Evidence of the factors that influence the utilisation of Kangaroo Mother Care by parents with low-birth-weight infants in low- and middle-income countries (LMICs): a scoping review protocol
The Sustainable Development Goal (SDG) 3 emphasises on reducing neonatal deaths caused by low birth weight (LBW) complications by the implementation and utilisation of Kangaroo Mother Care (KMC) in low- and middle-income countries (LMICs). Despite the empirical evidence of KMC optimising low-birth-weight infants’ (LBWIs’) survival, its advantages and the LMICs implementing the service, studies have shown that LBW infant deaths occurring in LMICs are largely contributing to global child mortality. The aim of this scoping review is to map out the literature on barriers, challenges and facilitators of KMC utilisation by parents with LBWIs.
Methods and analysis
This scoping review will use Endnote X7 reference management software to manage articles. The review search strategy will use SCIELO and LILACS databases. Other databases will be used via EBSCOHost search engine and these are Academic search complete, CINAHL with full text, Education source, Health source: Nursing/Academic Edition, Medline with full text and Medline. We will also use Google Scholar, JSTOR, Open grey search engines and reference lists. A two-phase search mapping out process will be done. In phase 1, one reviewer will perform the title screening and removal of duplicates. Two reviewers will do a parallel abstract screening according to eligibility criteria. Phase 2 will involve the reading of full articles and exclusion of articles, in accordance with the eligibility criteria. Data extraction from the articles will be done by two reviewers independently and parallel to the data extraction form.
The data quality assessment of the eligible studies will be done using the Mixed Method Appraisal Tool (MMAT). The extraction of the synthesised results and thematic content analysis of the studies will be done by NVIVO version 10.
We expect to find studies on barriers, challenges and facilitating factors of KMC utilisation by parents with LBWIs in LMICs. The review outcomes will guide future research and practice and inform policy. The findings will be disseminated in print, electronic and conference presentations related to maternal child and neonatal health.
KeywordsBarriers Challenges Facilitating factors Kangaroo Mother Care utilisation Low-birth-weight infants LMICs Parents
Kangaroo Mother Care
Low birth weight
Low- and middle-income countries
Mixed Method Appraisal Tool
Sustainable Development Goals
Sample, Phenomenon of Interest, Design, Evaluation and Research type
University of KwaZulu-Natal
World Health Organization
Global prevalence and impact of LBWI on neonatal mortality
Kangaroo Mother Care (KMC), a skin-to-skin contact between the medically stable low-birth-weight infant (LBWI), weighing less than 2500 g, and the parent’s bare chest [1, 2], has proven to reduce LBWI mortality by almost 50% [3, 4, 5, 6]. Currently, low birth weight (LBW) mortality is a global leading cause of neonatal mortality contributing to 60–80% of neonatal deaths [7, 8]. Globally, an estimated 20 million low-birth-weight infants (LBWIs) are born annually, with low- and middle-income countries (LMICs) accounting for 18 million births . LMICs bear a higher burden of LBWI outcomes due to the high prevalence of LBWI deaths as compared to high-income countries . Each year, more than 50% of the LBWIs that are born in LMICs do not survive compared to their counterparts born in high-income countries .
Management of LBWIs in LMICs and its outcomes
The high LBWI deaths in LMICs are due to low economic income levels, poverty, poor health-seeking behaviour and weak health systems’ links [7, 10]. As such in LMICs, the management of LBWI complications has been more of Kangaroo Mother Care as compared to conventional/incubator care, since around 1978 [4, 10, 11, 12, 13]. LMICs strive to improve neonatal health through the implementation of KMC, among other interventions [2, 14], for instance, incorporating KMC package and guidelines in medical and nursing college syllabi, in-service training and existing national health care initiatives [15, 16, 17]. However, although by 2015, 62 countries achieved the three-quarter child mortality reduction target, LBWI mortality contributed largely to child mortality deaths despite the LMICs implementing KMC [8, 18, 19]. Therefore, it is evident that KMC utilisation in LMICs is a challenge as LBWI mortality in LMICs still contributes largely to global neonatal and child mortality [3, 8, 10, 12, 18].
