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Rodríguez-Orozco JE, Martínez-Rubio CF, Moreno-Vargas E, Peña-Ortiz A, Pizarro-Peñaranda MC, Rojo-Bustamante E, Villarreal-García DE, Bayona-Ortiz HF. Comparative global analysis of stroke rehabilitation recommendations across income levels. J Clin Epidemiol 2024; 170:111334. [PMID: 38548231 DOI: 10.1016/j.jclinepi.2024.111334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 03/06/2024] [Accepted: 03/20/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC). STUDY DESIGN AND SETTING We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC. RESULTS The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations. CONCLUSION There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.
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Affiliation(s)
| | - Carlos Fernando Martínez-Rubio
- Neurology Department, Hospital Universitario Fundación Santa Fe de Bogotá, Cra. 7 #117 -15, Bogotá, Colombia; Universidad de los Andes, Cra. 7 #116-5, Bogotá, Colombia; Universidad El Bosque, Ak. 9 #131a-2, Bogotá, Colombia
| | - Eder Moreno-Vargas
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra. 98 #18-49, Cali, Valle del Cauca, Colombia
| | - Angélica Peña-Ortiz
- Neurology Department, Hospital Universitario Fundación Santa Fe de Bogotá, Cra. 7 #117 -15, Bogotá, Colombia; Universidad de los Andes, Cra. 7 #116-5, Bogotá, Colombia
| | | | - Estefanía Rojo-Bustamante
- Neurology Department, Hospital Universitario Fundación Santa Fe de Bogotá, Cra. 7 #117 -15, Bogotá, Colombia; Universidad El Bosque, Ak. 9 #131a-2, Bogotá, Colombia
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Kouanda S, Ouedraogo AM, Sogo AE, Bagaya O, Sorgho TEV, Hien YC, Gbenou DV, Sawadogo Windsouri SR, Zoungrana W, Dadjoari M, Zombré Sanou VM, Usmanova G, Jain Y, Chahar R, Kumar S, Kumar SVV, Srivastava A, Nair TS, Sarkar AH, Bajpai N, Patwardhan V, Joshi CS, Chotiya M, Baswal D, Musange S, Sayinzoga F, Mutabazi V, Murindahabi NK, Nzeyimana D, Rwabufigiri BN, Kabuteni TJ, Mugabo M, Mbizvo M, Chizuni C, Chelwa N, Muliokela R, Phiri C, Kasonda K, Okpara N, Nyirenda M, Malumo SB, Mwiche A, Simushi V, Nsubuga Bakyaita N, Barreix M, Tunçalp Ö, Thwin SS, Bucagu M, Tamrat T, Habib N, Lefevre AE, Lorencatto F. New Antenatal Model in Africa and India (NAMAI) study: implementation research to improve antenatal care using WHO recommendations. Health Res Policy Syst 2023; 21:82. [PMID: 37563619 PMCID: PMC10416399 DOI: 10.1186/s12961-023-01014-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/19/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND In 2020, an estimated 287 000 women died globally from pregnancy-related causes and 2 million babies were stillborn. Many of these outcomes can be prevented by quality healthcare during pregnancy and childbirth. Within the continuum of maternal health, antenatal care (ANC) is a key moment in terms of contact with the health system, yet it remains an underutilized platform. This paper describes the protocol for a study conducted in collaboration with Ministries of Health and country research partners that aims to employ implementation science to systematically introduce and test the applicability of the adapted WHO ANC package in selected sites across four countries. METHODS Study design is a mixed methods stepped-wedge cluster randomized implementation trial with a nested cohort component (in India and Burkina Faso). The intervention is composed of two layers: (i) the country- (or state)-specific ANC package, including evidence-based interventions to improve maternal and newborn health outcomes, and (ii) the co-interventions (or implementation strategies) to help delivery and uptake of the adapted ANC package. Using COM-B model, co-interventions support behaviour change among health workers and pregnant women by (1) training health workers on the adapted ANC package and ultrasound (except in India), (2) providing supplies, (3) conducting mentoring and supervision and (4) implementing community mobilization strategies. In Rwanda and Zambia, a fifth strategy includes a digital health intervention. Qualitative data will be gathered from health workers, women and their families, to gauge acceptability of the adapted ANC package and its components, as well as experience of care. The implementation of the adapted ANC package of interventions, and their related costs, will be documented to understand to what extent the co-interventions were performed as intended, allowing for iteration. DISCUSSION Results from this study aim to build the global evidence base on how to implement quality ANC across different settings and inform pathways to scale, which will ultimately lead to stronger health systems with better maternal and perinatal outcomes. On the basis of the study results, governments will be able to adopt and plan for national scale-up, aiming to improve ANC nationally. This evidence will inform global guidance. TRIAL REGISTRATION NUMBER ISRCTN, ISRCTN16610902. Registered 27 May 2022. https://www.isrctn.com/ISRCTN16610902.
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Triplett NS, Mbwayo A, Kiche S, Liu L, Silva J, AlRasheed R, Johnson C, Amanya C, Munson S, Weiner BJ, Collins PY, Dorsey S. Co-developed implementation guidelines to maximize acceptability, feasibility, and usability of mobile phone supervision in Kenya. Glob Ment Health (Camb) 2023; 10:e31. [PMID: 37854429 PMCID: PMC10579659 DOI: 10.1017/gmh.2023.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/11/2023] [Accepted: 05/16/2023] [Indexed: 10/20/2023] Open
Abstract
Opportunities exist to leverage mobile phones to replace or supplement in-person supervision of lay counselors. However, contextual variables, such as network connectivity and provider preferences, must be considered. Using an iterative and mixed methods approach, we co-developed implementation guidelines to support the implementation of mobile phone supervision with lay counselors and supervisors delivering a culturally adapted trauma-focused cognitive behavioral therapy in Western Kenya. Guidelines were shared and discussed with lay counselors in educational outreach visits led by supervisors. We evaluated the impact of guidelines and outreach on the acceptability, feasibility, and usability of mobile phone supervision. Guidelines were associated with significant improvements in acceptability and usability of mobile phone supervision. There was no evidence of a significant difference in feasibility. Qualitative interviews with lay counselors and supervisors contextualized how guidelines impacted acceptability and feasibility - by setting expectations for mobile phone supervision, emphasizing importance, increasing comfort, and sharing strategies to improve mobile phone supervision. Introducing and discussing co-developed implementation guidelines significantly improved the acceptability and usability of mobile phone supervision. This approach may provide a flexible and scalable model to address challenges with implementing evidence-based practices and implementation strategies in lower-resourced areas.
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Affiliation(s)
- Noah S. Triplett
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Anne Mbwayo
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Sharon Kiche
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Lucy Liu
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Jacinto Silva
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Rashed AlRasheed
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Clara Johnson
- Department of Psychology, University of Washington, Seattle, WA, USA
| | | | - Sean Munson
- Department of Human Centered Design & Engineering, University of Washington, Seattle, WA, USA
| | - Bryan J. Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Pamela Y. Collins
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle, WA, USA
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Namutebi M, Nalwadda GK, Kasasa S, Muwanguzi PA, Kaye DK. Midwives' perceptions towards the ministry of health guidelines for the provision of immediate postpartum care in rural health facilities in Uganda. BMC Pregnancy Childbirth 2023; 23:261. [PMID: 37072738 PMCID: PMC10111670 DOI: 10.1186/s12884-023-05585-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/08/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Guidelines for clinical practice have been part of the Ministry of health's efforts to improve the quality of care for over two decades. Their benefits have been documented in Uganda. However, having practice guidelines may not always result in their use in care provision. We explored the midwives' perceptions towards the ministry of health guidelines for providing immediate postpartum care. METHODS An exploratory descriptive qualitative study was conducted in three districts in Uganda from September 2020 to January 2021. In-depth interviews with 50 midwives from 35 health centers and 2 hospitals in Mpigi, Butambala, and Gomba districts were done. Thematic analysis of data was done. RESULTS Three themes emerged; awareness and use of the guidelines, perceived drivers, and perceived barriers to the provision of immediate postpartum care. The subthemes for theme I included; awareness of the guidelines, variations in the postpartum care practices, variations in preparedness to manage women with complications, and varied access to continuing midwifery education. Fear of complications and litigation were the perceived drivers of guideline use. On the other hand, lack of knowledge, busy maternity units, organization of the care, and the midwives' perceptions about their clients were the barriers to guideline use. Midwives felt that new guidelines and policies regarding immediate postpartum care should be disseminated widely. CONCLUSION The midwives felt that the guidelines were good for the prevention of postpartum complications but their knowledge of the guidelines for the provision of immediate postpartum care was suboptimal. They desired on-job training and mentorship to help them bridge the knowledge gaps. Variations in patient assessment, monitoring, and pre-discharge care were acknowledged and said to be due to a poor reading culture and health facility factors like patient-midwife ratios, unit setup, and prioritization of labor.
