Scaling up kangaroo mother care (KMC): A change package developed through the integration of quality improvement and implementation research for the NEST360 Alliance in Ethiopia, Kenya, Malawi, Nigeria, and Tanzania

Scaling up kangaroo mother care (KMC): A change package developed through the integration of quality improvement and implementation research for the NEST360 Alliance in Ethiopia, Kenya, Malawi, Nigeria, and Tanzania | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Scaling up kangaroo mother care (KMC): A change package developed through the integration of quality improvement and implementation research for the NEST360 Alliance in Ethiopia, Kenya, Malawi, Nigeria, and Tanzania Kylie Dougherty, Amelia E. Pelt, Nebiyou Hailemariam, Hannah Mwaniki, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7602222/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Kangaroo mother care (KMC) is an evidence-based intervention known to reduce newborn mortality. NEST360 is an initiative supporting mortality reduction in small and sick newborns in five countries in Africa (Ethiopia, Kenya, Malawi, Nigeria, and Tanzania) including through increase in KMC coverage. Combining quality improvement (QI) and implementation research (IR), NEST360 developed a facility-level resource to improve KMC adoption and quality of care. Methods Using data from QI projects, team meetings, literature, and interviews with high-performing facilities, NEST360 developed a change package including a driver diagram and change ideas. Input from multidisciplinary experts, including NEST360’s external advisory committee for improving quality, facility and NEST360 QI leads, clinical experts, and the African Neonatal Association refined the package, aligning it with NEST360’s QI training materials and global and national guidelines. Change ideas were mapped to the implementation research (IR) Expert Recommendations for Implementation Change (ERIC) implementation strategies. Results The driver diagram included five primary drivers mapped to 62 change ideas, with mechanisms linked to barriers and measurable process measures. Sixty-one of the 62 change ideas were mapped to ERIC strategies, with change physical structure and equipment and conduct ongoing trainings the most common. The package is being piloted at select NEST360-supported sites to improve KMC coverage and quality while assessing user preferences. Conclusions This project offers a practical example for combining QI and implementation research to address KMC barriers and enhance quality of care and newborn survival. This approach provides great value, taking local solutions and turns them into generalizable knowledge that can be shared and used in other hospitals and/or countries. Next steps include refining the package, as well as analyzing QI project data to evaluate change idea effectiveness. kangaroo mother care quality improvement implementation research change package implementation strategies sub-Saharan Africa Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Kangaroo Mother Care (KMC), an evidence-based intervention (EBI) for preterm and low-birth weight newborns, has long been recognized for its potential to improve neonatal outcomes, particularly in low-resource settings (Boundy et al., 2016; "Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight," 2021; Sindhu & Mari Jeeva, 2023). Centered around continuous skin-to-skin contact, exclusive breastfeeding, and early discharge with close follow-up, KMC has demonstrated to significantly reduce newborn mortality, improve thermal regulation, support weight gain, decrease the risk of infection, and strengthen mother-infant bonding (Boundy et al., 2016; "Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight," 2021; Sindhu & Mari Jeeva, 2023). Moreover, recent evidence suggests that initiating KMC within the first few hours of life can yield even greater survival benefits for newborns weighing less than 2,000 grams ("Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight," 2021; Sindhu & Mari Jeeva, 2023). Despite its well-documented benefits, and endorsement from the World Health Organization (WHO), the routine practice and scale-up of KMC remain inconsistent across many health systems (Cho et al., 2022; "Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight," 2021; Kourouma et al., 2021). Barriers such as limited provider training, lack of space, cultural perceptions about newborn care, inadequate caregiver support, and absence of standardized monitoring tools can hinder KMC adoption (Chan et al., 2017; Chan et al., 2016). These challenges are further compounded by systemic issues like understaffing, inadequate leadership support, and insufficient integration of KMC into routine facility workflows (Chan et al., 2017; Chan et al., 2016). The NEST360 Alliance is a global initiative committed to improving small and sick newborn care (SSNC), which is in-hospital care for newborns less than 28 weeks gestations, less than 2,500 grams, or experiencing additional health concerns such as respiratory distress syndrome or congenital abnormalities in sub-Saharan Africa through multi-level interventions ( Standards for improving quality of care for small and sick newborns in health facilities. , 2020). Specifically, NEST360 works to ensure the provision of necessary supplies and trained health workers to provide high-quality SSNC in level 2+ neonatal units (See Figure 1 for details on level 2+ care) ( NEST360 ). NEST360 supports facilities in Kenya, Malawi, Nigeria, Tanzania, and Ethiopia through collaborations with national governments to implement sustainable, scalable solutions across clinical care, equipment, workforce capacity, and data use linked with QI ( NEST360 ). As part of its mission to reduce mortality in level 2+ neonatal care units, NEST360 has prioritized the adoption and institutionalization of KMC for small and sick newborns across its supported facilities as one of selected interventions known to reduce newborn mortality. However, despite this focus, KMC coverage for newborns weighing less than 2,500 grams remained low. In response, the team prioritized improving KMC coverage in February 2024. Other work implementing KMC has been challenged by barriers at the unit, hospital, regional, or national level (Chan et al., 2017; Chan et al., 2016). Common barriers preventing KMC include a lack of social support for mothers and family members, inadequate leadership buy-in, and lack of training for healthcare providers (Chan et al., 2017). To overcome these barriers, clinicians and hospital leadership need to introduce activities and strategies that can help facilitate KMC uptake or implementation (Bilal et al., 2021). Quality improvement (QI) and implementation research (IR) offer complementary, and at times overlapping, strategies to address the gaps between existence of EBIs such as KMC and their delivery. QI focuses on adapting and improving care processes at the local level through iterative cycles of change focusing on individuals or unit and often refer to the activities they introduce to improve care as “change ideas” ( Model for improvement: Selecting changes ). Examples of QI adaptations could be performing onboard training for new staff members at the specific newborn unit where the QI project is occurring. IR follows a more systematic approach to identify generalizable information that can enable the adoption of EBIs and actions to overcome barriers or leverage enablers at the local level and more broadly which are commonly referred to as “implementation strategies” (Corrêa et al., 2023; Tyler & Glasgow, 2021). IR strategies can address local and individual barriers, such as using training when knowledge barriers are identified, and also include strategies that target broader system barriers such as introducing updated policy to decrease staff rotation of trained nurses for an entire region. Together, these approaches support mapping from barriers to strategies designed to drive improvements in care quality at both the individual facility and larger systems levels of the health system (Leeman et al., 2021). While these approaches are often viewed as separate from one another (Leeman et al., 2021), a growing body of literature has called for the integration of QI and IR to capitalize on their respective strengths (Corrêa et al., 2023; Leeman et al., 2021; Tyler & Glasgow, 2021). Authors argue that it is possible to pair the adaptability and responsiveness of QI with the potential of IR to expand to include focus on systems, and create generalizable learning from the QI which can be spread to other sites and countries, to accelerate the uptake of EBIs like KMC (Corrêa et al., 2023; Leeman et al., 2021; Tyler & Glasgow, 2021). In response to the need for a practical, scalable solution to the variable coverage of KMC, NEST360 developed a package to support cross-facility KMC implementation using a blended QI and IR approach. The goal of this change package was to serve as an adaptable practical resource that addresses unique locally identified gaps and can be used by frontline health workers, facility teams, QI coaches, and clinical mentors, while still creating generalizable knowledge that can also be used by a wider audience to strengthen broader efforts to improve KMC. This paper aims to describe the development process and examines areas of alignment and overlap between QI and IR activities designed to enhance care coverage. Methods Development of Driver Diagram To identify the key components enabling effective implementation of KMC at the facility level, a driver diagram was developed, which is a visual tool commonly used in QI to map the necessary drivers and actions required to achieve a specific goal (Institute for Healthcare Improvement). This diagram served as a foundation for a change package intended to map common barriers preventing KMC adoption to locally identified solutions which would promote KMC implementation across NEST360-supported sites. Identification of barriers and change ideas Multiple data sources were used to identify barriers preventing KMC adoption as well as change ideas implemented to improve KMC uptake. These sources included documentation from NEST360-supported facility-level QI projects previously in four countries (Kenya, Malawi, Nigeria, and Tanzania), as Ethiopia had only joined NEST360 in 2024 and so had not documented QI projects, notes from country QI review meetings (all countries), and published literature on KMC barriers, facilitators, and QI projects. Additional insights were gathered through informal discussions with country teams, including clinical and QI leads and staff from high-performing, positive outlier facilities that had demonstrated consistent KMC practice, including nurses, doctors, data managers, and biomeds. Development of Change Package A research team member (KD) collected the available data sources and extracted barriers, change ideas, and process measures to develop a preliminary version of the driver diagram and accompanying change ideas tables. This initial draft was circulated among a diverse group of stakeholders from all NEST360-supported countries for feedback. These stakeholders included members of NEST360’s improving quality external advisory committee, internal NEST360 QI and clinical lead team members from all countries, and a representative from the African Neonatal Association. Their input guided multiple iterations