Problem statement and aim of the study
The measure of success of KMC not only depends on KMC implementation but also on the utilisation of the service by the beneficiaries, parents with LBWIs [20, 21]. As such, the success of service utilisation largely depends on the utilisation determinants, absence of challenges and barriers, perceived quality of care, cost of care, supportive factors, cultural factors, health system factors and provider factors . There are many studies focusing on KMC service delivery and healthcare providers; however, not many studies have focused on factors that influence KMC utilisation by parents with LBWIs . World Health Organization (WHO) emphasises on employing strategies that will facilitate attaining the Sustainable Development Goal (SDG) 3, which aims at reducing newborn deaths to 12 neonatal deaths per 1000 live births per country [8, 10, 18]. In order to enhance achieving SDG 3, this scoping review, therefore, aims at mapping out existing literature on the factors influencing KMC utilisation by parents with LBWIs in LMICs. The objective of the study will be to identify and describe the factors influencing KMC utilisation by parents with LBWI in LMICs.
Significance of the study
This study will facilitate the identification of strategies/recommendations to inform policy development and/or update and inform future research and practice, by employing approaches to facilitate the uptake of KMC by parents with LBWIs.
Identifying the research question
Identifying relevant studies
Charting the data
Collating, summarising and reporting the results.
Identifying the research question
What are the facilitating factors of KMC utilisation by parents with LBWIs in LMICs?
What are the barriers and challenges to KMC utilisation by parents with LBWIs in LMICs?
What are the experiences of KMC utilisation by parents with LBWIs in LMICs?
Eligibility of research question
Framework determining eligibility of research question
Parents/guardian of LBWIs utilising KMC
Phenomenon of interest
Kangaroo Mother Care
Randomised control clinical trials; non-randomised experiments; survey; cross-sectional, case control and cohort studies
Barriers, challenges, bottlenecks, enablers, experiences and facilitating factors to KMC utilisation
Qualitative, quantitative and mixed method
Identifying relevant studies
The scoping review will include qualitative, quantitative and mixed method primary research articles published in peer-reviewed journals and grey literature that address the research question. The review will include the following study designs: randomised control clinical trials, non-randomised experiments, survey, cross-sectional study designs, case control and cohort studies. The electronic databases that will be used to search for relevant articles will include Academic search complete, CINAHL with full text, Education source, Health source: Nursing/Academic Edition, Medline with full text and Medline. All these electronic databases will be accessed via EBSCOHost search engine. We will also search for studies from SCIELO and LILACS databases. Google Scholar search engine, JSTOR search engine, Open Grey search engine, ‘the cited by’ and reference lists will also be used to search for the relevant literature. Articles written only in English and those that can automatically be translated in English will be reviewed. The LMICs have been implementing KMC since it was introduced in 1978 by Ray; however, we will only include studies published between 1990 and 2017. The year 1990 was marked as the baseline for the United Nations development goals, as such that will be our starting point.
The search terms of this scoping review have originated from indexed subject headings, keywords of relevant studies, terms from this scoping review protocol that recurred repetitively and the Medical Subject Headings (MeSH) terms. The string/Boolean search terms for this review will include kangaroo mother care OR kangaroo care OR skin to skin OR kangaroo-mother care method OR skin to skin contact AND parents OR mother OR father OR family caregivers AND low-birth-weight infants OR preterm infants OR premature infants OR very low birth weight infants AND utilization OR uptake OR compliance AND facilitators OR enablers OR motivators OR experience OR perception OR attitudes. The identified studies will be screened using eligibility criteria.
The following criteria will guide the selection of studies.
❖ Studies written in English and in other languages with English version
❖ Studies aiming at factors that influence the utilisation of KMC by parents of LBWIs in LMICs.
❖ Studies focusing on experience/views/perception of parents with LBWIs on the utilisation of KMC in LMICs.
❖ Studies with the above criteria and published between 1990 and 2017
❖ Studies written in other languages aside English; without English version
❖ Studies with the above inclusion criteria but published before 1990
❖ Studies with the above inclusion criteria but focusing on high-income countries
❖ Studies with the above inclusion criteria but with incubator care as the phenomenon of interest whether in LMICs or high-income countries
Study selection procedure
The selection of studies in this scoping review will involve two phases, as follows:
Electronic search record
Number of studies retrieved
The Endnote X7 library will then be shared with the two reviewers, who in parallel will independently screen the article abstracts according to the eligibility criteria. The full text of the eligible articles will be searched and kept in the EndNote X7 library. The reviewers will consult the University of KwaZulu-Natal Librarian to assist with the articles that will not have full text.
Data charting form
Author and date
Title of the study
Aim of the study/ research question
❖ Sample size
❖ Characteristics of participants
• % and number of males
• % and number of women
Data collection (methodology)
Outcome of the study/results
Conclusion of the study
The search strategy will be piloted to determine the validity and reliability of the criteria of the study selection. Table 4 in the Appendix narrates the pilot search results done on Medline via EBSCOHost search engine using the MeSH terms.
