Primary health care and public health: foundations of universal health systems

Protocol to develop strategies to improve the effectiveness and efficiency of Village Health Workers in service delivery in a selected district of Zimbabwe

Village Health Workers (VHWs) in Zimbabwe complement the healthcare staff in primary health care delivery. In 2015 the Ministry of Health streamlined services offered by the VHWs with the VHW Strengthening Plan to improve the effectiveness of the program. However, these continue to offer services not addressing the current and emerging health problems. This three-phased study seeks to develop strategies to improve the effectiveness and efficiency of VHWs in service delivery. Systematic literature review shall be used to develop a conceptual framework to guide the development of VHWs service delivery strategies. Exploratory sequential mixed methods design shall explore VHWs roles in primary health care. A survey in the first stage shall collect qualitative data from 45 purposely selected healthcare workers and VHWs using interviews and then thematically analyzed with MAXQDA. The variables generated will have a cross-sectional survey used to collect quantitative data from 134 VHWs and analyzed on SPSS. The SWOT and basic logic models shall be used to develop strategies validated by the Delphi Technique and Key Stakeholders. Informed consent will be maintained in the study with findings published in journals and presentation symposiums. This protocol was approved by the University of Venda Research Ethics Committee (Registration FHS/23/pH/11/0709).

Exploring the role of physician associates in Aotearoa New Zealand primary health care

Introduction New Zealand's health care system faces significant shortages in health care workers. To address workforce challenges and meet the population's health needs, health care systems around the world have introduced new clinical roles, such as physician associates/assistants (PAs) into existing health care teams. Aim This article aims to examine the benefits, challenges, and broader implications of regulating PAs in the context of New Zealand's primary care sector, with a specific emphasis on how it may impact general practice. Methods A range of literature surrounding the role, impact, and perception of PAs were selected and included in this article. Results The PA profession can significantly strengthen New Zealand's primary care workforce, improving patient access and continuity of care. However, the global deployment of PAs has faced scrutiny due to concerns about its potential risks to patient safety and the overall viability of such a role. Discussion If regulated, the PA profession can reshape New Zealand's primary care, offering a partial solution to current medical staff shortages. Trained under a generalised medical model similar to doctors, PAs possess the necessary skills to perform both routine and non-routine medical tasks. This dual capability can significantly improve primary care service provision, reduce existing workloads, and allow for a more efficient deployment of doctor expertise. However, medico-legal issues and the supervisory burden can impede widespread integration into general practice. Despite challenges, the success of the PA role relies on mutual trust, respect, and support from other clinical team members within primary health care.

Sufficiency for PSS tracking gait disorders in multiple sclerosis: A managerial perspective

This study primarily aimed to explore the capabilities of digitalisation in the healthcare context, focusing on a specific disease. In this case, the study examined the potential of remote monitoring of gait to address the sensitivity of multiple sclerosis progression to gait characteristics by adopting a non-invasive approach to remotely quantify gait disturbances in a patient's daily life. To better understand the managerial aspects associated with this approach, the researchers conducted a literature review along with a set of semi-structured interviews. The target population included MS patients as well as the key agents involved in their care: patients' family members, neurologists, MS nurses, physiotherapists, medical directors, and pharmacist. The study identifies the perceived barriers and drivers that could contribute to the successful deployment of PSS remote gait monitoring as a healthcare service: i) At mega-level governance. Implications on privacy and security data are notable barriers missing on the speech. ii) At macro level, funding is highlighted as main barrier. The cost and lack of health system subsidies may render initiatives unsustainable, as emphasised by the interviewees. iii) At meso level, useable data is recognised as a driver. The data collection process can align with diverse interests to create value and business opportunities for the ecosystem actors, enhance care, attract stakeholders, such as insurers and pharma, and form partnerships. iv) At micro-level processes, we find two potential barriers: wearable device and app usability (comfort, navigation, efficiency) and organisational/behavioural aspects (training, digital affinity, skills), which are crucial for value creation in innovation ecosystems among patients and healthcare professionals. Finally, we find an interesting gap in the literature and interviews. Stakeholders' limited awareness of technological demands, especially from information technologies, for a successful long-term service, can be consider two key barriers for PSS.

Oral health through primary healthcare in a developed economy dominated by private dental practitioners: A leap forward in Hong Kong?

After two and a half decades of preparation, and prompted by advocacy from the World Health Organization in 2014, the Health Bureau of Hong Kong recently implemented the city's primary healthcare blueprint. Integrated within it is an approach to primary oral healthcare. This review provides a brief background and discusses the development of primary oral healthcare in Hong Kong - a developed economy in Asia dominated by private dental services.

The role and needs of family doctors in sexual medicine: contributions of a preliminary Portuguese qualitative study for a global action

Sexual health is fundamental for overall well-being and quality of life, making it the focus of intervention in Sexual Medicine (SM). Within the National Health Services, Primary Care Physicians (PCPs) guarantee comprehensive care in a biopsychosocial action, including in sexual health. This exploratory study aimed to investigate PCPs' perceptions about their role in SM and how to improve it. A cross-sectional online qualitative design was used, and a sample of 73 Portuguese PCPs was collected. Data was analyzed employing a summative content analysis. Three categories were established regarding how PCPs perceive their role in SM: "Protagonist", "Antagonist", and "Circumstantial". Concerning improving PCP's practice, two categories were identified: "Legitimizing Sexual Health" and "Enhancing Professional Development". In relation to SM, PCPs recognize themselves as institutional gatekeepers and comprehensive caregivers, resorting to familiar tasks to practice in a conditioned framework. To improve their role in SM, PCPs highlighted education investment, making specific suggestions for educational content, resource expedition, detailed guidelines creation, and raising provider and patient awareness beyond the biomedical scope. The results stress the need for an institutional effort to uphold PCPs' crucial role in SM to ensure adequate resource use and consistent, comprehensive sexual healthcare provision, enhancing overall patient care and placing sexual health as an essential field in primary care.

What is meant by 'integrated personalized diabetes management': A view into the future and what success should look like

Integrated personalized diabetes management (IPDM) has emerged as a promising approach to improving outcomes in patients with diabetes mellitus (DM). This care approach emphasizes the integration and coordination of different providers, including physicians, nurses, dietitians, social workers and pharmacists. The goal of IPDM is to provide patients with personalized care that is tailored to their needs. This review addresses the concept of integrated care and the use of technology (including data, software applications and artificial intelligence) as well as managerial, regulatory and financial aspects. The implementation and upscaling of digitally enabled IPDM are discussed, with elaboration of successful practices and related evidence. Finally, recommendations are made. It is concluded that the adoption of digitally enabled IPDM on a global level is inevitable, considering the challenges created by an increasing prevalence of patients with DM and the need for better outcomes and improvement of health system sustainability.

'Space to talk': a Portuguese focus group study of parents' experiences, needs and preferences in parenting support during prenatal and well-child care

OBJECTIVE

To explore the experiences, needs and preferences of a group of parents regarding the parenting support received during prenatal and well-child care in the Portuguese National Health Service.

