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BACKGROUND: Little is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala. METHODS: We used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation. RESULTS: We found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions. CONCLUSION: Implementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.

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Programmes to modify the safety culture have led to lasting improvements in patient safety and quality of care in high-income settings around the world, although their use in low-income and middle-income countries (LMICs) has been limited. This analysis explores (1) how to measure the safety culture using a health culture survey in an LMIC and (2) how to use survey data to develop targeted safety initiatives using a paediatric nephrology unit in Guatemala as a field test case. We used the Safety, Communication, Operational Reliability, and Engagement survey to assess staff views towards 13 health climate and engagement domains. Domains with low scores included personal burnout, local leadership, teamwork and work-life balance. We held a series of debriefings to implement interventions targeted towards areas of need as defined by the survey. Programmes included the use of morning briefings, expansion of staff break resources and use of teamwork tools. Implementation challenges included the need for education of leadership, limited resources and hierarchical work relationships. This report can serve as an operational guide for providers in LMICs for use of a health culture survey to promote a strong safety culture and to guide their quality improvement and safety programmes.

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The authors evaluated the effects on malaria vectors of bed nets impregnated with permethrin over the course of a 16-month controlled study in four communities of Northern Guatemala. Anopheles albimanus and An. vestitipennis were the known malaria vectors in the area. Households were allocated to one of three experimental groups: those receiving bed nets impregnated with 500 mg/m2 of permethrin, those receiving untreated bed nets, and those where no intervention measures were taken. The impact of the treated and untreated bed nets on mosquito abundance, behavior, and mortality was determined by indoor/outdoor night-bite mosquito collections, morning pyrethrum spray collections, inspection of bed net surfaces for dead mosquitoes, and capture-release-recapture studies. The duration of the treated nets' residual insecticide effect was assessed by modified WHO cone field bioassays, and their pyrethrin content was estimated by gas-liquid chromatography analysis. The most important observation was that fewer mosquitoes were found to be resting in the households with treated bed nets. The treated nets probably functioned by both repelling and killing vector mosquitoes. Capture-release-recapture studies showed exit rates from houses with treated nets were higher (94%) than those from control houses (72%), a finding that suggests repellency. However, no significant differences were noted between the indoor night-bite mosquito collections at houses with and without treated nets. The horizontal surfaces of treated bed nets were nearly 20 times more likely to contain dead anopheline mosquitoes than were the comparable surfaces of untreated nets. the bioassays indicated that unwashed permethrin-impregnated bed nets retained their insecticidal activity for 6 months after treatment.

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Permethrin-impregnated bed nets were evaluated as a control measure for malaria in northern Guatemala. Twelve hundred forty participants were allocated to one of three experimental groups (impregnated bed nets [IBN], untreated bed nets [UBN], and controls) and followed up for a period of 13 months. The incidence density of malaria was significantly lower in both IBN (86 cases/1,000 person-years) and UBN groups (106/1,000) compared with that in controls (200/1,000). No difference in malaria incidence was noted between the IBN and UBN groups. Complaints of fever and chills were less frequent in the IBN group compared with controls. The participants were enthusiastic about the nets, which they saw as a means for avoiding nuisance insects more than for preventing malaria. Most (85%) wanted to wash their nets every 4-12 weeks, a practice known to shorten the duration of residual insecticide action. Larger studies are needed to determine whether or not impregnated bed nets offer an advantage over untreated nets in this setting.

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The thermogenic effect of nicotine intake after calorie consumption was investigated to determine if nicotine influences metabolic response to a calorie challenge. Smokers and nonsmokers (10 males in each group), matched for body weight, age, and physical fitness, each participated in four sessions that involved consuming a liquid calorie load (4.77 kcal/kg body wt) or water, followed by nicotine (15 micrograms/kg body wt) or placebo via nasal spray every 20 min for 2 h. Energy expenditure was significantly increased above baseline resting metabolic rate (RMR) over the 2 h by nicotine alone (6.5% of RMR, p less than 0.01). However, the combined effect of nicotine after calorie load (20.1% of RMR, p less than 0.001) was not significantly greater than the effect of calorie load alone (18.4% of RMR, p less than 0.001). Smokers and nonsmokers did not differ in baseline RMR or in response to nicotine or calorie load. These results confirm the thermogenic effect of nicotine but suggest that the effect of nicotine after calorie consumption is less than additive.

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A one-year study of the biting and resting habits of the malaria vector Anopheles albimanus was carried out in four rural villages of northern Haiti. Man-biting rates and nightly biting cycles were determined by the use of all-night man-biting captures inside and outside houses. Seasonal changes in density and behavior were determined by repeating the captures on a bimonthly basis throughout one year. Exophily was demonstrated in these anopheline populations by a comparison of inside-biting with inside-resting densities. These behavior characteristics are discussed in relation to malaria transmission and to the choice of malaria control methods.

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Three methods of capturing Anopheles albimanus mosquitoes were compared during a field study in four villages in northern Haiti. Updraft ultraviolet (UV) light traps proved to be more effective than biting collections, regardless of season or whether the tests were done indoors or outdoors. Biting collections were in turn more effective than the Centers for Disease Control (CDC) miniature light traps. Updraft UV light traps and biting collections yielded more An. albimanus outdoors than indoors; the reverse was found for the CDC miniature light traps. The updraft UV light traps caught An. albimanus on 86% of the occasions used outside and 75% of the occasions inside. The biting collections were equally as successful as the traps in catching mosquitoes outside but caught An. albimanus only on 64% of the occasions when used inside houses. The CDC miniature light traps were successful in collecting An. albimanus on 33% of the occasions outside and 60% of the occasions inside.

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