Natalie Paulse, Andre Venter

Abstract:

Aim: This research aimed to establish directives for an education programme that will improve parents’ knowledge and practice of kangaroo mother care (KMC) for preterm babies.

Methods: The Delphi method was used to assess expert consensus on the directives that could improve parent knowledge/skills for KMC practice. The panel of experts included international and local (South African) representatives. Data from focus group interviews, together with the literature review, were used to populate the 134 statements for the Delphi survey. Panelists rated the likely usefulness of each statement for inclusion as a directive for KMC. 

Results: A 100% response rate was achieved in rounds 1 and 2. After Round 3, consensus was achieved in 89,9% statements for inclusion as directives for KMC. Panellists rated a few statements differently but overall, there was considerable agreement about which statements were essential for inclusion in a KMC programme. The statements that panellists disagreed on related to problems associated with KMC and the characteristics of a suitable instructor. 

Conclusions: We identified directives for a KMC education programme. The implementation of these directives needs to be evaluated to see that it enhances KMC practice for preterm babies. 

Keywords: Delphi, Kangaroo Mother Care, Patient education, Preterm babies. 

1. Introduction

Kangaroo Mother Care (KMC) is a high-impact, low-tech, low-cost intervention addressing preterm newborns’ morbidity and mortality. (1,2) KMC is recommended as routine care for all clinically stable newborns who weigh 2000g or less. (3-5) 

Despite KMC being introduced more than four decades ago and regarded as the intervention with the highest impact on newborn survival and health,(6) some countries still find the goals of increased coverage and sustained practice elusive. Despite several policies in South Africa (SA) and the Maternal, Newborn, Child, and Women’s Health (MNCWH) strategic plan, implementation remains uneven. (7) Education programs to increase parental awareness of the benefits of KMC are needed. (8) Most education and training strategies focus on healthcare providers. (9) The World Health Organisation (WHO) guidelines stress the importance of parents adopting KMC due to an informed decision. (5) In order to achieve this, patient education is necessary. (10) Patient education is a cornerstone of caring for patients, with strong evidence that it improves health outcomes too. (11) 

Successful education depends on an understanding and application of theories and models of behavior change to health education. (10,11) Theories focusing on individual health behavior include the health belief model, theory of reasoned action, and stages of change models. (12) A model that applies to KMC implementation is the stages of change theory, developed by Prochaska, DiClemente, and others. (13) The stages of change theory depict that the behavior change takes place over a period of time. This applies to KMC implementation: Although Dr. Rey introduced KMC in 1978, institutions have been slow to adopt this practice. (14) 

KMC is still underutilized, despite all its benefits. (15) Mothers still demonstrate a lack of knowledge of KMC, according to recent studies. (16-19) Thus, it is evident from the literature that there is a need to improve patient education on KMC. 

2. Patients and Methods 

This study followed an exploratory sequential design. A mixed methods approach was used, which combined qualitative and quantitative methods. (20) The study’s first phase was a qualitative exploration of inquiry using focus groups. Data from the qualitative phase and the literature review were used to populate statements for the Delphi survey. The Delphi survey was used as the data collection tool for the quantitative phase of the study. The goal of the Delphi was to obtain expert opinions and to obtain consensus on the directives that could improve parent knowledge/ skills for KMC practice. (21) 

During each round, the participants completed the questionnaire and returned it to the researcher via email. The researcher then collected and analyzed the data and gave all participants feedback. Feedback reflected the groups’ opinions on the research Issues. The participants were allowed to reassess their initial opinions and answers they had given in previous rounds, and they were allowed to change or maintain their original opinion. (22) 

Analysis was twofold; firstly, to provide feedback between rounds and, secondly, to identify when consensus had been reached. A consensus of 75% was accepted for this study. (23) If no consensus and no further changes occurred after the last round, stability was declared. 

Analysis was accomplished by combining computer packages (survey monkey tool) and manual techniques. Descriptive statistics were applied because the questionnaires were designed to collect nominal and ordinal data. 

3. Results 

3.1 Demographic details 

The panel of experts included international and local (SA) representatives. The average age of the panelists was 55.6 years – their ages ranged from 30 to 70 years. The majority of the expert panel was female (76,9%). The fields of expertise ranged from neonatologists, pediatricians, and family medicine specialists to those working in nursing and allied health sciences. 