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Affiliation(s)
- Mariam Namutebi
- Department of Nursing, College of Health Sciences, School of Health Sciences, Makerere University, Kampala, Uganda.
| | - Gorrette K Nalwadda
- Department of Nursing, College of Health Sciences, School of Health Sciences, Makerere University, Kampala, Uganda
| | - Simon Kasasa
- Department of Epidemiology and biostatistics, College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Patience A Muwanguzi
- Department of Nursing, College of Health Sciences, School of Health Sciences, Makerere University, Kampala, Uganda
| | - Dan K Kaye
- Department of Obstetrics and Gynecology, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda
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Adepoju VA, Adejumo OA, Adepoju OE, Adeniyi MO, Etuk V, Nzekwe I, Inegbeboh JO, Adelekan A, Oladimeji O. Do private health providers adhere to National Tuberculosis Guideline while assigning treatment outcome? Findings from a lower middle-income country. Front Public Health 2022; 10:924132. [PMID: 36211674 PMCID: PMC9540382 DOI: 10.3389/fpubh.2022.924132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/18/2022] [Indexed: 01/24/2023] Open
Abstract
Background Treatment success rate is an important indicator to measure the performance of the National Tuberculosis Program (NTP). There are concerns about the quality of outcome data from private facilities engaged by NTP. Adherence of private providers of tuberculosis care to NTP guideline while assigning treatment outcomes to patients is rarely investigated. We aimed to determine whether Lagos private for-profit (PFP) and private not-for-profit (PNFP) facilities adhere to domestic TB guideline while assigning treatment outcome and the availability of periodic sputum acid-fast bacilli (AFB) results. Method A retrospective review of facility treatment register and treatment cards of TB patients managed between January and December 2016 across 10 private directly observed treatment short-course (DOTS) facilities involved in the public-private mix (PPM) in Lagos, Nigeria. The study took place between January and June 2019. Results Of the 1,566 patients, majority (60.7%) were male, >30 years (50.2%), HIV-negative (88.4%), and attended PNFP (78.5%). The reported treatment success rate (TSR) was 84.2% while the actual TSR was 53.8%. In total, 91.1, 77.6, and 70.3% of patients had sputum acid-fast bacilli (AFB) at 2/3, month 5, and month 6, respectively, while 68.6% had all the three sputum AFB in the register. Healthcare workers (HCWs) were adherent in assigning treatment outcome for 65.6% of TB patients while 34.4% of patients were assigned incorrect treatment outcomes. Most variations between reported and actual treatment outcomes were found with cured (17%) and completed (13.4%). Successful and unsuccessful outcomes were overreported by 30.4% and 4.1%, respectively. DOTS providers in private facilities with available TB guideline (OR 8.33, CI 3.56-19.49, p < 0.0001) and PNFP facility (OR 4.42, CI 1.91-10.3, p = 0.001) were more likely to adhere to National TB Guideline while assigning TB treatment outcome. Conclusion Frontline TB providers in Lagos private hospitals struggled with assigning correct treatment outcome for TB patients based on NTBLCP guideline. Increased access to all the periodic follow-up AFB tests for TB patients on treatment and availability of National TB Guideline for referencing could potentially improve the adherence of private TB service providers while assigning TB treatment outcomes.
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Affiliation(s)
- Victor Abiola Adepoju
- Department of HIV and Infectious Diseases, Jhpiego (an Affiliate of John Hopkins University), Abuja, Nigeria,*Correspondence: Victor Abiola Adepoju ;
| | - Olusola Adedeji Adejumo
- Department of Community Medicine and Primary Health Care, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Oluwatoyin Elizabeth Adepoju
- Department of Adolescent Research, Adolescent Friendly Research Initiative and Care (ADOLFRIC), Ado-Ekiti, Nigeria
| | - Marius Olusola Adeniyi
- Department of Primary Healthcare Services, Ondo State Primary Healthcare Development Agency, Akure, Nigeria
| | - Victoria Etuk
- International Research Center of Excellence (IRCE), Institute of Human Virology of Nigeria, Abuja, Nigeria
| | - Iheoma Nzekwe
- Department of HIV and Infectious Diseases, Jhpiego (an Affiliate of John Hopkins University), Abuja, Nigeria
| | - Jude O. Inegbeboh
- Department of HIV/AIDS, Birnin Kebbi, Kebbi State Children Emergency Fund (UNICEF), Abuja, Nigeria
| | | | - Olanrewaju Oladimeji
- Department of Public Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
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Choosing Wisely—Barriers and Solutions to Implementation in Low and Middle-Income Countries. Curr Oncol 2022; 29:5091-5096. [PMID: 35877263 PMCID: PMC9320636 DOI: 10.3390/curroncol29070403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Globally, there is increasing emphasis on value-based cancer care. Rising healthcare costs and reduced health care spending and budgets, especially in low- and middle-income countries (LMICs), call for patients, providers, and healthcare systems to apply the Choose Wisely (CW) approach. This approach seeks to advance a dialogue on avoiding unnecessary medical tests, treatments, and procedures. Several factors have been described as barriers and facilitators to the implementation of the Choosing Wisely recommendations in high-income countries but none for LMICs. In this review, we attempt to classify potential barriers to the Choose Wisely implementation relative to the sources of behavior and potential intervention functions that can be implemented in order to reduce these barriers.
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Ssegujja E, Ddumba I, Andipatin M. Health workers' social networks and their influence in the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000798. [PMID: 36962455 PMCID: PMC10021602 DOI: 10.1371/journal.pgph.0000798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Health workers' peer networks are known to influence members' behaviours and practices while translating policies into service delivery. However, little remains known about the extent to which this remains true within interventions aimed at addressing the stillbirth burden in low-resource settings like Uganda. The objective of this study was to examine the health workers' social networks and their influence on the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. A qualitative exploratory design was adopted on a purposively selected sample of 16 key informants. The study was conducted in Mukono district among sub-national health systems, managers, health facility in-charges, and frontline health workers. Data was collected using semi-structured interview guides in a face-to-face interview with respondents. The analysis adopted a thematic approach utilising Atlas. ti software for data management. Participants acknowledged that workplace social networks were influential during the implementation of policies to address stillbirth. The influence exerted was in form of linkage with other services, caution, and advice regarding strict adherence to policy recommendations perhaps reflective of the level of trust in providers' ability to adhere to policy provisions. At the district health management level and among non-state actors, support in perceived areas of weak performance in policy implementation was observed. In addition, timely initiation of contact and subsequent referral was another aspect where health workers exerted influence while translating policies to address the stillbirth burden. While the level of support from among network peers was observed to influence health workers' adoption and implementation of strategies to address the stillbirth burden, different mechanisms triggered subsequent response and level of adherence to recommended policy aspects. Drawing from the elicited responses, we infer that health workers' social networks influence the direction and extent of success in policy implementation to address the stillbirth burden at the subnational level.
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Affiliation(s)
- Eric Ssegujja
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Faculty of Community and Health Sciences, School of Public Health, University of the Western Cape, Cape Town, Republic of South Africa
| | - Isaac Ddumba
- Department of Health, Mukono District Local Government, Mukono, Uganda
| | - Michelle Andipatin
- Faculty of Community and Health Sciences, Department of Psychology, University of the Western Cape, Cape Town, Republic of South Africa
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A more practical guide to incorporating health equity domains in implementation determinant frameworks. Implement Sci Commun 2021; 2:61. [PMID: 34090524 PMCID: PMC8178842 DOI: 10.1186/s43058-021-00146-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 04/07/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Due to striking disparities in the implementation of healthcare innovations, it is imperative that researchers and practitioners can meaningfully use implementation determinant frameworks to understand why disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted the first published adaptation of an existing implementation determinant framework with health equity domains to create the Health Equity Implementation Framework. We recommended integrating these three health equity domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance. METHODS We completed a consensus process with our authorship team to clarify steps to incorporate a health equity lens into an implementation determinant framework. RESULTS We describe steps to integrate health equity domains into implementation determinant frameworks for implementation research and practice. For each step, we compiled examples or practical tools to assist implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative measures. CONCLUSION Incorporating health equity domains within implementation determinant frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers and practitioners to concretely capture and understand barriers and facilitators to implementation disparities.