DESIGN AND SETTING

We undertook descriptive-interpretive qualitative research running multiple focus groups in Porto, Northern Portugal.

PARTICIPANTS, DATA COLLECTION AND ANALYSIS

Purposive sampling was used between April and November 2018. Focus groups were conducted with 11 parents of a 0-3 years old with well-child visits done in primary care units. Thematic analysis was performed in a broadly inductive coding strategy and findings are reported in accordance with Consolidated Criteria for Reporting Qualitative Research guidelines.

RESULTS

Three main themes were identified to describe parents' experience when participating in their children's healthcare: (1) logistics/delivery matter, including accessibility, organisation and provision of healthcare activities, unit setting and available equipment; (2) prenatal and well-child care: a relational place to communicate, with parents valuing a tripartite space for the baby, the family and the parent himself, where an available and caring health provider plays a major role and (3) parenting is challenging and looks for support, based on key points for providers to watch for and ask about, carefully explained and consensual among health providers.

CONCLUSION

This study provides insight into parents' needs and healthcare practices that affect the parenting experience. To meet parents' preferences, sensitive health providers should guarantee a relational place to communicate and person-centredness, accounting for the whole family system to support healthy parenting collaboratively. Future studies are warranted to further strengthen the knowledge in the field of a population-based approach for parenting support.

Young persons and healthcare professionals experience of virtual gastroenterology consultations: a multicentre survey conducted during the COVID-19 pandemic

Objective

To explore Young Persons (YP) and healthcare professionals (HCP) experiences of virtual consultations (VC) and establish whether developmentally appropriate healthcare can be delivered virtually.

Method

YP and HCP questionnaire surveys were designed and piloted. Electronic questionnaire links were sent by post, email or text message January-April 2021 to YP aged 13-25 years old, with predefined chronic gastrointestinal conditions, attending a gastroenterology/hepatology VC. HCP undertaking VC were invited to complete staff questionnaire. Results were anonymous and collated using Excel version 2302.

Results

Five UK hospital trusts participated, with 35 HCP responses. Of the 100 YP completing the survey 66% were female and 34% male aged between 13 years and 25 years (median: 18 years). 13% were new appointments and 87% follow ups, 29% were by video, 69% by phone and 2% gave no response. 80% of HCP spoke to YP directly but not privately (69%). 87% of YP and 88% HCP found VC useful. 83% of YP want VC again, although 20% preferred face to face. 43% of HCP required improved phone/internet connection. 77% of YP required hospital appointments for tests following VC.

Conclusions

Overall respondents were satisfied with VC, finding them useful, convenient and time saving. Successful VC rely on appropriate patient selection and availability of reliable technology. Patient preference is key which may alter with time.

Quality of care in the context of universal health coverage: a scoping review

INTRODUCTION

Universal health coverage (UHC) is an emerging priority of health systems worldwide and central to Sustainable Development Goal 3 (target 3.8). Critical to the achievement of UHC, is quality of care. However, current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries. The primary objective of this scoping review was to summarize the existing conceptual and empirical literature on quality of care within the context of UHC and identify knowledge gaps.

METHODS

We conducted a scoping review using the Arksey and O'Malley framework and further elaborated by Levac et al. and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines. We systematically searched MEDLINE, EMBASE, CINAHL-Plus, PAIS Index, ProQuest and PsycINFO for reviews published between 1 January 1995 and 27 September 2021. Reviews were eligible for inclusion if the article had a central focus on UHC and discussed quality of care. We did not apply any country-based restrictions. All screening, data extraction and analyses were completed by two reviewers.

RESULTS

Of the 4128 database results, we included 45 studies that met the eligibility criteria, spanning multiple geographic regions. We synthesized and analysed our findings according to Kruk et al.'s conceptual framework for high-quality systems, including foundations, processes of care and quality impacts. Discussions of governance in relation to quality of care were discussed in a high number of studies. Studies that explored the efficiency of health systems and services were also highly represented in the included reviews. In contrast, we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC, particularly country-specific measures and measures related to equity.

CONCLUSION

There is growing evidence on the relationship between quality of care and UHC, especially related to the governance and efficiency of healthcare services and systems. However, several knowledge gaps remain, particularly related to monitoring and evaluation, including of equity. Further research, evaluation and monitoring frameworks are required to strengthen the existing evidence base to improve UHC.

Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study

BACKGROUND

Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.

METHODS

An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.

RESULTS

Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.

CONCLUSION

While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

Rural primary care workforce views on trauma-informed care for parents experiencing complex trauma: A descriptive study

BACKGROUND

An important service system for rural parents experiencing complex trauma is primary health care.

AIM

To investigate workforce knowledge, attitudes and practices, and barriers and enablers to trauma-informed care in rural primary health care.

MATERIAL & METHODS

This study used a descriptive, cross-sectional design. It involved an on-line survey conducted in 2021 in rural Victoria, Australia. Participants were the primary health care workforce. The main outcome measures were study-developed and included, a 21-item Knowledge, Attitudes and Practices tool, a 16-item Barriers and Enablers to Trauma-Informed Care Implementation tool, and three open-ended questions.

RESULTS

The 63 respondents were from community health (n = 40, 63%) and child and family services (n = 23, 37%). Many (n = 43, 78%) reported undertaking trauma-informed care training at some point in their career; with 32% (n = 20) during higher education. Respondents self-rated their knowledge, attitudes and practices positively. Perceived enablers were mainly positioned within the service (e.g. workforce motivation and organisational supports) and perceived barriers were largely external structural factors (e.g. availability of universal referral pathways, therapeutic-specific services). Open-ended comments were grouped into four themes: (1) Recognition and understanding; (2) Access factors; (3) Multidisciplinary and collaborative approaches; and (4) Strengths-based and outcome-focused approaches.

DISCUSSION & CONCLUSION

Primary health care is an important driver of population health and well-being and critical in rural contexts. Our findings suggest this sector needs a rural trauma-informed care implementation strategy to address structural barriers. This also requires policy and system development. Long-term investment in the rural workforce and primary care service settings is essential to integrate trauma-informed care.

Unveiling the Significance and Challenges of Integrating Prevention Levels in Healthcare Practice

In recent years, there has been a global increase in human life expectancy, but preventable morbidity and mortality remain significant concerns. To address these issues, preventive healthcare practice has gained importance in various healthcare disciplines. Its goal is to maintain and promote health, reduce risk factors, diagnose illnesses early, and prevent complications. This approach encompasses different stages of disease progression, including primordial prevention, primary prevention, secondary prevention, tertiary prevention, and quaternary prevention. Primordial prevention focuses on addressing root causes and social determinants of diseases to prevent the emergence and development of risk factors. Primary prevention aims to prevent diseases before they occur by implementing interventions such as vaccinations and health education. Secondary prevention focuses on early detection and prompt intervention to prevent the progression of diseases. Tertiary prevention manages the consequences of diseases by restoring health and providing rehabilitation. Lastly, quaternary prevention aims to protect patients from unnecessary medical interventions and harm caused by excessive medicalization. Despite the recognition of the cost-effectiveness of preventive measures, a significant portion of healthcare resources and attention is still allocated to disease management, and only a small percentage of individuals receive all recommended preventive services. Healthcare providers need to prioritize the implementation of preventive care services, even when clinical interventions are necessary, and overcome barriers to preventive care. By investing in preventive care and implementing these strategies, healthcare practitioners can play a crucial role in disease prevention and contribute to the well-being of individuals, families, communities, and countries.

