Family Involvement in Kangaroo Care for Low Birth Weight (LBW) and Preterm Newborns-a Point-of-care Quality Improvement (POCQI) Study

Family Involvement in Kangaroo Care for Low Birth Weight (LBW) and Preterm Newborns-a Point-of-care Quality Improvement (POCQI) Study | 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 Family Involvement in Kangaroo Care for Low Birth Weight (LBW) and Preterm Newborns-a Point-of-care Quality Improvement (POCQI) Study Prashanti Pangnuri, Leslie E Lewis², Sheila S Mathai³, Shrikiran Aroor, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7573858/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Preterm and low birth weight (LBW) infants face increased risks of hypothermia, infections, and poor weight gain. Kangaroo Care (KC), a low-cost, evidence-based intervention involving skin-to-skin contact, improves neonatal health outcomes but is underutilised due to barriers in implementation and family involvement. Objective To improve the duration and inclusivity in Kangaroo Care practices through a quality improvement (QI) initiative involving structured family participation in a tertiary neonatal care setting in India. Methods A hospital-based QI study was conducted from July 2024 to April 2025 using the POCQI model. The study enrolled LBW/preterm neonates and involved three phases: pre-intervention, intervention (with two PDSA cycles), and sustenance. Interventions included audiovisual education and counselling of family members. Data was collected via and analyzed using SPSS version 27.0 Results The average duration of KC increased from 3 to 6 hours per neonate per day during hospitalization. The proportion of neonates receiving > 4 hours of KC increased from 6% to 90%. Involvement by fathers improved significantly from 52% to 93%. Involvement by extended family members increased from 3 hours to 5.5 hours. Enhanced caregiver education and consistent monitoring were key drivers. Conclusion Engaging the family through education-focused QI strategies fosters shared responsibility, strengthens kangaroo care adherence, and improves implementation within existing resources. Kangaroo Care Quality Improvement Preterm Neonates Family Involvement Low Birth Weight Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION India continues to face a significant burden of neonatal morbidity and mortality, largely attributed to preterm birth and low birth weight (LBW). LBW and pre-term infants are highly vulnerable to hypothermia, infections, and feeding issues, leading to decreased weight gain, increased mortality and developmental delays. In resource-limited settings like India, low-cost interventions such as KC are vital for improving neonatal outcomes [ 2 , 3 , 4 ]. The evolution of KC in India has progressed from sporadic efforts to national endorsement. Over the past three decades, India has led in promoting and scaling up KC, moving from pilot projects to integration into national neonatal health strategies [ 5 ]. However, challenges remain consistent implementation. Family involvement beyond the mother is an essential yet underexplored aspect of effective KC. Recent studies have shown that both internationally and in India, fathers and extended family can provide KC, ensuring continuity of care and strengthening family-centered neonatal support [ 6 , 7 , 8 , 9 ]. Despite its potential, KC implementation at health facilities faces challenges. A case study from Bihar showed improvements in infrastructure and awareness but highlighted gaps in scaling-up, family engagement, and data recording [ 10 , 11 ]. Quality improvement interventions, such as those implemented by Jegannathan et al. in South India, demonstrate how structural and behavioral changes—like mother-NICU units, KC slings, father-friendly spaces, and integration of documentation—can extend KC duration from an average of 4.6 to 16.6 hours/day. Targeted QI strategies are needed to address these areas through staff training, infrastructure upgrades, and inclusive family education [ 12 ]. Paternal involvement has been consistently validated. Studies have shown that both maternal and paternal KC equally stabilized preterm infants’ vital signs and improved cerebral oxygen saturation [ 13 ]. Research has also emphasised reduced maternal stress, improved bonding, and increased satisfaction when fathers and extended relatives (e.g., grandparents) are supported to participate [ 14 – 18 ]. Despite its potential, KMC implementation at health facilities faces challenges. METHODOLOGY This hospital-based Point of Care Quality Improvement (QI) study aimed to enhance Kangaroo Care (KC) practices in preterm and low birth weight (LBW) infants by involving family members. Conducted in the Department of Neonatology (Level II and Level III NICUs) of a tertiary care hospital's Neonatology department, the study spanned 10 months from July 2024 to April 2025. It was implemented in three phases: pre-intervention (July–October), intervention (December–March), and sustenance (March–April) phases. Hemodynamically stable preterm or LBW infants (< 2.5 kg) with consenting family members were included, while those with critical illness, major congenital anomalies, or requiring immediate surgery were excluded. Purposive consecutive sampling was done, with each twin counted separately, 181 neonates were enrolled based on NICU admissions. Time-based groups corresponding to each phase were compared for outcomes. The primary outcome was the weighted average duration of KC per neonate per day, while secondary outcomes were the family members involvement in hours. For weighted average duration of KC per neonate per day analysis, the numerator was the cumulative kangaroo care duration of all neonates, and the denominator was the total number of days kangaroo care was provided. To calculate kangaroo care per neonate per day, we divided the total duration received (numerator) by the number of days it was given (denominator). After each phase, we calculated the percentages of mother, father, and family involved in KC and plotted a time-series charts. Ethical approval was obtained prior to the study. No consent was required for observational data in Phase 1, while informed consent was taken in subsequent phases. All data were anonymized and securely