4. Discussion 

Information deemed necessary for inclusion in a patient education program can be grouped into: 

1. Content about KMC 
2. Equipment needs 
3. Instructors, instructional media, and methods 

1.1.1 Content about KMC 

The benefits listed in Table II are all considered essential content for inclusion into a KMC education program aimed at parents. A benefit listed in Table II but not common in other guides is preventing malnutrition. This benefit is important in the setting of this study, as malnutrition is a major cause of morbidity and mortality in SA. The panel did not deem it necessary to explain the origins of KMC; or the association with the kangaroo, although many experts explained that they found it useful. 

Benefits that did not meet the criteria for inclusion into a KMC program in the Delphi consensus process are listed in Table III. 

Literature on teaching strategies recommends that the essential information should be focused on first. (24) 

Experts advise against warning parents that they may feel discomfort during KMC; fall asleep on top of their babies; that the babies might still cry even while in the KMC position; and that babies may become hot and sweaty. These messages may lead to negative attitudes about KMC and cause anxiety. Teaching mothers by demonstrating how to secure the baby in the KMC position safely will assist in alleviating such fears. 

1.1.2 Equipment needs 

For adopting KMC practice, the panel agreed that a lack of equipment was a barrier. This is also supported in other studies. (25) 

1.1.3 Instructors, instructional media, and methods 

Parents should be exposed to KMC prior to the birth of their babies. This has been shown to improve their knowledge about KMC. (26) Antenatal clinics and prenatal birth classes were identified as suitable for introducing the concept of KMC. 

A wide variety of resources, such as; videos, pamphlets, posters, and websites on the internet, are readily available. Health educators must carefully consider which tools will be most effective for their target group. The initial assessment of the patient will guide these decisions. 

No consensus was reached on the ideal candidate for the role of instructor. Not all experts believed that it needed to be a health professional, nor did they agree that the nurse in charge should fulfill this role. Nursing staff should not be solely responsible for teaching mothers about KMC; instead, an interdisciplinary team is required. Administrative staff and cleaning personnel who interact with patients regularly should not be involved in teaching mothers about KMC. Furthermore, they recommend that personnel involved in teaching parents must receive training. Collaboration among various disciplines is encouraged in the literature so that the team can develop that teaching protocols. 

Protocols should outline provider responsibilities to save time and prevent confusion.13 

4.2 Conclusion: 

The overall aim of this study was to produce directives for a patient education program to enhance KMC practice. Table I summarizes the recommended content for inclusion into a KMC education program. This research incorporated the perceptions and experiences of multiple stakeholders involved in KMC. The Delphi survey provided validation by experts, who reached a consensus on what is deemed relevant for inclusion in a patient education program. 

References: 

1. Arya S, Naburi H, Kawaza K, Newton S, Anyabolu CH, Bergman N, et al.Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight. NEJM. 2022;384:2028- 2038 http://dx.doi.org/10.1056/NEJMoa2026486 

2. Lassi ZS, Middleton PF, Crowther C, Bhutta ZA. Interventions to improve health and later survival: An overview of systematic reviews. EBioMedicine. 2015;2:985-1000. http://dx.doi.org/10.1016/j.ebiom.2015.05.023 

3. World Health Organization. WHO recommendations on newborn health:guidelines approved by the WHO Guidelines Review Committee. 2017. https://apps.who.int/iris/handle/10665/259269. License: CC BY-NC-SA 3.0 IGO 

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20. Curry L, Nunez-Smith M. Mixed Methods in health sciences research – A practical primer. Thousand Oaks: Sage; 2015. 

21. Balasubramanian R, Agarwal D. Delphi technique – A review. International Journal of Public Health Dentistry. 2012;3(2):16- 25. 

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Acknowledgments: 

I wish to express my sincere thanks and appreciation for the following: 

• My promoter, Prof. André Venter, Head of the Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Free State, for his guidance, and time he gave, and the input he made in this study and this article. 
• My co-promoter, Dr Johan Bezuidenhout, Head of the Division Health Sciences Education, Faculty of Health Sciences, University of the Free State, for his valuable input and encouragement in my research journey. 
• The facilitator, Ms van Heerden, for her assistance with the focus group discussions. 
• Ms. Juliet Paulse, for her meticulous attention to editing and formatting the layout of this article. 
• The participants in the study, without whom this study, would not have been possible. 
• The staff at all the participating facilities for assisting with the organization and recruitment of participants for the focus group discussions. 
• The Department of Health Sciences Education for creating such a wonderful research environment that re-energized and kept me motivated throughout the journey. 

Credit author statement: 

• Natalie Paulse: Conceptualization, methodology, writing-original draft preparation and data curation. 
• Prof Andre Venter: Supervision, writing-reviewing, and editing. 

Declaration of interests: 

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.