Assessing healthcare access using the Levesque's conceptual framework- a scoping review

INTRODUCTION

Countries are working hard to improve access to healthcare through Universal Healthcare Coverage. To genuinely address the problems of healthcare access, we need to recognize all the dimensions and complexities of healthcare access. Levesque's Conceptual Framework of Access to Health introduced in 2013 provides an interesting and comprehensive perspective through the five dimensions of access and the five abilities of the population to access healthcare. The objectives of this paper are to identify and analyze all empirical studies that applied Levesque's conceptual framework for access to healthcare and to explore the experiences and challenges of researchers who used this framework in developing tools for assessing access.

METHODS

A scoping review was conducted by searching through four databases, for studies citing Levesque et al. 2013 to select all empirical studies focusing on healthcare access that applied the framework. An initial 1838 documents underwent title screening, followed by abstract screening, and finally full text screening by two independent reviewers. Authors of studies identified from the scoping review were also interviewed.

RESULTS

There were 31 studies identified on healthcare access using the Levesque framework either a priori, to develop assessment tool/s (11 studies), or a posteriori, to organize and analyze collected data (20 studies). From the tools used, 147 unique questions on healthcare access were collected, 91 of these explored dimensions of access while 56 were about abilities to access. Those that were designed from the patient's perspective were 73%, while 20% were for health providers, and 7% were addressed to both. Interviews from seven out of the 26 authors, showed that while there were some challenges such as instances of categorization difficulty and unequal representation of dimensions and abilities, the overall experience was positive.

CONCLUSION

Levesque's framework has been successfully used in research that explored, assessed, and measured access in various healthcare services and settings. The framework allowed researchers to comprehensively assess the complex and dynamic process of access both in the health systems and the population contexts. There is still potential room for improvement of the framework, particularly the incorporation of time-related elements of access.

Vietnam's success story against COVID-19

Vietnam's close proximity to China where the COVID-19 outbreak started made it one of the countries expected to have widespread transmission of the virus. However, the country opposed this expectation and attained low spread of COVID-19 infection due to its proactive approaches in containing the disease. As of March 11, 2021, Vietnam has a total of 2529 confirmed cases, equivalent to 26 cases per one million population-compared to the global rate of 15,223 cases. The low-cost model approach used by Vietnam in dealing with previous public health issues, tackle the importance of a strategic public health system, good governance, and citizen cooperation in the fight against COVID 19 pandemic. This paper aims to analyze Vietnam's achievement in its early and continued success in combating COVID-19 by taking into account various aspects of its health system and experience on outbreaks that have previously occurred and how these can be applied to current COVID-19 responses.

"We do not know how to screen and provide treatment": a qualitative study of barriers and enablers of implementing perinatal depression health services in Ethiopia

BACKGROUND

Qualitative studies evaluating maternal mental health services are lacking in Ethiopia, and the available evidence targets severe mental illnesses in the general population. We conducted a qualitative study to explore barriers to, enablers of, or opportunities for perinatal depression health services implementations in Ethiopia.

METHODS

We conducted a total of 13 face to face interviews with mental and maternal health service administrators from different levels of the Ethiopian healthcare system. We interviewed in Amharic (a local language), transcribed and translated into English, and imported into NVivo. We analysed the translated interviews inductively using thematic framework analysis.

RESULTS

The study identified: (i) health administrators' low literacy about perinatal depression as individual level barriers; (ii) community low awareness, health-seeking behaviours and cultural norms about perinatal depression as socio-cultural level barriers; (iii) lack of government capacity, readiness, and priority of screening and managing perinatal depression as organisational level barriers; and (iv) lack of mental health policy, strategies, and healthcare systems as structural level barriers of perinatal mental health implementation in Ethiopia. The introduction of the new Mental Health Gap Action Programme (mhGap), health professionals' commitment, and simplicity of screening programs were identified enablers of, or opportunities for, perinatal mental health service implementation.

CONCLUSIONS

This qualitative inquiry identified important barriers and potential opportunities that could be used to address perinatal depression in Ethiopia. Building the capacity of policy makers and planners, strengthening the mental healthcare system and governance should be a priority issue for an effective integration of maternal mental health care with the routine maternal health services in Ethiopia.