of the change package to enhance its clarity, contextual relevance, and practical utility. Mapping to Implementation Strategies To gain a better understanding of how the QI change ideas mapped to broader implementation strategy categories, each change idea was mapped to one of the strategies from the Expert Recommendations for Implementation Change (ERIC) compilation. ERIC is a taxonomy of 73 disease-agnostic discrete implementation strategies (i.e., single actions) grouped into 9 conceptual categories, such as adapt and tailor to context, support clinicians or provide interactive assistance (Powell et al., 2015; Waltz et al., 2015). Thus, ERIC provides a standardized menu for selecting implementation strategies across diverse contexts (Powell et al., 2015). The authors chose to map these change ideas to ERIC to 1) explore the connection and overlap, and 2) examine the potential in using ERIC to provide a uniform language and promote replicability of these KMC change ideas in NEST360-supported hospitals and other settings. Two independent coders (KD, AEVP) mapped each change idea to an ERIC strategy, as relevant. Discrepancies were resolved through discussion in meetings. The coders aimed to select the best fitting single strategy category, when possible. However, when a change idea encompassed multiple distinct components or actions, coders allowed for mapping to more than one strategy to more accurately capture its scope. Ethical approval The study presented in this manuscript was deemed program evaluation work and not human subjects research, so Northwestern University waived the requirement of an IRB review. RESULTS Final change package The collaborative development process resulted in the creation of a comprehensive KMC change package designed to support QI initiatives at the facility level. This process developed two outputs: a finalized driver diagram (see Figure 2) and a detailed change package. The driver diagram outlines the five primary drivers identified as essential for effective KMC implementation: 1) parental involvement, 2) staff, 3) clinical processes, 4) clinical governance, and 5) health facility capacity. These drivers reflect key components that need to be in place to enable NEST360’s goal of all newborns < 2,500 grams receiving KMC. First, parental involvement, focus on the importance of parents, particularly mothers, being equipped and ready to provide KMC. These findings from NEST360 QI projects not only included providing parents with time during a shift to be with their newborn and offer care, but also ensuring the family members have the knowledge and level of comfort to perform KMC. Second, staffing refers to the nurses and clinicians on the unit having the knowledge and confidence to teach family members about KMC, and encouragement to support and practice it, as well as having an adequate number of staff available to support parents and newborns. Third, clinical processes focus on the steps that clinicians need to take to identify which newborns should receive KMC and to ensure that while receiving KMC newborns are receiving all other care they need, including receiving oxygen therapy or having their vital signs taken. Fourth, clinical governance, centers around protocols, guidelines, and leadership buy-in and support. Fifth, infrastructure refers to the physical space where KMC occurs as well as the availability of equipment and resources, such as KMC chairs, KMC wraps, or a space for mothers to have meals or use the bathroom. If any of these drivers are not present, hospitals will struggle to reach their KMC goal. This means NEST360-supported hospitals must ensure that families are empowered to provide KMC, staff are trained to support it, systems are in place to identify and monitor eligible babies, clear care guidelines exist with leadership backing, and the physical environment is comfortable and calming for KMC. A total of 62 change ideas were identified and organized under the appropriate primary driver and change concept. Each change idea includes a brief rationale explaining its potential to influence the corresponding barrier, which was defined as a change concept, and an example process measure to guide measurement and evaluation efforts at the facility level. The finalized change package was distributed to all NEST360-supported facilities via the NEST360 country QI lead (Figure 3 shows a snapshot of the finalized Change Package). It is currently undergoing piloting in Kenya, Malawi, Nigeria, Tanzania, and Ethiopia. To pilot the change package country QI leads have provided orientations on the change package to NEST360-supported hospitals, and at least two hospitals per country have been tasked with using the package to develop their next QI project. Insights from the piloting phase will inform further refinements, with the goal of optimizing the package’s usability and appropriateness prior to broader dissemination across the NEST360 network and other potential implementation settings. The final change package has been published as an open access resource on the NEST360 website (NEST360). Supplemental File 1 presents the final version of the KMC change package. Mapping QI change ideas to IR ERIC strategies Sixty-one of the 62 change ideas were mapped to one or more ERIC strategies (98%), with some change ideas mapped to two strategies (12 change ideas (19%)) (Table 1). This dual mapping was needed when the change idea encompassed more than one discrete action. For example, the change idea, use parental KMC champions to provide KMC counseling to mothers and surrogates in the newborn ward was mapped to the ERIC strategies, 1) identify and prepare champions and 2) conduct educational meetings. The one change idea that could not be mapped to an ERIC strategy was hire additional nursing staff to monitor and support KMC. The most common ERIC strategies that mapped to the change ideas were change in physical structure and equipment and conduct educational meetings, which were mapped to 10 and 11 change ideas, respectively. Twenty-four ERIC strategies mapped to a change idea, and 49 strategies did not map to any change ideas. When looking at the nine thematic categories of ERIC strategies, train and educate stakeholders (25 change ideas, 40%) , change infrastructure (12 change ideas, 19%), and use evaluative and iterative strategies (9 change ideas, 14%) were frequently mapped. Conversely, fewer change ideas were attributed to strategies in the ERIC categories of support clinicians (3 change ideas, 5%) or utilize financial strategies (3 change ideas, 5%). DISCUSSION This study advances the work to improve SSNC in NEST360-supported countries by creating a package designed to address the range of gaps and underlying causes in gaps in quality and coverage of KMC through a field-based, context-sensitive approach. The change package offers pragmatic strategies that were used in relevant clinical settings to increase KMC adoption and improve SSNC. While prior research has identified common barriers and facilitators to KMC (Chan et al., 2017; Chan et al., 2016; Cho et al., 2022; Kourouma et al., 2021), this package moves beyond documentation of causes to offer actionable strategies for addressing these challenges, along with process indicators to monitor and guide change. This study demonstrates how QI and IR can be used together to create a flexible package that aligns with NEST360’s QI training materials, incorporated real-world lessons from facility QI projects, and presents them in a generalizable format suitable for broad implementation and adaptation. The package was shaped by multidisciplinary stakeholder input, including feedback from internal and external partners, which enriched its contextual relevance and practical utility. The collaborative, iterative development process involving country teams, regional networks like the African Neonatal Association, and frontline ward staff demonstrates how real-world implementation and co-production of global goods can generate tools that are adaptable across settings and scalable over time. By mapping frontline QI change ideas to standardized, theory-informed strategies, QI efforts can gain rigor and replicability through integration with IR frameworks and its standardized terminology (Tyler & Glasgow, 2021). This mapping process can also help implementers to identify if there are conceptual gaps in the activities that they are implementing. For example, few change ideas mapped to strategies under the conceptual domain of utilize financial strategies (Waltz et al., 2015).This provides a potential area for future innovation if implementers are not seeing the changes they had hoped. Being able to compare local change ideas to standardized IR terms can also provide insight into the level of control that change idea is addressing. Many of the change ideas implemented to promote KMC focused on the clinician, family, and physical environment, while few addressed leadership, policy, or higher-level health system change. This suggests that while frontline and interpersonal factors are being addressed, there may be missed opportunities for overcoming system-level barriers. Mapping change ideas to IR strategies and their conceptual domains can help individuals not only explore alignment between the two but also identify possible new methods and pathways for enacting change. The development of the change package also highlighted conceptual overlap between QI and IR, beyond the match between change ideas and ERIC IR strategies. Specifically, the rationale column included for each change idea was intentionally designed to address a gap or group of gaps, similar to a mechanism of action, which is a core concept in IR that explains how and why a strategy is expected to produce change (Walker et al., 2025). Additionally, the change concepts, which represented the identified gaps that the specific change ideas target are similar to implementation barriers that must be addressed to enable successful KMC adoption. In addition, the almost complete mapping from the QI change ideas to one or more of an ERIC strategies and the QI change ideas showed how these two disciplines can build on each other. This mapping was not surprising given that the original development of the ERIC taxonomy drew in part from QI frameworks and taxonomies (Powell et al., 2012). Mapping each change idea to the ERIC taxonomy further allowed us to develop generalizable recommendations, and accelerate the spread of local innovations, demonstrating strong alignment between frontline QI practices and established IR frameworks. However, it is important to acknowledge that many widely used IR frameworks and tools, including ERIC, were developed in high-income settings and do not fully capture the realities of low-resource settings (Lovero et al., 2023). This was seen when one of the KMC change ideas could not be mapped to an ERIC strategy, which shows that while ERIC has many uses it does not comprehensively cover the breadth of all strategies used for implementation work in low-resource settings, a limitation which has been identified by previous research (Lovero et al., 2023). For example, in many low-income settings, there are often an insufficient number of nurses and clinicians available to care for patients in the hospital settings (Imam et al., 2023; Macey et al., 2022). Thus a common strategy to overcome this barrier is to hire and train additional staff to