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Schukow CP, Allen TC. Digital and Computational Pathology Are Pathologists' Physician Extenders. Arch Pathol Lab Med 2024; 148:866-870. [PMID: 38531382 DOI: 10.5858/arpa.2023-0537-ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Casey P Schukow
- From the Department of Pathology, Corewell Health's Beaumont Hospital, Royal Oak, Michigan
| | - Timothy Craig Allen
- From the Department of Pathology, Corewell Health's Beaumont Hospital, Royal Oak, Michigan
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Linley K. Family Health Clinical Officers: Key professionals to strengthen primary healthcare in Kenya. Afr J Prim Health Care Fam Med 2024; 16:e1-e3. [PMID: 39099276 PMCID: PMC11304214 DOI: 10.4102/phcfm.v16i1.4594] [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: 04/30/2024] [Revised: 06/11/2024] [Accepted: 06/11/2024] [Indexed: 08/06/2024] Open
Abstract
Primary healthcare (PHC) is recognised as the means to achieve universal health coverage, a national priority for Kenya. With only approximately 200 family physicians for a population of over 54 million, innovative solutions for providing quality PHC are needed. Clinical Officers, as mid-level health workers, already provide much of the primary care across Kenya, but without specialised training. To provide highly trained Family Health practitioners, a Higher Diploma in Family Health for Clinical Officers (FHCO) was launched by the government in 2018. With experience in delivering innovative and strategic higher diplomas, AIC Kijabe Hospital has been involved in curriculum development of this new diploma since its inception, and in October 2021 the first cohort of FHCO trainees was admitted to Kijabe College of Health Science, graduating in 2023. The second cohort is underway with plans for an annual intake. The FHCO graduates are running Family Medicine clinics at AIC Kijabe Hospital and its satellite clinics and are heavily involved in teaching. They are well-trained to deliver comprehensive, evidence-based, cost-effective and holistic care. As the programme expands, we expect graduates to be working across the country and leading efforts in enhancing the health and well-being of individuals, families and communities within primary healthcare networks (PCNs). By training FHCOs, this higher diploma is an efficient and cost-effective way to improve PHC, particularly for underserved Kenyans, and thus is a key part of enabling the Kenyan Government to achieve universal health coverage. This model of training could easily be replicated in other countries.
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Affiliation(s)
- Katherine Linley
- School of Clinical Medicine and Surgery, Kijabe College of Health Sciences, Division of Education and Research, AIC Kijabe Hospital, Kijabe.
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McPake B, Dayal P, Zimmermann J, Williams GA. How can countries respond to the health and care workforce crisis? Insights from international evidence. Int J Health Plann Manage 2024; 39:879-887. [PMID: 38278780 DOI: 10.1002/hpm.3766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/28/2024] Open
Abstract
Future global health security requires a health and care workforce (HCWF) that can respond effectively to health crises as well as to changing health needs with ageing populations, a rise in chronic conditions and growing inequality. COVID-19 has drawn attention to an impending HCWF crisis with a large projected shortfall in numbers against need. Addressing this requires countries to move beyond a focus on numbers of doctors, nurses and midwives to consider what kinds of healthcare workers can deliver the services needed; are more likely to stay in country, in rural and remote areas, and in health sector jobs; and what support they need to deliver high-quality services. In this paper, which draws on a Policy Brief prepared for the World Health Organization (WHO) Fifth Global Forum on Human Resources for Health, we review the global evidence on best practices in organising, training, deploying, and managing the HCWF to highlight areas for strategic investments. These include (1). Increasing HCWF diversity to improve the skill-mix and provide culturally competent care; (2). Introducing multidisciplinary teams in primary care; (3). Transforming health professional education with greater interprofessional education; (4). Re-thinking employment and deployment systems to address HCWF shortages; (5). Improving HCWF retention by supporting healthcare workers and addressing migration through destination country policies that limit draining resources from countries with greatest need. These approaches are departures from current norms and hold substantial potential for building a sustainable and responsive HCWF.
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Affiliation(s)
- Barbara McPake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Prarthna Dayal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia Zimmermann
- European Observatory on Health Systems and Policies, London School of Economics and Political Science, London, UK
| | - Gemma A Williams
- European Observatory on Health Systems and Policies, London School of Economics and Political Science, London, UK
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Moodley SV, Wolvaardt J, Grobler C. Knowledge, confidence, and practices of clinical associates in the management of mental illness. S Afr J Psychiatr 2023; 29:2074. [PMID: 37928935 PMCID: PMC10623624 DOI: 10.4102/sajpsychiatry.v29i0.2074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/31/2023] [Indexed: 11/07/2023] Open
Abstract
Background Additional human resources are needed to provide mental health services in underserved areas in South Africa (SA). Clinical associates, the mid-level medical worker cadre in SA, could potentially be used to deliver these services. Aim The study explored the self-reported knowledge, confidence, and current practices of clinical associates related to mental health assessment and management. Setting South Africa. Methods A cross-sectional study was conducted. The link to the electronic questionnaire was distributed to clinical associates via databases and social media. Data were analysed with Stata v17. Results Of the 209 participants, 205 (98.1%) indicated they had training on management of patients with mental illness during their undergraduate degree and 192 (91.9%) had a mental health rotation. Few (10.7%) had any additional mental health training. Most participants rated their knowledge of priority mental disorders as 'good' or 'excellent'. Only 43.2% of the participants felt quite or very confident to perform a mental health examination. Participants who felt quite or very confident to manage patients presenting with suicide risk, aggression, and confusion were 44.9%, 46.9% and 53.1%, respectively. Factors associated with a confidence score of 75% and higher were male gendered, working in Gauteng or Northern Cape provinces, and in a rural area. The majority of participants were already involved in mental health assessment and management in their current work. Conclusion Clinical associates have a contribution to make in mental health service provision, but this may need to be supplemented by additional practical training. Contribution Potential gaps in training have been identified.
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Affiliation(s)
- Saiendhra V Moodley
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Jacqueline Wolvaardt
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Christoffel Grobler
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Olivas ET, Valdez M, Muffoletto B, Wallace J, Stollak I, Perry HB. Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 6. Management of pregnancy complications at Community Birthing Centers (Casas Maternas Rurales). Int J Equity Health 2023; 21:204. [PMID: 36855147 PMCID: PMC9976365 DOI: 10.1186/s12939-022-01758-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+. METHODS We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff. RESULTS During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere. CONCLUSION The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right.
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Affiliation(s)
- Elijah T Olivas
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mario Valdez
- Curamericas/Guatemala, Calhuitz, San Sebastián Coatán, Huehuetenango, Guatemala
| | | | | | - Ira Stollak
- Curamericas Global, Raleigh, North Carolina, USA
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Gallagher JE, Mattos Savage GC, Crummey SC, Sabbah W, Varenne B, Makino Y. Oral Health Workforce in Africa: A Scarce Resource. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2328. [PMID: 36767693 PMCID: PMC9915704 DOI: 10.3390/ijerph20032328] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 06/18/2023]
Abstract
The World Health Organization (WHO) African Region (AFR) has 47 countries. The aim of this research was to review the oral health workforce (OHWF) comprising dentists, dental assistants and therapists, and dental prosthetic technicians in the AFR. OHWF data from a survey of all 47 member states were triangulated with the National Health Workforce Accounts and population data. Descriptive analysis of workforce trends and densities per 10,000 population from 2000 to 2019 was performed, and perceived workforce challenges/possible solutions were suggested. Linear regression modelling used the Human Development Index (HDI), years of schooling, dental schools, and levels of urbanization as predictors of dentist density. Despite a growth of 63.6% since 2010, the current workforce density of dentists (per 10,000 population) in the AFR remains very low at 0.44, with marked intra-regional inequity (Seychelles, 4.297; South Sudan 0.003). The stock of dentists just exceeds that of dental assistants/therapists (1:0.91). Workforce density of dentists and the OHWF overall was strongly associated with the HDI and mean years of schooling. The dominant perceived challenge was identified as 'mal-distribution of the workforce (urban/rural)' and 'oral health' being 'considered low priority'. Action to 'strengthen oral health policy' and provide 'incentives to work in underserved areas' were considered important solutions in the region. Whilst utilising workforce skill mix contributes to overall capacity, there is a stark deficit of human resources for oral health in the AFR. There is an urgent need to strengthen policy, health, and education systems to expand the OHWF using innovative workforce models to meet the needs of this region and achieve Universal Health Coverage (UHC).
