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Abu-Zaid MH, Adebajo A, El Miedany Y. Potential for biosimilars in rheumatology in Africa. Ann Rheum Dis 2023; 82:1508-1510. [PMID: 37468221 DOI: 10.1136/ard-2023-224315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
Biosimilars are products which are highly similar to a reference biologic product (RBP). In Africa, regulatory frameworks for biosimilar approval are still in development in many countries and few biosimilars for rheumatic diseases are currently available. The use of biosimilar medicines in Africa provides an important opportunity to treat more rheumatology patients with biologic drugs. This editorial aims to shed a light on the potential benefits, challenges and current efforts, regarding the use of biosimilars in Africa in Rheumatology.
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Affiliation(s)
| | - Adewale Adebajo
- Rheumatology and Health Services Research, The University of Sheffield, Sheffield, UK
- NIHR Sheffield Clinical Research Facility, Sheffield, UK
| | - Yasser El Miedany
- Rheumatology, Canterbury Christ Church College, Chatham, UK
- Rheumatology and Rehabilitation, Ain Shams University Faculty of Medicine, Cairo, Egypt
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Belrhiti Z, Van Belle S, Criel B. How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco. BMJ Glob Health 2021; 6:bmjgh-2021-006140. [PMID: 34261759 PMCID: PMC8280911 DOI: 10.1136/bmjgh-2021-006140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background In Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals. Methods We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of ‘negotiated order’ and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco. Results Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care. Conclusion The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.
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Affiliation(s)
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Pierron A, Fond-Harmant L, Alla F. Supporting parents by combatting social inequalities in health: a realist evaluation. BMC Public Health 2021; 21:1252. [PMID: 34187587 PMCID: PMC8244179 DOI: 10.1186/s12889-021-11237-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To reduce social inequities in health, the World Health Organization's Commission on Social Determinants of Health recommends acting as soon as life begins. In this context, parenting support is promoted as a major lever. The objective of the present research was to develop an intervention theory establishing the conditions for the success of interventions, policies, and organizations supporting parenting in terms of reducing or preventing social inequalities in health for both mother and child in the perinatal period. METHODS To meet these objectives, we conducted a realist evaluation based on a multiple-case study. The study evaluated two border towns in Europe. We collected data from three sources: documentary reviews, focus groups and interviews with professionals, and parental questionnaires. RESULTS The main results concerning the fight against social inequalities in health show a true willingness on the part of those involved to carry out universal actions, coordinated between professionals and institutions, in response to the demands of parents; however, the reality on the ground shows the complexity of their implementation and the multiplicity of results. Our middle-range theory showed that to be effective in tackling social inequalities in health, actions must address structural determinants at the macro-systemic level. However, the field of realist evaluation shows that it is first and foremost the actions focused on individual behavior that are implemented. While there is a general political desire to combat social inequalities in health in early childhood, the results show that the strategies in place are potentially not the most effective. Effective support actions would respond to individual strategies; however, current approaches target parents' behavior, aiming to empower them but without giving them the means to do so. CONCLUSIONS This research constitutes a body of knowledge gathered for reflection and action. In particular, any perinatal policy should clearly state among its objectives the intention to reduce social inequalities in health. The policy should also state that it will be evaluated according to the criteria of proportionate universalism, interprofessional coordination, and actions based on the diversity of parents' needs.
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Affiliation(s)
- Annabelle Pierron
- Bordeaux Population Health Research Center, UMR 1219, Méthodes pour la recherche interventionnelle en santé des populations, Université de Bordeaux, 33000, , 1 rue Jean Burguet, Bordeaux, France.
| | - Laurence Fond-Harmant
- Directrice de Recherche. ACSAL Agence pour la Coopération Scientifique, LEPS UR 3412-Université Sorbonne Paris Nord, Afrique, Luxembourg
| | - François Alla
- Bordeaux Population Health Research Center, CHU INSERM, UMR 1219 CIC-EC 1401, Université de Bordeaux, Bordeaux, France
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Agyenim-Boateng A, Cameron H, Bemah Boamah Mensah A. Health professionals’ perception of disrespectful and abusive intrapartum care during facility-based childbirth in LMIC: A qualitative systematic review and thematic synthesis. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/24/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 01/25/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Belrhiti Z, Van Damme W, Belalia A, Marchal B. Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation. BMJ Open 2020; 10:e031160. [PMID: 31900266 PMCID: PMC6955542 DOI: 10.1136/bmjopen-2019-031160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco. DESIGN We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations. SETTINGS Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called 'advanced regionalisation'. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National 'Concours Qualité', a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence. PARTICIPANTS We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January-February 2018. RESULTS We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving. CONCLUSIONS We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.
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Affiliation(s)
- Zakaria Belrhiti
- Ecole Nationale de Santé Publique, Rabat, Morocco
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussel, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussel, Belgium
| | | | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Belrhiti Z, Van Damme W, Belalia A, Marchal B. The effect of leadership on public service motivation: a multiple embedded case study in Morocco. BMJ Open 2020; 10:e033010. [PMID: 31900272 PMCID: PMC6955481 DOI: 10.1136/bmjopen-2019-033010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES We aimed at exploring the underlying mechanisms and contextual conditions by which leadership may influence 'public service motivation' of health providers in Moroccan hospitals. DESIGN We used the realist evaluation (RE) approach in the following steps: eliciting the initial programme theory, designing the study, carrying out the data collection, doing the data analysis and synthesis. In practice, we adopted a multiple embedded case study design. SETTINGS We used purposive sampling to select hospitals representing extreme cases displaying contrasting leadership practices and organisational performance scores using data from the Ministry of Health quality assurance programmes from 2011 to 2016. PARTICIPANTS We carried out, on average, 17 individual in-depth interviews in 4 hospitals as well as 7 focus group discussions and 8 group discussions with different cadres (administrators, nurses and doctors). We collected relevant documents (eg, performance audit, human resource availability) and carried out observations. RESULTS Comparing the Intervention-Context-Actor-Mechanism-Outcome configurations across the hospitals allowed us to confirm and refine our following programme theory: "Complex leaders, applying an appropriate mix of transactional, transformational and distributed leadership styles that fit organisational and individuals characteristics [I] can increase public service motivation, organisational commitment and extra role behaviours [O] by increasing perceived supervisor support and perceived organizational support and satisfying staff basic psychological needs [M], if the organisational culture is conducive and in the absence of perceived organisational politics [C]". CONCLUSIONS In hospitals, the archetype of complex professional bureaucracies, leaders need to be able to balance between different leadership styles according to the staff's profile, the nature of tasks and the organisational culture if they want to enhance public service motivation, intrinsic motivation and organisational commitment.