What improves access to primary healthcare services in rural communities? A systematic review

BACKGROUND

To compile key strategies from the international experiences to improve access to primary healthcare (PHC) services in rural communities. Different innovative approaches have been practiced in different parts of the world to improve access to essential healthcare services in rural communities. Systematically collecting and combining best experiences all over the world is important to suggest effective strategies to improve access to healthcare in developing countries. Accordingly, this systematic review of literature was undertaken to identify key approaches from international experiences to enhance access to PHC services in rural communities.

METHODS

All published and unpublished qualitative and/or mixed method studies conducted to improvement access to PHC services were searched from MEDLINE, Scopus, Web of Science, WHO Global Health Library, and Google Scholar. Articles published other than English language, citations with no abstracts and/or full texts, and duplicate studies were excluded. We included all articles available in different electronic databases regardless of their publication years. We assessed the methodological quality of the included studies using mixed methods appraisal tool (MMAT) version 2018 to minimize the risk of bias. Data were extracted using JBI mixed methods data extraction form. Data were qualitatively analyzed using emergent thematic analysis approach to identify key concepts and coded them into related non-mutually exclusive themes.

RESULTS

Our analysis of 110 full-text articles resulted in ten key strategies to improve access to PHC services. Community health programs or community-directed interventions, school-based healthcare services, student-led healthcare services, outreach services or mobile clinics, family health program, empanelment, community health funding schemes, telemedicine, working with traditional healers, working with non-profit private sectors and non-governmental organizations including faith-based organizations are the key strategies identified from international experiences.

CONCLUSION

This review identified key strategies from international experiences to improve access to PHC services in rural communities. These strategies can play roles in achieving universal health coverage and reducing disparities in health outcomes among rural communities and enabling them to get healthcare when and where they want.

The Benefits and Barriers of Using Point-of-Care Ultrasound in Primary Healthcare in the United States

An effective healthcare system should embrace practices that enhance overall quality and productivity. Training primary care physicians in Point-of-Care Ultrasound (POCUS) has become part of the processes that improve the quality of patient care and serve to guide the diagnostic impression quickly and effectively. With the purpose of highlighting the applications and challenges of POCUS use in US primary health care, we conducted a narrative review based on PubMed-indexed and Cochrane Library English text publications searched in May-July 2022 using a combination of key terms including point of care ultrasound, primary care, and US healthcare. Many studies have shown that POCUS has a positive impact on fostering medical attention and reducing morbidity, mortality, and healthcare costs. Besides assisting in procedures, POCUS has a head-to-toe application in evaluating inflammatory and infectious conditions, acute abdomen, cardiopulmonary function, musculoskeletal and vascular pathologies. However, its uniform implementation is limited across the US healthcare system due to multitudes of barriers such as lack of training, resource scarcity, and low reimbursement. Training primary care physicians in general and emergency care providers, in particular, is key to scaleup POCUS use. Large size studies are paramount to further explore the effectiveness of POCUS and identify key challenges to its implementation.

Determinants of farmers' biosecurity mindset: A social-ecological model using systems thinking

Commercial poultry is often farmed in high-density facilities, therefore, predisposing exposure to threats of infectious diseases. Studies suggest that it is likely that farmers have little motivation to practise on-farm biosecurity. In Taiwan, where high-density intensive poultry production is commonplace, unfortunately, several avian influenza outbreaks have occurred over the past decade despite the establishment of biosecurity procedures. To develop effective interventions, it is essential to understand the determinants of farmers' biosecurity mindset through systems thinking. In this qualitative study, we directly explored the opinions of Taiwan's chicken farmers, and a grounded theory analysis was performed. The study revealed that farmers allocate resources based on their justification for the optimisation of resource utilisation, and biosecurity is the most concerning challenge. Farmers focus on the economic aspects of their production systems, particularly when the implementation of biosecurity increases production costs, and there are multifaceted, complex barriers to implementing on-farm biosecurity. Although the participant farmers accepted to take major responsibility for disease management, paradoxically, some farmers blamed the practicality of government regulations and government employees' attitudes. Additionally, the farmers rejected the government's intentions to ask farmers to take major responsibility for the outbreaks of avian influenza while some of them intended to ignore the perceived risks. Government interventions that were considered not directly related to biosecurity also negatively influenced farmers' willingness to improve biosecurity. Using the interview results together with information in the scientific literature, we constructed a modified six-level social-ecological model to explain the complex influences of macro socio-economic conditions on farmers' biosecurity mindset. The novelty of this research lies in its wider relevance to Taiwan's chicken production industry in that it provides first-hand evidence-based knowledge to demonstrate a wide number of determinants of farmers' biosecurity mindset. This social-ecological model highlights the importance of systems thinking for the development of behavioural interventions and allows adaptation to the local context. The findings of this study have relevance to Taiwan's chicken production industry and potentially to similar systems in other countries in the wider region and should result in more effective animal health management at the farm level.

Distribution Patterns of Primary Health Care Centers in Osun State, Southwestern Nigeria: Implications for Sustainable Development Goals and Containment of COVID-19 Pandemic

This article examines the distribution patterns of primary health care centers (PHCC) in the 30 Local Government Areas (LGAs) of Osun State, Nigeria, using secondary data. The study focused on the problem of inequality and inadequacy in the distribution pattern of PHCCs among the population. The provision of PHCCs in the state was analyzed using three criteria: among the three senatorial districts; among the 30 LGAs; and on the basis of population per PHCC. Findings revealed that although PHCCs were almost equally distributed among senatorial districts, disparities exist in distribution patterns among the LGAs and within each senatorial district and in terms of population ratio per PHCC in the state. Sixty percent (60%) of the LGAs had fewer than 26 PHCCs, which is the expected average number of PHCCs in the state. The inequalities observed in the study favored rural areas against urban areas. The study further revealed inadequacies in the provision of PHCCs in terms of the population ratio per PHCCs. The study concluded that to achieve the Sustainable Development Goals (SDGs) by 2030—and to contain the COVID-19 pandemic—there is a need for government intervention in the provision of PHCCs in Osun State for equal and adequate distribution.

Resilience development and digitalization of the healthcare supply chain: an exploratory study in emerging economies

Purpose

Healthcare supply chains (HSCs) have been adopting Industry 4.0 (I4.0) as a means to boost their resilience. The first objective of this study is to identify the effect of contextual variables of HSCs on resilience development and I4.0 adoption. Second, the paper examines the pervasiveness of the relationship between resilience and I4.0 across different contextual characteristics.

Design/methodology/approach

179 organizations from the HSC in Brazil and India were surveyed. Responses were analyzed using multivariate data techniques.

