Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building

Interrelationship between subjective wellbeing and health

BACKGROUND

Subjective wellbeing (SWB) and health are important facets of any person's life, and they tend to influence each other. This importance is reflected in the vastness of literature aiming to explore this association. However, most of this literature is based on sampling national population which may present different population characteristics to those of a province. Thus, the paper aims to investigate if the association between perceived health and SWB is moderated by population characteristics at a provincial level. We intend to add value to subjective wellbeing and health literature by reviewing the relationship between SWB and health in the Eastern Cape stratified by age, gender, rural and urban and different income classifications.

METHODS

Different population characteristics tend to associate to subjective wellbeing and health differently, therefore influencing how these two variables influence each other. Thus, the paper aims to investigate if the association between perceived health and SWB is moderated by population characteristics at a provincial level. Utilising the South African National Income Dynamics Survey from 2008 to 2017, this study examined the relationship between subjective wellbeing and health using a random effects model stratified according to aforementioned population characteristics.

RESULTS

A better perceived health status is associated with higher subjective wellbeing. A better subjective wellbeing is also associated with a higher health status. Determinants of subjective wellbeing and health associate with these variables differently besides income and employment which led to higher subjective wellbeing and health. Health associates to subjective wellbeing different across populations characteristics.

CONCLUSION

Subjective wellbeing and health are interdependent as reflected in the World Health Organisation (WHO) and United Nation (UN) statements. Higher income and level of education and being employed is associated with both higher SWB and health. Therefore, improving these economic outcomes maybe associated with an improvement in well-being and health as desired by WHO and UN. Provinces differ, and different population characteristics tend to associate with subjective wellbeing and health differently, therefore influencing how these two variables influence each other. Health improvement policies must consider subjective wellbeing. Well-being improvement policies need to be cognisant of the differences in provincial and population characteristics.

Planning, implementing and governing systems-based co-creation: the DISCOVER framework

BACKGROUND

Increasingly, public health faces challenges requiring complex, multifaceted and multi-sectoral responses. This calls for systems-based approaches that facilitate the kind of collective and collaborative thinking and working required to address complexity. While the literature on systems thinking, system dynamics and the associated methodologies is extensive, there remains little clear guidance on how to plan, govern and implement participatory systems approaches within a co-creation process.

METHODS

We used a three-step process to develop DISCOVER, a framework for implementing, and governing systems-based co-creation: Stage 1: We conducted a literature analysis of key texts to identify well-documented methods and phases for co-creation using a systems approach, as well as areas where gaps existed. Stage 2: We looked for the most appropriate methods and approaches to fill the gaps in the knowledge production chain. Stage 3: We developed the framework, identifying how the different tools and approaches fit together end-to-end, from sampling and recruiting participants all the way through to responding with an action plan.

RESULTS

We devised DISCOVER to help guide researchers and stakeholders to collectively respond to complex social, health and wider problems. DISCOVER is a strategic research planning and governance framework that provides an actionable, systematic way to conceptualise complex problems and move from evidence to action, using systems approaches and co-creation. In this article, we introduce the eight-step framework and provide an illustrative case study showcasing its potential. The framework integrates complementary approaches and methods from social network analysis, systems thinking and co-creation literature. The eight steps are followed sequentially but can overlap.

CONCLUSIONS

DISCOVER increases rigour and transparency in system approaches to tackling complex issues going from planning to action. It is being piloted in environmental health research but may be suitable to address other complex challenges and could be incorporated into research proposals and protocols for future projects.

Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review

BACKGROUND

Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.

METHODS

Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.

RESULTS

More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.

CONCLUSION

A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.

Association between antenatal care facility readiness and provision of care at the client level and facility level in five low- and middle-income countries

BACKGROUND

Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level.

METHODS

To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels.

RESULTS

Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect.

CONCLUSIONS

The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures.

Applications of Participatory System Dynamics Methods to Public Health: A Systematic Review

System dynamics, and specifically qualitative participatory applications of system dynamics, have potential to benefit public health research, scholarship, and practice. A systematic review was conducted to examine the existing applications of participatory system dynamics (PSD) to public health research. Three databases were searched using unique search terms related to PSD and methodological applications in public health research. A total of 57 unique articles met inclusion criteria and were included for review. The studies included for review were conducted globally and represent a wide breadth of public health issues. The review identified several advantages to adopting PSD methods in public health scholarship and practice. The PSD methods provide innovative frameworks for conceptualizing complex and nuanced public health problems. The participatory nature of PSD allows for increased community engagement and empowerment to address public health problems, as well as to mitigate existing power dynamics between research institutions and marginalized communities that are disproportionately impacted by social and health inequities. Finally, causal loop diagrams developed using PSD methods have unique potential to convey complex concepts to policy makers and interventionists. This systematic review reports evidence for PSD's potential to advance equity in public health research and practice.

