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Berdzuli N, Llop-Gironés A, Farcasanu D, Butu C, Grbic M, Betran AP. From evidence to tailored decision-making: a qualitative research of barriers and facilitating factors for the implementation of non-clinical interventions to reduce unnecessary caesarean section in Romania. BMJ Open 2024; 14:e065004. [PMID: 38417956 PMCID: PMC10900340 DOI: 10.1136/bmjopen-2022-065004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 01/16/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVE To improve understanding of the drivers of the increased caesarean section (CS) rate in Romania and to identify interventions to reverse this trend, as well as barriers and facilitators. DESIGN A formative research study was conducted in Romania between November 2019 and February 2020 by means of in-depth interviews and focus-group discussions. Romanian decision-makers and high-level obstetricians preselected seven non-clinical interventions for consideration. Thematic content analysis was carried out. PARTICIPANTS 88 women and 26 healthcare providers and administrators. SETTINGS Counties with higher and lower CS rates were selected for this research-namely Argeș, Bistrița-Năsăud, Brașov, Ialomița, Iași, Ilfov, Dolj and the capital city of București (Bucharest). RESULTS Women wanted information, education and support. Obstetricians feared malpractice lawsuits; this was identified as a key reason for performing CSs. Most obstetrics and gynaecology physicians would oppose policies of mandatory second opinions, financial measures to equalise payments for vaginal and CS births and goal setting for CS rates. In-service training was identified as a need by obstetricians, midwives and nurses. In addition, relevant structural constraints were identified: perceived lower quality of care for vaginal birth, a lack of obstetricians with expertise in managing complicated vaginal births, a lack of anaesthesiologists and midwives, and family doctors not providing antenatal care. Finally, women expressed the need to ensure their rights to dignified and respectful healthcare through pregnancy and childbirth. CONCLUSION Consideration of the views, values and preferences of all stakeholders in a multifaceted action tailored to Romanian determinants is critical to address relevant determinants to reduce unnecessary CSs. Further studies should assess the effect of multifaceted interventions.
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Affiliation(s)
- Nino Berdzuli
- Country Health Programs, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Alba Llop-Gironés
- Country Health Programs, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Dana Farcasanu
- Centre for Health Policies and Services, Bucharest, Romania
| | - Cassandra Butu
- World Health Organization Country Office for Romania, Copenhagen, Denmark
| | - Miljana Grbic
- World Health Organization Country Office for Romania, Bucharest, Romania
| | - Ana Pilar Betran
- Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Jullien S, Mateescu I, Brînzac MG, Dobocan C, Pop I, Weber MW, Butu C, Carai S. Unnecessary hospitalisations and polypharmacy practices in Romania: A health system evaluation for strengthening primary health care. J Glob Health 2023; 13:04039. [PMID: 37143374 PMCID: PMC10160704 DOI: 10.7189/jogh.13.04039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Background Children and pregnant women usually have multiple contacts with the health care system. While most conditions can be managed by primary health care (PHC) providers, hospitalisations are nevertheless common and often unjustified. The number of hospitalizations decreased in Romania at the start of the COVID-19 pandemic. While this is likely due to the disruption of health services and public health measures established to limit the spread of COVID-19, it also suggests that a proportion of hospitalisations prior to the pandemic were unnecessary. This healthcare system evaluation in Romania quantified unnecessary and unnecessarily prolonged hospitalisations in children, pregnant women and women hospitalised for delivery, and assessed antibiotic and polypharmacy practices in these groups. Methods We conducted the healthcare system evaluation in 10 hospitals across the country. We extracted data from medical records of patients hospitalized between 2019 and 2020. In each hospital, we randomly selected 40 medical records for each of the following groups: children 2-59 months of age, pregnant women, and women hospitalised for delivery. Clinical data were compared against WHO standards indicating a need for inpatient treatment or antibiotic therapy. Results Among 209 children and 349 pregnant women, unnecessary hospitalisations accounted for 57.9% and 56.2% of hospitalisations, respectively. Among necessary hospitalisations, a large proportion was unnecessarily prolonged, including 44.4% (n = 32/72) in children, 23.3% (n = 34/146) in pregnant women, and 45.8% (n = 110/240) in women after delivery. The proportion of unnecessary and unnecessarily prolonged hospitalisations did not differ between the pre-pandemic, the lockdown, and the post-lockdown periods. Antibiotics were prescribed to 53.1% (n = 43/81) of children with diarrhoea, while 50.8% (n = 61/120) of women with caesarean section received an unjustified prolonged course of antibiotics. Children and women were commonly prescribed unnecessary medications. Conclusions Findings of this evaluation should inform evidence-based decisions and actions for strengthening PHC and the healthcare system structure and improving the management of common diseases in mothers, newborns, and children. The evaluation should be repeated periodically to monitor progress.