Systemic factors for enhancing intersectoral collaboration for the operationalization of One Health: a case study in India

Background

One Health is a collaborative, multisectoral, and transdisciplinary approach—working at the local, regional, national, and global levels—with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. Operationalization of the One Health approach is still unclear for various local health systems with their respective targets. In this scenario, the empirical study of intersectoral collaboration between the human and animal health systems provides an opportunity to investigate the appropriate strategies and their enabling factors at the local health system level. Thus, this study documented and validated the innovative strategy for intersectoral collaboration, focusing on effectual prevention and control of zoonotic diseases with its enabling factors for a city in western India, Ahmedabad.

Methods

This case study was conducted in three phases: phase I (qualitative data collection, i.e., vignette interview), phase II (quantitative data collection through modified policy Delphi), and phase III (participatory workshop). The vignette data were handled for content analysis, and the Delphi data, like other quantitative data, for descriptive statistics. The participatory workshop adapts the computerized Sensitivity Model^® developed by Vester to analyse the health system dynamics.

Result

Out of the possible 36 strategies, this study validated the top 15 essential (must-have) and five preferred (should-have) strategies for the study area. For operationalization of the One Health approach, the enabling factors that were identified through the systems approach are micro-level factors at the individual level (trust, leadership, motivation, knowledge), meso-level factors at the organizational level (human resource, capacity-building, shared vision, decision-making capacity, laboratory capacity, surveillance), macro-level factors at the system level (coordinated roles, relationships, common platform), and external factors outside of the system (guidelines/policies, community participation, a specific budget, political will, smart technology).

Discussion

This study reveals that the micro-level factors at the individual level are potential levers of the health system. More attention to these factors could be beneficial for the operationalization of the One Health approach. This study recommends a systems approach through a bottom-up exploration to understand the local health system and its enabling factors, which should be accounted for in formulating future One Health policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-021-00727-9.

Health, longevity, infrastructure and competitiveness: The Four Horsemen of COVID-19

Many researchers around the world are working to reach a general framework to provide solutions for COVID-19 in different ways. From our economic and business orientation, "Health, Longevity, Infrastructure and Competitiveness" are presented in this paper as the Four Horsemen of COVID-19. Our aim is to analyse the relationship between these proposed four factors and their influence on COVID-19. Using the Global Competitive Index (GCI), Health Systems in Transition (HiT) and the System of Health Accounts (SHA), we complete a database for a total of 28 countries of the European Union, including the United Kingdom and using variables related to the environment of each region (competitiveness, security, infrastructure, population and health system). Our study is focused on a descriptive analysis and a binary logistic model (logit), trying to distinguish between countries with more and less incidence of COVID-19. According to the results, the presence of these four factors - which are desirables for any country - implies a greater transmission of the virus in these regions. However, a higher annual expenditure in the health system is related to a lower incidence of COVID-19.

Health system responsiveness: a systematic evidence mapping review of the global literature

BACKGROUND

The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness.

METHODS

A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts.

RESULTS

Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system.

CONCLUSIONS

This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.

Factors associated with involuntary psychiatric hospitalization in Portugal

Background

Identifying which factors contribute to involuntary psychiatric hospitalization may support initiatives to reduce its frequency. This study examines the sociodemographic, clinical, and contextual factors associated with involuntary hospitalization of patients from five Portuguese psychiatric departments in 2002, 2007 and 2012.

Methods

Data from all admissions were extracted from clinical files. A Poisson generalized linear model estimated the association between the number of involuntary hospitalizations per patient in one year and sociodemographic, clinical, and contextual factors.

Results

An increment of involuntary hospitalizations was associated with male gender [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.31; 95%CI 1.06–1.62, p < 0.05], having secondary and higher education [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.45; 95%CI 1.05–2.01, p < 0.05, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.89; 95%CI 1.38–2.60, p < 0.001, respectively], a psychiatric diagnosis of psychosis [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 2.02; 95%CI 1.59–2.59, p < 0.001], and being admitted in 2007 and in 2012 [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.61; 95%CI 1.21–2.16, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.73; 95%CI 1.31–2.32, p < 0.001, respectively]. A decrease in involuntary hospitalizations was associated with being married/cohabitating [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.74; 95%CI 0.56–0.99, p < 0.05], having experienced a suicide attempt [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.26; 95%CI 0.15–0.42, p < 0.001], and belonging to the catchment area of three of the psychiatric services evaluated [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.65; 95%CI 0.49–0.86, p < 0.01, exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.49–0.90, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.46–0.96, p < 0.05 for Hospital de Magalhães Lemos, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, respectively].

