Audit Culture: Unintended Consequences of Accountability Practices in Evidence-Based Programs

'Ending AIDS' between comparison and commensuration and the role of global health indicators

The use of targets and indicators in global health has become ubiquitous within global health and disease elimination programmes. The drive to 'end AIDS' has become a global flagship endeavour, including nation-states, donor organisations, NGOs, pharmaceutical companies, medical researchers, and activists. Almost synonymous with the campaign of ending AIDS is UNAIDS' 90-90-90 targets. Beyond indicators' role in neoliberal global health, an essential aspect of indicators and quantitative metrics is their ability to provide a basis for measurements and comparability across time and between different actors and entities. These processes are based on what has been called, commensuration, visual simplification, and serialisation. This article seeks to provide an account of how we can think about indicators in the drive to end AIDS as doing work that is contingent upon commensuration, simplification, and serialisation. The argument is that by attending to issues of commensuration, visual simplification, and serialisation we are better able to see how we risk erasing and foreclosing other forms of conceptualising what the end of AIDS could be. Logics of quantification risks erasing and foreclosing other qualitative aspects of the HIV epidemic as well as obscuring various epistemological tensions inherent in counting towards the end of AIDS.

Lessons Learned from Implementing the SHIELD Intervention: A Peer Education Intervention for People Who Use Drugs

HIV prevention and care peer education interventions have demonstrated effectiveness at changing HIV risk and care behaviors among a variety of at-risk populations in different settings. However, little is known about the implementation of this type of intervention in community-based settings. Further, there is limited information available regarding the facilitators and barriers to implementing peer education interventions in community-based settings. In this study, we explore implementation facilitators, barriers, and strategies to overcome these barriers among 12 organizations that implemented the SHIELD intervention, an evidenced-based peer education intervention for people who use drugs. Guided by the Consolidated Framework for Implementation Research, we identified several facilitators and barriers at the outer, inner individuals, and intervention level of the implementation process. Future evidence-based public health programs should, in addition to addressing effectiveness, be relevant to the needs and lives of clients.

Case analyses of state-sponsored asthma quality improvement interventions - benefits and technical assistance efforts

OBJECTIVE

A cross-case analysis was used to discover how two states benefited from expanded use of evaluation for asthma quality improvement initiatives. If an asthma quality improvement (QI) initiative is successfully evaluated, data can inform how to effectively integrate clinical practice guidelines and circumvent non-clinical reasons that interrupt QI projects such as low staff interest. This article addresses a gap in the literature on quality of evaluation support needed to improve and sustain asthma QI at local health care organizations by describing the similar discoveries observed at two independent QI statewide initiatives in Indiana and Montana.

METHODS

As part of a larger review, two states funded through the National Asthma Control Program at the Centers for Disease Control and Prevention were identified based on similarities in evaluation approaches. Each state used an iterative stakeholder-driven evaluation approach, mixed methods, process evaluation indicators, and active use of evaluation findings. The asthma QI initiatives and evaluations in Indiana and Montana were coordinated independent of each other.

RESULTS

Although both states found that asthma QI initiatives improved health outcomes, evaluation data were able to further pinpoint areas that would improve quality of technical support to health care organizations and identify markers of sustainability, such as nontraditional benefits to staff, and intervention sites.

CONCLUSION

Findings suggest that when evaluation is used to guide implementation, data are available to develop site-specific assistance and identify sustainability markers to prevent interruption of positive health outcomes associated with an asthma QI initiative.

Performance indicator as the main and the only goal: a "dark side" of the intervention aims to accelerate HIV treatment entry among people who inject drugs in Kyiv, Ukraine

BACKGROUND

To improve healthcare entry and antiretroviral therapy (ART) initiation for HIV-positive people who inject drugs (PWID) in Ukraine, an intervention built upon a successful community-based harm reduction project and the existing best practices was developed. In this article, we present the results of the study conducted in collaboration with one of the recipient organizations of the intervention in Kyiv. The research question was formulated as follows: how does the interaction between different actors work to lead it to a positive outcome (initiation PWIDs into ART) within the limited period of the intervention implementation?

METHODS

The central focus of the study was on the work activities of case managers. Their daily routines as well as their interactions with their clients and medical workers were observed and analyzed. Using the institutional ethnography approach, we explore the institutional orders, power imbalances, and social factors that play different roles in coordinating the process of PWIDs entry into healthcare and HIV treatment.

RESULTS

The most intriguing result of the study is that the performance indicator that must be completed in order to receive a full salary-as a way to manage the activities of case managers-produces conditions for them to develop their cooperation with medical workers but leaves the clients and their needs out of this "boat" because interaction with them, in fact, does not help to meet case managers' goals.

CONCLUSIONS

Accountability of case managers' work assumes the primacy of the result over the process, which makes the process itself less important and the need to achieve the goal becomes the main and the only goal. This can be identified as an unintended consequence of the intervention implementation on the ground, or wider-an unintended consequence of the payment by results practice as a part of the general number-based policy.

Synthetic social support: Theorizing lay health worker interventions

Levels of social support are strongly associated with health outcomes and inequalities. The use of lay health workers (LHWs) has been suggested by policy makers across the world as an intervention to identify risks to health and to promote health, particularly in disadvantaged communities. However, there have been few attempts to theorize the work undertaken by LHWs to understand how interventions work. In this article, the authors present the concept of 'synthetic socialsupport' and distinguish it from the work of health professionals or the spontaneous social support received from friends and family. The authors provide new empirical data to illustrate the concept based on qualitative, observational research, using a novel shadowing method involving clinical and non-clinical researchers, on the everyday work of 'pregnancy outreach workers' (POWs) in Birmingham, UK. The service was being evaluated as part of a randomized controlled trial. These LHWs provided instrumental, informational, emotional and appraisal support to the women they worked with, which are all key components of social support. The social support was 'synthetic' because it was distinct from the support embedded in spontaneous social networks: it was non-reciprocal; it was offered on a strictly time-limited basis; the LHWs were accountable for the relationship, and the social networks produced were targeted rather than spontaneous. The latter two qualities of this synthetic form of social support may have benefits over spontaneous networks by improving the opportunities for the cultivation of new relationships (both strong and weak ties) outside the women's existing spontaneous networks that can have a positive impact on them and by offering a reliable source of health information and support in a chaotic environment. The concept of SSS can help inform policy makers about how deploying lay workers may enable them to achieve desired outcomes, specify their programme theories and evaluate accordingly.