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Affiliation(s)
- Sophie Jullien
- World Health Organization Regional Office for Europe, Quality of care and patient safety office, Athens, Greece
- World Health Organization Regional Office for Europe, Child and Adolescent Health, Copenhagen, Denmark
| | - Irina Mateescu
- World Health Organization Romania country office, Bucharest, Romania
| | - Monica G Brînzac
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babeș-Bolyai University, Cluj-Napoca, Romania
| | | | - Ioana Pop
- World Health Organization Romania country office, Bucharest, Romania
| | - Martin W Weber
- World Health Organization Regional Office for Europe, Quality of care and patient safety office, Athens, Greece
- World Health Organization Regional Office for Europe, Child and Adolescent Health, Copenhagen, Denmark
| | - Cassandra Butu
- World Health Organization Romania country office, Bucharest, Romania
| | - Susanne Carai
- World Health Organization Regional Office for Europe, Quality of care and patient safety office, Athens, Greece
- World Health Organization Regional Office for Europe, Child and Adolescent Health, Copenhagen, Denmark
- Witten Herdecke University, Witten, Germany
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Dube E, Pistol A, Stanescu A, Butu C, Guirguis S, Motea O, Popescu AE, Voivozeanu A, Grbic M, Trottier MÈ, Brewer NT, Leask J, Gellin B, Habersaat KB. Vaccination barriers and drivers in Romania: a focused ethnographic study. Eur J Public Health 2022; 33:222-227. [PMID: 36416573 PMCID: PMC10066483 DOI: 10.1093/eurpub/ckac135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In 2016-18, a large measles outbreak occurred in Romania identified by pockets of sub-optimally vaccinated population groups in the country. The aim of the current study was to gain insight into barriers and drivers from the experience of measles vaccination from the perspectives of caregivers and their providers. METHODS Data were collected by non-participant observation of vaccination consultations and individual interviews with health workers and caregivers in eight Romanian clinics with high or low measles vaccination uptake. Romanian stakeholders were involved in all steps of the study. The findings of this study were discussed during a workshop with key stakeholders. RESULTS Over 400 h of observation and 161 interviews were conducted. A clear difference was found between clinics with high and low measles vaccination uptake which indicates that being aware of and following recommended practices for both vaccination service delivery and conveying vaccine recommendations to caregivers may have an impact on vaccine uptake. Barriers identified were related to shortcomings in following recommended practices for vaccination consultations by health workers (e.g. correctly assessing contraindications or providing enough information to allow an informed decision). These observations were largely confirmed in interviews with caregivers and revealed significant knowledge gaps. CONCLUSIONS The identification of key barriers provided an opportunity to design specific interventions to improve vaccination service delivery (e.g. mobile vaccination clinics, use of an electronic vaccination registry system for scheduling of appointments) and build capacity among health workers (e.g. guidance and supporting materials and training programmes).
