How to do (or not to do) ... a social network analysis in health systems research

Scaling up One Health: A network analysis in Lao PDR

Background

One Health focuses on sustainable health for humans, animals, and ecosystems. The approach has been well demonstrated, yet most efforts have not been scaled up. Understanding the organisations involved in scaling up processes is critical to translating research into practice. The Lao People's Democratic Republic has successfully implemented One Health projects for multiple decades; however, the organisational network has not been described and scaling up efforts have been limited.

Methods

Data from organisations involved in One Health projects over the past five years were collected by key-informant interview or workshop. The network was investigated using a mixture of quantitative network analysis and qualitative thematic analysis.

Results

The organisational network was quantitatively described as sparse and centralised. Organisations were required to harness pre-existing relationships to maximise scarce resources and make co-ordination and alignment of priorities more efficient. A lack of international organisations in the top 10% of resource sharing metrics suggests a potential disconnect between donors. This was reflected in the challenges faced by national organisations and a feeling of being stretched thin over numerous externally funded projects with donor-driven priorities.

Conclusions

It appears that high-level political support for country ownership of development and aid priorities remains unrealised. Developing network capacity and capability may assist scaling up efforts and build resilience in the network and its core organisations. This may allow for the inclusion of more development, education, environment, and water, sanitation, and hygiene organisations that were perceived to be lacking. Future One Health programmes should focus on practical activities that do not overload staff capacity. There is much for One Health to learn about the art of scaling up and organisations are encouraged to include implementation science in their research to inform future scaling up efforts.

Healthcare social network research and the ECHO model™: Exploring a community of practice to support cultural brokers and transfer cultural knowledge

BACKGROUND

Project ECHO® networks at Children's Health Queensland Hospital and Health Service (CHQHHS) are communities of practice designed to mitigate services and systems fragmentation by building collaborative partnerships addressing priority child and youth health needs. Aboriginal and Torres Strait Islander people experience the negative impacts of fragmentation in addition to historical challenges of absent or culturally inappropriate health services. Access to culturally safe and responsive services can be improved by engaging Aboriginal and Torres Strait Islander Health Workers and similar roles in an online community of practice, supporting the integration of cultural and clinical knowledge and self-determination of Aboriginal and Torres Strait Islander consumers in decisions affecting their health. Analysing professional support networks and knowledge sharing patterns helps identify enablers and barriers to partnerships. Using social network research, the multilevel network inclusive of ECHO network members and their colleagues was studied to identify interdisciplinary and cross-sector advice exchange patterns, explore the position of cultural brokers and identify common relational tendencies.

METHODS

Social network theories and methods informed the collection of network data and analysis of advice-seeking relationships among ECHO network members and their nominees. Registered members from two ECHO networks were invited to complete the Qualtrics survey. Networks analysed comprised 398 professionals from mainstream health, Aboriginal and Torres Strait Islander Community Controlled Health Organisation, education, disability and child safety service settings.

RESULTS

Brokers were well represented, both those who hold knowledge brokerage positions as well as cultural brokers who incorporate clinical and cultural knowledge enabling holistic care for Aboriginal and Torres Strait Islander patients (38 individuals, 17% of network). Professionals who occupy brokerage positions outside the ECHO network tend to be more connected with co-members within the network.

CONCLUSIONS

This study is the first application of contemporary social network theories and methods to investigate an ECHO network. The findings highlight the connectivity afforded by brokers, enabling the coordination and collaboration necessary for effective care integration. Inclusion of cultural brokers in an ECHO network provides sustained peer group support while also cultivating relationships that facilitate the integration of cultural and clinical knowledge.

Faculty members as academic knowledge brokers in Iran's health sector: a social network analysis study

BACKGROUND

Interaction between researchers and policymakers is an essential factor to facilitate the evidence-informed policymaking. One of the effective ways to establish this relationship and promote evidence-informed policymaking is to employ people or organizations that can play the role of knowledge brokers. This study aims to analyze the communication network and interactions between researchers and policymakers in Iran's health sector and identify key people serving as academic knowledge brokers.

METHODS

This study was a survey research. Using a census approach, we administered a sociometric survey to faculty members in the health field in top ten Iranian medical universities to construct academic-policymaker network using social network analysis method. Network maps were generated using UCINET and NetDraw software. We used Indegree Centrality, Outdegree Centrality, and Betweenness Centrality indicators to determine knowledge brokers in the network.

RESULTS

The drawn network had a total of 188 nodes consisting of 94 university faculty members and 94 policymakers at three national, provincial, and university levels. The network comprised a total of 177 links, with 125 connecting to policymakers and 52 to peers. Of 56 faculty members, we identified four knowledge brokers. Six policymakers were identified as key policymakers in the network, too.

CONCLUSIONS

It seems that the flow of knowledge produced by research in the health field in Iran is not accomplished well from the producers of research evidence to the users of knowledge. Therefore, it seems necessary to consider incentive and support mechanisms to strengthen the interaction between researchers and policymakers in Iran's health sector.

Unravelling collaborative governance dynamics within healthcare networks: a scoping review

In many countries, healthcare systems suffer from fragmentation between hospitals and primary care. In response, many governments institutionalized healthcare networks (HN) to facilitate integration and efficient healthcare delivery. Despite potential benefits, the implementation of HN is often challenged by inefficient collaborative dynamics that result in delayed decision-making, lack of strategic alignment and lack of reciprocal trust between network members. Yet, limited attention has been paid to the collective dynamics, challenges and enablers for effective inter-organizational collaborations. To consider these issues, we carried out a scoping review to identify the underlying processes for effective inter-organizational collaboration and the contextual conditions within which these processes are triggered. Following appropriate methodological guidance for scoping reviews, we searched four databases [PubMed (n = 114), Web of Science (n = 171), Google Scholar (n = 153) and Scopus (n = 52)] and used snowballing (n = 22). A total of 37 papers addressing HN including hospitals were included. We used a framework synthesis informed by the collaborative governance framework to guide data extraction and analysis, while being sensitive to emergent themes. Our review showed the prominence of balancing between top-down and bottom-up decision-making (e.g. strategic vs steering committees), formal procedural arrangements and strategic governing bodies in stimulating participative decision-making, collaboration and sense of ownership. In a highly institutionalized context, the inter-organizational partnership is facilitated by pre-existing legal frameworks. HN are suitable for tackling wicked healthcare issues by mutualizing resources, staff pooling and improved coordination. Overall performance depends on the capacity of partners for joint action, principled engagement and a closeness culture, trust relationships, shared commitment, distributed leadership, power sharing and interoperability of information systems To promote the effectiveness of HN, more bottom-up participative decision-making, formalization of governance arrangement and building trust relationships are needed. Yet, there is still inconsistent evidence on the effectiveness of HN in improving health outcomes and quality of care.

Representation of the hierarchical and functional structure of an ambulatory network of medical consultations through Social Network Analysis, with an emphasis on the role of medical specialties

BACKGROUND

Ambulatory Health Care Networks (Amb-HCN) are circuits of patient referral and counter-referral that emerge, explicitly or spontaneously, between doctors who provide care in their offices. Finding a meaningful analytical representation for the organic and hierarchical functioning of an Amb-HCN may have managerial and health policymaking implications. We aimed to characterize the structural and functional topology of an Amb-HCN of a private health insurance provider (PHIP) using objective metrics from graph theory.

METHODS

This is a cross-sectional quantitative study with a secondary data analysis study design. A Social Network Analysis (SNA) was conducted using office visits performed between April 1, 2021 and May 15, 2022, retrieved from secondary administrative claim databases from a PHIP in Belo Horizonte, Southeastern Brazil. Included were beneficiaries of a healthcare plan not restricting the location or physician caring for the patient. A directional and weighted network was constructed, where doctors were the vertices and patient referrals between doctors, within 7-45 days, were the network edges. Vertex-level SNA measures were calculated and grouped into three theoretical constructs: patient follow-up (aimed at assessing the doctor's pattern of patient follow-up); relationship with authorities (which assessed whether the doctor is an authority or contributes to his or her colleague's authority status); and centrality (aimed at positioning the doctor relative to the network graph). To characterize physician profiles within each dimension based on SNA metrics results, a K-means cluster analysis was conducted. The resulting physician clusters were assigned labels that sought to be representative of the observed values of the vertex metrics within the clusters.