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Affiliation(s)
- Zakaria Belrhiti
- Ecole Nationale de Sante Publique, Rabat, Morocco
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Gerontology, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Vanhaecht K, de Witte K, Sermeus W. The Care Process Organization Triangle: A Framework to Better Understand how Clinical Pathways Work. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/205343450701100202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clinical pathways, also known as care pathways or integrated care pathways, are used worldwide to make care processes transparent and organize care around patient needs. Although this is in international use, it is still unclear why pathways sometimes work and sometimes do not. To better understand how pathways work, there is a growing need for paradigms or organizing concepts. Different quality and health-care management gurus have developed frameworks to better understand how certain processes or methods work. This paper will provide an overview of several frameworks and integrate them into Donabedian's Structure–Process–Outcome configuration. In view of this configuration, the care process organization triangle was developed. In this paper, we will describe the three cornerstones of this triangle by integrating the literature on clinical pathways. The care process organization triangle is only one model, but as Deming described it: ‘Some models can be quite useful’.
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Affiliation(s)
- Kris Vanhaecht
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven
- Belgian Dutch Clinical Pathway Network, Leuven
- European Pathway Association, Leuven
| | - Karel de Witte
- Belgian Dutch Clinical Pathway Network, Leuven
- Center for Organisation and Personnel Psychology, Catholic University Leuven, Leuven, Belgium
| | - Walter Sermeus
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven
- Belgian Dutch Clinical Pathway Network, Leuven
- European Pathway Association, Leuven
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Tumusiime P, Kwamie A, Akogun OB, Elongo T, Nabyonga-Orem J. Towards universal health coverage: reforming the neglected district health system in Africa. BMJ Glob Health 2019; 4:e001498. [PMID: 31681483 PMCID: PMC6797439 DOI: 10.1136/bmjgh-2019-001498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/07/2019] [Accepted: 04/27/2019] [Indexed: 11/27/2022] Open
Abstract
In most African countries, the district sphere of governance is a colonial creation for harnessing resources from the communities that are located far away from the centre with the assistance of minimally skilled personnel who are subordinate to the central authority with respect to decision-making and initiative. Unfortunately, postcolonial reforms of district governance have retained the hierarchical structure of the local government. Anchored to such a district arrangement, the (district) health system (DHS) is too weak and impoverished to function in spite of enormous knowledge and natural resources for a seamless implementation of universal health coverage (UHC). Sadly, the quick-fix projects of the 1990s with the laudable intention to reduce the burden of disease within a specified time-point dealt the fatal blow on the DHS administration by diminishing it to a stop-post and a warehouse for commodities (such as bednets and vaccines) destined for the communities. We reviewed the situation of the district in sub-Saharan African countries and identified five attributes that are critical for developing a UHC-friendly DHS. In this analytical paper, we discuss decision-making authority, coordination, resource control, development initiative and management skills as critical factors. We highlight the required strategic shifts and recommend a dialogue for charting an African regional course for a reformed DHS for UHC. Further examination of these factors and perhaps other ancillary criteria will be useful for developing a checklist for assessing the suitability of a DHS for the UHC that Africa deserves.
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Affiliation(s)
- Prosper Tumusiime
- Health Systems and Services Cluster, WHO Regional office for Africa, Brazzaville, Congo
| | - Aku Kwamie
- School of Public Health, University of Ghana, Legon, Ghana
| | - Oladele B Akogun
- Tropical Health and Diseases Research, Federal University of Technology Yola, Yola, Nigeria
- Common Heritage Foundation, Common Heritage Foundation, Abuja, Nigeria
| | - Tarcisse Elongo
- Health Systems and Services Cluster, WHO Regional office for Africa, Brazzaville, Congo
| | - Juliet Nabyonga-Orem
- Health systems and services cluster, World Health Organization, Inter-Country Support Team for Eastern & Southern Africa, Harare, Zimbabwe
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Doricci GC, Guanaes-Lorenzi C. Co-management in the context of Brazil's National Humanization Policy: an integrative review. CIENCIA & SAUDE COLETIVA 2019; 26:2949-2959. [PMID: 34378688 DOI: 10.1590/1413-81232021268.11742019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 09/16/2019] [Indexed: 11/21/2022] Open
Abstract
Co-management is one of the guiding principles of Brazil's National Humanization Policy (NHP), which has been studied since its creation in 2003. This article presents an integrative review of literature on co-management in the context of the NHP. We performed searches of the VHL, CAPES, Scopus and ProQuest databases for articles on co-management published after the creation of the NHP. We conducted a detailed analysis of 36 articles, organizing the results into two predefined categories: theoretical bases and reports on co-management in practice. The articles drew on the following theoretical bases: the circle method/institutional support, ergology, Hermeneutics, schizoanalysis, Habermas' theory of communicative action and Paulo Freire's pedagogy for liberation. Few studies provided original theoretical contributions. Regarding practice, the authors mentioned the implementation of co-management devices and the creation of different collective spaces, which were presented as a being participatory in themselves. The articles offered little reflection on the process of developing a culture of participation. We conclude by pointing to the need for studies that explore the relational construction of co-management in the everyday practice of health care teams.
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Affiliation(s)
- Giovanna Cabral Doricci
- Faculdade de Psicologia, Universidade de Ribeirão Preto UNAERP. Av. Costábile Romano 2201, Ribeirânia. 14096-900 Ribeirão Preto SP Brasil.
| | - Carla Guanaes-Lorenzi
- Faculdade de Psicologia, Universidade de Ribeirão Preto UNAERP. Av. Costábile Romano 2201, Ribeirânia. 14096-900 Ribeirão Preto SP Brasil.
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Bradley S, McCourt C, Rayment J, Parmar D. Midwives' perspectives on (dis)respectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and meta-synthesis. Reprod Health 2019; 16:116. [PMID: 31345239 PMCID: PMC6659209 DOI: 10.1186/s12978-019-0773-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 07/09/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In the past decade, the negative impact of disrespectful maternity care on women's utilisation and experiences of facility-based delivery has been well documented. Less is known about midwives' perspectives on these labour ward dynamics. Yet efforts to provide care that satisfies women's psycho-socio-cultural needs rest on midwives' capacity and willingness to provide it. We performed a systematic review of the emerging literature documenting midwives' perspectives to explore the broader drivers of (dis)respectful care during facility-based delivery in the sub-Saharan African context. METHODS Seven databases (CINAHL, PsychINFO, PsychArticles, Embase, Global Health, Maternity and Infant Care and PubMed) were systematically searched from 1990 to May 2018. Primary qualitative studies with a substantial focus on the interpersonal aspects of care were eligible if they captured midwives' voices and perspectives. Study quality was independently assessed by two reviewers and PRISMA guidelines were followed. The results and findings from each study were synthesised using an existing conceptual framework of the drivers of disrespectful care. RESULTS Eleven papers from six countries were included and six main themes were identified. 'Power and control' and 'Maintaining midwives' status' reflected midwives' focus on the micro-level interactions of the mother-midwife dyad. Meso-level drivers of disrespectful care were: the constraints of the 'Work environment and resources'; concerns about 'Midwives' position in the health systems hierarchy'; and the impact of 'Midwives' conceptualisations of respectful maternity care'. An emerging theme outlined the 'Impact on midwives' of (dis)respectful care. CONCLUSION We used a theoretically informed conceptual framework to move beyond the micro-level and interrogate the social, cultural and historical factors that underpin (dis)respectful care. Controlling women was a key theme, echoing women's experiences, but midwives paid less attention to the social inequalities that distress women. The synthesis highlighted midwives' low status in the health system hierarchy, while organisational cultures of blame and a lack of consideration for them as professionals effectively constitute disrespect and abuse of these health workers. Broader, interdisciplinary perspectives on the wider drivers of midwives' disrespectful attitudes and behaviours are crucial if efforts to improve the maternity care environment - for women and midwives - are to succeed.