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Maaløe N, Ørtved AMR, Sørensen JB, Sequeira Dmello B, van den Akker T, Kujabi ML, Kidanto H, Meguid T, Bygbjerg IC, van Roosmalen J, Meyrowitsch DW, Housseine N. The injustice of unfit clinical practice guidelines in low-resource realities. LANCET GLOBAL HEALTH 2021; 9:e875-e879. [PMID: 33765437 PMCID: PMC7984859 DOI: 10.1016/s2214-109x(21)00059-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 12/18/2022]
Abstract
To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark.
| | - Anna Marie Rønne Ørtved
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira Dmello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Comprehensive Community-Based Rehabilitation in Tanzania, Dar es salaam, Tanzania; Medical College of East Africa, Aga Khan University, Dar es Salaam, Tanzania
| | - Thomas van den Akker
- Athena Institute, Faculty of Science, VU University, Amsterdam, Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Edna Adan Hospital, Hargeisa, Somalia
| | - Hussein Kidanto
- Medical College of East Africa, Aga Khan University, Dar es Salaam, Tanzania
| | | | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jos van Roosmalen
- Athena Institute, Faculty of Science, VU University, Amsterdam, Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Medical College of East Africa, Aga Khan University, Dar es Salaam, Tanzania
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Baluku JB, Mugabe P, Mwebaza S, Nakaweesi J, Senyimba C, Opio JP, Mukasa B. Cryptococcal Antigen Screening Among Antiretroviral Therapy-Experienced People With HIV With Viral Load Nonsuppression in Rural Uganda. Open Forum Infect Dis 2021; 8:ofab010. [PMID: 33604402 PMCID: PMC7880263 DOI: 10.1093/ofid/ofab010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/05/2021] [Indexed: 11/12/2022] Open
Abstract
Background The World Health Organization recommends screening for the cryptococcal antigen (CrAg), a predictor of cryptococcal meningitis, among antiretroviral therapy (ART)-naïve people with HIV (PWH) with CD4 <100 cells/mm3. CrAg positivity among ART-experienced PWH with viral load (VL) nonsuppression is not well established, yet high VLs are associated with cryptococcal meningitis independent of CD4 count. We compared the frequency and positivity yield of CrAg screening among ART-experienced PWH with VL nonsuppression and ART-naïve PWH with CD4 <100 cells/mm3 attending rural public health facilities in Uganda. Methods We reviewed routinely generated programmatic reports on cryptococcal disease screening from 104 health facilities in 8 rural districts of Uganda from January 2018 to July 2019. A lateral flow assay (IMMY CrAg) was used to screen for cryptococcal disease. PWH were eligible for CrAg screening if they were ART-naïve with CD4 <100 cell/mm3 or ART-experienced with an HIV VL >1000 copies/mL after at least 6 months of ART. We used Pearson's chi-square test to compare the frequency and yield of CrAg screening. Results Of 71 860 ART-experienced PWH, 7210 (10.0%) were eligible for CrAg screening. Among 15 417 ART-naïve PWH, 5719 (37.1%) had a CD4 count measurement, of whom 937 (16.4%) were eligible for CrAg screening. The frequency of CrAg screening was 11.5% (830/7210) among eligible ART-experienced PWH compared with 95.1% (891/937) of eligible ART- naïve PWH (P < .001). The CrAg positivity yield was 10.5% among eligible ART-experienced PWH compared with 13.8% among eligible ART-naïve PWH (P = .035). Conclusions The low frequency and high positivity yield of CrAg screening among ART-experienced PWH with VL nonsuppression suggest a need for VL- directed CrAg screening in this population. Studies are needed to evaluate the cost-effectiveness and impact of CrAg screening and fluconazole prophylaxis on the outcomes of ART-experienced PWH with VL nonsuppression.
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Affiliation(s)
| | - Pallen Mugabe
- Directorate of Programs Mildmay Uganda, Kampala, Uganda
| | - Shem Mwebaza
- Directorate of Programs Mildmay Uganda, Kampala, Uganda
| | | | | | - Joel Peter Opio
- Division of Global HIV and TB, US centers for Disease Control and Prevention, Kampala, Uganda
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Haddad SM, Souza RT, Cecatti JG, Barreix M, Tamrat T, Footitt C, Mehl GL, Syah IF, Shankar AH, Tunçalp Ö. Building a Digital Tool for the Adoption of the World Health Organization's Antenatal Care Recommendations: Methodological Intersection of Evidence, Clinical Logic, and Digital Technology. J Med Internet Res 2020; 22:e16355. [PMID: 33001032 PMCID: PMC7983224 DOI: 10.2196/16355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 06/26/2020] [Accepted: 07/26/2020] [Indexed: 11/14/2022] Open
Abstract
Background One of the key mandates of the World Health Organization (WHO) is to develop guidelines, defined as “a document containing recommendations for clinical practice or public health policy.” Guidelines represent the global standard for information sources shaping clinical practice and public health policies. Despite the rigorous development process and the value of guidelines for setting standards, implementing such standards within local contexts and at the point of care is a well-documented challenge. Digital technologies enable agile information management and may facilitate the adaptation of guidelines to diverse settings of health services delivery. Objective The objective of this paper is to detail the systematic and iterative process involved in transforming the WHO Antenatal Care (ANC) guidelines into a digital decision-support and patient-record application for routine use in primary health care settings, known as the WHO digital ANC module. Methods The WHO convened a team of clinical and digital health experts to develop the WHO digital ANC module as a tool to assist health care professionals in the implementation of WHO evidence-based recommendations for pregnant women. The WHO digital ANC module’s creation included the following steps: defining a minimum viable product (MVP), developing clinical workflows and algorithms, algorithm testing, developing a data dictionary, and the creation of a user interface or application development. The overall process of development took approximately 1 year to reach a stable prototype and to finalize the underlying content requirements of the data dictionary and decision support algorithms. Results The first output is a reference software reflecting the generic WHO ANC guideline content, known as the WHO digital ANC module. Within it, all actionable ANC recommendations have related data fields and algorithms to confirm whether the associated task was performed. WHO recommendations that are not carried out by the health care worker are saved as pending tasks on a woman’s health record, and those that are adequately fulfilled trigger messages with positive reinforcement. The second output consists of the structured documentation of the different components which contributed to the development of the WHO digital ANC module, such as the data dictionary and clinical decision support workflows. Conclusions This is a novel approach to facilitate the adoption and adaptation of recommendations through digital systems at the health service delivery level. It is expected that the WHO digital ANC module will support the implementation of evidence-based practices and provide information for monitoring and surveillance; however, further evidence is needed to understand how the WHO digital ANC module impacts the implementation of WHO recommendations. Further, the module’s implementation will inform the WHO’s ongoing efforts to create a pathway to adaptive and integrated (Smart) Guidelines in Digital Systems to improve health system quality, coverage, and accountability.
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Affiliation(s)
- Samira M Haddad
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Center for Research in Reproductive Health of Campinas (CEMICAMP), Campinas, Brazil
| | - Renato T Souza
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Center for Research in Reproductive Health of Campinas (CEMICAMP), Campinas, Brazil
| | - Jose Guilherme Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Center for Research in Reproductive Health of Campinas (CEMICAMP), Campinas, Brazil
| | - Maria Barreix
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Tigest Tamrat
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Garrett L Mehl
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Anuraj H Shankar
- Summit Institute of Development, Mataram, Indonesia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Özge Tunçalp
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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DeBoer RJ, Ndumbalo J, Meena S, Ngoma MT, Mvungi N, Siu S, Selekwa M, Nyagabona SK, Luhar R, Buckle G, Lin TK, Breithaupt L, Kennell-Heiling S, Mushi B, Philipo GS, Mmbaga EJ, Mwaiselage J, Van Loon K. Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa. Implement Sci Commun 2020; 1:24. [PMID: 32885183 PMCID: PMC7427872 DOI: 10.1186/s43058-020-00007-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/09/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. METHODS In preparation for the launch of Tanzania's first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. DISCUSSION We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of "proven" guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.
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Affiliation(s)
- Rebecca J. DeBoer
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | | | - Stephen Meena
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | | | | | - Sadiq Siu
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah K. Nyagabona
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rohan Luhar
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Geoffrey Buckle
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Tracy Kuo Lin
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Lindsay Breithaupt
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Stephanie Kennell-Heiling
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Beatrice Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Elia J. Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Katherine Van Loon
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
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Ssensamba JT, Mukuru M, Nakafeero M, Ssenyonga R, Kiwanuka SN. Health systems readiness to provide geriatric friendly care services in Uganda: a cross-sectional study. BMC Geriatr 2019; 19:256. [PMID: 31533635 PMCID: PMC6749715 DOI: 10.1186/s12877-019-1272-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/06/2019] [Indexed: 11/30/2022] Open
Abstract
Background As ageing emerges as the next public health threat in Africa, there is a paucity of information on how prepared its health systems are to provide geriatric friendly care services. In this study, we explored the readiness of Uganda’s public health system to offer geriatric friendly care services in Southern Central Uganda. Methods Four districts with the highest proportion of old persons in Southern Central Uganda were purposively selected, and a cross-section of 18 randomly selected health facilities (HFs) were visited and assessed for availability of critical items deemed important for provision of geriatric friendly services; as derived from World Health Organization’s Age-friendly primary health care centres toolkit. Data was collected using an adapted health facility geriatric assessment tool, entered into Epi-data software and analysed using STATA version 14. Kruskal-Wallis and Dunn’s post hoc tests were conducted to determine any associations between readiness, health facility level, and district. Results The overall readiness index was 16.92 (SD ±4.19) (range 10.8–26.6). This differed across districts; Lwengo 17.91 (SD ±3.15), Rakai 17.63 (SD ±4.55), Bukomansimbi 16.51 (SD ±7.18), Kalungu 13.74 (SD ±2.56) and facility levels; Hospitals 26.62, Health centers four (HCIV) 20.05 and Health centers three (HCIII) 14.80. Low readiness was due to poor scores concerning; leadership (0%), financing (0%), human resources (1.7%) and health management information systems (HMIS) (11.8%) WHO building blocks. Higher-level HFs were statistically significantly friendlier than lower-level HFs (p = 0.015). The difference in readiness between HCIIIs and HCIVs was 2.39 (p = 0.025). Conclusion There is a low readiness for public health facilities to provide geriatric friendly care services in Uganda. This is due to gaps in all of the health system building blocks. There is a need for health system reforms in Uganda to adequately cater for service provision for older adults if the 2020 global healthy ageing goal is to be met.