Conclusions

The findings suggest that involuntary psychiatric hospitalizations in Portugal are associated with several sociodemographic, clinical, and contextual factors. This information may help identify high-risk patients and inform the development of better-targeted preventive interventions to reduce these hospitalizations.

Utilization of traditional medicine and its integration into the healthcare system in Qokolweni, South Africa; prospects for enhanced universal health coverage

Despite the WHO providing a framework for the integration of traditional medicines into the health systems with pandemics like HIV/AIDS and the COVID-19, most countries are yet to adopt the recommendations. This study explored why the integration of traditional medicines with the biomedical healthcare system in Qokolweni in Eastern Cape, South Africa was stalling. The research employed qualitative research methods; participant observation and in-depth ethnographic interviews of community members, traditional healers, and nurses. The study found that: traditional medicines are widely used in Qokolweni due to accessibility and long-built trust; the practice is broad and not certified. To achieve the integration of traditional medicine into the conventional health systems, the central government needs to show political will by setting up regulatory strategies that provide for the scientific evaluation and certification of traditional medicines. This will build confidence among biomedical scientists and health practitioners, thereby fostering easy collaboration and integration.

Country-Wide Resilience Model for the Health System: A Case Study on Iran, under Coronavirus Outbreak

Background

The outbreak of the COVID-19 virus has had many destructive impacts on socio-economic and health systems. The health systems of countries could be supportive in crisis management, but they also are affected by the impact of the crisis, consequently, their operational level has declined. This study pursued resilience in an overall national health system under pandemic stress.

Methods

Based on WHO building blocks, by interviewing informants of the Ministry of Health and Medical Education, in Tehran-Iran, early 2021 a rich picture of the current situation depicted, the resilience model was extracted via a mixed method of Soft System Methodology (SSM) and total interpretive structural modeling (TISM). Dynamic capabilities were applied for the orchestration of the Iranian health system.

Results

Particular functional and structural suggestions applicable for designing a ubiquitous resilience model for the country-wide health system are presented in this study. The variables of crisis sensing, opportunity seizing, and reconfiguration are the cornerstones of health system resilience.

Conclusion

Well-suited health technology assessment (HTA) and health information system (HIS) play significant roles in the overall strengthening of the health system. All reforms for resilience will have a lasting result when the capabilities created by the resilience model are learned and reused in a dynamic cycle.

[Evaluation of health center's primary care responsiveness by patients with chronic illnesses]

OBJECTIVE

To evaluate the health systems' response capacity according to the perception of chronic patients, and the factors related to that perception.

METHOD

Source of data: patients diagnosed with at least one chronic disease who visited primary care centers during June and July 2015 in a basic health area of La Rioja.

DESIGN

cross-sectional descriptive study based on interviews to over 18s who visited primary care centers. The dependent variable was the health systems' response capacity and independent variables were sociodemographic and health related. In order to collect data, trained interviewers conducted a short questionnaire in Spanish from the World Health Organization Multi-country Survey Study with 403 subjects. Descriptive statistics, bivariate and multivariate logistic regression were performed.

RESULTS

The overall health systems' response capacity was considered good by 87.10%. The domains that scored highest were: confidentiality (99.3%), dignity (98.3%) and communication (97.3%). Those evaluated worst were: rapid service (38,6%) and quality of basic services (31.8%). Low social class was the most important factor associated with the responsiveness, mainly with autonomy and rapid service. Sex, educational level, and occupation were related to communication domain, and patients with worse perceived health rated the general response worse. The domains considered most important were dignity (33.5%) and rapid service (30.5%).

CONCLUSIONS

The domains best evaluated were those related to respect for people. Rapid service has a low health systems' response capacity, but a high importance, and therefore requires priority action.

Participatory simulation modeling to inform colorectal cancer screening in a complex remote northern health system: Canada's Northwest Territories

BACKGROUND & AIMS

Colorectal cancer (CRC) mortality in the Northwest Territories (NWT), a northern region of Canada, could be reduced by implementing a CRC screening program. However, this may require additional colonoscopy resources. We used participatory simulation modeling to predict colonoscopy demand and to develop strategies for implementing a feasible and effective CRC screening program in this complex remote northern health system.

