Consumer focus group testing with stakeholders to generate an enteral resuscitation training flipbook for primary health center and first-level hospital providers in Nepal

Abstract

Introduction: Enteral resuscitation (EResus) is operationally advantageous to intravenous resuscitation for burn-injured patients in some low-resource settings. However, there is minimal guidance and no training materials for EResus tailored to non-burn care providers. We aimed to develop and consumer-test a training flipbook with doctors and nurses in Nepal to aid broader dissemination of this life-saving technique.

Materials and methods: We used individual cognitive interviews with Nepali (n = 12) and international (n = 4) burn care experts to define key elements of EResus and specific concepts for its operationalization at primary health centers and first-level hospitals in Nepal. Content, prototype illustrations, and wireframe layouts were developed and revised with the burn care experts. Subsequently, eight consumer testing focus groups with Nepali stakeholders (5-10 people each) were facilitated. Prompts were generated using the Questionnaire Appraisal System (QAS) framework. The flipbook was iteratively revised and tested based on consumer feedback organized according to the domains of clarity, assumptions, knowledge/memory, and sensitivity/bias.

Results and discussion: The flipbook elements were iterated until consumers made no additional requests for changes. Examples of consumer inputs included: clarity-minimize medical jargon, add shrunken organs and wilted plants to represent burn shock; assumptions-use locally representative figures, depict oral rehydration salts sachet instead of a graduated bottle; knowledge/memory-clarify complex topics, use Rule-of-9 s and depict approximately 20% total body surface area to indicate the threshold for resuscitation; sensitivity/bias-reduce anatomic illustration details (e.g. urinary catheter placement, body contours).

Conclusion: Stakeholder engagement, consumer testing, and iterative revision can generate knowledge translation products that reflect contextually appropriate education materials for inexperienced burn providers. The EResus Training Flipbook can be used in Nepal and adapted to other contexts to facilitate the implementation of EResus globally.

Keywords: Burn; Enteral resuscitation; Implementation; Infographic; Low- and middle-income countries; Medical Education.

Figure 1.

Study participants and setting.

Figure 2.

A. Shows the design of the flipbook page conveying the concept of resuscitation before focus group feedback. B. Shows the design of the same page after focus group feedback was incorporated based on the question, “Do the images and text appropriately describe and convey the concept of resuscitation?”

Figure 2.

A. Shows the design of the flipbook page conveying the concept of resuscitation before focus group feedback. B. Shows the design of the same page after focus group feedback was incorporated based on the question, “Do the images and text appropriately describe and convey the concept of resuscitation?”

Figure 3.

A. Shows the flipbook design conveying the importance of using a nasogastric tube and its placement in a patient. B. Shows the revised first page of how to place and use a nasogastric tube based on consumer feedback to separate the important concepts of nasogastric tube placement, use, and importance. C. Shows the revised second page of the importance of implementing a nasogastric tube for oral feeding after consumers noted that this should be its own page to enhance engagement.

Figure 3.

A. Shows the flipbook design conveying the importance of using a nasogastric tube and its placement in a patient. B. Shows the revised first page of how to place and use a nasogastric tube based on consumer feedback to separate the important concepts of nasogastric tube placement, use, and importance. C. Shows the revised second page of the importance of implementing a nasogastric tube for oral feeding after consumers noted that this should be its own page to enhance engagement.

Figure 3.

A. Shows the flipbook design conveying the importance of using a nasogastric tube and its placement in a patient. B. Shows the revised first page of how to place and use a nasogastric tube based on consumer feedback to separate the important concepts of nasogastric tube placement, use, and importance. C. Shows the revised second page of the importance of implementing a nasogastric tube for oral feeding after consumers noted that this should be its own page to enhance engagement.

Figure 4.

A. The initial flipbook page showing the difference between enteral and IV resuscitation. B. The revised flipbook page still articulating the difference between enteral and IV resuscitation but tailored with a Jeevan Jal ORS packet and a water bottle instead of water in a cup with a straw to more appropriately convey the concepts used in Nepal.

Figure 4.

A. The initial flipbook page showing the difference between enteral and IV resuscitation. B. The revised flipbook page still articulating the difference between enteral and IV resuscitation but tailored with a Jeevan Jal ORS packet and a water bottle instead of water in a cup with a straw to more appropriately convey the concepts used in Nepal.

Figure 5.

A. Shows the initial Rule of 9s illustrations to highlight how to calculate burn TBSA%. B. After consumer focus groups, the calculation of burn TBSA% was split into this first page on the Rule of 9s and 1% hand rule with more apparent differences between the sizes of body parts depending on the patient’s age. C. The second page showing an example of how to calculate burn TBSA% in an adult and child and the size of burn that would indicate the need for EResus. Focus group participants noted that the importance of teaching these concepts warranted their separation into two pages.

Figure 5.

A. Shows the initial Rule of 9s illustrations to highlight how to calculate burn TBSA%. B. After consumer focus groups, the calculation of burn TBSA% was split into this first page on the Rule of 9s and 1% hand rule with more apparent differences between the sizes of body parts depending on the patient’s age. C. The second page showing an example of how to calculate burn TBSA% in an adult and child and the size of burn that would indicate the need for EResus. Focus group participants noted that the importance of teaching these concepts warranted their separation into two pages.

Figure 5.

A. Shows the initial Rule of 9s illustrations to highlight how to calculate burn TBSA%. B. After consumer focus groups, the calculation of burn TBSA% was split into this first page on the Rule of 9s and 1% hand rule with more apparent differences between the sizes of body parts depending on the patient’s age. C. The second page showing an example of how to calculate burn TBSA% in an adult and child and the size of burn that would indicate the need for EResus. Focus group participants noted that the importance of teaching these concepts warranted their separation into two pages.

Figure 6.

The unchanged page on how to correctly place a Foley catheter based on consumer feedback that this concept is culturally appropriate to show and well-understood by nurses in peripheral sites of Nepal.

Figure 7.

The added flipbook page after consumer feedback that it is crucial to involve families to encourage patients to use a nasogastric tube, so teaching this to healthcare providers is equally as important.