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Affiliation(s)
- Jude Thaddeus Ssensamba
- Makerere University College of Health Sciences, School of Public Health, Department of Health Policy and Planning, Kampala, Uganda. .,Center for Innovations in Health Africa, Plot 1-3 School Road Namuwongo, P.O. Box 220, Kampala, Uganda.
| | - Moses Mukuru
- Makerere University College of Health Sciences, School of Public Health, Department of Health Policy and Planning, Kampala, Uganda
| | - Mary Nakafeero
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Ronald Ssenyonga
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Suzanne N Kiwanuka
- Makerere University College of Health Sciences, School of Public Health, Department of Health Policy and Planning, Kampala, Uganda
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Bottom-up development of national obstetric guidelines in middle-income country Suriname. BMC Health Serv Res 2019; 19:651. [PMID: 31500615 PMCID: PMC6734520 DOI: 10.1186/s12913-019-4377-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/29/2019] [Indexed: 11/16/2022] Open
Abstract
Background Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname. Methods Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH). Results The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented. Conclusion Development of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines. Electronic supplementary material The online version of this article (10.1186/s12913-019-4377-6) contains supplementary material, which is available to authorized users.
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Pather MK, Mash R. Family physicians' experience and understanding of evidence-based practice and guideline implementation in primary care practice, Cape Town, South Africa. Afr J Prim Health Care Fam Med 2019; 11:e1-e10. [PMID: 31170792 PMCID: PMC6556914 DOI: 10.4102/phcfm.v11i1.1592] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/31/2018] [Accepted: 09/03/2018] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In primary care, patients present with multimorbidity and a wide spectrum of undifferentiated illnesses, which makes the application of evidence-based practice (EBP) principles more challenging than in other practice contexts. AIM The goal of this study was to explore the experiences and understanding of family physicians (FP) in primary care with regard to EBP and the implementation of evidence-based guidelines. SETTING The study was conducted in Cape Town primary care facilities and South African university departments of Family Medicine. METHODS For this phenomenological, qualitative study, 27 purposefully selected FPs from three groups were interviewed: senior academic FPs; local FPs in public-sector practice; and local FPs in private-sector practice. Data were analysed using the framework method with the assistance of ATLAS.ti, version 6.1. RESULTS Guideline development should be a more inclusive process that incorporates more evidence from primary care. Contextualisation should happen at an organisational level and may include adaptation as well as the development of practical or integrated tools. Organisations should ensure synergy between corporate and clinical governance activities. Dissemination should ensure that all practitioners are aware of and know how to access guidelines. Implementation should include training that is interactive and recognises individual practitioners' readiness to change, as well as local barriers. Quality improvement cycles may reinforce implementation and provide feedback on the process. CONCLUSION Evidence-based practice is currently limited in its capacity to inform primary care. The conceptual framework provided illustrates the key steps in guideline development, contextualisation, dissemination, implementation and evaluation, as well as the interconnections between steps and barriers or enablers to progress. The framework may be useful for policymakers, health care managers and practitioners in similar settings.
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Affiliation(s)
- Michael K Pather
- Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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Maaløe N, Meguid T, Housseine N, Tersbøl BP, Nielsen KK, Bygbjerg IC, van Roosmalen J. Local adaption of intrapartum clinical guidelines, United Republic of Tanzania. Bull World Health Organ 2019; 97:365-370. [PMID: 31551633 PMCID: PMC6747036 DOI: 10.2471/blt.18.220830] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/06/2018] [Accepted: 03/01/2019] [Indexed: 11/27/2022] Open
Abstract
Problem Gaps exist between internationally derived clinical guidelines on care at the time of birth and realistic best practices in busy, low-resourced maternity units. Approach In 2014-2018, we carried out the PartoMa study at Zanzibar's tertiary hospital, United Republic of Tanzania. Working with local birth attendants and external experts, we created easy-to-use and locally achievable clinical guidelines and associated in-house training to assist birth attendants in intrapartum care. Local setting Around 11 500 women gave birth annually in the hospital. Of the 35-40 birth attendants employed, each cared simultaneously for 3-6 women in labour. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1-5 per 1000 live births. Externally derived clinical guidelines were available, but rarely used. Relevant changes Staff attendance at the repeated trainings was good, despite seminars being outside working hours and without additional remuneration. Many birth attendants appreciated the intervention and were motivated to improve care. Improvements were found in knowledge, partograph skills and quality of care. After 12 intervention months, stillbirths had decreased 34% to 39 per 1000 total births, while newborns with an Apgar score of 1-5 halved to 28 per 1000 live births. Lessons learnt After 4 years, birth attendants still express high demand for the intervention. The development of international, regional and national clinical guidelines targeted at low-resource maternity units needs to be better attuned to input from end-users and the local conditions, and thereby easier to use effectively.
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen, Denmark
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania
| | | | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen, Denmark
| | | | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen, Denmark
| | - Jos van Roosmalen
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Tessema GA, Gomersall JS, Laurence CO, Mahmood MA. Healthcare providers' perspectives on use of the national guideline for family planning services in Amhara Region, Ethiopia: a qualitative study. BMJ Open 2019; 9:e023403. [PMID: 30787080 PMCID: PMC6398659 DOI: 10.1136/bmjopen-2018-023403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore healthcare providers' views on barriers to and facilitators of use of the national family planning (FP) guideline for FP services in Amhara Region, Ethiopia. DESIGN Qualitative study. SETTING Nine health facilities including two hospitals, five health centres and two health posts in Amhara Region, Northwest Ethiopia. PARTICIPANTS Twenty-one healthcare providers working in the provision of FP services in Amhara Region. PRIMARY AND SECONDARY OUTCOME MEASURES Semistructured interviews were conducted to understand healthcare providers' views on barriers to and facilitators of the FP guideline use in the selected FP services. RESULTS While the healthcare providers' views point to a few facilitators that promote use of the guideline, more barriers were identified. The barriers included: lack of knowledge about the guideline's existence, purpose and quality, healthcare providers' personal religious beliefs, reliance on prior knowledge and tradition rather than protocols and guidelines, lack of availability or insufficient access to the guideline and inadequate training on how to use the guideline. Facilitators for the guideline use were ready access to the guideline, convenience and ease of implementation and incentives. CONCLUSIONS While development of the guideline is an important initiative by the Ethiopian government for improving quality of care in FP services, continued use of this resource by all healthcare providers requires planning to promote facilitating factors and address barriers to use of the FP guideline. Training that includes a discussion about healthcare providers' beliefs and traditional practices as well as other factors that reduce guideline use and increasing the sufficient number of guideline copies available at the local level, as well as translation of the guideline into local language are important to support provision of quality care in FP services.