FINDINGS

Overall, 666,263 individuals performed 3,863,222 office visits with 4,554 physicians. A total of 577 physicians (12.7%) had very low consultation productivity and contributed very little to the network (i.e., about 1.1% of all referrals made or received), being excluded from subsequent doctor profiles analysis. Cluster analysis found 951 (23.9%) doctors to be central in the graph and 1,258 (31.6%) to be peripheral; 883 (22.2%) to be authorities and 266 (6.7%) as seeking authorities; 3,684 (92.6%) mostly shared patients with colleagues, with patient follow-up intensities ranging from weak to strong. Wide profile dispersion was observed among specialties and, more interestingly, within specialties. Non-primary-care medical specialties (e.g., cardiology, endocrinology etc.) were associated with central profile in the graph, while surgical specialties predominated in the periphery, along with pediatrics. Only pediatrics was associated with strong and prevalent (i.e., low patient sharing pattern) follow-up. Many doctors from internal medicine and family medicine had unexpectedly weak and shared patient follow-up profiles. Doctor profiles exhibited pairwise relationships with each other and with the number of chronic comorbidities of the patients they treated. For example, physicians identified as authorities were frequently central and treated patients with more comorbidities. Ten medical communities were identified with clear territorial and specialty segregation.

CONCLUSIONS

Viewing the Amb-HCN as a social network provided a topological and functional representation with potentially meaningful and actionable emerging insights into the most influential actors and specialties, functional hierarchies, factors that lead to self-constituted medical communities, and dispersion from expected patterns within medical specialties.

Integration of Dementia Systems in Central America: A Social Network Approach

Introduction

Action 3 of the UN Decade of Healthy Ageing plan is to deliver integrated care to improve older adults' lives. Integrated care is vital in meeting the complex needs of people with dementia but little is known about how this is or could be delivered in low and middle income countries (LMIC). This paper provides insights into previously unknown care system structures and on the potential and reality of delivering integrated care in Central America for people with dementia.

Methods

A social network analysis (SNA) methodology was adopted to engage with providers of services for older adults and families with dementia in Guatemala, El Salvador, Honduras, Costa Rica and Panama. Sixty-eight (68) semi-structured interviews were completed, 57 with organisations and 11 with families.

Results

Across the five countries there was evidence of fragmentation and low integration within the dementia care systems. A variety of services and types of providers are present in all five countries, and high levels of diversified connections exist among organisations of differing disciplines. However, unawareness among network members about other members that they could potentially form active links with is a barrier on the path to integration.

Conclusion

This innovative and robust study demonstrates SNA can be applied to evaluate LMIC care systems. Findings provide baselines of system structures and insights into where resources are needed to fortify integration strategies. Results suggest that Central American countries have the building blocks in place to develop integrated care systems to meet the needs of people with dementia, but the links across service providers are opportunistic rather than context based coordinated integration policies.

Leveraging collaborative research networks against antimicrobial resistance in Asia

Background

Antimicrobial resistance (AMR) is a global health security threat requiring research collaboration globally and regionally. Despite repeated calls for international research collaboration in Asia, literature analyzing the nature of collaborative AMR research in Asia has been sparse. This study aims to describe the characteristics of the AMR research network in Asia and investigate the factors influencing collaborative tie formation between organizations.

Methods

We carried out a mixed-methods study by combining social network analysis (SNA) and in-depth interviews. SNA was first conducted on primary data to describe the characteristics of the AMR research network in Asia. Exponential random graph models (ERGMs) were then used to examine the influence of factors such as organization type, country affluence levels, regional proximity and One Health research on collaborative tie formation among organizations. In-depth interviews were conducted with network participants to provide contextual insights to the quantitative data.

Results

The results reveal that the research network exhibits a core-periphery structure, where a minority of organizations have a significantly higher number of collaborations with others. The most influential organizations in the network are academic institutions from high-income countries within and outside Asia. The ERGM results demonstrate that organizations prefer to collaborate with others of similar organization types, country-based affluence levels and One Health domains of focus, but also with others across different World Health Organization regions. The qualitative analysis identified three main themes: the challenges that impede collaboration, the central role of academic institutions, and the nature of collaborations across One Health domains, giving rise to important empirical milestones in understanding AMR research in Asia.

Conclusion

We thus recommend leveraging academic institutions as "integrators" to bridge differences, increasing funds channelled towards research capacity building to alleviate structural barriers to collaboration, streamlining collaborative mechanisms to overcome cumbersome administrative hurdles, and increasing efforts to establish trust between all organizations.

Correlation Between the Social Network Structure and Well-Being of Health Care Workers in Intensive Care Units: Prospective Observational Study

BACKGROUND

Effective communication strategies are becoming increasingly important in intensive care units (ICUs) where patients at high risk are treated. Distributed leadership promotes effective communication among health care professionals (HCPs). Moreover, beyond facilitating patient care, it may improve well-being among HCPs by fostering teamwork. However, the impact of distributed leadership on the communication structure and well-being of HCPs remains unclear.

OBJECTIVE

We performed a social network analysis (SNA) to assess the characteristics of each HCP in the network, identify the number of HCP connections, analyze 4 centralities that can measure an HCP's importance, and evaluate the impact of distributed leadership structure on the well-being and communication structure of the medical staff.

METHODS

Wearable sensors were used to obtain face-to-face interaction data from the ICU medical staff at Mie University Hospital, Japan. Participants wore a badge on the front of their clothing during working hours to measure the total frequency of face-to-face interactions. We collected data about the well-being of medical staff using the Center for Epidemiological Studies-Depression (CES-D) questionnaire and measured 4 centralities using SNA analysis. A CES-D questionnaire was administered during the study to measure the well-being of the HCPs.

RESULTS

Overall, 247 ICU workers participated in this clinical study for 4 weeks yearly in February 2016, 2017, and 2018. The distributed leadership structure was established within the ICU in 2017 and 2018. We compared these results with those of the traditional leadership structure used in 2016. Most face-to-face interactions in the ICU were among nurses or between nurses and other professionals. In 2016, overall, 10 nurses could perform leadership tasks, which significantly increased to 24 in 2017 (P=.046) and 20 in 2018 (P=.046). Considering the increased number of nurses who could perform leadership duties and the collaboration created within the organization, SNA in 2018 showed that the betweenness (P=.001), degree (P<.001), and closeness (P<.001) centralities significantly increased compared with those in 2016. However, the eigenvector centrality significantly decreased in 2018 compared with that in 2016 (P=.01). The CES-D scores in 2018 also significantly decreased compared with those in 2016 (P=.01). The betweenness (r=0.269; P=.02), degree (r=0.262; P=.03), and eigenvector (r=0.261; P=.03) centralities and CES-D scores were positively correlated in 2016, whereas the closeness centrality and CES-D scores were negatively correlated (r=-0.318; P=.01). In 2018, the degree (r=-0.280; P=.01) and eigenvector (r=-0.284; P=.01) centralities were negatively correlated with CES-D scores.

CONCLUSIONS

Face-to-face interactions of HCPs in the ICU were measured using wearable sensors, and nurses were found to be centrally located. However, the introduction of distributed leadership created collaboration and informal leadership in the organization, altering the social network structure of HCPs and increasing organizational well-being.

TRIAL REGISTRATION

University Hospital Medical Information Network (UMIN) UMIN000037046; https://center6.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000042211.

Leveraging Social Networks to Integrate Depression Treatment into Primary Health and Tuberculosis Care in Brazil

Background

Tuberculosis (TB) and depression are highly comorbid and linked to higher rates of death and disability. Several evidence-based treatments for depression have been successfully implemented in low- and middle-income countries, but more knowledge is needed on how to bring these innovations to scale within complex 'real world' public health systems.

Objective

To explore whether the principles of social network analysis could be used to enhance receptivity to integrating depression treatment into primary care for individuals with and without TB in Brazil.

Methods

We used existing scales to identify settings and providers with high receptivity and connectivity within the primary care network. We trained and supervised existing staff in three primary care sites to deliver a brief evidence-based intervention over one year, coupled with active dissemination activities. Afterwards, we reassessed receptivity among individuals involved, and not involved, in the pilot.

Results

Highly significant changes were observed in mental health literacy, attitudes towards evidence-based practices, work self-efficacy, and implementation leadership supporting our hypothesis. Limited social connections between primary care clinics precluded the examination of the hypothesis that targeting settings with high connectivity could capitalize on the information flow between and transcend the decentralized structure of the network, but leveraging the centralized nature of the TB program to integrate mental health services emerged as a promising alternative.