support the unit (Vasan et al., 2017). However, this change idea was not reflected in the ERIC strategies. This may be because implementers in high-income settings assume that there is already adequate staff and do not need to identify strategies to overcome this barrier. Additionally, while most change ideas mapped to ERIC strategies, not all fully aligned with the ERIC definition, which we believe could be a limitation on the use of ERIC across all settings. This was seen when the change idea, Recognize parental KMC champions was mapped to alter incentive/allowance structures . This match was selected because the recognition of parental KMC champions can be seen as a driver and motivator to change parental behavior, however, the definition of incentives and allowances as defined by ERIC specifically focuses on financial incentives as a driver of change. We recommend the definition of alter incentive/allowance structures be expanded to include incentives beyond financial ones. Another area where the change ideas showed limited alignment was with the ERIC strategy tailor strategies. We noted that this strategy did not clearly capture the intent behind specific change ideas such as clustering care to reduce KMC interruptions, assessing KMC eligibility during morning rounds, or prescribing KMC by physicians. While these activities do represent efforts to tailor implementation to context, we argue that nearly all change ideas could be categorized as tailored strategies, since tailoring is inherent to the process of developing context-specific implementation approaches. Prior research has pointed out that modifying workflows and integrating interventions into routine care is an implementation strategy not fully covered by ERIC (Van Pelt et al., 2022). We propose the inclusion of the strategy modifying workflow and/or integration into routine care as it more accurately reflects the KMC-related change ideas currently mapped to tailor strategies. Limitations While this project provides valuable insight into the integration of QI and IR to enhance KMC adoption, several limitations should be acknowledged. First, the development of the change package was primarily informed by data and experiences from NEST360-supported facilities in five countries. As such, the generalizability of specific change ideas or implementation strategies may be limited outside of these settings, particularly in regions with different health system structures or resources limitations. Our integration of IR methods to create more generalizable strategies was deigned to help mitigate this limitation. Second, while the change package was designed through an iterative, participatory process, the piloting phase is still ongoing at the time of writing. As such, the effectiveness and feasibility of using a change package to guide change idea selection and track process measures has not been fully explored. Data from the pilot phase will be critical to assess implementation outcomes, identify barriers to uptake, and refine the package based on real-world experiences. Fourth, although stakeholder engagement was broad, direct input from families and frontline healthcare workers was limited during the development of the change package. Future iterations of the change package should prioritize incorporating caregiver perspectives to ensure strategies are not only effective but also acceptable and culturally appropriate. CONCLUSION This study demonstrates the value of integrating IR into QI to advance work to address barriers to increasing KMC coverage for SSN in resource-limited settings. Through a collaborative, data-driven process, this work developed a change package grounded in real-world QI experience and informed by established IR lessons and tools. By aligning local, facility-level insights with standardized tools like ERIC, and following IR principles that emphasis the identification and use of generalizable knowledge, this deliverable bridges the gap between theory and practice, making IR more actionable in resource-limited settings. The change package provides a practical roadmap for facilities seeking to improve KMC coverage and quality, offering a set of adaptable strategies, and context-specific guidance. Importantly, this work underscores the power of cross-disciplinary collaboration and locally driven innovation in developing tools to address persistent gaps in newborn care. With continued refinement and stakeholder engagement, the developed KMC change package has the potential to serve not only as an open access resource from NEST360 but as a scalable, sustainable package to improve neonatal outcomes. Declarations ETHICS APPROVAL AND CONSENT TO PUBLISH The study presented in this manuscript was deemed program evaluation work and not human subjects research, so Northwestern University waived the requirement of an IRB review. AUTHOR CONTRIBUTIONS All authors made substantial contributions to the development of this manuscript. KD and LH conceptualized the study. KD coordinated the overall project, and eld the drafting of the manuscript. KD and AVP performed the change idea and ERIC mapping process and interpretation of the findings. CB, NH, HW, SO, RT, ZK, AF, and ED supported the development of the KMC change package. JW and NR provided review of the final change package. All authors contributed to critical revisions and final approval of this manuscript, and all agree to be accountable for all aspects of the work. DATA AVAILABILITY The change package described in this paper is available in its entirety in the resources section at https://nest360.org/project/nest360-change-package/. 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Identifying Mechanisms of Action for Implementation Strategies Using a Retrospective Implementation Mapping Logic Model Approach. Prev Sci , 26 (2), 161-174. https://doi.org/10.1007/s11121-025-01790-2 Waltz, T. J., Powell, B. J., Matthieu, M. M., Damschroder, L. J., Chinman, M. J., Smith, J. L., Proctor, E. K., & Kirchner, J. E. (2015). Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Science , 10 (1), 109. https://doi.org/10.1186/s13012-015-0295-0 Table Table 1. KMC Change ideas mapped to ERIC strategies Change Concept Change Idea ERIC Strategy Parental Involvement Facilitate mother-newborn time Utilize wheelchairs to transport non-ambulatory mothers to the newborn Change physical structure and equipment Expand access to who can provide KMC Remove visitor restrictions for the newborn ward Mandate change, tailor strategies Provide support and encouragement for other KMC providers Prepare patients/consumers to be active participants Ensure a KMC provider is frequently available Establish a regular, set time for KMC to encourage mothers to show up to perform KMC (access at any other times is not restricted) Intervene with patients/consumers to enhance uptake and adherence Have mothers or another relative stay at the hospital until the baby is discharged Involve patients/consumers and family members Increase parental knowledge and understanding of KMC Provide parental counseling and education (possibly through KMC champions), and start the education during antenatal care visits Conduct educational meetings Hang KMC educational material around the newborn ward and antenatal ward Distribute educational materials Utilize videos to provide KMC education for parents Develop educational materials, distribute educational materials Share educational material via smartphones and WhatsApp including nationally pre-recorded audio on KMC Distribute educational materials Provide encouragement to family members (including mom) Staff provide verbal encouragement to family members while they practice KMC at least once a day and provide corrections to newborn positioning if necessary Intervene with patients/consumers to enhance uptake and adherence Use parental KMC champions to provide KMC counseling to mothers/surrogates in the newborn ward Identify and prepare champions, conduct educational meetings Recognize parental KMC champions Alter incentive/allowance structures Encourage peer education and demonstrations of KMC Involve patients/consumers and family members, conduct educational meetings Enable privacy to respect cultural norms Place screens or curtains around/near the newborn’s bed/warmer to provide privacy for the individual practicing KMC Change physical structure and equipment Change Concept Change Idea ERIC Strategy Staff Changes Increase staff knowledge Provide KMC simulation-based training for staff using KMC training and education material Conduct educational meetings Providing training to staff on which types of newborns should receive KMC Conduct educational meetings Increase peripheral hospital staff knowledge Mentor peripheral hospital staff Conduct educational outreach visits Increase staff confidence Providing training to staff on which types of newborns should receive KMC Conduct educational meetings, conduct ongoing training Utilize more senior nurses to mentor junior nurses Create a learning collaborative Cross mentorship with all staff to encourage capacity beyond just the champions Provide ongoing consultation Increase staff motivation Develop and utilize KMC Champions to provide mentorship to clinicians (including nursing staff) Identify and prepare champions, create a learning collaborative Recognize a KMC champion every month Alter incentive/allowance structures Facilitate cross learning activities between facilities Capture and share local knowledge, Create a learning collaborative Prevent the loss of trained staff Monitor for staff turnover and retrain Purposely reexamine implementation, conduct educational meetings Reduce staff rotations when possible Obtain formal commitments Increase staffing Hire additional nursing staff to monitor and support KMC No match with an ERIC strategy Floater nurses during peak hours (collaborate with postnatal and other units to share staff) Revise professional roles Multi-departmental training Train multiple departments, including maternal in newborn care Revise professional roles Change Concept Change Idea ERIC Strategy Clinical Processes Clearly define which newborns should receive KMC Assessing eligibility of the babies for KMC during morning rounds Tailor strategy Reporting if the newborn is eligible for KMC during daily hand off Tailor strategy Doctors provide and document KMC prescriptions Facilitate relay of clinical data to providers Enable frequent monitoring of the newborn Use continuous monitoring devices to track newborn vitals during KMC Tailore strategies Decrease interruptions Cluster care for the newborn so there are fewer interruptions to KMC Tailor strategy Use devices that are KMC compatible Use devices that are better suited for KMC (ex. Pumani has longer cords than other CPAP) Change physical structure and equipment Update KMC documentation/ registers Review KMC documentation form with stakeholders Audit and provide feedback Include KMC duration and frequency into routine charting Change record systems Include KMC as part of quality indicators review and tracking Purposefully reexamine the implementation Increase staff knowledge about KMC documentation Providing KMC training for staff on how to complete KMC documentation forms Conduct ongoing trainings, conduct educational meetings Provide practice examples during KMC mentorship and training sessions and highlight the importance of KMC documentation Develop educational materials, make