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Affiliation(s)
- Eve Dube
- Direction des risques biologiques et de la santé au travail, Institut National de Santé Publique du Québec, Québec, QC, Canada.,Axe maladies infectieuses et immunitaires, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,Vaccine Acceptance and Demand, Vaccine Acceptance Research Network, Sabin Vaccine Institute, Washington, DC, USA
| | - Adriana Pistol
- Centre for Communicable Disease Surveillance and Control, National Institute of Public Health Romania, Bucharest, Romania
| | - Aurora Stanescu
- Centre for Communicable Disease Surveillance and Control, National Institute of Public Health Romania, Bucharest, Romania
| | - Cassandra Butu
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | | | - Oana Motea
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | - Anca Elvira Popescu
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | | | - Miljana Grbic
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | - Marie-Ève Trottier
- Direction des risques biologiques et de la santé au travail, Institut National de Santé Publique du Québec, Québec, QC, Canada
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - Julie Leask
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Bruce Gellin
- Vaccine Acceptance and Demand, Sabin Vaccine Institute, Washington, DC, USA
| | - Katrine Bach Habersaat
- Vaccine-Preventable Diseases and Immunization, World Health Organization (WHO) Behavioural and Cultural Insights unit and WHO Europe, Copenhagen, Denmark
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Jansen DE, Carai S, Scott E, Butu C, Pop I, Park M, Rajan D, Weber MW, Wolfe I. COVID-19 has exposed the need for health system assessments to be more child health-sensitive. J Glob Health 2022; 12:03048. [PMID: 35841617 PMCID: PMC9288253 DOI: 10.7189/jogh.12.03048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Danielle Emc Jansen
- Department of General Practice & Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.,Department of Sociology and Interuniversity Centre for Social Science Theory and Methodology (ICS), University of Groningen, Groningen, the Netherlands.,Accare, University Centre for Child and Adolescent Psychiatry, Groningen, the Netherlands
| | - Susanne Carai
- WHO Athens Office for Quality of Care and Patient Safety, Athens, Greece.,Universitat Witten/Herdecke, Witten, Germany
| | | | | | - Ioana Pop
- WHO Country Office, Bucharest, Romania
| | - Minhye Park
- WHO Athens Office for Quality of Care and Patient Safety, Athens, Greece
| | - Dheepa Rajan
- WHO, Department for Health System Governance and Financing, Geneva, Switzerland
| | - Martin W Weber
- WHO Athens Office for Quality of Care and Patient Safety, Athens, Greece
| | - Ingrid Wolfe
- Department of Women's and Children's Health, King's College London, London, England
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Habersaat KB, Pistol A, Stanescu A, Hewitt C, Grbic M, Butu C, Jackson C. Measles outbreak in Romania: understanding factors related to suboptimal vaccination uptake. Eur J Public Health 2021; 30:986-992. [PMID: 32460309 PMCID: PMC7536253 DOI: 10.1093/eurpub/ckaa079] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background A large measles outbreak started in Romania in 2016. Current study aimed to (i) clarify who was affected by the outbreak, (ii) identify their barriers and drivers to vaccination and (iii) explore variation by population group. Methods This was a two-component study. Outbreak surveillance data for 6743 measles cases were reviewed to identify key characteristics. A survey was administered via telephone to 704 caregivers of measles cases (520 respondents) to explore capability, opportunity and motivation barriers to vaccination. Data were summarized descriptively for respondent characteristics and statements. Differences by population group (education, household income, ethnicity, setting and mobility) were explored using χ2 tests, Fisher’s exact tests or regression models. Results Most cases were unvaccinated and lived in low coverage areas. Ethnic minorities were disproportionally affected. Most caregivers felt welcome at health facilities. Some were less satisfied with the waiting time and had found the vaccine out of stock. Not everybody knew that vaccines were free of charge. Less than half knew the child’s next vaccination date, some had not been informed and did not know where to seek this information. Some said their peers did not vaccinate. Beliefs were generally supportive of vaccination; but many were concerned about vaccine safety and found they had not received good information about this. Conclusions varied greatly between minorities and less educated groups, compared with people with higher education levels. Conclusions Identifying characteristics of the population affected and underlying factors can inform a strategy to avoid future outbreaks and further research to obtain deeper insights.