Conclusions

The findings of this study strongly suggest that social networks may be leveraged to change individual providers' attitudes, thereby contributing to the enhanced dissemination of evidence-based interventions.

Individual interactions in a multi-country implementation-focused quality of care network for maternal, newborn and child health: A social network analysis

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 303 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN.

Stakeholders, Relationships, and Coordination: 2015 Baseline Study of Needed Enablers for Bridging Agriculture-Nutrition Gaps in Nigeria

BACKGROUND

Renewed efforts by the Nigerian government to address malnutrition have led to nutrition actions by several sectors, including the agriculture sector. However, the success of these actions depends on the characteristics of the stakeholders involved, including their relationships and coordination.

OBJECTIVE

This article reports a 2015 study of nutrition-sensitive agricultural stakeholders in Nigeria that assessed what the stakeholders do, where they work and how they are organized to improve nutrition. The study provides a baseline for assessing progress and measuring stakeholder and coordination changes in the Nigerian nutrition-sensitive agriculture landscape.

METHODS

Semi-structured interviews (n = 17) and focus group discussions (n = 2) were held with federal, state, and local government level stakeholders; reviews of stakeholder program documents were also conducted.

RESULTS

The study identified 7 groups of nutrition-sensitive agriculture stakeholders and several coordination challenges. Political leadership, advocacy and provision of material and human resource support by nongovernmental organizations, and donor interest and funding have been vital for mobilizing nutrition-sensitive agriculture. Still, although stakeholders frequently highlighted that nutrition was an important consideration in their interventions, nutrition goals and activities and/or indicators to measure outcomes were not regularly communicated. Also, while coordination mechanisms existed, there appeared to be minimal actual cross-sectoral partnerships because of inadequate trust, competition, and conflicts over institutional turf and mandates.

CONCLUSIONS

Needed enablers for improving nutrition-sensitive agriculture in Nigeria included improved stakeholder nutrition literacy, as well as enhanced stakeholder engagement facilitated by role definition, clarification, and consensus. Exploring different approaches to coordination may also be necessary.

One Health Surveillance System in Gujarat, India: A Health Policy and Systems Research Protocol for Exploring the Cross-Sectoral Collaborations to Detect Emerging Threats at the Human-Animal-Environment Interface

The close interaction between humans, animals and the ecosystem has been a reason for the emergence and re-emergence of zoonotic diseases worldwide. Zoonoses are estimated to be responsible for 2.5 billion human illnesses and 2.7 million deaths worldwide. Gujarat is a western state in India with more than 65 million people and 26 million livestock, and includes surveillance systems for humans and animals; however, more evidence is needed on joint collaborative activities and their effect on the early warning response for zoonoses. Thus, this study aims to investigate sectoral collaborations for early warning and response systems for emerging and re-emerging zoonoses, aiming to develop a One Health surveillance (OHS) system in Gujarat, India. This case study uses policy content analysis followed by qualitative and quantitative data collection among state- and district-level surveillance actors to provide insight into the current cross-sectoral collaborations among surveillance actors. It helps identify triggers and documents factors helpful in strengthening cross-sectoral collaborations among these systems and facilitates the establishment of an OHS system in Gujarat, India.

Design and implementation of ParkinsonAKTIV: an interventional study to evaluate the effectiveness of a novel online platform to guide quickcard-based treatment decisions

INTRODUCTION

Patients with Parkinson's Disease (PD) require an all-encompassing and individualized care including pharmacological as well as non-pharmacological treatment approaches, such as physical therapy, occupational therapy and speech and swallowing therapy. ParkinsonAKTIV is an innovative, multidisciplinary, and comprehensive approach to guide this non-pharmacological PD treatment in northwestern Germany. Its online communication platform called JamesAKTIV has been developed to enhance and standardize PD healthcare professionals' communication. The implementation of ParkinsonAKTIV and JamesAKTIV is accompanied through a detailed process evaluation and to gather evidence on the impact on patient-related outcomes, such as health-related quality of life and healthcare costs for people with PD through an effectiveness evaluation.

METHODS

The study design contains two parts: (1) first, a quantitative effectiveness evaluation is conducted utilizing a prospective quasi-experimental approach with a control group which examines PD patient's health-related quality of life and physician-assessed PD patient's health status (Unified Parkinson Disease Rating Scale). Moreover, a health economic evaluation of the ParkinsonAKTIV intervention is conducted using patient-reported outcomes and cost data as well as routine data from a statutory health insurance. (2) Second, a mixed-methods process evaluation among healthcare professionals, which examines the feasibility and potential barriers and facilitators of ParkinsonAKTIV for routine care, is performed. Quantitative results from a social network analysis and a survey among healthcare professionals will be triangulated with data from qualitative stakeholder interviews and focus group discussions.

PERSPECTIVE

Findings are expected to provide evidence of an increase in quality of life of patients with PD, less severe PD symptoms, and a better ability to participate in activities of daily living. ParkinsonAKTIV has the potential of increasing PD patients' quality of care through sufficient and more tailored prescription of non-pharmacological therapies. It is anticipated that ParkinsonAKTIV will improve communication among health professionals. Results from the ParkinsonAKTIV study will provide first practice-oriented evidence and a roadmap for implementation of an online tool for a comprehensive, multidisciplinary care PD network for patients and their caregivers in routine care in Germany. Trial registration ClinicalTrials.gov: registration number NCT05251298 (retrospectively registered: https://clinicaltrials.gov/ct2/show/record/NCT05251298 ).

Describing the state of a research network: A mixed methods approach to network evaluation

Diabetes Action Canada Strategy for Patient-Oriented Research (SPOR) Network in Chronic Disease was formed in 2016 and is funded primarily through the Canadian Institutes of Health Research (CIHR). We propose a novel mixed-methods approach to a network evaluation integrating the State of Network Evaluation framework and the Canadian Academy of Health Sciences (CAHS) preferred framework and indicators. We measure key network themes of connectivity, health and results, and impact and return on investment associated with health research networks. Our methods consist of a longitudinal cross-sectional network survey of members and social network analysis to examine Network Connectivity and assess the frequency of interactions, the topics discussed during them, and how networking effectively facilitates interactions and collaboration among members. Network Health will be evaluated through semistructured interviews, a membership survey inquiring about satisfaction and experience with the Network, and a review of documentary sources related to funding and infrastructure to evaluate Network Sustainability. Finally, we will examine Network Results and Impact using the CAHS preferred framework and indicators to measure returns on investment in health research across the five domains of the CAHS framework, which include: advancing knowledge, capacity building, informing decision making, health impact, and economic and social impact. Indicators will be assessed with various methods, including bibliometric analyses, review of relevant documentary sources (annual reports), member activities informing health and research policy, and Patient Partner involvement. The Network Evaluation will provide members and stakeholders with information for planning, improvements, and funding future Network endeavors.

Using social network analysis approach in developing rural psychiatrist workforce

OBJECTIVE

This study examines how rural and remote junior doctors career decisions are influenced by highly connected principles within a discipline.

METHODS

Social network analysis was completed with data collected, by structured interview, with five psychiatry trainees and three early career psychiatrists in a rural location rated MM3 using the Modified Monash Model. UNICET software was used to determine the interactions between individual networks to look for overlap and common influencers.

RESULTS

A single central, highly connected, psychiatrist was found at the core of the entire social network. This connector was instrumental in recruitment and retention in rural psychiatry workforce.

CONCLUSION

Improving the understanding of human capital can encourage innovative solutions in developing sustainable strategies for recruiting and retaining rural psychiatry workforces.

Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic

BACKGROUND

Health challenges like coronavirus disease 2019 (COVID-19) are becoming increasingly complex, transnational, and unpredictable. Studying health system responses to the COVID-19 pandemic is an opportunity to enhance our understanding of health system resilience and establish a clearer link between theoretical concepts and practical ideas on how to build resilience.

METHODS

This narrative literature review aims to address four questions using a health system resilience framework: (i) What do we understand about the dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? A scientific literature database search was conducted in December 2020 and in April 2022 to identify publications that discussed health system resilience in relation to COVID-19, excluding articles on psychological and other types of resilience. A total of 63 publications were included.

RESULTS

There is good understanding around information sharing, flexibility and good leadership, learning, maintaining essential services, and the need for legitimate, interdependent systems. Decision-making, localized trust, influences on interdependence, and transformation remain uncertain. Vertical interdependence, monitoring risks beyond the health system, and consequences of changes on the system were not discussed. Teamwork, actor legitimacy, values, inclusivity, trans-sectoral resilience, and the role of the private sector are identified as lessons from COVID-19 that should be further explored for health system resilience.