METHODS

Using a participatory simulation modeling approach, we first developed a conceptual model of CRC screening with local collaborators. This approach informed our parameter adjustments of an existing microsimulation model, OncoSim-CRC, using data from a retrospective cohort review of CRC screening between 2014-2019 and secondary data. Model scenarios reflecting program implementation were run for 500 million cases. Validity was assessed, and outputs analyzed with collaborators. Alternative scenarios were developed to reduce colonoscopy demand and results were presented to end-users.

RESULTS

We estimated that colonoscopy demand with a CRC screening program phased-in over 5 years would surpass capacity within 2 years. If demand is met, screen-detected cancers would increase by 110 %, and clinically-detected cases would reduce by 26 % over the next 30 years. We also found that prolonging the phase-in period, or revising adenoma follow-up guidelines would reduce colonoscopy demand while still improving cancer detection. Both strategies were considered feasible by collaborators. The adjusted model was valid, and the projections informed local end-users plans for CRC screening delivery.

CONCLUSIONS

Using participatory simulation modeling, we projected that a screening program would improve CRC detection but surpass current colonoscopy capacity. Phasing-in the screening program and reducing endoscopic adenoma follow-up would enhance feasibility of a CRC screening program in the NWT and help maintain its effectiveness.

Strategic purchasing and the performance of health-care systems in upper middle income countries: A comparative study

BACKGROUND

Providing financial resources for health services is one of the most important issues in the study of health systems, of which purchasing health services is very essential. The World Health Organization considers strategic purchasing as a key option for improving the performance of health systems. The aim of this study was to identify payment methods for service providers and strategic purchasing strategies in upper middle income countries.

MATERIALS AND METHODS

The present study was conducted in the form of a comparative analysis involving comprehensive surveys from 2000 to 2019, by searching keywords for the objective of the study by the search engines through databases including ProQuest, PubMed, Google Scholar, Irandoc, SID, Magiran, Science Direct, Scopus, ISI Web of Science, EBSCO, and Cochrane.

RESULTS

A total of five upper middle income countries that used strategic purchases entered the study. Overall, all of them implemented rather similar strategies in terms of strategic purchasing and paying to the providers of the services.

CONCLUSION

According to the results of this study, per capita payment for primary health-care and outpatient services seems to be the best option for controlling the costs of the health sector, while the appropriate option for the inpatient department is the most common use of diagnosis-related group. The payment method is to control the costs of the inpatient department.

Building resource constraints and feasibility considerations in mathematical models for infectious disease: A systematic literature review

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Mathematical model capabilities to explore complex systems now enable priority-setting to consider local resource constraints.

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Common objectives of model-based analyses incorporating constraints are to assess real-world feasibility or allocate resources efficiently.

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Constraints may be incorporated via (i) model-based estimation; (ii) linkage of mathematical and health system models; or (iii) optimisation.

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Models can then project constrained intervention effects and costs and resource requirement s for delivering interventions at full scale.

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'Health system constraints' should be systematically defined for routine operationalisation in model-based priority-setting.

Priority setting for infectious disease control is increasingly concerned with physical input constraints and other real-world restrictions on implementation and on the decision process. These health system constraints determine the ‘feasibility’ of interventions and hence impact. However, considering them within mathematical models places additional demands on model structure and relies on data availability. This review aims to provide an overview of published methods for considering constraints in mathematical models of infectious disease.

We systematically searched the literature to identify studies employing dynamic transmission models to assess interventions in any infectious disease and geographical area that included non-financial constraints to implementation. Information was extracted on the types of constraints considered and how these were identified and characterised, as well as on the model structures and techniques for incorporating the constraints.

A total of 36 studies were retained for analysis. While most dynamic transmission models identified were deterministic compartmental models, stochastic models and agent-based simulations were also successfully used for assessing the effects of non-financial constraints on priority setting. Studies aimed to assess reductions in intervention coverage (and programme costs) as a result of constraints preventing successful roll-out and scale-up, and/or to calculate costs and resources needed to relax these constraints and achieve desired coverage levels. We identified three approaches for incorporating constraints within the analyses: (i) estimation within the disease transmission model; (ii) linking disease transmission and health system models; (iii) optimising under constraints (other than the budget).

The review highlighted the viability of expanding model-based priority setting to consider health system constraints. We show strengths and limitations in current approaches to identify and quantify locally-relevant constraints, ranging from simple assumptions to structured elicitation and operational models. Overall, there is a clear need for transparency in the way feasibility is defined as a decision criteria for its systematic operationalisation within models.