training dynamic Cross mentorship to all staff so champions are not the only ones documenting KMC Provide ongoing training Monitor KMC documentation Perform routine chart reviews of KMC documentation to track progress Audit and provide feedback Perform KMC audits with feedback Audit and provide feedback Change Concept Change Idea ERIC Strategy Clinical Governance Build QI capacity Provide QI training for staff using QI training and educational material Conduct educational meetings, conduct ongoing training Include examples of how to use KMC data for QI activities within the KMC and QI training for staff Develop educational materials, make training dynamic Conducting QI coaching at facilities with a regional and/or country QI expert Provide ongoing consultation Identify facility-level QI champions and provide them with training Identify and prepare champions, conduct educational meetings Increase the frequency of QI activities Conduct monthly QI meetings with the ward improvement team, and document best practices whenever wards achieve their targets Facilitation, capture and share local knowledge Monitor QI progress Perform monthly data audits during ward improvement meetings and develop action plans Audit and provide feedback Audit documentation quality Audit and provide feedback Increase leadership capacity Educate leaders on importance of KMC Inform local opinion leaders Include leadership in KMC monitoring Incorporate KMC into management review metrics and regularly review outcomes Purposefully reexamine the implementation Ensure guidelines are current Align KMC guidelines with national standards Develop educational materials Make guidelines and standards of practice readily available Post guidelines and standards of practice throughout the unit and leave copies in multiple locations Distribute educational materials Change Concept Change Idea ERIC Strategy Facility Change Create a comfortable place to perform KMC If space is available, place beds next to the neonatal warmer/bed Change physical structure and equipment If funds and space are available, purchase reclining chairs and/or beds for the KMC and/or newborn unit Change physical structure and equipment Create privacy on the unit Utilize infrastructure funds to create cubicles in the KMC or newborn unit Change physical structure and equipment Place screens or curtains around/near the newborn’s bed/warmer to provide privacy for the individual practicing KMC Change physical structure and equipment Ensure the availability of gowns and wraps Facilities subsidize KMC wraps and gowns Alter patient/consumer fees Demonstrate how to use the Kitenges as KMC wrap Conduct educational meetings Ensure facilities for daily needs are available Explore abandoned rooms to create space for family members to bathe and prepare food Change physical structure and equipment Repurpose nearby non-functional material stores to create space for family members to bathe and prepare food Change physical structure and equipment Use devices that are KMC compatible Use devices that are better suited for KMC (ex. Pumani has longer cords than other CPAP) Change physical structure and equipment Additional Declarations No competing interests reported. Supplementary Files NEST360ChangePackageFinalweb.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Sep, 2025 Editor assigned by journal 17 Sep, 2025 Submission checks completed at journal 17 Sep, 2025 First submitted to journal 12 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7602222","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516648896,"identity":"a4bfac4e-0eff-480b-bfc2-b051652fd60f","order_by":0,"name":"Kylie Dougherty","email":"data:image/png;base64,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","orcid":"","institution":"Northwestern University","correspondingAuthor":true,"prefix":"","firstName":"Kylie","middleName":"","lastName":"Dougherty","suffix":""},{"id":516648897,"identity":"d7cb167f-e2dd-4a1d-88c4-a834743dd99b","order_by":1,"name":"Amelia E. 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Bohne","email":"","orcid":"","institution":"Rice University","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"A.","lastName":"Bohne","suffix":""},{"id":516648915,"identity":"a1070c28-dc6f-49c0-bf94-1cd38cd2802f","order_by":12,"name":"Lisa R Hirschhorn","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"R","lastName":"Hirschhorn","suffix":""}],"badges":[],"createdAt":"2025-09-12 16:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7602222/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7602222/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93611205,"identity":"b6c47b74-25b5-48bb-aa8d-02675e006167","added_by":"auto","created_at":"2025-10-15 16:12:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96270,"visible":true,"origin":"","legend":"\u003cp\u003eExamples of care given at Level 1, 2, and 3 neonatal care units. Adapted from Cross (Cross et al., 2023).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7602222/v1/4ebd0040e28fe36d961be111.png"},{"id":93611207,"identity":"b31f7d0f-c80c-41f3-a144-a63d50ee8ef6","added_by":"auto","created_at":"2025-10-15 16:12:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":112760,"visible":true,"origin":"","legend":"\u003cp\u003eKangaroo Mother Care (KMC) Driver Diagram\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7602222/v1/c20bb791cd38c4514ea7e095.png"},{"id":93611206,"identity":"83bf3975-80ce-4137-9eea-55e8e576c312","added_by":"auto","created_at":"2025-10-15 16:12:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":271720,"visible":true,"origin":"","legend":"\u003cp\u003eSnapshot of a section of the change package focusing on change ideas to increase staff knowledge and comfort\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7602222/v1/6af6d12ad58c436f4f5414fd.png"},{"id":93612565,"identity":"2edc2717-8bbf-473c-861f-617631c0df97","added_by":"auto","created_at":"2025-10-15 16:20:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1266656,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7602222/v1/e7910fd9-527e-4a25-8024-609a34c66996.pdf"},{"id":93611208,"identity":"10ad9d99-7a74-4830-8d40-bc7e58a3d002","added_by":"auto","created_at":"2025-10-15 16:12:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":754590,"visible":true,"origin":"","legend":"","description":"","filename":"NEST360ChangePackageFinalweb.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7602222/v1/222314226ffa62ebe5ca4b15.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Scaling up kangaroo mother care (KMC): A change package developed through the integration of quality improvement and implementation research for the NEST360 Alliance in Ethiopia, Kenya, Malawi, Nigeria, and Tanzania","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eKangaroo Mother Care (KMC), an evidence-based intervention (EBI) for preterm and low-birth weight newborns, has long been recognized for its potential to improve neonatal outcomes, particularly in low-resource settings (Boundy et al., 2016; \u0026quot;Immediate \u0026ldquo;Kangaroo Mother Care\u0026rdquo; and Survival of Infants with Low Birth Weight,\u0026quot; 2021; Sindhu \u0026amp; Mari Jeeva, 2023). Centered around continuous skin-to-skin contact, exclusive breastfeeding, and early discharge with close follow-up, KMC has demonstrated to significantly reduce newborn mortality, improve thermal regulation, support weight gain, decrease the risk of infection, and strengthen mother-infant bonding (Boundy et al., 2016; \u0026quot;Immediate \u0026ldquo;Kangaroo Mother Care\u0026rdquo; and Survival of Infants with Low Birth Weight,\u0026quot; 2021; Sindhu \u0026amp; Mari Jeeva, 2023). Moreover, recent evidence suggests that initiating KMC within the first few hours of life can yield even greater survival benefits for newborns weighing less than 2,000 grams (\u0026quot;Immediate \u0026ldquo;Kangaroo Mother Care\u0026rdquo; and Survival of Infants with Low Birth Weight,\u0026quot; 2021; Sindhu \u0026amp; Mari Jeeva, 2023). Despite its well-documented benefits, and endorsement from the World Health Organization (WHO), the routine practice and scale-up of KMC remain inconsistent across many health systems (Cho et al., 2022; \u0026quot;Immediate \u0026ldquo;Kangaroo Mother Care\u0026rdquo; and Survival of Infants with Low Birth Weight,\u0026quot; 2021; Kourouma et al., 2021). Barriers such as limited provider training, lack of space, cultural perceptions about newborn care, inadequate caregiver support, and absence of standardized monitoring tools can hinder KMC adoption (Chan et al., 2017; Chan et al., 2016). These challenges are further compounded by systemic issues like understaffing, inadequate leadership support, and insufficient integration of KMC into routine facility workflows (Chan et al., 2017; Chan et al., 2016).\u003c/p\u003e\n\u003cp\u003eThe NEST360 Alliance is a global initiative committed to improving small and sick newborn care (SSNC), which is in-hospital care for newborns less than 28 weeks gestations, less than 2,500 grams, or experiencing additional health concerns such as respiratory distress syndrome or congenital abnormalities in sub-Saharan Africa through multi-level interventions (\u003cem\u003eStandards for improving quality of care for small and sick newborns in health facilities.\u0026nbsp;\u003c/em\u003e, 2020). Specifically, NEST360 works to ensure the provision of necessary supplies and trained health workers to provide high-quality SSNC in level 2+ neonatal units (See Figure 1 for details on level 2+ care) (\u003cem\u003eNEST360\u003c/em\u003e). NEST360 supports facilities in Kenya, Malawi, Nigeria, Tanzania, and Ethiopia through collaborations with national governments to implement sustainable, scalable solutions across clinical care, equipment, workforce capacity, and data use linked with QI (\u003cem\u003eNEST360\u003c/em\u003e). As part of its mission to reduce mortality in level 2+ neonatal care units, NEST360 has prioritized the adoption and institutionalization of KMC for small and sick newborns across its supported facilities as one of selected interventions known to reduce newborn mortality. However, despite this focus, KMC coverage for newborns weighing less than 2,500 grams remained low. In response, the team prioritized improving KMC coverage in February 2024. Other work implementing KMC has been challenged by barriers at the unit, hospital, regional, or national level (Chan et al., 2017; Chan et al., 2016). Common barriers preventing KMC include a lack of social support for mothers and family members, inadequate leadership buy-in, and lack of training for healthcare providers (Chan et al., 2017).