Findings

Large HSC agents are more likely to develop resilience abilities and adopt I4.0 technologies when these factors are analyzed independently. However, the joint analysis of resilience and I4.0 displayed a large number of significant correlations among small organizations.

Originality/value

Findings provide managers of HSC arguments to enhance resilience through the digitalization. HSC organizations can identify HSC organizations' context to tailor initiatives on resilience and digitalization.

Teaching Family Medicine and General Practice

The teaching of family medicine and general practice should aim to develop an appreciation of the unique nature and role of the specialty. Teachers should relate patient cases to the principles of family medicine. These principles include (1) compassionate care; (2) a generalist/holistic approach focusing on the whole person, family, and community; (3) continuity of relationship, i.e., building a patient-physician bond of trust; (4) reflective mindfulness; and (5) lifelong learning. The curriculum, instructional strategy, and assessment should be carefully aligned. Core competencies include patient-centered communication, physical examination skills, clinical procedures, palliative care, humanities in medicine, holistic care, shared decision-making, family therapy, home and community visits, chronic disease care, problem-based documentation, team-based care, data-driven improvement, information mastery, ethics and professionalism, and work-life balance. Family medicine/general practice is defined as the medical specialty that manages common and long-term illnesses, focusing on overall health and well-being. Hence, clerkship schedules should maximize clinical exposure and opportunities for self-reflection. A learner-centered approach should begin with a self-identified inventory of learning needs based on the curriculum; next, these needs should be chosen as topics for student presentations. Teaching methods should include mini-workshops: a combination of didactic lectures and small-group exercises. Individual face-to-face formative feedback should occur at midcourse and culminate in a group reflection on the learning experience. Clinical supervision should gradually decrease as each resident demonstrates safe patient care. Procedure skills training should be closely supervised, formally documented, and constitute about one-fourth of learning sessions.

Quality Assessment of Services in Primary Healthcare in Iran: A Systematic Review and Meta-analysis

Background

Primary healthcare (PHC) plays an important role in achieving universal health coverage (UHC). The SERVQUAL instrument is the tool for evaluating the quality of services in the health sector. The main purpose of this study is to evaluate the quality of services provided in PHC in Iran using the SERVQUAL instrument.

Materials and Method

We searched eight databases from January 2000 to September 2021. We analyzed the mean of various SERVQUAL instrument items using the DerSimonian-Laird approach via a random model with 95% confidence interval. Also, we used I2 to evaluate the heterogeneity of the studies.

Results

Finally, 17 studies were chosen for analysis in the present study. There were 8,767 study participants, out of which 8,237 were female and 530 were male. The mean dimensions of perception were as follows: Tangibles = 3.71, reliability = 4, responsiveness = 3.79, assurance = 3.83, and empathy = 3.86. For the expectation, the mean dimension were: Tangibles = 4.46, reliability = 4.46, responsiveness = 4.36, assurance = 4.36, and empathy = 4.36 respectively. The total gap quality between perception and expectation was -0.53.

Conclusion

All dimensions of quality based on SERVQUAL were negative, and the quality of service in PHC is not satisfactory. Therefore, policymakers must adopt serious and effective programs to improve services in this area. We also recommend that quality management of services in PHC in Iran should move toward comprehensive optimization in all areas, and quality in this area should be a priority.

A social media microinfluencer intervention to reduce coronavirus disease 2019 vaccine hesitancy in underserved Tennessee communities: A protocol paper

Background

Central to effective public health policy and practice is the trust between the population served and the governmental body leading health efforts, but that trust has eroded in the years preceding the pandemic. Vaccine hesitancy among adults is also a growing concern across the United States. Recent data suggest that the trustworthiness of information about the coronavirus 2019 (COVID-19) vaccine was a larger concern than the vaccine’s adverse effects or risks.

Objective

This study aims to describe the methods used to create a public health microinfluencer social media vaccine confidence campaign for the COVID-19 vaccine in underserved Tennessee communities. A secondary objective is to describe how the Social-Ecological Model (SEM) and Social Cognitive Theory may address vaccine hesitancy using community pharmacies.

Methods

In late 2020, 50 independent community pharmacies in underserved communities across Tennessee were involved in a public health project with the State of Tennessee Department of Health and the University of Tennessee Health Science Center College of Pharmacy. The project involved a 3-pronged, pharmacy-based COVID-19 vaccination outreach project, including (1) social media messaging (i.e., microinfluencer approach), (2) community partner collaboration, and (3) in-pharmacy promotion. Quantitative and qualitative data will assess the quality and effectiveness of the program. Social media outcomes will also be assessed to measure the impact of the microinfluencer social media training.

Results

Project implementation is planned for 6 months (January 2021 to June 2021) after an initial month of planning by the research team (December 2020) and preceding several months of assessment (July 2021 and beyond).

Conclusions

Novel, theory-based approaches will be necessary to improve vaccine confidence. One approach to promoting public health, derived from the SEM, may be to use trusted microinfluencers on social media platforms, such as local community pharmacists and community leaders.

Reflections on a complex intervention targeting healthy eating in young children

In this article, the author offers her experiences of conducting a public health nursing intervention based on the use of the Medical Research Council framework for complex interventions. This article provides examples aimed at helping and inspiring others who might be interested in conducting a complex intervention study. The intervention focused on counseling about food and feeding practices provided by public health nurses in a sample of child health centers in Norway 2015-2018. Aspects of food and nutrition are central to public health nurses' counseling at the child health center, and they experience challenges when counseling on these themes. This article offers an approach to handling the complexity of public health nursing interventions on counseling among families. The topics presented on planning and performing an intervention and the related challenges might have relevance for public health nursing in several countries.

Improving access to primary health care: a cross-case comparison based on an a priori program theory

Background

Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative.

Methods

IMPACT’s evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results.

Results

Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors.

Discussion

The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways.

Conclusions

All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of ‘cases’.

Working with communities: Meeting the health needs of those living in vulnerable communities when Primary Health Care and Universal Health Care are not available

RATIONALE, AIMS, AND OBJECTIVES

The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs.

METHODS

We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action.

RESULTS

From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training.

CONCLUSION

Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

The anthropology of health systems: A history and review

Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.

Empowering in-service nurses in management of viral hepatitis through Programmed Approach to Knowledge and Sensitization on Hepatitis (PRAKASH): An experience from a capacity building initiative

BACKGROUND

Nursing fraternity are at an increased risk of acquiring hepatitis B and hepatitis C infections mainly attributable to occupational risk and close contact with the patients while treatment. However, unawareness and negligence about the severity, mode of transmission and preventive measures about the disease can further predispose the nursing fraternity to a higher risk of infection. To overcome these lacunae in knowledge, a training program named Project PRAKASH was initiated for in-service nurses across the country. The objective of the program was to impart up-to-date knowledge to the nursing professionals in the management of viral hepatitis and to assess the effectiveness of the training program through pre-post-knowledge assessment survey.