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Affiliation(s)
- Susan Bradley
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW UK
| | - Christine McCourt
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW UK
| | - Juliet Rayment
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW UK
| | - Divya Parmar
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW UK
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Abstract
Purpose The purpose of this paper is to explore the way “hybrid” clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms. Design/methodology/approach The authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle. Findings Kenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids’ understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms. Practical implications Understanding hybrids’ interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system’s leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles. Originality/value The authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.
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Affiliation(s)
- Jacinta Nzinga
- Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Gerry McGivern
- Warwick Business School, University of Warwick , Coventry, UK
| | - Mike English
- Centre for Geographic Medicine Research Coast, Kilifi, Kenya
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Munar W, Wahid SS, Curry L. Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol. Gates Open Res 2018. [DOI: 10.12688/gatesopenres.12782.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background. Evaluations of performance measurement and management interventions in public, primary care delivery systems of low- and middle-income countries are scarce. In such contexts, few studies to date have focused on characterizing how, why and under what contextual conditions do such complex, multifaceted arrangements lead to intended and unintended consequences for the healthcare workforce, the healthcare organizations involved, and the communities that are served. Methods. Case-study design with purposeful outlier sampling of high-performing primary care delivery systems in El Salvador and Honduras, as part of the Salud Mesoamerica Initiative. Case study design is suitable for characterizing individual, interpersonal and collective mechanisms of change in complex adaptive systems. The protocol design includes literature review, document review, non-participant observation, and qualitative analysis of in-depth interviews. Data analysis will use inductive and deductive approaches to identify causal patterns organized as ‘context-mechanism-outcome’ configurations. Findings will be triangulated with existing secondary data sources collected including country-specific performance measurement data, impact, and process evaluations conducted by the Salud Mesoamerica Initiative. Discussion. This realist evaluation protocol aims to characterize how, why and under what conditions do performance measurement and management arrangements contribute to the improvement of primary care system performance in two low-income countries.
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Moosa S, Peersman W, Derese A, Kidd M, Pettigrew LM, Howe A, Martinez-Bianchi V, De Maeseneer J. Emerging role of family medicine in South Africa. BMJ Glob Health 2018; 3:e000736. [PMID: 30233837 PMCID: PMC6135463 DOI: 10.1136/bmjgh-2018-000736] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Shabir Moosa
- Department of Family Medicine, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Wim Peersman
- Social and Community Work Research Group, Odisee University College, Brussels, Belgium
| | - Anselme Derese
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Michael Kidd
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, Australia
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Howe
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Jan De Maeseneer
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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Villa S, Restuccia JD, Anessi-Pessina E, Rizzo MG, Cohen AB. Quality improvement strategies and tools: A comparative analysis between Italy and the United States. Health Serv Manage Res 2018; 31:205-217. [PMID: 29486603 DOI: 10.1177/0951484818755534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Italian and American hospitals, in two different periods, have been urged by external circumstances to extensively redesign their quality improvement strategies. This paper, through the use of a survey administered to chief quality officers in both countries, aims to identify commonalities and differences between the two systems and to understand which approaches are effective in improving quality of care. In both countries chief quality officers report quality improvement has become a strategic priority, clinical governance approaches, and tools-such as disease-specific quality improvement projects and clinical pathways-are commonly used, and there is widespread awareness that clinical decision making must be supported by protocols and guidelines. Furthermore, the study clearly outlines the critical importance of adopting a system-wide approach to quality improvement. To this extent Italy seems lagging behind compared to US in fact: (i) responsibilities for different dimensions of quality are spread across different organizational units; (ii) quality improvement strategies do not typically involve administrative staff; and (iii) quality performance measures are not disseminated widely within the organization but are reported primarily to top management. On the other hand, in Italy chief quality officers perceive that the typical hospital organizational structure, which is based on clinical directories, allows better coordination between clinical specialties than in the United States. In both countries, the results of the study show that it is not the single methodology/model that makes the difference but how the different quality improvement strategies and tools interact to each other and how they are coherently embedded with the overall organizational strategy.
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Affiliation(s)
- Stefano Villa
- 1 Department of Management, Università Cattolica del Sacro Cuore, Rome, Italy.,2 CERISMAS (Research Centre in Healthcare Management), Università Cattolica del Sacro Cuore, Milan, Italy
| | | | - Eugenio Anessi-Pessina
- 2 CERISMAS (Research Centre in Healthcare Management), Università Cattolica del Sacro Cuore, Milan, Italy.,4 Department of Management, Università Cattolica del Sacro Cuore, Milano, Italy
| | - Marco Giovanni Rizzo
- 1 Department of Management, Università Cattolica del Sacro Cuore, Rome, Italy.,2 CERISMAS (Research Centre in Healthcare Management), Università Cattolica del Sacro Cuore, Milan, Italy
| | - Alan B Cohen
- 3 Questrom School of Business, Boston University, Boston, MA, USA
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Larson E, Leslie HH, Kruk ME. The determinants and outcomes of good provider communication: a cross-sectional study in seven African countries. BMJ Open 2017; 7:e014888. [PMID: 28674138 PMCID: PMC5734554 DOI: 10.1136/bmjopen-2016-014888] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To determine the extent of provider communication, predictors of good communication and the association between provider communication and patient outcomes, such as patient satisfaction, in seven sub-Saharan African countries. DESIGN Cross-sectional, multicountry study. SETTING Data from recent Service Provision Assessment (SPA) surveys from seven countries in sub-Saharan Africa. SPA surveys include assessment of facility inputs and processes as well as interviews with caretakers of sick children. These data included 3898 facilities and 4627 providers. PARTICIPANTS 16 352 caregivers visiting the facility for their sick children. PRIMARY AND SECONDARY OUTCOME MEASURES We developed an index of four recommended provider communication items for a sick child assessment based on WHO guidelines. We assessed potential predictors of provider communication and considered whether better provider communication was associated with intent to return to the facility for care. RESULTS The average score of the composite indicator of provider communication was low, at 35% (SD 26.9). Fifty-four per cent of caregivers reported that they were told the child's diagnosis, and only 10% reported that they were counselled on feeding for the child. Caregivers' educational attainment and provider preservice education and training in integrated management of childhood illness were associated with better communication. Private facilities and facilities with better infrastructure received higher communication scores. Caretakers reporting better communication were significantly more likely to state intent to return to the facility (relative risk: 1.19, 95% CI 1.16 to 1.22). CONCLUSIONS There are major deficiencies in communication during sick child visits. These are associated with lower provider education as well as less well-equipped facilities. Poor communication, in turn, is linked to lower satisfaction and intention to return to facility among caregivers of sick children. Countries should test strategies for enhancing quality of communication in their efforts to improve health outcomes and patient experience.