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Affiliation(s)
- Gizachew Assefa Tessema
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Reproductive Health, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Judith Streak Gomersall
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Caroline O Laurence
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mohammad Afzal Mahmood
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
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Barac R, Als D, Radhakrishnan A, Gaffey MF, Bhutta ZA, Barwick M. Implementation of Interventions for the Control of Typhoid Fever in Low- and Middle-Income Countries. Am J Trop Med Hyg 2018; 99:79-88. [PMID: 30047365 PMCID: PMC6128369 DOI: 10.4269/ajtmh.18-0110] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/05/2018] [Indexed: 01/12/2023] Open
Abstract
Past research has focused on typhoid fever surveillance with little attention to implementation methods or effectiveness of control interventions. This study purposefully sampled key informants working in public health in Chile, India, Pakistan, Bangladesh, Thailand, Vietnam, South Africa, and Nigeria to 1) scope typhoid-relevant interventions implemented between 1990 and 2015 and 2) explore contextual factors perceived to be associated with their implementation, based on the Consolidated Framework for Implementation Research (CFIR). We used a mixed methods design and collected quantitative data (CFIR questionnaire) and qualitative data (interviews with 34 public health experts). Interview data were analyzed using a deductive qualitative content analysis and summary descriptive statistics are provided for the CFIR data. Despite relatively few typhoid-specific interventions reportedly implemented in these countries, interventions for diarrheal disease control and regulations for food safety and food handlers were common. Most countries implemented agricultural and sewage treatment practices, yet few addressed the control of antibiotic medication. Several contextual factors were perceived to have influenced the implementation of typhoid interventions, either as enablers (e.g., economic development) or barriers (e.g., limited resources and habitual behaviors). Consolidated Framework for Implementation Research factors rated as important in the implementation of typhoid interventions were remarkably consistent across countries. The findings provide a snapshot of typhoid-relevant interventions implemented over 25 years and highlight factors associated with implementation success from the perspective of a sample of key informants. These findings can inform systematic investigations of the implementation of typhoid control interventions and contribute to a better understanding of the direct effects of implementation efforts.
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Affiliation(s)
- Raluca Barac
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Daina Als
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | | | - Michelle F. Gaffey
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Melanie Barwick
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
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Nabyonga-Orem J, Nabukalu BJ, Andemichael G, Khosi-Mthetwa R, Shaame A, Myeni S, Quinto E, Dovlo D. Moving towards universal health coverage: The need for a strengthened planning process. Int J Health Plann Manage 2018; 33:1093-1109. [PMID: 30074277 DOI: 10.1002/hpm.2585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/29/2018] [Indexed: 11/08/2022] Open
Abstract
As countries embrace the ambitious universal health coverage (UHC) agenda whose major tenents include reaching everyone with the needed good quality services, strengthening the planning process to work towards a common objective is paramount. Drawing from country experiences-Swaziland and Zanzibar, we reviewed strategic planning processes to assess the extent to which they impact on realising alignment towards a collective health sector objective. Employing qualitative approaches, we reviewed strategic plans under implementation in the health sector and using an interview guide consisting of open-ended questions, interviewed key informants at the national and district level. Results showed that strategic plans are too many with majority of program strategies not well aligned to the health sector strategic plan, are not costed, and there overlaps in objectives among the several strategies addressing the same program. Weaknesses in the development process, perceived poor quality of the strategies, limited capacity, high staff turnover, and inadequate funding were the identified challenges that abate the utility of the strategic plans. Moving towards UHC starts with a robust planning process that rallies all actors and all available resources around a common objective. The planning process should be strengthened through ensuring participatory processes, evidence informed prioritisation, MoH institutional capacity to lead the process, and consideration for implementation feasibility. Flexibility to take into consideration emerging evidence and new developments in global health needs consideration.
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Affiliation(s)
- Juliet Nabyonga-Orem
- Health Systems and Services Cluster, Inter-Country Support Team for Eastern and Southern Africa; World Health Organization, Harare, Zimbabwe
| | | | | | | | - Attiye Shaame
- Ministry of Health, Directorate of Policy, Planning, and Research, Ministry of Health, Zanzibar, United Republic of Tanzania
| | - Sebentile Myeni
- Ministry of Health, Swaziland, Monitoring and Evaluation Unit, Mbabane, Swaziland
| | - Ebony Quinto
- Ministry of Health Headquarters, Kampala, Uganda
| | - Delanyo Dovlo
- World Health Organization Regional Office for Africa, Health Systems and Services Cluster, Brazzaville, Republic of Congo
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Dissemination and use of WHO family planning guidance and tools: a qualitative assessment. Health Res Policy Syst 2018; 16:42. [PMID: 29789001 PMCID: PMC5964918 DOI: 10.1186/s12961-018-0321-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/26/2018] [Indexed: 11/13/2022] Open
Abstract
Background As countries continue to improve their family planning (FP) programmes, they may draw on WHO’s evidence-based FP guidance and tools (i.e. materials) that support the provision of quality FP services. Methods To better understand the use and perceived impact of the materials and ways to strengthen their use by countries, we conducted qualitative interviews with WHO regional advisors, and with stakeholders in Ethiopia and Senegal who use WHO materials. Results WHO uses a multi-faceted strategy to directly and indirectly disseminate materials to country-level decision-makers. The materials are used to develop national family planning guidelines, protocols and training curricula. Participants reported that they trust the WHO materials because they are evidence based, and that they adapt materials to the country context (e.g. remove content on methods not available in the country). The main barrier to the use of national materials is resource constraints. Conclusions Although the system and processes for dissemination work, improvements might contribute to increased use of the materials. For example, providers may benefit from additional guidance on how to counsel women with characteristics or medical conditions where contraceptive method eligibility criteria do not clearly rule in or rule out a method.
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Maaløe N, Housseine N, Meguid T, Nielsen BB, Jensen A, Khamis RS, Mohamed AG, Ali MM, Said SM, van Roosmalen J, Bygbjerg IC. Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi-experimental pre-post study (The PartoMa study). BJOG 2017; 125:235-245. [PMID: 28892306 DOI: 10.1111/1471-0528.14933] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. DESIGN Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. SETTING Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. POPULATION Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention
month (1 October 2015 until 31 January 2016) [corrected]. METHODS Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). MAIN OUTCOME MEASURES Stillbirths and neonates with 5-minute Apgar score ≤5. RESULTS Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved. CONCLUSION Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.
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Affiliation(s)
- N Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - N Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - T Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,School of Health & Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania
| | - B B Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Akg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - R S Khamis
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | | | - M M Ali
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - S M Said
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - J van Roosmalen
- Athena Institute, VU University of Amsterdam, Amsterdam, the Netherlands
| | - I C Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Travado L, Bultz BD, Ullrich A, Asuzu CC, Turner J, Grassi L, Jacobsen P. 2016 President's Plenary International Psycho-Oncology Society: challenges and opportunities for growing and developing psychosocial oncology programmes worldwide. Psychooncology 2017; 26:1231-1238. [PMID: 28599340 DOI: 10.1002/pon.4471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 01/02/2023]
Abstract
Consistent with the International Psycho-Oncology Society's (IPOS) vision and goals, we are committed to improving quality cancer care and cancer policies through psychosocial care globally. As part of IPOS's mission, upon entering "Official Relations" for a second term with the World Health Organization (WHO), IPOS has dedicated much attention to reaching out to countries, which lack formalized psychosocial care programmes. One of IPOS's strategies to accomplish this goal has been to bring psycho-oncology training programmes to low- and middle-income countries and regions. To this end, the IPOS Board approved a new position on the Board of Directors for a member from a low- to middle-income country (LMIC). The IPOS 2016 President's Plenary focused on challenges and opportunities that exist in growing and developing psychosocial oncology programmes worldwide. The plenary presentations highlight how IPOS and WHO have aligned their goals to help LMICs support cancer patients as an essential element of cancer and palliative care. IPOS country representatives are strongly supported in liaising with national health authorities and with WHO Country Representatives in LMICs. The plenary speakers discussed the role IPOS Federation has taken in building a global network of psychosocial leaders and the impact this had in assisting LMICs in meeting IPOS's psychosocial care objectives. The plenary highlighted the challenges of expanding psychosocial reach into these countries. One significant question remains: Can psychosocial guidelines be adapted to LMICs and regions?
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Affiliation(s)
- Luzia Travado
- Psycho-oncology Service, Champalimaud Clinical Center, Champalimaud Foundation, Lisbon, Portugal
| | - Barry D Bultz
- Daniel Family Leadership Chair in Psychosocial Oncology, Division of Psychosocial Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Psychosocial and Rehabilitation Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Andreas Ullrich
- World Health Organization, Noncommunicable Diseases and Mental Health Cluster, Switzerland
| | - Chioma C Asuzu
- Department of Counselling and Human Development Studies and Unit of Psycho-Oncology, Department of Radiation Oncology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Jane Turner
- Faculty of Medicine, The University of Queensland, St Lucia, Australia
| | - Luigi Grassi
- Institute of Psychiatry, Section of Neurology, Psychiatry and Psychology, Department of Biomedical and Speciality Surgical Sciences, University of Ferrara, Ferrara, Italy.,University Hospital Psychiatry Unit, Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara, Italy
| | - Paul Jacobsen
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, USA
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Cox JA, Vlieghe E, Mendelson M, Wertheim H, Ndegwa L, Villegas MV, Gould I, Levy Hara G. Antibiotic stewardship in low- and middle-income countries: the same but different? Clin Microbiol Infect 2017; 23:812-818. [PMID: 28712667 DOI: 10.1016/j.cmi.2017.07.010] [Citation(s) in RCA: 282] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Antibiotic resistance (ABR) is a quickly worsening problem worldwide, also in low- and middle-income countries (LMICs). Appropriate antibiotic use in humans and animals, i.e. antibiotic stewardship (ABS), is one of the cornerstones of the World Health Organization's global action plan for ABR. Many LMICs are in the process of developing stewardship programs. AIMS We highlight challenges for ABS initiatives in LMICs, give an outline of (inter)national recommendations and demonstrate examples of effective, contextualized stewardship interventions. SOURCES We searched PubMed for articles on ABS interventions in humans in LMICs. Relevant websites and experts were consulted for additional sources. CONTENT Evidence on effective and feasible stewardship interventions in LMICs is limited, and challenges for implementation of interventions are numerous. Nevertheless, several initiatives at the international and local levels in Latin America, Africa and Asia have shown that ABS effective interventions are feasible in LMICs, although contextualization is essential. IMPLICATIONS Specific guidance for setting up antimicrobial stewardship programs in LMICs should be developed. Strategic points might need to be progressively addressed in LMICs, such as (a) ensuring availability of diagnostic testing, (b) providing dedicated education in ABR both for healthcare workers and the general public, (c) creating or strengthening (inter)national agencies towards better regulations and audit on production, distribution and dispensing of drugs, (d) strengthening healthcare facilities, (e) exploring a broader synergism between policy makers, academia, professional bodies and civil society and (f) designing and studying easy and scalable ABS interventions for both hospital and community settings.