Ancillary benefits of seasonal influenza vaccination in middle-income countries

While seasonal influenza vaccines (SIV) remain the best method to prevent influenza-associated illnesses, implementing SIV programs may benefit countries beyond disease reduction, strengthening health systems and national immunization programs, or conversely, introduce new challenges. Few studies have examined perceived impacts of SIV introduction beyond disease reduction on health systems; understanding such impacts will be particularly salient in the context of COVID-19 vaccine introduction. We collected qualitative data from key informants-Partnership for Influenza Vaccine Introduction (PIVI) contacts in six middle-income PIVI vaccine recipient countries-to understand perceptions of ancillary benefits and challenges from SIV implementation. Respondents reported benefits associated with SIV introduction, including improved attitudes to SIV among risk groups (characterized by increased demand) and perceptions that SIV introduction improved relationships with other ministries and collaboration with mass media. Challenges included sustaining investment in SIV programs, as vaccine supply did not always meet coverage goals, and managing SIV campaigns.

Readiness to deliver person-focused care in a fragile situation: the case of Mental Health Services in Lebanon

BACKGROUND

Evidence suggests wide variability in the provision of mental healthcare across countries. Countries experiencing fragility related risks suffer from a high burden of mental-ill health and additionally have limited capacity to scale up mental health services given financial and human resource shortages. Integration of mental health services into routine primary care is one potential strategy for enhancing service availability, however little is known about the experiences of currently active health care providers involved in mental health and psychosocial support service (MHPSS) provision at primary care level. This study aims to determine how healthcare providers offering MHPSS services at primary care levels in Lebanon perceive mental health and the health system's ability to address the rising mental ill-health burden with a view to identify opportunities for strengthening MHPSS service implementation geared towards integrated person focused care model.

METHODS

A qualitative study design was adopted including 15 semi-structured interviews and 2 participatory group model-building workshops with health care providers (HCPs) involved in mental healthcare delivery at primary care level. Participants were recruited from two contrasting fragility contexts (Beirut and Beqaa). During workshops, causal loop diagrams depicting shared understandings of factors leading to stress and mental ill health, associated health seeking behaviors, and challenges and barriers within the health system were elicited. This research is part of a larger study focused on understanding the dynamics shaping mental health perceptions and health seeking behaviours among community members residing in Lebanon.

RESULTS

Findings are organized around a causal loop diagram depicting three central dynamics as described by workshop participants. First, participants linked financial constraints at household levels and the inability to secure one's livelihood with contextual socio-political stressors, principally referring to integration challenges between host communities and Syrian refugees. In a second dynamic, participants linked exposure to war, conflict and displacement to the occurrence of traumatic events and high levels of distress as well as tense family and community relations. Finally, participants described a third dynamic linking cultural norms and patriarchal systems to exposure to violence and intergenerational trauma among Lebanon's populations. When describing help-seeking pathways, participants noted the strong influence of social stigma within both the community and among health professionals; the latter was noted to negatively affect patient-provider relationships. Participants additionally spoke of difficulties in the delivery of mental health services and linked this to the design of the health system itself, noting the current system being geared towards patient centered care, which focuses on the patient's experiences with a disease only, rather than person focused care where providers and patients acknowledge broader structural and social influences on health and work together to reach appropriate decisions for tackling health and other social needs. Barriers to delivery of person focused care include the lack of coherent mental health information systems, limited human capacity to deliver MHPSS services among primary health care staff and inadequate service integration and coordination among the many providers of mental health services in our study contexts. Critically however, provider accounts demonstrate readiness and willingness of health professionals to engage with integrated person focused care models of care.

CONCLUSIONS

Mental ill health is a major public health problem with implications for individual health and wellbeing; in a fragile context such as Lebanon, the burden of mental ill health is expected to rise and this presents substantive challenges for the existing health system. Concrete multi-sectoral efforts and investments are required to (1) reduce stigma and improve public perceptions surrounding mental ill health and associated needs for care seeking and (2) promote the implementation of integrated person focused care for addressing mental health.

Patient Safety in Dental Practice: Lessons to Learn About the Risks and Limits of Professional Liability

Introduction

Health professionals should work with the notion of risk involved in the health care process. Dental practice risk is of particular interest because it encompasses both aesthetic and functional components. Focusing on guidelines suggested by the World Health Organization and objectives on patient safety, this study has 2 objectives: to present Portuguese medicolegal data on corporal damage evaluation related to iatrogenic sequelae during dental practice and to present updated evidence on patient safety.