\u003c/p\u003e\n\u003cp\u003eTo overcome these barriers, clinicians and hospital leadership need to introduce activities and strategies that can help facilitate KMC uptake or implementation (Bilal et al., 2021). Quality improvement (QI) and implementation research (IR) offer complementary, and at times overlapping, strategies to address the gaps between existence of EBIs such as KMC and their delivery. QI focuses on adapting and improving care processes at the local level through iterative cycles of change focusing on individuals or unit and often refer to the activities they introduce to improve care as \u0026ldquo;change ideas\u0026rdquo; (\u003cem\u003eModel for improvement: Selecting changes\u003c/em\u003e). Examples of QI adaptations could be performing onboard training for new staff members at the specific newborn unit where the QI project is occurring. IR follows a more systematic approach to identify generalizable information that can enable the adoption of EBIs and actions to overcome barriers or leverage enablers at the local level and more broadly which are commonly referred to as \u0026ldquo;implementation strategies\u0026rdquo; (Corr\u0026ecirc;a et al., 2023; Tyler \u0026amp; Glasgow, 2021). IR strategies can address local and individual barriers, such as using training when knowledge barriers are identified, and also include strategies that target broader system barriers such as introducing updated policy to decrease staff rotation of trained nurses for an entire region. Together, these approaches support mapping from barriers to strategies designed to drive improvements in care quality at both the individual facility and larger systems levels of the health system (Leeman et al., 2021). While these approaches are often viewed as separate from one another (Leeman et al., 2021), a growing body of literature has called for the integration of QI and IR to capitalize on their respective strengths (Corr\u0026ecirc;a et al., 2023; Leeman et al., 2021; Tyler \u0026amp; Glasgow, 2021). Authors argue that it is possible to pair the adaptability and responsiveness of QI with the potential of IR to expand to include focus on systems, and create generalizable learning from the QI which can be spread to other sites and countries, to accelerate the uptake of EBIs like KMC (Corr\u0026ecirc;a et al., 2023; Leeman et al., 2021; Tyler \u0026amp; Glasgow, 2021).\u003c/p\u003e\n\u003cp\u003eIn response to the need for a practical, scalable solution to the variable coverage of KMC, NEST360 developed a package to support cross-facility KMC implementation using a blended QI and IR approach. The goal of this change package was to serve as an adaptable practical resource that addresses unique locally identified gaps and can be used by frontline health workers, facility teams, QI coaches, and clinical mentors, while still creating generalizable knowledge that can also be used by a wider audience to strengthen broader efforts to improve KMC. This paper aims to describe the development process and examines areas of alignment and overlap between QI and IR activities designed to enhance care coverage.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDevelopment of Driver Diagram\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo identify the key components enabling effective implementation of KMC at the facility level, a driver diagram was developed, which is a visual tool commonly used in QI to map the necessary drivers and actions required to achieve a specific goal (Institute for Healthcare Improvement). This diagram served as a foundation for a change package intended to map common barriers preventing KMC adoption to locally identified solutions which would promote KMC implementation across NEST360-supported sites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIdentification of barriers and change ideas\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eMultiple data sources were used to identify barriers preventing KMC adoption as well as change ideas implemented to improve KMC uptake. These sources included documentation from NEST360-supported facility-level QI projects previously in four countries (Kenya, Malawi, Nigeria, and Tanzania), as Ethiopia had only joined NEST360 in 2024 and so had not documented QI projects, notes from country QI review meetings (all countries), and published literature on KMC barriers, facilitators, and QI projects. Additional insights were gathered through informal discussions with country teams, including clinical and QI leads and staff from high-performing, positive outlier facilities that had demonstrated consistent KMC practice, including nurses, doctors, data managers, and biomeds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDevelopment of Change Package\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A research team member (KD) collected the available data sources and extracted barriers, change ideas, and process measures to develop a preliminary version of the driver diagram and accompanying change ideas tables. This initial draft was circulated among a diverse group of stakeholders from all NEST360-supported countries for feedback. These stakeholders included members of NEST360\u0026rsquo;s improving quality external advisory committee, internal NEST360 QI and clinical lead team members from all countries, and a representative from the African Neonatal Association. Their input guided multiple iterations of the change package to enhance its clarity, contextual relevance, and practical utility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMapping to Implementation Strategies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo gain a better understanding of how the QI change ideas mapped to broader implementation strategy categories, each change idea was mapped to one of the strategies from the Expert Recommendations for Implementation Change (ERIC) compilation. ERIC is a taxonomy of 73 disease-agnostic discrete implementation strategies (i.e., single actions) grouped into 9 conceptual categories, such as \u003cem\u003eadapt and tailor to context, support clinicians\u003c/em\u003e or \u003cem\u003eprovide interactive assistance\u003c/em\u003e (Powell et al., 2015; Waltz et al., 2015). Thus, ERIC provides a standardized menu for selecting implementation strategies across diverse contexts (Powell et al., 2015). The authors chose to map these change ideas to ERIC to 1) explore the connection and overlap, and 2) examine the potential in using ERIC to provide a uniform language and promote replicability of these KMC change ideas in NEST360-supported hospitals and other settings. Two independent coders (KD, AEVP) mapped each change idea to an ERIC strategy, as relevant. Discrepancies were resolved through discussion in meetings. The coders aimed to select the best fitting single strategy category, when possible. However, when a change idea encompassed multiple distinct components or actions, coders allowed for mapping to more than one strategy to more accurately capture its scope.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study presented in this manuscript was deemed program evaluation work and not human subjects research, so Northwestern University waived the requirement of an IRB review.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eFinal change package\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe collaborative development process resulted in the creation of a comprehensive KMC change package designed to support QI initiatives at the facility level. This process developed two outputs: a finalized driver diagram (see Figure 2) and a detailed change package. The driver diagram outlines the five primary drivers identified as essential for effective KMC implementation: 1) parental involvement, 2) staff, 3) clinical processes, 4) clinical governance, and 5) health facility capacity. These drivers reflect key components that need to be in place to enable NEST360\u0026rsquo;s goal of all newborns \u0026lt; 2,500 grams receiving KMC. First, parental involvement, focus on the importance of parents, particularly mothers, being equipped and ready to provide KMC. These findings from NEST360 QI projects not only included providing parents with time during a shift to be with their newborn and offer care, but also ensuring the family members have the knowledge and level of comfort to perform KMC. Second, staffing refers to the nurses and clinicians on the unit having the knowledge and confidence to teach family members about KMC, and encouragement to support and practice it, as well as having an adequate number of staff available to support parents and newborns. Third, clinical processes focus on the steps that clinicians need to take to identify which newborns should receive KMC and to ensure that while receiving KMC newborns are receiving all other care they need, including receiving oxygen therapy or having their vital signs taken. Fourth, clinical governance, centers around protocols, guidelines, and leadership buy-in and support. Fifth, infrastructure refers to the physical space where KMC occurs as well as the availability of equipment and resources, such as KMC chairs, KMC wraps, or a space for mothers to have meals or use the bathroom. If any of these drivers are not present, hospitals will struggle to reach their KMC goal. This means NEST360-supported hospitals must ensure that families are empowered to provide KMC, staff are trained to support it, systems are in place to identify and monitor eligible babies, clear care guidelines exist with leadership backing, and the physical environment is comfortable and calming for KMC.\u003c/p\u003e\n\u003cp\u003eA total of 62 change ideas were identified and organized under the appropriate primary driver and change concept. Each change idea includes a brief rationale explaining its potential to influence the corresponding barrier, which was defined as a change concept, and an example process measure to guide measurement and evaluation efforts at the facility level.\u003c/p\u003e\n\u003cp\u003eThe finalized change package was distributed to all NEST360-supported facilities via the NEST360 country QI lead (Figure 3 shows a snapshot of the finalized Change Package). It is currently undergoing piloting in Kenya, Malawi, Nigeria, Tanzania, and Ethiopia. To pilot the change package country QI leads have provided orientations on the change package to NEST360-supported hospitals, and at least two hospitals per country have been tasked with using the package to develop their next QI project. Insights from the piloting phase will inform further refinements, with the goal of optimizing the package\u0026rsquo;s usability and appropriateness prior to broader dissemination across the NEST360 network and other potential implementation settings. The final change package has been published as an open access resource on the NEST360 website (NEST360). Supplemental File 1 presents the final version of the KMC change package.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMapping QI change ideas to IR ERIC strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSixty-one of the 62 change ideas were mapped to one or more ERIC strategies (98%), with some change ideas mapped to two strategies (12 change ideas (19%)) (Table 1). This dual mapping was needed when the change idea encompassed more than one discrete action. For example, the change idea, \u003cem\u003euse parental KMC champions to provide KMC counseling to mothers and surrogates in the newborn ward\u0026nbsp;\u003c/em\u003ewas mapped to the ERIC strategies, 1) \u003cem\u003eidentify and prepare champions\u003c/em\u003e and 2) \u003cem\u003econduct educational meetings.\u0026nbsp;\u003c/em\u003eThe one change idea that could not be mapped to an ERIC strategy was \u003cem\u003ehire additional nursing staff to monitor and support KMC.