McFadden Alison ، Gavine Anna, Malcolm CariAlmutairi, Amal2025-07-032025https://hdl.handle.net/20.500.14154/75747Background: Kangaroo Care (KC), a globally recognised practice involving skin-to-skin contact (SSC) between parents and their preterm infants, is widely endorsed for its physiological, neurobehavioral, developmental, and parental benefits. Despite its significant role in improving survival rates and promoting bonding and breastfeeding, the implementation of KC varies across healthcare settings, often influenced by organisational, practical, and resource-related factors. To initiate this study, a systematic review of the literature was conducted, highlighting a research gap in the Eastern Mediterranean Region (EMR), including Saudi Arabia, where cultural and organisational factors may pose additional barriers to KC adoption. Moreover, KC in Saudi Arabia remains underutilised and insufficiently studied, particularly in NICU setting. Aim: This PhD aimd to explore how KC was perceived, practiced by parents and HCPs in one NICU. It sought to provide insights into the factors that influenced KC implementation, examining the cultural, contextual, and organisational processes, as well as the challenges and opportunities for integrating KC as a standard practice in Saudi neonatal care. Design and methods: A focused ethnographic study was conducted in a large neonatal unit in Saudi Arabia. Data generation, employing purposive sampling with maximum variation, was carried out in three iterative steps: observations and fieldnotes, interviews and a focus group, and document collection. One hundred and fifty hours of observations, 13 interviews with parents (n=13), and 15 interviews and one focus group with HCPs (n=19), and documentary analysis were conducted. Reflexive thematic analysis adapted from Braun and Clarke, (2021) was applied informed by a social-ecological model and family integrated care model. Findings: The systematic review showed generally positive attitudes toward KC among HCPs but identified barriers, including unclear guidelines, staff shortages, and inadequate training. Parents were often uninformed about KC and relied on HCPs for guidance. Practical challenges, such as discomfort with prolonged KC, medical equipment, and lack of private spaces, hindered implementation. The ethnographic study found parents were often unaware of KC before their NICU experience, relying heavily on HCPs for guidance. Initial apprehension, driven by their infants’ fragility and the medicalised NICU environment, highlighted the lack of formal KC training among both parents and HCPs. A hierarchical NICU structure prioritised physician-led decision-making, limiting nurses’ autonomy and excluding parents, particularly in unstable infant cases. Cultural norms, including modesty expectations and traditional gender roles, restricted paternal involvement, while religious practices and open NICU layouts added barriers. Restrictive visitation policies, rigid routines, and an overemphasis on hygiene protocols led to KC being viewed as supplementary rather than integral, deviating from WHO guidelines promoting prolonged SSC. Organisational barriers like inconsistent policies and inadequate staffing further impeded KC implementation. Facilitators included supportive HCP attitudes, particularly among those with international experience, and private NICU spaces that encouraged greater parental participation. Conclusions and implications: The findings of this study emphasise the need for culturally informed, systemic changes to integrate KC as a routine practise of neonatal care in this NICU. There is need for integrating KC into healthcare education, policies, and practices through mandatory training for HCPs, parental education, and infrastructural improvements to ensure privacy. Aligning NICU protocols with WHO guidelines and FiCare can address organisational and cultural barriers, enhancing KC adoption and neonatal outcomes. Future research should focus on scaling up KC implementation, standardising practices, and exploring strategies to promote consistent adherence to evidence-based guidelines.437enKangaroo carePreterm infantsSaudi ArabiaNeonatal intensive care unitFocused ethnographySocial-ecological modelFamily integrated careCultural barriersOrganisational barriersThesis