Factors Affecting the Implementation of Continuous Positive Airway Pressure (CPAP) in Low- and Middle-Income Countries: A Qualitative Evidence Synthesis

ObjectiveTo identify the facilitators and barriers affecting the implementation of CPAP in low- and middle-income countries (LMICs). MethodsElectronic databases--PubMed, Embase, Cochrane CENTRAL, EMBASE, and EBSCO--were searched from their inception until July 2, 2023. All types of studies reporting factors that influence CPAP implementation in neonates with respiratory distress were included. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with PROSPERO (CRD42024497038). The primary outcomes were the facilitators and barriers to CPAP implementation. The identified facilitators and barriers were categorized into five key themes, along with various subthemes under each: medical devices (intrinsic characteristics of CPAP and cost), service delivery (availability of equipment, infrastructure, supplies, and accessories, and monitoring devices), workforce (availability of staff and training), information (perceptions of parents, healthcare workers, and communication), and governance and leadership. FindingsOf the 42 studies included in the review, 30 were conducted in Africa, 9 in Asia, 1 each from Oceania and Central America, and 1 across multiple LMICs; 15 were multi-center studies. Among the facilitators, the most frequently identified subthemes, listed in decreasing order of frequency, were the training of health personnel (n=23), the availability of structured unit protocols for CPAP administration (n=12), and the ease of use of the CPAP device (n=10). The main barriers identified included staff shortages (n=15), a lack of CPAP devices (n=11), and insufficient supplies and accessories for CPAP administration (n=10). ConclusionsSufficient staffing, ongoing training, and appropriate infrastructure are essential for the effective implementation of CPAP in LMIC settings.