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Affiliation(s)
- Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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18
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Haque H, Hill PC, Gauld R. Aid effectiveness and programmatic effectiveness: a proposed framework for comparative evaluation of different aid interventions in a particular health system. Glob Health Res Policy 2017; 2:7. [PMID: 29202075 PMCID: PMC5683205 DOI: 10.1186/s41256-017-0029-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 02/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Against a backdrop of changing concepts of aid effectiveness, development effectiveness, health systems strengthening, and increasing emphasis on impact evaluation, this article proposes a theory-driven impact evaluation framework to gauge the effect of aid effectiveness principles on programmatic outcomes of different aid funded programs in the health sector of a particular country. METHODS The foundation and step-by-step process of implementing the framework are described. RESULTS With empirical evidence from the field, the steps involve analysis of context, program designs, implementation mechanisms, outcomes, synthesis, and interpretation of findings through the programs' underlying program theories and interactions with the state context and health system. CONCLUSIONS The framework can be useful for comparatively evaluating different aid interventions both in fragile and non-fragile state contexts.
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Affiliation(s)
- Hasibul Haque
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, 9016 New Zealand
| | - Philip C. Hill
- Centre for International Health, University of Otago, Dunedin, 9016 New Zealand
| | - Robin Gauld
- Dean’s Office, School of Business, University of Otago, Dunedin, 9016 New Zealand
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Bradley S, McCourt C, Rayment J, Parmar D. Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: A qualitative systematic review and thematic synthesis of women's perceptions and experiences. Soc Sci Med 2016; 169:157-170. [PMID: 27723514 DOI: 10.1016/j.socscimed.2016.09.039] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 11/25/2022]
Abstract
The psycho-social elements of labour and delivery are central to any woman's birth experience, but international efforts to reduce maternal mortality in low-income contexts have neglected these aspects and focused on technological birth. In many contexts, maternity care is seen as dehumanised and disrespectful, which can have a negative impact on utilisation of services. We undertook a systematic review and meta-synthesis of the growing literature on women's experiences of facility-based delivery in sub-Saharan Africa to examine the drivers of disrespectful intrapartum care. Using PRISMA guidelines, databases were searched from 1990 to 06 May 2015, and 25 original studies were included for thematic synthesis. Analytical themes, that were theoretically informed and cognisant of the cultural and social context in which the dynamics of disrespectful care occur, enabled a fresh interpretation of the factors driving midwives' behaviour. A conceptual framework was developed to show how macro-, meso- and micro-level drivers of disrespectful care interact. The synthesis revealed a prevailing model of maternity care that is institution-centred, rather than woman-centred. Women's experiences illuminate midwives' efforts to maintain power and control by situating birth as a medical event and to secure status by focusing on the technical elements of care, including controlling bodies and knowledge. Midwives and women are caught between medical and social models of birth. Global policies encouraging facility-based delivery are forcing women to swap the psycho-emotional care they would receive from traditional midwives for the technical care that professional midwives are currently offering. Any action to change the current performance and dynamic of birth relies on the participation of midwives, but their voices are largely missing from the discourse. Future research should explore their perceptions of the value and practice of interpersonal aspects of maternity care and the impact of disrespectful care on their sense of professionalism and personal ethics.
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Affiliation(s)
- Susan Bradley
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW, England, UK.
| | - Christine McCourt
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW, England, UK.
| | - Juliet Rayment
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW, England, UK.
| | - Divya Parmar
- School of Health Sciences, City, University of London, 1 Myddelton Street, London, EC1R 1UW, England, UK.
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20
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Kawonga M, Blaauw D, Fonn S. The influence of health system organizational structure and culture on integration of health services: the example of HIV service monitoring in South Africa. Health Policy Plan 2016; 31:1270-80. [PMID: 27198977 DOI: 10.1093/heapol/czw061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2016] [Indexed: 11/14/2022] Open
Abstract
Administrative integration of disease control programmes (DCPs) within the district health system has been a health sector reform priority in South Africa for two decades. The reforms entail district managers assuming authority for the planning and monitoring of DCPs in districts, with DCP managers providing specialist support. There has been little progress in achieving this, and a dearth of research exploring why. Using a case study of HIV programme monitoring and evaluation (M&E), this article explores whether South Africa's health system is configured to support administrative integration. The article draws on data from document reviews and interviews with 54 programme and district managers in two of nine provinces, exploring their respective roles in decision-making regarding HIV M&E system design and in using HIV data for monitoring uptake of HIV interventions in districts. Using Mintzberg's configurations framework, we describe three organizational parameters: (a) extent of centralization (whether district managers play a role in decisions regarding the design of the HIV M&E system); (b) key part of the organization (extent to which sub-national programme managers vs district managers play the central role in HIV monitoring in districts); and (c) coordination mechanisms used (whether highly formalized and rules-based or more output-based to promote agency). We find that the health system can be characterized as Mintzberg's machine bureaucracy. It is centralized and highly formalized with structures, management styles and practices that promote programme managers as lead role players in the monitoring of HIV interventions within districts. This undermines policy objectives of district managers assuming this leadership role. Our study enhances the understanding of organizational factors that may limit the success of administrative integration reforms and suggests interventions that may mitigate this.
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Affiliation(s)
- Mary Kawonga
- Department of Community Health, School of Public Health, University of the Witwatersrand, Faculty of Health Sciences
| | - Duane Blaauw
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Faculty of Health Sciences
| | - Sharon Fonn
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
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Lacouture A, Breton E, Guichard A, Ridde V. The concept of mechanism from a realist approach: a scoping review to facilitate its operationalization in public health program evaluation. Implement Sci 2015; 10:153. [PMID: 26519291 PMCID: PMC4628377 DOI: 10.1186/s13012-015-0345-7] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 10/26/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Public health interventions are complex by nature, and their evaluation requires unpacking their intervention logic and their interactions with open social systems. By focusing on the interrelationships between context, mechanism, and outcome, Pawson and Tilley's realist approach appears a promising innovation for public health-related evaluation works. However, and as expected of any methodological innovation, this approach is being constructed gradually by answering the multiple challenges to its operationalization that fall in its path. One of these challenges, users of this approach agree on, is the necessity of clarifying its key concept of mechanism. METHOD We first collected the definitions of mechanism from published works of Pawson and colleagues. Secondly, a scoping review was conducted to identify the ones quoted by users of the realist approach for evaluating public health interventions (1997-2012). We then appraised the clarity and precision of this concept against the three dimensions defined by Daigneault and Jacobs "term, sense and referent." RESULTS Of the 2344 documents identified in the scoping review, 49 documents were included. Term: Users of the realist approach use adjectives qualifying the term mechanism that were not specifically endorsed by Pawson and colleagues. Sense: None of the attributes stated by Pawson and colleagues has been listed in all of the documents analyzed, and some contributions clarified its attributes. Referent: The concept of mechanism within a realist approach can be ascribed to theory-based evaluation, complex social interventions, and critical realism. CONCLUSION This review led us to reconsider the concept of mechanism within the realist approach by confronting the theoretical stance of its proponents to the practical one of its users. This resulted in a clearer, more precise definition of the concept of mechanism which may in turn trigger further improvements in the way the realist approach is applied in evaluative practice in public health and potentially beyond. A mechanism is hidden but real, is an element of reasoning and reactions of agents in regard to the resources available in a given context to bring about changes through the implementation of an intervention, and evolves within an open space-time and social system of relationships.