maintained. Baseline data was collected in Phase 1, and barriers were addressed through two PDSA cycles in Phase 2. Sustained strategies were continued in Phase 3. Data was recorded by nursing and medical staff, capturing the caregiver relationship and KC duration. Time-series tracking was done using daily logs and visual display boards. Data analysis was performed using Microsoft Excel and SPSS version 2; normality was tested by Shapiro-Wilk and median differences analyzed using the Mann-Whitney U test. Statistical significance was set at p < 0.05. RESULTS PHASE 1 Focused Group Discussions were held with all stakeholders to systematically identify and analyze the barriers to family involvement in Kangaroo Care (KC), A Fishbone (Ishikawa) Diagram (Fig. 1) was developed. This tool facilitated a structured brainstorming process with members of the Quality Improvement (QI) team including pediatric residents, nurses, and consultants, as well as input from family members who were either participating in or hesitant about providing KC. The barriers were categorized into four major domains: People, Place, Procedure, and Policy, as discussed in Fig. 1. The QI team identified and addressed the barriers at multiple levels. The knowledge gap and fear among family members were mitigated with structured counselling and reassurance sessions, while documentation lapses were corrected by integrating KC records into routine care. KC slings were also provided to help in infant positioning. The team addressed issues of screening all kangaroo caregivers for communicable diseases, place-related constraints, visiting hours and privacy concerns by educating health care workers and administration staff and permitting evening/night KC sessions and reinforcing privacy during care. The team resolved policy gaps through updated guidelines and sensitization of healthcare workers. Procedural challenges, including incomplete documentation, improper positioning of the baby and the caregiver, and limited staff awareness, were overcome through staff training, ergonomic support, and improved visibility of KC policies within the NICU. FIGURE NO 1: ISHIKAWA DIAGRAM FOR BARRIERS FACED BY FAMILY MEMBERS IN PROVIDING KANGAROO CARE . PHASE II AND III Data was collected from 47 babies during the pre-intervention phase, 94 babies during the implementation phase and 40 babies during the sustenance phase. During the study period, Kangaroo Care duration showed a significant upward trend from baseline levels. The weighted average increased from a baseline of 3 hours per neonate per day to 6 hours by the end of the study, with a maximum observed duration of 11 hours. A noticeable improvement occurred after the second PDSA Cycle, following the introduction of audiovisual tools, enhanced counselling and Kangaroo Care sling which helped increase caregiver confidence and participation. This resulted in more consistent and prolonged Kangaroo Care sessions, reflecting the effectiveness of the implemented interventions. TABLE NO 1: DEMOGRAPHIC CHARACTERISTICS OF NEONATES RECEIVING KANGAROO CARE ACROSS ALL THE PHASES OF STUDY Category PHASE 1 PHASE 2 PHASE 3 Pre-intervention Implementation phase Sustenance phase PDSA 1 PDSA 2 Number of neonates n (%) n = 47(%) n = 54(%) n = 40(%) n = 40(%) Male 21(45) 27(50) 24(60) 23(58) Female 26(55) 27(50) 16(40) 17(42) Gestational age (weeks) = 32 weeks 34(72) 10(19) 25(63) 22(55) Birth weight(grams) =1500 32(68) 30(55) 22(55) 21(52) Over the QI phases, the proportion of neonates with birth weights < 1500g, < 32 weeks receiving KMC also improved, indicating better inclusion of higher-risk infants Table 2 AVERAGE KANGAROO CARE DURATION BY FAMILY MEMBERS ACROSS ALL THE PHASES OF THE STUDY Phases Pre-Intervention Implementation Phase Sustenance Phase PDSA 1 PDSA 2 Relationship Weighted Average (Hours) (N = 47) Weighted Average (Hours)(N = 47) Weighted Average (Hours)(N = 40) Weighted Average (Hours)(N = 40) Mother 2.2 4.2 5 5.3 Father 2.2 3.9 5.1 5.5 Family Members 3 4.7 4.8 5.5 In the baseline phase (n = 47), most neonates (92%) received less than 4 hours of kangaroo care per day, while only 4% achieved 4–6 hours, and a mere 2% received more than 6 hours. With the first intervention cycle (n = 54), kangaroo care duration improved, with 39% of babies still receiving less than 4 hours, 46% achieving 4–6 hours, and 15% surpassing 6 hours daily. Further improvement in the second cycle (n = 40) was seen, with only 17% remaining in the < 4-hour category, 70% received 4–6 hours, and 13% exceeded 6 hours daily. By the sustenance phase (n = 40), kangaroo care practices were more consistently maintained, with just 10% of babies receiving < 4 hours, while 55% received 4–6 hours, and a substantial 35% benefitted from more than 6 hours of kangaroo care per day. This reflects enhanced adherence and sustained practice through QI interventions Notably, involvement from fathers and other family members also rose, highlighting growing family participation in KMC. Family involvement increased across study phases. Maternal participation rose from 98% pre-intervention to 100% thereafter. Father involvement climbed from 53.2% to 87% in PDSA 1, remained steady in PDSA 2, and peaked at 93% in phase 3. Family member participation rose from 21.3% in phase 1 to 40% in PDSA 2, then declined to 25% in phase 3, reflecting variable broader engagement. (Table 2 , Fig. 4 ) Figure 2 depicts the improvement of Kangaroo Care duration in the study as time-series charts. There was a shift of the weighted average from 3 hours per day to 6 hours per day (Fig. 3 ) with a maximum peak of 11 hours during the study period. Additionally Kangaroo care per neonate per was also plotted during each phase of the study which showed gradual increasing trend. Improvement had come into picture after the second phase where audiovisual sensitization techniques were used DISCUSSION This quality improvement (QI) initiative highlights how structured support, and systematic reinforcement can transform Kangaroo Care (KC) practices in a tertiary neonatal unit in India. What makes the findings particularly significant is the consistent increase in not only the duration of KC but also the involvement of family members beyond the mother, a shift that reflects both cultural change and