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Affiliation(s)
- Jennifer E. Gallagher
- Dental Public Health, King’s College London, Faculty of Dentistry, Oral & Craniofacial Sciences, Denmark Hill Campus, London SE5 9RS, UK
| | - Grazielle C. Mattos Savage
- Dental Public Health, King’s College London, Faculty of Dentistry, Oral & Craniofacial Sciences, Denmark Hill Campus, London SE5 9RS, UK
| | - Sarah C. Crummey
- Dental Public Health, King’s College London, Faculty of Dentistry, Oral & Craniofacial Sciences, Denmark Hill Campus, London SE5 9RS, UK
| | - Wael Sabbah
- Dental Public Health, King’s College London, Faculty of Dentistry, Oral & Craniofacial Sciences, Denmark Hill Campus, London SE5 9RS, UK
| | - Benoit Varenne
- Dental Office, WHO Oral Health Programme NCD Department, Division of UHC/Communicable and NCDs, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Yuka Makino
- Dental Office, Noncommunicable Diseases Team, WHO Regional Office for Africa, Cité Djoué, Brazzaville P.O. Box 06, Congo
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Aurizki GE, Wilson I. Nurse-led task-shifting strategies to substitute for mental health specialists in primary care: A systematic review. Int J Nurs Pract 2022; 28:e13046. [PMID: 35285121 PMCID: PMC9786659 DOI: 10.1111/ijn.13046] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 01/26/2022] [Accepted: 02/20/2022] [Indexed: 12/30/2022]
Abstract
AIM The study aimed to synthesize evidence comparing task-shifting interventions led by general practice nurses and mental health specialists in improving mental health outcomes of adults in primary care. DESIGN This study used a systematic review of randomized controlled trials. DATA SOURCES Articles from the databases CINAHL, MEDLINE, APA PsycInfo, PubMed, EMBASE, Cochrane EBM Reviews, Web of Science Core Collection, and ProQuest Dissertation and Thesis published between 2000 and 2020 were included. REVIEW METHODS The review was arranged based on the Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS Twelve articles met the eligibility criteria. Eight studies revealed that nurse-led intervention was significantly superior to its comparator. The review identified three major themes: training and supervision, single and collaborative care and psychosocial treatments. CONCLUSION Nurses could be temporarily employed to provide mental health services in the absence of mental health specialists as long as appropriate training and supervision was provided. This finding should be interpreted with caution due to the high risk of bias in the studies reviewed and the limited generalisability of their findings.
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Affiliation(s)
- Gading Ekapuja Aurizki
- Faculty of NursingUniversitas AirlanggaSurabayaEast JavaIndonesia,Advanced Leadership for Professional Practice (Nursing) ProgrammeThe University of ManchesterManchesterUK
| | - Ian Wilson
- Division of Nursing, Midwifery and Social Work, School of Health SciencesThe University of ManchesterManchesterUK
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Data, turf, and the healthcare professions. JAAPA 2022; 35:13-15. [DOI: 10.1097/01.jaa.0000854500.33618.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schmude M, Salim N, Azadzoy H, Bane M, Millen E, O'Donnell L, Bode P, Türk E, Vaidya R, Gilbert S. Investigating the Potential for Clinical Decision Support in Sub-Saharan Africa With AFYA (Artificial Intelligence-Based Assessment of Health Symptoms in Tanzania): Protocol for a Prospective, Observational Pilot Study. JMIR Res Protoc 2022; 11:e34298. [PMID: 35671073 PMCID: PMC9214611 DOI: 10.2196/34298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/17/2022] [Accepted: 04/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Low- and middle-income countries face difficulties in providing adequate health care. One of the reasons is a shortage of qualified health workers. Diagnostic decision support systems are designed to aid clinicians in their work and have the potential to mitigate pressure on health care systems. OBJECTIVE The Artificial Intelligence-Based Assessment of Health Symptoms in Tanzania (AFYA) study will evaluate the potential of an English-language artificial intelligence-based prototype diagnostic decision support system for mid-level health care practitioners in a low- or middle-income setting. METHODS This is an observational, prospective clinical study conducted in a busy Tanzanian district hospital. In addition to usual care visits, study participants will consult a mid-level health care practitioner, who will use a prototype diagnostic decision support system, and a study physician. The accuracy and comprehensiveness of the differential diagnosis provided by the diagnostic decision support system will be evaluated against a gold-standard differential diagnosis provided by an expert panel. RESULTS Patient recruitment started in October 2021. Participants were recruited directly in the waiting room of the outpatient clinic at the hospital. Data collection will conclude in May 2022. Data analysis is planned to be finished by the end of June 2022. The results will be published in a peer-reviewed journal. CONCLUSIONS Most diagnostic decision support systems have been developed and evaluated in high-income countries, but there is great potential for these systems to improve the delivery of health care in low- and middle-income countries. The findings of this real-patient study will provide insights based on the performance and usability of a prototype diagnostic decision support system in low- or middle-income countries. TRIAL REGISTRATION ClinicalTrials.gov NCT04958577; http://clinicaltrials.gov/ct2/show/NCT04958577. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/34298.
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Affiliation(s)
| | - Nahya Salim
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | | | - Mustafa Bane
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | | | | | | | | | | | - Stephen Gilbert
- Ada Health GmbH, Berlin, Germany.,Else Kröner Fresenius Center for Digital Health, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
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Helfrich AM, Fraser JA, Hickey PW. Destination based errors in chloroquine malaria chemoprophylaxis vary based on provider specialty and credentials. Travel Med Infect Dis 2022; 47:102310. [DOI: 10.1016/j.tmaid.2022.102310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022]
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Anbupriya M, Gayathri K, Hariharan S. Prior experience of physiotherapy treatment among the general public: A qualitative analysis. ASIAN JOURNAL OF PHARMACEUTICAL RESEARCH AND HEALTH CARE 2022. [DOI: 10.4103/ajprhc.ajprhc_51_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Baratto PS, Valmórbida JL, Leffa PDS, Sangalli CN, Feldens CA, Vitolo MR. Primary Health Care Intervention Reduces Added Sugars Consumption During Childhood. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2021; 53:999-1007. [PMID: 34404628 DOI: 10.1016/j.jneb.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the effectiveness of a training program for health workers regarding infant feeding practices to reduce sugar consumption in children. DESIGN A cluster randomized trial was conducted at 20 health centers in southern Brazil randomly assigned to an intervention (n = 9) or control (n = 11) group. PARTICIPANTS The 715 pregnant women enrolled were assessed when their children were aged 6 months, 3 years, and 6 years. INTERVENTION A training session for primary care workers based on the Brazilian National Guidelines for Children. MAIN OUTCOME MEASURE Mothers were asked when sugar was first offered to children. Added sugars intake was obtained from dietary recalls. ANALYSIS The effectiveness of the intervention was modeled using generalized estimation equations and Poisson regression with robust variance. RESULTS Children attending intervention health centers had a 27% reduced risk of sugar introduction before 4 months of age (relative risk, 0.73; 95% confidence interval [CI], 0.61-0.87) as well as lower added sugars consumption (difference, -6.36 g/d; 95% CI, -11.49 to -1.23) and total daily energy intake (difference, -116.90 kcal/d; 95% CI, -222.41 to -11.40) at 3 years of age. CONCLUSIONS AND IMPLICATIONS Health care worker training in infant feeding guidelines may be an effective intervention to delay the introduction of added sugars and lower the subsequent intake of added sugars in infants and toddlers.
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Affiliation(s)
- Paola Seffrin Baratto
- Graduate Program in Pediatrics, Child and Adolescent Health Care, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Julia Luzzi Valmórbida
- Graduate Program in Pediatrics, Child and Adolescent Health Care, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Paula Dos Santos Leffa
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Caroline Nicola Sangalli
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | | | - Márcia Regina Vitolo
- Graduate Program in Pediatrics, Child and Adolescent Health Care, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil; Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.
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van Ginneken N, Chin WY, Lim YC, Ussif A, Singh R, Shahmalak U, Purgato M, Rojas-García A, Uphoff E, McMullen S, Foss HS, Thapa Pachya A, Rashidian L, Borghesani A, Henschke N, Chong LY, Lewin S. Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries. Cochrane Database Syst Rev 2021; 8:CD009149. [PMID: 34352116 PMCID: PMC8406740 DOI: 10.1002/14651858.cd009149.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries. OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care. SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019). SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs. PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs). DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs). Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects. Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention. MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs). Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination. Intervention effects *Unless indicated, comparisons were usual care at T2. "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence. Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists); g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death); e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08); b. may have uncertain effects on symptoms/functioning/SU/AEs. Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11); d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects. Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11); b. may have uncertain effects on symptoms/functioning/SU/AEs. PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU. Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13); c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13); c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs; b. may have uncertain effects on recovery/symptoms(PTS)/functioning. AUTHORS' CONCLUSIONS PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.
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Affiliation(s)
- Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Amin Ussif
- Norwegian Institute of Public Health, Oslo, Norway
| | - Rakesh Singh
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Ujala Shahmalak
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Antonio Rojas-García
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Sarah McMullen
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | | | - Ambika Thapa Pachya
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Anna Borghesani
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Lee-Yee Chong
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Association of Organizational Behavior with Work Engagement and Work-Home Conflicts of Physician in China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105405. [PMID: 34069341 PMCID: PMC8158697 DOI: 10.3390/ijerph18105405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/25/2021] [Accepted: 05/03/2021] [Indexed: 12/20/2022]
Abstract
This study aimed to examine how organizational behavior is associated with work engagement (WE) and work-home conflicts (WHCs) of physicians. The data were from a national cross-sectional survey of 3255 Chinese physicians. We examined organizational fairness, leadership attention, and team interaction for organizational behavior. The results indicate that greater organizational fairness is associated with higher WE and lower WHCs. High task fairness was associated with greater pride, and more enjoyment in work, lower sense of guilt towards their family, and less complaints from family members. Physicians reporting higher levels of leaders' attention to their opinions reported experiencing more enjoyment of their work, and less effects on their care for family. A greater number of dinners with colleagues per month was associated with higher WE and lower WHCs, whilst a greater number of clinical case meetings per month was associated with higher WE and higher WHCs. The results suggest that the behavior of organizations could be an important intervention to improve the wellbeing of physicians.