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Affiliation(s)
- J A Cox
- Unit of Tropical Laboratory Medicine, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium
| | - E Vlieghe
- Unit of Tropical Laboratory Medicine, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium; Department of General Internal Medicine, Infectious Diseases and Tropical Medicine, University Hospital Antwerp, Antwerp, Belgium.
| | - M Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - H Wertheim
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Viet Nam; Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom; Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
| | - L Ndegwa
- Infection Prevention Network-Kenya (IPNET-Kenya), Nairobi, Kenya
| | - M V Villegas
- Hospital Epidemiology and Bacterial Resistance Area, Centro Internacional de Entrenamiento e Investigaciones Médicas (CIDEIM), Cali and Universidad El Bosque, Bogotá, Colombia
| | - I Gould
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - G Levy Hara
- Infectious Diseases Unit, Hospital Carlos G Durand, Buenos Aires, Argentina
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24
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Maaløe N, Housseine N, van Roosmalen J, Bygbjerg IC, Tersbøl BP, Khamis RS, Nielsen BB, Meguid T. Labour management guidelines for a Tanzanian referral hospital: The participatory development process and birth attendants' perceptions. BMC Pregnancy Childbirth 2017; 17:175. [PMID: 28592237 PMCID: PMC5463375 DOI: 10.1186/s12884-017-1360-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While international guidelines for intrapartum care appear to have increased rapidly since 2000, literature suggests that it has only in few instances been matched with reviews of local modifications, use, and impact at the targeted low resource facilities. At a Tanzanian referral hospital, this paper describes the development process of locally achievable, partograph-associated, and peer-reviewed labour management guidelines, and it presents an assessment of professional birth attendants' perceptions. METHODS Part 1: Modification of evidence-based international guidelines through repeated evaluation cycles by local staff and seven external specialists in midwifery/obstetrics. Part 2: Questionnaire evaluation 12 months post-implementation of perceptions and use among professional birth attendants. RESULTS Part 1: After the development process, including three rounds of evaluation by staff and two external peer-review cycles, there were no major concerns with the guidelines internally nor externally. Thereby, international recommendations were condensed to the eight-paged 'PartoMa guidelines ©'. This pocket booklet includes routine assessments, supportive care, and management of common abnormalities in foetal heart rate, labour progress, and maternal condition. It uses colour codes indicating urgency. Compared to international guidelines, reductions were made in frequency of assessments, information load, and ambiguity. Part 2: Response rate of 84% (n = 84). The majority of staff (93%) agreed that the guidelines helped to improve care. They found the guidelines achievable (89%), and the graphics worked well (90%). Doctors more often than nurse-midwives (89% versus 74%) responded to use the guidelines daily. CONCLUSIONS The PartoMa guidelines ensure readily available, locally achievable, and acceptable support for intrapartum surveillance, triage, and management. This is a crucial example of adapting evidence-based international recommendations to local reality. TRIAL REGISTRATION This paper describes the intervention of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Natasha Housseine
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, the Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Rashid Saleh Khamis
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania
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García-Fernández L, Benites C, Huamán B. [Access barriers to comprehensive care for people affected by tuberculosis and human immunodeficiency virus coinfection in Peru, 2010-2015]. Rev Panam Salud Publica 2017; 41:e23. [PMID: 28591330 PMCID: PMC6660896 DOI: 10.26633/rpsp.2017.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Identify the programmatic barriers that hinder access to comprehensive care of patients with tuberculosis and human immunodeficiency virus (TB/HIV) coinfection. METHODS This is a mixed-method study. Qualitative research was conducted via in-depth interviews with key actors and the quantitative component involved cross-sectional descriptive analysis of programmatic data from 2010-2015 on tuberculosis and HIV programs at health facilities in the cities of Lima and Iquitos. RESULTS Twenty-two key actors in seven establishments were interviewed. The identified barriers were: little or no coordination between tuberculosis and HIV teams, separate management of tuberculosis and HIV cases at different levels of care, insufficient financing, limited or poorly trained human resources, and lack of an integrated information system. It was found that HIV screening in TB patients increased (from 18.8% in 2011 to 95.2% in 2015), isoniazid coverage of HIV patients declined (from 62% to 9%), and the proportion of deaths among TB/HIV coinfection cases averaged 20%. CONCLUSIONS There is poor coordination between HIV and TB health strategies. Management of TB/HIV coinfection is fragmented into different levels of care, which has an impact on comprehensive patient care. As a result of this research, a technical document was prepared to establish joint procedures that should be implemented to improve comprehensive care of TB/HIV coinfection.
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Affiliation(s)
- Lisset García-Fernández
- Estrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAPerúEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDA. Ministerio de Salud de Perú, Perú.,La correspondencia se debe dirigir a Lisset García-Fernández. Correo electrónico:
| | - Carlos Benites
- Estrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAPerúEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDA. Ministerio de Salud de Perú, Perú.
| | - Byelca Huamán
- Estrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAPerúEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDA. Ministerio de Salud de Perú, Perú.
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Implementation and Operational Research: What Happens After a Negative Test for Tuberculosis? Evaluating Adherence to TB Diagnostic Algorithms in South African Primary Health Clinics. J Acquir Immune Defic Syndr 2016; 71:e119-26. [PMID: 26966843 PMCID: PMC4804742 DOI: 10.1097/qai.0000000000000907] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction and Background: Diagnostic tests for tuberculosis (TB) using sputum have suboptimal sensitivity among HIV-positive persons. We assessed health care worker adherence to TB diagnostic algorithms after negative sputum test results. Methods: The XTEND (Xpert for TB—Evaluating a New Diagnostic) trial compared outcomes among people tested for TB in primary care clinics using Xpert MTB/RIF vs. smear microscopy as the initial test. We analyzed data from XTEND participants who were HIV positive or HIV status unknown, whose initial sputum Xpert MTB/RIF or microscopy result was negative. If chest radiography, sputum culture, or hospital referral took place, the algorithm for TB diagnosis was considered followed. Analysis of intervention (Xpert MTB/RIF) effect on algorithm adherence used methods for cluster-randomized trials with small number of clusters. Results: Among 4037 XTEND participants with initial negative test results, 2155 (53%) reported being or testing HIV positive and 540 (14%) had unknown HIV status. Among 2155 HIV-positive participants [684 (32%) male, mean age 37 years (range, 18–79 years)], there was evidence of algorithm adherence among 515 (24%). Adherence was less likely among persons tested initially with Xpert MTB/RIF vs. smear [14% (142/1031) vs. 32% (364/1122), adjusted risk ratio 0.34 (95% CI: 0.17 to 0.65)] and for participants with unknown vs. positive HIV status [59/540 (11%) vs. 507/2155 (24%)]. Conclusions: We observed poorer adherence to TB diagnostic algorithms among HIV-positive persons tested initially with Xpert MTB/RIF vs. microscopy. Poor adherence to TB diagnostic algorithms and incomplete coverage of HIV testing represents a missed opportunity to diagnose TB and HIV, and may contribute to TB mortality.