improved caregiver confidence. Improvement in KC duration from 3 hours to 6 hours aligned with the studies of Verma and Bera, who have both reported that consistent increase in KMC duration with adequate support [ 3 , 9 ]. Improvement after the implementation of audiovisual tools and structured counselling was observed. This is supported by Kumari et al. and Jegannathan et al [ 8 , 12 ], who found that structured teaching significantly improved knowledge and willingness among mothers to practice KC. Jayanna et al demonstrated that implementation research and system-level interventions could accelerate KC uptake in Indian public hospitals, like the sustained improvements observed in our study [ 11 ]. One of the most promising outcomes of this QI initiative was the rise in involvement by fathers and other family members in delivering KC. Weighted average durations for fathers and family members rose steadily across phases, reaching parity with maternal KC by the sustenance phase. Interestingly, fathers' comparable duration pre-intervention (2.2 hours to 5.5 hours) supports Yaman et al. findings about paternal KC feasibility, and how the involvement of mother and father could have similar effects on the newborn, hence enabling us to support paternal kangaroo care [ 13 ]. A systematic review on the subject of father and kangaroo care by Garnica-Torres et al shows similar findings [ 15 ]. Our study's evidence of consistent KC participation across both genders and improved inclusion of extremely and very preterm neonates also demonstrates a shift toward more equitable and risk-sensitive neonatal care. These findings reinforce those of Dahiya, who advocated for KC not only as a clinical practice but as a public health strategy to reduce neonatal morbidity and mortality in resource-limited settings [ 1 ]. The family involvement patterns demonstrate striking parallels with existing literature. The duration increased from 3 hours to 5 hours which is similar to the findings by Jefferies et al., Dargahiyan et al. and Sivanandan et al. [ 14 , 17 , 18 ] The sustained impact observed in our study suggests that integration of KC into daily neonatal routines, with reinforcement through audiovisual methods, kangaroo care slings, and direct counselling, is crucial for long-term adoption. These strategies appear to be more effective than one-time training sessions, as indicated by the limited knowledge retention observed in the pre-experimental study by Kumari et al and Jegannathanet al. [ 8 , 12 ]. This QI study demonstrates that family-focused, education-driven interventions can substantially increase Kangaroo Care adherence in Indian NICUs. The findings are consistent with prior research showing the clinical benefits of KC and underline the importance of engaging both mothers and other family caregivers in the practice. Future work should explore how to integrate these improvements into long-term policy and routine practice to further reduce neonatal morbidity and mortality in India. CONCLUSION This QI initiative demonstrates that structured family involvement significantly improves KC duration in LBW infants. Interventions such as counselling, educational media, policy updates, and comfort aids led to sustained increase in family involvement in KC. The limitations are that this study was conducted in a single institution and the follow up has been for a limited period of time efforts should focus on long-term sustainability and adaptation to varied contexts. Abbreviations LBW Low Birth Weight KMC Kangaroo Mother Care KC Kangaroo Care POCQI Point of Care Quality Improvement PDSA Plan Do Study Act QI Quality Improvement Declarations Ethics Approval and consent to participate : The Institutional Ethics Committee (IEC) of Kasturba Medical College and Kasturba Hospital, Manipal. Registration number of IEC ECR/146/Inst/KA/2013/RR-19- Study Approval Number: IEC 138/2023 on 08/10/2023. Informed consent to conduct the study was taken from parents during the implementation and sustenance phases. Clinical Trial Registration : Not applicable Consent for publication- No consent for publication was mandatory as the study involved routine and data was completely anonymized. Availability of data and materials: Data available and uploaded as a supplementary file Competing Interests: None Funding: This study was supported by Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka-576104. No external funding was received. Author’s Contribution : PP wrote the initial study protocol, collected data and wrote the initial manuscript draft; LEL was involved in implementation of actions and restructuring the initial draft of paper; SSM was responsible for supervision of study, making policy changes and finalizing the manuscript; SA was responsible for supervision of study and intellectual contributions to the paper; PK contributed intellectually to the study; RBY supervised the study and scrutinized the data; SCM helped in implementation of the QI initiative and scrutinized the manuscript. Acknowledgements- Nil References Dahiya V, Bear RJ, Mellor DJ. Kangaroo Mother Care 1: Alleviation of Physiological Problems in Premature Infants. J Perinat Educ. 2017;26(3):117–24. Ahirrao Ny. A systematic review of kangaroo mother care to promote LBW care and reduce morbidity and mortality in preterm. nj-ras [internet]. 2019jun.15 [cited 2025sep.9];7(03). available from: https://www.ayurlog.com/index.php/ayurlog/article/view/360 Verma P, Verma V. Effect of Kangaroo Mother Care on Heart rate, Respiratory rate and Temperature in Low-Birth-Weight Babies. Int J Med Res Rev [Internet]. 2014Apr.30 [cited 2025Sep.9];2(2):80 – 5. Available from: https://ijmrr.medresearch.in/index.php/ijmrr/article/view/65 Deepak H. D. The effect of kangaroo mother care on stabilization of vital signs heart rate, respiratory rate and arterial saturation in low-birth-weight preterm babies. Int J Contemp Pediatr [Internet]. 2023 Jan. 24 [cited 2025 Sep. 9];10(2):181-5. Available from: https://www.ijpediatrics.com/index.php/ijcp/article/view/4708 Udani RH, SR PN, Bergh A-M. Kangaroo Mother Care in India: Down the Memory Lane. J Neonatology. 2024;38(2):319–24. 10.1177/09732179241237885 . Majhi V, Vaghela MN. A Study on Effect of Kangaroo Mother Care on Preterm Infants. Int J Res Publication Reviews. 