METHODOLOGY

One-day training program titled 'Hepatitis Induction Program' was conducted for a period of 2 years (2018-2020) among nursing professionals. It was accompanied by administration of 54-item knowledge, attitude and practice (KAP) questionnaire with four sections: demographic details, knowledge (30 items), attitude (11 items) and practice (13 items), followed by post-knowledge assessment. An Impact Assessment Survey (IAS) was also administered to assess the change in attitude and practice among 10% of the attendees, at least 6 months post training.

RESULT

A total of 32 one-day training programmes were organised which witnessed the training of 5,253 nursing professionals from 292 institutions across 12 states. A data of 4,474 participants were included in the final analysis: improvement in the knowledge score was significant (P-value < 0.001) with mean knowledge score of 19.3 ± 4.4 in pre-test and 25.7 ± 3.9 in the post-test.

CONCLUSION

The one-day training resulted in improvement of knowledge and significant changes in the attitude and practices of the nursing professionals.

Homecare for sick family members while waiting for medical help during the 2014-2015 Ebola outbreak in Sierra Leone: a mixed methods study

INTRODUCTION

Caring for an Ebola patient is a known risk factor for disease transmission. In Sierra Leone during the outbreak in 2014/2015, isolation of patients in specialised facilities was not always immediately available and caring for a relative at home was sometimes the only alternative. This study sought to assess population-level protective caregiving intentions, to understand how families cared for their sick and to explore perceived barriers and facilitators influencing caregiving behaviours.

METHODS

Data from a nationwide household survey conducted in December 2014 were used to assess intended protective behaviours if caring for a family member with suspected Ebola. Their association with socio-demographic variables, Ebola-specific knowledge and risk perception was analysed using multilevel logistic regression. To put the results into context, semi-structured interviews with caregivers were conducted in Freetown.

RESULTS

Ebola-specific knowledge was positively associated with the intention to avoid touching a sick person and their bodily fluids (adjusted OR (AOR) 1.29; 95% CI 1.01 to 1.54) and the intention to take multiple protective measures (AOR 1.38; 95% CI 1.16 to 1.63). Compared with residing in the mostly urban Western Area, respondents from the initial epicentre of the outbreak (Eastern Province) had increased odds to avoid touching a sick person or their body fluids (AOR 4.74; 95% CI 2.55 to 8.81) and to take more than one protective measure (AOR 2.94; 95% CI 1.37 to 6.34). However, interviews revealed that caregivers, who were mostly aware of the risk of transmission and general protective measures, felt constrained by different contextual factors. Withholding care was not seen as an option and there was a perceived lack of practical advice.

CONCLUSIONS

Ebola outbreak responses need to take the sociocultural reality of caregiving and the availability of resources into account, offering adapted and acceptable practical advice. The necessity to care for a loved one when no alternatives exist should not be underestimated.

The Implications of Zinc Therapy in Combating the COVID-19 Global Pandemic

The global pandemic from COVID-19 infection has generated significant public health concerns, both health-wise and economically. There is no specific pharmacological antiviral therapeutic option to date available for COVID-19 management. Also, there is an urgent need to discover effective medicines, prevention, and control methods because of the harsh death toll from this novel coronavirus infection. Acute respiratory tract infections, significantly lower respiratory tract infections, and pneumonia are the primary cause of millions of deaths worldwide. The role of micronutrients, including trace elements, boosted the human immune system and was well established. Several vitamins such as vitamin A, B6, B12, C, D, E, and folate; microelement including zinc, iron, selenium, magnesium, and copper; omega-3 fatty acids as eicosapentaenoic acid and docosahexaenoic acid plays essential physiological roles in promoting the immune system. Furthermore, zinc is an indispensable microelement essential for a thorough enzymatic physiological process. It also helps regulate gene-transcription such as DNA replication, RNA transcription, cell division, and cell activation in the human biological system. Subsequently, zinc, together with natural scavenger cells and neutrophils, are also involved in developing cells responsible for regulating nonspecific immunity. The modern food habit often promotes zinc deficiency; as such, quite a few COVID-19 patients presented to hospitals were frequently diagnosed as zinc deficient. Earlier studies documented that zinc deficiency predisposes patients to a viral infection such as herpes simplex, common cold, hepatitis C, severe acute respiratory syndrome coronavirus (SARS-CoV-1), the human immunodeficiency virus (HIV) because of reducing antiviral immunity. This manuscript aimed to discuss the various roles played by zinc in the management of COVID-19 infection.

Prevalence of anemia in pediatric patients of traumatic brain injury and problems associated with management in a developing country: Unfolding of an underrated comorbidity

Background

Pediatric anemia has a high prevalence in developing countries such as Pakistan. It is common knowledge among hospital specialties but little is done to manage this condition by hospitalists. The issue is compounded with a poor primary care infrastructure nationally. The aim of this study is to bring to light the high prevalence of anemic children in neurosurgery and to describe the difficulties in managing their anemia in a tertiary hospital setting. A literature review is presented highlighting the socioeconomic difficulties that contribute to this widespread comorbidity and the difficulty in managing it from a hospital specialty point of view.

Methods

A prospective descriptive case series was carried out between March 2020 and September 2020. All patients under the age of 13 who presented to our department for traumatic brain injury (TBI) meeting our inclusion and exclusion criteria were enrolled and assessed for the presence and severity of anemia. Demographic data were collected. Following discharge, patients were referred to our hospital's pediatrics' anemia clinic which was before their first neurosurgery follow-up 2 weeks following discharge and attendance to follow up was documented.

Results

The prevalence of anemia was 78.9%. Over 95% of patients attended their neurosurgery follow-up but only 28% of patients attended their referral to the anemia clinic.

Conclusion

Anemia is highly prevalent in children presenting to neurosurgery for TBI and its longitudinal management has difficulties with lost to follow up in a tertiary hospital setting. There is a need for national initiatives to reduce the prevalence of anemia but concurrently better strategies need to be devised to manage anemic children in a hospital setting.

Project ECHO COVID-19: Vulnerable Populations and Telehealth Early in the Pandemic

INTRODUCTION/OBJECTIVES

Project ECHO COVID-19 was launched nationwide on March 4, 2020 to disseminate guidance about COVID-19 in a timely and scalable manner to meet the urgent needs of primary care settings, the first line of defense in a pandemic.

METHODS

Data from post-session surveys were analyzed to assess participant satisfaction, knowledge gaps, change in knowledge, and anticipated changes in practice as a result of Project ECHO COVID-19. A content analysis was conducted of the 243 questions and concerns posted by over 2000 participants in the Question and Answer function of Zoom during the first 8 sessions (March 4-April 29, 2020).

RESULTS

Of 5243 registrants, 49% attended at least one session. Respondents agreed or strongly agreed that didactic sessions (97%) and case presentations (96%) met their learning needs; 93% reported gaining new knowledge, and 88% would implement that knowledge. Only 32% and 53% of respondents anticipated changing workflows and adapting to telehealth, respectively, despite the need for both as the pandemic continued. The content analysis identified 3 categories: clinical operations (eg, testing, triage, telehealth, billing); patient care (diagnosis and treatment of COVID-19, management of high-risk vulnerable populations); and epidemiology (viral spread, implications for public health).