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Abstract
OBJECTIVE To determine the opinions of supervising physicians about the introduction of clinical associates at South African district hospitals in 2012. METHODS Twenty-four healthcare professionals in Gauteng and North West provinces were selected to participate in cross-sectional qualitative interviews exploring their opinions on the clinical practice of clinical associates, the effect of the new cadre, their achievements, and the concerns of the supervisors. The inductive content analysis process generated several themes. RESULTS Three positive themes related to clinical associate practice were identified: professionalism, skill level, and efficiencies in patient management. Themes of concern included overtime and calls, writing prescriptions, and supervision. CONCLUSIONS Interview results highlighted acceptance and appreciation for the introduction of clinical associates. Baseline opinions enhanced curriculum development and will inform further research on the effect of clinical associates on healthcare delivery in South Africa.
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Morikawa MJ. Global Health Lessons from a District Hospital. South Med J 2020; 113:418-419. [PMID: 32885256 DOI: 10.14423/smj.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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van Schalkwyk MC, Bourek A, Kringos DS, Siciliani L, Barry MM, De Maeseneer J, McKee M. The best person (or machine) for the job: Rethinking task shifting in healthcare. Health Policy 2020; 124:1379-1386. [PMID: 32900551 DOI: 10.1016/j.healthpol.2020.08.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 05/27/2020] [Accepted: 08/23/2020] [Indexed: 12/27/2022]
Abstract
Globally, health systems are faced with the difficult challenge of how to get the best results with the often limited number of health workers available to them. Exacerbating this challenge is the task of meeting ever-changing needs of service users and managing unprecedented technological advances. The process of matching skills to changing needs and opportunities is termed task shifting. It involves questioning health service goals, what health workers do, asking if it can be done in a better way, and implementing change. Task shifting in healthcare is often conceptualised as a process of transferring responsibility for 'simple' tasks from high-skilled but scarce health workers to those with less expertise and lower pay, and predominantly viewed as a means to reduce costs and promote efficiency. Here we present a position paper based on the work and expertise of the European Commission Expert Panel on Effective ways of Investing in Health. It contends that this is over simplistic, and aims to provide a new task shifting framework, informed by relevant evidence, and a series of recommendations. While far from comprehensive, there is a growing body of evidence that certain tasks traditionally undertaken by one type of health worker can be undertaken by others (or machines), in some cases to a higher standard, thus challenging the persistence of rigid professional boundaries. Task shifting has the potential to contribute to health systems strengthening when accompanied by adequate planning, resources, education, training and transparency.
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Affiliation(s)
- May Ci van Schalkwyk
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Aleš Bourek
- Masaryk University Center for Healthcare Quality, Czech Republic
| | - Dionne Sofia Kringos
- Amsterdam UMC, University of Amsterdam, Department of Public Health and Occupational Health, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York, United Kingdom
| | - Margaret M Barry
- Head of World Health Organization Collaborating Centre for Health Promotion Research, School of Health Sciences, National University of Ireland, Galway, Ireland
| | - Jan De Maeseneer
- Department of Public Health and Primary Health Care, Ghent University, Belgium
| | - Martin McKee
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, United Kingdom.
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18
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Koortzen M, Biggs LW, Wolvaardt J, Turner A, Bac M, Volpe M. Final-year medical students need to know their future supervisory role of clinical associates. S Afr Fam Pract (2004) 2020; 62:e1-e4. [PMID: 32787392 PMCID: PMC8377999 DOI: 10.4102/safp.v62i1.5019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND A clinical associate (ClinA) is a mid-level health professional who may only practise under the supervision of a medical doctor. By extension, medical students need to be prepared for this responsibility. This study explored whether final-year medical students at one university were aware of this supervisory role, felt prepared and were knowledgeable about the ClinAs' scope of practice. METHODS A descriptive, cross-sectional study was conducted. The population included all final-year medical students who had completed their District Health and Community Obstetrics rotations (March to November 2017). After an end-of-rotation session, 151 students were given questionnaires to complete. A list of 20 treatments or procedures was extracted from the ClinAs' gazetted scope of practice for a 'knowledge test'. Data were analysed with Stata and Microsoft Excel. Ethical permission was granted. RESULTS The response rate was 77.4% (n/N = 117/151). The majority of participants (76.1%, n = 86) had worked with a qualified or student ClinA before and had a generally positive impression (81.4%; n = 70). Almost half (47.8%; n = 56) thought that the ClinAs' scope of work was similar to registered nurses rather than a doctor's (38.2%; n = 44). Most were unaware that they would be required to supervise ClinAs once qualified (65.8%; n = 77). On average, participants identified 12 out of 20 treatments or procedures that a ClinA could perform. CONCLUSION Despite having worked with ClinAs, participants appeared largely unaware of their future legal obligation of supervision. Adequate clinical supervision is based on the knowledge of the scope of practice, which was variable. Formal training on the scope of the work of ClinAs is needed to prepare future doctors for their supervisory role. Medical schools have an obligation to adequately prepare their students in this regard as part of their transformative education with elements of interprofessional education.
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Moola S, Bhaumik S, Nambiar D. Mid-level health providers for primary healthcare: a rapid evidence synthesis. F1000Res 2020; 9:616. [PMID: 34249345 PMCID: PMC8237370 DOI: 10.12688/f1000research.24279.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Healthcare services, in many countries, are increasingly being provided by cadres not trained as physicians, and these substitute health workers are referred to as mid-level health providers (MLHPs). The objective of this study was to rapidly synthesise evidence on the effectiveness of MLHPs involved in the delivery of healthcare, with a perspective on low- and middle-income countries. Methods: The review team performed an overview of systematic reviews assessing various outcomes for participants receiving care from MLHPs. The team evaluated systematic reviews for methodological quality and certainty of the evidence. Also, the review team consulted relevant stakeholders in India. Results: The final report included seven
systematic reviews, with six assessed as moderate to high methodological quality. Mortality outcomes concerning pregnancy and childbirth care services showed no significant differences in care provided by MLHPs when compared with doctors. Pregnancy care provided by midwives was found to improve the quality of care slightly. The risk of failure or incomplete abortion for surgical abortion procedures provided by MLHPs was twice when compared to the procedures provided by doctors. Moderate to high certainty evidence showed that initiation and maintenance of antiretroviral therapy for HIV-infected patients by a nurse or clinical officer slightly reduced mortality. High certainty evidence showed that chronic disease management by non-medical prescribers reduced some important physiological measures compared to medical prescribing by doctors. Conclusions: To date, this is the first rapid overview of the evidence on MLHPs. Low-quality evidence suggests that MLHPs might be suitable to deliver quality pregnancy care. Moderate and high-quality evidence from trials suggests that MLHPs are helpful for chronic disease management and initiation and maintenance of antiretroviral therapy in people with HIV/AIDS. However, the roles and subsequent training and regulation of MLHPs might be different for different care domains.
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Affiliation(s)
- Sandeep Moola
- George Institute for Global Health, Vishakhapatnam, India
| | - Soumyadeep Bhaumik
- George Institute for Global Health, Vishakhapatnam, India.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Devaki Nambiar
- George Institute for Global Health, Vishakhapatnam, India.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Schwarz D, Dhungana S, Kumar A, Acharya B, Agrawal P, Aryal A, Baum A, Choudhury N, Citrin D, Dangal B, Dhimal M, Gauchan B, Gupta T, Halliday S, Karmacharya B, Kishore S, Koirala B, Kshatriya U, Levine E, Maru S, Rimal P, Sapkota S, Schwarz R, Shrestha A, Thapa A, Maru D. An integrated intervention for chronic care management in rural Nepal: protocol of a type 2 hybrid effectiveness-implementation study. Trials 2020; 21:119. [PMID: 31996250 PMCID: PMC6990567 DOI: 10.1186/s13063-020-4063-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/09/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. METHODS A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels. DISCUSSION This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future. TRIAL REGISTRATION ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.
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Affiliation(s)
- Dan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA USA
- Department of Medicine, Harvard Medical School, Boston, MA USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
- Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital, Boston, MA USA
| | - Santosh Dhungana
- Department of Internal Medicine, Hurley Medical Center, Flint, MI USA
| | - Anirudh Kumar
- Department of Medicine, NYU Langone Health, New York, NY USA
| | - Bibhav Acharya
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Psychiatry, University of California San Francisco, San Francisco, CA USA
| | | | - Anu Aryal
- Nyaya Health Nepal, Kathmandu, Nepal
- School of Medical Sciences, Kathmandu University, Dhulikhel, Nepal
| | - Aaron Baum
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Nandini Choudhury
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Anthropology, University of Washington, Seattle, WA USA
- Henry M. Jackson School of International Studies, University of Washington, Seattle, WA USA
| | | | - Meghnath Dhimal
- Nepal Health Research Council, Ministry of Health and Population, Kathmandu, Nepal
| | | | - Tula Gupta
- Nyaya Health Nepal, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
| | - Scott Halliday
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Biraj Karmacharya
- School of Medical Sciences, Kathmandu University, Dhulikhel, Nepal
- Nepal Technology Innovation Center, Kathmandu University, Dhulikhel, Nepal
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Sandeep Kishore
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Young Professionals Chronic Disease Network, New York, NY USA
| | - Bhagawan Koirala
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Erica Levine
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Sheela Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | | | - Sabitri Sapkota
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA USA
- Department of Medicine, Harvard Medical School, Boston, MA USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Archana Shrestha
- School of Medical Sciences, Kathmandu University, Dhulikhel, Nepal
- Yale School of Public Health, Center for Methods in Implementation and Prevention Science, New Haven, CT USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT USA
| | | | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Psychiatry, University of California San Francisco, San Francisco, CA USA
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY USA
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Bogren M, Erlandsson K, Johansson A, Kalid M, Abdi Igal A, Mohamed J, Said F, Pedersen C, Byrskog U, Osman F. Health workforce perspectives of barriers inhibiting the provision of quality care in Nepal and Somalia - A qualitative study. SEXUAL & REPRODUCTIVE HEALTHCARE 2019; 23:100481. [PMID: 31783321 DOI: 10.1016/j.srhc.2019.100481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/15/2019] [Accepted: 11/18/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In this paper settings from Nepal and Somalia are used to focus on the perspectives of healthcare providers within two fragile health systems. The objective of this study was to describe barriers inhibiting quality healthcare in Nepal and Somalia from a health workforce perspective. METHODS Data were collected through 19 semi-structured interviews with healthcare providers working in healthcare facilities. Ten interviews were conducted in Nepal and nine in Somalia. RESULTS Various structural barriers inhibiting the availability, accessibility, and acceptability of the quality care were similar in both countries. Barriers inhibiting the availability of quality care were linked to healthcare providers being overburdened with multiple concurrent jobs. Barriers inhibiting the accessibility to quality healthcare included long distances and the uncertain availability of transportation, and barriers to acceptability of quality healthcare was inhibited by a lack of respect from healthcare providers, characterised by neglect, verbal abuse, and lack of competence. CONCLUSIONS Inequality, poverty, traditional and cultural practices plus the heavy burden placed on healthcare providers are described as the underlying causes of the poor provision of quality care and the consequential shortcomings that emerge from it. In order to improve this situation adequate planning and policies that support the deployment and retention of the healthcare providers and its equitable distribution is required. Another important aspect is provision of training to equip healthcare providers with the ability to provide respectful quality care in order for the population to enjoy good standard of healthcare services.