CONCLUSION

Knowledge of health system resilience has continued to cohere following the pandemic. The eventual consequences of system changes and the resilience of subsystems are underexplored. Through governance, the concept of health system resilience can be linked to wider issues raised by the pandemic, like inclusivity. Our findings show the utility of resilience theory for strengthening health systems for crises and the benefit of continuing to refine existing resilience theory.

Local Dynamics of Collaboration for Maternal, Newborn and Child Health: A Social Network Analysis of Healthcare Providers and Their Managers in Gert Sibande District, South Africa

BACKGROUND

Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services. This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH coordination structures in a rural South African district. It examined the role and position of actors, the nature of their relationships, and the overall structure of the collaborative network in two sub-districts.

METHODS

Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within teams).

RESULTS

The overall network structure reflected a predominantly hierarchical mode of clustering of organisational relationships around hospitals and their referring primary healthcare (PHC) facilities. Clusters were linked through (and dependent on) a combination of district MNCH programme and line managers, identified as central connectors or boundary spanners. Overall network density remained low suggesting potential for strengthening collaborative relationships. Within cluster collaborative patterns (inter-professional and across levels) varied, highlighting the significance of small units in district functioning.

CONCLUSION

SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics which could point to system strengths and weaknesses. It offers insights on the level of fragmentation within and across small units, and the need to strengthen cohesion and improve collaborative relationships, and ultimately, the delivery of health services.

Food Safety Awareness and Opinions in China: A Social Network Analysis Approach

Over recent years, food safety has garnered widespread attention and concern from society. Concurrently, social media sites and online forums have become popular platforms to disseminate news, share opinions, and connect with one’s social network. In this research, we focus on the intersection of food safety and online social networking by utilizing natural language processing techniques and social network analysis to study public opinions related to food safety. Using real data collected from a popular Chinese question-and-answer platform, we first identify hot topics related to food safety, and then analyze the emotional state of users in each community (i.e., users communicating about the same topic) to understand the public’s sentiment related to different food safety topics. We proceed by forming semantic networks to analyze the characteristics of food safety opinion networks. Our results show that Internet users form modular communities, each with differences in topics of concern and emotional states of community users. Users focus on a wide range of topics, showing that overall, food safety awareness is increasing. This paper provides novel insights that can help interested stakeholders monitor the discussions and opinions related to food safety.

Analyzing annual changes in network structures of a social media application-based information-sharing system in a Japanese community

Background

Understanding the evolution of social network services (SNSs) can provide insights into the functions of interprofessional information-sharing systems. Using social network analysis, we aimed to analyze annual changes in the network structure of SNS-based information sharing among healthcare professionals over a 3-year period in Japan.

Methods

We analyzed data on SNS-based information sharing networks with online message boards for healthcare professionals for 2018, 2019, and 2020 in a Japanese community.

These networks were created for each patient so that healthcare professionals could post and view messages on the web platform. In the social network analysis (SNA), healthcare professionals registered with a patient group were represented as nodes, and message posting and viewing relationships were represented as links. We investigated the structural characteristics of the networks using several measures for SNA, including reciprocity, assortativity and betweenness centrality, which reflect interrelational links, the prevalence of similar nodes with neighbors, and the mediating roles of other nodes, respectively. Next, to compare year-to-year trends in networks of patients overall, and between receiving nursing care levels 1–3 (lighter care requirement) and levels 4–5 (heavier care requirement), we described the annual structural differences and analyzed each measure for SNA using the Steel–Dwass test.

Results

Among 844, 940, and 1063 groups in each year, groups for analysis in care levels 1–3/4–5 were identified as 106/135, 79/89, and 57/57, respectively. The overall annual assessment showed a trend toward increased diameter and decreased density, but the differences were not significant. For those requiring care levels 1–3, assortativity decreased significantly, while for those requiring care levels 4–5, reciprocity decreased and betweenness centrality increased significantly. No significant differences were found in the other items.

Discussion

This study revealed that the network of patients with a lighter care requirement had more connections consisting of nodes with different links, whereas the network of patients with a heavier care requirement had more fixed intermediary roles and weaker interrelationships among healthcare professionals. Clarifying interprofessional collaborative mechanisms underlying development patterns among healthcare professionals can contribute to future clinical quality improvement.

Inter-individual relationships within a Canadian SPOR research network: a social network study

Background

Efforts have been made by health research granting agencies to bring research closer to patients’ concerns. In Canada, such efforts were formalized in 2011 with the funding of the Strategy for Patient-Oriented Research (SPOR)’s research networks to address research priorities identified by patients and accelerate the translation of research findings into patient care and health care policy. Among these networks, SPOR Diabetes Action Canada (DAC) has created patient-partner circles to facilitate their integration within the network. The nature of the relationships within this atypical patient-oriented research network is systematically explored in this paper.

Methods

A cross-sectional social network study was conducted among the SPOR DAC’s network members to examine inter-individual interactions, and the topics discussed the most between members. Descriptive data analyses were conducted to explore which discussion topics were discussed most among members whose primary roles were research, administration, governance, and patient representation.

Results

The response rate was 51.9%, providing data on 76.5% of the maximum number of connections in the network. The survey captured 2763 inter-individual relationships. Responses to a sub-question inserted in the survey show that 482 of these relationships (17,4%) existed before joining the network in collaboration on a research project. Most ties captured in the survey were yearly or quarterly, while few relationships were monthly, weekly, or daily. In measured relationships, members discussed several topics, the most frequent being scientific research, patient engagement, network coordination and governance, and operations and management. The topics associated with the most significant proportion of relationships captured in the survey were scientific research (45.4%) and patient engagement (40.7%). Management & operations and governance & coordination follow, corresponding to 24.3 and 23.9% of the captured relationships. All discussion topic subnetworks were either somewhat or highly centralized, meaning that relationships were not equally distributed among members involved in these discussions. Of the 1256 relationships involving exchanges about scientific research, 647 (51.5%) involved a researcher, 419 (33.3%) an administrator, 182 (14.5%) a patient partner, and 82 (6.5%) a member whose primary role is network governance.

Conclusions

Scientific research and patient engagement were the most common topics discussed, consistent with the patient-centered research at the heart of the SPOR Diabetes Action Canada network. The study identified several relationships where a patient partner has discussed scientific research with a researcher. However, relationships involving research discussions were three times more common between a researcher and an administrator than between a researcher and a patient partner, although twice as many patient partners as administrators participated in the survey. The institutionalization of patient-partner involvement in large research networks is an evolving practice for which optimal engagement methods are still being explored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08343-1.

Qualitative systems mapping for complex public health problems: A practical guide

Systems mapping methods are increasingly used to study complex public health issues. Visualizing the causal relationships within a complex adaptive system allows for more than developing a holistic and multi-perspective overview of the situation. It is also a way of understanding the emergent, self-organizing dynamics of a system and how they can be influenced. This article describes a concrete approach for developing and analysing a systems map of a complex public health issue drawing on well-accepted methods from the field of social science while incorporating the principles of systems thinking and transdisciplinarity. Using our case study on HIV drug resistance in sub-Saharan Africa as an example, this article provides a practical guideline on how to map a public health problem as a complex adaptive system in order to uncover the drivers, feedback-loops and other dynamics behind the problem. Qualitative systems mapping can help researchers and policy makers to gain deeper insights in the root causes of the problem and identify complexity-informed intervention points.

Mapping regional cooperation of state actors for health research systems in Africa: A social network analysis

Regional bodies can potentially play an important role in improving health research in Africa. This study analyses the network of African state-based regional organisations for health research and assesses their potential relationship with national health research performance metrics. After cataloguing organisations and their membership, we conducted a social network analysis to determine key network attributes of national governments' connections via regional organisations supporting functions of health research systems. This data was used to test the hypothesis that state actors with more connections to other actors via regional organisations would have higher levels of health research performance across indicators. With 21 unique regional organisations, the African continent is densely networked around health research systems issues. In general, the regional network for health research is inclusive. No single actor serves as a nexus. However, when statistics are grouped by African Union regions, influential poles emerge, with the most predominate spheres of influence in Eastern and Western Africa. Further, when connectivity data was analysed against national health research performance, there were no statistically significant relationships between increased connectivity and higher performance of key health research metrics. The inclusive and dense network dynamics of African regional organisations for health research strengthening present key opportunities for knowledge diffusion and cooperation to improve research capacity on the continent. Further reflection is needed on appropriate and meaningful ways to assess the role of regionalism and evaluate the influence of regional organisations in strengthening health research systems in Africa.