Materials and methods

A retrospective study was performed by analysing data from the database of the Laboratory of Forensic Dentistry of the Faculty of Medicine, University of Coimbra, Portugal, from 2013 to 2018.

Results

One hundred seven medicolegal files were selected according to the inclusion and exclusion criteria. Iatrogenic sequelae (73.8%, 79 out of 107) were categorised as risks (60 out of 79) and malpractice (19 out of 79). The risk was associated mostly with mandibular dysfunction and orthodontic treatment (62.2%). Malpractice was mostly associated with neurological deficit and implant rehabilitation (47.4%).

Discussion and conclusion

Greater attention to these data by professionals was emphasised, especially when considering patient safety and health care quality. This article presents the Portuguese data on professional liability in the field of dental practice, categorising iatrogenic sequelae into risks and malpractice, as well as the oral rehabilitation procedure and timeline.

Fare well to Nova Scotia? Public health investments remain chronically underfunded

Inspired by Fiset-Laniel et al.’s (2020) article entitled “Public health investments: neglect or wilful omission? Historical trends in Quebec and implications for Canada”, we assessed public health investments since the establishment of the Nova Scotia provincial health authority in 2015. We analyzed Nova Scotia Department of Health and Wellness budgets from 2015−2016 to 2019–2020 and observed that less than 1% of funding was budgeted for public health annually, an amount well below the recommendation that 5–6% of healthcare funding be spent on public health. Healthcare spending has increased annually since 2015–2016, but proportions of funding to different programs and services have remained static. Specifically, we did not observe a change in investment in public health over time, suggesting that while the government does not necessarily spend too much or too little on healthcare, it spends far too little on public health. This chronic under-funding is problematic given the high rates of non-communicable diseases in Nova Scotia and health inequities experienced within the population. The 2020 COVID-19 pandemic has highlighted the importance of public health work, and the need for a pandemic recovery plan that prioritizes investment in all areas of public health in Nova Scotia.

[Planetary health-transformative education regarding the climate and sustainability crises for health professionals]

Die Dringlichkeit der Klima- und Nachhaltigkeitskrise und ihre Auswirkungen auf die menschliche Gesundheit rücken auch im deutschen Gesundheitswesen zunehmend in den Fokus. Um ein weiteres Fortschreiten der Klima- und Nachhaltigkeitskrise zu verhindern, sind tiefgreifende Transformationsprozesse in allen gesellschaftlichen Sektoren notwendig (z. B. Verkehr, Energieerzeugung, Ernährungssystem). Angehörige der Gesundheitsberufe haben auf Basis ihrer ethischen Verpflichtung des Nichtschadens und ihrer guten Vertrauenswerte in der Gesellschaft das Potenzial, einen wichtigen Beitrag zu den notwendigen Transformationsprozessen zu leisten.

Damit sie dieses Potenzial zur Gänze ausschöpfen können, sollten Angehörige der Gesundheitsberufe im Rahmen ihrer Aus‑, Fort- und Weiterbildung bei der Entwicklung von Kompetenzen begleitet werden, die zu transformativem Handeln befähigen. Wir führen in diesem Artikel in das Konzept der planetaren Gesundheit ein, das hierfür sowohl inhaltliche als auch ethische Orientierung gibt. Außerdem geben wir einen Überblick über aktuelle Lehr- und Lernformate und identifizieren Aspekte, die zur Weiterentwicklung der Lehre im Bereich planetare Gesundheit beitragen könnten.

Universal health coverage and COVID-19: recent developments and implications

Universal health coverage (UHC) is meant to access the key health services including disease prevention, treatment, rehabilitation, and health promotion. UHC varies according to demographics, epidemiology, and technology-based trends, as well as according to people’s expectations. Globally, the transition towards UHC has been associated with the intent of improving accessibility and affordability of healthcare. The COVID-19 pandemic has disrupted the health systems of even the most developed economies of the world in an unprecedented manner. The situation is also very challenging for the countries with the existing health inequities as well as the countries with the developing healthcare systems. This has amplified the need to accelerate efforts to build strong and resilient health systems to achieve progress towards UHC. This commentary discusses a global overview of UHC in the wake of COVID19. It also highlights the initiatives taken by Pakistan to promote the goals of UHC.