Cultural adaptations and methodological innovations to group model building for the systems actions to reduce malnutrition in all its forms in Southeast Asian countries and China (SYSTAM CHINA-SEACS International Consortium) project

BACKGROUND

Group Model Building (GMB) is a participatory system dynamics method increasingly used to address complex public health issues like obesity. GMB represents a set of well-defined steps to engage key stakeholders to identify shared drivers and solutions of a given problem. However, GMB has not yet been applied specifically to develop multi-duty interventions that address multiple inter-related issues such as malnutrition in all its forms (MIAIF). Moreover, a recent systematic review of empirical applications of a systems approach to developing obesity interventions found no published work from non-western, low- and middle-income countries (LMICs). In this paper we describe adaptations and innovations to a common GMB process to co-develop systemic MIAIF interventions with Chinese decision-makers.

METHODS

We developed, piloted and implemented multiple cultural adaptations and two methodological innovations to the commonly used GMB process in Fang Cheng Gang city, China. We included formal, ceremonial and policy maker engagement events before and between GMB workshops, and incorporated culturally tailored arrangements during participant recruitment (officials of the same seniority level joined the same workshop) and workshop activities (e.g., use of individual scoring activities and hand boards). We made changes to the commonly used GMB activities which enabled mapping of shared drivers of multiple health issues (in our case MIAIF) in a single causal loop diagram. We developed and used a 'hybrid' GMB format combining online and in person facilitation to reduce travel and associated climate impact.

RESULTS

Our innovative GMB process led to high engagement and support from decision-makers representing diverse governmental departments across the whole food systems. We co-identified and prioritised systemic drivers and intervention themes of MIAIF. The city government established an official Local Action Group for long-term, inter-departmental implementation, monitoring and evaluation of the co-developed interventions. The 'hybrid' GMB format enabled great interactions while reducing international travel and mitigating limitations of fully online GMB process.

CONCLUSIONS

Cultural and methodological adaptations to the common GMB process for an Asian LMIC setting were successful. The 'hybrid' GMB format is feasible, cost-effective, and more environmentally friendly. These cultural adaptations could be considered for other Asian settings and beyond to address inter-related, complex issues such as MIAIF.

Health system resilience: a critical review and reconceptualisation

This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neglect of equity and of who is bearing the costs of resilience strategies. Resilience depends crucially on relationships between system actors and components, and-as amply shown during the COVID-19 pandemic-relationships with wider systems (eg, economic, political, and global governance structures). Resilience is therefore connected to power imbalances, which need to be addressed to enact the transformative strategies that are important in dealing with more persistent shocks and stressors, such as climate change. We discourage the framing of resilience as an outcome that can be measured; instead, we see it emerge from systemic resources and interactions, which have effects that can be measured. We propose a more complex categorisation of shocks than the common binary one of acute versus chronic, and outline some of the implications of this for resilience strategies. We encourage a shift in thinking from capacities towards capabilities-what actors could do in future with the necessary transformative strategies, which will need to encompass global, national, and local change. Finally, we highlight lessons emerging in relation to preparing for the next crisis, particularly in clarifying roles and avoiding fragmented governance.

Sabounchi N. Application of group model building in implementation research: A systematic review of the public health and healthcare literature

BACKGROUND

Group model building is a process of engaging stakeholders in a participatory modeling process to elicit their perceptions of a problem and explore concepts regarding the origin, contributing factors, and potential solutions or interventions to a complex issue. Recently, it has emerged as a novel method for tackling complex, long-standing public health issues that traditional intervention models and frameworks cannot fully address. However, the extent to which group model building has resulted in the adoption of evidence-based practices, interventions, and policies for public health remains largely unstudied. The goal of this systematic review was to examine the public health and healthcare applications of GMB in the literature and outline how it has been used to foster implementation and dissemination of evidence-based interventions.

METHODS

We searched PubMed, Web of Science, and other databases through August 2022 for studies related to public health or health care where GMB was cited as a main methodology. We did not eliminate studies based on language, location, or date of publication. Three reviewers independently extracted data on GMB session characteristics, model attributes, and dissemination formats and content.