\u0026nbsp;\u003c/em\u003eThe most common ERIC strategies that mapped to the change ideas were \u003cem\u003echange in physical structure and equipment\u0026nbsp;\u003c/em\u003eand \u003cem\u003econduct educational meetings,\u0026nbsp;\u003c/em\u003ewhich were mapped to 10 and 11 change ideas, respectively. Twenty-four ERIC strategies mapped to a change idea, and 49 strategies did not map to any change ideas. When looking at the nine thematic categories of ERIC strategies, \u003cem\u003etrain and educate stakeholders\u0026nbsp;\u003c/em\u003e(25 change ideas, 40%)\u003cem\u003e, change infrastructure\u0026nbsp;\u003c/em\u003e(12 change ideas, 19%), and \u003cem\u003euse evaluative and iterative strategies\u0026nbsp;\u003c/em\u003e(9 change ideas, 14%) were frequently mapped. Conversely, fewer change ideas were attributed to strategies in the ERIC categories of \u003cem\u003esupport clinicians\u0026nbsp;\u003c/em\u003e(3 change ideas, 5%) or \u003cem\u003eutilize financial strategies\u0026nbsp;\u003c/em\u003e(3 change ideas, 5%).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study advances the work to improve SSNC in NEST360-supported countries by creating a package designed to address the range of gaps and underlying causes in gaps in quality and coverage of KMC through a field-based, context-sensitive approach. The change package offers pragmatic strategies that were used in relevant clinical settings to increase KMC adoption and improve SSNC. While prior research has identified common barriers and facilitators to KMC (Chan et al., 2017; Chan et al., 2016; Cho et al., 2022; Kourouma et al., 2021), this package moves beyond documentation of causes to offer actionable strategies for addressing these challenges, along with process indicators to monitor and guide change.\u003c/p\u003e\n\u003cp\u003eThis study demonstrates how QI and IR can be used together to create a flexible package that aligns with NEST360’s QI training materials, incorporated real-world lessons from facility QI projects, and presents them in a generalizable format suitable for broad implementation and adaptation. The package was shaped by multidisciplinary stakeholder input, including feedback from internal and external partners, which enriched its contextual relevance and practical utility. The collaborative, iterative development process involving country teams, regional networks like the African Neonatal Association, and frontline ward staff demonstrates how real-world implementation and co-production of global goods can generate tools that are adaptable across settings and scalable over time.\u003c/p\u003e\n\u003cp\u003eBy mapping frontline QI change ideas to standardized, theory-informed strategies, QI efforts can gain rigor and replicability through integration with IR frameworks and its standardized terminology (Tyler \u0026amp; Glasgow, 2021). This mapping process can also help implementers to identify if there are conceptual gaps in the activities that they are implementing. For example, few change ideas mapped to strategies under the conceptual domain of \u003cem\u003eutilize financial strategies\u0026nbsp;\u003c/em\u003e(Waltz et al., 2015).This provides a potential area for future innovation if implementers are not seeing the changes they had hoped. Being able to compare local change ideas to standardized IR terms can also provide insight into the level of control that change idea is addressing. Many of the change ideas implemented to promote KMC focused on the clinician, family, and physical environment, while few addressed leadership, policy, or higher-level health system change. This suggests that while frontline and interpersonal factors are being addressed, there may be missed opportunities for overcoming system-level barriers. Mapping change ideas to IR strategies and their conceptual domains can help individuals not only explore alignment between the two but also identify possible new methods and pathways for enacting change.\u003c/p\u003e\n\u003cp\u003eThe development of the change package also highlighted conceptual overlap between QI and IR, beyond the match between change ideas and ERIC IR strategies. Specifically, the rationale column included for each change idea was intentionally designed to address a gap or group of gaps, similar to a mechanism of action, which is a core concept in IR that explains how and why a strategy is expected to produce change (Walker et al., 2025). Additionally, the change concepts, which represented the identified gaps that the specific change ideas target are similar to implementation barriers that must be addressed to enable successful KMC adoption. In addition, the almost complete mapping from the QI change ideas to one or more of an ERIC strategies and the QI change ideas showed how these two disciplines can build on each other. This mapping was not surprising given that the original development of the ERIC taxonomy drew in part from QI frameworks and taxonomies (Powell et al., 2012). Mapping each change idea to the ERIC taxonomy further allowed us to develop generalizable recommendations, and accelerate the spread of local innovations, demonstrating strong alignment between frontline QI practices and established IR frameworks.\u003c/p\u003e\n\u003cp\u003eHowever, it is important to acknowledge that many widely used IR frameworks and tools, including ERIC, were developed in high-income settings and do not fully capture the realities of low-resource settings (Lovero et al., 2023). This was seen when one of the KMC change ideas could not be mapped to an ERIC strategy, which shows that while ERIC has many uses it does not comprehensively cover the breadth of all strategies used for implementation work in low-resource settings, a limitation which has been identified by previous research (Lovero et al., 2023). For example, in many low-income settings, there are often an insufficient number of nurses and clinicians available to care for patients in the hospital settings (Imam et al., 2023; Macey et al., 2022). Thus a common strategy to overcome this barrier is to hire and train additional staff to support the unit (Vasan et al., 2017). However, this change idea was not reflected in the ERIC strategies. This may be because implementers in high-income settings assume that there is already adequate staff and do not need to identify strategies to overcome this barrier.\u003c/p\u003e\n\u003cp\u003eAdditionally, while most change ideas mapped to ERIC strategies, not all fully aligned with the ERIC definition, which we believe could be a limitation on the use of ERIC across all settings. This was seen when the change idea, \u003cem\u003eRecognize parental KMC champions\u0026nbsp;\u003c/em\u003ewas mapped to \u003cem\u003ealter incentive/allowance structures\u003c/em\u003e. This match was selected because the recognition of parental KMC champions can be seen as a driver and motivator to change parental behavior, however, the definition of incentives and allowances as defined by ERIC specifically focuses on financial incentives as a driver of change. We recommend the definition of \u003cem\u003ealter incentive/allowance structures\u0026nbsp;\u003c/em\u003ebe expanded to include incentives beyond financial ones. Another area where the change ideas showed limited alignment was with the ERIC strategy \u003cem\u003etailor strategies.\u0026nbsp;\u003c/em\u003eWe noted that this strategy did not clearly capture the intent behind specific change ideas such as \u003cem\u003eclustering care to reduce KMC interruptions, assessing KMC eligibility during morning rounds,\u0026nbsp;\u003c/em\u003eor \u003cem\u003eprescribing KMC by physicians.\u0026nbsp;\u003c/em\u003eWhile these activities do represent efforts to tailor implementation to context, we argue that nearly all change ideas could be categorized as tailored strategies, since tailoring is inherent to the process of developing context-specific implementation approaches. Prior research has pointed out that \u003cem\u003emodifying workflows and\u003c/em\u003e \u003cem\u003eintegrating interventions into routine care\u0026nbsp;\u003c/em\u003eis an implementation strategy not fully covered by ERIC (Van Pelt et al., 2022). We propose the inclusion of the strategy \u003cem\u003emodifying workflow and/or integration into routine care\u003c/em\u003e as it more accurately reflects the KMC-related change ideas currently mapped to \u003cem\u003etailor strategies.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile this project provides valuable insight into the integration of QI and IR to enhance KMC adoption, several limitations should be acknowledged. First, the development of the change package was primarily informed by data and experiences from NEST360-supported facilities in five countries. As such, the generalizability of specific change ideas or implementation strategies may be limited outside of these settings, particularly in regions with different health system structures or resources limitations. Our integration of IR methods to create more generalizable strategies was deigned to help mitigate this limitation. Second, while the change package was designed through an iterative, participatory process, the piloting phase is still ongoing at the time of writing. As such, the effectiveness and feasibility of using a change package to guide change idea selection and track process measures has not been fully explored. Data from the pilot phase will be critical to assess implementation outcomes, identify barriers to uptake, and refine the package based on real-world experiences. Fourth, although stakeholder engagement was broad, direct input from families and frontline healthcare workers was limited during the development of the change package. Future iterations of the change package should prioritize incorporating caregiver perspectives to ensure strategies are not only effective but also acceptable and culturally appropriate.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study demonstrates the value of integrating IR into QI to advance work to address barriers to increasing KMC coverage for SSN in resource-limited settings. Through a collaborative, data-driven process, this work developed a change package grounded in real-world QI experience and informed by established IR lessons and tools. By aligning local, facility-level insights with standardized tools like ERIC, and following IR principles that emphasis the identification and use of generalizable knowledge, this deliverable bridges the gap between theory and practice, making IR more actionable in resource-limited settings. The change package provides a practical roadmap for facilities seeking to improve KMC coverage and quality, offering a set of adaptable strategies, and context-specific guidance. Importantly, this work underscores the power of cross-disciplinary collaboration and locally driven innovation in developing tools to address persistent gaps in newborn care. With continued refinement and stakeholder engagement, the developed KMC change package has the potential to serve not only as an open access resource from NEST360 but as a scalable, sustainable package to improve neonatal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICS APPROVAL AND CONSENT TO PUBLISH\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study presented in this manuscript was deemed program evaluation work and not human subjects research, so Northwestern University waived the requirement of an IRB review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made substantial contributions to the development of this manuscript. KD and LH conceptualized the study. KD coordinated the overall project, and eld the drafting of the manuscript. KD and AVP performed the change idea and ERIC mapping process and interpretation of the findings. CB, NH, HW, SO, RT, ZK, AF, and ED supported the development of the KMC change package. JW and NR provided review of the final change package. All authors contributed to critical revisions and final approval of this manuscript, and all agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe change package described in this paper is available in its entirety in the resources section at https://nest360.org/project/nest360-change-package/. Requests for additional tools, material, and learnings are available from the NEST360 Steering Committee upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBilal, S. M., Tadele, H., Abebo, T. A., Tadesse, B. T., Muleta, M., W/Gebriel, F., Alemayehu, A., Haji, Y., Kassa, D. 