Using social network analysis to understand multisectoral governance in district-level tobacco control programme implementation in India

INTRODUCTION

Interest in multisectoral policies has increased, particularly in the context of low-income and middle-income countries and efforts towards Sustainable Development Goals, with greater attention to understand effective strategies for implementation and governance. The study aimed to explore and map the composition and structure of a multisectoral initiative in tobacco control, identifying key factors engaged in policy implementation and their patterns of relationships in local-level networks in two districts in the state of Karnataka, India.

METHODS

Social network analysis (SNA) was used to examine the structure of two district tobacco control networks with differences in compliance with the India's national tobacco control law. The survey was administered to 108 respondents (n=51 and 57) in two districts, producing three distinct network maps about interaction, information-seeking and decision-making patterns within each district. The network measures of centrality, density, reciprocity, centralisation and E-I index were used to understand and compare across the two districts.

RESULTS

Members from the department of health, especially those in the District Tobacco Control Cell, were the most frequently consulted actors for information as they led district-level networks. The most common departments engaged beyond health were education, police and municipal. District 1's network displayed high centralisation, with a district nodal officer who exercised a central role with the highest in-degree centrality. The district also exhibited greater density and reciprocity. District 2 showed a more dispersed pattern, where subdistrict health managers had higher betweenness centrality and acted as brokers in the network.

CONCLUSION

Collaboration and cooperation among sectors and departments are essential components of multisectoral policy. SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics. It can be used as a visual learning tool for policy planners and implementers to understand the structure of actual implementation and concentrate their efforts to improve and enhance collaboration.

Evidence-based approaches for promoting gender equity in global mental health research: Study protocol for social network analysis of researchers in Nepal

There are increasing efforts for capacity building of researchers in low- and middle-income countries (LMIC) to foster local ability to conduct high quality research. However, female researchers remain underrepresented in scientific communities, particularly in LMIC where they have limited networking and mentorship opportunities. This protocol is for a Social Network Analysis (SNA) to evaluate if gender-sensitive, need-based capacity building can improve researchers' networking and mentorship opportunities in Nepal. The conceptual framework is informed by Social Cognitive Career Theory. Cross-sectional and longitudinal SNA are used to a) assess individual researchers’ network characteristics and their association with academic productivity; and b) examine if the association of network characteristics and academic productivity is mediated by self-efficacy and outcome expectations. Recruitment is designed to include early-career and senior researchers conducting mental health research, as well as students interested in pursuing a career in mental health research. The network characteristics will be mapped for approximately 150 researchers in working in Nepal. SNA characteristics in the network (individual density, homophily, and centrality) will be compared with academic productivity (total peer reviewed publications, h-index), including mediation effects via self-efficacy and outcome expectations. Ultimately, this study will generate information to design more evidence-based strategies for capacity building of a gender-equitable research workforce in global mental health.

Making sense of the French public hospital system: a network-based approach to hospital clustering using unsupervised learning methods

BACKGROUND

Hospitals in the public and private sectors tend to join larger organizations to form hospital groups. This increasingly frequent mode of functioning raises the question of how countries should organize their health system, according to the interactions already present between their hospitals. The objective of this study was to identify distinctive profiles of French hospitals according to their characteristics and their role in the French hospital network.

METHODS

Data were extracted from the national hospital database for year 2016. The database was restricted to public hospitals that practiced medicine, surgery or obstetrics. Hospitals profiles were determined using the k-means method. The variables entered in the clustering algorithm were: the number of stays, the effective diversity of hospital activity, and a network-based mobility indicator (proportion of stays followed by another stay in a different hospital of the same Regional Hospital Group within 90 days).

RESULTS

Three hospital groups were identified by the clustering algorithm. The first group was constituted of 34 large hospitals (median 82,100 annual stays, interquartile range 69,004 - 117,774) with a very diverse activity. The second group contained medium-sized hospitals (with a median of 258 beds, interquartile range 164 - 377). The third group featured less diversity regarding the type of stay (with a mean of 8 effective activity domains, standard deviation 2.73), a smaller size and a higher proportion of patients that subsequently visited other hospitals (11%). The most frequent type of patient mobility occurred from the hospitals in group 2 to the hospitals in group 1 (29%). The reverse direction was less frequent (19%).

CONCLUSIONS

The French hospital network is organized around three categories of public hospitals, with an unbalanced and disassortative patient flow. This type of organization has implications for hospital planning and infectious diseases control.

Power analysis in health policy and systems research: a guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

Reflections on benefits and challenges of longitudinal organisational network analysis as a tool for health systems research and practice

As health systems practitioners and researchers increasingly turn towards systems thinking approaches and work on building interorganisational networks, they have demonstrated increasing interest in network analysis for investigating relationships and interactions between system actors, both at the individual and organisational levels. Despite the potential of network-based approaches to improve health system efficiency, effectiveness and responsiveness, both the theoretical and practical guidance on designing and evaluating network-building strategies is underdeveloped within the field. While there are multiple tools and resources to help users collect, manage and analyse network data, there is much less guidance on the practical applications of this information. One apparent gap is the limited application of longitudinal organisational network analysis, in which data are collected from the same organisational actors repeatedly over multiple time points. This yields insights into the dynamic nature of networks, including how the network structure and interactions change over time. Given that networks are rarely static, the addition of the time dimension has the potential to substantially enhance the analytical value of network analysis and contribute to more nuanced guidance for interested practitioners and policymakers. In this article, the authors draw on their experiences in conducting longitudinal network analysis of interorganisational relationships in the USA and India to comment on the opportunities and challenges of the methodology within the field of health systems research. We also provide suggestions as to how some of these challenges may be addressed or mitigated.

Shifting From Sectoral to Integrated Surveillance by Changing Collaborative Practices: Application to West Nile Virus Surveillance in a Small Island State of the Caribbean

After spreading in the Americas, West Nile virus was detected in Guadeloupe (French West Indies) for the first time in 2002. Ever since, several organizations have conducted research, serological surveys, and surveillance activities to detect the virus in horses, birds, mosquitoes, and humans. Organizations often carried them out independently, leading to knowledge gaps within the current virus' situation. Nearly 20 years after the first evidence of West Nile virus in the archipelago, it has not yet been isolated, its impact on human and animal populations is unknown, and its local epidemiological cycle is still poorly understood. Within the framework of a pilot project started in Guadeloupe in 2019, West Nile virus was chosen as a federative model to apply the "One Health" approach for zoonotic epidemiological surveillance and shift from a sectorial to an integrated surveillance system. Human, animal, and environmental health actors involved in both research and surveillance were considered. Semi-directed interviews and a Social Network Analysis were carried out to learn about the surveillance network structure and actors, analyze information flows, and identify communication challenges. An information system was developed to fill major gaps: users' needs and main functionalities were defined through a participatory process where actors also tested and validated the tool. Additionally, all actors shared their data, which were digitized, cataloged, and centralized, to be analyzed later. An R Shiny server was integrated into the information system, allowing an accessible and dynamic display of data showcasing all of the partners' information. Finally, a series of virtual workshops were organized among actors to discuss preliminary results and plan the next steps to improve West Nile Virus and vector-borne or emerging zoonosis surveillance. The actors are willing to build a more resilient and cooperative network in Guadeloupe with improved relevance, efficiency, and effectiveness of their work.

Transnational Networks' Contribution to Health Policy Diffusion: A Mixed Method Study of the PerformanceBased Financing Community of Practice in Africa

BACKGROUND

Transnational networks such as Communities of Practice (CoPs) are flourishing, yet their role in diffusing health systems reforms has been seldom investigated. Over the past decade, performance-based financing (PBF) has rapidly spread in Africa. This study explores how, through the PBF Community of Practice's attributes, structure, and strategies, PBF diffusion was fostered in sub-Saharan Africa (SSA).

METHODS

Informed by the diffusion entrepreneurs' (DEs) framework dimensions, we used a mixed methods convergent design to investigate how the attributes, structure, and strategies of this community fostered the diffusion of PBF. The quantitative strand of work included firstly a semantic discourse analysis of textual data extracted from CoP's online discussion forum (n=1346 posts). Secondly, the relational data extracted from these 1346 forum posts was examined using social network analysis (SNA). We confronted these quantitative results with a thematic analysis of qualitative interviews (n=40) and data extracted from the CoP's key documentation (n=17).