CONCLUSIONS

Care of vulnerable populations and clinical operations should be addressed when planning education and clinical interventions for public health crises. Adapting the Project ECHO model to be more scalable was an effective means of creating a community of practice among health professionals when evidence-based guidance was not available to manage the implications of a pandemic.

Sexual and Gender-Based Violence Among Refugees and Internally Displaced Persons in the Democratic Republic of the Congo: Post-Conflict Scenario

The ongoing humanitarian crisis in the Democratic Republic of the Congo has triggered sexual and gender-based violence, including rape, sexual slavery, trafficking, intimate partner violence, and sexual exploitation. Gender inequalities and abuse of power experienced by women and young girls at refugee settings further exacerbate their vulnerability to different forms of violence. This study aimed to offer an evidence-based approach to developing strategies in tackling the complex problem of sexual and gender-based violence among refugees and internally displaced persons in the Congo. We conducted a narrative review of all the relevant papers known to the authors to explore the origins of the problem, its implications on public health, and its impact on equity. The study revealed that sexual assault survivors face physical and psychological sufferings, excruciating emotions, and profound disruption of their social well-being since they are often stigmatized and ostracized by society. The analysis of current government policies revealed a lack of programs to address survivors' specific concerns and policy enforcement problems. This study suggested strategic objectives and policy implementation steps. The proposed strategies address women empowerment and gender stigma, provision of effective health services, and adequate response action.

An implementation history of primary health care transformation: Alberta's primary care networks and the people, time and culture of change

BACKGROUND

Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment.

METHODS

Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses.

RESULTS

Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success.

CONCLUSIONS

Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.

Equity and efficiency of health care resource allocation in Jiangsu Province, China

Background

Jiangsu was one of the first four pilot provinces to engage in comprehensive health care reform in China, which has been on-going for the past 5 years. This study aims to evaluate the equity, efficiency and productivity of health care resource allocation in Jiangsu Province using the most recent data, analyse the causes of deficiencies, and discuss measures to solve these problems.

Methods

Data were extracted from the Jiangsu Health/Family Planning Statistical Yearbook (2015–2019) and Jiangsu Statistical Yearbook (2015–2019). The Gini coefficient (G), Theil index (T) and health resource density index (HRDI) were chosen to study the fairness of health resource allocation in Jiangsu Province. Data envelopment analysis (DEA) and the Malmquist productivity index (MPI) were used to analyse the efficiency and productivity of this allocation.

Results

From 2014 to 2018, the total amount of health resources in Jiangsu Province increased. The G of primary resource allocation by population remained below 0.15, and that by geographical area was between 0.14 and 0.28; additionally, the G of health financial resources was below 0.26, and that by geographical area was above 0.39. T was consistent with the results for G and Lorenz curves. The HRDI shows that the allocated amounts of health care resources were the highest in southern Jiangsu, except for the number of health institutions. The average value of TE was above 0.93, and the DEA results were invalid for only two cities. From 2014 to 2018, the mean TFPC in Jiangsu was less than 1, and the values exceeded 1 for only five cities.

Conclusion

The equity of basic medical resources was better than that of financial resources, and the equity of geographical allocation was better than that of population allocation. The overall efficiency of health care resource allocation was high; however, the total factor productivity of the whole province has declined due to technological regression. Jiangsu Province needs to further optimize the allocation and increase the utilization efficiency of health care resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01320-2.

A renewed framework for the essential public health functions in the Americas

This report presents the results of a consensus decision making process conducted to elaborate a renewed conceptual framework of the essential public health functions for the Americas. The emerging framework consists of four pillars encompassing action-oriented components relating to the new scope and concerns of public health. The four pillars call for adopting a human rights approach to public health, addressing the social determinants of health, ensuring access to both individuals and population-based services, and expanding the stewardship role of health authorities through a collaborative implementation of public health functions. Public health functions were conceptualized as a set of capacities that are part of an integrated policy cycle the encompasses four stages: assessment, policy development, allocation of resources, and access. The framework provides a road map for evaluation and development by health authorities of integrated enabling public health policies through intersectoral collaboration. The application of the framework would require engaging countries working to improve public health through national assessments and systematic incorporation of these findings into quality improvement efforts and sectoral and intersectoral decision-making processes around policy and investments priorities promoted by governments. Work is ongoing in the definition of a list of public health functions that gives operational clarity to each dimension of this framework and guides performance evaluation.

Primary health care contributions to universal health coverage, Ethiopia

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

Qualitative evaluation of the general practitioner chronic non-communicable diseases training programme

BACKGROUND

In China, general practitioners have limited ability to provide care for common chronic non-communicable diseases because they lack postgraduate training. In an attempt to improve general practitioners' skills in this regard, the present authors previously launched the Chronic Non-Communicable Diseases Training Programme. The present study aims to evaluate the effectiveness of this programme.

METHODS

Thirty-nine trainee general practitioners who participated in the programme underwent semi-structured interviews, which explored how they performed the training, what they achieved from the programme, and their suggestions for future programmes. The interview data were analysed using a thematic analysis approach.

RESULTS

Under the guidance of supervisors, the thirty-nine trainee general practitioners completed the structured but individualised training plan, which comprised a four-day basic theory class, 3 months practising in a ward, and 6 months assisting in an outpatient clinic. They reported an improvement in their ability to provide care for chronic non-communicable diseases and perform two-way referral, as well as their communication with patients. They also reported that, since returning to their communities, they had become more confident, were building better relationships with their patients, and had changed their clinic behaviours from copying prescriptions to making medical decisions independently. Their principal suggestion for the training programme was to alter the order of the training, as they preferred to practice in the ward before assisting in the outpatient clinic.

CONCLUSION

The course comprised a learner-centred, practice- and apprenticeship-based, general-practitioner training programme. Given the participants' progress and the beneficial effects of the programme reported in the interview data, it appears to be worthwhile to extend the General Practitioner Chronic Non-Communicable Diseases Training Programme.

Developing a program theory of patient engagement in patient-oriented research and the impacts on the health care system: protocol for a rapid realist review

BACKGROUND

The patient-oriented research (POR) discourse has been criticized as being fragmented, lacking consistent terminology and having few evaluative studies. Our research team will use rapid realist review methodology to generate broad, process-based program theory regarding how partnering patients with researchers in POR generates an impact within a health care system.

METHODS

This protocol for a rapid realist review will involve multiple steps, including research question development; preliminary program theory and search strategy development; study selection and appraisal; data extraction, analysis and synthesis; and program theory refinement. We will be guided by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards for realist synthesis. Unlike traditional reviews, a realist review aims to discover and understand causal processes that exist within a complex environment, asking questions regarding what works for whom, under what circumstances, how and why. Our multidisciplinary team consists of patient partners, health care professionals, a health sciences librarian and health services researchers. Patient partners are full research partners, supporting development of our guiding research question and identifying community partners and stakeholder groups to disseminate our findings. Patient partners will be asked to recommend literature sources, to review and vet our set of search terms, and to review, evaluate and reflect on our initial program theory in light of their personal, lived expertise.