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Affiliation(s)
- Katrine Bach Habersaat
- Vaccine-preventable Diseases and Immunization, World Health Organization (WHO) Regional Office for Europe, Copenhagen, Denmark
| | - Adriana Pistol
- National Center for Communicable Diseases Surveillance and Control, National Institute of Public Health, Bucharest, Romania
| | - Aurora Stanescu
- National Center for Communicable Diseases Surveillance and Control, National Institute of Public Health, Bucharest, Romania
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
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Njau J, Janta D, Stanescu A, Pallas SS, Pistol A, Khetsuriani N, Reef S, Ciurea D, Butu C, Wallace AS, Zimmerman L. Assessment of Economic Burden of Concurrent Measles and Rubella Outbreaks, Romania, 2011-2012. Emerg Infect Dis 2019; 25:1101-1109. [PMID: 31107215 PMCID: PMC6537719 DOI: 10.3201/eid2506.180339] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We estimated the economic impact of concurrent measles and rubella outbreaks in Romania during 2011–2012. We collected costs from surveys of 428 case-patients and caretakers, government records, and health staff interviews. We then estimated financial and opportunity costs. During the study period, 12,427 measles cases and 24,627 rubella cases were recorded; 27 infants had congenital rubella syndrome (CRS). The cost of the outbreaks was US $9.9 million. Cost per case was US $439 for measles, US $132 for rubella, and US $44,051 for CRS. Up to 36% of households needed to borrow money to pay for illness treatment. Approximately 17% of patients continued to work while ill to pay their treatment expenses. Our key study findings were that households incurred a high economic burden compared with their incomes, the health sector bore most costs, and CRS costs were substantial and relevant to include in rubella outbreak cost studies.
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Kriss JL, Stanescu A, Pistol A, Butu C, Goodson JL. The World Health Organization Measles Programmatic Risk Assessment Tool-Romania, 2015. Risk Anal 2017; 37:1096-1107. [PMID: 27439071 PMCID: PMC9245689 DOI: 10.1111/risa.12669] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/04/2016] [Indexed: 05/30/2023]
Abstract
Despite global improvement in annual measles incidence and mortality since 2000, progress toward elimination goals has slowed. The World Health Organization (WHO) European Region (EUR) established a regional goal for measles and rubella elimination by 2015. Romania is one of 13 EUR countries in which measles remains endemic. To identify barriers to meeting programmatic targets and to aid in prioritizing efforts to strengthen measles elimination strategy implementation, the WHO and U.S. Centers for Disease Control and Prevention developed a measles programmatic risk assessment tool that uses routinely collected data to estimate district-level risk scores. The WHO measles programmatic risk assessment tool was used to identify high-risk areas in order to guide measles elimination program activities in Romania. Of the 42 districts in Romania, 27 (64%) were categorized as very high or high risk. Many of the very-high-risk districts were clustered in the western part of the country or were clustered around the capital Bucharest in the southeastern part of the country. The overall risk scores in the very-high-risk districts were driven primarily by poor surveillance quality and suboptimal population immunity. The measles risk assessment conducted in Romania was the first assessment to be completed in a European country. Annual assessments using the programmatic risk tool could provide valuable information for immunization program and surveillance staff at the national level and in each district to guide activities to enhance measles elimination efforts, such as strengthening routine immunization services, improving immunization campaign planning, and intensifying surveillance.
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Affiliation(s)
- Jennifer L. Kriss
- Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Aurora Stanescu
- National Institute of Public Health, National Centre for Communicable Diseases Surveillance and Control, Bucharest, Romania
| | - Adriana Pistol
- National Institute of Public Health, National Centre for Communicable Diseases Surveillance and Control, Bucharest, Romania
| | - Cassandra Butu
- World Health Organization Country Office, Bucharest, Romania
| | - James L. Goodson
- Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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