2024;5(4):2556–8. Bhimani A, Ali Aa A, Ns AG. Insights-Journal Of Life And Social Sciences The Impact Of Fathers’ Involvement In Kangaroo Care On Newborn: A Systemic Review Original Article. 2025. Kumari A, Rani K, Pundir N. The Efficiency of Teaching Programme on Kangaroo Mother Care Among Mothers of Low-Birth-Weight Babies: A Pre-Experimental Study. Int J Sci Healthc Res. 2024;9(2):150–6. Bera A, Ghosh J, Singh AK, Hazra A, Som T, Munian D. Effect of Kangaroo mother care on vital physiological parameters of the low birth weight newborn. Indian J Community Med. 2014;39(4):245–91. Neogi SB, Chauhan M, Sharma J, Negandhi P, Sethy G. Rolling out of kangaroo mother care in secondary level facilities in Bihar-Some experiences. Indian J Public Health. 2016;60(4):302–8. Jayanna K, Rao S, Kar A, Gowda PD, Thomas T, Swaroop N, et al. Accelerated scale-up of Kangaroo Mother Care: Evidence and experience from an implementation-research initiative in south India. Acta Paediatr Int J Paediatrics. 2023;112(S473):15–26. Jegannathan S, Natarajan M, Solaiappan M, Shanmugam R, Tilwani SA. Quality improvement initiative to improve the duration of Kangaroo Mother Care in tertiary care neonatal unit of South India. BMJ Open Qual. 2022;11. Yaman A, Kandemir İ, Özek E, Bilgen HS. Should Fathers Also Do Kangaroo Care? Am J Perinatol. 2024;41(01):e142–7. 10.1055/a-1850-3422 . Epub 2022 May 12. PMID: 35554892. Jefferies A. Kangaroo care for preterm infants and family. Paediatr Child Health. 2012;17:141–6. 10.1093/pch/17.3.141 . Garnica-Torres Z, Dias B, G., Da Silva PJ. A systematic review of fatherhood and kangaroo care in the NICU. Child Youth Serv Rev. 2024;157:107417. https://doi.org/10.1016/j.childyouth.2023.107417 . Chan G, Bergelson I, Smith ER, Skotnes T, Wall S. Barriers and enablers of kangaroo mother care implementation from a health systems perspective: a systematic review. Health Policy Plann. 2017;32(10):1466–75. Dargahiyan Z, Ghasemi F, Karami K, Valizadeh F, Mohammadi R. A comparative study of the effects of Kangaroo care by mothers and maternal grandmothers on the vital signs of hospitalized preterm newborns: A randomized controlled clinical trial study. Trials. 2023;24:275. https://doi.org/10.1186/s13063-023-07288-y . Sivanandan S, Bethou A, Ramanujam SS, Kumar C, Chinnasamy K, Natarajan P, et al. Implementing Family-Centered Care in the Neonatal Intensive Care Unit – A Quality Improvement Initiative. Indian J Pediatr. 2021;88(9):872–8. Additional Declarations No competing interests reported. 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16:47:07","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89053,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/5bbb2d8220f852ce5e4f6300.png"},{"id":95665730,"identity":"444e166f-1fe8-4cfe-bd93-1c18acbb71d2","added_by":"auto","created_at":"2025-11-11 16:47:07","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69360,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/1fbf807dec9e8f95faecb479.png"},{"id":95665731,"identity":"ab1c6b48-dede-48d2-9efd-9f21a52fc055","added_by":"auto","created_at":"2025-11-11 16:47:07","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70595,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/fdf026400e35b79e1d451e10.png"},{"id":95798536,"identity":"315b5cc8-13df-4757-92c9-622dd2ff5f59","added_by":"auto","created_at":"2025-11-13 08:16:58","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":64722,"visible":true,"origin":"","legend":"","description":"","filename":"dc8572d6de5c4834b53abe7213b48ef51structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/fe447b6da73575cc164ab2d5.xml"},{"id":95665728,"identity":"a27041f4-b1ee-440d-a85f-e1cc92e7011e","added_by":"auto","created_at":"2025-11-11 16:47:07","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76135,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/2c97021444ac3b080842bf98.html"},{"id":95665716,"identity":"60ecaf83-d67a-405d-a49c-c8462f7da37f","added_by":"auto","created_at":"2025-11-11 16:47:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":95579,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eISHIKAWA DIAGRAM FOR BARRIERS FACED BY FAMILY MEMBERS IN PROVIDING KANGAROO CARE\u003c/strong\u003e.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/7b941cccbebf0734287045e0.png"},{"id":95798497,"identity":"ba648f0d-3d69-49f8-947b-57a9c951dee8","added_by":"auto","created_at":"2025-11-13 08:16:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":188612,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTIME-SERIES CHARTS OF DURATION OF KC\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/a13ff5dd130b502fbc4632a8.png"},{"id":95665714,"identity":"abbd0072-bc13-481b-a428-8659530e9364","added_by":"auto","created_at":"2025-11-11 16:47:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20249,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWEIGHTED AVERAGE DURATION OF KC ACROSS ALL PHASES\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/a5e461e89f3e8aba54e06078.png"},{"id":95798761,"identity":"2a073cbe-52c4-4963-bb29-0a205dad7850","added_by":"auto","created_at":"2025-11-13 08:17:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":90992,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eINCREASE IN DURATION FO KC BY FAMILY MEMEBERS DURING STUDY\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/bed4ca96c0b1249763e4ac51.png"},{"id":95804587,"identity":"e41dc0dd-d894-4732-8e63-058c3ed9511a","added_by":"auto","created_at":"2025-11-13 08:38:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1123566,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/934ddb45-355c-4c76-83f8-0156babacc41.pdf"},{"id":95797605,"identity":"27d03380-864b-4e12-876c-315e0f43952f","added_by":"auto","created_at":"2025-11-13 08:07:21","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27145,"visible":true,"origin":"","legend":"","description":"","filename":"MASTERCHARTKANGAROOCARE.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7573858/v1/ab69e3e44b02881d852a0550.