War on Diabetes in Singapore: a policy analysis

BACKGROUND

In April 2016, the Singapore Ministry of Health (MOH) declared War on Diabetes (WoD) to rally a whole-of-nation effort to reduce diabetes burden in the population. This study aimed to explore how this policy has been positioned to bring about changes to address the growing prevalence of diabetes, and to analyse the policy response and the associated challenges involved.

METHODS

This qualitative study, using Walt and Gilson's policy triangle framework, comprised analysis of 171 organizational documents on the WoD, including government press releases, organizational archives, YouTube videos, newspaper reports and opinion editorials. It also involved interviews with 31 policy actors, who were policy elites and societal policy actors.

RESULTS

Findings showed that the WoD policy generated a sense of unity and purpose across most policy actors. Policy actors were cognisant of the thrusts of the policy and have begun to make shifts to align their interests with the government policy. Addressing those with diabetes directly is essential to understanding their needs. Being clear on who the intended targets are and articulating how the policy seeks to support the identified groups will be imperative. Issues of fake news, unclear messaging and lack of regulation of uncertified health providers were other identified problem areas. High innovation, production and marketing costs were major concerns among food and beverage enterprises.

CONCLUSION

While there was greater public awareness of the need to combat diabetes, continuing dialogues with the various clusters of policy actors on the above issues will be necessary. Addressing the various segments of the policy actors and their challenges in response to the WoD would be critical.

A Retrospective Analysis of Therapeutic Inertia in Type 2 Diabetes Management Across a Diverse Population of Health Care Organizations in the USA

INTRODUCTION

If their target glycated hemoglobin (HbA1c) is not achieved after 3 months, timely treatment intensification is recommended in people with type 2 diabetes to maintain glycemic control and minimize vascular complications. We retrospectively investigated potential therapeutic inertia in the management of type 2 diabetes in multiple health care organizations across the USA.

METHODS

Electronic health records were analyzed from 22 American Medical Group Association (AMGA) health care organizations. Bolus insulin-naïve patients with type 2 diabetes and HbA1c ≥ 8.0% (≥ 64 mmol/mol) at baseline were followed for 24 months to identify the frequency and average duration of therapeutic inertia (no new class of glucose-lowering medication prescribed, or not achieving their target HbA1c [< 8.0%; < 64 mmol/mol]).

RESULTS

The study cohort comprised almost 28,000 patients. Therapeutic inertia was observed in ≈ 50% of patients after 6 months, and in > 10% after 24 months. Less therapeutic inertia was observed in patients receiving one or no oral antidiabetic drugs (OADs) (36% or 28%, respectively, at 6 months), while more inertia was seen following multiple OADs or basal insulin (54% of those on baseline basal insulin at 6 months). Although an observable action was recorded for 90% of patients, many (44%) had still not achieved their target HbA1c after 24 months.

CONCLUSION

The results corroborate the presence of therapeutic inertia in people with type 2 diabetes, suggesting that treatment intensification guidelines are not being followed. Extensive variability in the presence of therapeutic inertia was observed both across and within organizations; investigating this further and sharing best practices across providers might help improve the quality of patient care at organizational and national levels.

Evaluating the design and implementation fidelity of an adapted Plan-Do-Study-Act approach to improve health system performance in a Nigerian state

BACKGROUND

The Plan-Do-Study-Act (PDSA) cycle is fundamental to many quality improvement (QI) models. For the approach to be effective in the real-world, variants must align with standard elements of the PDSA. This study evaluates the alignment between theory, design and implementation fidelity of a PDSA variant adapted for Nigeria's health system performance improvement.

METHODS

An iterative consensus building approach was used to develop a scorecard evaluating new conceptual indices of design and implementation fidelity of QI interventions (design and implementation index, defects and gaps) based on Taylor's theoretical framework.

RESULTS

Design (adaptation) scores were optimal across all standard features indicating that design was well adapted to the typical PDSA. Conversely, implementation fidelity scores were only optimal with two standard features: prediction-based test of change and the use of data over time. The other features, use of multiple iterative cycles and documentation had implementation gaps of 17 % and 50 % respectively.

CONCLUSION

This study demonstrates how both adaptation and implementation fidelity are important for success of QI interventions. It also presents an approach for evaluating other QI models using Taylor's PDSA assessment framework as a guide, which might serve to strengthen the theory behind future QI models and provide guidance on their appropriate use.