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Affiliation(s)
- Anthony Lacouture
- EHESP French School of Public Health, Sorbonne Paris Cité, Rennes, France.
- CNRS, UMR CRAPE Centre for Research on Political Action in Europe-6051, Rennes, France.
- ESPUM School of Public Health University of Montreal, Montreal, Quebec, Canada.
| | - Eric Breton
- EHESP French School of Public Health, Sorbonne Paris Cité, Rennes, France
- CNRS, UMR CRAPE Centre for Research on Political Action in Europe-6051, Rennes, France
| | - Anne Guichard
- Faculty of Nursing, Laval University, Quebec, Quebec, Canada
| | - Valéry Ridde
- ESPUM School of Public Health University of Montreal, Montreal, Quebec, Canada
- IRSPUM University of Montreal Public Health Research Institute, Montreal, Quebec, Canada
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Hernández AR, Hurtig AK, Dahlblom K, San Sebastián M. Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala. Int J Equity Health 2015; 14:91. [PMID: 26449232 PMCID: PMC4599024 DOI: 10.1186/s12939-015-0225-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/28/2015] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Mid-level health workers are on the front-lines in underserved areas in many LMICs, and their performance is critical for improving the health of vulnerable populations. However, improving performance in low-resource settings is complex and highly dependent on the organizational context of local health systems. This study aims to examine the views of actors from different levels of a regional health system in Guatemala on actions to support the performance of auxiliary nurses, a cadre of mid-level health workers with a prominent role in public sector service delivery. A concept mapping study was carried out to develop an integrated view on organizational support and identify locally relevant strategies for strengthening performance. METHODS A total of 93 regional and district managers, and primary and secondary care health workers participated in generating ideas on actions needed to support auxiliary nurses' performance. Ideas were consolidated into 30 action items, which were structured through sorting and rating exercises, involving a total of 135 of managers and health workers. Maps depicting participants' integrated views on domains of action and dynamics in sub-groups' interests were generated using a sequence of multivariate statistical analyses, and interpreted by regional managers. RESULTS The combined input of health system actors provided a multi-faceted view of actions needed to support performance, which were organized in six domains, including: Communication and coordination, Tools to orient work, Organizational climate of support, Motivation through recognition, Professional development and Skills development. The nature of relationships across hierarchical levels was identified as a cross-cutting theme. Pattern matching and go-zone maps indicated directions for action based on areas of consensus and difference across sub-groups of actors. CONCLUSIONS This study indicates that auxiliary nurses' performance is interconnected with the performance of other health system actors who require support, including managers and community-level collaborators. Organizational climate is critical for making auxiliary nurses feel supported, and greater attention to improving the quality of hierarchical relationships is needed in LMIC settings. The participatory nature of the concept-mapping process enabled health system actors to collaborate in co-production of context-specific knowledge needed to guide efforts to strengthen performance in a vulnerable region.
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Affiliation(s)
- Alison R Hernández
- Division of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden.
| | - Anna-Karin Hurtig
- Division of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden.
| | - Kjerstin Dahlblom
- Division of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden.
| | - Miguel San Sebastián
- Division of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden.
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Herepath A, Kitchener M, Waring J. A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03400] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BackgroundHospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.ObjectivesThis study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.DesignWe used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.SettingWelsh Government and NHS Wales.ParticipantsInterviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.Main outcome measuresIdentification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.ResultsAn innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.ConclusionsHeightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrea Herepath
- Sir Roland Smith Centre for Strategic Management, Department of Entrepreneurship, Strategy and Innovation, Lancaster University Management School, Lancaster University, Lancaster, UK
- Cardiff Business School, Cardiff University, Cardiff, UK
| | | | - Justin Waring
- Nottingham University Business School, University of Nottingham, Nottingham, UK
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Kwamie A, Agyepong IA, van Dijk H. What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West District, Ghana. Health Syst Reform 2015; 1:167-177. [DOI: 10.1080/23288604.2015.1032475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Aku Kwamie
- School of Public Health; University of Ghana; Accra, Ghana
- Sociology of Development and Change; Wageningen University; Wageningen, The Netherlands
| | - Irene Akua Agyepong
- School of Public Health; University of Ghana; Accra, Ghana
- Julius Global Health; University Medical Center; Utrecht, The Netherlands
| | - Han van Dijk
- Sociology of Development and Change; Wageningen University; Wageningen, The Netherlands
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25
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Renedo A, Marston C. Developing patient-centred care: an ethnographic study of patient perceptions and influence on quality improvement. BMC Health Serv Res 2015; 15:122. [PMID: 25903663 PMCID: PMC4407290 DOI: 10.1186/s12913-015-0770-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 02/27/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Understanding quality improvement from a patient perspective is important for delivering patient-centred care. Yet the ways patients define quality improvement remains unexplored with patients often excluded from improvement work. We examine how patients construct ideas of 'quality improvement' when collaborating with healthcare professionals in improvement work, and how they use these understandings when attempting to improve the quality of their local services. METHODS We used in-depth interviews with 23 'patient participants' (patients involved in quality improvement work) and observations in several sites in London as part of a four-year ethnographic study of patient and public involvement (PPI) activities run by Collaborations for Leadership in Applied Health Research and Care for Northwest London. We took an iterative, thematic and discursive analytical approach. RESULTS When patient participants tried to influence quality improvement or discussed different dimensions of quality improvement their accounts and actions frequently started with talk about improvement as dependent on collective action (e.g. multidisciplinary healthcare professionals and the public), but usually quickly shifted away from that towards a neoliberal discourse emphasising the role of individual patients. Neoliberal ideals about individual responsibility were taken up in their accounts moving them away from the idea of state and healthcare providers being held accountable for upholding patients' rights to quality care, and towards the idea of citizens needing to work on self-improvement. Participants portrayed themselves as governed by self-discipline and personal effort in their PPI work, and in doing so provided examples of how neoliberal appeals for self-regulation and self-determination also permeated their own identity positions. CONCLUSIONS When including patient voices in measuring and defining 'quality', governments and public health practitioners should be aware of how neoliberal rationalities at the heart of policy and services may discourage consumers from claiming rights to quality care by contributing to public unwillingness to challenge the status quo in service provision. If the democratic potential of patient and public involvement initiatives is to be realised, it will be crucial to help citizens to engage critically with how neoliberal rationalities can undermine their abilities to demand quality care.