RESULTS

CoP members' attributes included: representation systems anchored in clinical and economic sciences, strong expectations that the CoP would boost professional visibility and career, and significant health systems knowledge and social resources. The CoP's core group, dominated by high-income country (HIC) members, critically matched PBF principles to major health systems issues in Africa. The broad consensus in online PBF thematic discussions created a strong sense of community, a breeding ground for emulation among CoP members. The CoP also sought to produce and promote experiential knowledge exchanges about PBF amongst African practitioners. Findings from network analyses showed that the promoted Africa-driven community was led by HIC members, although their prominence tended to decrease with time.

CONCLUSION

This empirical research highlighted some of the constituting features, structure, and strategies of policy networks in influencing health policy diffusion. Despite good intentions to disrupt the established governance landscape, influential actors coming from HICs continued to drive the framing, and shaped health systems policy experimentation, emulation, and learning in African countries. Beyond mere knowledge exchange platforms, CoP can act as meaningful transnational policy networks pursuing the diffusion of health systems reforms, such as PBF.

A social network analysis of the organizations focusing on tuberculosis, malaria and pneumonia

In this paper,we present an original study on the use of social media data to analyze the structure of the global health networks (GHNs) relative to health organizations targeted to malaria, tuberculosis (TBC) and pneumonia as well as twitter popularity, evaluating the performance of their strategies in response to the arising health threats. We use a machine learning ensemble classifier and social network analysis to discover the Twitter users that represent organizations or groups active for each disease. We have found evidence that the GHN of TBC is the more mature, active and global. Meanwhile, the networks of malaria and pneumonia are found to be less connected and lacking global coverage. Our analysis validates the use of social media to analyze GHNs and to propose these networks as an important organizational tool in mobilizing the community versus global sustainable development goals.

A realist evaluation of the implementation of a large-scale school eye health programme in India: a qualitative study

PURPOSE

This study investigates how and in what circumstances a school-based eye health programme, the Refractive Errors Among CHildren (REACH) programme, achieved its desired outcomes: accessibility, standards of refractive care, fidelity and availability of comprehensive services, for over 2 million school children in six districts across India.

METHODS

We conducted a realist evaluation to identify programme aspects and their causal relationships with outcomes. Deductive and inductive thematic analysis of qualitative data included three phases: 1. theory gleaning, 2. eliciting programme theory, 3. revisiting programme theory. The Initial Programme Theories (IPTs) were developed and revised through review of the literature, programme documents and field notes. We reviewed informal and formal discussions from the participatory advisory workshops and conducted semi-structured interviews with key stakeholders for the development and refinement of the IPTs. We based our analysis on the programme designers' perspective; used contexts, mechanisms and outcomes configuration for the analysis and presentation of the findings and reported the revised IPTs for the REACH programme.

RESULTS

We identified four major programme aspects of the REACH programme for evaluation: programme governing unit, human resource, innovation and technology and funding. Based on the intended outcomes of the programme, themes and contexts were sorted and IPTs were defined. We revised the IPTs based on the analysis of the interviews (n = 19). The contexts and mechanisms that were reported to have potential influence on the attainment of favourable programme outcomes were identified. The revisions to the IPTs included: co-designing a collaborative model and involving local government officials to reinforce trust, community partnerships; local well-trained staff to encourage participation; use of the web-based data capturing system with built-in quality control measures and continued technical support; pre-determined costs and targets for the outputs promoted transparency and adherence with costs.

CONCLUSION

This process provided a comprehensive understanding of the opportunities and possibilities for a large-scale school eye health programme in diverse local contexts in India. This illustrated the importance of embracing principles of system thinking and considering contextual factors for School Eye Health programmes in low and middle-income countries.

A network analysis of patient referrals in two district health systems in Tanzania

Patient referral systems are fragile and overlooked components of the health system in Tanzania. Our study aims at exploring patient referral networks in two rural districts in Tanzania, Kilolo and Msalala. Firstly, we ask whether secondary-level facilities act as gatekeepers, mediating referrals from primary- to tertiary-level facilities. Secondly, we explore the facility and network-level determinants of patient referrals focusing on treatment of childhood illnesses and non-communicable diseases. We use data collected across all public health facilities in the districts in 2018. To study gatekeeping, we employ descriptive network analysis tools. To explore the determinants of referrals, we use exponential random graph models. In Kilolo, we find a disproportionate share of patients referred directly to the largest hospital due to geographical proximity. In Msalala, small and specialized secondary-level facilities seem to attract more patients. Overall, the results call for policies to increase referrals to secondary facilities avoiding expensive referrals to hospitals, improving timeliness of care and reducing travel-related financial burden for households.

Analyses of interlinked actors in determining the potential business beneficiaries of small-scale pig farming systems in West Papua, Indonesia

Pig production is a key livelihood sector and a source of economic and social beneficiaries, which has many interest and interlinked actors. The inventory which includes all resources and the roles played by actors is utmost important in pig farming system. Some stakeholders are interlinked in function, forming a complex system with multi-disciplinary actors. This research aims to distinctively map and provide clear involvement of actors or stakeholders in relation to their contribution towards pig business. As much as 32 institutions were interviewed based on the roles and resources of individuals working inside the organizations formally and informally. The parameters collected inlude the structure, status of law, and types of organization. As well as stakeholders' role, effect, importance, threat, and turn-back impact. The data obtained include resources sharing, duration, continuity, power, and interventions. Those related to intervention were policy, finance, space, time, access, satisfaction, knowledge, skills, threats, and power. In terms of innovation, the data collected include power, finance, space, time, access, satisfaction, knowledge, skills, threats, and power. And were stored in Microsoft excel worksheet and exported to Social Network Visualizer software version 2.5. The key and strategic stakeholder in pig business beneficiary were identified and determined based on power and interest. The following were identified in the first rank: crop farmers, private credit business, village officer, and local community. In the second rank, the factors identified include government (local and national), student community services, and security.

Characterization of international partnerships in global retinoblastoma care and research: A network analysis

Global cooperation is an integral component of global health research and practice. One Retinoblastoma World (1RBW) is a cooperative network of global treatment centers that care for children affected by retinoblastoma. The study aimed to determine the number, scope and nature of collaborations within 1RBW, and uncover how they are perceived to contribute towards improving retinoblastoma outcomes. A cross-sectional, mixed-methods egocentric network analysis was conducted. Treatment centers (n = 170) were invited to complete an electronic survey to identify collaborative activities between their institution (ego), and respective partners (alters). Network maps were generated to visualize connectivity. Key informants (n = 18) participated in semi-structured interviews to add details about the reported collaborations. Interviews were analysed through inductive thematic analysis. Surveys were completed by 56/170 (33%) of 1RBW treatment centers. Collectively, they identified 112 unique alters (80 treatment centers; 32 other organizations) for a total network size of 168 nodes. Most collaborations involved patient referrals, consultations and twinning/capacity building. Interviews identified four main themes: conceptualization of partnership; primary motivation for collaborations; common challenges to collaboration; and benefits to partnership. There is extensive global collaboration to reduce global retinoblastoma mortality, but there is room to expand connectivity through active efforts to include actors located at network peripheries.

Partnership and Participation-A Social Network Analysis of the 2017 Global Fund Application Process in the Democratic Republic of the Congo and Uganda

Background

The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 as a public-private partnership between governments, the private sector, civil society, and populations affected by the three diseases. A key principle of the Global Fund is country ownership in accessing funding through "engagement of in-country stakeholders, including key and vulnerable populations, communities, and civil society." Research documenting whether diverse stakeholders are actually engaged and on how stakeholder engagement affects processes and outcomes of grant applications is limited.

Objective

To examine representation during the 2017 Global Fund application process in the Democratic Republic of the Congo (DRC) and Uganda and the benefits and drawbacks of partnership to the process.

Methods

We developed a mixed-methods social network survey to measure network structure and assess perceptions of how working together in partnership with other individuals/organizations affected perceived effectiveness, efficiency, and country ownership of the application process. Surveys were administered from December 2017-May 2018, initially to a set of central actors, followed by any individuals named during the surveys (up to 10) as collaborators. Network analyses were conducted using R.

Findings

Collaborators spanning many organizations and expertise areas contributed to the 2017 applications (DRC: 152 nodes, 237 ties; Uganda: 118 nodes, 241 ties). Participation from NGOs and civil society representatives was relatively strong, with most of their ties being to different organization types, Uganda (63%), and DRC (67%), highlighting their collaborative efforts across the network. Overall, the perceived benefits of partnership were high, including very strong ratings for effectiveness in both countries. Perceived drawbacks of partnership were minimal; however, less than half of respondents thought partnership helped reduce transaction costs or financial costs, suggesting an inclusive and participatory process may come with short-term efficiency tradeoffs.