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Affiliation(s)
- Malin Bogren
- Institute of Health Care and Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Kerstin Erlandsson
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
| | | | | | | | | | - Fatumo Said
- Ministry of Health, Garowe, Puntland, Somalia
| | - Christina Pedersen
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
| | - Ulrika Byrskog
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
| | - Fatumo Osman
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
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Miles CH, Petersen M, van der Laan MJ. Causal inference when counterfactuals depend on the proportion of all subjects exposed. Biometrics 2019; 75:768-777. [PMID: 30714118 PMCID: PMC6679813 DOI: 10.1111/biom.13034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
The assumption that no subject's exposure affects another subject's outcome, known as the no-interference assumption, has long held a foundational position in the study of causal inference. However, this assumption may be violated in many settings, and in recent years has been relaxed considerably. Often this has been achieved with either the aid of a known underlying network, or the assumption that the population can be partitioned into separate groups, between which there is no interference, and within which each subject's outcome may be affected by all the other subjects in the group via the proportion exposed (the stratified interference assumption). In this article, we instead consider a complete interference setting, in which each subject affects every other subject's outcome. In particular, we make the stratified interference assumption for a single group consisting of the entire sample. We show that a targeted maximum likelihood estimator for the i.i.d. setting can be used to estimate a class of causal parameters that includes direct effects and overall effects under certain interventions. This estimator remains doubly-robust, semiparametric efficient, and continues to allow for incorporation of machine learning under our model. We conduct a simulation study, and present results from a data application where we study the effect of a nurse-based triage system on the outcomes of patients receiving HIV care in Kenyan health clinics.
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Affiliation(s)
- Caleb H. Miles
- Department of Biostatistics, Columbia Mailman School of Public Health, New York, New York, U.S.A
| | - Maya Petersen
- Division of Biostatistics, University of California at Berkeley, Berkeley, California, U.S.A
- Division of Epidemiology, University of California at Berkeley, Berkeley, California, U.S.A
| | - Mark J. van der Laan
- Division of Biostatistics, University of California at Berkeley, Berkeley, California, U.S.A
- Department of Statistics, University of California at Berkeley, Berkeley, California, U.S.A
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Bitton A, Fifield J, Ratcliffe H, Karlage A, Wang H, Veillard JH, Schwarz D, Hirschhorn LR. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Glob Health 2019; 4:e001551. [PMID: 31478028 PMCID: PMC6703296 DOI: 10.1136/bmjgh-2019-001551] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/25/2019] [Accepted: 06/15/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed. METHODS Guided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised. RESULTS We retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period. CONCLUSION Our findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.
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Affiliation(s)
- Asaf Bitton
- Ariadne Labs, Boston, Massachusetts, USA
- Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | - Hong Wang
- The Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Jeremy H Veillard
- World Bank Group, Washington, District of Columbia, USA
- Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Dan Schwarz
- Ariadne Labs, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lisa R Hirschhorn
- Ariadne Labs, Boston, Massachusetts, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Pérez-Martínez E, Sebastián-Viana T, Velasco-Vázquez D, Del Gallego-Lastra R. Postpartum complications in women attended by midwives instead of obstetricians. Midwifery 2019; 75:80-88. [PMID: 31051412 DOI: 10.1016/j.midw.2019.04.009] [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: 06/03/2018] [Revised: 03/26/2019] [Accepted: 04/22/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate changes in the frequency of visits to the hospital emergency department due to puerperal complications in low risk postpartum women attended by midwives instead of obstetricians. DESIGN A quasi-experimental retrospective study with non-random allocation, comprising two groups: a control group of women attended by obstetricians and an intervention group of women attended by midwives. SETTING A level 2 hospital in Madrid (España). PARTICIPANTS Low risk postpartum women attended at the maternity unit of the Fuenlabrada University Hospital between 2013 and 2015. METHODS We gathered variables to record the homogeneity of the groups and to assess for confounders and interactions. In the case of women with different behaviours and/or who generated confounders or interactions, a multivariate adjustment with logistic regression was performed. The Homer & Lemeshow goodness-of-fit test for logistic regression was used to determine the validity of the model. MEASUREMENTS AND FINDINGS The intervention group comprised a total of 1308 women, whereas there were 1313 women in the control group. In the first 40-days postpartum, 33 women in the intervention group (2.5%) attended the hospital emergency department compared to 41 in the control group (3.1%). This difference was not statistically significant (p value 0.354). The relative risk of this decrease was 0.808 (95% CI 0.514; 1.270). The NNT was 167. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Care by midwives of low risk postpartum women did not lead to a worsening of puerperal complications requiring emergency department care. Furthermore, care by midwives was more effective than obstetrician care with lower emergency department attendance rates. Their qualification and capacity to provide health education were determinant factors.
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Affiliation(s)
- Eva Pérez-Martínez
- Hospital Universitario de Fuenlabrada, Madrid, Spain Faculty of Nursing Centro Universitario San Rafael-Nebrija, Madrid, Spain.
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Barone MA, Mbuguni Z, Achola JO, Almeida A, Cordero C, Kanama J, Marquina A, Muganyizi P, Mwanga J, Ouma D, Shannon C, Tibyehabwa L. Safety of Tubal Occlusion by Minilaparotomy Provided by Trained Clinical Officers Versus Assistant Medical Officers in Tanzania: A Randomized, Controlled, Noninferiority Trial. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:484-499. [PMID: 30120168 PMCID: PMC6172133 DOI: 10.9745/ghsp-d-18-00108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/26/2018] [Indexed: 11/20/2022]
Abstract
Trained clinical officers—nonphysicians with 3 years of specialized training—conducted the procedure safely and effectively compared with procedures performed by more advanced assistant medical officers. This evidence supports policy change allowing properly trained and supported clinical officers to perform minilaparotomy. Background: Tubal occlusion by minilaparotomy is a safe, highly effective, and permanent way to limit childbearing. We aimed to establish whether the safety of the procedure provided by trained clinical officers (COs) was not inferior to the safety when provided by trained assistant medical officers (AMOs), as measured by major adverse event (AE) rates. Methods: In this randomized, controlled, open-label noninferiority trial, we enrolled participants at 7 health facilities in Arusha region, Tanzania, as well as during outreach activities conducted in Arusha and neighboring regions. Consenting, eligible participants were randomly allocated by a research assistant at each site to minilaparotomy performed by a trained CO or by a trained AMO, in a 1:1 ratio. We asked participants to return at 3, 7, and 42 days postsurgery. The primary outcome was the rate of major AEs following minilaparotomy performed by COs versus AMOs, during the procedure and through 42 days follow-up. The noninferiority margin was 2%. The trial is registered with ClinicalTrials.gov, Identifier NCT02944149. Results: We randomly allocated 1,970 participants between December 2016 and June 2017, 984 to the CO group and 986 to the AMO group. Most (87%) minilaparotomies were conducted during outreach services. In the intent-to-treat analysis, 0 of 978 participants had a major AE in the CO group compared with 1 (0.1%) of 984 in the AMO group (risk difference: –0.1% [95% confidence interval: –0.3% to 0.1%]), meeting the criteria for noninferiority. We saw no evidence of differences in measures of procedure performance, participant satisfaction, or provider self-efficacy between the groups. Conclusions: Tubal occlusion by minilaparotomy performed by trained COs is safe, effective, and acceptable to women, and the procedure can be safely and effectively provided in outreach settings. Our results provide evidence to support policy change in resource-limited settings to allow task shifting of minilaparotomy to properly trained and supported COs, increasing access to female sterilization and helping to meet the rising demand for the procedure among women wanting to avoid pregnancy. They also suggest high demand for these services in Tanzania, given the large number of women recruited in a relatively short time period.