RESULTS

Seventy-two studies were included in the final review. Majority of GMB activities were in the fields of nutrition (n = 19, 26.4%), health care administration (n = 15, 20.8%), and environmental health (n = 12, 16.7%), and were conducted in the United States (n = 29, 40.3%) and Australia (n = 7, 9.7%). Twenty-three (31.9%) studies reported that GMB influenced implementation through policy change, intervention development, and community action plans; less than a third reported dissemination of the model outside journal publication. GMB was reported to have increased insight, facilitated consensus, and fostered communication among stakeholders.

CONCLUSIONS

GMB is associated with tangible benefits to participants, including increased community engagement and development of systems solutions. Transdisciplinary stakeholder involvement and more rigorous evaluation and dissemination of GMB activities are recommended.

How to do (or not to do)…Using Causal Loop Diagrams for Health System Research in Low- and Middle-Income Settings

Causal loop diagrams (CLDs) are a systems thinking method that can be used to visualize and unpack complex health system behaviour. They can be employed prospectively or retrospectively to identify the mechanisms and consequences of policies or interventions designed to strengthen health systems and inform discussion with policymakers and stakeholders on actions that may alleviate sub-optimal outcomes. Whilst the use of CLDs in health systems research has generally increased, there is still limited use in low- and middle-income settings. In addition to their suitability for evaluating complex systems, CLDs can be developed where opportunities for primary data collection may be limited (such as in humanitarian or conflict settings) and instead be formulated using secondary data, published or grey literature, health surveys/reports and policy documents. The purpose of this paper is to provide a step-by-step guide for designing a health system research study that uses CLDs as their chosen research method, with particular attention to issues of relevance to research in low- and middle-income countries (LMICs). The guidance draws on examples from the LMIC literature and authors’ own experience of using CLDs in this research area. This paper guides researchers in addressing the following four questions in the study design process; (1) What is the scope of this research? (2) What data do I need to collect or source? (3) What is my chosen method for CLD development? (4) How will I validate the CLD? In providing supporting information to readers on avenues for addressing these key design questions, authors hope to promote CLDs for wider use by health system researchers working in LMICs.

Assessing the functionality of an emergency obstetric referral system and continuum of care among public healthcare facilities in a low resource setting: an application of process mapping approach

BACKGROUND

Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study.

METHODS

The study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system.

RESULTS

Out of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial.

CONCLUSION

Our findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.

Health system determinants of tuberculosis mortality in South Africa: a causal loop model

Background

Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to each other.

Results

Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socio-economic status). Through the development and refinement of the causal loop diagram, additional explanatory and linking variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’ illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TB-related mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how this negatively affects the demand for higher levels of stewardship.

Conclusions

Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system, increasing health care worker support, and using windows of opportunity to target points of leverage within the South African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this model may allow for the identification of additional areas of intervention.

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

This paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017–18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes. The paper offers five sets of insights that add to the limited empirical health system resilience literature: 1) resilience is a process not an end-state; 2) resilience strategies are deployed in combination rather than linearly, after each other; 3) three sets of organizational resilience capacities work together to support collective problem-solving and action entailed in EHSR; 4) these capacities can be nurtured by mid-level managers’ leadership practices and simple adaptations of routine organizational processes, such as meetings; 5) central level actions must nurture EHSR by enabling the leadership practices and micro-governance processes entailed in everyday decision-making.

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Resilience to chronic stress will prepare health systems to face acute shocks.

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Collective problem-solving and sensemaking enable everyday resilience.

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Distributed leadership, feeling safe and reflective practice are key processes.

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New forms of health system strengthening are needed to nurture resilience.

Developing a Preliminary Causal Loop Diagram for Understanding the Wicked Complexity of the COVID-19 Pandemic

COVID-19 is a wicked problem for policy makers internationally as the complexity of the pandemic transcends health, environment, social and economic boundaries. Many countries are focusing on two key responses, namely virus containment and financial measures, but fail to recognise other aspects. The systems approach, however, enables policy makers to design the most effective strategies and reduce the unintended consequences. To achieve fundamental change, it is imperative to firstly identify the “right” interventions (leverage points) and implement additional measures to reduce negative consequences. To do so, a preliminary causal loop diagram of the COVID-19 pandemic was designed to explore its influence on socio-economic systems. In order to transcend the “wait and see” approach, and create an adaptive and resilient system, governments need to consider “deep” leverage points that can be realistically maintained over the long-term and cause a fundamental change, rather than focusing on “shallow” leverage points that are relatively easy to implement but do not result in significant systemic change.