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Nabyonga-Orem J, Gebrikidane M, Mwisongo A. Assessing policy dialogues and the role of context: Liberian case study before and during the Ebola outbreak. BMC Health Serv Res 2016; 16 Suppl 4:219. [PMID: 27454117 PMCID: PMC4959377 DOI: 10.1186/s12913-016-1454-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background In the last decade participatory approaches have gained prominence in policy-making, becoming the focus of good policy-making processes. Policy dialogue is recognised as an important aspect of policy-making among several interactive and innovative policy-making models applied in different contexts and sectors. Recently there has been emphasis on the quality of policy dialogue in terms of how it should be conducted to attain participation and inclusiveness. However, there is paucity of evidence on how the context influences policy dialogue, particularly participation of stakeholders. Liberia’s context, which is characterised as post-war, highly donor dependent and in recovery from the recent catastrophic Ebola outbreak, provides an opportunity to understand the influence of context on policy dialogue. Methods This was an exploratory study using qualitative methods. Key informant interviews were conducted using an interview guide. A total of 16 interviews were conducted, 12 at the national level and 4 at the sub national level. Data were analysed using inductive thematic content analysis. Results The respondents felt that the dialogues were a success and involved important stakeholders; however, there were concerns about the improper methodology and facilitation used to conduct them. Opinions among the respondents about the process of generating and selecting the themes for the dialogues were extremely divergent. Both before and during the Ebola outbreak, the context was instrumental in shaping the dialogues according to the issue of focus, requirements for participation and the decisions to be made. Policy dialogues have become a platform for policy discussions and decisions in Liberia. It is a process that is well recognised and appreciated and is highly attributed to the success of the negotiations during the Ebola outbreak. Conclusions To sustain and strengthen policy dialogues in future, there needs to be proper information sharing through diverse forums and avenues, stakeholders’ empowerment and competent facilitation. These will ensure that the process is credible and legitimate.
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Affiliation(s)
- Juliet Nabyonga-Orem
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.
| | - Mesfin Gebrikidane
- Health Systems and Services, World Health Organization Liberia Country Office, PO Box 316, Monrovia, Liberia
| | - Aziza Mwisongo
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo
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Ako-Arrey DE, Brouwers MC, Lavis JN, Giacomini MK. Health systems guidance appraisal--a critical interpretive synthesis. Implement Sci 2016; 11:9. [PMID: 26800684 PMCID: PMC4724139 DOI: 10.1186/s13012-016-0373-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health systems guidance (HSG) are systematically developed statements that assist with decisions about options for addressing health systems challenges, including related changes in health systems arrangements. However, the development, appraisal, and reporting of HSG poses unique conceptual and methodological challenges related to the varied types of evidence that are relevant, the complexity of health systems, and the pre-eminence of contextual factors. To address this gap, we are conducting a program of research that aims to create a tool to support the appraisal of HSG and further enhance HSG development and reporting. The focus of this paper was to conduct a knowledge synthesis of the published and grey literatures to determine quality criteria (concepts) relevant for this process. METHODS We applied a critical interpretive synthesis (CIS) approach to knowledge synthesis that enabled an iterative, flexible, and dynamic analysis of diverse bodies of literature in order to generate a candidate list of concepts that will constitute the foundational components of the HSG tool. Using our review questions as compasses, we were able to guide the search strategy to look for papers based on their potential relevance to HSG appraisal, development, and reporting. The search strategy included various electronic databases and sources, subject-specific journals, conference abstracts, research reports, book chapters, unpublished data, dissertations, and policy documents. Screening the papers and data extraction was completed independently and in duplicate, and a narrative approach to data synthesis was executed. RESULTS We identified 43 papers that met eligibility criteria. No existing review was found on this topic, and no HSG appraisal tool was identified. Over one third of the authors implicitly or explicitly identified the need for a high-quality tool aimed to systematically evaluate HSG and contribute to its development/reporting. We identified 30 concepts that may be relevant to the appraisal of HSG and were able to cluster them into three meaningful domains: process principles, content, and context principles. CONCLUSIONS Our study showed the role that the quality criteria play in the development, appraisal, and reporting of HSG and demonstrated the link and resonance within and between the various concepts in the three domains.
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Affiliation(s)
- Denis E Ako-Arrey
- McMaster University, Juravinski Hospital Site, G Wing, 2nd Floor, Room 207, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada.
| | - Melissa C Brouwers
- McMaster University, Juravinski Hospital Site, G Wing, 2nd Floor, Room 207, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada.
| | - John N Lavis
- McMaster University, MML-417, 1280 Main St. West, Hamilton, ON, L8S 4L6, Canada.
| | - Mita K Giacomini
- McMaster University, CRL-218, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
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Mala P, Zuber P, Politi C, Paccaud F. Ideal and reality: do countries adopt and follow recommended procedures in comprehensive multiyear planning guidelines for national immunization programmes? Implement Sci 2015; 10:48. [PMID: 25885916 PMCID: PMC4399755 DOI: 10.1186/s13012-015-0239-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 03/28/2015] [Indexed: 11/21/2022] Open
Abstract
Background Meticulous steps and procedures are proposed in planning guidelines for the development of comprehensive multiyear plans for national immunization programmes. However, we know very little about whether the real-life experience of those who adopt these guidelines involves following these procedures as expected. Are these steps and procedures followed in practice? We examined the adoption and usage of the guidelines in planning national immunization programmes and assessed whether the recommendations in these guidelines are applied as consistently as intended. Methods We gathered information from the national comprehensive multiyear plans developed by 77 low-income countries. For each of the 11 components, we examined how each country applied the four recommended steps of situation analysis, problem prioritization, selection of interventions, and selection of indicators. We then conducted an analysis to determine the patterns of alignment of the comprehensive multiyear plans with those four recommended planning steps. Results Within the first 3 years following publication of the guidelines, 66 (86%) countries used the tool to develop their comprehensive multiyear plans. The funding conditions attached to the use of these guidelines appeared to influence their rapid adoption and usage. Overall, only 33 (43%) countries fully applied all four recommended planning steps of the guidelines. Conclusions Adoption and usage of the guidelines for the development of comprehensive multiyear plans for national immunization programmes were rapid. However, our findings show substantial variation between the proposed planning ideals set out in the guidelines and actual use in practice. A better understanding of factors that influence how recommendations in public health guidelines are applied in practice could contribute to improvements in guidelines design. It could also help adjust strategies used to introduce them into public health programmes, with the ultimate goal of a greater health impact.
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Braddick L, Tuckey V, Abbas Z, Lissauer D, Ismail K, Manaseki-Holland S, Ditai J, Stokes T. A mixed-methods study of barriers and facilitators to the implementation of postpartum hemorrhage guidelines in Uganda. Int J Gynaecol Obstet 2015; 132:89-93. [PMID: 26475077 DOI: 10.1016/j.ijgo.2015.06.047] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 06/08/2015] [Accepted: 09/16/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the level of adherence to postpartum hemorrhage clinical guideline recommendations and to explore context-specific barriers and facilitators to evidence-based obstetric care. METHODS Using direct observation of deliveries at a Ugandan healthcare facility, a mixed-methods study was conducted between February and March 2014 to document practices related to the active management of the third stage of labor (AMTSL). The degree to which practice concurred with WHO postpartum hemorrhage guidelines was determined. Semi-structured interviews were conducted with maternal healthcare practitioners. RESULTS Of 154 women, individual AMTSL, in the form of administering a uterotonic during the third stage of labor, controlled cord traction, or delayed cord clamping, occurred in 105 (68.2%), 119 (77.3%), and, of a subset of 60 patients, 37 (61.7%) individuals, respectively. However, only 18 of 53 (34.0%) individuals observed for receipt of all of the three AMTSL components received all of the essential elements of AMTSL. Three major themes influencing the uptake of evidence-based practice were identified through 18 interviews: healthcare system issues; current knowledge, awareness, and use of clinical guidelines; and healthcare practitioner attitudes to updating their clinical practice. CONCLUSION Overall guideline adherence was low. There is a need to address context-specific barriers to uptake, ensuring guideline implementation to reduce maternal mortality in low-resource settings.
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Affiliation(s)
- Louise Braddick
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Victoria Tuckey
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Zan Abbas
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - David Lissauer
- Birmingham Centre for Women's and Children's Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Khaled Ismail
- Birmingham Centre for Women's and Children's Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Semira Manaseki-Holland
- School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Ditai
- Sanyu Africa Research Institute (SAfRI), University of Liverpool, UK and Uganda
| | - Tim Stokes
- School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
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Katahoire AR, Henriksson DK, Ssegujja E, Waiswa P, Ayebare F, Bagenda D, Mbonye AK, Peterson SS. Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda. BMC Public Health 2015; 15:797. [PMID: 26286146 PMCID: PMC4545317 DOI: 10.1186/s12889-015-2129-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 08/07/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Community and District Empowerment for Scale-up (CODES) project pioneered the implementation of a comprehensive district management and community empowerment intervention in five districts in Uganda. In order to improve effective coverage and quality of child survival interventions CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. This paper presents early implementation experiences in five pilot districts and lessons learnt during the first 2 years of implementation. METHODS This qualitative study was comprised of 38 in-depth interviews with members of the District Health Teams (DHTs) and two implementing partners. These were supplemented by observations during implementation and documents review. Thematic analysis was used to distill early implementation experiences and lessons learnt from the process. RESULTS All five districts health teams with support from the implementing partners were able to adopt the UNICEF tools and to develop district health operational work plans that were evidence-based. Members of the DHTs described the approach introduced by the CODES project as a more systematic planning process and very much appreciated it. Districts were also able to implement some of the priority activities included in their work plans but limited financial resources and fiscal decision space constrained the implementation of some activities that were prioritized. Community dialogues based on Citizen Report Cards (CRC) increased community awareness of available health care services, their utilization and led to discussions on service delivery, barriers to service utilization and processes for improvement. Community dialogues were also instrumental in bringing together service users, providers and leaders to discuss problems and find solutions. The dialogues however are more likely to be sustainable if embedded in existing community structures and conducted by district based facilitators. U report as a community feedback mechanism registered a low response rate. CONCLUSION The UNICEF tools were adopted at district level and generally well perceived by the DHTs. The limited resources and fiscal decision space however can hinder implementation of prioritized activities. Community dialogues based on CRCs can bring service providers and the community together but need to be embedded in existing community structures for sustainability.