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Medical stakeholder perspectives on implementing a computerized battery to identify neurocognitive impairments among youth in Botswana. \u003cem\u003eAIDS Care\u003c/em\u003e,\u003cem\u003e 34\u003c/em\u003e(12), 1513-1521. https://doi.org/10.1080/09540121.2021.1990202 \u003c/li\u003e\n\u003cli\u003eVasan, A., Mabey, D. C., Chaudhri, S., Brown Epstein, H.-A., \u0026amp; Lawn, S. D. (2017). Support and performance improvement for primary health care workers in low- and middle-income countries: a scoping review of intervention design and methods. \u003cem\u003eHealth Policy and Planning\u003c/em\u003e,\u003cem\u003e 32\u003c/em\u003e(3), 437-452. https://doi.org/10.1093/heapol/czw144 \u003c/li\u003e\n\u003cli\u003eWalker, T. J., Are, F., Heredia, N. I., Onadeko, K., Saving, E. E., Kang, E., \u0026amp; Fernandez, M. E. (2025). Identifying Mechanisms of Action for Implementation Strategies Using a Retrospective Implementation Mapping Logic Model Approach. \u003cem\u003ePrev Sci\u003c/em\u003e,\u003cem\u003e 26\u003c/em\u003e(2), 161-174. https://doi.org/10.1007/s11121-025-01790-2 \u003c/li\u003e\n\u003cli\u003eWaltz, T. J., Powell, B. J., Matthieu, M. M., Damschroder, L. J., Chinman, M. J., Smith, J. L., Proctor, E. K., \u0026amp; Kirchner, J. E. (2015). Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. \u003cem\u003eImplementation Science\u003c/em\u003e,\u003cem\u003e 10\u003c/em\u003e(1), 109. https://doi.org/10.1186/s13012-015-0295-0 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e KMC Change ideas mapped to ERIC strategies\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"906\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Concept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Idea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eERIC Strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParental Involvement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eFacilitate mother-newborn time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUtilize wheelchairs to transport non-ambulatory mothers to the newborn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eExpand access to who can provide KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eRemove visitor restrictions for the newborn ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eMandate change, tailor strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProvide support and encouragement for other KMC providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePrepare patients/consumers to be active participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEnsure a KMC provider is frequently available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eEstablish a regular, set time for KMC to encourage mothers to show up to perform KMC \u003cem\u003e(access at any other times is not restricted)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eIntervene with patients/consumers to enhance uptake and adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eHave mothers or another relative stay at the hospital until the baby is discharged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eInvolve patients/consumers and family members\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease parental knowledge and understanding of KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProvide parental counseling and education (possibly through KMC champions), and start the education during antenatal care visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eHang KMC educational material around the newborn ward and antenatal ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDistribute educational materials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUtilize videos to provide KMC education for parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDevelop educational materials, distribute educational materials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eShare educational material via smartphones and WhatsApp including nationally pre-recorded audio on KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDistribute educational materials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eProvide encouragement to family members (including mom)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eStaff provide verbal encouragement to family members while they practice KMC at least once a day and provide corrections to newborn positioning if necessary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eIntervene with patients/consumers to enhance uptake and adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUse parental KMC champions to provide KMC counseling to mothers/surrogates in the newborn ward\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eIdentify and prepare champions, conduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eRecognize parental KMC champions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAlter incentive/allowance structures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eEncourage peer education and demonstrations of KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eInvolve patients/consumers and family members, conduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEnable privacy to respect cultural norms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003ePlace screens or curtains around/near the newborn\u0026rsquo;s bed/warmer to provide privacy for the individual practicing KMC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Concept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Idea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eERIC Strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff Changes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease staff knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProvide KMC simulation-based training for staff using KMC training and education material\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProviding training to staff on which types of newborns should receive KMC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease peripheral hospital staff knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eMentor peripheral hospital staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct educational outreach visits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease staff confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProviding training to staff on which types of newborns should receive KMC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct educational meetings, conduct ongoing training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUtilize more senior nurses to mentor junior nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCreate a learning collaborative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eCross mentorship with all staff to encourage capacity beyond just the champions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eProvide ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease staff motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eDevelop and utilize KMC Champions to provide mentorship to clinicians (including nursing staff)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eIdentify and prepare champions, create a learning collaborative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eRecognize a KMC champion every month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAlter incentive/allowance structures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eFacilitate cross learning activities between facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCapture and share local knowledge, Create a learning collaborative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003ePrevent the loss of trained staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eMonitor for staff turnover and retrain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePurposely reexamine implementation, conduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eReduce staff rotations when possible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u0026nbsp;Obtain formal commitments\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease staffing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eHire additional nursing staff to monitor and support KMC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo match with an ERIC strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eFloater nurses during peak hours (collaborate with postnatal and other units to share staff)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eRevise professional roles\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMulti-departmental training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eTrain multiple departments, including maternal in newborn care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eRevise professional roles\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Concept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Idea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eERIC Strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Processes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eClearly define which newborns should receive KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eAssessing eligibility of the babies for KMC during morning rounds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTailor strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eReporting if the newborn is eligible for KMC during daily hand off\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTailor strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eDoctors provide and document KMC prescriptions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eFacilitate relay of clinical data to providers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEnable frequent monitoring of the newborn\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUse continuous monitoring devices to track newborn vitals during KMC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTailore strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eDecrease interruptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eCluster care for the newborn so there are fewer interruptions to KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTailor strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUse devices that are KMC compatible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUse devices that are better suited for KMC (ex. Pumani has longer cords than other CPAP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUpdate KMC documentation/ registers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eReview KMC documentation form with