INTERPRETATION

We will share the results of our rapid realist review with community partners and stakeholder groups. We will also disseminate our program theory by means of publication in a peer-reviewed journal and presentation at scientific conferences.

Evidence on result-based financing in maternal and child health in low- and middle-income countries: a systematic review

Introduction

Result-Based Financing (RBF) is an umbrella term for financial mechanisms that link incentives to outputs or outcomes. International development agencies are promoting RBF as a viable financing approach for the realization of universal health coverage, with numerous pilot trials, particularly in low- and middle-income countries (LMICs). There is limited synthesized evidence on the performance of these mechanisms and the reasons for the lack of RBF institutionalization. This study aims to review the evidence of RBF schemes that have been scaled or institutionalized at a national level, focusing on maternal, newborn, and child health (MNCH) programming in LMICs.

Methods

A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors identified and reviewed country-level RBF evaluation reports for the period between January 2000 and June 2019. Data were extracted from both published and gray literature on RBF application in MNCH using a predesigned matrix. The matrix headers included country of application; program setting; coverage and duration; evaluation design and methods; outcome measures; and key findings. A content thematic analysis approach was used to synthesize the evidence and emerging issues.

Results

The review identified 13 reports from 11 countries, predominantly from Sub-Saharan Africa. Performance-based financing was the most common form of RBF initiatives. The majority of evaluation designs were randomized trials. The evaluations focused on outputs, such as coverage and service utilization, rather than outcomes. RBF schemes in all 11 countries expanded their scope, either geographically or accordingly in terms of performance indicators. Furthermore, only three studies conducted a cost-effectiveness analysis, and only two included a discussion on RBF's sustainability. Only three countries have institutionalized RBF into their national policy. On the basis of the experience of these three countries, the common enabling factors for institutionalization seem to be political will, domestic fund mobilization, and the incorporation of demand-side RBF tools.

Conclusion

RBF evidence is still growing, partial, and inconclusive. This limited evidence may be one of the reasons why many countries are reluctant to institutionalize RBF. Additional research is needed, particularly regarding cost-effectiveness, affordability, and sustainability of RBF programs.

Defining and classifying public health systems: a critical interpretive synthesis

Background

The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population. Several frameworks exist to conceptualise healthcare systems, highlighting the stark contrast of frameworks unique to public health systems. The objectives of this study were to define public health systems and assess differences between healthcare systems and public health systems within established health systems frameworks.

Methods

A critical interpretive synthesis was conducted. Databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. Data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on a current leading health systems and policy classification scheme – health systems arrangements (governance, financial and delivery arrangements).

Results

A total of 5933 unique documents were identified and 67 were included in the analysis. Definitions of public health and public health systems varied significantly as did their roles and functions across jurisdictions. Public health systems arrangements generally followed those of health systems, with the addition of partnerships (community and inter-sectoral) and communication playing a larger role in public health. A public health systems framework and conceptualisation of how public health currently fits within health systems are presented.

Conclusions

Public health systems are unique and vital entities within health systems. In addition to examining how public health and public health systems have been defined within the literature, this review suggests that establishing the scope of public health is crucial to understanding its role within the larger health system and adds to the discourse around the relationship between public health, healthcare and population health. More broadly, this study addresses an important gap in understanding public health systems and provides conceptual and practical contributions as well as areas for future research.

Application of Disease Etiology and Natural History to Prevention in Primary Health Care: A Discourse

The principles of etiology and natural history of disease are essential to recognizing opportunities for prevention across the illness spectrum. They have a bearing on how illness is experienced, how differently it can be perceived at the time of first contact with the health system, and how it may appear at later stages. Opportunities for prevention arise at every stage in the process, and three main levels are described: primary, secondary, and tertiary. Prevention strategies include health promotion focused on determinants, clinical prevention to reduce modifiable risk factors, case finding, screening, and addressing functional outcomes relevant to quality of life; the importance of preventing errors is also recognized. The distinction between incidence effects and treatment effects of prevention is explored. This review also examines the differing roles of language in health science and public communication, aspects of disease classification, related issues in patient-centered care, the prevention paradox, and integrated models of disease prevention.

Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries

The prevalence of long-term (chronic) non-communicable diseases (NCDs) is increasing globally due to an ageing global population, urbanization, changes in lifestyles, and inequitable access to healthcare. Although previously more common in high- and upper-middle-income countries, lower-middle-income countries (LMICs) are more affected, with NCDs in LMICs currently accounting for 85–90% of premature deaths among 30–69 years old. NCDs have both high morbidity and mortality and high treatment costs, not only for the diseases themselves but also for their complications. Primary health care (PHC) services are a vital component in the prevention and control of long-term NCDs, particularly in LMICs, where the health infrastructure and hospital services may be under strain. Drawing from published studies, this review analyses how PHC services can be utilized and strengthened to help prevent and control long-term NCDs in LMICs. The review finds that a PHC service approach, which deals with health in a comprehensive way, including the promotion, prevention, and control of diseases, can be useful in both high and low resource settings. Further, a PHC based approach also provides opportunities for communities to better access appropriate healthcare, which ensures more significant equity, efficiency, effectiveness, safety, and timeliness, empowers service users, and helps healthcare providers to achieve better health outcomes at lower costs.

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Addressing quadruple aims through primary care and public health collaboration: ten Canadian case studies

BACKGROUND

Health systems in Canada and elsewhere are at a crossroads of reform in response to rising economic and societal pressures. The Quadruple Aim advocates for: improving patient experience, reducing cost, advancing population health and improving the provider experience. It is at the forefront of Canadian reform debates aimed to improve a complex and often-fragmented health care system. Concurrently, collaboration between primary care and public health has been the focus of current research, looking for integrated community-based primary health care models that best suit the health needs of communities and address health equity. This study aimed to explore the nature of Canadian primary care - public health collaborations, their aims, motivations, activities, collaboration barriers and enablers, and perceived outcomes.

METHODS

Ten case studies were conducted in three provinces (Nova Scotia, Ontario, and British Columbia) to elucidate experiences of primary care and public health collaboration in different settings, contexts, populations and forms. Data sources included a survey using the Partnership Self-Assessment Tool, focus groups, and document analysis. This provided an opportunity to explore how primary care and public health collaboration could serve in transforming community-based primary health care with the potential to address the Quadruple Aims.

RESULTS

Aims of collaborations included: provider capacity building, regional vaccine/immunization management, community-based health promotion programming, and, outreach to increase access to care. Common precipitators were having a shared vision and/or community concern. Barriers and enablers differed among cases. Perceived barriers included ineffective communication processes, inadequate time for collaboration, geographic challenges, lack of resources, and varying organizational goals and mandates. Enablers included clear goals, trusting and inclusive relationships, role clarity, strong leadership, strong coordination and communication, and optimal use of resources. Cases achieved outcomes addressing the Q-Aims such as improving access to services, addressing population health through outreach to at-risk populations, reducing costs through efficiencies, and improving provider experience through capacity building.

CONCLUSIONS

Primary care and public health collaborations can strengthen community-based primary health care while addressing the Quadruple Aims with an emphasis on reducing health inequities but requires attention to collaboration barriers and enablers.

