii) clinical education and support, (iii) technical training and support, and (iv) infrastructure and systems support. Outcome measures: We used quantitative QOC scores evaluating assessment, diagnosis, treatment, and monitoring practices against World Health Organization and Nigerian standards. We evaluated mean differences in QOC scores between study periods (baseline, oximetry, full oxygen system), using mixed-effects linear regression. Results: 7,141 eligible participants; 6,893 (96.5%) had adequate data for analysis. Mean paediatric QOC score (maximum 6) increased from 1.64 to 3.00 (adjusted mean difference 1.39; 95% CI 1.08–1.69, p<0.001) for severe pneumonia and 2.81 to 4.04 (aMD 1.53; 95% CI 1.23–1.83, p<0.001) for severe malaria, comparing the full intervention to baseline, but did not change for diarrhoea with severe dehydration (aMD -0.12; 95% CI -0.46–0.23, p = 0.501). After excluding practices directly related to pulse oximetry and oxygen, we found aMD 0.23 for severe pneumonia (95% CI -0.02–0.48, p = 0.072) and 0.65 for severe malaria (95% CI 0.41–0.89, p<0.001) comparing full intervention to baseline. Sub-analysis showed some improvements (and no deterioration) in care processes not directly related to oxygen or pulse oximetry. Conclusion: Improvements in hospital oxygen systems were associated with higher QOC scores, attributable to better use of pulse oximetry and oxygen as well as broader improvements in clinical care, with no negative distortions in care practices. Trial registration: ACTRN12617000341325
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Some studies aimed to assess the impact of interventions on patients' quality of life and satisfaction with healthcare services.
“Some studies aimed to assess the impact of interventions on patients' quality of life and satisfaction with healthcare services (57, 58).”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [58]
The Methods > Outcomes section (page unavailable) says this study focused on care-process outcomes, with a primary measure of quality-of-care scores drawn from case notes. Those scores assess clinical assessment, diagnosis, treatment and monitoring—not patients’ quality of life or satisfaction with healthcare services. (LLM, conf=0.85)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredGraham et al. (2021) chose the stepped wedge design to allow all clusters to eventually receive potentially beneficial intervention while enabling rigorous evaluation, and because it is efficient and pragmatic.
“The stepped wedge design was chosen as it allows all clusters to eventually receive potentially beneficial intervention while enabling a rigorous evaluation of its effectiveness. This design is efficient and pragmatic, enabling the logistics of implementation to be managed effectively”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [58]
The Methods (Study design; page unavailable) say the full oxygen system was introduced in stages to all 12 hospitals. The Discussion (Limitations; page unavailable) says the design was useful for evaluating outcome changes and flexible enough to incorporate implementation learning. The paper does not say these were the reasons the design was chosen, or describe it as efficient and pragmatic for managing implementation logistics. (LLM, conf=0.86)
Experimental — accuracy not yet measuredGraham et al. (2021) randomly allocated hospitals to receive the full oxygen system at pre-specified dates using a computer-based random sequence generator.
“Hospitals were randomly allocated to receive the full oxygen system at pre-specified dates using a computer-based random sequence generator”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [58]
Graham et al. (2021) used 12 steps in the intervention rollout, with the full oxygen system introduced in steps 7-12.
“The intervention rollout involved 12 steps, with the full oxygen system being introduced in steps 7–12”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [58]
Graham et al. (2021) had a duration of 4 months between steps.
“4 months”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [58]
Graham et al. (2021) included 12 clusters (hospitals).
“12 clusters, each representing a hospital”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [58]
Graham et al. (2021) calculated sample size with sufficient power to detect changes in mortality and clinical practices, aiming for 99% power to detect a 10-percentage-point change in the proportion of hypoxaemic children receiving oxygen therapy.
“The sample size was calculated with sufficient power to detect changes in mortality and clinical practices. The study aimed for 99% power to detect a 10-percentage-point change in the proportion of hypoxaemic children receiving oxygen therapy and various other powers for detecting reductions in mortality rates for different patient groups”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [58]
The Methods sections on Sample and Statistical analysis describe participant selection and analysis, but do not report a sample-size calculation or power targets. Searches for “99% power,” a 10-percentage-point change in oxygen treatment, and mortality power found no passage stating those targets. The Results report observed changes in oxygen use, not the power planned to detect them. (LLM, conf=0.72)
Experimental — accuracy not yet measured
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Metadata
- Authors
- Graham, H. R., Maher, J., Bakare, A. A., Nguyen, C. D., Ayede, A. I., Oyewole, O. B., Gray, A., Izadnegahdar, R., Duke, T., & Falade, A. G.
- Affiliations
- Royal Children's Hospital (AU)
- University College Hospital, Ibadan (NG)
- University of Ibadan (NG)
- Gates Foundation (US)
- Corresponding author
- Graham, Hamish R.
- ORCID
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2021-07-08
- Volume
- 16
- Issue
- 7
- Pages
- e0254229
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC8266122
- OpenAlex
- W3177542554
- Cited by
- 8
- References
- 40
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 1 · 2023: 2 · 2022: 1
- FWCI
- 0.72
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Minerva Access (University of Melbourne) (submittedVersion, cc-by)
- Funders
- Bill and Melinda Gates Foundation
- World Health Organization
- Topics
- Health Sciences › Medicine › Epidemiology › Pneumonia and Respiratory Infections
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Quality and Management
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Keywords
- quality of care, pediatric intensive care, severe pneumonia, severe malaria, pulse oximetry, hospital facilities, pediatric hospital admissions, Nigeria
- MeSH terms
- Adolescent, Child, Child, Preschool, Diarrhea, Female, Hospitals, Humans, Infant, Infant, Newborn, Malaria, Male, Nigeria, Oximetry, Oxygen, Oxygen Inhalation Therapy, Pneumonia, Quality of Health Care
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