A mapping of facilitators and barriers to evidence-based management in health systems: a scoping review study

BACKGROUND

Healthcare settings are complex, and the decision-making process is usually complicated, too. Precise use of best evidence from different sources for increasing the desired outcomes is the result of EBM. Therefore, this study aimed to map the potential facilitators and barriers to EBM in health systems to help the healthcare managers to better implement EBM in their organizations.

METHODS

The present study was a scoping review (SR) conducted in 2020 based on the integration of the frameworks presented by Arksey and O'Malley (2005) and Levac et al. (2010) considering the Joanna Briggs Institute guideline (2015). These frameworks consist of 6 steps. After finalizing the search strategy, 7 databases were searched, and the PRISMA-ScR was used to manage the retrieval and inclusion of the evidence. Microsoft Excel 2013 was used to extract the data, and the graphic description was presented. The summative analysis approach was used applying MAXQDA10.

RESULTS

According to the systematic search, 4815 studies were retrieved after eliminating duplicates and unrelated articles, 49 articles remained to extract EBM facilitators and barriers. Six main aspects attitude toward EBM, external factors, contextual factors, resources, policies and procedures, and research capacity and data availability were summarized as EBM facilitators. The barriers to EBM were similarly summarized as attitude toward EBM, external factors, contextual factors, policies and procedures, limited resources, and research capacity and data availability. The streamgraphs describe that the international attention to the sub-aspects of facilitators and barriers of EBM has been increased since 2011.

CONCLUSIONS

The importance of decision-making regarding complex health systems, especially in terms of resource constraints and uncertainty conditions, requires EBM in the health system as much as possible. Identifying the factors that facilitate the use of evidence, as well as its barriers to management and decision-making in the organization, can play an important role in making systematic and reliable decisions that can be defended by the officials and ultimately lead to greater savings in organization resources and prevent them from being wasted.

Dental caries experience and associated factors in adults: a cross-sectional community survey within Ethiopia

Background

Ethiopia is a developing sub-Saharan African country with increasing prevalence of non-communicable diseases (NCDs), including oral conditions. Oral health and dental care have been given little consideration, and there is limited information relating to population oral health and use of dental services in the country. The aim of this study was to examine the burden and associated factors of dental caries experience and investigate access to dental care amongst adults within Ethiopia.

Methods

This community-based oral health survey is a baseline study for the ASSET - Health System Strengthening in sub-Saharan Africa project undertaken in the Butajira area, south-central Ethiopia. A stratified random sample of households and individuals participated in the study. The survey instruments were mainly based on the WHO Oral Health Survey Methods manual (5^th ed.). Face-to-face interviews and clinical dental examinations were conducted. The data were analysed for descriptive statistics; and Poisson regression models were built to assess the association of dental caries and predictor variables in adults (≥18 years).

Results

Most of the study population (n = 626) were female (63.9%), married (71.4%) and Muslim (76.0%). Just over half (53.2%) lived in rural areas and many (44.4%) had no formal education. A majority (74.0%) reported never utilising dental care services, and the main reason was never experiencing any dental problem (71.3%). Sixty percent (n = 377) of the adults had experienced dental caries, 88.0% (n = 332) of whom had untreated carious teeth. Pain or discomfort was reported by 16.5, and 7.2% had one or more PUFA component. Most (59.9%) adults with dental caries experience reported tooth pain or discomfort during the last year. In the fully adjusted Poisson regression model, increasing age, dental care utilisation and Khat chewing had positive significant associations with dental caries experience, whilst education status was negatively associated (p < 0.05).

Conclusion

This study demonstrated a high burden of dental caries and considerable consequences resulting from untreated disease in this population of adults. There was evidence of social inequity, limited utilisation of dental care and oral health awareness. This highlights the need for oral health system strengthening focusing on health promotion and expanding overall access to care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10199-9.

Health system stewardship in Iran: Far from perfect!

This debate article highlights that to perform efficiently and meaningfully, the structure and organization of a health system need to be adjusted to its philosophy, mission, and expected duties. Development of the required organizational structure, in line with the objectives and strategies of the national health policy are fundamental principles of healthcare stewardship. Despite several reforms and initiatives in the course of the last few decades, the Ministry of Health and Medical Education (MoHME), as the steward of the health system in Iran, has not been performing efficient enough to respond to serious emerging challenges. In order to move in line with sustainable health development agenda and reach universal health coverage (UHC), we advocate fundamental structural and institutional reforms within the MoHME in Iran.