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Affiliation(s)
- Alicia Renedo
- Department of Social & Environmental Health Research, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Cicely Marston
- Department of Social & Environmental Health Research, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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Vareilles G, Pommier J, Kane S, Pictet G, Marchal B. Understanding the motivation and performance of community health volunteers involved in the delivery of health programmes in Kampala, Uganda: a realist evaluation protocol. BMJ Open 2015; 5:e006752. [PMID: 25631314 PMCID: PMC4316434 DOI: 10.1136/bmjopen-2014-006752] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The recruitment of community health volunteers to support the delivery of health programmes is a well-established approach in many countries, particularly where health services are not readily available. However, studies on management of volunteers are scarce and current research on human resource management of volunteers faces methodological challenges. This paper presents the protocol of a realist evaluation that aims at identifying the factors influencing the performance of community health volunteers involved in the delivery of a Red Cross immunisation programme in Kampala (Uganda) with a specific focus on motivation. METHODS AND ANALYSIS The realist evaluation cycle structures the protocol. To develop the theoretical basis for the evaluation, the authors conducted interviews and reviewed the literature on community health volunteers' performance, management and organisational behaviour. This led to the formulation of the initial programme theory, which links the intervention inputs (capacity-building strategies) to the expected outcomes (positive work behaviour) with mechanisms that point in the direction of drivers of motivation. The contextual elements include components such as organisational culture, resource availability, etc. A case study design will be adopted. We define a case as a Red Cross branch, run by a programme manager, and will select two cases at the district level in Kampala. Mixed methods will be used in data collection, including individual interviews of volunteers, participant observation and document review. The thematic analysis will be based on the initial programme theory and will seek for context-mechanism-outcome configurations. Findings from the two cases will be compared. DISCUSSION We discuss the scope for applying realist evaluation and the methodological challenges we encountered in developing this protocol. ETHICS AND DISSEMINATION The study was approved by the Ethical Committee at Rennes University Hospital, France. Results will be published in scientific journals, and communicated to respondents and relevant institutions.
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Affiliation(s)
- Gaëlle Vareilles
- EHESP Rennes, Sorbonne Paris Cité, Rennes, France
- CNRS, UMR CRAPE Centre de Recherches sur l'Action Politique en Europe-6051, Rennes, France
| | - Jeanine Pommier
- EHESP Rennes, Sorbonne Paris Cité, Rennes, France
- CNRS, UMR CRAPE Centre de Recherches sur l'Action Politique en Europe-6051, Rennes, France
| | - Sumit Kane
- Department of Development, Policy and Practice, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Gabriel Pictet
- International Federation of Red Cross and Red Crescent Societies, Community Health and Innovation, Geneva, Switzerland
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Nayiga S, DiLiberto D, Taaka L, Nabirye C, Haaland A, Staedke SG, Chandler CIR. Strengthening patient-centred communication in rural Ugandan health centres: A theory-driven evaluation within a cluster randomized trial. EVALUATION (LONDON, ENGLAND : 1995) 2014; 20:471-491. [PMID: 25983612 PMCID: PMC4425297 DOI: 10.1177/1356389014551484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article describes a theory-driven evaluation of one component of an intervention to improve the quality of health care at Ugandan public health centres. Patient-centred services have been advocated widely, but such approaches have received little attention in Africa. A cluster randomized trial is evaluating population-level outcomes of an intervention with multiple components, including 'patient-centred services.' A process evaluation was designed within this trial to articulate and evaluate the implementation and programme theories of the intervention. This article evaluates one hypothesized mechanism of change within the programme theory: the impact of the Patient Centred Services component on health-worker communication. The theory-driven approach extended to evaluation of the outcome measures. The study found that the proximal outcome of patient-centred communication was rated 10 percent higher (p < 0.008) by care seekers consulting with the health workers who were at the intervention health centres compared with those at control health centres. This finding will strengthen interpretation of more distal trial outcomes.
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Affiliation(s)
- Susan Nayiga
- Infectious Disease Research Collaboration, Uganda
| | | | - Lilian Taaka
- Infectious Disease Research Collaboration, Uganda
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Reynolds J, DiLiberto D, Mangham-Jefferies L, Ansah EK, Lal S, Mbakilwa H, Bruxvoort K, Webster J, Vestergaard LS, Yeung S, Leslie T, Hutchinson E, Reyburn H, Lalloo DG, Schellenberg D, Cundill B, Staedke SG, Wiseman V, Goodman C, Chandler CIR. The practice of 'doing' evaluation: lessons learned from nine complex intervention trials in action. Implement Sci 2014; 9:75. [PMID: 24935096 PMCID: PMC4079170 DOI: 10.1186/1748-5908-9-75] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/13/2014] [Indexed: 01/16/2023] Open
Abstract
Background There is increasing recognition among trialists of the challenges in understanding how particular ‘real-life’ contexts influence the delivery and receipt of complex health interventions. Evaluations of interventions to change health worker and/or patient behaviours in health service settings exemplify these challenges. When interpreting evaluation data, deviation from intended intervention implementation is accounted for through process evaluations of fidelity, reach, and intensity. However, no such systematic approach has been proposed to account for the way evaluation activities may deviate in practice from assumptions made when data are interpreted. Methods A collective case study was conducted to explore experiences of undertaking evaluation activities in the real-life contexts of nine complex intervention trials seeking to improve appropriate diagnosis and treatment of malaria in varied health service settings. Multiple sources of data were used, including in-depth interviews with investigators, participant-observation of studies, and rounds of discussion and reflection. Results and discussion From our experiences of the realities of conducting these evaluations, we identified six key ‘lessons learned’ about ways to become aware of and manage aspects of the fabric of trials involving the interface of researchers, fieldworkers, participants and data collection tools that may affect the intended production of data and interpretation of findings. These lessons included: foster a shared understanding across the study team of how individual practices contribute to the study goals; promote and facilitate within-team communications for ongoing reflection on the progress of the evaluation; establish processes for ongoing collaboration and dialogue between sub-study teams; the importance of a field research coordinator bridging everyday project management with scientific oversight; collect and review reflective field notes on the progress of the evaluation to aid interpretation of outcomes; and these approaches should help the identification of and reflection on possible overlaps between the evaluation and intervention. Conclusion The lessons we have drawn point to the principle of reflexivity that, we argue, needs to become part of standard practice in the conduct of evaluations of complex interventions to promote more meaningful interpretations of the effects of an intervention and to better inform future implementation and decision-making.