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Affiliation(s)
- Mark A Barone
- EngenderHealth, New York, NY, USA. Now with Population Council, New York, NY, USA.
| | - Zuhura Mbuguni
- Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | | | - Annette Almeida
- RESPOND Tanzania Project, EngenderHealth, Dar es Salaam, Tanzania. Now with Jhpiego, Dar es Salaam, Tanzania
| | | | - Joseph Kanama
- RESPOND Tanzania Project, EngenderHealth, Dar es Salaam, Tanzania
| | | | - Projestine Muganyizi
- Association of Gynaecologists and Obstetricians of Tanzania, Dar es Salaam, Tanzania
| | - Jamilla Mwanga
- RESPOND Tanzania Project, EngenderHealth, Dar es Salaam, Tanzania
| | - Daniel Ouma
- EngenderHealth, Nairobi, Kenya. Now with Population Council, Nairobi, Kenya
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Dietrich EJ, Leroux T, Santiago CF, Helgeson MD, Richard P, Koehlmoos TP. Assessing practice pattern differences in the treatment of acute low back pain in the United States Military Health System. BMC Health Serv Res 2018; 18:720. [PMID: 30223830 PMCID: PMC6142362 DOI: 10.1186/s12913-018-3525-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 09/05/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute low back pain is one of the most common reasons for individuals to seek medical care in the United States. The US Military Health System provides medical care to approximately 9.4 million beneficiaries annually. These patients also routinely suffer from acute low back pain. Within this health system, patients can receive care and treatment from physicians, or physician extenders including physician assistants and nurse practitioners. Given the diversity of provider types and their respective training programs, it would be informative to evaluate variation in care delivery, adherence to clinical guidelines, and differences within the MHS among a complex mix of provider types. METHODS This study was a retrospective, cross-sectional quantitative analysis that examined variations in treatment between provider types within the Military Health System in 2015 for treatment of acute low back pain using administrative data. In addition to descriptive and summary statistics, binomial logistic regression models were used to assess variation in practice patterns among physicians and mid-level practitioners for prescribing of non-steroidal anti-inflammatory, opioids, plain radiography, computed tomography, and magnetic resonance imaging. RESULTS With regard to prescribing practices, results indicated that the odds of receiving non-steroidal anti-inflammatory prescriptions increased significantly for both physician assistants and nurse practitioners when compared to physicians. For basic radiological referrals, odds increased significantly for ordering plain radiography for physician assistants and nurse practitioners when compared to physicians. For more advanced imaging, odds significantly decreased for ordering computed tomography (CT) and slightly decreased for magnetic resonance for physician assistants, nurse practitioners and physician residents compared to the physician group. Additionally this study discovered differences in the prescribing patterns between provider categories. Both contractors and civilians had higher odds of prescribing opioids compared to active duty providers. CONCLUSIONS As physician assistants and nurse practitioners continue to gain popularity as physician extenders in the US and in addressing provider shortages for the Military Health System, further research should be conducted to determine what impact, if any, the differences found in this study have on patient outcomes. In addition, provider type warrants further investigation to determine if labor mix and outsourcing decisions within a single payer system impacts health delivery and value based care.
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Affiliation(s)
- Erich J Dietrich
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 21779, USA.
| | - Todd Leroux
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 21779, USA
| | - Carla F Santiago
- Naval Hospital Okinawa, Chatan, , Nakagami District, , Okinawa Prefecture, 904-0103, Japan
| | | | - Patrick Richard
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 21779, USA
| | - Tracey P Koehlmoos
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 21779, USA
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Bogren M, Erlandsson K, Byrskog U. What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students. BMC Health Serv Res 2018; 18:639. [PMID: 30111324 PMCID: PMC6094463 DOI: 10.1186/s12913-018-3447-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/05/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND With professional midwives being introduced in Bangladesh in 2013, the aim of this study was to describe midwifery students perceptions on midwives' realities in Bangladesh, based on their own experiences. METHOD Data were collected through 14 focus group discussions that included a total of 67 third-year diploma midwifery students at public nursing institutes/colleges in different parts of Bangladesh. Data were analyzed deductively using an analytical framework identifying social, professional and economical barriers to the provision of quality care by midwifery personnel. RESULTS The social barriers preventing midwifery quality care falls outside the parameters of Bangladeshi cultural norms that have been shaped by beliefs associated with religion, society, and gender norms. This puts midwives in a vulnerable position due to cultural prejudice. Professional barriers include heavy workloads with a shortage of staff who were not utilized to their full capacity within the health system. The reason for this was a lack of recognition in the medical hierarchy, leaving midwives with low levels of autonomy. Economical barriers were reflected by lack of supplies and hospital beds, midwives earning only low and/or irregular salaries, a lack of opportunities for recreation, and personal insecurity related to lack of housing and transportation. CONCLUSION Without adequate support for midwives, to strengthen their self-confidence through education and through continuous professional and economic development, little can be achieved in terms of improving quality care of women during the period around early and late pregnancy including childbirth.The findings can be used for discussions aimed to mobilize a midwifery workforce across the continuum of care to deliver quality reproductive health care services. No matter how much adequate support is provided to midwives, to strengthen their self-confidence through education, continuous professional and economic development, addressing the social barriers is a prerequisite for provision of quality care.
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Affiliation(s)
- Malin Bogren
- School of Education, Health and Social Studies, Dalarna University, 791 88 Falun, Sweden
| | - Kerstin Erlandsson
- School of Education, Health and Social Studies, Dalarna University, 791 88 Falun, Sweden
| | - Ulrika Byrskog
- School of Education, Health and Social Studies, Dalarna University, 791 88 Falun, Sweden
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Couper I, Ray S, Blaauw D, Ng'wena G, Muchiri L, Oyungu E, Omigbodun A, Morhason-Bello I, Ibingira C, Tumwine J, Conco D, Fonn S. Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda. BMC Health Serv Res 2018; 18:553. [PMID: 30012128 PMCID: PMC6048766 DOI: 10.1186/s12913-018-3362-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. METHODS Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. RESULTS Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. CONCLUSIONS MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.
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Affiliation(s)
- Ian Couper
- Ukwanda Centre for Rural Health, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa. .,Centre for Rural Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sunanda Ray
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Duane Blaauw
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Private Bag 3, Johannesburg, 2050, South Africa
| | - Gideon Ng'wena
- Maseno University School of Medicine, PO Box 333, Maseno, Kenya
| | - Lucy Muchiri
- Department of Human Pathology, School of Medicine, College of Health Sciences, University of Nairobi, P.O. Box 19676, Nairobi, 00202, Kenya
| | - Eren Oyungu
- School of Medicine, Moi University, PO Box 4606, Eldoret, 030100, Kenya
| | - Akinyinka Omigbodun
- College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria
| | - Imran Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Charles Ibingira
- College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
| | - James Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Daphney Conco
- School of Public Health, University of the Witwatersrand, Wits Education Campus, 27 Saint Andrews Road, Parktown, Johannesburg, 2193, South Africa
| | - Sharon Fonn
- School of Public Health, University of the Witwatersrand, Wits Education Campus, 27 Saint Andrews Road, Parktown, Johannesburg, 2193, South Africa
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A mobile clinic approach to the delivery of community-based mental health services in rural Haiti. PLoS One 2018; 13:e0199313. [PMID: 29924866 PMCID: PMC6010262 DOI: 10.1371/journal.pone.0199313] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 06/05/2018] [Indexed: 12/02/2022] Open
Abstract
This study evaluates the use of a mental health mobile clinic to overcome two major challenges to the provision of mental healthcare in resource-limited settings: the shortage of trained specialists; and the need to improve access to safe, effective, and culturally sound care in community settings. Employing task-shifting and supervision, mental healthcare was largely delivered by trained, non-specialist health workers instead of specialists. A retrospective chart review of 318 unduplicated patients assessed and treated during the mobile clinic’s first two years (January 2012 to November 2013) was conducted to explore outcomes. These data were supplemented by a quality improvement questionnaire, illustrative case reports, and a qualitative interview with the mobile clinic’s lead community health worker. The team evaluated an average of 42 patients per clinic session. The most common mental, neurological, or substance abuse (MNS) disorders were depression and epilepsy. Higher follow-up rates were seen among those with diagnoses of bipolar disorder and neurological conditions, while those with depression or anxiety had lower follow-up rates. Persons with mood disorders who were evaluated on at least two separate occasions using a locally developed depression screening tool experienced a significant reduction in depressive symptoms. The mental health mobile clinic successfully treated a wide range of MNS disorders in rural Haiti and provided care to individuals who previously had no consistent access to mental healthcare. Efforts to address these common barriers to the provision of mental healthcare in resource-limited settings should consider supplementing clinic-based with mobile services.
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Villar Uribe M, Alonge OO, Bishai DM, Bennett S. Can task-shifting work at scale?: Comparing clinical knowledge of non-physician clinicians to physicians in Nigeria. BMC Health Serv Res 2018; 18:308. [PMID: 29716609 PMCID: PMC5930443 DOI: 10.1186/s12913-018-3133-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 04/17/2018] [Indexed: 11/24/2022] Open
Abstract
Background In contexts with severe physician shortages, the World Health Organization advocates task shifting to cadres with shorter training. To investigate the effects of task shifting at scale in primary health care, we assessed the clinical knowledge of non-physician clinicians versus physicians working in public primary care facilities in Nigeria. Methods We assessed 4138 health workers using clinical vignettes of hypothetical patients suffering from illnesses commonly seen in primary care. Facility-level fixed effects models were used to compare health worker knowledge of (i) consultation guidelines, (ii) diagnostic accuracy and (iii) treatment guidelines. Results Unadjusted averages of overall health worker knowledge were low across all types of worker except medical officers. After adjustment for potential confounding, the differences across all three measures between cadres became small or statistically insignificant. Conclusion Non-physician clinicians can provide the same quality of primary care, for a set of common illnesses, as Medical Officers with similar personal characteristics, but clinical skills across cadres need strengthening.