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFamily Involvement in Kangaroo Care for Low Birth Weight (LBW) and Preterm Newborns-a Point-of-care Quality Improvement (POCQI) Study\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIndia continues to face a significant burden of neonatal morbidity and mortality, largely attributed to preterm birth and low birth weight (LBW). LBW and pre-term infants are highly vulnerable to hypothermia, infections, and feeding issues, leading to decreased weight gain, increased mortality and developmental delays. In resource-limited settings like India, low-cost interventions such as KC are vital for improving neonatal outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe evolution of KC in India has progressed from sporadic efforts to national endorsement. Over the past three decades, India has led in promoting and scaling up KC, moving from pilot projects to integration into national neonatal health strategies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, challenges remain consistent implementation. Family involvement beyond the mother is an essential yet underexplored aspect of effective KC. Recent studies have shown that both internationally and in India, fathers and extended family can provide KC, ensuring continuity of care and strengthening family-centered neonatal support [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite its potential, KC implementation at health facilities faces challenges. A case study from Bihar showed improvements in infrastructure and awareness but highlighted gaps in scaling-up, family engagement, and data recording [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eQuality improvement interventions, such as those implemented by Jegannathan et al. in South India, demonstrate how structural and behavioral changes\u0026mdash;like mother-NICU units, KC slings, father-friendly spaces, and integration of documentation\u0026mdash;can extend KC duration from an average of 4.6 to 16.6 hours/day. Targeted QI strategies are needed to address these areas through staff training, infrastructure upgrades, and inclusive family education [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Paternal involvement has been consistently validated. Studies have shown that both maternal and paternal KC equally stabilized preterm infants\u0026rsquo; vital signs and improved cerebral oxygen saturation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Research has also emphasised reduced maternal stress, improved bonding, and increased satisfaction when fathers and extended relatives (e.g., grandparents) are supported to participate [\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Despite its potential, KMC implementation at health facilities faces challenges.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eThis hospital-based Point of Care Quality Improvement (QI) study aimed to enhance Kangaroo Care (KC) practices in preterm and low birth weight (LBW) infants by involving family members. Conducted in the Department of Neonatology (Level II and Level III NICUs) of a tertiary care hospital's Neonatology department, the study spanned 10 months from July 2024 to April 2025. It was implemented in three phases: pre-intervention (July\u0026ndash;October), intervention (December\u0026ndash;March), and sustenance (March\u0026ndash;April) phases. Hemodynamically stable preterm or LBW infants (\u0026lt;\u0026thinsp;2.5 kg) with consenting family members were included, while those with critical illness, major congenital anomalies, or requiring immediate surgery were excluded. Purposive consecutive sampling was done, with each twin counted separately, 181 neonates were enrolled based on NICU admissions. Time-based groups corresponding to each phase were compared for outcomes. The primary outcome was the weighted average duration of KC per neonate per day, while secondary outcomes were the family members involvement in hours.\u003c/p\u003e\u003cp\u003eFor weighted average duration of KC per neonate per day analysis, the numerator was the cumulative kangaroo care duration of all neonates, and the denominator was the total number of days kangaroo care was provided. To calculate kangaroo care per neonate per day, we divided the total duration received (numerator) by the number of days it was given (denominator). After each phase, we calculated the percentages of mother, father, and family involved in KC and plotted a time-series charts.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003ewas obtained prior to the study. No consent was required for observational data in Phase 1, while informed consent was taken in subsequent phases. All data were anonymized and securely maintained.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eBaseline data was collected in Phase 1, and barriers were addressed through two PDSA cycles in Phase 2. Sustained strategies were continued in Phase 3. Data was recorded by nursing and medical staff, capturing the caregiver relationship and KC duration. Time-series tracking was done using daily logs and visual display boards. Data analysis was performed using Microsoft Excel and SPSS version 2; normality was tested by Shapiro-Wilk and median differences analyzed using the Mann-Whitney U test. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003ePHASE 1\u003c/h2\u003e\u003cp\u003eFocused Group Discussions were held with all stakeholders to systematically identify and analyze the barriers to family involvement in Kangaroo Care (KC), A Fishbone (Ishikawa) Diagram (Fig.\u0026nbsp;1) was developed. This tool facilitated a structured brainstorming process with members of the Quality Improvement (QI) team including pediatric residents, nurses, and consultants, as well as input from family members who were either participating in or hesitant about providing KC. The barriers were categorized into four major domains: People, Place, Procedure, and Policy, as discussed in Fig.\u0026nbsp;1. The QI team identified and addressed the barriers at multiple levels. The knowledge gap and fear among family members were mitigated with structured counselling and reassurance sessions, while documentation lapses were corrected by integrating KC records into routine care. KC slings were also provided to help in infant positioning.