stakeholders\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAudit and provide feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eInclude KMC duration and frequency into routine charting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange record systems\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eInclude KMC as part of quality indicators review and tracking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePurposefully reexamine the implementation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease staff knowledge about KMC documentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProviding KMC training for staff on how to complete KMC documentation forms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct ongoing trainings, conduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProvide practice examples during KMC mentorship and training sessions and highlight the importance of KMC documentation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDevelop educational materials, make training dynamic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eCross mentorship to all staff so champions are not the only ones documenting KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eProvide ongoing training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMonitor KMC documentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003ePerform routine chart reviews of KMC documentation to track progress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAudit and provide feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003ePerform KMC audits with feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAudit and provide feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Concept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Idea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eERIC Strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Governance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBuild QI capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eProvide QI training for staff using QI training and educational material\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct educational meetings, conduct ongoing training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eInclude examples of how to use KMC data for QI activities within the KMC and QI training for staff\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDevelop educational materials, make training dynamic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eConducting QI coaching at facilities with a regional and/or country QI expert\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eProvide ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eIdentify facility-level QI champions and provide them with training\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eIdentify and prepare champions, conduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease the frequency of QI activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eConduct monthly QI meetings with the ward improvement team, and document best practices whenever wards achieve their targets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eFacilitation, capture and share local knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMonitor QI progress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003ePerform monthly data audits during ward improvement meetings and develop action plans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAudit and provide feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eAudit documentation quality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAudit and provide feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eIncrease leadership capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eEducate leaders on importance of KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eInform local opinion leaders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eInclude leadership in KMC monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eIncorporate KMC into management review metrics and regularly review outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePurposefully reexamine the implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEnsure guidelines are current\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eAlign KMC guidelines with national standards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDevelop educational materials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMake guidelines and standards of practice readily available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003ePost guidelines and standards of practice throughout the unit and leave copies in multiple locations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDistribute educational materials\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Concept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange Idea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eERIC Strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility Change\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCreate a comfortable place to perform KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eIf space is available, place beds next to the neonatal warmer/bed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eIf funds and space are available, purchase reclining chairs and/or beds for the KMC and/or newborn unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCreate privacy on the unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUtilize infrastructure funds to create cubicles in the KMC or newborn unit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003ePlace screens or curtains around/near the newborn\u0026rsquo;s bed/warmer to provide privacy for the individual practicing KMC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEnsure the availability of gowns and wraps\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eFacilities subsidize KMC wraps and gowns\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAlter patient/consumer fees\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eDemonstrate how to use the Kitenges as KMC wrap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eConduct educational meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEnsure facilities for daily needs are available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eExplore abandoned rooms to create space for family members to bathe and prepare food\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eRepurpose nearby non-functional material stores to create space for family members to bathe and prepare food\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUse devices that are KMC compatible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUse devices that are better suited for KMC (ex. Pumani has longer cords than other CPAP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eChange physical structure and equipment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-implementation-research-and-applications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gira","sideBox":"Learn more about [Global Implementation Research and Applications](http://link.springer.com/journal/43477)","snPcode":"43477","submissionUrl":"https://submission.springernature.com/new-submission/43477/3","title":"Global Implementation Research and Applications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"kangaroo mother care, quality improvement, implementation research, change package, implementation strategies, sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-7602222/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7602222/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eBackground\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eKangaroo mother care (KMC) is an evidence-based intervention known to reduce newborn mortality. NEST360 is an initiative supporting mortality reduction in small and sick newborns in five countries in Africa (Ethiopia, Kenya, Malawi, Nigeria, and Tanzania) including through increase in KMC coverage. Combining quality improvement (QI) and implementation research (IR), NEST360 developed a facility-level resource to improve KMC adoption and quality of care.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eUsing data from QI projects, team meetings, literature, and interviews with high-performing facilities, NEST360 developed a change package including a driver diagram and change ideas. Input from multidisciplinary experts, including NEST360’s external advisory committee for improving quality, facility and NEST360 QI leads, clinical experts, and the African Neonatal Association refined the package, aligning it with NEST360’s QI training materials and global and national guidelines. Change ideas were mapped to the implementation research (IR) Expert Recommendations for Implementation Change (ERIC) implementation strategies.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe driver diagram included five primary drivers mapped to 62 change ideas, with mechanisms linked to barriers and measurable process measures. Sixty-one of the 62 change ideas were mapped to ERIC strategies, with \u003cem\u003echange physical structure and equipment \u003c/em\u003eand \u003cem\u003econduct ongoing trainings\u003c/em\u003ethe most common. The package is being piloted at select NEST360-supported sites to improve KMC coverage and quality while assessing user preferences.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis project offers a practical example for combining QI and implementation research to address KMC barriers and enhance quality of care and newborn survival. This approach provides great value, taking local solutions and turns them into generalizable knowledge that can be shared and used in other hospitals and/or countries. Next steps include refining the package, as well as analyzing QI project data to evaluate change idea effectiveness.\u003c/p\u003e","manuscriptTitle":"Scaling up kangaroo mother care (KMC): A change package developed through the integration of quality improvement and implementation research for the NEST360 Alliance in Ethiopia, Kenya, Malawi, Nigeria, and Tanzania","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 16:12:33","doi":"10.21203/rs.3.rs-7602222/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-17T16:11:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-17T11:26:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-17T11:26:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Implementation Research and Applications","date":"2025-09-12T15:57:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-implementation-research-and-applications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gira","sideBox":"Learn more about [Global Implementation Research and Applications](http://link.springer.com/journal/43477)","snPcode":"43477","submissionUrl":"https://submission.springernature.com/new-submission/43477/3","title":"Global Implementation Research and Applications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"cecdb361-5e52-4cc5-b9e9-7ca70b741ff7","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T22:08:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 16:12:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7602222","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7602222","identity":"rs-7602222","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}