Table 2

Programme theories based on international literature (high-income countries (HICs) and low-/middle-income countries (LMICs))

Programme theories enhancing the KMC uptake
Programme theory 1: family-centred care (FCC)FCC has become more widespread, especially in paediatric and neonatal units with the aim to place parents and family at the centre and promote their empowerment and autonomy in the care of their baby. FCC supports parents and strengthens parent–child bonding, by encouraging KMC.37 82 Therefore, FCC is expected to promote the KMC uptake.
Programme Theory 2: Baby Friendly Initiative (BFI)The BFI has been developed by UNICEF UK in response to the very low rate of breast feeding in the UK.79 This programme involves standards and 10 steps to follow to properly promote breast feeding and hence, to enable services to be accredited. SSC is involved in some of these steps as it facilitates the lactation, improves the child’s development and reinforces parents–child bonding.79 While the BFI accreditation may take years to be completed, it could be expected that hospitals working towards this award are already promoting SSC and breastfeeding practices. Therefore, BFI hospitals (already accredited or not yet) could increase the uptake of SSC and breastfeeding practices and hence, could improve KMC uptake.
Programme Theory 3: Best Beginnings—Small Wonders Change Program (SWCP)‘Best beginnings’ UK charity has developed resources to promote the involvement of parents in their baby’s care to enhance every newborn’s health. The SWCP is a resource that educates both parents and staff using a DVD, a workshop and SWCP facilitators to strengthen FCC and parental involvement in KC/SSC and breast feeding.36 38 49 Hence, SWCP could increase the uptake of KMC.
Programme Theory 4: Bliss CharityBliss is a UK charity that aims to offer the best care possible for every newborn. This charity supports parents and staff with neonatal care and encourages research with the purpose of improving survival and well-being of children.83 Moreover, Bliss Charity, by developing the Bliss Baby Charter Audit tool, aims to assess and promote FCC and its related interventions, such as KMC.61 82 Therefore, such a charity may increase the uptake of KMC.
Programme Theory 5: NHS/NICE guidelinesGuidelines and approval from the NHS and/or NICE are essential to promote the proper use of a method of care.84 Regarding KMC, confusion about the definition is important and, hence, guidelines are necessary to promote KMC.20 In the UK, few local guidelines exist and they are developed by and for specific trusts/hospitals.62 Hence, those guidelines involving the use of KMC may potentially lead to a higher rate of this method.
Programme Theory 6: knowledge and confidenceAn intervention aiming to improve knowledge and confidence on a practice may enhance the intention and behaviour of the staff to support the uptake of such practice.36 68 Hence, we may expect that such process may be relevant to KMC as well.
Programme theories reducing the KMC uptake
Rival Programme Theory 1: healthcare workers: lack of training, knowledge and confidenceThe non-inclusion of KMC practice in the curriculum/training programme of healthcare workers (HCWs) would be an important barrier in the uptake of such method.25 This lack of training leads to poor knowledge of the benefits of KMC and poor confidence in its practice. Hence, HCWs may perceive it as not being based on scientific evidence but only on perceptions which might prevent its promotion.25 As KMC is a reverse innovation—innovation created by and for LMICs, which is used in HICs to improve health outcomes at a reduced cost—it could potentially be assumed that medical staff may be reluctant to implement KMC as perceiving it as an ‘inferior method’.24 25 85–88 Altogether, HCWs may find it easier and quicker, putting the stable preterm child in an incubator and might feel more comfortable/reassured of using continuous incubator care when children are unstable.
Rival Programme Theory 2: healthcare workers: lack of guidance/guidelinesThere is a lack of clear and written protocols on the adequate use of KMC. HCWs are uncertain about when to start this method and concerned about the stability of the child while in KMC. Poor and inconsistent guidance, especially in unstable and high-risk babies, make them feel not confident enough to support KMC.24 25
Rival Programme Theory 3: healthcare workers: lack of resourcesTime for training and supporting parents in doing KMC, the shortage of nurses available for such support and the short parents’ visits due to strict policies may be considered by the HCWs as barriers for implementing KMC.24 25
Rival Programme Theory 4: healthcare workers: cultural/social normsStandard care for newborns has been the norm for decades and some healthcare facilities and staff do not promote early contact between the baby and the mother right after the birth. Hence, they tend to directly bathe the baby and wrap it which prevents the early onset of KMC.25 79
Rival Programme Theory 5: caregivers: lack of knowledge/supportThe lack of knowledge and support parents have on KMC impacts the rate of use of this method as confidence may decrease and concerns on its benefits may arise.24 If there is a poor understanding on its use as well as a lack of support from the staff, the uptake of KMC may be low.41 89
Rival Programme Theory 6: caregivers: cultural normsThe lack of support from the community and/or family may also negatively impact the use of KMC.41 89 The mothers may feel uncomfortable of practising KMC in public, may be reluctant to hold the baby covered by dirt/blood, or may feel negatively pressured on the choice to practice KMC by the family and in laws.89
Rival Programme Theory 7: healthcare facilities: poor infrastructureLack of private spaces, reclining chairs, beds and other infrastructure that facilitate the use of KMC may prevent the uptake of this method.41
Rival Programme Theory 8: healthcare facilities: management and leadershipInadequate management, strict parental visits policies, lack of KMC champions, absence of leaders and insufficient budget may lead to poor uptake of KMC.24 25
Rival Programme Theory 9: healthcare facilities: elasticity in the deliveryThere is an important interchangeability in the terms used for describing and defining KMC. Indeed, very few studies exploring KMC are really assessing the use of the four components of KMC. Most of them only include the main component, SSC. Hence, it may prevent the right implementation of KMC as some may think they have properly implemented it while they have just implemented KC/SSC.25
  • KC, Kangaroo Care; KMC, Kangaroo Mother Care; NHS, National Health Service; NICE, National Institute for Clinical Excellence; SSC, skin-to-skin contact.