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Affiliation(s)
| | | | - Eric Ssegujja
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Peter Waiswa
- Karolinska Institutet, Solna, Sweden.
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Florence Ayebare
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Danstan Bagenda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
- College of Public Health, University of Nebraska Medical Center, Omaha, USA.
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, USA.
| | - Anthony K Mbonye
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
- Ministry of Health, Kampala, Uganda.
| | - Stefan Swartling Peterson
- Karolinska Institutet, Solna, Sweden.
- Uppsala University, Uppsala, Sweden.
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
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Cockburn L, Fanfon TN, Bramall A, Ngole EM, Kuwoh P, Anjonga E, Difang BME, Kiani S, Muso PS, Trivedi N, Sama J, Teboh S. Best practice guidelines for stroke in Cameroon: An innovative and participatory knowledge translation project. Afr J Disabil 2014; 3:92. [PMID: 28729996 PMCID: PMC5433442 DOI: 10.4102/ajod.v3i1.92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 05/22/2014] [Indexed: 11/14/2022] Open
Abstract
Background Although the adherence to stroke guidelines in high-income countries has been shown to be associated with improved patient outcomes, the research, development and implementation of rehabilitation related guidelines in African countries is lacking. Objectives The purpose of this article is to describe how a group of front-line practitioners collaborated with academics and students to develop best practice guidelines (BPG) for the management and rehabilitation of stroke in adult patients in Cameroon. Method A working group was established and adapted internationally recognised processes for the development of best practice guidelines. The group determined the scope of the guidelines, documented current practices, and critically appraised evidence to develop guidelines relevant to the Cameroon context. Results The primary result of this project is best practice guidelines which provided an overview of the provision of stroke rehabilitation services in the region, and made 83 practice recommendations to improve these services. We also report on the successes and challenges encountered during the process, and the working group’s recommendations aimed at encouraging others to consider similar projects. Conclusion This project demonstrated that there is interest and capacity for improving stroke rehabilitation practices and for stroke guideline development in Africa.
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Affiliation(s)
- Lynn Cockburn
- Department of Occupational Science and Occupational Therapy, University of Toronto, Canada
| | | | - Alexa Bramall
- Undergraduate Medical Education MD Program, Faculty of Medicine, University of Toronto, Canada
| | - Eta M Ngole
- Buildings Bridges Cameroon (BBCAM), Yaoundé, Cameroon.,Ministry of Public Health, North West Region, Cameroon
| | - Pius Kuwoh
- Director, Regional Hospital, Limbe South West Region, Cameroon
| | | | | | | | - Petra S Muso
- St. Elizabeth's Catholic General Hospital, Shisong, Banso, Cameroon
| | | | - Julius Sama
- Ministry of Public Health, North West Region, Cameroon
| | - Sylvian Teboh
- St. Joseph's Children's and Adults Home (SAJOCAH), Bafut, Cameroon
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Nabyonga-Orem J, Ssengooba F, Macq J, Criel B. Malaria treatment policy change in Uganda: what role did evidence play? Malar J 2014; 13:345. [PMID: 25179532 PMCID: PMC4164770 DOI: 10.1186/1475-2875-13-345] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 08/26/2014] [Indexed: 01/22/2023] Open
Abstract
Background Although increasing attention is being paid to knowledge translation (KT), research findings are not being utilized to the desired extent. The present study explores the role of evidence, barriers, and factors facilitating the uptake of evidence in the change in malaria treatment policy in Uganda, building on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitatory factors for KT. Application of the MRT to a health policy case will contribute to refining it. Methods Using a case study approach and mixed methods, perceptions of respondents on whether evidence was available, had been considered and barriers and facilitatory factors to the uptake of evidence were explored. In addition, the respondents’ rating of the degree of consistency between the policy decision and available evidence was assessed. Data collection methods included key informant interviews and document review. Qualitative data were analysed using content thematic analysis, whereas quantitative data were analysed using Excel spreadsheets. The two data sets were eventually triangulated. Results Evidence was used to change the malaria treatment policy, though the consistency between evidence and policy decisions varied along the policy development cycle. The availability of high-quality and contextualized evidence, including effective dissemination, Ministry of Health institutional capacity to lead the KT process, intervention of the WHO and a regional professional network, the existence of partnerships for KT with mutual trust and availability of funding, tools, and inputs to implement evidence, were the most important facilitatory factors that enhanced the uptake of evidence. Among the barriers that had to be overcome were resistance from implementers, the health system capacity to implement evidence, and financial sustainability. Conclusion The results agree with facilitatory factors identified in the earlier developed MRT, though additional factors emerged. These results refine the earlier MRT stating that high-quality and contextualized evidence will be taken up in policies, leading to evidence-informed policies when the MoH leads the KT process, partnerships are in place for KT, the WHO and regional professional bodies play a role, and funding, tools, and required inputs for implementing evidence are available. Electronic supplementary material The online version of this article (doi:10.1186/1475-2875-13-345) contains supplementary material, which is available to authorized users.
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Mori AT, Kaale EA, Ngalesoni F, Norheim OF, Robberstad B. The role of evidence in the decision-making process of selecting essential medicines in developing countries: the case of Tanzania. PLoS One 2014; 9:e84824. [PMID: 24416293 PMCID: PMC3885598 DOI: 10.1371/journal.pone.0084824] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 11/20/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Insufficient access to essential medicines is a major health challenge in developing countries. Despite the importance of Standard Treatment Guidelines and National Essential Medicine Lists in facilitating access to medicines, little is known about how they are updated. This study aims to describe the process of updating the Standard Treatment Guidelines and National Essential Medicine List in Tanzania and further examines the criteria and the underlying evidence used in decision-making. METHODS This is a qualitative study in which data were collected by in-depth interviews and document reviews. Interviews were conducted with 18 key informants who were involved in updating the Standard Treatment Guidelines and National Essential Medicine List. We used a thematic content approach to analyse the data. FINDINGS The Standard Treatment Guidelines and National Essential Medicine List was updated by committees of experts who were recruited mostly from referral hospitals and the Ministry of Health and Social Welfare. Efficacy, safety, availability and affordability were the most frequently utilised criteria in decision-making, although these were largely based on experience rather than evidence. In addition, recommendations from international guidelines and medicine promotions also influenced decision-making. Cost-effectiveness, despite being an important criterion for formulary decisions, was not utilised. CONCLUSIONS Recent decisions about the selection of essential medicines in Tanzania were made by committees of experts who largely used experience and discretionary judgement, leaving evidence with only a limited role in decision-making process. There may be several reasons for the current limited use of evidence in decision-making, but one hypothesis that remains to be explored is whether training experts in evidence-based decision-making would lead to a better and more explicit use of evidence.
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Affiliation(s)
- Amani Thomas Mori
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Eliangiringa Amos Kaale
- School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Frida Ngalesoni
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Ole Frithjof Norheim
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Laxminarayan R, Duse A, Wattal C, Zaidi AKM, Wertheim HFL, Sumpradit N, Vlieghe E, Hara GL, Gould IM, Goossens H, Greko C, So AD, Bigdeli M, Tomson G, Woodhouse W, Ombaka E, Peralta AQ, Qamar FN, Mir F, Kariuki S, Bhutta ZA, Coates A, Bergstrom R, Wright GD, Brown ED, Cars O. Antibiotic resistance-the need for global solutions. THE LANCET. INFECTIOUS DISEASES 2013; 13:1057-98. [PMID: 24252483 DOI: 10.1016/s1473-3099(13)70318-9] [Citation(s) in RCA: 2513] [Impact Index Per Article: 228.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. Here, we describe the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed.
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Affiliation(s)
- Ramanan Laxminarayan
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA; Princeton University, Princeton NJ, USA; Public Health Foundation of India, New Delhi, India
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