Conclusions

Social network analysis can be useful for identifying who is included and excluded from the process, which can support efforts to ensure stronger, more meaningful engagement in future Global Fund application processes.

A Social Network Analysis Approach for Contact Tracing in the Hospital Setting

Since the beginning of the COVID-19 pandemic, the State of Delaware has implemented various strategies including a stay-at-home order, mask-wearing requirements in public places, and community-based testing to control the spread of the disease. Health systems across the U.S. have taken actions including symptom monitoring and screening for visitors and healthcare workers, providing personal protection equipment (PPE), and contact tracing of confirmed infected individuals to provide maximum possible protection for healthcare workers. Despite such efforts, there remains a significant risk of intra-hospital transmission of COVID-19. Healthcare workers who contact patients with COVID-19 or were exposed to the disease in the community may transmit the infection to coworkers in the inpatient setting. In addition to universal and case-based precautions to prevent exposure and disease transmission, contact tracing is essential to minimizing the impact of outbreaks among healthcare workers and the community. A rapid increase in cases can quickly diminish hospital infection control and prevention program capacity to perform high-quality contact tracing. This article will describe an approach using the application of social network analysis (SNA) and Electronic Medical Records (EMR) to enhance the current efforts in COVID-19 contact tracings.

Financing of physical rehabilitation services in Iran: a stakeholder and social network analysis

Background

Inadequate financing is one of the major barriers in securing equitable access to high-quality physical rehabilitation services, without imposing financial hardship. Despite this, no sufficient attention has been paid to physical rehabilitation services and no specific financial resources have been allocated to such services in many countries including Iran. Owing to the fact that effective decision- and policy-making requires identifying possible stakeholders and actors and their characteristics, in the current study a stakeholder analysis and also a social network analysis (SNA) was conducted to identify the potential stakeholders and also their characteristics involved in physical rehabilitation financing (PRF)-related policies in Iran.

Methods

The present study was performed in two phases. Firstly, semi-structured interviews and relevant document review were conducted to identify the stakeholders. Then, the position, power, interest, and influence of each stakeholder were determined using a web-based questionnaire. Secondly, SNA approach was utilized to map and visualize the interactions among stakeholders.

Results

The findings showed that there are different stakeholders in PRF-related decision- and policy-making processes in Iran. In addition, the position, power, interest, and influence level of the identified stakeholders were varied. Moreover, although some stakeholders, like the Ministry of Health and the parliament have the highest level of power and position, they lack sufficient interest to participate in PRF-policies. Furthermore, SNA demonstrated that social network density was low, which indicates the lack of proper collaboration and interaction among the stakeholders.

Conclusion

As many powerful and influential stakeholders had low interest levels to warrant participate in the FPR-related decision- and policy-making processes in Iran, employing careful and effective strategies, that is ongoing negotiations, receiving advocacy, and making senior managers and policy-makers aware can be helpful.

Professional advice for primary healthcare workers in Ethiopia: a social network analysis

BACKGROUND

In an era of increasingly competitive funding, governments and donors will be looking for creative ways to extend and maximise resources. One such means can include building upon professional advice networks to more efficiently introduce, scale up, or change programmes and healthcare provider practices. This cross-sectional, mixed-methods, observational study compared professional advice networks of healthcare workers in eight primary healthcare units across four regions of Ethiopia. Primary healthcare units include a health centre and typically five satellite health posts.

METHODS

One hundred sixty staff at eight primary healthcare units were interviewed using a structured tool. Quantitative data captured the frequency of healthcare worker advice seeking and giving on providing antenatal, childbirth, postnatal and newborn care. Network and actor-level metrics were calculated including density (ratio of ties between actors to all possible ties), centrality (number of ties incident to an actor), distance (average number of steps between actors) and size (number of actors within the network). Following quantitative network analyses, 20 qualitative interviews were conducted with network study participants from four primary healthcare units. Qualitative interviews aimed to interpret and explain network properties observed. Data were entered, analysed or visualised using Excel 6.0, UCINET 6.0, Netdraw, Adobe InDesign and MaxQDA10 software packages.

RESULTS

The following average network level metrics were observed: density .26 (SD.11), degree centrality .45 (SD.08), distance 1.94 (SD.26), number of ties 95.63 (SD 35.46), size of network 20.25 (SD 3.65). Advice networks for antenatal or maternity care were more utilised than advice networks for post-natal or newborn care. Advice networks were typically limited to primary healthcare unit staff, but not necessarily to supervisors. In seeking advice, a colleague's level of training and knowledge were valued over experience. Advice exchange primarily took place in person or over the phone rather than over email or online fora. There were few barriers to seeking advice.

CONCLUSION

Informal, inter-and intra-cadre advice networks existed. Fellow primary healthcare unit staff were preferred, particularly midwives, but networks were not limited to the primary healthcare unit. Additional research is needed to associate network properties with outcomes and pilot network interventions with central actors.

Global health systems partnerships: a mixed methods analysis of Mozambique's HPV vaccine delivery network actors

Background

Global health partnerships have expanded exponentially in the last two decades with Gavi, the Vaccine Alliance considered the model’s pioneer and leader because of its vaccination programs’ implementation mechanism. Gavi, relies on diverse domestic and international partners to carry out the programs in low- and middle-income countries under a partnership engagement framework (PEF). In this study, we utilized mixed methods to examine Mozambique’s Gavi driven partnership network which delivered human papillomavirus (HPV) vaccine during the demonstration phase.

Methods

Qualitative tools gauged contextual factors, prerequisites, partner performance and practices while a social network analysis (SNA) survey measured the partnership structure and perceived added value in terms of effectiveness, efficiency and country ownership. Forty key informants who were interviewed included frontline Ministry of Health workers, Ministry of Education staff and supporting partner organization members, of whom 34 participated in the social network analysis survey.

Results

Partnership structure SNA connectivity measurement scores of reachability (100%) and average distance (2.5), were high, revealing a network of very well-connected HPV vaccination implementation collaborators. Such high scores reflect a network structure favorable for rapid and widespread diffusion of information, features necessary for engaging and handling multiple implementation scales. High SNA effectiveness and efficiency measures for structural holes (85%) and low redundancy (30%) coupled with high mean perceived effectiveness (97.6%) and efficiency (79.5%) network outcome scores were observed. Additionally, the tie strength average score of 4.1 on a scale of 5 denoted high professional trust. These are all markers of a collaborative partnership environment in which disparate institutions and organizations leveraged each entity’s comparative advantage. Lower perceived outcome scores for country ownership (24%) were found, with participants citing the prominent role of several out-of-country partner organizations as a major obstacle.

Conclusions

While there is room for improvement on the country ownership aspects of the partnership, the expanded, diverse and inclusive collaboration of institutions and organizations that implemented the Mozambique HPV vaccine demonstration project was effective and efficient. We recommend that the country adapt a similar model during national scale up of HPV vaccination.

How Geographical Isolation and Aging in Place Can Be Accommodated Through Connected Health Stakeholder Management: Qualitative Study With Focus Groups

Background

In remote areas, connected health (CH) is needed, but as local resources are often scarce and the purchasing power of residents is usually poor, it is a challenge to apply CH in these settings. In this study, CH is defended as a technological solution for reshaping the direction of health care to be more proactive, preventive, and precisely targeted—and thus, more effective.

Objective

The objective of this study was to explore the identity of CH stakeholders in remote areas of Taiwan and their interests and power in order to determine ideal strategies for applying CH. We aimed to explore the respective unknowns and discover insights for those facing similar issues.

Methods

Qualitative research was conducted to investigate and interpret the phenomena of the aging population in a remote setting. An exploratory approach was employed involving semistructured interviews with 22 participants from 8 remote allied case studies. The interviews explored perspectives on stakeholder arrangements, including the power and interests of stakeholders and the needs of all the parties in the ecosystem.

Results

Results were obtained from in-depth interviews and focus groups that included identifying the stakeholders of remote health and determining how they influence its practice, as well as how associated agreements bring competitive advantages. Stakeholders included people in government sectors, industrial players, academic researchers, end users, and their associates who described their perspectives on their power and interests in remote health service delivery. Specific facilitators of and barriers to effective delivery were identified. A number of themes, such as government interests and power of decision making, were corroborated across rural and remote services. These themes were broadly grouped into the disclosure of conflicts of interest, asymmetry in decision making, and data development for risk assessment.