Charting the data
We plan to use the elements included in the data charting form (see Table 3) to facilitate the standardised data extraction. The elements in the data charting form will be regularly updated, in order to address the research question.
Collating, summarising and reporting the results
The study outcomes that will guide data extraction will include challenges of KMC utilisation, barriers of KMC utilisation and facilitating factors of KMC utilisation. The thematic content analysis will be used to code arising themes and analyse the narrative account of the extracted data. The extracted data will be coded using NVIVO software version 10 . Three stages will be used to guide collating, summarising and reporting of the results. The stages include coding text, developing descriptive themes and generating analytical themes . However, these stages are interrelated in such a way that the free coding of the primary study findings facilitates the organisation of the codes into descriptive themes. The descriptive themes enhance the development of the analytical themes.
Stages 1 and 2: Coding text and developing descriptive themes
In this review, two reviewers will independently and in parallel do the line-by-line coding of the primary study findings, in relation to the context and meaning. However, the coding of the study findings will not strictly depend on the research question, as there might be few studies addressing the review question directly . The reviewers will then categorise the initial codes into major groups, depending on their similarities and differences, then new codes will be assigned to these grouped codes, in order to give a descriptive meaning to the groups. Hence, descriptive themes will be developed. One reviewer will write a draft summary of the descriptive themes, which will be reviewed by the rest of the reviewers and they will agree on the final version of the descriptive themes.
Stage 3: Generating analytical themes
Independently and in parallel, the reviewers will deduce the barriers, challenges and facilitating factors of KMC utilisation by parents with LBWIs from the descriptive themes. In this stage, the reviewers will, through narration, analyse the descriptive themes and examine the relationship between themes to the review question. The reviewer will then examine the meaning of the study findings to the review question. The implications of the findings will be considered for intervention development. Through the narrative analysis process, individually, the reviewers will be able to develop analytical themes and proposed interventions. Then, the reviewers will together discuss the review question and the implications in relation to the descriptive themes. During the group discussion, we anticipate that more analytical themes and implications for intervention development will emerge. The process will be repeated until we no longer have emerging analytical themes and implications for intervention development. The reviewers will summarise stage 3 by agreeing and approving the identified analytical themes and implications for intervention development. The implications will form the recommendations of the review. Finally, the results will be reported.
The Mixed Method Appraisal Tool (MMAT) version 2011 will be used to assess the quality of the eligible studies in terms of the appropriateness of the study aim, the study design, methodology, sampling strategy, data collection, data analysis, result presentation, discussion and conclusion.
This scoping review will form part of the study on ‘Utilization of Kangaroo Mother Care in Mangochi district, Southern Malawi’. Mapping out the evidence that exists on barriers, challenges and facilitating factors of KMC utilisation in LMICs will provide evidence-based knowledge gaps, inform future research and enrich the main study’s findings. The barriers and challenges to KMC utilisation that prevent parents with LBW infants from utilising the only low-cost effective measure in LMICs that manages LBW complications and prevents LBWIs’ deaths will be identified. The outcomes of this scoping review will inform future research and identify the evidence-based interventions, which will inform policies and guidelines. This is in order to improve KMC utilisation in LMICs, prevent LBWI deaths and contribute towards the SDG 3 goal of 12 neonatal deaths per 1000 live births per country by 2030 [3, 8]. Although rigorous steps will be followed throughout this review, we anticipate some limitations. Firstly, studies may be omitted from the review if they were not published in the databases searched or if they were not published at all. Secondly, articles may not be accessible if they were published in languages other than English.
The authors acknowledge the University of KwaZulu-Natal (UKZN), College of Health Science, for the provision of resources towards the development of this scoping review protocol. The authors extend their gratitude to the following: the UKZN Subject Librarian: Nursing and Public Health, Nkululeko Magwaza, for assisting with the search term strategy and Professor Myra Taylor for assisting with editing this document.
This study has been funded by the University of KwaZulu-Natal, College of Health Sciences Doctoral Research Scholarship Grant. The authors declare that the funders had no role in developing this protocol.
Availability of data and materials
The published scoping review study will contain all the generated and analysed data gathered during this study, for open access.
CTM conceptualised the study and drafted the study proposal under the supervision of SM and TGG. CTM, SM and TGG contributed to the development of the study background, design, methodology, the outcomes to guide data extraction and method of data synthesis. CTM prepared the manuscript and SM and TGG supervised and reviewed it. CTM, SM and TGG reviewed the final version of the protocol and approved it.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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