Mapping system dynamics shaping neonatal infection prevention and antimicrobial stewardship in Botswana

An interview-led qualitative system-dynamics study in a tertiary neonatal unit in Botswana identified four reinforcing feedback structures associated with persistent challenges in infection prevention and control and antimicrobial stewardship. The study mapped overcrowding, transmission, length of stay, workload, burnout, staff turnover, infection-control adherence, infections, support for infection control, shared accountability, communication norms, material shortages and governance gaps as interacting parts of the hospital system.

Researchers developed an interview-led qualitative system-dynamics workflow involving stakeholders from the neonatal unit, hospital services and health-system governance. The evidence base comprised 67 semi-structured interviews across these groups and a one-day group model-building workshop. Interview data were analysed with hybrid inductive-deductive thematic analysis. Themes were translated into system-dynamics variables and causal relationships, represented in 10 seed causal loop diagrams and then combined into an integrated diagram containing 62 variables and 92 causal relationships. Expert review and stakeholder feedback were used to validate the findings and diagrams.

Four dominant reinforcing structures emerged from the analysis. The first links overcrowding with transmission and longer hospital stays. The second connects heavy workload to burnout and staff turnover, while the third links workload to reduced adherence to infection-prevention and control practices and, in turn, infections. The fourth centres on support for infection control, shared accountability and communication norms. Material shortages and governance gaps amplified these harmful feedback loops. The results therefore depict the challenges as system dynamics in which several conditions can sustain one another, rather than as a sequence driven by one isolated factor.

This was a qualitative mapping study rather than a clinical trial or an analysis of measured infection outcomes. It did not test interventions, establish that any single mapped relationship was causal, or demonstrate effects on neonatal survival, length of admission or antimicrobial use. The research was conducted in one tertiary neonatal unit in Botswana, and its integrated diagram represented relationships identified through qualitative analysis and stakeholder validation. The authors said the workflow can produce causal loop diagrams whose variables, causal relationships and feedback structures remain traceable to the interview evidence, particularly when repeated group model-building workshops are not feasible. They identified the mapped structures as potential leverage points for future systems-informed implementation research in comparable resource-constrained hospital settings, but the study did not evaluate interventions at those points.

Subject of Research: Qualitative system-dynamics mapping of neonatal infection prevention and antimicrobial stewardship in a Botswana tertiary neonatal unit

Article Title: Mapping system dynamics shaping neonatal infection prevention and antimicrobial stewardship in Botswana

Article References: Jadeja, N., Strysko, J., Matula, S. T., Magagani, L., Mokomane, M., Coffin, S. E., Steenhoff, A. P., Kagiso, M., Holmes, A., Nakstad, B., & Zhu, N. (2026). Mapping system dynamics shaping neonatal infection prevention and antimicrobial stewardship in Botswana. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15357-6

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15357-6

Keywords: neonatal infections, system dynamics, Botswana, infection prevention, antimicrobial stewardship, healthcare-associated infections, antimicrobial resistance, causal loop diagrams, qualitative research, hospital governance, Mapping, system