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Adoption of paediatric and neonatal pulse oximetry by 12 hospitals in Nigeria: a mixed-methods realist evaluation
  1. Hamish R Graham1,2,
  2. Ayobami A Bakare2,
  3. Amy Gray1,
  4. Adejumoke Idowu Ayede2,3,
  5. Shamim Qazi4,
  6. Barbara McPake5,
  7. Rasa Izadnegahdar6,
  8. Trevor Duke1,
  9. Adegoke G Falade2,3
  1. 1Centre for International Child Health, University of Melbourne, MCRI, The Royal Children’s Hospital, Parkville, Victoria, Australia
  2. 2Department of Paediatrics, University College Hospital, Ibadan, Nigeria
  3. 3Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
  4. 4Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
  5. 5Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
  6. 6Bill and Melinda Gates Foundation, Seattle, Washington, USA
  1. Correspondence to Dr Hamish R Graham; hamish.graham{at}


Introduction Pulse oximetry is a life-saving tool for identifying children with hypoxaemia and guiding oxygen therapy. This study aimed to evaluate the adoption of oximetry practices in 12 Nigerian hospitals and identify strategies to improve adoption.

Methods We conducted a mixed-methods realist evaluation to understand how oximetry was adopted in 12 Nigerian hospitals and why it varied in different contexts. We collected quantitative data on oximetry use (from case notes) and user knowledge (pretraining/post-training tests). We collected qualitative data via focus groups with project nurses (n=12) and interviews with hospital staff (n=11). We used the quantitative data to describe the uptake of oximetry practices. We used mixed methods to explain how hospitals adopted oximetry and why it varied between contexts.

Results Between January 2014 and April 2017, 38 525 children (38% aged ≤28 days) were admitted to participating hospitals (23 401 pretraining; 15 124 post-training). Prior to our intervention, 3.3% of children and 2.5% of neonates had oximetry documented on admission. In the 18 months of intervention period, all hospitals improved oximetry practices, typically achieving oximetry coverage on >50% of admitted children after 2–3 months and >90% after 6–12 months. However, oximetry adoption varied in different contexts. We identified key mechanisms that influenced oximetry adoption in particular contexts.

Conclusion Pulse oximetry is a simple, life-saving clinical practice, but introducing it into routine clinical practice is challenging. By exploring how oximetry was adopted in different contexts, we identified strategies to enhance institutional adoption of oximetry, which will be relevant for scale-up of oximetry in hospitals globally.

Trial registration number ACTRN12617000341325.

  • child health
  • pneumonia
  • intervention study
  • other diagnostic or tool
  • qualitative study

This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Handling editor Seye Abimbola

  • Contributors HRG contributed to study conception and design, project planning, interviews, data management and data analysis, and drafted the manuscript. AAB contributed to study design, project planning, interviews, data management and data analysis. AG contributed to study design, data management and data analysis. AIA contributed to study design, project planning and data management. SQ contributed to study design and evaluation planning. BM contributed to study design and data analysis. RI contributed to study conception and design, and project planning. TD contributed to study conception and design, project planning, and data analysis. AGF contributed to study conception and design, project planning, and data management. All authors read and approved the final manuscript. No medical writer or editor was involved in the generation of our manuscript.

  • Funding This work was supported by the Bill and Melinda Gates Foundation (OPP1123577) and the WHO. Neither organisation was involved in the writing of the manuscript or the decision to submit it for publication. The corresponding author had full access to the data and has final responsibility for the decision to submit for publication.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Our study was approved by the University of Melbourne Health Sciences Human Ethics Sub-Committee (ID: 1647681.1) and the University of Ibadan/University College Hospital Ibadan Ethics Committee (ID: UI/EC/16/0445).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We will make data created during this research available after completion of final evaluation analyses in December 2018 (including restricted de-identified clinical datasets and data from interviews and focus groups due to privacy and confidentiality requirements).

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