Using mobile phones to improve community health workers performance in low-and-middle-income countries

Background

In low-and-middle-income countries community health workers are the core component of the PHC system as they act as a liaison between the communities and the healthcare facilities. Evidence suggests that the services offered by these workers have helped in the decline of maternal and child morbidity and mortality rates and the burden of communicable and non-communicable diseases. However, the coverage and the overall progress towards achieving the SDG targets is very sluggish. The recent consensus concerning this current pace of progress, is that it relates to financial and human resources constraints. CHWs are overburdened as they are expected to accomplish more although they may not obtain the required support to perform their duties. The health systems of LMICs, have given very little attention to the work environment of CHWs; which has negatively affected CHWs productivity, and quality of services. This debate is intended to explore the potential of mobile phone technology in LMICs for improving CHWs performance and effectiveness.

Discussion

To improve CHWs productivity, some studies involved the use of mobile phones for data collection and reporting, while other studies used mobile technology for patient to provider communication, patient education, CHWs supervision, and monitoring and evaluation. A wide range of benefits exists for using mobile phones including reduction in CHWs workload, improvement in data collection, reporting and monitoring, provision of quality healthcare services, supportive supervision, better organization of CHWs tasks and improvement in community health outcomes. However, a number of studies suggests that CHWs encounter unique challenges when adopting and using mobile health solutions for health service delivery such as, lack of CHWs training on new mHealth solutions, weak technical support, issues of internet connectivity and other administrative challenges. Future research efforts should be directed to explore health system readiness for adopting sustainable mHealth solutions to improve CHWs workflows in LMICs.

Conclusion

Future research efforts and policy dialogue should be directed to explore health system readiness for adopting sustainable mHealth solutions to improve CHWs workflows in LMICs.

National Health Policy Reform for Primary Care in Chile: A Qualitative Analysis of the Health Program Documents

Introduction: Chilean policy makers reformed the national health policy for primary health care (PHC), shifting from the traditional biomedical model to the integral family and community health model with a biopsychosocial approach, to guide the delivery of PHC throughout the country. Purpose: To evaluate the implementation of the national health policy for PHC through an analysis of the program documents for PHC; and to identify to what extent the national health policy is expressed in each program document, and across all the documents. Methods: A qualitative document analysis with a purposive sample of program documents for PHC. The Chilean Ministry of Health website was systematically searched between October and December 2018 to identify relevant program documents. Thematic and content analysis were performed to identify evidence of the biopsychosocial approach to care delivery with each program document, including the types of interactions between professionals that contribute to person-centered or fragmented care. Results: The study included 13 PHC program documents. Three themes and 10 categories emerged from the data. Most program justifications focused on the biopsychosocial approach to care while including biomedical interventions and supporting independent professional work. Only 4 of the 13 programs were consistent in the justification, interventions, and types of stated professional interactions: 2 from the biopsychosocial and 2 from the biomedical perspectives. Conclusion: In terms of the national health policy for PHC in Chile, interprofessional collaboration and person-centered care processes and practices were partially aligned with the written content of the health program documents. As such, policy makers and health sector leaders are advised to analyze draft health program documents for consistency in translating national health policies into the written communications that define the actualization of the care model in PHC and direct professionals how to provide PHC to individuals and families.

Quality, safety and performance management in primary health care: from scoping review to research priority setting and implementation plan in the Eastern Mediterranean Region

INTRODUCTION

Strong primary health care (PHC) leads to better health outcomes, improves health equity and accelerates progress towards universal health coverage (UHC). The Astana Declaration on PHC emphasised the importance of quality care to achieve UHC. A comprehensive understanding of the quality paradigm of PHC is critical, yet it remains elusive in countries of the Eastern Mediterranean Region (EMR). This study used a multistep approach to generate a policy-relevant research agenda for strengthening quality, safety and performance management in PHC in the EMR.

METHODS

A multistep approach was adopted, encompassing the following steps: scoping review and generation of evidence and gap maps, validation and ranking exercises, and development of an approach for research implementation. We followed Joanna Briggs Institute guidelines for conducting scoping reviews and a method review of the literature to build the evidence and gap maps. For the validation and ranking exercises, we purposively sampled 55 high-level policy-makers and stakeholders from selected EMR countries. We used explicit multicriteria for ranking the research questions emerging from the gap maps. The approach for research implementation was adapted from the literature and subsequently tailored to address the top ranked research question.

RESULTS

The evidence and gap maps revealed limited production of research evidence in the area of quality, safety and performance management in PHC by country and by topic. The priority setting exercises generated a ranked list of 34 policy-relevant research questions addressing quality, safety and performance management in PHC in the EMR. The proposed research implementation plan involves collaborative knowledge generation with policy-makers along with knowledge translation and impact assessment.

CONCLUSION

Study findings can help inform and direct future plans to generate, disseminate and use research evidence to enhance quality, safety and performance management in PHC in EMR and beyond. Study methodology can help bridge the gap between research and policy-making.

Knowledge, attitudes and practices on tuberculosis transmission and prevention among auxiliary healthcare professionals in three Brazilian high-burden cities: a cross-sectional survey

Background

Tuberculosis elimination requires treatment of latently infected high-risk persons, such as contacts of index cases. Identification and referral of tuberculosis contacts for investigation are major barriers in the contact cascade-of-care. These tasks rely heavily on auxiliary primary healthcare workers in many low- and middle-income countries. We aimed to understand their knowledge, attitudes and practices (KAP) regarding contact investigation in Brazil.

Methods

We conducted a cross-sectional KAP survey on tuberculosis transmission and prevention among 135 auxiliary healthcare workers in three tuberculosis high-burden Brazilian cities. Trained interviewers applied a translated version of a previously applied questionnaire. Open answers were classified in pre-defined objective categories and analysed quantitatively. Answers were further classified as satisfactory or not according to criteria set by a panel of three specialists.

Results

Although 66% had received tuberculosis training in the past 10 years, only 19% were trained for tuberculosis prevention. 64% could not clearly distinguish latent tuberculosis infection (LTBI) from active tuberculosis; 63% did not know how to diagnose LTBI and 52% did not know how to prevent progression to active tuberculosis. Most believed that it is important to investigate adult (99%) and child (96%) contacts for LTBI. However, not all invite contacts - children (81%) or adults (71%) - to the clinic, despite only 24% perceiving difficulties for investigation.

Conclusions

Gaps in KAP among auxiliary health workers have been reported in other areas, such as obstetrics and other infectious diseases. To the best of our knowledge, this is the first KAP survey on tuberculosis transmission and prevention among auxiliary health care workers, and relevant gaps were also found. Knowledge gaps were notably related to LTBI management, including how to recognize it and prevent progression to active tuberculosis through treatment, despite most recognizing the importance of investigating contacts. Auxiliary healthcare workers in three Brazilian high-burden cities have important knowledge gaps despite their perception of the importance of tuberculosis prevention among contacts. They need to incorporate contact referral as one of their tasks to enable progress toward the target of tuberculosis elimination.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4231-x) contains supplementary material, which is available to authorized users.