\u003c/p\u003e\u003cp\u003eThe team addressed issues of screening all kangaroo caregivers for communicable diseases, place-related constraints, visiting hours and privacy concerns by educating health care workers and administration staff and permitting evening/night KC sessions and reinforcing privacy during care. The team resolved policy gaps through updated guidelines and sensitization of healthcare workers. Procedural challenges, including incomplete documentation, improper positioning of the baby and the caregiver, and limited staff awareness, were overcome through staff training, ergonomic support, and improved visibility of KC policies within the NICU.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFIGURE NO 1: ISHIKAWA DIAGRAM FOR BARRIERS FACED BY FAMILY MEMBERS IN PROVIDING KANGAROO CARE\u003c/b\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePHASE II AND III\u003c/h3\u003e\n\u003cp\u003eData was collected from 47 babies during the pre-intervention phase, 94 babies during the implementation phase and 40 babies during the sustenance phase. During the study period, Kangaroo Care duration showed a significant upward trend from baseline levels. The weighted average increased from a baseline of 3 hours per neonate per day to 6 hours by the end of the study, with a maximum observed duration of 11 hours. A noticeable improvement occurred after the second PDSA Cycle, following the introduction of audiovisual tools, enhanced counselling and Kangaroo Care sling which helped increase caregiver confidence and participation. This resulted in more consistent and prolonged Kangaroo Care sessions, reflecting the effectiveness of the implemented interventions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTABLE NO 1: DEMOGRAPHIC CHARACTERISTICS OF NEONATES RECEIVING KANGAROO CARE ACROSS ALL THE PHASES OF STUDY\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePHASE 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003ePHASE 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePHASE 3\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePre-intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eImplementation phase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSustenance phase\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePDSA 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePDSA 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of neonates n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;47(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;54(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;40(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;40(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27(50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24(60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23(58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26(55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27(50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16(40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17(42)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGestational age (weeks)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;32 weeks\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13(28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15(38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18(45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;= 32 weeks\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34(72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25(63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22(55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth weight(grams)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;1500\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15(31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24(44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19(48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;=1500\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32(68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30(55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22(55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21(52)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOver the QI phases, the proportion of neonates with birth weights\u0026thinsp;\u0026lt;\u0026thinsp;1500g, \u0026lt; 32 weeks receiving KMC also improved, indicating better inclusion of higher-risk infants\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAVERAGE KANGAROO CARE DURATION BY FAMILY MEMBERS ACROSS ALL THE PHASES OF THE STUDY\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePhases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eImplementation Phase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSustenance Phase\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePDSA 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePDSA 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWeighted Average (Hours)\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeighted Average (Hours)(N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWeighted Average (Hours)(N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWeighted Average (Hours)(N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFather\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn the baseline phase (n\u0026thinsp;=\u0026thinsp;47), most neonates (92%) received less than 4 hours of kangaroo care per day, while only 4% achieved 4\u0026ndash;6 hours, and a mere 2% received more than 6 hours. With the first intervention cycle (n\u0026thinsp;=\u0026thinsp;54), kangaroo care duration improved, with 39% of babies still receiving less than 4 hours, 46% achieving 4\u0026ndash;6 hours, and 15% surpassing 6 hours daily. Further improvement in the second cycle (n\u0026thinsp;=\u0026thinsp;40) was seen, with only 17% remaining in the \u0026lt;\u0026thinsp;4-hour category, 70% received 4\u0026ndash;6 hours, and 13% exceeded 6 hours daily. By the sustenance phase (n\u0026thinsp;=\u0026thinsp;40), kangaroo care practices were more consistently maintained, with just 10% of babies receiving\u0026thinsp;\u0026lt;\u0026thinsp;4 hours, while 55% received 4\u0026ndash;6 hours, and a substantial 35% benefitted from more than 6 hours of kangaroo care per day. This reflects enhanced adherence and sustained practice through QI interventions\u003c/p\u003e\u003cp\u003eNotably, involvement from fathers and other family members also rose, highlighting growing family participation in KMC. Family involvement increased across study phases. Maternal participation rose from 98% pre-intervention to 100% thereafter. Father involvement climbed from 53.2% to 87% in PDSA 1, remained steady in PDSA 2, and peaked at 93% in phase 3. Family member participation rose from 21.3% in phase 1 to 40% in PDSA 2, then declined to 25% in phase 3, reflecting variable broader engagement. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;4 )\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts the improvement of Kangaroo Care duration in the study as time-series charts. There was a shift of the weighted average from 3 hours per day to 6 hours per day (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) with a maximum peak of 11 hours during the study period. Additionally Kangaroo care per neonate per was also plotted during each phase of the study which showed gradual increasing trend. Improvement had come into picture after the second phase where audiovisual sensitization techniques were used\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis quality improvement (QI) initiative highlights how structured support, and systematic reinforcement can transform Kangaroo Care (KC) practices in a tertiary neonatal unit in India. What makes the findings particularly significant is the consistent increase in not only the duration of KC but also the involvement of family members beyond the mother, a shift that reflects both cultural change and improved caregiver confidence.\u003c/p\u003e\u003cp\u003eImprovement in KC duration from 3 hours to 6 hours aligned with the studies of Verma and Bera, who have both reported that consistent increase in KMC duration with adequate support [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImprovement after the implementation of audiovisual tools and structured counselling was observed. This is supported by Kumari et al. and Jegannathan et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], who found that structured teaching significantly improved knowledge and willingness among mothers to practice KC. Jayanna et al demonstrated that implementation research and system-level interventions could accelerate KC uptake in Indian public hospitals, like the sustained improvements observed in our study [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne of the most promising outcomes of this QI initiative was the rise in involvement by fathers and other family members in delivering KC. Weighted average durations for fathers and family members rose steadily across phases, reaching parity with maternal KC by the sustenance phase. Interestingly, fathers' comparable duration pre-intervention (2.2 hours to 5.5 hours) supports Yaman et al. findings about paternal KC feasibility, and how the involvement of mother and father could have similar effects on the newborn, hence enabling us to support paternal kangaroo care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A systematic review on the subject of father and kangaroo care by Garnica-Torres et al shows similar findings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur study's evidence of consistent KC participation across both genders and improved inclusion of extremely and very preterm neonates also demonstrates a shift toward more equitable and risk-sensitive neonatal care. These findings reinforce those of Dahiya, who advocated for KC not only as a clinical practice but as a public health strategy to reduce neonatal morbidity and mortality in resource-limited settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The family involvement patterns demonstrate striking parallels with existing literature. The duration increased from 3 hours to 5 hours which is similar to the findings by Jefferies et al., Dargahiyan et al. and Sivanandan et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe sustained impact observed in our study suggests that integration of KC into daily neonatal routines, with reinforcement through audiovisual methods, kangaroo care slings, and direct counselling, is crucial for long-term adoption. These strategies appear to be more effective than one-time training sessions, as indicated by the limited knowledge retention observed in the pre-experimental study by Kumari et al and Jegannathanet al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis QI study demonstrates that family-focused, education-driven interventions can substantially increase Kangaroo Care adherence in Indian NICUs. The findings are consistent with prior research showing the clinical benefits of KC and underline the importance of engaging both mothers and other family caregivers in the practice. Future work should explore how to integrate these improvements into long-term policy and routine practice to further reduce neonatal morbidity and mortality in India.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis QI initiative demonstrates that structured family involvement significantly improves KC duration in LBW infants. Interventions such as counselling, educational media, policy updates, and comfort aids led to sustained increase in family involvement in KC.\u003c/p\u003e\u003cp\u003eThe limitations are that this study was conducted in a single institution and the follow up has been for a limited period of time efforts should focus on long-term sustainability and adaptation to varied contexts.