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Affiliation(s)
- Manuela Villar Uribe
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Olakunle O Alonge
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - David M Bishai
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sara Bennett
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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What is the impact of professional nursing on patients’ outcomes globally? An overview of research evidence. Int J Nurs Stud 2018; 78:76-83. [DOI: 10.1016/j.ijnurstu.2017.10.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 10/17/2017] [Indexed: 11/20/2022]
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Egger JR, Stankevitz K, Korom R, Angwenyi P, Sullivan B, Wang J, Hatfield S, Smith E, Popli K, Gross J. Evaluating the effects of organizational and educational interventions on adherence to clinical practice guidelines in a low-resource primary-care setting in Kenya. Health Policy Plan 2017; 32:761-768. [PMID: 28334856 DOI: 10.1093/heapol/czx004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2017] [Indexed: 11/12/2022] Open
Abstract
Background Mid-level care providers serve as the backbone of primary care in many parts of sub-Saharan Africa. Despite this, research suggests that the quality and consistency of this care is uneven. This study assessed the degree to which a set of four simple, low-cost interventions could improve adherence to a set of clinical quality measures (CQMs) associated with four common health conditions seen in a resource-constrained primary care setting. Methods A quasi-experimental, longitudinal study was carried out in three primary care clinics in Nairobi, Kenya from August 2014 to January, 2015. Mid-level clinical officers (COs) at each clinic participated in four interventions aimed at improving CQM adherence. A group of temporary COs acted as a control group. Clinical encounter data were abstracted from eligible medical charts and assessed for CQM adherence. Mixed-effects logistic regression models were then fitted to these data to determine whether adherence to CQMs improved over time, and if this adherence differed by provider type and other characteristics. Results Adherence to CQMs increased from 41.4% to 77.1% for COs that took part in the intervention, and dropped slightly from 26.5% to 21.8% for temporary COs over the 6-month study period. This difference was statistically different between treatment groups and suggests that environmental interventions alone cannot change behaviour. Adherence also varied significantly by health condition, but did not vary by provider gender, age or clinic site. Conclusions This study demonstrates the potential for low-tech, low-cost interventions to improve the quality of care delivered by mid-level care providers in resource-constrained settings. Given the widespread utilization of mid-level care providers across sub-Saharan Africa, multicomponent interventions such as this one, that consist of simple educational modules and clinic-based feedback sessions, could lead to substantial improvements in the quality of primary care in these settings.
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Affiliation(s)
- Joseph R Egger
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
| | | | | | - Philip Angwenyi
- Greater Baltimore Medical Center, 6701 N Charles St, Baltimore, MD 21204
| | - Brittney Sullivan
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA.,Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710, USA
| | - Jun Wang
- McKinsey & CO, 133 Peachtree St NE # 4600, Atlanta, GA 30303, USA
| | - Sonia Hatfield
- International Trade Administration, 1401 Constitution Ave NW, Washington, DC 20230, USA
| | - Emma Smith
- College of Arts & Sciences, Duke University, Durham, NC 27710, USA
| | - Karishma Popli
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia PA 19104
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Leong DP, Joseph PG, McKee M, Anand SS, Teo KK, Schwalm JD, Yusuf S. Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease. Circ Res 2017; 121:695-710. [PMID: 28860319 DOI: 10.1161/circresaha.117.311849] [Citation(s) in RCA: 227] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.
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Affiliation(s)
- Darryl P Leong
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.).
| | - Philip G Joseph
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Martin McKee
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Sonia S Anand
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Koon K Teo
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Jon-David Schwalm
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Salim Yusuf
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
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Steinke M, Rogers M, Lehwaldt D, Lamarche K. An examination of advanced practice nurses’ job satisfaction internationally. Int Nurs Rev 2017; 65:162-172. [DOI: 10.1111/inr.12389] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- M.K. Steinke
- School of Nursing; Indiana University at Kokomo; Kokomo IN USA
| | - M. Rogers
- University of Huddersfield; Huddersfield UK
| | - D. Lehwaldt
- School of Nursing and Human Sciences; Dublin City University; Dublin Ireland
| | - K. Lamarche
- Faculty of Health Disciplines; Athabasca University in Athabasca; AB Canada
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Agho AO, John EB. Occupational therapy and physiotherapy education and workforce in Anglophone sub-Saharan Africa countries. HUMAN RESOURCES FOR HEALTH 2017; 15:37. [PMID: 28606103 PMCID: PMC5469184 DOI: 10.1186/s12960-017-0212-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 06/02/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Sub-Saharan Africa (SSA) countries are faced with the challenge of educating a critical mass of occupational therapists (OTs) and physiotherapists (PTs) to meet the growing demand for health and rehabilitation services. The World Federation of Occupational Therapy (WFOT) and World Confederation of Physical Therapy (WCPT) have argued for the need of graduate-level training for OTs and PTs for decades. However, very few studies have been conducted to determine the availability of OT and PT training programs and practitioners in SSA countries. METHODS Initial data were collected and compiled from an extensive literature search conducted using MEDLINE and PubMed to examine the availability of OT and PT education and training programs in SSA countries. Additional data were collected, compiled, and collated from academic institutions, ministries of health, health professions associations, and licensing authorities in SSA countries. Secondary data were also collected from the websites of organizations such as the World Bank, World Health Organization (WHO), WFOT, and WCPT. RESULTS This investigation revealed that there are limited number of OT and PT training programs and that these training programs in Anglophone SSA countries are offered at or below the bachelor's level. More than half of the countries do not have OT or PT training programs. The number of qualified OTs and PTs appears to be insufficient to meet the demand for rehabilitation services. Nigeria and South Africa are the only countries offering post-entry-level masters and doctoral-level training programs in physiotherapy and occupational therapy. CONCLUSIONS Higher learning institutions in SSA countries need to collaborate and partner with other regional and foreign universities to elevate the educational training and increase the supply of PTs and OTs in the region.
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Affiliation(s)
- Augustine O. Agho
- Office of Academic Affairs, Old Dominion University, Norfolk, VA United States of America
| | - Emmanuel B. John
- Department of Physical Therapy, Chapman University, Irvine, CA United States of America
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Hamm J, Bodegraven PV, Bac M, Louw JM. Cost effectiveness of clinical associates: A case study for the Mpumalanga province in South Africa. Afr J Prim Health Care Fam Med 2016; 8:e1-e6. [PMID: 28155324 PMCID: PMC5125259 DOI: 10.4102/phcfm.v8i1.1218] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/31/2016] [Accepted: 08/06/2016] [Indexed: 11/26/2022] Open
Abstract
Background The National Department of Health of South Africa decided to start a programme to train mid-level healthcare workers, called clinical associates, as one of the measures to increase healthcare workers at district level in rural areas. Unfortunately, very little is known about the cost effectiveness of clinical associates. Aims To determine, on a provincial level, the cost effectiveness of training and employing clinical associates and medical practitioners compared to the standard strategy of training and employing only more medical practitioners. Methods A literature study was performed to answer several sub questions regarding the costs and effectiveness of clinical associates. The results were used to present a case study. Results The total cost for a province to pay for the full training of a clinical associate is R 300 850. The average employment cost per year is R196 329 and for medical practitioners these costs are R 730 985 and R 559 397, respectively. Effectiveness Clinical associates are likely to free up the time of a medical practitioner by 50–76%. They can provide the same quality of care as higher level workers, provided that they receive adequate training, support and supervision. Furthermore, they seem more willing to work in rural areas compared to medical practitioners. Conclusions The case study showed that training and employing clinical associates is potentially a cost-effective strategy for a province to meet the increasing demand for rural healthcare workers. This strategy will only succeed when clinical associates receive adequate training, support and supervision and if the province keeps investing in them.
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Affiliation(s)
| | | | - Martin Bac
- Family Medicine Department, University of Pretoria.
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Koblinsky M, Moyer CA, Calvert C, Campbell J, Campbell OMR, Feigl AB, Graham WJ, Hatt L, Hodgins S, Matthews Z, McDougall L, Moran AC, Nandakumar AK, Langer A. Quality maternity care for every woman, everywhere: a call to action. Lancet 2016; 388:2307-2320. [PMID: 27642018 DOI: 10.1016/s0140-6736(16)31333-2] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 07/20/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.