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Affiliation(s)
- Joanna Reynolds
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana. Health Res Policy Syst 2014; 12:29. [PMID: 24935521 PMCID: PMC4073809 DOI: 10.1186/1478-4505-12-29] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 04/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP ‘works’ when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams. Methods We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms. Results The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP’s underlying goal of organisational control. Conclusions Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.
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Affiliation(s)
- Aku Kwamie
- University of Ghana, School of Public Health, P,O, Box LG 13, Accra, Ghana.
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More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala. BMC Health Serv Res 2014; 14:112. [PMID: 24602196 PMCID: PMC3973852 DOI: 10.1186/1472-6963-14-112] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 02/21/2014] [Indexed: 11/22/2022] Open
Abstract
Background Mid-level health workers (MLHWs) form the front-line of service delivery in many low- and middle-income countries. Supervision is a critical institutional intervention linking their work to the health system, and it consists of activities intended to support health workers’ motivation and enable them to perform. However its impact depends not only on the frequency of these activities but also how they are carried out and received. This study aims to deepen understanding of the mechanisms through which supervision activities support the performance of auxiliary nurses, a cadre of MLHWs, in rural Guatemala. Methods A multiple case study was conducted to examine the operation of supervision of five health posts using a realist evaluation approach. A program theory was formulated describing local understanding of how supervision activities are intended to work. Data was collected through interviews and document review to test the theory. Analysis focused on comparison of activities, outcomes, mechanisms and the influence of context across cases, leading to revision of the program theory. Results The supervisor’s orientation was identified as the main mechanism contributing to variation observed in activities and their outcomes. Managerial control was the dominant orientation, reflecting the influence of standardized performance criteria and institutional culture. Humanized support was present in one case where the auxiliary nurse was motivated by the sense that the full scope of her work was valued. This orientation reflected the supervisor’s integration of her professional identity as a nurse. Conclusions The nature of the support health workers received was shaped by supervisors’ orientation, and in this study, nursing principles were central to humanized support. Efforts to strengthen the support that supervision provides to MLHWs should promote professional ethos as a means of developing shared performance goals and orient supervisors to a more holistic view of the health worker and their work.
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Goicolea I, Vives-Cases C, Sebastian MS, Marchal B, Kegels G, Hurtig AK. How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol. Implement Sci 2013; 8:36. [PMID: 23522404 PMCID: PMC3617002 DOI: 10.1186/1748-5908-8-36] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 03/20/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues-such as IPV management-get integrated into health systems, and that focuses on healthcare teams' learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services. METHODS This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management. DISCUSSION Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.
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Affiliation(s)
- Isabel Goicolea
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden
- Public Health Research Group, Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain
| | - Carmen Vives-Cases
- Public Health Research Group, Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain
| | - Miguel San Sebastian
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Guy Kegels
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Anna-Karin Hurtig
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umea University, SE-90187 Umea, Sweden
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Chandler CIR, Kizito J, Taaka L, Nabirye C, Kayendeke M, DiLiberto D, Staedke SG. Aspirations for quality health care in Uganda: How do we get there? HUMAN RESOURCES FOR HEALTH 2013; 11:13. [PMID: 23521859 PMCID: PMC3610284 DOI: 10.1186/1478-4491-11-13] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 02/28/2013] [Indexed: 06/01/2023]
Abstract
BACKGROUND Despite significant investments and reforms, health care remains poor for many in Africa. To design an intervention to improve access and quality of health care at health facilities in eastern Uganda, we aimed to understand local priorities for qualities in health care, and factors that enable or prevent these qualities from being enacted. METHODS In 2009 to 2010, we carried out 69 in-depth interviews and 6 focus group discussions with 65 health workers at 17 health facilities, and 10 focus group discussions with 113 community members in Tororo District, Uganda. RESULTS Health-care workers and seekers valued technical, interpersonal and resource qualities in their aspirations for health care. However, such qualities were frequently not enacted, and our analysis suggests that meeting aspirations required social and financial resources to negotiate various power structures. CONCLUSIONS We argue that achieving aspirations for qualities valued in health care will require a genuine reorientation of focus by health workers and their managers toward patients, through renewed respect and support for these providers as professionals.
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Affiliation(s)
- Clare I R Chandler
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - James Kizito
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Lilian Taaka
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Christine Nabirye
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Miriam Kayendeke
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Deborah DiLiberto
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel St, London, WCIE 7HT, UK
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel St, London, WCIE 7HT, UK
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Goicolea I, Coe AB, Hurtig AK, San Sebastian M. Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach. Glob Health Action 2012; 5:GHA-5-18748. [PMID: 22855646 PMCID: PMC3409349 DOI: 10.3402/gha.v5i0.18748] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 07/04/2012] [Accepted: 07/05/2012] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite evidence showing that adolescent-friendly health services (AFSs) increase young people's access to these services, health systems across the world are failing to integrate this approach. In Latin America, policies aimed at strengthening AFS abound. However, such services are offered only in a limited number of sites, and providers' attitudes and respect for confidentiality have not been addressed to a sufficient extent. METHODS The aim of this study was to explore the mechanisms that triggered the transformation of an 'ordinary' health care facility into an AFS in Ecuador. For this purpose, a realist evaluation approach was used in order to analyse three well-functioning AFSs. Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth organisations and (iii) observations at the health care facilities. Thematic analysis was carried out, driven by the realist evaluation approach, namely exploring the connections between mechanisms, contexts and outcomes. RESULTS The results highlighted that the development of the AFSs was mediated by four mechanisms: grounded self-confidence in trying new things, legitimacy, a transformative process and an integral approach to adolescents. Along this process, contextual factors at the national and institutional levels were further explored. CONCLUSION The Ministry of Health of Ecuador, based on the New Guidelines for Comprehensive Care of Adolescent Health, has started the scaling up of AFSs. Our research points towards the need to recognise and incorporate these mechanisms as part of the implementation strategy from the very beginning of the process. Although contextually limited to Ecuador, many mechanisms and good practices in these AFS may be relevant to the Latin American setting and elsewhere.
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Affiliation(s)
- Isabel Goicolea
- Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
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Fonn S, Ray S, Blaauw D. Innovation to improve health care provision and health systems in sub-Saharan Africa - promoting agency in mid-level workers and district managers. Glob Public Health 2011; 6:657-68. [PMID: 20582782 DOI: 10.1080/17441692.2010.489905] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Initiatives to address the human resource crisis in African health systems have included expanded training of mid-level workers (MLWs). Currently, MLWs are the backbone of many health systems in Africa but they are often de-motivated and they often operate in circumstances in which providing high quality care is challenging. Therefore, assuming that introducing additional people will materially change health system performance is unrealistic. We briefly critique such unifocal interventions and review the literature to understand the factors that affect the motivation and performance of MLWs. Three themes emerge: the low status and inadequate recognition of MLWs, quality of care issues and working in poorly managed systems. In response we propose three interrelated interventions: a regional association of MLWs to enhance their status and recognition, a job enrichment and mentoring system to address quality and a district managers' association to improve health systems management. The professionalisation of MLWs and district managers to address confidence, self-esteem and value is considered. The paper describes the thinking behind these interventions, which are currently being tested in Kenya, Nigeria, South Africa and Uganda for their acceptability and appropriateness. We offer the policy community a complementary repertoire to existing human resource strategies in order to effect real change in African health systems.
