title: Improving childhood nutrition and wellness in South Africa: involving mothers/caregivers of malnourished or HIV positive children and health care workers as co-designers to enhance a local quality improvement intervention.
abstract: A significant proportion of children admitted to a hospital in a South African sub-district in 2010 were severely malnourished and - when concurrently HIV positive - were not correctly initiated on antiretroviral therapy. Audit data over a subsequent four year period revealed that 60 % of malnourished children admitted to the hospital were HIV positive. To supplement an ongoing local quality improvement (QI) intervention addressing poor nutritional outcomes in children in this setting, Experience-based Co-design (EBCD) was used to enhance previously low levels of mother, carer and staff engagement.
  
  
  
  EBCD was implemented over an 8 month period. Non-participant observation was conducted comprising a total of 10 h in 5 different clinical locations. Semi-structured interviews were undertaken with 14 purposively selected staff members as well as 10 mothers/caregivers. The staff interviews were audio-taped whilst the mothers/caregiver interviews were filmed; both sets of experiences were analysed for key 'touchpoints'. Mothers/caregivers and staff participated in separate feedback events and then came together to identify their shared priorities for improving the service. Participants worked together in 3 smaller co-design teams to implement improvements.
  
  
  
  There was overlap in staff and mother/carer views as to their priorities for QI. However, whilst staff typically highlighted pragmatic issues, mothers/caregivers were more likely to identify experiential and relational issues. A total of 38 QI interventions were proposed after the priorities had been discussed and delegated to the 3 co-design teams; 25 of these changes had been implemented or were being planned for by the end of the study period. Examples included: a point of care blood machine being bought to shorten the time in the emergency department whilst waiting for laboratory results; a play area being organised for children attending the HIV clinic; the development of three standard operating procedures to improve clinical handover and waiting times; and privacy screens installed to improve privacy in reception.
  
  
  
  The impact of EBCD was noted both in practical improvements focused on a better experience for mothers/caregivers and children within the system and in reflections from stakeholders as to the value added to the ongoing QI intervention by the co-design process.
authors: Department of Family Medicine and Rural Health, University of the Witwatersrand, Phillip Tobias Building, York Road, Parktown, Johannesburg, South Africa. cvandeventer@nwpg.gov.za.
authors: Claire
authors: C
authors: van Deventer
authors: Health Care Quality & Innovation, Florence Nightingale Faculty of Nursing & Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
authors: Glenn
authors: G
authors: Robert
authors: University of the Witwatersrand, Phillip Tobias Building, York Road, Parktown, Johannesburg, South Africa.
authors: Anne
authors: A
authors: Wright
mesh_terms: D001291:Attitude of Health Personnel; D017028:Caregivers; D002648:Child; D015362:Child Nutrition Disorders / Q000517:prevention & control*; D002675:Child, Preschool; D005260:Female; D006679:HIV Seropositivity; D006282:Health Personnel; D006293:Health Promotion / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D009035:Mothers; D009752:Nutritional Status; D036301:Qualitative Research; D058996:Quality Improvement; D013019:South Africa
keywords: Child nutrition; Chronically ill children; Co-design; Experience-based Co-design; HIV; Quality improvement