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Affiliation(s)
| | - Cheryl A Moyer
- Department of Learning Health Sciences and Department of Obstetrics and Gynecology, Global REACH, University of Michigan Medical School, Ann Arbor, MI
| | - Clara Calvert
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Wendy J Graham
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Steve Hodgins
- Saving Newborn Lives, Save the Children, Washington, DC, USA
| | - Zoe Matthews
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Lori McDougall
- Partnership for Maternal Newborn and Child Health, Geneva, Switzerland
| | | | | | - Ana Langer
- Maternal Health Task Force, Women and Health Initiative, Harvard TH Chan School of Public Health, Boston, MA, USA
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Akseer N, Salehi AS, Hossain SMM, Mashal MT, Rasooly MH, Bhatti Z, Rizvi A, Bhutta ZA. Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study. LANCET GLOBAL HEALTH 2016; 4:e395-413. [DOI: 10.1016/s2214-109x(16)30002-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 03/05/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
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Lassi ZS, Musavi NB, Maliqi B, Mansoor N, de Francisco A, Toure K, Bhutta ZA. Systematic review on human resources for health interventions to improve maternal health outcomes: evidence from low- and middle-income countries. HUMAN RESOURCES FOR HEALTH 2016; 14:10. [PMID: 26971317 PMCID: PMC4789263 DOI: 10.1186/s12960-016-0106-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/04/2016] [Indexed: 05/23/2023]
Abstract
There is a broad consensus and evidence that shows qualified, accessible, and responsive human resources for health (HRH) can make a major impact on the health of the populations. At the same time, there is widespread recognition that HRH crises particularly in low- and middle-income countries (LMICs) impede the achievement of better health outcomes/targets. In order to achieve the Sustainable Development Goals (SDGs), equitable access to a skilled and motivated health worker within a performing health system is need to be ensured. This review contributes to the vast pool of literature towards the assessment of HRH for maternal health and is focused on interventions delivered by skilled birth attendants (SBAs). Studies were included if (a) any HRH interventions in management system, policy, finance, education, partnership, and leadership were implemented; (b) these were related to SBA; (c) reported outcomes related to maternal health; (d) the studies were conducted in LMICs; and (e) studies were in English. Studies were excluded if traditional birth attendants and/or community health workers were trained. The review identified 25 studies which revealed reasons for poor maternal health outcomes in LMICs despite the efforts and policies implemented throughout these years. This review suggested an urgent and immediate need for formative evidence-based research on effective HRH interventions for improved maternal health outcomes. Other initiatives such as education and empowerment of women, alleviating poverty, establishing gender equality, and provision of infrastructure, equipment, drugs, and supplies are all integral components that are required to achieve SDGs by reducing maternal mortality and improving maternal health.
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Affiliation(s)
- Zohra S. Lassi
- />Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
- />Robinson Research Institute, The University of Adelaide, Adelaide, South Australia Australia
| | - Nabiha B. Musavi
- />Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Blerta Maliqi
- />Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Nadia Mansoor
- />Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Kadidiatou Toure
- />Partnership for Maternal Newborn & Child Health, Geneva, Switzerland
| | - Zulfiqar A. Bhutta
- />Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
- />Centre for Global Child Health, The Hospital for Sick children, Toronto, Canada
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Huicho L, Molina C, Diez-Canseco F, Lema C, Miranda JJ, Huayanay-Espinoza CA, Lescano AG. Factors behind job preferences of Peruvian medical, nursing and midwifery students: a qualitative study focused on rural deployment. HUMAN RESOURCES FOR HEALTH 2015; 13:90. [PMID: 26625909 PMCID: PMC4667493 DOI: 10.1186/s12960-015-0091-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 11/18/2015] [Indexed: 05/15/2023]
Abstract
BACKGROUND Deployment of health workforce in rural areas is critical to reach universal health coverage. Students' perceptions towards practice in rural areas likely influence their later choice of a rural post. We aimed at exploring perceptions of students from health professions about career choice, job expectations, motivations and potential incentives to work in a rural area. METHODS In-depth interviews and focus groups were conducted among medical, nursing and midwifery students from universities of two Peruvian cities (Ica and Ayacucho). Themes for assessment and analysis included career choice, job expectations, motivations and incentives, according to a background theory a priori built for the study purpose. RESULTS Preference for urban jobs was already established at this undergraduate level. Solidarity, better income expectations, professional and personal recognition, early life experience and family models influenced career choice. Students also expressed altruism, willingness to choose a rural job after graduation and potential responsiveness to incentives for practising in rural areas, which emerged more frequent from the discourse of nursing and midwifery students and from all students of rural origin. Medical students expressed expectations to work in large urban hospitals offering higher salaries. They showed higher personal, professional and family welfare expectations. Participants consistently favoured both financial and non-financial incentives. CONCLUSIONS Nursing and midwifery students showed a higher disposition to work in rural areas than medical doctors, which was more evident in students of rural origin. Our results may be useful to improve targeting and selection of undergraduate students, to stimulate the inclination of students to choose a rural job upon graduation and to reorient school programmes towards the production of socially committed health professionals. Policymakers may also consider using our results when planning and implementing interventions to improve rural deployment of health professionals.
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Affiliation(s)
- Luis Huicho
- Instituto Nacional de Salud del Niño, Lima, Peru.
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru.
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru.
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.
- , Batallón Libres de Trujillo 227, LI33, Lima, Peru.
| | - Cristina Molina
- Project Development and Evaluation, Universidad ESAN, Lima, Peru.
| | - Francisco Diez-Canseco
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | - J Jaime Miranda
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Carlos A Huayanay-Espinoza
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Andrés G Lescano
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.
- Department of Parasitology, US Naval Medical Research Unit 6 (NAMRU-6), Lima, Peru.
- Public Health Training Program, US Naval Medical Research Unit 6 (NAMRU-6), Lima, Peru.
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Sales M, Kieny MP, Krech R, Etienne C. Human resources for universal health coverage: from evidence to policy and action. Bull World Health Organ 2015; 91:798-798A. [PMID: 24347697 DOI: 10.2471/blt.13.131110] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | - Marie-Paule Kieny
- Global Health Workforce Alliance, World Health Organization, Geneva, Switzerland
| | - Ruediger Krech
- Ethics, Equity, Trade and Human Rights, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Carissa Etienne
- Pan American Health Organization, Washington, United States of America
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Hoogenboom G, Thwin MM, Velink K, Baaijens M, Charrunwatthana P, Nosten F, McGready R. Quality of intrapartum care by skilled birth attendants in a refugee clinic on the Thai-Myanmar border: a survey using WHO Safe Motherhood Needs Assessment. BMC Pregnancy Childbirth 2015; 15:17. [PMID: 25652646 PMCID: PMC4332741 DOI: 10.1186/s12884-015-0444-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 01/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing the number of women birthing with skilled birth attendants (SBAs) as one of the strategies to reduce maternal mortality and morbidity must be partnered with a minimum standard of care. This manuscript describes the quality of intrapartum care provided by SBAs in Mae La camp, a low resource, protracted refugee context on the Thai-Myanmar border. METHODS In the obstetric department of Shoklo Malaria Research Unit (SMRU) the standardized WHO Safe Motherhood Needs Assessment tool was adapted to the setting and used: to assess the facility; interview SBAs; collect data from maternal records during a one year period (August 2007 - 2008); and observe practice during labour and childbirth. RESULTS The facility assessment recorded no 'out of stock' or 'out of date' drugs and supplies, equipment was in operating order and necessary infrastructure e.g. a stand-by emergency car, was present. Syphilis testing was not available. SBA interviews established that danger signs and symptoms were recognized except for sepsis and endometritis. All SBAs acknowledged receiving theoretical and 'hands-on' training and regularly attended deliveries. Scores for the essential elements of antenatal care from maternal records were high (>90%) e.g. providing supplements, recording risk factors as well as regular and correct partogram use. Observed good clinical practice included: presence of a support person; active management of third stage; post-partum monitoring; and immediate and correct neonatal care. Observed incorrect practice included: improper controlled cord traction; inadequate hand washing; an episiotomy rate in nulliparous women 49% (34/70) and low rates 30% (6/20) of newborn monitoring in the first hours following birth. Overall observed complications during labour and birth were low with post-partum haemorrhage being the most common in which case the SBAs followed the protocol but were slow to recognize severity and take action. CONCLUSIONS In the clinic of SMRU in Mae La refugee camp, SBAs were able to comply with evidence-based guidelines but support to improve quality of care in specific areas is required. The structure of the WHO Safe Motherhood Needs Assessment allowed significant insights into the quality of intrapartum care particularly through direct observation, identifying a clear pathway for quality improvement.
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Affiliation(s)
- Gabie Hoogenboom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - May Myo Thwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - Kris Velink
- AVAG Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands.
| | - Marijke Baaijens
- AVAG Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands.
| | - Prakaykaew Charrunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - François Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Casey SE, Chynoweth SK, Cornier N, Gallagher MC, Wheeler EE. Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies. Confl Health 2015; 9:S3. [PMID: 25798189 PMCID: PMC4331815 DOI: 10.1186/1752-1505-9-s1-s3] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan. Methods Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers. Results All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services. Conclusion Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care.
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Affiliation(s)
- Sara E Casey
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY 10032 USA
| | - Sarah K Chynoweth
- University of New South Wales, High St, Kensington NSW 2052, Australia
| | - Nadine Cornier
- United Nations High Commissioner for Refugees, Rue de Montbrillant 94, 1201 Geneva, Switzerland
| | - Meghan C Gallagher
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY 10032 USA
| | - Erin E Wheeler
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY 10032 USA
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Sander LD, Holtzman D, Pauly M, Cohn J. Time savings--realized and potential--and fair compensation for community health workers in Kenyan health facilities: a mixed-methods approach. HUMAN RESOURCES FOR HEALTH 2015; 13:6. [PMID: 25637089 PMCID: PMC4328757 DOI: 10.1186/1478-4491-13-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/13/2015] [Indexed: 05/27/2023]
Abstract
BACKGROUND Sub-Saharan Africa faces a severe health worker shortage, which community health workers (CHWs) may fill. This study describes tasks shifted from clinicians to CHWs in Kenya, places monetary valuations on CHWs' efforts, and models effects of further task shifting on time demands of clinicians and CHWs. METHODS Mixed methods were used for this study. Interviews were conducted with 28 CHWs and 19 clinicians in 17 health facilities throughout Kenya focusing on task shifting involving CHWs, time savings for clinicians as a result of task shifting, barriers and enabling factors to CHWs' work, and appropriate CHW compensation. Twenty CHWs completed task diaries over a 14-day period to examine current CHW tasks and the amount of time spent performing them. A modeling exercise was conducted examining a current task-shifting example and another scenario in which additional task shifting to CHWs has occurred. RESULTS CHWs worked an average of 5.3 hours per day and spent 36% of their time performing tasks shifted from clinicians. We estimated a monthly valuation of US$ 117 per CHW. The modeling exercise demonstrated that further task shifting would reduce the number of clinicians needed while maintaining clinic productivity by significantly increasing the number of CHWs. CONCLUSIONS CHWs are an important component of healthcare delivery in Kenya. Our monetary estimates of current CHW contributions provide starting points for further discussion, research and planning regarding CHW compensation and programs. Additional task shifting to CHWs may further offload overworked clinicians while maintaining overall productivity.