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Affiliation(s)
- Sharon Fonn
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Van Belle SB, Marchal B, Dubourg D, Kegels G. How to develop a theory-driven evaluation design? Lessons learned from an adolescent sexual and reproductive health programme in West Africa. BMC Public Health 2010; 10:741. [PMID: 21118510 PMCID: PMC3001738 DOI: 10.1186/1471-2458-10-741] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 11/30/2010] [Indexed: 11/17/2022] Open
Abstract
Background This paper presents the development of a study design built on the principles of theory-driven evaluation. The theory-driven evaluation approach was used to evaluate an adolescent sexual and reproductive health intervention in Mali, Burkina Faso and Cameroon to improve continuity of care through the creation of networks of social and health care providers. Methods/design Based on our experience and the existing literature, we developed a six-step framework for the design of theory-driven evaluations, which we applied in the ex-post evaluation of the networking component of the intervention. The protocol was drafted with the input of the intervention designer. The programme theory, the central element of theory-driven evaluation, was constructed on the basis of semi-structured interviews with designers, implementers and beneficiaries and an analysis of the intervention's logical framework. Discussion The six-step framework proved useful as it allowed for a systematic development of the protocol. We describe the challenges at each step. We found that there is little practical guidance in the existing literature, and also a mix up of terminology of theory-driven evaluation approaches. There is a need for empirical methodological development in order to refine the tools to be used in theory driven evaluation. We conclude that ex-post evaluations of programmes can be based on such an approach if the required information on context and mechanisms is collected during the programme.
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Affiliation(s)
- Sara B Van Belle
- Institute of Tropical Medicine, Nationalestraat 155, B-2000 Antwerp, Belgium.
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van Olmen J, Criel B, Devadasan N, Pariyo G, De Vos P, Van Damme W, Van Dormael M, Marchal B, Kegels G. Primary Health Care in the 21st century: primary care providers and people's empowerment. Trop Med Int Health 2010; 15:386-90. [PMID: 20149164 DOI: 10.1111/j.1365-3156.2010.02475.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Marchal B, Dedzo M, Kegels G. A realist evaluation of the management of a well-performing regional hospital in Ghana. BMC Health Serv Res 2010; 10:24. [PMID: 20100330 PMCID: PMC2828434 DOI: 10.1186/1472-6963-10-24] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Accepted: 01/25/2010] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Realist evaluation offers an interesting approach to evaluation of interventions in complex settings, but has been little applied in health care. We report on a realist case study of a well performing hospital in Ghana and show how such a realist evaluation design can help to overcome the limited external validity of a traditional case study. METHODS We developed a realist evaluation framework for hypothesis formulation, data collection, data analysis and synthesis of the findings. Focusing on the role of human resource management in hospital performance, we formulated our hypothesis around the high commitment management concept. Mixed methods were used in data collection, including individual and group interviews, observations and document reviews. RESULTS We found that the human resource management approach (the actual intervention) included induction of new staff, training and personal development, good communication and information sharing, and decentralised decision-making. We identified 3 additional practices: ensuring optimal physical working conditions, access to top managers and managers' involvement on the work floor. Teamwork, recognition and trust emerged as key elements of the organisational climate. Interviewees reported high levels of organisational commitment. The analysis unearthed perceived organisational support and reciprocity as underlying mechanisms that link the management practices with commitment. Methodologically, we found that realist evaluation can be fruitfully used to develop detailed case studies that analyse how management interventions work and in which conditions. Analysing the links between intervention, mechanism and outcome increases the explaining power, while identification of essential context elements improves the usefulness of the findings for decision-makers in other settings (external validity). We also identified a number of practical difficulties and priorities for further methodological development. CONCLUSION This case suggests that a well-balanced HRM bundle can stimulate organisational commitment of health workers. Such practices can be implemented even with narrow decision spaces. Realist evaluation provides an appropriate approach to increase the usefulness of case studies to managers and policymakers.
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Affiliation(s)
- Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine-Antwerp, Nationalestraat 155, B-2000 Antwerp, Belgium
| | - McDamien Dedzo
- Volta Regional Health Directorate, PO Box HP 72, Ho, Volta Region, Ghana
| | - Guy Kegels
- Department of Public Health, Institute of Tropical Medicine-Antwerp, Nationalestraat 155, B-2000 Antwerp, Belgium
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Meessen B, Musango L, Kashala JPI, Lemlin J. Reviewing institutions of rural health centres: the Performance Initiative in Butare, Rwanda. Trop Med Int Health 2006; 11:1303-17. [PMID: 16903893 DOI: 10.1111/j.1365-3156.2006.01680.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In many low-income countries, performance of pyramidal health systems with a public purpose is not meeting the expectations and needs of the populations they serve. A question that has not been studied and tested sufficiently is, 'What is the right package of institutional mechanisms required for organisations and individuals working in these health systems?' This paper presents the experience of the Performance Initiative, an innovative contractual approach that has reshaped the incentive structure in place in two rural districts of Rwanda. It describes the general background, the initial analysis, the institutional arrangement and the results after 3 years of operations. At this stage of the experience, it shows that 'output-based payment + greater autonomy' is a feasible and effective strategy for improving the performance of public health centres. As part of a more global package of strategies, contracting-in approaches could be an interesting option for governments, donors and non-governmental organisations in their effort to achieve some of the Millennium Development Goals.
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Affiliation(s)
- Bruno Meessen
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
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Abstract
PURPOSE The objective of this research is to investigate the success of TQM and barriers to its successful implementation in health care services organizations in Isfahan province, Iran, 2004. DESIGN/METHODOLOGY/APPROACH This descriptive and cross-sectional research was done via two questionnaires (TQM success and its barriers). The statistical population of this research consists of all managers of health care services organizations who implemented TQM in their organizations (90 managers). FINDINGS TQM success in Isfahan health care organizations was high. In correlation analyses between the success of TQM and its principles, success, process management and focus on employees had a positive and the greatest effect and focus on material resources and on suppliers had a lower effect. In correlation analysis between the barriers to TQM and the problem dimensions, human resource, strategic and structural problems were the most important obstacles and barriers to TQM successful implementation respectively. RESEARCH LIMITATIONS/IMPLICATIONS Although conducted in Iran, it is anticipated that the findings may well have relevance on a broader scale. ORIGINALITY/VALUE By replicating this study in different countries and contexts the results could be very fruitful for developing a model of TQM that can be implemented easily, effectively, efficiently and successfully in a cross-cultural context.
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