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLBW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow Birth Weight\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKMC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKangaroo Mother Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKangaroo Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePOCQI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePoint of Care Quality Improvement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePDSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePlan Do Study Act\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality Improvement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and consent to participate\u003c/strong\u003e: The Institutional Ethics Committee (IEC) of Kasturba Medical College and Kasturba Hospital, Manipal. Registration number of IEC ECR/146/Inst/KA/2013/RR-19- Study Approval Number: IEC 138/2023 on 08/10/2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e to conduct the study was taken from parents during the implementation and sustenance phases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication-\u0026nbsp;\u003c/strong\u003eNo consent for publication was mandatory as the study involved routine and data was completely anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Data available and uploaded as a supplementary file\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was supported by Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka-576104. No external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contribution\u003c/strong\u003e: \u003cstrong\u003ePP\u003c/strong\u003e wrote the initial study protocol, collected data and wrote the initial manuscript draft; \u003cstrong\u003eLEL\u003c/strong\u003e was involved in implementation of actions and restructuring the initial draft of paper; \u003cstrong\u003eSSM\u003c/strong\u003e was responsible for supervision of study, making policy changes and finalizing the manuscript; \u003cstrong\u003eSA\u003c/strong\u003e was responsible for supervision of study and intellectual contributions to the paper; \u003cstrong\u003ePK\u003c/strong\u003e contributed intellectually to the study; \u003cstrong\u003eRBY\u003c/strong\u003e supervised the study and scrutinized the data; \u003cstrong\u003eSCM\u003c/strong\u003e helped in implementation of the QI initiative and scrutinized the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements-\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDahiya V, Bear RJ, Mellor DJ. Kangaroo Mother Care 1: Alleviation of Physiological Problems in Premature Infants. J Perinat Educ. 2017;26(3):117\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhirrao Ny. A systematic review of kangaroo mother care to promote LBW care and reduce morbidity and mortality in preterm. nj-ras [internet]. 2019jun.15 [cited 2025sep.9];7(03). available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ayurlog.com/index.php/ayurlog/article/view/360\u003c/span\u003e\u003cspan address=\"https://www.ayurlog.com/index.php/ayurlog/article/view/360\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVerma P, Verma V. Effect of Kangaroo Mother Care on Heart rate, Respiratory rate and Temperature in Low-Birth-Weight Babies. Int J Med Res Rev [Internet]. 2014Apr.30 [cited 2025Sep.9];2(2):80\u0026thinsp;\u0026ndash;\u0026thinsp;5. 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Indian J Pediatr. 2021;88(9):872\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Kangaroo Care, Quality Improvement, Preterm Neonates, Family Involvement, Low Birth Weight","lastPublishedDoi":"10.21203/rs.3.rs-7573858/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7573858/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePreterm and low birth weight (LBW) infants face increased risks of hypothermia, infections, and poor weight gain. Kangaroo Care (KC), a low-cost, evidence-based intervention involving skin-to-skin contact, improves neonatal health outcomes but is underutilised due to barriers in implementation and family involvement.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo improve the duration and inclusivity in Kangaroo Care practices through a quality improvement (QI) initiative involving structured family participation in a tertiary neonatal care setting in India.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA hospital-based QI study was conducted from July 2024 to April 2025 using the POCQI model. The study enrolled LBW/preterm neonates and involved three phases: pre-intervention, intervention (with two PDSA cycles), and sustenance. Interventions included audiovisual education and counselling of family members. Data was collected via and analyzed using SPSS version 27.0\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe average duration of KC increased from 3 to 6 hours per neonate per day during hospitalization. The proportion of neonates receiving\u0026thinsp;\u0026gt;\u0026thinsp;4 hours of KC increased from 6% to 90%. Involvement by fathers improved significantly from 52% to 93%. Involvement by extended family members increased from 3 hours to 5.5 hours. Enhanced caregiver education and consistent monitoring were key drivers.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eEngaging the family through education-focused QI strategies fosters shared responsibility, strengthens kangaroo care adherence, and improves implementation within existing resources.\u003c/p\u003e","manuscriptTitle":"Family Involvement in Kangaroo Care for Low Birth Weight (LBW) and Preterm Newborns-a Point-of-care Quality Improvement (POCQI) Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 16:47:02","doi":"10.21203/rs.3.rs-7573858/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-22T13:21:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-20T10:14:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-17T10:59:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82843933302881952320267898750633330477","date":"2025-11-13T16:01:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211782066894145249659855724655028186514","date":"2025-11-10T01:42:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57331677013531863530628433053095813308","date":"2025-11-05T07:10:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63345943755748329406548260134091277526","date":"2025-11-02T15:26:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236126400439073045079205244852016891940","date":"2025-11-02T07:25:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-31T05:33:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T12:03:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-08T13:05:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-08T09:18:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-10-08T09:14:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91f7a6e4-1b5d-4670-8d9b-095ef0ff9992","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T18:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-11 16:47:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7573858","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7573858","identity":"rs-7573858","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}