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Affiliation(s)
- Laura D Sander
- Johns Hopkins Bloomberg School of Public Health, 1000 E. Eager Street, Baltimore, MD, 21202, USA.
| | - David Holtzman
- Baylor International Pediatrics AIDS Initiative, Maseru, Lesotho.
| | - Mark Pauly
- University of Pennsylvania Wharton School, Philadelphia, PA, USA.
| | - Jennifer Cohn
- Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Jansen C, Codjia L, Cometto G, Yansané ML, Dieleman M. Realizing universal health coverage for maternal health services in the Republic of Guinea: the use of workforce projections to design health labor market interventions. Risk Manag Healthc Policy 2014; 7:219-32. [PMID: 25429245 PMCID: PMC4243577 DOI: 10.2147/rmhp.s46418] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Universal health coverage requires a health workforce that is available, accessible, and well-performing. This article presents a critical analysis of the health workforce needs for the delivery of maternal and neonatal health services in Guinea, and of feasible and relevant interventions to improve the availability, accessibility, and performance of the health workforce in the country. Methods A needs-based approach was used to project human resources for health (HRH) requirements. This was combined with modeling of future health sector demand and supply. A baseline scenario with disaggregated need and supply data for the targeted health professionals per region and setting (urban or rural) informed the identification of challenges related to the availability and distribution of the workforce between 2014 and 2024. Subsequently, the health labor market framework was used to identify interventions to improve the availability and distribution of the health workforce. These interventions were included in the supply side modeling, in order to create a “policy rich” scenario B which allowed for analysis of their potential impact. Results In the Republic of Guinea, only 44% of the nurses and 18% of the midwives required for maternal and neonatal health services are currently available. If Guinea continues on its current path without scaling up recruitment efforts, the total stock of HRH employed by the public sector will decline by 15% between 2014 and 2024, while HRH needs will grow by 22% due to demographic trends. The high density of HRH in urban areas and the high number of auxiliary nurses who are currently employed pose an opportunity for improving the availability, accessibility, and performance of the health workforce for maternal and neonatal health in Guinea, especially in rural areas. Conclusion Guinea will need to scale up its recruitment efforts in order to improve health workforce availability. Targeted labor market interventions need to be planned and executed over several decades to correct entrenched distortions and mismatches between workforce need, supply, and demand. The case of Guinea illustrates how to design and operationalize HRH interventions based on workforce projections to accompany and facilitate universal health coverage reforms.
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Affiliation(s)
- Christel Jansen
- Health Unit, Royal Tropical Institute, Amsterdam, the Netherlands
| | - Laurence Codjia
- Health Workforce, World Health Organization, Geneva, Switzerland
| | - Giorgio Cometto
- Global Health Workforce Alliance, World Health Organization, Geneva, Switzerland
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Van Lerberghe W, Matthews Z, Achadi E, Ancona C, Campbell J, Channon A, de Bernis L, De Brouwere V, Fauveau V, Fogstad H, Koblinsky M, Liljestrand J, Mechbal A, Murray SF, Rathavay T, Rehr H, Richard F, ten Hoope-Bender P, Turkmani S. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. Lancet 2014; 384:1215-25. [PMID: 24965819 DOI: 10.1016/s0140-6736(14)60919-3] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.
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Affiliation(s)
| | - Zoe Matthews
- Evidence for Action, University of Southampton, Southampton UK
| | - Endang Achadi
- Center for Family Welfare, Faculty of Public Health University of Indonesia, Depok, West Java, Indonesia
| | | | - James Campbell
- Instituto de Cooperación Social Integrare, Barcelona, Spain
| | - Amos Channon
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | | | - Vincent De Brouwere
- Woman & Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | | | | | | | - Susan F Murray
- International Development Institute, King's College London, London, UK
| | - Tung Rathavay
- National Reproductive Health Program, Phnom Penh, Cambodia
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Palmer JJ, Chinanayi F, Gilbert A, Pillay D, Fox S, Jaggernath J, Naidoo K, Graham R, Patel D, Blanchet K. Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020. HUMAN RESOURCES FOR HEALTH 2014; 12:44. [PMID: 25128163 PMCID: PMC4237800 DOI: 10.1186/1478-4491-12-44] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 07/28/2014] [Indexed: 05/04/2023]
Abstract
BACKGROUND Development of human resources for eye health (HReH) is a major focus of the Global Action Plan 2014 to 2019 to reduce the prevalence of avoidable visual impairment by 25% by the year 2019. The eye health workforce is thought to be much smaller in sub-Saharan Africa than in other regions of the world but data to support this for policy-making is scarce. We collected HReH and cataract surgeries data from 21 countries in sub-Sahara to estimate progress towards key suggested population-based VISION 2020 HReH indicators and cataract surgery rates (CSR) in 2011. METHODS Routinely collected data on practitioner and surgery numbers in 2011 was requested from national eye care coordinators via electronic questionnaires. Telephone and e-mail discussions were used to determine data collection strategies that fit the national context and to verify reported data quality. Information was collected on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and 'mid-level refractionists' and combined with publicly available population data to calculate practitioner to population ratios and CSRs. Associations with development characteristics were conducted using Wilcoxon rank sum tests and Spearman rank correlations. RESULTS HReH data was not easily available. A minority of countries had achieved the suggested VISION 2020 targets in 2011; five countries for ophthalmologists/cataract surgeons, four for ophthalmic nurses/clinical officers and two for CSR. All countries were below target for optometrists, even when other cadres who perform refractions as a primary duty were considered. The regional (sample) ratio for surgeons (ophthalmologists and cataract surgeons) was 2.9 per million population, 5.5 for ophthalmic clinical officers and nurses, 3.7 for optometrists and other refractionists, and 515 for CSR. A positive correlation between GDP and CSR as well as many practitioner ratios was observed (CSR P = 0.0042, ophthalmologists P = 0.0034, cataract surgeons, ophthalmic nurses and optometrists 0.1 > P > 0.05). CONCLUSIONS With only a minority of countries in our sample having reached suggested ophthalmic cadre targets and none having reached targets for refractionists in 2011, substantially more targeted investment in HReH may be needed for VISION 2020 aims to be achieved in sub-Saharan Africa.
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Affiliation(s)
- Jennifer J Palmer
- International Centre for Eye Health Clinical Research Department, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St., London WC1B 7HT, UK
| | - Farai Chinanayi
- African Vision Research Institute, 172 Umbilo Road Umbilo, Durban 4001, South Africa
| | - Alice Gilbert
- International Centre for Eye Health Clinical Research Department, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St., London WC1B 7HT, UK
| | - Devan Pillay
- African Vision Research Institute, 172 Umbilo Road Umbilo, Durban 4001, South Africa
| | - Samantha Fox
- International Centre for Eye Health Clinical Research Department, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St., London WC1B 7HT, UK
| | - Jyoti Jaggernath
- African Vision Research Institute, 172 Umbilo Road Umbilo, Durban 4001, South Africa
| | - Kovin Naidoo
- African Vision Research Institute, 172 Umbilo Road Umbilo, Durban 4001, South Africa
| | - Ronnie Graham
- International Agency for the Prevention of Blindness (Africa Region), 172 Umbilo Road Umbilo, Durban 4001, South Africa
| | - Daksha Patel
- International Centre for Eye Health Clinical Research Department, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St., London WC1B 7HT, UK
| | - Karl Blanchet
- International Centre for Eye Health Clinical Research Department, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St., London WC1B 7HT, UK
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Cometto G, Witter S. Tackling health workforce challenges to universal health coverage: setting targets and measuring progress. Bull World Health Organ 2013; 91:881-5. [PMID: 24347714 PMCID: PMC3853956 DOI: 10.2471/blt.13.118810] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 06/25/2013] [Accepted: 06/26/2013] [Indexed: 11/27/2022] Open
Abstract
Human resources for health (HRH) will have to be strengthened if universal health coverage (UHC) is to be achieved. Existing health workforce benchmarks focus exclusively on the density of physicians, nurses and midwives and were developed with the objective of attaining relatively high coverage of skilled birth attendance and other essential health services of relevance to the health Millennium Development Goals (MDGs). However, the attainment of UHC will depend not only on the availability of adequate numbers of health workers, but also on the distribution, quality and performance of the available health workforce. In addition, as noncommunicable diseases grow in relative importance, the inputs required from health workers are changing. New, broader health-workforce benchmarks - and a corresponding monitoring framework - therefore need to be developed and included in the agenda for UHC to catalyse attention and investment in this critical area of health systems. The new benchmarks need to reflect the more diverse composition of the health workforce and the participation of community health workers and mid-level health workers, and they must capture the multifaceted nature and complexities of HRH development, including equity in accessibility, sex composition and quality.
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Affiliation(s)
- Giorgio Cometto
- Global Health Workforce Alliance, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Sophie Witter
- ReBUILD, Queen Margaret University, Edinburgh, Scotland
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