Conclusions

This study contributes to current knowledge by exploring the features of CH in remote areas and investigating its implementation from the perspectives of stakeholder management. It offers insights into managing remote health through a CH platform, which can be used for preliminary quantitative research. Consequently, these findings could help to more effectively facilitate diverse stakeholder engagement for health information sharing and social interaction.

[Network analysis of the regulation of gastrointestinal cancer treatment]

High complexity is a fundamental component of Brazil's National Policy for Cancer Prevention and Control under the Unified National Health System (SUS). The policy mandates guaranteeing comprehensive patient care. Regulation is part of the organizational structure and is responsible for defining treatment flows. In Rio de Janeiro, the Central Regulating Office launched its activities in June 2015, organizing high-complexity outpatient procedures. The current study aims to analyze commuting for treatment by individuals with gastrointestinal tumors in the state of Rio de Janeiro, before and after the implementation of regulation, from the perspective of Social Network Analysis. This ecological study compared the periods before (2013) and after (2016) implementation of the Central Regulating Office. The study drew on secondary data from the Brazilian Health Informatics Department. Two sociograms were designed for the years 2013 and 2016, correlating place of residence with place of hospitalization. This approach allowed identifying some changes in the dynamics of relations between the state's microregions after implementation of the regulation. The microregions with high-complexity oncology establishments displayed an increase in the number of hospitalizations in 2016. The microregion of Rio de Janeiro also maintained degree centrality in the two moments. The use of Social Network Analysis to assess public policies can contribute to health planning and management.

Intersectoral collaboration for people-centred mental health care in Timor-Leste: a mixed-methods study using qualitative and social network analysis

BACKGROUND

Intersectoral collaboration is fundamental to the provision of people-centred mental health care, yet there is a dearth of research about how this strategy operates within mental health systems in low- and middle-income countries. This is problematic given the known attitudinal, structural and resource barriers to intersectoral collaboration in high-income country mental health systems. This study was conducted to investigate intersectoral collaboration for people-centred mental health care in Timor-Leste, a South-East Asian country in the process of strengthening its mental health system.

METHODS

This study employed a mixed-methods convergent design. Qualitative data elicited from in-depth interviews with 85 key stakeholders and document review were complemented with quantitative social network analysis to assess understandings of, the strength and structure of intersectoral collaboration in the Timorese mental health system.

RESULTS

There was consensus among stakeholder groups that intersectoral collaboration for mental health is important in Timor-Leste. Despite resource restrictions discussed by participants, interview data and social network analysis revealed evidence of information and resource sharing among organisations working within the health and social (disability and violence support) sectors in Timor-Leste (network density = 0.55 and 0.30 for information and resource sharing, respectively). Contrary to the assumption that mental health services and system strengthening are led by the Ministry of Health, the mixed-methods data sources identified a split in stewardship for mental health between subnetworks in the health and social sectors (network degree centralisation = 0.28 and 0.47 for information and resource sharing, respectively).

CONCLUSIONS

Overall, the findings suggest that there may be opportunities for intersectoral collaborations in mental health systems in LMICs which do not exist in settings with more formalised mental health systems such as HICs. Holistic understandings of health and wellbeing, and a commitment to working together in the face of resource restrictions suggest that intersectoral collaboration can be employed to achieve people-centred mental health care in Timor-Leste.

"It's like these CHCs don't exist, are they featured anywhere?": Social network analysis of community health committees in a rural and urban setting in Kenya

BACKGROUND

In Kenya, Community Health Committees (CHC) were established to enhance community participation in health services. Their role is to provide leadership, oversight in delivery of community health services, promote social accountability and mobilize resources for community health. CHCs form social networks with other actors, with whom they exchange health information for decision-making and accountability. This case study aimed to explore the structure of a rural and an urban CHC network and to analyze how health-related information flowed in these networks. Understanding the pathways of information in community settings may provide recommendations for strategies to improve the role and functioning of CHCs.

METHODS

In 2017, we conducted 4 focus group discussions with 27 community discussants and 10 semi-structured interviews with health professionals in a rural area and an urban slum. Using social network analysis, we determined the structure of their social networks and how health related information flowed in these networks.

RESULTS

Both CHCs were composed of respected persons nominated by their communities. Each social network had 12 actors that represented both community and government institutions. CHCs were not central actors in the exchange of health-related information. Health workers, community health volunteers and local Chiefs in the urban slum often passed information between the different groups of actors, while CHCs hardly did this. Therefore, CHCs had little control over the flow of health-related information. Although CHC members were respected persons who served in multiple roles within their communities, this did not enhance their centrality. It emerged that CHCs were often left out in the flow of health-related information and decision-making, which led to demotivation. Community health volunteers were more involved by other actors such as health managers and non-governmental organizations as a conduit for health-related information.

CONCLUSION

Social network analysis demonstrated how CHCs played a peripheral role in the flow of health-related information. Their perception of being left out of the information flow led to demotivation, which hampered their ability to facilitate community participation in community health services; hence challenging effective participation through CHCs.

Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems

Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.

Is cancer prevention influenced by the built environment? A multidisciplinary scoping review

The built environment is a significant determinant of human health. Globally, the growing prevalence of preventable cancers suggests a need to understand how features of the built environment shape exposure to cancer development and distribution within a population. This scoping review examines how researchers across disparate fields understand and discuss the built environment in primary and secondary cancer prevention. It is focused exclusively on peer-reviewed sources published from research conducted in Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States from 1990 to 2017. The review captured 9958 potential results in the academic literature, and this body of results was scoped to 268 relevant peer-reviewed journal articles indexed across 13 subject databases. Spatial proximity, transportation, land use, and housing are well-understood features of the built environment that shape cancer risk. Built-environment features predominantly influence air quality, substance use, diet, physical activity, and screening adherence, with impacts on breast cancer, lung cancer, colorectal cancer, and overall cancer risk. The majority of the evidence fails to provide direct recommendations for advancing cancer prevention policy and program objectives for municipalities. The expansion of interdisciplinary work in this area would serve to create a significant population health impact.

Healthcare network analysis of patients with diabetes and their physicians

OBJECTIVES

To illustrate methods using administrative data on patients with diabetes that can offer a foundation for using network analyses in managed care.

STUDY DESIGN

The study used an administrative claims database to analyze patients with diabetes in a large health plan in Hawaii in 2010.

METHODS

The networks were explored graphically and analyzed at several levels of complexity. Levels ranged from major components comprising the majority in the networks to smaller, highly connected cliques to communities of patients and physicians grouped by a network algorithm. The attributes of patients linked by seeing the same primary physicians were evaluated using an exponential random graph model that predicted links in the network.

RESULTS

The study included 41,941 patients with diabetes of Native Hawaiian (16.3%), Filipino (14.2%), Japanese (46.7%), white (11.2%), and other (11.6%) ethnicity. About half were 65 years or older. When examined by Hawaiian island of residence, at least 95% of patients and at least 78% of physicians belonged to loosely connected major components within a network. Smaller communities of patients, identified by being closely linked together, averaged 150 to 177 patients; communities of physicians averaged 3 to 8 physicians. The average numbers of patients sharing physicians and physicians sharing patients were greater on the island of Oahu than on the rural neighboring islands. Patients of the same ethnicity were significantly more likely to share the same primary physician.

CONCLUSIONS

Network analyses reveal structures and links that health plans could leverage to strengthen quality improvement and disease management programs.

Network Modeling of PrEP Uptake on Referral Networks and Health Venue Utilization Among Young Men Who Have Sex with Men

The objective of this study is to identify individual-level factors and health venue utilization patterns associated with uptake of pre-exposure prophylaxis (PrEP) and to evaluate whether PrEP uptake behavior is further diffused among young men who have sex with men (YMSM) through health venue referral networks. A sample of 543 HIV-seronegative YMSM aged 16-29 were recruited in 2014-2016 in Chicago, IL, and Houston, TX. Stochastic social network models were estimated to model PrEP uptake. PrEP uptake was associated with more utilization of health venues in Houston and higher levels of sexual risk behavior in Chicago. In Houston, both Hispanic and Black YMSM compared to White YMSM were less likely to take PrEP. No evidence was found to support the spread of PrEP uptake via referral networks, which highlights the need for more effective PrEP referral network systems to scale up PrEP implementation among at-risk YMSM.